Joumal of Advanced Nursing, 1996,23, 954-959

The biomedical construction of ageing:implications for nursing care of older people

Tina Koch RN CHC BA PhDProfessor of Nursing, RDNS Ghair m Domiciliary Nursing and School of Nursing,Flinders University of South Australia, Adelaide, Australia

and Christine Webb BA MSc PhD RN RSCN RNTProfessor of Nursing, The University of Manchester, Manchester, England

Accepted for publication 24 July 1995

KOCH T & WEBB C (1996) foumal of Advanced Nursing 23, 954-959The biomedical constniction of ageing: implications for nnrsing care of olderpeopleTbis paper reports on an existential pbenomenological study carried out m acare of elderly people setting m a 1000-bed hospital in the United KingdomFourteen participants were interviewed, eacb on several occasions Two tbemesderived from these narratives are discussed, revealing negative expenenceswbicb are related to feelings of powerlessness Tbese two tbemes, routinegeriatric style and segregation, are sbovini to arise from tbe bistory and culture oftbe wards and are sbown to result m care deprivation and depersonalizationPatients' individual needs are ignored as tbey become tbe objects of inflexibleroutines witbin bealtb care practice In order to understand tbe situation, tbebistory of care of older people and tbe biomedical construction of ageing areexamined It is concluded tbat wbat is needed is a wider social and politicalmovement wbicb opposes ageism and cballenges ageist stereotypes In addition,in bealtb care tbere is a need for a review of tbe routine geriatric style of careand of segregation based on age and a social gerontology programme for nurseeducation

.<.Trw<n.r̂ r.>T.-.rr.T<-.>.T several literature sources A review of the literature wasI N T R O D U C T I O N j i i _ x i j i J ^ I J , . X J l

deliberately delayed until data were generated, m keepingTbe focus of this paper is the theoretical analysis of the with tbe metbodological approach The term 'geriatric' isthemes identified m a study which took place in a used in the paper because tbis is tbe term used by patients1000-bed National Health Service (NHS) hospital m the themselves, and fictional names are used to ensure patientUnited Kingdom (UK) Fourteen patients were eacb mter- anonymity and confidentialityviewed on several occasions, and journal and observationdata were also collected ^ ^ ^ ^ ^ Carrying out the study

The methodological approach of the study was lnHu- -^ ^enced by Heidegger's (1962) existential phenomenology The aim of this study was to listen to the voices of olderand Gadamer's (1976) philosophical hermeneutics Cuba patients as they descnbed their expenences of bemg a& Lincoln's (1989) construcUvist paradigm guides the patient m a care of elderly people ward Interviews wereanalysis of researcb joumal data, patient interviews and non-directive, and patients were asked to tell their own

story about what it was like being m hospitalCorrespondence Professor T Koch School of Nursing Flinders University The research proposal was approved by the appropnateof South Australia GPO Box 2100 Adelaide 5001 Australia e mail ethics committee and permission was gamed from the hos-NUGAK@CCJ'liNDERS EDU AU pital's nurse managers to coUect data in two wards Durmg

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Biomedical construction of ageing

the same year an mquiry was instigated into these wardsThe health authonty reported deficiencies in equipment,poorly maintained wards, limited pnvate facilities, and anunsafe environment They summed up their review bywntmg that wards afforded a desolate and dispmting vista

In 1991, the first author spent 7 months m care of elderlypeople wards m two large Nightmgale wards of a lai^eNHS hospital m the UK The first few months were fororientation to tbe setting and sbe gave direct care topatients as a supernumerary registered nurse Dunng theremainmg months she distanced herself from hands oncare and generated data by interviewing 14 willingand articulate older patients about their expenences mhospital

Only wben patients felt confident tbat their storieswould be treated confidentially and that the researcherwas an outsider did their concems emerge The researchertalked nearly every day with them and sometimes tapedtheir narratives The taped interviews were later tran-scnbed verbatim and analysed for common themes

The common tbemes of routine genatnc style of care(from Baker 1978) and segregation will be discussed

ROUTINE GERIATRIC STYLE

The term 'routine genatnc style' was coined by Baker(1978,1983) to describe the 'conveyor belt' way of organiz-ing care m the wards she studied Patients subjected tothis style m the present study felt dominated by tbedemands of the work timetable, powerless to bave anyinfluence on their own care and unable to express theirindividual needs

The routme genatnc style resulted in depnvabon ofcare, such as being unwasbed, unsafe and unfed Patients'concems revolved around food, safety, comfort, hygieneand the feeling that their care was compromised by theuse of untrained stafi' However, patients tended to makeexcuses for care deprivation on the grounds that nurseswere largely untrained and that there were not enoughstaff Patients believed their care would be compromisedif they complained about their predicament

Through all the patients' stories, the 'genatnc routine'was one of the most abborred yet tolerated aspects of careTbere was little vanation m tbis routme, and little noticewas taken of patients who had individual requirementsThe routme controlled older patients m terms of a singleset of norms that could be accommodated withm theschedule of the ward In this context, needs becamereduced to nursing practices based on bygiene, pressurearea care, medications and food, but even these needs werescarcely met Patients believed that they were deprived ofinformation and that they were inadequately prepared fortests and procedures

Feelings of bemg treated as an object were a consequenceof the genatnc routine Patients recounted their expen-

ences in a way that is evocabve and distressing, and theirdistress emerged clearly, as they talked of their pain, fear,anger, sense of resignation and powerlessness

Patients had low expectations of care and said that theysuffered in silence For example, Hilda bad no realisticalternative but to accept the care that had been mappedout for her

Anybody that can manage must cope My higgest worry here islack of stafF They could do with twice the staff Sometimes you'llask for it [the toilet], and they keep you waiting for it And thismoming I, said I'll be bursting in a minute 'Oh yes I'll fetchit' Well they put you on it, and they are gone so long, I could hedoing two or three times hefore they return I try not to ask forattention hecause I know how husy they are I do my hest

Stoicism and suffering in silence were perceived bypatients as commendable strategies What is remarkableabout this story is that Hilda saw aisking for care as animposition, and was apologetic for her needs In this situ-ation she accepted that priority was given to incontinentpatients, and that others must queue for attention Patientscolluded with inadequate nursing care Lilian had this tosay

They haven't got time to change my hed everyday here They areworked to death here Only it's at certain times they are husy Atmeal time, dinner time That's my only complaint really Youcan't get anything done I mean something that is important Idon't ask unless it is important

The congested routine appeared to stretch nurses to theirmaximum capabilities and patients felt that they could notcomplam To them it was obvious tbat nurses were run offtheir feet, and patients saw it as their role to diminish andnot increase the burden

There was little vanation in this routine, and little noticewas taken of patients wbo had individual requirementsAda Jones felt as if she was 'a puppet on a string' Whenshe had been diagnosed as havmg metastatic cancer, andhad endured an episode of septicaemia a day earlier, shesaid in an interview

I am sitting out of hed hut I don't want to he here They just siteveryone out of hed I have to sit here until they put me hack andI don't know when Yesterday I couldn't get hack to sleep aftergetting soaked like that I fell asleep, I slept for ahout an hourthen I was up at six I was awake That is why I wanted to staym hed I wanted to have a dnnk of somethmg and go hack tosleep It IS the only thing that gives me my strength hack SleepIS the hest thing Never mind getting me up, gettmg this and get-tmg that It's not as if I have got had legs It is different for peoplethat have to get up to get their muscles gomg I can understandthat But I just let them I am just like a puppet on a stnng I justlet them do what they want to

I just sit here until they put me hack to hed I insisted to he puthack yesterday, I was so ill I was told off, they said 'Don't dictate

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to me'' I said I want to he put to hed, I feel very, very ill Thensister came Well they don't know, they are domg their joh, that'stheir )oh It is very hard to explain They are not thinking actuallyof the patient They are all resolved to put everyone m their chairsThat IS the important thing

Routine practice was mappropnately applied to this sickolder woman, mamly by untrained auxiliaries andenrolled nurses who usually undertook the genatnc rou-tine Staff were determmed to put everyone m their chairsand only when the sister came along were Ada's vnsheslistened to This example indicates the routine genatncstyle expenenced by patients subjected to the routine'sitting out of bed'

SEGREGATION

Patients were also troubled by their segregation based onage Elsie was vexed by the G for genatnc on case notesfiles

I am old, I am 82, funny enough, hut I don't thmk of myself as anold lady I mean I found out what the G was in front of the numher,I really got a hit vexed, hecause I didn't really think of myself asgeriatric Well I think I am young and I am 82 I don't thmk thatI am old at all hecause I make things for old people I wasknitting here the other day One of the nurses and a lady walkedpast and said what are you knitting'' Bed socks I said, for the oldladies at B and they hurst out laughing Did you hear shedoesn't think she is an old lady'

Elsie did not think of herself as an old lady, she rejectedthe stereotype Among patients, use of the word 'old' didnot refer to calendar age but rather to a state of declmeand infirmity What they were rejectmg was more likelyto have been the negative image of incapacity and 'sen-ility' Often patients used the term genatnc to refer to aconfused old person Elsie could be forgiven for rejectingthe label 'old', as this did not fit her ovwi experience

Patients admitted to care of elderly people wardsexpressed an overwhelming unhappmess about such geri-atric segregation In addition, they were profoundly affec-ted by others m the ward, particularly when other patientswere 'talked down to' or deprived of care

In relation to age segregation of older patients in hospi-tal, Joseph had this to say

I have known for many years now that if you were over a certainage m the Bntish health service that you were elderly and weresent to a geriatric ward But they don't segregate them in othercountnes I don't think they should he segregated You want tohe in touch with things that are going on m the world now Notwhat was gomg on m the world 60 or 70 years ago I do thinkthere is a hit of class consciousness here It does happen here youknow A geriatric patient is down a peg or two You are certainlynot reaching the lower middle classes, never mind the middleclass'

Segregation remforces the notion that each patientsbould be treated m the same way and so the two themesof routine genatnc style and segregation are linked Tbenotions of heterogeneity and diversity of older people andtheir rights to individual care are given only lip-serviceIn the 'real' world of this genatnc setting, dehumanized,objectified care prevails

What matters to patients

Above all, patients stated that a personal approach to caremattered most to them and that being acknowledged asmdividuals by staff was of paramount importance Patientsseemed to want nursing care that would allow them tomake their own judgements based on adequate infor-mation, participation and self-direction

HISTORY OF GERIATRIC WARDS

The nursing literature confirms that the inhumane experi-ences reported by patients were shaped, m part, by thehistory of geriatric wards (Baker 1978, Evers 1986, Norton1988a, b, c, d, e) It is discouraging to find that the cultureof inhumane care which has already been well docu-mented, and concems identified many years ago, are stillevident m the wards studied

In the 1930s, Warren (cited m Denham 1983), tbe pioneerof modem genatnc medicme, demonstrated that applyingorthodox medicme to older patients could be 'successful',and that success could be measured m throughput of patientsm hospital beds

Another development in the speciality of genatnc medi-cme has been a change of focus from cure to rehabilitationThe medical model bas been sbifted m the 'direction of afunctional conception of health' (Wilkin & Hughes 1986)This implies active intervention designed to returnpatients to a state of independence, usually measured byan activities of daily living scale

A further historical factor pertinent to genatnc nursingm the UK is its acquisition of a poor image It 'mhenteda nursing staff steeped in the traditions of custodial-typecare, compnsed largely of untrained assistant nurses andauxiliaries, and lacking m professional status through itsassociations with Poor Law nursing' (Norton 1988e p 24)In fact, the wards studied •were housed m a formerworkhouse building As a result, custodial-type careaccompanied by a genatnc care routine has continued tohave an impact on the way tbe nursing of older people isvalued Baker (1978 p 24) observed that

the interaction of historical and medical factors which largelydetermines the context within which genatnc nursing is practisedproduces circumstances in which elderly sick or dependentpeople tend to he douhly devalued

In the setting studied by Baker (1978) tbe routine

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genatnc style placed emphasis on physical activities at theexpense of psychosocial needs Tidiness of the ward wasput before patients' needs, and expectations of msmagersand medical staff were put before patients' needs Actualnursing care was deficient, and tbe organization of workwas geared to completing it with the minimum effort or'maximum economy of human resources'

In Evers' 1981a study, it appeared that the quality ofpatients' expenences was related to the extent to whichpatients 'fitted in' with tbe implicit goals of nursing staffEvers suggests tbat inhumane treatment by the actions orinactions of nursing staff were usually unintentional, theywere a function of the routine

Substantial research, then, has confirmed tbat inhumanecanng practices for older people have existed m UK hospi-tals (Wells 1975, 1980, Baker 1978, 1983, Evers 1981a, b,Kappeli 1984, Miller 1989) Much of the work has focusedon nurses

Recommendations from this literature are broad and callfor education of all bealth care workers Organizationalchange, adequate material and human resources, and nursecontrol of long-stay wards, are recommended, and thereare calls for an examination of routines m genatnc wardsand of methods of delivenng nursing care The literaturequestions the use of untrained personnel, and the deliveryof care based solely on medical pnonties

From the findings of the present study, it appears thatlittle bas changed m the years following the earlier workIt seems that the inertia of institutions is related to culturalperceptions of ageing and that this influences the policies,health care and health caregivers Ageist assumptions areheld not only by bealth care workers but also by patientsthemselves, and ageism affects decision-makers who dis-tribute resources, teacbers of health care workers andpeople m the vnder community

BIOMEDICAL CONSTRUCTION OF OLD AGE

Another lnfiuence on the organization and practice ofhealth is tbe biomedical construction of old age, whichhas important implications for the way in which nursesview older people, and also the way in which ageism isperpetuated m the wider community

In the view of Victor (1987), 'the notion of "wear andlean" IS probably the oldest perspective, and can be tracedto the ideas of Aristotle' Descartes (1596-1650), who wasa French philosopher and mathematician, presented themodel of the mind-body split, known as Cartesian duality,which offers a mechanistic view of the person TheCartesian duality inherent in the medical model is denvedfrom positivist science 'aspirmg to the problem solvingand objectivity of the natural sciences' (Wilkin & Hughes1986 p 165)

A mechanistic view of the person is perpetuated byCartesian metaphors of the 'machme' and tbe 'container'

In the machine metaphor, the machine has primary qualit-ies, such as mass and motion, that are essential to its func-tion Any qualities tbat are not able to be measured areIgnored Finally, the machine is composed of mdepmndentparts, and each part can be inspected individually to deter-mine the nature of its function Parts are assumed to pwr-form as components m unison (Thompson et al 1989)

This metaphor appears to be a conceptual fit with thescientific method and in particular biomedical science

Thus the hody, passive and determinate, could he scientificallyinvestigated as an object of nature It was also made susceptihleto hiomedical interventions Since the machine hody is extrinsicto the essential self it can and must he entered, studied and tam-pered with in order to he repaired The person fades into thebackground and the focus is upon the person as a hiomedicalohject

(Parker 1991 p 5)

Another Cartesian metaphor is the container, where thebody IS viewed as a container for tbe mmd, and withinthe mind symbolic representation takes place Tbesenotions have certain implications for studying humanactivity Events occumng outside the container are con-sidered to be objective, whereas inside the containerevents are supposedly subjective Experience is thereforeviewed as a subjective event Symbols representing theworld aie manipulated in the mmd, and tbese manipu-lations permit the external world to be brougbt intointernal consciousness by cognitive processes Structuresand functions can therefore be isolated and studied(Tbompson et al 1989) From Thompson's perspective tbeconsciousness is seen as dominant over matter, that is tosay, the mind controls tbe body, and in some instancescontrols it to sucb an extent that disease is understood tooccur through human choice

Biomedical science, in accord with Descartes' philos-ophy of dualistic thought and the scientific method, baspowerfully influenced how patients make sense of theirbodies and how nurses approach the care of patients (Gibb1990) Usmg the Cartesian metaphor of the machine, themachine or body can be entered, studied and tamperedwith m order to be repaired The body is the object ofinquiry The patient as subject fades into the backgroundand becomes a biomedical object susceptible to medicalintervention Generated witbin medical discourse(Armstrong 1983, 1984) and the pathological view ofageing are images of ageing which are consistent with aview of human beings as machines

Central to this image is the idea that the human machinegrinds to a halt when parts wear out and there is an increas-ing need for maintenance The influence of this view mhealth care has been significant m determining ageist atti-tudes, and the depersonali2ation reported m the nursmgliterature and found m the present study is the legacy ofCartesian duality

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In the nursmg profession, the specialty of care of elderlypeople has evolved, tied intimately to genatnc medicmeand to the idea of Cartesian duality A medical perceptionof health has a narrow focus on pathological processesaffecting parts of the body rather than the whole personand has tended to confirm a constmct of agemg as a timeof decay and decline Nurses are influenced by the medicalmodel and bave succumbed to negative stereotypmg of oldage by associating it with decay and detenoration Thebiomedical constmct has been concemed with degenerat-ive as opposed to adaptive and developmental progressEstes & Binney (1989 p 587) refer to the biomedicalizationof ageing, where old age is viewed as

a process of detrimental physical decline and places ageing underthe domain and control of hiomedicine Medicine, with its focuson individual organic pathology and intervention, has hecome apowerful and pervasive force m the defimtion and treatment ofageing

According to Benner & Wmbel (1989 p 187) this patho-logical model

puts helpers in a superior position and those they help in aninferior position To he helped or he in need of help means thatone IS incompetent, wrong, hapless, helpless, or stupid

It produces categones and labels for patients that limitpossibilities for mtervention Labels and categories reducethe understandings a nurse may develop, and deny thepatient's history and personal meanings As a result,patients conform to the label and refrain from being assert-ive or requesting help

As suggested by Baker (1978), tbe success of medicaltreatment is judged m terms of cure and throughput ofpatients Medical staff m the wards used for tbe presentstudy were committed to patient turnover and nine of the14 participants were treated for reversible medical con-ditions and were discharged home If one accepts this asa cntenon for success, there is a role for the practice ofacute geriatric medicine However, if one combines thissuccess cntenon with patients' actual expenence of careas reported in the present study, then a 'careless' pictureemerges

Responses by staff to the older patients were rooted mthe biological model of decline, forcing negative stereot3rp-mg of patients A rebabilitative focus was not evident mthis study and was impeded by the routine style of organiz-ation of nursing care

One of the arguments for segregation of older patients isthat they require specialist skills However, nurses in thepresent research setting were disadvantaged m terms ofthese skills, as patients' care deprivation expenences pam-fuUy reveal Needs and problems became compartmental-ized according to chronological age Nursing practicebased on Cartesian duality, reflected a reductionistapproacb to care, wbere only the most basic needs were

considered, and even these were sometimes not met Thereseemed to be an implicit assumption that needs could bereduced to narrow notions of pathology, and that they werenot only basic but were the same for all patients Henceroutmized geriatric care and stereotyping m tbe researchwards produced nursing care that was not responsive toindividual needs

The need for segregation should be questioned, and itcould be argued that older patients require nursing skillsthat are needed by patients of all ages Patients should beacknowledged as mdividuals

CONCLUSION

We have pursued the idea that constructions of old agehave been dominated by the biomedical model, and tbatm the care of elderly people wards studied the medicaliz-ation of old age pervades The encroachment of ageistviews on the lives of the older patients admitted tothe research wards was devastating, as indicated by thecommon tbemes

This pathology perspective reinforces the low esteem mwhich older people are held, reduces them to objects mbeds, and discourages understandmg of older patients ashuman beings who want to be in control of tbeir own lives

The biomedical construction has been pursued in thispaper, not to ignore other theones of agemg but ratber tosuggest that this construction of the status of older peopleIS particularly evident m these wards and, we suggest,withm health care and the wider community

In devaluing patients by using stereotypes, nurses at tbesame time devalue themselves What is needed first is awider social and political movement wbicb opposesageism and challenges ageist stereotypes Pnority shouldbe given to tackling this neglected form of oppression

In this study the research wards were resource deprived,both in material and human terms, whereas tbe children'swards were mucb better resourced Thus resource distri-bution vinthm a large hospital is shown to be skewedtowards younger patients The way resources are distrib-uted depends on the beliefs and priorities of decisionmakers Change will not occur until untenable workingconditions are addressed and resources are reallocated

It IS encouraging to see that nurses are beginning toreview some of tbe biological processes which accompanyageing and to recognize that there is little uniformity inthe ageing process (Matheson & McConnell 1988) AgeingIS complex and varied, and is influenced by life stressors,lifestyles and social support systems Nurses should exam-ine ageing m order to dispel its negative images and topromote the importance of the individual person's healtbstatus rather than their chronological age This is animportant area for nursing reseeirch

Peace (1990) suggests that there is a need to recognizetbe division between genatnc medicme and geron-

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tology the former addresses tbe problems relating tomalfunctionmg m the older adult, the latter identifies thecharactenstics of normal agemg Stereotyping of ageing hasdominated education programmes for health care pro-fessionals, who are thus presented with a bias m teachmgtowards the social pathology of ageing (Peace 1990) Thisperspective focuses on problems sucb as malfunctionmgand dependency By contrast, areas relatmg to develop-ment and growth m later life are almost ignored in edu-cation programmes (Johnson & Connely 1990)

Health is normal in old age Degenerative conditions dooccur, but many can be allayed by treatment and manage-ment Serious lllness in old age can be overcome and indi-viduals can sustain or even improve tbeir health

Education programmes need to address not only prob-lems relatmg to malfunctioning in the older adult, but alsocharacteristics of normal ageing Programmes sbould focusupon assisting tbe older person in helping bim/herself tofulfil the potential of old age Finally, it is important todevelop nursing education and research programmes witha focus on the way older people can exert more controlover tbe quality of then- lives

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