Graham D. Rowles

Place and personal identity in old age: observations from Appalachia

Abstract This paper explores the phenomenon of attachment to place in old age. Three complementary dimensions of attachment—physical, social and autobiographical insideness—are identified from a three year in-depth study of elderly residents of an Appalachian community. It is argued that autobiographical insideness may be particularly important to old people in sustaining a sense of personal identity and may be adaptive in old age. The paper develops the hypothesis that the increasing mobility of current elderly generations is resulting in changing manifestations of attachment to place. Whereas the old-old (persons over 75 years of age) remain strongly attached to their proximate physical environment, the young-old (those under 75 years of age) appear to be developing identifications with places that involve greater emphasis upon vicarious involvement in displaced settings.

Habituation and Being in Place

Over the duration of our lives, we each develop a rhythm and a routine in our use of space and in our relationships with the places of our lives that provide a sense of being in place. We gradually come to wear our environment like a glove, as, with increasing familiarity, it almost literally becomes a part of our persona. As we grow older or become increasingly frail, we adapt to reduced physical capabilities and changes in our environment in a manner that allows us to continue functioning effectively. This article explores the implications for occupational therapy of habitual use of the environment by older people and the sense of being in place that characteristically results. It is argued that sensitivity to the development and the maintenance of being in place provides a template for effective intervention when physical capabilities are compromised. Using the framework provided by complexity theory, and empirical observations from an ethnographic study of growing old in an Appalachian community, the article considers homeostatic adjustments that older people make in the use and the meaning of the spaces and the places of their lives as they accommodate to changing circumstances. By exploring the role and the uses of habituation (learning through repetition) in this process of gradual, often almost imperceptible, environmental adjustment, occupational therapists will be able to enrich their potential for developing strategies for intervention that effectively use a knowledge of habit in treatment.

Individualizing Care: FAMILY ROLES IN NURSING HOME DECISION-MAKING

l. Family members remain fully involved in nursing home decision-making after their relative has been admitted to a facility. 2. Family involvement in nursing home decision-making serves to individualize care and provide a continuing link to the residents personal history and preferences. 3. Family members assume an array of decision-making roles in nursing homes, including: caregiving, pampering, comforting, engaging, educating, monitoring, mediating, colluding and controlling.

Aging in Rural Environments

In 1978 some 8,467,000 persons over 65 years of age (approximately 38% of the noninstitutionalized elderly population) resided outside standard metropolitan statistical areas (U.S. Bureau of the Census, 1979). An increasing proportion of these old people live in small-town and rural environments. During the 1970s the significant numbers of elderly who had “aged in place” in such settings were complemented by a steady stream of return migrants from metropolitan areas (Aday & Miles, 1982; Beale, 1976; Bowles, 1978; Fuguitt & Tordella, 1980; Koebernick & Beegle, 1978). As this transition has occurred, a few pioneering anthologies (Atchley & Byerts, 1975; Youmans, 1967) have been supplemented by a proliferation of research on the rural and small town elderly (Ansello & Cipolla, 1980; Kim & Wilson, 1981; Wilkinson, Rowles, & Maxwell, 1982). Unfortunately, very little of this research has been concerned with the environmental experience, defined as physical, cognitive, and emotional transactions with the physical setting, of rural old people.

Place in occupational science: A life course perspective on the role of environmental context in the quest for meaning

The ultimate focus of each human life is a search for meaning. Building on the perspective of Victor Frankl, I suggest that this involves four overlapping domains: achieving a sense of worth through occupation, experiencing fulfillment through interpersonal relationship, exercising the ability to choose ones course of action, and, through the process of simply “being,” developing understanding and acceptance of ones place in the cosmos. At different stages of life each of these domains has different manifestations and assumes a different level of priority. The trajectory of the quest for meaning is shaped by personal circumstances and by context – the places in which the individual lives out his or her life. Adopting a life course perspective, an autobiographical analysis of the integrative relationship between place and person in the discovery and creation of meaning is presented. Emphasis is placed on the potential of each individual to proactively discover and create meaning through the manipulation of place. The fledgling discipline of occupational science might usefully focus on developing deeper insight into the evolving rapprochement of person and place in the search for meaning as expressed through the four domains. This would not only provide a theoretical focus and agenda for empirical inquiry but also facilitate developing environment‐focused practice strategies which support and nurture the continuing search for meaning that remains the core motivation of each person regardless of their circumstances.

Nursing home residents, families, and decision making: Toward an understanding of progressive surrogacy

Abstract This article examines surrogate decision making for nursing home residents and offers a description of progressive surrogacy based on a three-year in-depth study of residents 75 years and older in four nursing homes. The authors describe and provide case study examples of progressive decline in health and cognitive ability among nursing home residents and discuss the parallel progressive loss of decision-making capacities. Evidence is presented that the need for surrogate decision making covers a full range of decisions affecting the daily lives of residents and their quality of life and not just quality of treatment and health care. Findings from the study suggest that families are highly involved in providing decision making assistance to their relatives or substitute decision making for those who cannot participate in decisions. Families are not abandoning relatives to the decision-making authority of nursing homes.

Patient–provider communication: Understanding diabetes management among adult females

OBJECTIVE The purpose of this study was to explore how adult women manage their diabetes. Recommendations for improving adherence and opportunities to maximize communication between the healthcare provider and individuals who have type 2 diabetes also were described. METHODS An exploratory qualitative descriptive design was used to describe the experience of living with type 2 diabetes in adult females. Data were obtained via individual in-depth interviews with five women over age 50 with type 2 diabetes. Participants were interviewed individually and participated in a focus group. RESULTS Participants clearly identified three major themes affecting adherence to treatment regimens: communication with the healthcare provider, knowledge of diabetes, and the consequences of poor glycemic control. For these participants, patient-provider communication was the most important factor affecting diabetes adherence. CONCLUSION Individual autonomy asserted in day-to-day management is often perceived as non-compliance by the healthcare provider; while providers descriptions of potential severe complications are viewed as scare tactics by the patients. PRACTICE IMPLICATIONS Improved communication offers the clinician the opportunity to develop a partnership with patients to build mutually acceptable treatment plans and reach mutually agreed upon goals. Empowering the individual with skills needed to negotiate treatment regimens will encourage positive health decisions and improved outcomes.

Between Worlds: A Relocation Dilemma for the Appalachian Elderly.

An historically based spatial separation of old people from their children has generated a critical relocation dilemma for the present generation of Appalachian elderly — reconciling the physical, social, and emotional support of a familiar environment with the desire to be close to family. This article, based on a four-year participant observation study of a panel of elderly persons in a rural northern Appalachian community, explores the tension between factors that reinforce inertia and those that encourage relocation to the homes of children living outside Appalachia. The article traces and illustrates a normative trajectory involving several phases — departure of children, accommodation, seasonal migration, crisis, relocation, holding on, and severance — that characterize the decision process whereby, over a period of years, the dilemma is gradually resolved.

What's rural about rural aging? An Appalachian perspective ∗

Abstract Despite the recent proliferation of literature on the aged in rural society, considerable ambiguity remains concerning the appropriate conceptualization of rurality as a potential influence upon the experience of growing old. This paper considers three alternative conceptualizations: aging in rural environments , in which rural is viewed as an ecological context; the environment of rural aging , in which rural is viewed as a socio-cultural context; and the rural environment of the aging , in which rural is viewed as a phenomenological perspective of those who are growing old. The applicability of each conceptualization is considered in relation to insights arising from an ethnographic study of aging in a single rural Appalachian community and other research on the elderly of Appalachia. While each conceptualization has heuristic value, it is concluded that studies focusing on rural as a socio-cultural context or as a phenomenological perspective are the most likely to result in significant theoretical advances in rural gerontology.

Community Integration of a Rural Nursing Home

Based on an ethnographic case study of Mountain View, a rural nursing home, the stereotype of the nursing home as an environment separated from its community context is challenged. Participant observation and repeated in-depth semistructured interviews with residents, family members, and staff, over a period of two years, and interviews with community officials reveal that the nursing home is historically, economically, socially, and psychologically integrated within the local setting. A high level of community integration is manifest in the permeability of the walls of the facility. Many residents are able to retain strong ties within the community through trips outside the facility and as a result of community involvement in activities at the nursing home. Most important, the community integration of Mountain View allows residents to maintain a temporal continuity in their lives. High levels of community integration may enable nursing homes to play an expanded role in the rural long-term care continuum.