Timonen, Virpi and O’Dwyer, Ciara
To be cited / referenced as:
Timonen, Virpi and O’Dwyer, Ciara (2009) ‘Living in Institutional Care:
Residents’ Experiences and Coping Strategies’, Social Work in Health Care,
2009.
Timonen, Virpi and O’Dwyer, Ciara:
Living in Institutional Care:
Residents’ Experiences and Coping Strategies
Living in Institutional Care
Timonen, Virpi and O’Dwyer, Ciara
Living in Institutional Care:
Residents’ Experiences and Coping Strategies
Virpi Timonen, DPhil
Ciara O’Dwyer, MSc
Abstract
Insights into daily living in residential care settings are rare. This article
draws on a qualitative dataset (semi-structured interviews and recordings
of residents’ council meetings) that gives a glimpse of the experiences and
coping strategies of (older) people living in residential care. The data
highlights the range of unmet needs of the residents, similar to the
categories of physiological, safety, love, esteem and self-actualisation
needs in Maslow’s hierarchy of needs theory. Our analysis indicates that
‘higher’ and ‘lower’ needs are closely inter-twined and mutually
reinforcing and should therefore be accorded equal emphasis by
professionals (including social workers) employed within residential care
settings.
Keywords: Residential care; Maslow’s Hierarchy of Needs, Quality of Life, Older People.
Virpi Timonen (timonenv@tcd.ie) is Director of the Social Policy and Ageing Research
Centre (SPARC), School of Social Work and Social Policy, 3 College Green, Trinity College
Dublin, Ireland. Ciara O’Dwyer (cmodwyer@tcd.ie) is Research Fellow in the Centre.
Acknowledgements
This study was supported by a grant from the Health Services Executive (Ireland). The
authors wish to thank Ms Ana Diaz and Ms Eileen Kelly for their help in collecting the data.
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INTRODUCTION
Numerous studies have outlined the unmet physiological and psychological needs of
people in residential care facilities (Barnes, 2006; Hansebo & Kihlgren, 2004; Kayser-Jones
et al., 2003; Nelson, 2000; Teno et al, 2004; Angus et al, 2005; Tuckett, 2007). It has long
been recognised that the traditional structures and work practices of institutional care settings
are not necessarily conducive to a good quality of life for residents. Research has also shown
that residents of care facilities attach great importance to the fulfilment of their psychological
needs. Robichaud et al. (2006) found
that three of the most important quality of life
indicators identified by a sample of Canadian residents of care facilities were being treated
with respect, access to relationships and positive attitudes from staff. Another Canadian study
suggested that interaction with family and friends, personal comfort, the physical
environment and mental stimulation were among the factors noted by residents as important
for their quality of life in long-term care (Guse & Masesar, 1999). Exploratory interviews
with Dutch people with dementia living in the community and in residential care settings
revealed that ‘being of use/giving meaning to life’ and ‘self-determination and freedom’ were
important quality of life domains (Droes et al., 2006).
It is only in recent years that more attention has been devoted to improving the quality
of residential care, and, in particular, ensuring that the care provided adheres to residents’
own expectations. While there is an extensive literature on the benefits of resident-centred
care, care settings have been slow to change, perhaps as a result of limited research outlining
what is important to older people who live in residential care settings (Kane & Kane, 2001).
Insights into daily living in residential care settings are rare. This article presents the
analysis of interview and group discussion data collected in the course of an evaluation of an
advocacy group (residents’ council) in an Irish residential care setting. The data give an
insight into the experiences and coping strategies of (in our sample, mostly older) people
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living in residential care settings. The study makes a contribution to the literature in a number
of respects: it draws on a large qualitative dataset that has some longitudinal elements; it
throws light on a (still) relatively new and poorly-understood phenomenon of resident
advocacy in institutional care; and it engages with a major theoretical construct, that of
Maslow’s hierarchy of needs. From the practice and policy point of view, the article
contributes to a greater understanding of the ways in which residents’ lives in institutional
care are constrained, and can be improved, by professionals (including, and perhaps
especially, social workers) employed within such settings.
We have organised our data analysis around the framework devised by Maslow (1943)
in his hierarchy of needs theory; the reasons for adopting this framework are outlined below
in the research methods and data analysis section. Our data revealed that residents had both
physical and psycho-social (unmet) needs. The article discusses residents’ unmet
physiological, safety, love, esteem and self-actualisation needs, and reflects on the need to
devote more attention to meeting residents’ needs across the full scale of needs from the
seemingly basic (but still often unmet) to the higher needs that are often seen as unattainable
for people in care settings.
Maslow’s Hierarchy of Needs Theory
Maslow’s Hierarchy of Needs Theory, first posited in 1943, was one of the first
frameworks for understanding how individuals’ assessment of quality of life could be related
to how well their needs were being met. Maslow suggested that needs were hierarchical, with
physiological needs taking precedence over other, psychological needs.
As illustrated in Figure 1 below, Maslow suggested that humans had needs on five
levels. The most basic needs of all humans were physiological, including the need for, inter
alia, oxygen, water, food, heat, sleep and sex. Once these needs are met, humans wish and
therefore seek to have their ‘safety’ needs met: these include structure, order, stability and
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protection. The third set of needs, which arise once the safety needs “are fairly well gratified”
(Maslow, 1943: 380), consist of love and affection needs and belonging needs, followed by
the esteem needs, whereby humans desire self-respect and the esteem of others, as well as
independence, confidence and achievement.
Maslow referred to the first four lower levels of need as the ‘deficit’ needs to highlight
their physiological nature, while the fifth, self-actualisation, he referred to as the ‘being’
needs; these needs involve individuals’ continuous desire to fulfil their full potential and do
what they are fitted for. While the term self-actualisation had previously been used by other
theorists, Maslow saw the term as having a specific and limited meaning: “it refers to the
desire… to become… everything that one is capable of becoming” (p. 382). Maslow
suggested that only approximately one per cent of all human beings were self-actualisers,
while others were still striving to have their lower needs met (Maslow, 1968).
Figure 1: Maslow’s Hierarchy of Needs
(Source: Maslow, 1968)
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Maslow’s theory is not without its critics, but as the focus of our article is not on criticising
the theory, we can only offer a cursory summary of some aspects of this critique. In their
review of studies based on Maslow’s theory, Wahba and Bridgewell (1976) found limited
evidence to suggest that human needs are hierarchical. Max-Neef (1991) argued that needs
are instead simultaneous and complementary with satisfaction thereof based on trade-offs, a
conclusion supported by Reiss’ research on motivation (2004, 2008). In addition, Geller
(1982) questioned Maslow’s narrow definition of the term ‘self-actualisation’, suggesting that
Maslow’s theory is unable to offer an adequate account of the origin and nature of human
needs.
In spite of its limitations, Maslow’s hierarchy of needs theory remains popular and has
been used as a framework for understanding how the needs of vulnerable people could be met
(Umoren, 1992; Zalenski & Raspa, 2006). In this article, we are using the hierarchy primarily
as an organising framework and a heuristic tool. We wish to emphasise that we did not set out
to test the theory, nor did we make any initial, guiding conjectures about life in institutional
care based on Maslow’s theory. Rather, the picture that began to emerge from our data bore
such a striking resemblance to Maslow’s categorisation of needs that we decided, at the data
analysis stage, to utilise it as a framework for organising our discussion of the data.
RESEARCH METHODS
The discussion presented in this article is based on data collected during the course of
an evaluation of a residents’ council established within a large, public-sector residential care
setting in Ireland, St. Anne’s.i The facility catered mainly for older people, many of whom
had cognitive impairments or severe physical disabilities. One unit catered exclusively for
younger people (under 65) with disabilities. The facility was located in an urban area,
approximately one kilometre from the nearest shops and other services, making it difficult for
residents to reach these without assistance.
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The group was set up by staff members from within the facility who wished to gain an
understanding of the views and concerns of residents and to bring any issues raised to the
attention of the facility’s management team. The group met with a staff member once a
month, in order to highlight aspects of life in the facility that they felt could be improved. The
group meetings were both observed and audio-recorded by the research team. In addition,
semi-structured interviews were conducted with twelve members of the group.ii All twelve of
the original group members were interviewed at the outset of the project. After the advocacy
group had been in operation for a one-year period, seven group members were reinterviewed. The five others were no longer in the group for a variety of reasons
(deteriorating health, death, loss of interest). All of the individual interviews were audiorecorded and transcribed. Ethical (human subject) approval for the study was obtained from
the researchers’ university, and highest standards of ethical conduct of research were adhered
to throughout the research process.
The data were analysed by the authors using both manual coding and NVivo qualitative
analysis software. The researchers read the interview and group meeting transcripts several
times in order to familiarise themselves with the data. While the overall purpose of the
research was to assess the extent to which the advocacy project helped to improve the lives of
those living within the facility, the focus of this article lies in our analysis of the content of
group discussions and individual interviews pertaining to life within the facility, and in
particular those aspects of life in institutional care that the respondents experienced as
unsatisfactory. Potentially relevant text was highlighted during a process of provisional
coding. Next, we questioned this provisionally coded data with the view to discovering
central concepts and categories (i.e. residents’ needs, how and why these were met or not
met, the role of structures, practices and professionals in enabling or preventing the meeting
of needs, and so on). Individual cases and transcripts were then compared for similarities and
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differences through a process of constant comparison. At an early stage of this process, the
resemblance between Maslow’s hierarchy of needs theory (1943) and the themes emerging
from our data became evident and we started to utilize his theory as a framework for
organizing and presenting the findings of our analysis. Below, we outline in detail how our
data corroborates and contradicts aspects of Maslow’s theory.
This project, in common with all research endeavours, had a number of limitations that
we wish to make explicit. This was a qualitative study that can not be argued to be
representative of the institutional care population of Ireland. However, the purpose of the
study was not to yield generalizable information (for that, a large-n quantitative study
utilising probability sampling would have been necessary), but rather to explore lives in
institutional care, and to make a contribution to theorising on the (met and unmet) needs of
institutional care residents. While the methods utilised by us were carefully documented and
are therefore replicable, our research findings are of uncertain transferability as the context in
which a study of this kind is carried out inevitably has a strong impact on the research
findings.
FINDINGS
Physiological Needs
Maslow (1943: 373) suggested that the basic, ‘pre-potent’ needs are physiological,
including the need for, inter alia, food, hydration, sleep, sex and oxygen. Evidence from both
the group meetings and the individual interviews suggested that these basic needs were not
always met:
I have to share a room with a man…[who is] on the suction machine sometimes
[as] he has very bad breathing…I had three hours sleep today…because of
hearing it through the night…that is why I am sleeping all through the day…so
when he gets up…to go down to the dayroom I do get in under the covers…I
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am just trying…to have a little rest but then all through the day there is
cleaners coming in and out.
(Male group member in his twenties, individual interview)
Resident 1: [nurses and care workers] talk very, very loudly among themselves.
At that hour in the morning [six o’clock], it’s not fair.
Resident 2: In my ward one [person] snores like a motorbike.
(Group discussion, 10th meeting)
As a result of poor physical facilities, residents were also at times unable to keep warm
and physically comfortable:
‘I came out of the bath…and the ward was…cold…You are freezing…You
wouldn’t get that at home’.
(Male group member in his fifties, 1st meeting)
Resident 1: I was in the shower now yesterday morning and it’s far too small
and they have to literally put down towels to get the water. It’s far too small in
every way, in every way…
Resident 2: There’s water on our unit, spilling out onto the floor when you’re
having a shower.
(Group discussion, 3rd meeting)
While residents always had enough to eat, many felt that the quality of food left a lot to
be desired:
…the food is still just the same, sometimes you can’t even eat the meat.
Especially the so-called lamb, I think he died before he was killed!
(Female group member in her eighties, 11th meeting)
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Frequent references were also made to meals being served cold, and to the lack of
variety in the food provided:
I found that the dinner yesterday was absolutely cold…it was cabbage, and
cold cabbage is horrible…and the potatoes were horrible, really watery, oh
they were horrible.
(Female group member in her eighties, 7th meeting)
…we never get a bit of broccoli or cauliflower, it’s carrots, carrots, carrots,
mushy peas and maybe turnip – it’s monotonous.
(Female group member in her eighties, 3rd meeting)
However, some of the remarks made by residents suggest that the poor quality of food
was not the central concern, but rather, what this and the organisation of mealtimes revealed
about the attitude towards residents:
I think [staff] should sample the food themselves to see…I am…disabled from
the neck down, not from the neck up, that’s how I know hot from cold.
(Female group member in her fifties, 6th meeting)
Resident 1: They clean the table before the meal is finished…. [You need] a
respectable time to eat your meals... You feel like you are in school.
Resident 2: …when they spray that stuff [cleaning solution] it splashes onto
you.
(Group discussion, 4th meeting)
Safety Needs
Using the behaviour of children as an example, Maslow suggested that human beings
prefer a “safe, orderly, predictable world” (p. 378), and, more broadly, attempt to seek safety
and stability including a “preference for familiar rather than unfamiliar things…” (p. 379). In
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this regard, residents appeared to feel emotionally ‘safe’. The sociability of the staff ensured
that some respondents had a largely positive experienced living in residential care settings:
This is a home from home.
(Male group member in his eighties, individual interview)
However, this perception was not shared by all. Another resident stated that the facility
did not feel like home, thus perhaps suggesting that she did not have her safety and stability
needs met within St. Anne’s:
I wouldn’t like to stay here for good…I’d like my own little place…
(Female group member in her eighties, individual interview)
Ensuring the physical safety of residents appeared to be one of the greatest concerns of
staff, largely as a result of health and safety legislation. However, the need to adhere to the
rules and regulations often inadvertently had a negative impact on residents’ lives,
particularly on their sense of independence:
We are not allowed into the kitchen any more.
(Male group member in his fifties, individual interview)
Resident 1: We have to get somebody to bring us out…that’s not always
available.
Resident 2: And I’m not allowed to go out yet on my own in the wheelchair. I’m
a novice.
Resident 1: You’re a danger to the public! [general laughter]
(Group discussion, 3rd meeting)
In his description of the need for safety, Maslow suggested that a natural aversion to
illness, being physically endangered and being in pain were among the safety-seeking
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mechanisms employed by humans. In this regard, it appeared that the care facility was not at
all times meeting the safety needs of residents:
When you are in pain there is nothing done about it…I am sometimes in a lot of
pain – for months in pain.
(Female group member in her fifties, individual interview)
[O]ften in our day room, a person becomes unwell and there’s no nurse
available and we keep…I’m not able to get up and walk and go out for a nurse
and I keep shouting for a nurse and a nurse can’t come…
(Female group member in her eighties, 2nd meeting)
Other comments made by the respondents indicated that they felt that their health was
somewhat under threat as a result of certain staff working practices:
I often watch [the nurses] when they are doing the medication. They can be
awful running their hand through their hair. And another thing very few of
them have in their possession handkerchiefs. They just use the back of their
hand but I am sorry to have to bring this up but it is true and another thing
yeah they don’t bring handkerchiefs for their nose or anything, it is not good
enough.
(Female group member in her eighties, 6th meeting)
The lack of privacy afforded to residents undermined their need for safety and security of
possessions:
I have a chest of drawers which I share with another lady.
(Female group member in her eighties, 8th meeting)
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The lack of safe, personal storage sometimes led to the loss of personal clothing and meant
that ensuring the safety of residents’ possessions required handing them over to a member of
nursing staff:
I looked in the wardrobe [for my] fleece and next thing…some fellow just shot
past me [wearing] my fleece.
Interviewer: If you wanted to keep something safe and private and secure, is
there anywhere…?
Resident: Only if it was money.
I: And…where would that go?
R: Into the Sister’s little safe I think.
I: OK but there’s nothing by your bed?
R: There is nowhere…in my room where I would be able to put anything.
(Male group member in his twenties, individual interview)
Love / Belonging Needs
Despite being surrounded by others, residents had few opportunities for either
providing or receiving affection or forming friendships:
[Living
here
is]
an
improvement
[compared
to
previously
living
alone]…[although I don’t] talk to anybody [except] Mary.
(Female group member in her eighties, individual interview)
Nobody communicates with anybody…there is no laughter. There is no
friendship, they don’t encourage that. People are vegetating.
(Female group member in her fifties, individual interview)
Residents also had to contend with difficulties in conducting a meaningful relationship
with family and friends:
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I only go out on Sunday, now my daughter could take me out, but if you could
understand her husband is coming in at an awkward hour and the children
from school. And then who drives me up – they are in work. I’d love to go out,
yeah outings I don’t expect my family because they have to wait till their
husband come in, their children from school, I’d like to go out more...
(Female group member in her fifties, individual interview)
Even when residents had the opportunity to spend time with family and friends who
came to visit, there was little space available to allow them to have private conversations:
I notice when visitors come in to certain people in my unit... in the day room
there’s a certain lady and she listens to every word that those people ... I think
it’s very wrong. It’s very embarrassing for the visitors to have someone
listening...
(Female group member in her eighties, 11th meeting)
Esteem Needs
Maslow (1943) suggested that every individual has a need for a stable, firmly based
(usually) high evaluation of themselves, for self-respect, and for the esteem of others. It
appeared that, at least in some cases, staff showed little respect for residents, and even more
worryingly, engaged in threatening behaviour:
Staff can sometimes address the patients in a way they shouldn’t speak to them,
in a derogatory way…[or] sarcastic…’sit down and be a good girl’ has been
said to me…
(Female group member in her fifties, 6th meeting)
It is possible that this lack of respect also led to residents lacking confidence in their
own abilities or opinions, as illustrated by the reply given by one individual when asked her
opinion on whether the facility was run like a hospital:
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Well I’m not long enough here to know. I’m just here [a few months]. So I
wouldn’t have any say on the matter or not anyway.
(Female group member in her eighties, 1st meeting)
In certain cases, residents had opportunities to improve their confidence and use their
skills to help other residents, although the extent to which this was actively encouraged by
staff was unclear. The following quote highlights the benefits of the use of such skills for a
resident’s level of self-confidence:
There is one resident who speaks very little. One day, I told him a story, and we
got on very well, I told him my story and we laughed, then he wanted me to tell
his wife the story, she came in, and she also laughed, I was getting him to say
more words [than he normally would] and he is still saying more words…
(Male group member in his eighties, 2nd meeting)
The residents recounted several occasions on which they had experienced disrespectful
treatment. Dignity was often absent from the lives of residents:
The nurse turned around and says I will give you your…injection, pulled up my
t-shirt … with visitors and other patients there…I said ‘please don’t do that’.
Her response was ‘who do you think you are?’ and ‘why do you want the
curtain pulled?...Doctors have done the very same thing, examined me…in the
hallway.
(Female group member in her fifties, 5th meeting)
SELF-ACTUALISATION NEEDS
According to Maslow (1943: 382), self-actualisation implies the desire for selffulfilment, “the desire to become … everything that one is capable of becoming”. As noted
earlier, much of the criticism of Maslow’s hierarchy of needs theory has been directed at his
assertion that less than two per cent of the world’s population are self-actualisers (Maslow,
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1968), given that the ability to self-actualise requires all of the ‘lower’ needs to be first
fulfilled. However, as the quotes below show, some respondents had great difficulties in
accepting the limited opportunities for self-development, self-fulfilment and self-expression,
in spite of having unmet ‘lower needs’. This was reflected in a great deal of frustration about
the lack of mental stimulation, autonomy and independence available to residents. In this
respect, therefore, our findings do not support Maslow’s theory as it was evident that some of
the residents aspired to, and in some cases managed to attain, self-actualisation despite also
having unmet ‘lower’ needs.
The lack of activities available to residents resulted in a large proportion of their time
being spent unoccupied:
[Resident]: Oh I’d like to see a lot more happening. We’re sitting down all day
doing nothing in the unit. Sitting on the bed looking at television. I’d like
something else. It drives me nuts by times.
I: Right, and have you said that to [the staff]?
R: Ah sure, they won’t listen to you.
(Male group member in his twenties, individual interview)
Resident 1: Some days everything just falls flat, do you agree with me?
Resident 2: Like the days you’re just staring out the window.
(Group discussion, 2nd meeting)
This resident spoke of her despair at the lack of mental stimulation provided within St
Anne’s, worrying about the effects on her morale and cognitive abilities:
What we want here is a home life. We want a sense of normality. Instead we
are vegetating in a room, it is hard and it is not right.
(Female group member in her fifties, 5th meeting)
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Even where enjoyable activities were provided, the role of residents was sometimes
confined to that of a passive observer, rather than an active participant:
Interviewer: I think they do a bit of cooking here, do they?
Resident: Yeah, but you are only standing looking at them [cookery class
instructors].’
(Female group member in her eighties, individual interview)
Table 1 below lists the activities currently available to and the activities wished for by
respondents, as voiced during the group meetings and individual interviews. The wished-for,
currently unavailable activities were evidently of a more (inter-)active, creative and
challenging nature than the activities actually available to respondents, hinting that this
channel of self-actualisation is not being utilised in a way that reflects residents’ interests and
wishes.
Table 1: Current and desired activities noted by respondents
Current activities
Wished-for activities
Prayers
Gardening, planting flowers
Bingo
Games, puzzles
Playing cards
Group activities
Knitting
Outings
Religious (hymns, benediction)
Crafts
Cookery
Computing
SONAS (sensory activity)
Story-telling
Aquarium (viewing)
Current affairs
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Residents also expressed a great deal of dissatisfaction with the regimented lifestyle
and prioritisation of routine over the needs of residents that characterised life in the facility:
Facilitator: If people want and look for a shower or a bath on a daily basis is
that ok?
Resident 1: No. We are nominated a designated specific day. Like a Tuesday.
Resident 2: Mine do it twice a week, Tuesday and Friday.
R 1: …if they are busy [on a Tuesday] they can’t do me. They don’t do me until
the next day.
Facilitator: [So showers are] not really available…on demand?
R 1: No, definitely [not].
(Group discussion, 7th meeting)
The frustration voiced by residents with regard to the lack of choice available to them
resulted partly from the failure of the management to recognise the ability of residents to
make more of the decisions regarding their own care. From the point of entry into the facility,
to the basic day-to-day decisions, residents had limited autonomy over their own lives:
Interviewer: [D]o you remember being part of making [the] decision to move
here?
Resident: No. (…) I felt terrible down-hearted.
(Female group member in her eighties, individual interview)
[…] staff maybe nurses and care staff talking over the people…almost as if the
patient is not there and…if they are having a change of medication or
whatever, [they should] include [us]…explain… why they are changing it.’
(Female group member in her fifties, 4th meeting)
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The level of frustration expressed by residents over their limited opportunities to
participate in decision-making concerning their care and lives in the institution is indicative of
the value placed by residents on having their ‘highest’ needs met.
COPING WITH THE LIMITATIONS AND CHALLENGES OF LIVING IN
INSTITUTIONAL CARE
With the exception of the advocacy initiative, the residents were largely expected to
develop their own coping mechanisms to deal with the losses and limitations they experienced
as a result of moving into and living in the facility. They used a number of coping
mechanisms, including humour:
Facilitator: John is making the point that nothing gets done unless it’s in the
book [nurses’ day book].
John: If you have to die, it has to be in the book! [General laughter]
(Male group member in his fifties, 3rd meeting)
Others appeared to ‘accept’ the negative elements of life in St. Anne’s, by distracting
themselves or keeping busy:
I don’t mind [having no activities] so much, ’cause I knit and read and I play
my cards, I keep myself occupied, others are just staring at the four walls.
(Female group member in her eighties, 2nd meeting)
Another resident used a similar approach, displaying a great deal of resilience but also
resignation in the face of what she perceived to be disrespectful treatment.
Facilitator: So does [staff ignoring you] bother you?
Resident: No, not really. I get over it. You have to, you have to.
(Female group member in her eighties, 10th meeting)
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Others tried to ‘rationalise’ the negative aspects of their lives, suggesting that things
could be worse, or that they should not expect much more, given their age and level of
dependence:
I don’t expect too much from the time I have left…I’ve done pretty good to go
as far as I have.
(Male group member in his eighties, individual interview)
[I am] thankful for what I have; [it] could be a lot worse.
(Female group member in her eighties, individual interview)
Others attempted to ‘avoid’ trouble, suggesting that putting up with poor treatment
from staff and trying to ‘keep quiet’ helped to ensure an easier life in St Anne’s:
I have been left sitting on a commode for [a very long time]. [The staff say]
‘what do you think I am? I have only two hands’. Well I said ‘Please, if you are
having a bad day, please don’t take it out on me’. They are short-staffed
anyway, which is totally fine but if you’re in pain it’s another thing. So. I don’t
know whether it’s worth [complaining further]’.
(Female group member in her eighties, 10th meeting)
Resident 1: I don’t like causing any trouble…I keep quiet.
Resident 2: [T]hat is [a way of] handling it…just keep quiet and that’s it…the
fear of causing trouble…that is what it is, isn’t it. Fear of causing trouble and
there is a backlash on you…
(Group discussion, 10th meeting)
It is possible that residents tended to desist from complaining as they were worried
about possible repercussions, as illustrated by the following quote:
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Living in Institutional Care
One of the women in there, come four o’clock when tea is over, she likes to go
to bed you know. She keeps saying ‘Will I go down now? Will I go down now?’
So, one of the sisters said to her, ‘If you don’t stop that I’m going to keep you
up until the night staff and you won’t go to bed until the night staff come out’.
[This] woman has a very bad leg, a pain in her leg. That can’t be right can it?
(Male group member in his fifties, 12th meeting)
The various coping mechanisms used highlight both the difficulties associated with living in
a residential care setting, the residents’ desire to be treated with respect, and their frustrations
with the lack of opportunities for personal growth.
DISCUSSION AND IMPLICATIONS
While the residents of St. Anne’s did have concerns about basic needs, such as food,
physical comfort and interference with sleep, the inadequacy of these basic provisions was
not the central difficulty for them. Rather, it was lack of mental stimulation and respect
shown to them and the loss of dignity and independence that ensued. As residents were never
strictly speaking left hungry, cold, without opportunities for sleeping, nor put in any direct
physical danger, it can be argued that this allowed residents to focus on their ‘higher’ esteem
and self-actualisation needs in accordance with Maslow’s theory where fulfilment of higher
needs is aspired to once lower needs are satisfied. However, in contradiction to Maslow’s
argument, it is also evident from our data that some residents can, and do, aspire to ‘higher’
needs even where their ‘lower’ needs remain unmet or are only inadequately met.
Furthermore, ‘lower’ and ‘higher’ needs are closely intertwined: inadequate provision for
lower needs (e.g. unappetising food served under pressure to consume it quickly) is an
indicator that ‘higher’ needs (e.g. for respect) are also being infringed or neglected. It is
therefore important to guard against the assumption that practices pertaining to ‘higher’ needs
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Timonen, Virpi and O’Dwyer, Ciara
(such as residents’ councils, advocacy and consultation initiatives) should only be
implemented when the ‘lower’ needs have been met. Given the central importance of ‘higher’
needs even for residents whose lower needs remain unmet, practices and policies that support
the achievement of esteem and self-actualisation needs should be implemented in parallel
with, and where necessary (e.g. due to resource constrains that prevent for instance the
improvement in the physical infrastructure of the care setting) prior to changes that pertain to
‘lower’ needs.
One possible explanation for the frustration expressed by the research participants may
lie in their limited capacity to change their circumstances. Abrams (1978) suggests that when
patients go into hospital, they assume the role of a passive recipient of healthcare. This is
largely as a result of the structured roles and work practices that allow staff to assume the role
of ‘guardians of knowledge’ and expect patients to be compliant and dependent. Similarly,
residents of St. Anne’s were expected to adapt the persona of “passive recipients” which
facilitated staff working practices, but also reflected the lack of focus on residents’ higher
needs. The internalisation of the role of a ‘passive recipient’ by some residents prevented
them from shaping their own personal development and the coping mechanisms that they
used acted as a poor substitute for progression towards meeting their esteem and selfactualisation needs. However, other residents were clearly in a position to aspire to the higher
(esteem and self-actualisation) needs despite the inadequate extent to which their ‘lower’
needs were met. We therefore noted considerable variance among our respondents regarding
the ability to meet, and interest in addressing, self-actualisation needs. Further study is
warranted in order to gain a deeper understanding of why some institutional care residents are
more focused on these self-actualisation needs than others, and also in order to gain an insight
into how residents can be assisted in the process of becoming aware of and striving towards
meeting these needs.
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Our study has indicated that Maslow’s framework can be used to gauge the types and
extent of unmet needs among institutional care residents. While we do not make any claims
about the generalisability or transferability of the results, we do recommend that the potential
of the approach used here be explored further both by researchers and practitioners,
especially social workers, working with people in institutional care. In social work practice
and research, utilisation of this relatively simple framework can help to gain a better
understanding of the key areas where residents’ needs remain unmet. We expect that this
framework would be particularly helpful for social work professionals who are considering
the initiation and on-going evaluation of residents’ councils and similar advocacy and
empowerment initiatives. Ideally, the qualitative approach outlined here would be used in
conjunction with ongoing collection of quantitative data on the quality of life and satisfaction
with care among institutional care recipients: together, these approaches can yield
a
comprehensive picture and understanding of the facets of life that are important to residents,
the areas where improvement is needed, and the ways in which residents can be more closely
and meaningfully involved in making choices and shaping their own lives in institutional
care.
i
This is a pseudonym.
All but one lived in the facility; due to the high level of cognitive impairment in all residents in one unit, a
volunteer who regularly visited the unit acted as the representative for that unit.
ii
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