Social Dynamics of People Residing in Nursing Homes
We would like to dedicate and wish to publish this Article in the memory of our Beloved Teacher Sir Majid Shehzad: We Love You Sir
Authors: Kh. Abdul Kareem Wyne, Arooba Salah ud din, Sadia Rana, Usman Minhas
ABSTRACT: Aging is a Natural Phenomenon. The Impact of socioeconomic pressures has constrained to change lifestyles. Pakistan is no exception. More and more people demanding independent family units have been forced to rearrange family structures. Therefore, a joint family system is becoming unpopular. Work demands, transfers and postings and relocation have contributed to this phenomenon. On the other hand, under present socio-economic conditions, in developing countries, family support is diminishing. The government welfare systems are almost nonexistent. The destitute elderly have no support to bank upon. Through this study, we have examined the issues forcing the elderly to shift to Nursing Homes in Pakistan. Although there are many types of violence are made against the elderly people but the most found among men was materialistic violence: under the subcategory of disputes of property. Women in the majority are facing emotional violence. The abuser after evaluating the complete scenario is found to be the son in the majority cases. As a whole this part of the system in Pakistan is being neglected as many others, an attention of government should be paid to such organizations.
- INTRODUCTION: Pakistan’s society has always stood for high value, respect and dignity of human life. Old age is regarded as a mark of esteem, wisdom and piety. This could be attributed to the strong ties that exist in the joint family system nurtured by religious values, dignifying the status of elderly segments of society.
The Constitution of Pakistan, however, declares promotion of the social and economic well-being of the people as one of its cherished objectives and inter-alia cast an obligation on the state to provide basic necessities of life for those citizens who are permanently or temporarily unable to earn their livelihood on account of Age, infirmity, sickness or unemployment.
1.1 BACKGROUND: Nursing Homes although this term refers to a multi-residence housing facility intended for senior citizens mainly but includes people of all ages. Typically, each person or couple in the home has an apartment-style room or suite of rooms. Additional facilities are provided within the building. This can include facilities for meals, gatherings, recreational activities, and some form of health or hospice care.
Before the 19th century, old people were incapacitated or broke lived in Almshouses. Many older Americans had been displaced by the industrial revolution unable to hold mechanized jobs. The civil war decimated some families’ ability to care for their elderly members. The local government of the time favoured “group housing” as opposed to what called outdoor welfare consisting of donations of food, clothing etc. to individual living independently. As a result, all kinds of people the physically incapacitated, orphans, mentally ill ended up living in Almshouses. As it began to unwind, women and church groups began founding homes for aged people who might have to spend their last days alongside the most despised society in Almshouse.
1.2 GLOBAL PERSPECTIVE: In the last few months, the United Nations Population Division and U.N Population Ageing Organizations have released several updated reports on the world population and the impact of the increase in those aged 60 and older.
As per the graphs, the number of older persons worldwide is expected to double by 2050. 1 in 8 people are aged 60 or over in 2017, however, 1 in 5 will be aged 60 or over in 2050. Almost all countries of the world are ageing. Older persons are becoming more likely to live alone and less likely to live with their children. 95 percent of all population growth is absorbed by the developing world and 5 percent by the developed world. The elderly population in developed countries has already surpassed the number of children (persons aged 0-14), every child. In the developing world, the proportion of the population aged 60 or over is expected to rise from 8 percent in 2005 to close to 20 percent by 2050
1.3 ROLE OF NGO’S: In order to access the ground facts for the purpose of this study efforts were made to contact with NGO’s like “Edhi Welfare Trust”, “Najjat Trust”, “Sweet Homes” and “ Baghbaan Nursing Home”. It was obvious that only three to four NGO’s have been silently operating in this field in the twin cities.
The Edhi Welfare Trust (ETW) houses elderly who either have been left by their children at the mercy of the ETW or family and relatives who left their elderly and sick to get rid of them due to socio-economic reason. We find a lesser number of Elderly people in other Nursing Homes due to lack of Resources etc.
1.4 SENIOR CITIZENS; POSITION WITH REFERENCE TO PAKISTAN: According to the 1998 census, there are 7.3 million senior citizens in Pakistan – a significant increase from 2 million in 1951. The Ageing Phenomenon started early in Pakistan because of poverty and malnutrition. Especially the Pakistani women enter the old age in 30s because if the social and cultural setup. Of those aged 60 or above in the country, 3.9 million are men and 3.4 million are women. They need special care, attention and protection. It is widely believed that youngsters want to be more independent and the new married couples like to live separately and do not want to live with their parents because of their privacy issues.
In developing countries, urbanization, modernization has changed the economic structure and societal values. Young generations are busy in gaining materialistic approach which made them neglect their duties for their parents and also to their children.
- Aged people leave their homes because of misbehaviour of son and daughter-in-law, lacking traditional values in children, adjustment problems in the family, seeking financial and medical help, constant companionship. Protection and security and stress-free living.
- Males (Adults) are usually found because of their Drug Addiction, They are sent to Nursing Homes so that they may get proper treatment and an eye check all the time. Females are preferred within the Adults because they are easy to handle for the management, and can be utilized in various home based jobs, the reasons for their increase in Nursing home is Divorce. They are neither accepted by their in-laws nor by their parents.
- Kids admitted are usually orphans or they have a single parent who cannot afford his or her child expenses.
- A majority of Infants adopted by the Nursing Homes are those whose parents are not officially married or have been in a relationship for a very lesser period of time.
1.5 MAJOR SERVICES & BENEFITS FOR SENIOR CITIZENS ACROSS BORDERS
1.5.1 Developed Countries; (USA, UK, Sweden, Australia, Finland, Japan, etc.)
- Companion system?
- Sheltered housing, residential home?
- Day Care Center?
- Self-care apartment?
- Hostel, nursing home?
- Basic pension, wife’s supplement?
- Grant – full widow’s pension?
- Children’s supplement?
- Supplemental disability allowance?
- National health insurance
1.5.2 Developing Countries; (INDIA, BHUTAN, NEPAL, BANGLADESH, SRILANKA)?
- The National Policy on Older Persons?
- Assistance to Voluntary Organizations?
- Central Assistance of Rs. 75/-?
- Annapurna Scheme?
- Income Tax Rebate?
- Higher rates of interest on saving schemes?
- Railways & airlines concession?
- Priority telephone connection
- METHODOLOGY: The research is an empirical study based on a consultative exercise through primary and secondary sources. Primary data which includes both qualitative and quantitative approach. As far as the quantitative data is concerned, Nursing Homes available in Rawalpindi and Islamabad were visited. The management of the organizations, policymakers, staff, caregivers, health professionals and the senior citizens were interviewed through a semi-structured questionnaire, separately. As there is a dearth of literature so the researcher has tried to collect data from different libraries and NGO’s in the twin cities and Internet resources were also checked so that it may help on the subject as well.
This type of Qualitative and Quantitative method for such type of research has been observed in previous surveys and census and has the researcher decided to use the same methods to come up with closest possible results.
- FINDINGS & RESULTS:
3.1 TYPES OF VIOLATION WITH ELDERLY PEOPLE:
3.1.1 EMOTIONAL VIOLENCE: Emotional abuse is also known as psychological abuse or as “chronic verbal aggression” by researchers. People who suffer from emotional abuse tend to have very low self-esteem; show personality changes (such as becoming withdrawn) and may even become depressed, anxious or suicidal. Emotional abuse symptoms vary but can invade any part of a person’s life. Signs of emotional abuse include:
- Yelling or swearing (read about Emotional Bullying)
- Name calling or insults; mocking
- Threats and intimidation
- Ignoring or excluding
- Denial of the abuse and blaming of the victim
Emotional abuse, like other types of abuse, tends to take the form of a cycle. In a relationship, this cycle starts when one partner emotionally abuses the other, typically to show dominance. The abuser then feels guilt, but not about what he (or she) has done, but moreover the consequences of his actions. The abuser then makes up excuses for his own behaviour to avoid taking responsibility for what has happened. The abuser then resumes “normal” behaviour as if the abuse never happened and may, in fact, be extra charming, apologetic and giving – making the abused party believe that the abuser is sorry. The abuser then begins to fantasize about abusing his partner again and sets up a situation in which more emotional abuse can take place.
Emotional Violence is abstract in nature. It is a heartbreaking phenomenon. We observed multiple cases among one was of a woman whose son dropped her at the Nursing Home, Her son had to go foreign for higher education. He mentioned the time period of a year but five years had passed, he never called neither came to take her mother back. The mother was found mentally unstable, tensed and emotionally disturbed.
3.1.2 PHYSICAL VIOLENCE: From simple assault to homicide, including armed robbery, physical violence can take many forms when an aggressor intentionally resorts to violence to intimidate or restrain a victim. Suicide also falls into that category. Physical violence leaves visible traces. It can comprise some or all of the following:
- A relationship between aggressor and victim
- Abuse of power, aggression
- The attack on personal safety
- Work environment deterioration
- Employment in jeopardy
Many respondents were the victim of physical violence. There was an old woman who was 70 years old, beaten up by her son, as she grew older her son did not want her to live with them because she was medically unfit. She needed someone to look after her. Her son mentioned that because of her they can’t pay attention to their children. Whenever her son took her mother back home from nursing home so that she could meet her grandchildren, They insist to go with her which her son doesn’t like so he makes her stay in the nursing home.
3.1.3 CHILDREN AGGRESSION: It’s normal for parents and young people to disagree and have conflict or arguments at times. However, if a young person is abusive or violent, it is more than conflict. It is an attempt to control and have power over you or others in the home. It can happen in families of any culture, religion or situation in life. A young person may frighten, threaten or hurt you by swearing, be calling you names, yelling, pushing, hitting, spitting or kicking. They might throw or break things, or punch holes in walls. Sometimes they steal money, run up debts or demand things you can’t afford. They may hurt pets or damage property. They can threaten to run away or harm themselves if you don’t give in to them. They might threaten you with knives or other weapons.
Young people can use abuse or violence for a number of reasons. It’s more common for adolescent boys to be violent toward their mother, especially if they are the sole parent, but this isn’t always the case. If a young person has seen violence between parents, or a parent has been violent toward them, they may believe it is normal. Violence or abuse can be a sign they:
- Haven’t learnt to control or manage feelings, especially anger. They act out their feelings without using any self-control
- Haven’t learnt to deal with the stresses of life, to solve problems or cooperate. They might think it’s their right to have all their demands met above others
- don’t value or respect other people, or their property
- see a parent, often the mother, as weak and powerless or think it’s OK to treat women this way
- Are affected by alcohol or drugs. Some drugs can trigger psychosis (being out of touch with the real world) and violence.
A young person might act aggressively if they have problems with their mental health. They may be anxious and lash out because they start to think they can’t trust those around them. Young people with a disability can be violent if they are frustrated or have trouble dealing with their feelings. They may find it hard to say how they feel or struggle to control their impulses. Whatever the reason, it doesn’t excuse it or mean you should put up with it. The longer you think it’s not serious, the bigger the problem can get. Everyone has the right to feel safe and be respected, including and especially parents. Violence towards parents or other family members is not good and in some case can be a crime.
In an interview with a mother at a nursing home, she explained her story only by questioning us. “Who wants to keep an old and uneducated woman with them?” Though she was a mother of three married sons she kept complaining about her daughter in laws that they are educated and they want privacy so they don’t want me to stay with them anymore.
3.1.4 PARENTS AGGRESSION: There are four primary styles of parenting that have been identified from a psychological perspective:
The authoritative parent – this style is considered to be the most preferred parenting style. The authoritative parent sets high standards for their child, but is forgiving and encouraging when their child fails to meet these standards. Parents who are authoritative tend to set routines, outline expectations and consequences, follow through and communicate effectively and frequently with their children. The authoritative parent-child bond is usually solid and respectful.
The neglectful parent – neglectful parents don’t care for their children’s basic needs. Often these types of parents don’t know where their children are, who they are spending time with, or what they are doing. They might leave kids home alone at ages where they need to be supervised. Children of neglectful parents may appear unkempt or underfed.
The permissive parent – this type of parent has a difficult time saying no. Often times, permissive parents are more concerned about being a child’s friend than they are with setting up routines and expectations. They tend to lack consistency in applying behavioural consequences. This parenting style can be just as harmful as a neglectful style because it can lead to children calling all the shots, and doing whatever it is they want.
The authoritarian parent – these parents are concerned with rules and the punishment associated with those rules. Authoritarian parents are rigid and don’t really allow children to make any choices. These types of parents often seem cold and have a difficult time expressing love to their children.
Communication tends to be from parent to child only, with no room for dialogue. The authoritarian parent is most likely to become an aggressive parent. Aggressive parenting can take many forms including verbal and physical aggression and can have detrimental effects on children. Research shows that babies exposed to aggressive parenting early on, are more likely to become aggressive children, teens, and even adults.
We had a chance to meet a woman in a nursing home who was a victim of domestic violence. She was physically tortured by her father as she was born a girl but her father wanted a boy so he used to beat her and made her do housework and at the age of 9 she was sent to an orphanage and as she grew old she was sent to old age home. Now she is waiting for her death to come.
3.1.5 PSYCHOLOGICAL PROBLEM: One of the ongoing problems with diagnosis and treatment of mental illness in seniors is the fact that older adults are more likely to report physical symptoms than psychiatric complaints (CDC). However, even the normal physical and emotional stresses that go along with ageing can be risk factors for mental illnesses like anxiety and depression. A number of potential triggers for mental illness in the elderly are listed below:
- Physical disability
- Long-term illness (e.g., heart disease or cancer)
- Dementia-causing illness (e.g. Alzheimer’s disease)
- Physical illnesses that can affect thought, memory, and emotion (e.g. thyroid or adrenal disease)
- Change of environment, like moving into assisted living
- Illness or loss of a loved one
- Medication interactions
- Alcohol or substance abuse
- Poor diet
We observed two weird cases; one among them was a doctor, currently living in Baghban old homes Due to mental torture by his family members he had to face mental issues. His family and wife abandoned him due to his unstable mental health.
The other case was of a chief engineer officer of Pakistan Navy. He had only one son he built three houses in Islamabad and bought almost twenty cars for his son but the son admitted him in an old house, As observed by the wardens his son always came in different cars to see his father. When his father was about to die the manager called his son to meet his father. His father cried and said that he wants to die in his son home but he refused to reply that “Baba these people are taking good care of you, who will take care of you at home, so you should stay here.” After three days his father died so we called his son and we asked him what to do with the body the son replied that I am busy so bury him and I will call you later to ask about the grave. Now nine years past but his son did not call to ask about the grave of his father. So this explains that it’s not necessary that only psychological patients live in the Old House, it can be the members of their families who themselves are not mentally stable and might think of their parents as a psycho.
3.1.6 FINANCIAL ISSUES: Declines in financial ability can easily be exploited by family, friends, and strangers. This point is especially vividly brought to life in the Times story, which starts off by relaying the true story of a man who got remarried late in life to a younger woman. This new wife proceeded to financially deplete her husband’s finances, despite the man’s family attempting to intervene. In other words, declines in financial ability make older adults very vulnerable to financial abuse, which can be perpetuated by family members and friends, as well as by scammers and strangers.
Even people who don’t have Alzheimer’s or a neurodegenerative disease often experience increasing difficulties managing their finances as they age. This is consistent with our improved understanding of “cognitive ageing,” which the Institute of Medicine recently covered in a groundbreaking new report.
Basically, even in the absence of disease, the brain’s abilities change as people age. This process proceeds a little differently for every person but it’s analogous to the ageing that we see in other parts of the body: things change with age and wear. Not all changes are negative, but the changes can eventually make managing finances harder.
The most commonly observed cases of old citizens facing due to financial issues mainly were because of the “property dispute” between their families and among women were affordability issues of their expenses which their children were unwilling to afford.
3.1.7 NO GUARDIAN: No guardian for older people left in this world of materialistic approach .one of the major reason is that there is no one in their family and friends willing to take the responsibility of them.Below are a few stories told by people themselves.
“I got married on 23 Nov 1974. We were unable to have a baby and my wife died in 2007. then I got married again in 1974. I and my wife lived together; she was a government employee in Fatima Jinnah School. I also used to do little jobs. On 30th April 1998, she got ill and she was in bed for nine years two months and fourteen days and she died. I was left alone so I shifted here.”
“I have done B.A. I have played hockey for ten years with Gulam Rasool and his son Akhtar Rasool. I used to work in a private company for twenty years as a manager. Four years before I was working with my brother when I had an accident and I was not able to walk and work so I asked my brother that I don’t want to become a burden on you and I shifted to old home.”
“I have only one son who was murdered by MQM in Karachi. Due to bad law and Order situation, his college announced a holiday and while coming back from college was murdered. He was doing BA-1. After a few years, my husband died of heart attack and I was left alone. My nephew is running this old home so I shifted here though he doesn’t like me staying here. I rented my house and now I have decided to live here for the rest of my life.”
“My brother in laws son dropped me here. My All family members died, my husband died after a few years of marriage. He was suffering from TB. Only my brother in laws son is alive and he is in Dubai. He dropped me here.”
3.1.8 GENERATION GAP: Generation gap is a difference of attitude between people of different generations, leading to lack of understanding. As in one case, the respondent narrated that she has 3 sons and all are married her daughter in laws thinks that she had an old way of thinking and they have different mindsets which are based on frequent quarrels among them and they don’t want her to live with them.
3.2 GRAPH OF ABUSERS OF PEOPLE RESIDING IN NURSING HOMES: Our elderly parents, who have raised us from child to a man, have invested years in our upbringing, are left in the lurch in spite of their expectations that their children will support during old age. Majority of them are suffering daily problems of life, which due to old age they cannot attend to, keeping their hopes and eyes towards some sort of care they deserve; It is observed that the Son is the abuser in the majority cases and are at the top of the list while Daughter in Laws hold the second position in this stance.
3.3 AGE GROUP OF PEOPLE RESIDING IN NURSING HOMES: According to researchers, the residents of old age homes are of different caste and religion and even spoke different languages. As well as in other cases, most of the women in old age home spent their whole lives in doing household works and had no income for their livelihood which forced them to depend on their family and due to this reason; the female residents were more in number as compared to males.
- DISCUSSION: At first, we picked a problem which is important socially for our society and all of us should know the facts regarding the “Social Dynamics of People Residing in Nursing Homes”. It was a challenge to get the facts because it’s hard to get someone’s life story which is a tragedy to that person. it is a sensitive topic for discussion. These issues included the multiple losses many of them had already experienced their family, home and independence as well as considering their future decline in health and death.
After selecting the topic, certain questions for the research were plotted to work accordingly and to cover different areas. Different old age homes were searched and visited, according to the time allotted by their management. Exploring the realities of life; what are the real causes of people moving to old age homes? What is lacking in our family system? Starting off with the questions, we spent time with those people and realized that the questions made were not enough to get the main story. We listened to everything they wanted to tell. We arranged the data. The main hurdles we faced were;
- Informed consent,
- Finding suitable space to meet with residents,
- Staff involvement and
- Ensuring privacy during interviews.
We used qualitative research methods to obtain the views on the research topic. Challenges include having a reasonable understanding of their participation finding opportunities to conduct interviews involvement of care home staff and trying to maintain privacy during the interviews. Since interviews covered issues regarding the resident’s care in the home, privacy was important. However, in the majority of cases, the resident’s door was left open or staff would enter the resident’s room during the course of an interview. Since most residents had mobility problems, moving them to places where they would have more privacy was time-consuming and usually involved enlisting the help of the busy nursing home staff.
There were people who start crying while telling their stories and some people were so depressed that they were repeating things again and again and by controlling them we realized that man is helpless at times, this was a learning part for life.
The facilities they were getting there were quite good because it’s a tough time economically nowadays. Most people have adjusted themselves to those old houses but some were not settled and they will not settle because they miss their families and everyone can’t forget the life tragedies and move on.
The majority of residents seemed to feel free to comment on their day-to-day routines and the care they received in the home. Although residents were satisfied with much of the care they received in the home. Most described situations which they felt could have been handled differently by staff and suggested ways in which their care should be improved.
Obtaining informed consent from residents was extremely important but time-consuming. Difficulty in recalling details of events from previous weeks was a problem for many respondents and one requiring some flexibility with procedures. A great deal of time and patience was needed to ensure that respondents recalled and understood the study and their role in it before they consented to take part.
After the collection of the samples, we did transcription which was a tough part because we have to locate things in a specific order and to present that information in a formal way. We convert the audio interviews and roughly written material in a hard form which will be presented. After that, we have written themes on different dimensions for describing the whole phenomenon logically which can be understood and briefly describe the whole topic and its significance. The lesson learned was that it is important to take as much time as necessary to check the understanding of participation in a gentle, non-threatening way and to be very tactful when excluding people who cannot provide informed consent.
After all, we realize that life is uncertain and there can be tragedies in life but to stay stable and positive and strong enough to fight back is the ultimate solution. We should be kind to those people who have lived a long life in such difficulties and still they have the courage to tell their stories and show us the different side of life. It was a great experience for us to explore and learn things. We learn that no matter how wonderful life you are living time can be changed at any moment and then there is a dark period which one should pass with patience and bravery. Those people were laughing as well so this shows that life can be tough for you but you should be positive and at times you have to move on.
5- CONCLUSION: Misbehavior of children, financial crises often lead to a feeling of ignorance and lack of emotional support in elderly which often compel to other places for living a problem-free life. There is a need for government and voluntary agencies in Pakistan to make arrangements for institutional support and care for the elderly. A number of studies have discussed various reasons for the elderly to be in old age home.
- Lack of care in the family,
- Insufficient housing,
- Economic hardships &
- Break up of the joint family are cited as reasons by studies.
The nuclear family system has also been expressed as one of the reasons for shifting the old age homes. The tradition of joint family in the culture of Pakistan is disappearing slowly, which was based on the love, affection and tradition. It has also the transformed family. People have started believing in the nuclear family rather than combined and joint.
All the respondents have reported that they are fully satisfied and do not have any problem in the institution. They gain a feeling of security and compassion from other inmates who belong to the similar age group, having similar attitudes and interests. All the respondents are of the view that institutional life can never be a substitute for family life, nevertheless, it can be concluded that in the present society old age homes offer great relief for the aged.
It seems that in Pakistan only political slogan and political speeches/ sermons and suggestion exists but no policy framework is concluded or put forward for implementation. Though some social workers and NGOs have been working in this filed but their number was negligible and their working was limited, as such no significant contribution is seen towards community participation in this area.
However in contrast to the majority of nations, policy work appears to have been done at Government level by USA & European Countries; are working towards protection, facilities and rights of their ageing population.
5.1 RECOMMENDATIONS: In this conclusion, recommendations for Senior Citizens in Pakistan are suggested as under which shall serve as a guideline for our policymakers and is a research topic within itself for further study.
- To develop reforms through discussions, seminars, conferences etc.
- To build public awareness and consensus required to support the reform through government, social parties, NGOs and the public.
- A new Government Department in the federal ministry for social welfare should be created to form policies and implementation of plans regarding senior citizens.
- To establish a Senior Citizen National Database.
- To make facilities for senior citizens in all the existing civil structures and buildings like shopping malls, roads etc. where old age people can easily walk, shop etc.
- To develop the products that meet the material needs of the old people.
- Mature age employment quota to the extent of 1% can be reserved for senior citizens.
- A free of cost vocational training and technical training should be provided to senior citizens.
- Public-private partnership schemes should be encouraged for construction of supportive housing such as hostels, old people homes and special nursing homes, training centres etc.
- To provide free medical service to the elderly in the Services hospitals or other designated centres.
- Banks to support credit facility for the senior citizen such as car loans, credit cards, microfinance facilities etc.
- Payment of Monthly Stipend to non-affording elderly shall be given by the government out of zakat or bait ul mal funds.
- 50% reduction on all domestic and city routines by rail, bus, aeroplane etc. be allowed to the older people
- Utility services like electricity, gas, phone etc. are provided at a minimal charge.
- Free legal counsel services are introduced for senior citizens
- NGOs and Social Welfare organizations should be encouraged to enhance their role towards elderly care services.
Probably old age is the age when a human being needs more attention. The government should concern about their health application of many helpful programs. The problem of elder abuse cannot be solved if the essential needs of older people-for food, shelter, security and access to health care are not met. The nations of the world must create an environment in which ageing is accepted as a natural part of the life cycle, where anti-ageing attitudes are discouraged, where older people are given the right to live in dignity-free of abuse and exploitation and are given opportunities to participate fully in educational, cultural and economic activities.
- Case Study; Senior Citizens
By Khalid Salahuddin & Dr Amanat Ali Jalbani
Journal of Independent Studies & Research
- Population Division Publication, Newsletter 2017
United Nations: Department of Economic and Social Affairs, USA