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ORIGINAL ARTICLE
Year : 2017  |  Volume : 22  |  Issue : 5  |  Page : 414-419

Ethnographic exploration of empowerment to improve elderly residents' quality of life


1 Department of Occupational Environmental Research Centre, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
2 Department of Professional Advancement and Continuing Education, Faculty of Education, University Putra Malaysia, Malaysia
3 Social Determinant of Health Research Centre, Alborz University of Medical Sciences, Karaj, Iran

Date of Web Publication27-Sep-2017

Correspondence Address:
Seyed Zia Tabatabaei
Department of Occupational Environmental Research Centre, Rafsanjan University of Medical Sciences, Rafsanjan
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijnmr.IJNMR_70_16

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  Abstract 

Background: Evidence underscores that empowerment is central to improve the elderly residents' quality of life. In truth, empowerment is a process through which individuals gain better control over their life. The aim of this study was to explore how perceived empowerment influence on the quality of life among elderly Malay residents. Materials and Methods: A focus ethnographic approach was employed in a Malaysian residential home between May 2011 and January 2012. Data were gathered from participant observations, field notes, in-depth interviews, and exploring related documents. Results: The analysis of the data gathered in the current study resulted in the development of three themes – social life and its requirements, caregivers' skills empowerment, and listening and supporting. Conclusions: Findings of the study provide new insights that are useful in charting new guideline for care providers and policy makers to improve the elderly residents' quality of life.

Keywords: Elderly people, empowerment, ethnographic study, nursing, quality of life


How to cite this article:
Tabatabaei SZ, Ebrahimi F, Hamzah AH, Rezaeian M, Kamrani MA. Ethnographic exploration of empowerment to improve elderly residents' quality of life. Iranian J Nursing Midwifery Res 2017;22:414-9

How to cite this URL:
Tabatabaei SZ, Ebrahimi F, Hamzah AH, Rezaeian M, Kamrani MA. Ethnographic exploration of empowerment to improve elderly residents' quality of life. Iranian J Nursing Midwifery Res [serial online] 2017 [cited 2022 Dec 6];22:414-9. Available from: https://www.ijnmrjournal.net/text.asp?2017/22/5/414/215685


  Introduction Top


Empowerment is a process through which individuals gain better control over their life.[1] In other words, empowerment is a dynamic process resulting from mutual interaction and enable people to master their environment and achieve self-determination.[2] This process can help elderly residents to enhance their autonomy, self-determination, responsibility, decision-making, participation, as well as increase their quality of life.[3] Even more simply defined, empowerment is an ongoing process for helping elderly residents to claim control over elements that influence their quality of life.[2]

Quality of life is defined as an individual's perception of their position in life, in the context of society, culture, and value systems in which they live.[4] Several factors, including functional and psychological, as well as social and environmental variables have been reported to influence individuals' ratings of their quality of life.[5] On the whole, the term quality of life is a concept that is employed by people to judge the level of satisfaction with different parts of their life.

One's overall satisfaction in life and perceptions of quality of life may affect the relationships between the person and other members of the community.[6] Such relationships increase self-esteem and can result in more positive attitudes. On the contrary, many scholars believe that negative quality of relationships with others can lead to a decrease in the quality of life.[4]

In this regard, the number of recent studies has been conducted to understand and explain the relationship between empowerment and elderly residents' quality of life within residential homes.[7] Furthermore, the importance of the empowerment of elderly residents in long-term care facilities also has been well documented throughout the literature from the developed and developing countries.[8],[9] For example, numerous scientific studies found that residents' empowerment such as making decisions, work as a group, abilities to meet their own needs, and meaningful engagement can improve quality of life in a residential care context.[10],[11]

Only one review article discussed the various issues and challenges Malaysian' health services are facing to empower older persons and their caregivers. In this study, scholars believed that a comprehensive restructuring of the health care system required for Malaysia to empower the elderly people for enhancing their knowledge, attitudes and skills to improve their quality of life.[12] Reviews of literature on ageing in Malaysia showed that, although several studies have examined the elderly residents' quality of life, still relatively little is known about the empowerment of elderly Malay residents and their caregivers.[12],[13] In other words, there is no evidence of study on comprehensive assessment in matters of empowerment needs that is applicable to the quality of life of elderly Malay residents in Malaysian' residential homes. Furthermore, there is a growing awareness of the need for research to contribute to elderly residents and staff and its relationship with empowerment and quality of life.

The overall aim of this ethnographic approach was to explore how perceived empowerment needs influence on quality of life among elderly Malay residents.


  Materials and Methods Top


Details of the project design have been reported previously.[14],[15] For the next step of this study, reported here, we purposefully selected, recruited, and interviewed with 8 elderly people and 1 head nurse. This study employed a method known as focus ethnographic research in Hill House (pseudonym) from May 2011 to January 2012.

The primary goal of ethnography is to comprehend the dynamic, holistic, and individual aspect of human experience in its entirety and within its own context.[16] Ethnography is the best method to elucidate the culture or subculture of a group to discover, detail, describe, and explain the lived experiences of people.[17] Hill House is a government funded housing and rehabilitation center for physically disabled individuals and those with no financial resources. This complex consists of several detached dormitories to accommodate its residents, as well as special buildings for physiotherapy units, the main hall, prayer room, class room, management office, common room, and kitchen and dining rooms.

Four data collection methods (participant observation, in-depth interviews, field notes, and review of related documents) were selected as the main data-collecting strategies. The trustworthiness of the current study was ensured through triangulation, member checks, peer examination, nine months engagement in the field of research, selecting knowledgeable and different participants, asking two knowledgeable colleagues to comment on the findings to eliminate any bias, and finally returning data to the participants to validate the descriptions and interpretations of study findings.

When the principal researcher entered into the elderly people' daily lives for data collection, he was cautious to be as unobtrusive as possible, just like “a fly on the wall.” In this regard, he immersed himself in the natural setting to look for any contextual nuances which are impossible to discover from any other methods apart from participant observation. In this technique, he managed “entry” into the world to be studied, established “rapport” with informants and successfully acquired “access” to places, people, and interactions. Along this line, at the initial stages of the research project, principal researcher initially spent over 600 hours observing general activities and asking broad informal questions to a number of residents and staffs. Basically, he focused directly on observing activities and behaviors that were most significant and relevant to research questions. In general, based on research goals, the principal researcher tried to go where residents in the study often go in their daily lives while respecting their privacy. Furthermore, he attended daily organized events such as religious practices and outdoor social activities. Depending on what, whom, and where to observe, he set up specific times based on when the particular activity takes place, such as religious ceremonies or national events.

Both semi-structured in-depth interviews and informal interviews were conducted in this study. At the beginning of the each interview, he talked with all of the participants about the aims, methods, benefits, and risks of the study. In the research study, 13 interviews were conducted with participants. In this ethnographic study, we also reviewed related documents including residents' medical charts (medical records, nursing notes and so forth) and review of related documents (the national policy for older person) to providing data, which covers a comprehensive range of events during a span of time.

Analyses of data began on the first day of data collection with reading, thinking, imagining, conceiving, conceptualizing, connecting, condensing, categorizing, and thereby, creating a new storyline.[14],[15] This strategy helped us access answers easily at a later time. During data analysis, we extract themes from the data to answer research questions.

Ethical considerations

Ethical approval was obtained from the Faculty of Medicine and Health Sciences' Ethics Committee at University Putra Malaysia (UPM), the Social Welfare Department, and Hill House' Gatekeepers. Participants were asked by principal researcher to read and sign the consent form prior to the commencement of each interview. All participants were informed regarding the purpose of the study and have right to refuse or stop any cooperation with researchers.


  Results Top


Profile of participants such as age, gender, marital status, educational level, and length of residing in residential home are shown in [Table 1]. Analysis of the data gathered in the current study resulted in the development of three themes illuminating empowerment of elderly residents and staff to enhance quality of residential home life. These themes are: (A) Social life and its requirements; (B) Caregivers skills empowerment; and (C) Listening and supporting.
Table 1: Profile of the elderly Malay residents

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Social life and its requirements

When elderly residents live in a certain community with others, regardless of their religion, beliefs and cultural behaviors, some basic principles are required to consider such as mutual communication, respect, forgiveness, cooperation, trust, and mutual commitment. Elderly people living in study setting were of different races consists of Malay, Chinese, and Indian background. Furthermore, they were living and some of them working with young staffs under the same roof and environment. Naturally, residents and staffs have different expectations and styles of living due to their level of education, family background, and environment they grew up in. Thus, some behaviors can perhaps lead to conflict among residents and sometimes between residents and staffs.

One day I was very angry at one resident who has very bad behavior. I have observed him many times. So, one day I scolded him because he threw rubbish everywhere and we had a little fight (Mr. Noah).

Another significant point to note is when older persons are admitted to residential homes, they tend to continue a particular set of behaviors. The educational empowerment might need to be considered from gatekeepers to improve social life skills of residents. For example, every weekday morning, three copies of Malay, Chinese, Indian, and English newspapers are provided for residents. The most pressing concern is that residents behave irresponsibly towards others, which they take away newspapers for reading and return them very late.

Right now we only have the newspaper. When I want to read them, some idiot will take it away. Told them many times they are not supposed to take the paper out of this place (Ms. Hana).

It is also important to bear in mind that the most elderly residents residing in the study setting have less formal education. However, living in a new community requires some considerations for others. Educational interventions for developing life skills can help residents improve their social life, and their ability to how live in a public institution. One of elderly residents who is living in ward nine and working part time in the facility support this view.

The only thing I am unhappy about is that the residents do not know how to take care of the facilities. After using the toilets, they do not flush. (Mr. Ahad).

Approximately 20 (depending on the capacity of each dormitory) mixed elderly people from difference Malaysian' races live in each dormitory. It is notable that the physical structure of the studied setting was not built with a residential home in mind. Due to that, a toilet is placed inside each dormitory including the mobile residents' place. When residents misuse toilet for any reason such as lack of education, mental problem, or forgetfully, they inconvenience other residents.

It is also difficult for me to pray due to the unpleasant smell from the toilet. I can't even swallow my food and I used to cry a lot. Sometimes I am praying, suddenly someone go to toilet without locking the door. This problem occurs because they mix all the races together (Mr. Kefil).

Caregivers' skills empowerment

All caregivers working in the study setting are aids and do not have any formal education. They learned their tasks from following co-workers and personal experiences. New caregivers learnt to carry out their formal care for elderly residents by observing senior caregivers. This matter is also a big concern because this kind of personnel does not educated how behaves with respect to others, especially elderly people with different background and race. For example, during observation period, one day two caregivers were going towards the dining hall after delivering meals to immobile residents in their dormitories. One resident was walking very slowly down the corridor because of his physical condition. Suddenly one of the caregivers made a face and insulted him. Although the care providers are known for their basic work principles, some of them did not receive any particular training on how to behave with others. An elderly resident shared her experience regarding staffs behavior during an in-depth interview.

There are some staffs that have bad mouths. They speak harshly to me. I do not mind them scolding me if I do any mistakes but these staffs like to scold unnecessarily (Ms. Farah).

Social skilled courses and workshops could be arranged for caregivers and other staffs according to their profession. This matter was also highlighted by the head nurse of clinic who has about 26 years' job experience. She obviously expressed that caregivers do not have formal education towards how care elderly residents with respect. Even though they have many years of experiences, caregivers need to update their knowledge and refresh their attitude.

The wards are handled by attendants. These attendants don't undergo any courses and classes. If we have trained persons handling the wards, maybe there would be better nursing care (head nurse).

This problem perhaps is caused by an overload of residents in this long-term care facility. From a review of informal documents, the maximum capacity of this setting is 250 persons, but due to the transfer of elderly people from another residential home, at present 301 older persons live in this facility. This means that the facility was working at approximately 20% more than the regular capacity. This heavy work may change attitude of caregivers and staffs regarding elderly residents.

Moreover, during the observation period it found that the elderly residents were concerned regarding behavior of staffs towards new admitted residents. They considered that training and educating new residents could help them to change their behaviors. From the excerpt in the field notes one resident mentioned that:

When a new resident comes to this facility in the first few days, certainly, she/he doesn't know any things about rules and routines, so the staffs fight with them instead of teaching them. They must let new residents adjust themselves with new environment (17.09.2011).

Listening and supporting

Residents prefer to speak to someone who will listen to them, understand their feelings, and support them emotionally. Participants felt a desire to share their experiences and interests with staff, but it seems that they are not interested in listening. Typically, elderly will develop institutionalism syndrome which reduces their social skills and ability to socialize with others because most of their time is spent inside the institute. In other words, moving to a residential home could be an isolating and depressing experience for some elderly people. Building a good rapport and a trusting relationship with others helps residents to be healthier and have a better quality of life during institutionalization. Establishing rapport give an opportunity for daily social network which is acknowledged as one of the best guarantees of a resident's wellbeing. On the contrary, lack of communication among residents and their care providers may prone them at risk of social isolation. From observations, most of elderly residents were silent and try to isolate themselves as far as possible. Obviously, residents in specific settings need to have good interaction with others to create a peaceful and enjoyable environment.

I cannot regard this place homelike because the people here are self-concerned. They will only be concern about their food and their own issues. We will not sit and chit-chat (Mr. Teruna).

They (staffs) need to talk to old folks during assembly on Monday. They assume we're ok; they never give us chance to talk (Mr. Amir).

Sometimes elderly residents may need to talk about their experiences and feelings regarding an issue or problem. They need someone to listen to them and mostly do not need or want a solution to their problems. The listener could be a resident or staff who can trust to and just listen without judgment.

I do counseling also. They will say, “Staff nurse, do you have time for me?”, “Yes, sure”. “I want to talk to you”. They just want to come and talk to you and you listen to them. When you listen to them, that's all they want (head nurse).

Sometimes, no one is willing to hear the concerns of the elderly residents, thus they keep quiet.

For us old folk, even if we have something to say, in the end we keep quiet because there's no one we can turn to (Mr. Daniel).


  Discussion Top


As was expected from the limitation of ethnographic research available regarding empowerment, this study revealed a considerable need for increased content in various aspects of empowerment for elderly residents and their caregivers. Finding of the present study indicated that elderly residents living in a Malaysian residential home were not satisfied with some behavior of others. They also claimed that there is a gap between residents' expectations and caregivers' performance. It appears that the only way to enhance quality of life is acquainting residents and care providers with empowerment principles and inviting them to participate in the educational empowerment programs. What's more, the quality of life mainly depends on the caregivers' and staffs' knowledge and attitudes on how look after the elderly residents.[18] From participant observations, formal and informal interviews, and review of related documents, all caregivers working in the studied setting did not obtain any professional training before and during work; thus, the lack of empowerment and formal educations affected the quality of care and consequently the elderly residents' quality of life.

The findings indicated that empowerment of staffs and residents are essential factors in enhancing elderly residents' quality of life. In other words, elderly individuals who live in Hill House may have gotten the feeling that they have lost their independence or may have also suffered from lack of dignity. They may have trouble coping with their loss of dignity as they feel unable to recover it. Therefore, the management has to make some decisions and draw some strategies to increase the social skills' of elderly residents and staffs. These policies may develop and deploy the necessary knowledge and confidence to increase personal satisfaction and finally improve the residents' quality of life.

Moreover, the high workload of the caregivers and care providers may limit their time to meet empowering needs of residents. Similar to other studies, care providers could facilitate elderly resident's empower by providing residents education and involving them in their care plan.[19] Findings of the present study indicated that empowering plays a significant role in the elderly residents' quality of life in their residential setting. Therefore, care providers and policy makers must create an environment and atmosphere in which elderly residents can feel their dignity is respected. In this regard, Campbell (2003) posited that compassion and caring are two important elements of nursing behaviors that empower elderly residents in residential homes.[20] Caregivers and other care providers need more education and information in how to provide empowering care to elderly residents with dignity and compassion.[21]

Furthermore, the importance of elderly and staffs' behavior in making a better environment has been a key point in the views of participants and it is a central focus in the movement to change the quality of life. Recent literature has suggested that, if care providers and residents have closer interaction with each others, they will have a critical influence on the residential homes' quality of life.[22] Significant shortcomings in the quality of interaction between care providers and residents and ability of staff to create family-like environments will influence the residents' quality of life. Therefore, improving the social environment of the residential home must be a major focus of policy makers and care providers to ease the residential settings and make it more comfortable.

Further, the residential home management must develop and organize educational programs and events such as meaningful social, cultural, and life skills programs for residents and staffs. With this recommendation in mind, interacting and living with others who have different personal manners and who vary in race, religion, expectation, and culture must be an important part of any educational program.[3] These kinds of programs need to cover principles and expectations that help older persons and care providers live with others in a better way, albeit it is impossible to fully satisfy. On the whole, programs must offer a variety of evolutionary education programs that present useful lessons in living skills to enable residents to better adjust and adapt themselves to new environment.[10]

In view of the fact that this project makes several important contributions, it is also limited in a number of ways. For one, this study is facility-specific and cannot exactly extend to the care needs of all elderly residents and of all cultures for a long-term care setting. Furthermore, according to the research criteria, this project focuses only on elderly residents who have intact cognitive skills and good functions.


  Conclusion Top


Findings of the current study provide new insights that are useful in charting innovative guidelines for care providers and policy makers to improve the elderly residents' culture and behavior. Therefore, the management has to make some decisions and draw strategies to increase the social skills' of residents and staffs. Finally, these results could evoke the attention of policy-makers and care providers and should lead to cultural changes where care is provided.

Acknowledgement

The authors would like to thank the elderly residents and caregivers who generously shared their knowledge and information with us.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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