Keywords

3.1 Learning Objectives

This chapter will provide you with the knowledge to:

  • Identify how ideas from the sociology of ageing can “shape” an individual’s experience of growing old

  • Examine the importance of narrative and biography to personal well-being

  • Reflect upon ways in which a “life history” approach can enhance the care of the older person in a range of health and social care environments

3.2 Introduction

Ageing is a multifaceted and complex phenomenon with biological, psychosocial, cultural and spiritual factors playing a vital role in determining why and how we grow old. As Phillips et al. observe [1], each facet of ageing is intimately and inextricably related: biological senescence (the physical process of ageing) both determines and is determined by our psychological, spiritual and social well-being.

This chapter focuses explicitly upon the sociological dimension of ageing, ways in which society can influence our attitudes towards older people and, therefore, from a health and social care perspective, helps to define the quality of care which they receive. It will draw upon ideas from the general discipline of sociology and social gerontology, a subset of gerontology (the study of ageing), which has enjoyed a recent surge in popularity amongst the health and social care research community [1,2,3]. The nature and importance of life history or life story/biographical approaches, as imbedded in and evolving from sociological discourse, will also be explored.

Throughout the chapter, readers are encouraged to reflect upon and explore the application of ideas within their own care settings through practice examples and reflective activities. This will offer an opportunity to examine personal views about age and ageing, which are central to effectively meeting the care needs of older people in a variety of care environments.

3.3 Social Theories of Age and Ageing: An Introductory Overview

There are many distinct ways of viewing and explaining society. Which theoretical position is adopted will depend upon a sociologist’s preferred perspective or underpinning value position about how the social world works [4]. As theoretical standpoints are numerous and complex, an attempt has been made to simplify and categorise some of the main themes which have emerged and highlight their relevance to working with older people in the health and social care sectors. In particular, there is focus upon a number of key ideas, which underpin and inform life history approaches.

3.3.1 Traditional Approaches

Theories of society can be broadly distinguished between those that propose “top down” or “bottom up” explanations about society, which in turn will influence how society is investigated and recommendations for promoting social well-being. “Top down” theories offer what is sometimes referred to as macro or structural perspectives [4]. These are concerned with the way in which the different parts or foundations, which make up the fabric of society, fit together and interact. For example, what role do institutions such as the economy, politics, religion, education and healthcare play in influencing when a person is defined as old and their existential journey through the later stages of the life course. Conversely, “Bottom up” or micro, social action perspectives highlight the experiences and choices which we make, our individual “agency”, throughout our lives. This will in turn impact upon our own attitudes towards meanings and expectations of old age with individuals rather than society controlling how old age is viewed and experienced [4].

Another dilemma which concerns sociologists is that of consensus versus conflict. Do societies exist in harmony and order through shared goals, values and beliefs systems or are they characterised by division and inequality [1, 4]? Both premises have many potential applications to healthcare and the social position of older people. For example, as people grow older, do they tend to “disengage” from their normal social roles and contacts including employment: a mutually beneficial transaction between the older person and society, which enables the transfer of power from the old to the young, and thus the continuing stability of a natural (evolutionary) social order? Or does society (and the older individual themselves) benefit from our seniors remaining active and involved in old age, either adopting new roles and social identities or continuing with the lifestyles beliefs and behaviours, which they have acquired earlier in their life course [4]? Each of these approaches emphasises the need to maintain a harmonious and stable society, although have differing views about the ways in which the older generation can contribute to this goal.

Conversely, conflict theorists working within the wider remit of critical sociology focus upon inequality, imbalances in power relationships and the way in which structural factors, including wealth and privilege serve to oppress and disadvantage certain social groups such as the old and frail [3, 4]. There are many variants on this theme, for example, attributing the loss of power and influence in old age to the growth of industrialisation and modernisation or demonstrating how a person’s status and prestige are dictated by the age group or strata to which they belong, thus determining access to social opportunity and resources. This includes investigations into the way in which specific social institutions such as a county’s welfare system including nationalised healthcare systems, may construct dependency and disempowerment in old age, rather than helping their older clientele [5].

3.3.2 Contemporary Approaches

Some of the more contemporary sociological approaches to explaining ageing adopt a much more nuanced and individualistic standpoint, focusing upon micro-level interactions which occur and define our own personal experiences of ageing. An example of this is Lars Tornstam’s developmental theory of gerotranscendence, which proposes that as we become older we tend to move beyond the rather limited narrow views of life associated with our younger years, becoming less self-centred and more focused upon things that are meaningful to us and that we enjoy [6]. This involves recalling and re-examining the lives we have lived and the choices we have made. The ability to reminisce and place meaningful interpretations on past life is of vital relevance to the notion of life history and will be expanded upon in a subsequent section.

The therapeutic benefits and enhanced life satisfaction associated with the process of gerotranscendence have been widely documented. These include greater life satisfaction, increased resiliency in retirement, enhanced motivation and the promotion of physical and mental well-being [6]. In addition, as Rajani and Jarwaid [6] observe, Tornstam’s theory is interesting because, as a natural process, it has universal applicability across continents, cultures and care settings. From a caring perspective, it potentially provides nurses and other health and social care practitioners with a useful frame of reference to promote positive attitudes towards growing old.

3.4 Ageism, Stigma and Stereotyping

Social attitudes towards ageing and the nature and persistence of social stereotypes are a key concern for social gerontologists. Prejudice and oppression may occur at any stage of the life course although much attention has been focused upon the impact of these processes upon older people and the often deleterious outcomes for their well-being [7,8,9]. Ageism refers to treating people differently and generally less favourably because of their age and arises from prejudices and intolerant beliefs systems, which often have their basis in damaging and inappropriate stereotypes. The latter refers to a set of fixed and overgeneralised ideas that are held about people or social groups. Negative stereotypes generate a fear of difference, people who are perceived as not “like us” or “the other”, and involve a process of labelling individuals with social characteristics, which is viewed as unacceptable and undesirable. This results in stigma, which may be “felt” by the individual as a mark of shame and disgrace and “enacted” by other members of society through discriminatory and exclusionary behaviours [10].

Ageism directed against older people is perceived as having its basis in a set of “myths” or misconceptions about the abilities and social value of our elders. Older people may internalise these values, thereby reinforcing and perpetuating the stereotypical assumptions that are held by the wider members of their community [7, 10]. Conventionally, Western societies are regarded as more ageist than Eastern societies, focusing upon decline and physical, cognitive and financial ineptitude rather than the spiritual growth and acquired wisdom of advancing years. Yet, both these views have been subject to challenge citing the pervasive presence of ageism across all cultural boundaries and the availability of social and economic resources being the most influential factor in determining attitudes towards our older citizens [11]. Moreover, older people may not merely experience discrimination on the basis of age but are often subject to multiple oppression, relating to the intersection of other categories of social such as race, ethnicity and gender, which may lead to significant poverty, ill health, housing disadvantage and social isolation, creating a “double” or even “triple jeopardy” of social discrimination [12].

3.4.1 Impact of Ageism

The potential scope and consequences of ageism are far-reaching. In the context of health and social care, beliefs and misconceptions are often deep-rooted and resistant to change, serving to undermine the quality of care provided and appear to persist across a wide range of international healthcare systems [9]. Such ageist assumptions are frequently implicit and expressed through unconscious bias rather than explicit actions and behaviours, therefore, potentially becoming an inherent feature of everyday practice [13].

Developing awareness of our hidden and sometimes institutionally entrenched prejudices and beliefs about ageing is essential for healthcare practitioners to ensure that we remain non-judgemental and deliver the highest quality of care possible. In response to this, a number of initiatives have been developed to counteract ageism amongst healthcare workers, with some excellent examples of high-quality practice both locally and internationally [14, 15].

There is increasing emphasis placed throughout the international literature on the importance of successful and active ageing [2]. Both these concepts attempt to countermand conventional negative stereotypes of older people with a more positive image of the social value and contributions that can be made in later life, stressing the importance of exploiting talents, experience and skills gained over the life course to promote a healthy and productive old age. However, such approaches have also been subject to rigorous criticism, accused of privileging the “young old” over the “frail old” [2, 3]. This has the effect of devaluing the experience of older people who by virtue of comorbidities and dependency may be unable to meet the criterion set by the “happy gerontology” paradigm [3, p. 93] but may equally regard their lives as rewarding and worthwhile [2].

On a micro-interactional level, other commentators have focused upon the benefits of promoting intergenerational relationships in combating ageist beliefs and misconceptions and sharing generational activity within intergenerational contact initiatives [14, 15]. Intergroup contact may be employed in several ways, for example, via family relationships, friendships, social and healthcare contact and every day interactions [14]. Alleged benefits include a reduction in negative attitudes towards older people and damaging age stereotypes, thus helping to counteract both direct and indirect ageism, providing opportunities for forging friendships and closer intergenerational ties [14].

The following practice example demonstrates how an intragenerational approach can be implemented within a health and social care setting.

Practice Example: The Role of Intergenerational Playgroups in Aged Care

Maria is an activity and lifestyle therapist in a residential care facility for aged residents with mild to moderate cognitive impairment. She has recently become concerned about a lack of interaction between residents and an apparent apathy to join in with some of the social activities. However, Maria has noticed that some of the older people seem to become notably more animated and actively engaged in their surroundings, in the company of children who often accompany visiting family members.

Maria raises this issue at the weekly staff meeting. Johan, one of the registered nursing practitioners, says that he has recently read an article about the benefits of intragenerational playgroup and wonders if it might be possible to introduce a similar scheme in their own establishment. Following discussion with the care managers and ensuring that legal and professional guidelines for safe practice are in place, Maria devises a diversional therapy/lifestyle programme, which facilitates interaction between three generations: the older residents, child carers (parent’s relatives and nannies) and preschool children. This comprises a weekly 2 h session facilitated by a diversional therapist and involving participation in and variety of shared activities including singing, baking, painting and structured and unstructured play. A month’s trial period is commenced.

Feedback suggests that everyone has benefited from this activity, increasing awareness and understanding of the needs of different age groups. For the older people, it seems to have provided them with a new zest for life, allowing them to make new friends, giving them a more clearly defined sense of roles and purpose and increasing their sense of dignity.

3.4.2 The Impact of Language

One interesting dimension of social interaction which makes a significant contribution towards what we believe and, therefore, how we behave is the role of language. This has led to a theoretical conundrum known as the Sapir-Whorf hypothesis. Put simply, does language determine thought or does thought determine language [16]? The power of words is undeniable. When we refer to the “miserable old man”, the “sweet little old lady” or even “the elderly”, we are reflecting not only ageist, but powerful gender stereotypes making automatic and damaging assumptions about person’s roles, intentions and capabilities. We are also at risk of devaluing individuality and personhood through the process of homogenisation (allocating all older people to one social category) and infantilisation (treating older people as children), and therefore, incapable of choice, control and self-determination [10].

In health and social care, comments are often made using powerful language to describe the global demographic shifts in age structure such as the “greying” of the population or the “Silver Tsunami” and the perceived increased burden, which this places on healthcare resources. Jenny Bristow [17] has referred to this emotive and homogenising choice of words as “Doomography”, claiming it is indicative of a wider gerontophobia, the idea that the increasing numbers of elderly population are a threat to the well-being of the wider population.

Reflective Question 1

Can changing the words which we use alter our views of older people?

Reflect upon the terms and expressions which you use to describe older people within your own workplace.

  • Do they generate positive or negative images of growing old?

  • Does this have an impact upon the way that older people are treated?

  • Will changing the language and terminology have a direct impact upon the quality of care that we can provide for older people and their carers?

Just as language can play an important role in determining how we think about older people, it also forms a vital medium in enabling older people to communicate their life stories, hopes, dreams and aspirations: how they were, are and want to be viewed as a person, helping us to challenge our biases and stereotypical assumptions. The following section considers how the power of narrative, past and present can be employed as a therapeutic tool to promote compassionate person-centred care.

3.5 Life History Approaches: Introduction and Origins

Growing old should not be viewed as a singular event but a natural continuation of the life course and the culmination of previous life experiences [7]. There are many different dimensions of our existence, which make us the unique person we are today, family, work, leisure, loves, hates and fears. A person’s present is inextricably linked to their past. Life history approaches empower older people to communicate the stories of their lives, linking past to present and enabling us as carers, to see the person beyond the diagnosis [18].

Life history methods were initially pioneered by anthropologists and later adopted by sociologists in an effort to better understand the life experiences of specific social groups, for example, native American Indians and other indigenous communities [4]. This was later adapted and applied to the healthcare arena by social scientists of symbolic interactionist tradition, such as Erving Goffman in his landmark studies of the experience of mental illness within institutional settings [19]. The importance and practical relevance of the approach has enjoyed a popular revival within contemporary gerontological nursing literature and regarded as fundamental to the ethos of delivering person-centred care [20].

3.5.1 Explaining Life Story Work

Essentially, life history, also referred to as biography or life story work, is used as a practical intervention with the aim of promoting person-centred care [18]. In relation to preferred terminology, most contemporary authorities tend to adopt the expression, “life story work”, perhaps to distinguish this very specific application from broader methodological approaches within the social sciences. Therefore, this will also be the preferred term for the remainder of the chapter.

As we have noted in the previous sections, damaging stereotypes about older people often operate by way of generalisation, based upon the premise that all older people share common, often negative characteristics, which do not allow for variation and individuality. For health and social care practitioners, this may create a barrier in our ability to provide holistic person-centred care. Life story work helps us to visualise life from the perspective of the storyteller [20]. This assists us in countering our misconceptions about ageing, providing a framework which we can utilise to understand the uniqueness of our older patients and clients, and ensuring that the care needs of both themselves and their family and/or carers are central to the care planning process [21]. The “taking it further” example at the end of this section provides a specific account of some of the way in which narratives provided by older people can enable a clearer insight into their world in addition to improving cognitive and physical function.

Life story approaches are particularly pertinent to the area of dementia care, where older people are often unable to communicate specific characteristics of their identity. Tom Kitwood’s seminal work on the need to preserve personhood of people with dementia through the implementation of person-centred care highlights the importance of biography in helping to restore self-esteem and social identity [22]. Additionally, understanding and validating what often appear to be challenging or irrational behaviours from the perspective of the person with dementia is of vital importance. Adopting a life history approach enables a “Deep Dive” into an older person’s past which in turn assists in rationalising their present, thus supporting the implementation of appropriate strategies and techniques to de-escalate traumatic events [18, 23].

Reflective Question 2

Think about what is important to you about your life making brief notes on the following:

  • What do you value?

  • Who do you value?

  • What are the things in life that contribute to your sense of self?

  • What are the things that make you who you are/are part of your identity?

Imagine you were put in a situation where you were unable to communicate these important personal characteristics to the people around you.

  • How would you feel? How might this impact upon your own and other people’s perceptions of your social value?

  • Which of the things you think that define you, as an individual person, do you consider the most important?

All the factors identified above are what helps to establish our status as a person determining our individual needs and aspirations. Denying or ignoring these elements of being can result in a process of social devaluation leading to a lack of agency and social esteem. Knowing and respecting a person’s unique biography can restore help to make them feel valued with an important role to play in their future care and well-being.

3.5.2 Life Story Work: Benefits and Applications

The alleged benefits of life story work have been widely documented throughout the literature (i.e. [18, 20, 21, 23]). Common themes focus upon the restoration of personhood, increased collaboration and partnership and enhance the ability to make cognitive, interpersonal and practical connections. From the perspective of the older person, accessing memories of significant events and past achievements is perceived as fostering a sense of pride, restoring dignity and self-esteem and building resilience [18, 21]. Active participation within the care process can create a sense of ownership and agency, determining what information is disclosed and how this might be used to inform their future care. Moreover, the advantages associated with the process of reminiscence are perhaps not merely confined to aspects of mental well-being. Reflecting upon one’s past may also result in physical improvements in mobility, for example, demonstrating balance, movement and actions that an older person may have used at a former point in their life course [24].

It is claimed that family members may also benefit through an increased sense of purpose, greater clarity of their roles within the caring relationship and the ability to view their loved one in a different and often more positive way [18, 21]. For care practitioners, engagement in life story work enables them to “See the person” beyond the diagnosis, thus placing them in a better position to identify and meet the older person’s unique care needs.

However, life story work is not without its critics. Some commentators [18, 21, 25] advise caution when implementing this approach as remembering past events can sometimes be distressing perhaps evoking painful memories and reminders of unreconciled loss. This is particularly the case for older people with memory problems, so life history methods need to be applied sensitively and judiciously [21]. Time constraints and lack of experience, knowledge and confidence on the part of the healthcare professional are other potential barriers which need to be recognised and addressed [18, 21]. Consequently, several authorities such as Grøndahl et al. [25] contend that the research base for unequivocally establishing the benefits of life story work is limited, and much more rigorous investigation is required to fully assess the impact of this popular and widespread intervention.

3.5.3 Implementing Life Story Work: Formats, Tools and Processes

As Thompson [21] observes, careful planning when introducing life story work is essential. This raises several key considerations, which can be summarised as follows:

  • What information is required?

  • How is this obtained and stored?

  • Why is it needed?

Information gathering will focus upon the collection of personal biographical details relating to the older person’s past, present and future preferences capturing and storing those precious memories that they have acquired on their journey through the life course [25]. Likes and dislikes, hobbies, interests and the idiosyncrasies of everyday living can be captured and recorded to create an image of the older person as they want to be seen, not merely through the distorting prism of age, ill health or some other convenient social label. Capturing personal highlights, achievements and successes are also vital in instilling a sense of pride and restoring self-esteem, which might have been eroded by health problems, decreasing mental capacity and increasing physical dependency [21].

When implementing a life story approach, the importance of time, privacy and the actual pacing of activity is a prime consideration [18]. Obtaining information in short bursts may be preferable to lengthy formal interviews, both for the older person and their relatives. The wishes of the older person and the need to maintain confidentiality should always be paramount. Also, the purpose for implementing a life story approach needs to be made clear and agreed by all concerned, and if the older person chooses to decline, then this must be respected [21].

As Kindell et al. [23] note, many formats can be utilised for implementing life story work including life story books, collages, DVDs and reminiscence or memory boxes. Profile documents, which provide a summary of the older person’s personal narrative, are relatively easy to compile and, therefore, have utility within busy acute care environments. A variety of free templates may be accessed via the Internet underpinning research (see further reading for links to these resources).

Hard copy life story resources are undoubtedly useful in terms of their tangible tactile properties. Touching a photograph of a loved one, holding a personal mementoes or keepsake from one’s past can evoke a range of emotions and memories both happy and sad, engaging a range of sensory reactions, which has been demonstrated to have been of particular benefit in reminiscence work [25]. With the growth of technology and digital resources, social network platforms and apps can also be exploited to great advantage as a means of capturing, storing and updating life story material [21]. Indeed, there are several commercial apps available, which enable an older person to curate precious memories by uploading photographs, together with an audio message. Websites such as Dementia UK provide a summary of some of the more popular online resources: see further reading for links.

It is recognised, however, that not all older people will be comfortable, conversant with, or have the skills, motivation or mental capacity required to use digital resources. Access and affordability to digital devices may also be a potential barrier [21]. Nevertheless, the increasing importance and usage of technology in all its forms as an adjunct to more conventional methods of life story work will perhaps gain in popularity for forthcoming generations, and therefore, as healthcare workers, we should be aware of this potential.

Direct involvement of the older person and, where relevant, significant others such as family members and carers is vital to the success of implementing life history work, enabling ownership and empowerment. Thus, the relationship between the care professional and their patients or clients should be one of inclusivity, mutual support and collaboration rather than clinical expert and passive recipient [18]. This includes consulting the older person from the outset, encouraging them to make decisions in relation to purpose, method and intended outcomes of the life story enterprise. It is their story, after all which should act as the main impetus for care, as demonstrated in the following case example.

3.5.4 Taking It Further

Older Person’s Narrations on Falls and Falling: Stories of Courage and Endurance

Clancy et al. [24] conducted a study in the north of Norway, which explored the perceptions of older people in five care facilities regarding falls, falling and falls prevention. A narrative approach was adopted, which enabled the older people to articulate their own accounts, perspectives and priorities based upon their own personal experiences. The intention of the study was to utilise the older person’s perceptions to inform and contextualise future falls prevention and health promotion strategies.

The study found that the actual experience of a fall, which had been prioritised by the researchers as the most significant event, was accorded less of a priority by the older people. They did not want to dwell upon the implications and consequences of falling, but what was important was the opportunity to tell stories about their former lives, strength and endurance. Telling these tales of times past brought them to life, thus establishing a sense of purpose and control.

The authors describe this transformative process as a “form of mental time travel” (p. 7) recalling memories of strength, vitality and well-being. To illustrate the beneficial results associated with reminiscence about times past, they provide an example of a highly dependent resident who was normally immobilised by severe pain but became a “multitasking genius” when given the opportunity to narrate about his life. Story telling seemed to overcome the stigma and embarrassment associated with falling, prompting the residents to recall what they could do rather than their disabilities. Reminders of their former abilities restored appeared to validate the older people’s sense of identity, self-esteem and social value.

The study is also instructive in that it demonstrates what was of actual importance to the older people concerned, rather than what we as the health and social care experts deem to be the priority.

  • Focusing upon your own area of practice, try to identify examples of specific occasions when there has been a difference in the care priorities identified by health and social care practitioners and the older people for whom you are caring.

  • Explore ways in which life story work may help to overcome these mismatches in expectation about the purpose and outcomes of care.

3.6 Summary of Main Points

The concept of person-centred care is of crucial importance in promoting the physical and psychosocial well-being of older people, restoring their sense of purpose, identity and social esteem. Life history or life story methods can assist care practitioners in facilitating a person-centred approach.

This chapter has attempted to focus upon several social factors, which will assist health and social care practitioners to develop the knowledge and skills required to implement life story techniques. This includes providing an overview of some of the key ideas underpinning the sociology of ageing including examples of traditional and contemporary sociological approaches to explaining ageing, the nature and impact of age discrimination and the power of language. The nature, potential benefits and challenges of life story work have also been highlighted together with practical suggestions for ways in which this might be implemented.

3.7 Suggested Reading

  1. 1.

    Giddens A, and Sutton P W. Essential Concepts in Sociology.2nd edition, Polity Press; 2017.This provides a general sociology textbook which is written in an interesting and accessible way provides an engaging introduction to sociology.

  2. 2.

    Sociology of Ageing Handbook. https://springerlink.bibliotecabuap.elogim.com/book/10.1007/978-1-4419-7374-0 https://epdf.pub/queue/handbook-of-sociology-of-aging.html. This compromises 45 chapters written by world renown authors and will allow you to explore in much more detail all of the key themes highlighted in this introductory chapter.

  3. 3.

    Dementia UK www.Dementiauk.org

    https://www.dementiauk.org/for-professionals/free-resources/life-story-work/?gclid=EAIaIQobChMI1fPLqaqr5gIVVYjVCh3w5wqpEAAYASAAEgLYdvD_BwE

    An extremely useful and accessible website which offers a range of free life story work tools and templates for use by both lay people and health and social care professionals. Also provides practical tips and advice to guide implementation.

  4. 4.

    Drury L, Abrams D, Swift HJ. Making intergenerational Connections- an Evidence Review. Age UK, London: 2017.

    https://www.ageuk.org.uk/globalassets/age-uk/documents/reports-and-publications/reports-and-briefings/active-communities/rb_2017_making_intergenerational_connections.pdf

    interesting report that pulls together the evidence about the nature and value of intergenerational initiatives suggests ways in which these can be implemented. These principles which may be of value within the health and social care sector