The Dilemma of Aging

Nancy Foner
taken from City University of New York website

The next book on my "F" list was a social science book about the people who work in nursing homes, titled, The Caregiving Dilemma, by Nancy Foner. Dr. Foner spent eight months in a nursing home in New York City in 1988-89, working with and studying the people and the systems that administrators, nurses, other medical professionals and nursing assistants must work within to provide care to elderly and incapacitated residents. Dr. Foner is an anthropologist and so her study is intended to be an ethnography, with particular attention being paid to the nursing assistants, who provide the bulk of the day-to-day care of nursing home residents everywhere in this country.

I was particularly interested in this book because I have worked in a nursing home as a nursing assistant and have had relatives who were residents of nursing homes. One of those relatives was my mother, who herself worked in a nursing home for much of her nurse's aide career and who shared with me her frustrations and triumphs over the years. My sympathies have always been with nurse's aides, therefore, and so I was glad to see they were getting some attention, especially since, as Foner points out repeatedly, such workers are the backbone of the facility yet they are often the least appreciated and supported.

Foner makes some very good points about how the way the system is set up contributes to the caregiving dilemma: that to do the job right requires more people and resources than facilities are willing or able to bring to bear. So often they opt for more efficiency (and lower costs) over more compassion; better physical care at the expense of emotional care. Of course, relatives want it all for their loved ones: physical and emotional care, and high quality service for low costs.

The facilities want to pay as little as possible for good workers, but they end up driving away the ones who are the most compassionate because their compassion is less valued since it doesn't improve the bottom line. Even non-profits have to worry about costs, and so they have to make tough choices about wages and physical vs. emotional care.

The book was published in 1994, so it's been over 20 years since her study came out. Whether or not it had an impact on the industry, it does seem that conditions have improved in nursing homes, at least to the extent that policies prohibit using restraints and seem to require more attention to the emotional and social needs of the residents, while still keeping the residents clean and safe. Even the food seems to have improved in quality--at least at one place--and residents were given a choice of dishes.

I worked in an assisted living facility in 1994 where I met at least one aide (they called them caregivers) who was crabby and abrupt with the residents. This seemed to be acceptable to the management, since they were not planning to fire her. But in recent years I have seen very few unkind nursing assistants. Whether or not it's because I was seeing them as a resident's family (and they were on their good behavior for me), I can't say.

But I was relieved that some things had improved in the forty years since I had first been a nurse's aid in a nursing home in my town. Things were pretty bleak back then. The activities consisted of watching a TV that was black and white and in need of repair--picture jumped repeatedly, "snow" on the screen obscured the view. Residents were called patients then and most stayed in bed all day and night, which of course contributed to bed sores, a constant danger for such people. I'm sure the food was barely palatable, and the staff was in short supply. Five years later, working at a nursing home, I was charged with caring for 25 patients on the day shift. There was no way I could give good care to such a large number of people.

This was an interesting and eye-opening book, but it left me feeling somewhat discouraged. Despite the improvements, the situation for the chronically ill elderly is looking bleak, especially with the numbers of Baby-Boomers aging into the need for care and the costs of such care skyrocketing with state governments unwilling or unable to continue to pay for it through Medicaid. What will happen is unknown, but it might become a crisis that will have to be dealt with one way or another.

I recommend this book highly.

My next "F" author is the famous economist, Thomas Friedman's rather prophetic book about globalization, The Lexus and the Olive Tree, which was published in 2000. So far it's very interesting a just a little bit disturbing.