The knowledge base of the nursing profession regarding the aged population is steadily expanding as more research is done on the physiological and psychological changes associated with aging. The insight gained from these studies should demonstrably affect the ability of nurses to give appropriate care to aged persons. However, because the physical aspects of the aging process are universal, it is generally not recognized that cultural and social factors play a very significant role in determining when a person is deemed "old."' Thus, the profession has given little attention to the process by which a person is given the label of "old" with its coexisting negative connotations, or to the impact that this label has upon a "deviant" member of a youthoriented culture. In this discussion the author will attempt to address these problems and explore specific nursing implications arising from this labeling process.
Review of the Literature
It has been documented that the aging process increases a person's vulnerability to disease.2 This decline in health is a traumatic experience for the older person and it may lead to some disorganization of the personality and a change in role behavior.2 A pervading feeling of anxiety may coexist with the personality disorganization, so that the process of growing old actually becomes a life crisis.3 It is the central thesis of this paper that in addition to the other complex problems with which they must deal during the prolonged crisis of aging, all aged persons are faced with unnecessary stress due to the "old" label. Some aged persons fight the label and its disciminatory impact; however, their attempts to overcome the label may be misconstrued by society as evidence of personal maladjustment/ Other aged persons act "old" in acquiescence to the labeling process, and by doing so, lose a hold on their personhood, because their behavior tends to be based not upon their true capabilities, but upon the limitations imposed upon them by society.
How does this potentially devastating labeling process begin? Borrowing a sociological reference point, the "community" can be seen as the original source of the label, in that it is through the interactions among people in a community setting that society imposes its intangible expectations upon individuals and groups.5 Thus, the community initiates the '"old" label which the individual accepts (or in a few cases, rejects); after its acceptance by the person, the community confirms the validity of the label.4'6-9 The concept of social competence is important in relationship to this three-phased labeling process. As a function of previous participation in problemsolving efforts within the community, each individual or group posesses some degree of social competence.9 The social competence gained from past experience then becomes the potential contribution that an individual or a group can make to the solution of problems faced by their respective interpersonal systems.10 As these skills of social competence are brought to bear in intergroup settings, the larger group gives feedback to the smaller group regarding the degree of its competence. For example, society gives feedback to the aged population as a whole or to aged persons individually, regarding their value or "significance." According to Klein, the degree of significance conferred, ie, whether the group or individual is considered normal or deviant, depends as much upon environmental conditions such as culture, norms, and roles, as upon the social competence enjoyed by the smaller system.5 However, the author speculates that although the social competence of the aged population is very likely greater than that posessed by any other social group due to its longterm experience with problemsolving, our society as a rule ignores this competence in conferring significance upon the aged because of the overwhelming influence of these environmental variables.
In his discussion of culture as a critical environmental variable in the age-labeling process, Busse described several theories relevant to aging and to various characteristics of societies. The summative inference of these theories was that the status of the aged as a group declines in cultural circumstances in which there exists a high degree of social change, in which the aged are numerous, and in which they have no socially valued and useful functions." The comparison to our own culture seems striking on these three counts. In our youth-oriented culture, effective social interaction continues only when the individual's behavior reflects the culture's emphasis upon psychological and physical well-being.12 If effective social interaction is a function of these particular factors, it is obvious that if the aged person's physical and psychological resources are inadequate, his social behavior will also be minimally effective, therefore making it more likely that he will be labeled as "old."
A second environmental condition that has a great deal of importance in the conferring of significance among community groups is that of social norms; deviance refers to an individual's departure . .from the norms, standardized practices, and approached outlets for his specific roles in a given society."7 The concept of deviance has application for age-role behavior in that persons are assigned the label "old" in order to point out their apparent deviation from the central norm of the youth-oriented culture-the norm of youth.
A third critical environmental variable that must be considered is that our society does not specify a role for the aged; as a result, there is very little anticipatory socialization for growing old. (The retirement counseling that is done in some industries is the only exception to this rule.) In addition to the lack of role content that is prescriptive of what the aged should and should not do, the aged undergo "role loss" due to the severing of social and occupational ties as the aging process occurs. Since the core social roles are marriage and being employed,4 the deviant role assigned by society to the aged may be due, at least in part, to the fact that most aged are widows or widowers and unemployed, both of which are also considered deviant roles. The relocation that often occurs at retirement or after the death of a spouse further predisposes the aged to the deviant label since "the roles played by a person in the past .. .cease to have any social reality unless he belongs to an enduring social network of people who have shared the same past."4 If the aged person relocates where those around him are not aware of his latent personal characteristics, such as former marital or occupational roles, they are likely to relate to him in terms of his obvious social characteristics, ie, his age. Therefore, the likelihood increases that the deviant label of "old" will be assigned.
Although the community is the source of the three-phased labeling process, the process cannot be consummated unless the person accepts the label as real and reflective of his true self. Because of the emotional trauma of undergoing the aging process, the person becomes highly suggestible6 and if the cues he gets from others lead him to feel that he is old, he will be likely to act that way; thus, he meets society's expectations of him. However, the degree of self-esteem that the person brings to the aging crisis'3 and the degree of his resolve to continue controlling the events of his life14 will likely influence whether he accepts or rejects the old label. In order to maintain a sense of identity independent of the effects of theaging process, a person must be reinforced in this effort by those around him.15 Each older person exists within a social setting and the rejection of the "old" label is a social process, as is the acceptance of the label.
Following from the community's denotation of deviance and the individual's acceptance of the label, the third phase of the labeling process is the community's confirmation or stabilization of the deviant label. In our society this has occurred in that a stigma has been placed on the aged as a group.4'6 The aged person is not accepted as a social equal in interactions with younger persons, solely due to the interference of the age factor. His age markedly distinguishes him as different and others reject him on this basis without recognizing the existence of any good or "normal" attributes that he might have.16 Unfortunately, the aged lack opportunities for altering their stigmatized status-opportunities that are open to other deviants like criminals or alcoholics through tion or That the aged are unable to overcome their stigma further perpetuates the likelihood that the labeling process will continue as a sociocultural phenomenon. The
theoretical and practical orientation of health professionals, including some nurses, also perpetuates this destructive labeling process. Various psychosocial theories that seek to explain the aged role have been extensively documented in the professional literature. One of these theories, disengagement, reflects the societal view of the aged person as a deviant. Disengagement has been defined as a mutual withdrawal that results in decreased interaction between society and the elderly person because he attempts to prepare for death by decreasing the number of roles he plays.17 Thus, the disengagement theory assigns to the old person the responsibility for role loss rather than locating this responsibility within social norms. The deviant label of the aged is perpetuated when this theoretical stance is adopted by nurses and then applied in their professional practices.18 Moreover, when society as a whole, and health professionals in particular, place their emphasis upon the carriers of deviance rather than on the preexisting circumstances and the labeling process itself, this has real implications for the kinds of social policies that are likely to be pursued. For example, public policy does not currently lead to the redefinition of the deviance associated with old age, but in fact exacerbates the exclusion of the aged from the mainstream of society,19 ie, promoting the construction and maintenance of isolating institutions such as high-rise apartment houses for the aged. It
has been argued by Palmore that the development of an "aged subculture" is an attempt by the aged who participate in the subculture to reduce the impact the society's labeling process has had upon them. Some of the reasons postulated for the inception of such a subculture are: the increased segregation of the aged from younger persons, the development of social welfare services for the aged, the increasing prevalence of group actitivy for the aged, and the increasing vigor of the aged. It seems that the aged who participate in the subculture have redefined their own social status apart from that of the wider culture because they reject former occupation and wealth as being important and gauge prestige on present health and social activity.1 This redefinition certainly decreases occupational and income competition with younger persons and thus removes, or at least reduces, some of the "role strain" associated with the aging process. If such a redefinition were widely accepted by society, it could bring the aged a certain amount of prestige within society as well as within the subculture since a person's status would come from what he does to take care of his own physical and social needs. Significance could thus be allotted by society to the aged based on the positive aspects of the aging process instead of its negative ones. That
this positive significance is now assigned by the aged subculture to the aged does not remedy the fact that the rest of society still holds negative views about the aged. However, the development of an aged subculture definitely has importance in that the aged who subscribe to its tenets refuse to accept the social label of deviance. As discussed previously, if this label is not accepted by those to whom it is assigned, it cannot be further stabilized by society. If the aged person does not accept the deviant label, he tends to interact with a younger person as though the stigma were not present by demonstrating that he has maintained a stable identity independent of his age. In such a situation, the younger person, as he receives verbal and nonverbal messages that tend to diminish the viability of the stigma, may begin to feel that this particular individual is not so "old" after all. The importance of the stigma of old age as an interfering factor in social interaction has been diminished, and thus the deviant label has not been verified as real.
Nursing Implications of the Independent Variables That Prevent Assigning of the Deviant Label
In order for the aged person to successfully cope with the aging process and its associated stresses, it is essential that the negative deviant connotations of the "old" label be avoided. It is essential that the aged person be able to maintain the degree of self-esteem that characterized him in his younger days, and that he be able to maintain a consistent identity as a person during the transition from middle age to old age.4 The foregoing review of the literature has revealed that there are many factors-independent variables-that may have an influence upon the dependent variable-the ability of the aged person to avoid the deviant label. These factors may be divided into three categories- environmental factors, role factors, and personal assets and abilities of the aged person. It is critically important for nurses who work in any health care setting with aged clients and their significant others to recognize that these variables have potential nursing implications. It must be remembered that while these factors obviously do not exist in isolation as separate influences upon the aged person's labeling process, it is likely that they work together in ways that are not yet understood. Nurse-researchers must investigate the variables singly and in combination as they occur among random samples of the aged population. They must carefully document the degree of impact that each variable has upon the aged person's subjective feelings about being old, upon the nature of his interactions with significant others and strangers, and upon the reasons these persons give for their labeling of the aged person as "old." Not until we truly understand these associations will we be able to interact constructively with aged clients, their significant others, ?nd community groups in order to alleviate the destructive effects of the labeling process.
The first environmental variable is that the aged person is less likely to be perceived as deviant if there are a number of resources in the community that facilitate the maintenance of an independent life-style and if the aged person is able to make successful use of these resources. In this context, nurses must consistently evaluate their community's health-related agencies in light of their emphasis on helping the aged to do for themselves. Nurses must be able to diagnose and handle problems that the aged have with utilizing an agency and actively work to promote changes in both the person and the agency in order that full utilization may result. For example, programs that transport meals to the homes of the aged are an invaluable resource for the aged person who is temporarily unable to cook for himself, but are misused if they are utilized on a long-term basis to the exception of other more permanent options that promote the person's independence. It is not a function of these programs to provide learning experiences about food purchase and preparation of special diets-knowledge that many older persons need. If this need is not identified and met through other means, an aged client may become overly dependent upon the "mobile meals" program. Nurses need to intervene in such situations to ensure optimum utilization of existing community resources and to make known to public officials the need for additional services. Furthermore, nurses should seek through political action to initiate comprehensive programs that will, whenever possible, maintain aged people in their homes through the provision of whatever services are necessary.20
Regarding the second environmental variable, that the deviant label is less likely when those in the aged person's social system relate to him/her in terms of his/her capacities rather than his/her limitations, the nurse must remember that he/she is often a very significant part of the aged person's social system. It is essential that his/her interactions with the client be based upon his/her knowledge of his/her unique strengths as well as his/her weaknesses, not upon some stereotype of what an "old" person should be able to do. Many nurses unknowingly condone and build their practices upon a negative stereotype of aged persons. Any nurse who has told a client that he/she is "doing well considering his/her age" is practicing based on such a stereotype, instead of individualizing her expectations of the client. Also for the aged person's benefit, nurses must utilize any influence that they have upon other persons who are part of his/her social system. Other health professionals, who may hold the view that little can be done to help the aged person because of his/her limited life expectency or his/her "stage of second childhood," must be reeducated by the nurse. Family members may overprotect an aged person out of guilt or anxiety, thus, regretably stabilizing the deviant label because the aged person's opportunities for utilizing his full capacities are hindered. The hospital nurse or the visiting nurse may tend to ignore the very significant fact that the family has taken over the decision-making power of the aged client and concentrate on influencing the decisions that the family makes. Instead, it is advisable that the nurse explore, verify, and finally assist with relieving the family's guilt and anxiety so that they will work with the aged person to promote his maximum autonomy. The latter course obviously involves more risk-taking and interpersonal skill, but nonetheless it is the only option to take if the aged person is to be spared the deviant label.
Nurses can also promote the positive aspects of role-related factors that may help the aged person avoid a deviant label. Being married is one of these factors. In this regard, the nurse can promote open communication between aging mates, thus reducing the likelihood of separation or divorce and can intervene in the crisis of death of the spouse to promote satisfactory crisis resolution. The remaining partner may need ongoing nursing support in order to follow through with a desire to socialize with members of the opposite sex. Society's labeling of aged persons as deviant is reflected in the prevalent view that it is inappropriate for them to remarry, or to have satisfying relationships with the opposite sex after a spouse's death. Nurses must overcome this societal predisposition by recognizing the long-term value of such relationships to the aged person's vitality and promote his right to formulate such bonds.
Nurses can and must facilitate the aged person's maintenance of any desired and feasible ties with his occupation or with a new occupation of his choice, thus addressing the second role-related variable that may reduce the frequency of deviant labeling. Industrial nurses need to be in the forefront of retirement counseling programs and should be actively involved in working with management on ways that retirement-age employees can continue participating in the industry's affairs. The nursing profession should be involved in discovering and institutionalizing activities that society as a whole and the aged in particular feel are satisfying and rewarding for them, such as being foster parents or tutors for school children. Nurses must also be aware of the third role-related variable: if the aged person remains in the same social environment that he lived in when he was practicing his occupation, he may continue to derive social status from the occupational role after retirement, thereby reducing the likelihood of being labeled as deviant. Since relocation after retirement or death of a spouse removes the aged person from his familiar environment, the likelihood that he will be labeled as deviant increases. The relocation decision can result in a crisis for aged persons,21 since they may be under pressure from family or friends to make a decision very soon after the precipating event, be it the spouse's death or retirement. Nurses in every care setting must make themselves available to aged sons who undergoing the relocation crisis, to the end that successful crisis resolution will result in avoidance of the deviant label. Of
all the variables discussed here, the nurse's role regarding the first of the personal asset and ability factors is the most widely recognized. Assisting the aged person with the maintenance of his physical and mental health has long been à nursing function, although the profession has not recognized that if health is maintained, appropriate social behavior is more likely. A person who exhibits appropriate social behavior, in turn, is less likely to be labeled as deviant due to his age. In order to assist aged persons with health maintenance, nurses must take advantage of every opportunity (and make opportunities where none exist) to teach aged persons as much as they are willing to learn about health and illness. Nurses need to be aware that aged clients are tempted to use the sick role as a substitute for either the occupational or the marital role.4 When this occurs, the client may benefit from therapeutic interactions with a nurse who can help him probe his reasons for adopting the sick role and help him discover satisfactory alternatives. The
second personal asset/ability variable is that if the aged person can maintain a personally acceptable degree of autonomy and selfesteem, he may still be perceived as deviant by society, but he is not as likely to adopt society's view of him; therefore, the deviant label cannot be stabilized. Nurses can implement this variable in their practice with aged persons by promoting independent strivings, reinforcing individual choices, and encouraging long-term problem solving.22'23 By practicing these activities, aged persons can continue to feel autonomous. Nurses can monitor selfesteem levels of their clients as they age, using standard interviewing techniques or psychological inventories. If a decline in self-esteem occurs, the nurse should intervene to return lost autonomy to the aged person and improve his coping skills, thus increasing self-esteem.13
The final independent variable that is related to the aged person's feelings about the life process in general and growing old in particular has, the author believes, a significant relationship to the adoption of the "old" label by the aged person- If the aged person-feels that old age is a stage of the life process to be enjoyed as any other stage, and therefore seeks out and utilizes opportunities to become involved in societal activities (including the aged subculture), he may still be perceived as deviant by society, but he is not likely to adopt society's view of him so the deviance cannot be stabilized. Society may stigmatize the aged person because of his physical appearance, his state of health, or his role loss, but if he stays involved or becomes involved in various activities, including extensive involvement with age peers,4 he may not feel "old and useless." Indeed, he may be one of those persons that nurses and other professionals and lay people point out as seeming to be "younger than he really is." Perhaps "seeming younger" is defined by the fact that the person remains involved with other people-a behavior that society does not expect of a deviant "old" person. It would seem that an aged person's attitude about life makes a tremendous difference in how he is perceived by those around him. If a person who was formerly enthusiastic about life's opportunities becomes fatalistic as he grows older, the nurse needs to give him special assistance to resolve this attitudinal crisis in order to avoid the deviant label.
In order to make strides toward altering society's negative attitudes about the aged, the nursing profession needs to be active in teaching the public in schools and community groups to understand aging as a normal stage of the life process, which does not deserve the deviant connotation it has been given. The advantages of aging and the positive contributions that the aged can make to society must be brought to the attention of the public, so that significance may be conferred upon the aged based on their social competence rather than upon discriminatory norms. Interaction among all age groups must be promoted so that the younger members of society will have a vehicle through which to understand the aged firsthand, and so that the aged will have a means through which to demonstrate their social competence. Younger people must learn to better understand and appreciate the aged with whom they appreciate the aged with whom they interact; such an experience should effectively serve as anticipatory socialization for their own aging process. The public must be thoroughly re-educated in this manner if the societal predisposition toward labeling the old as deviant is ever to be modified, and the nursing profession should take the lead in this critical endeavor.
In conclusion, it is extremely important that nurses realize that the physical reality of the aging process is not the sole determinant of being "old." Both the label one receives through socialization and one's degree of adoption of this label may be more significant to the progression of the "career" of the "old" deviant than is the physical reality of his aging process.6 It is the author's hope that the nursing profession will begin to concern itself as much with the recognition and alteration of this labeling process as with the care and cure of aged persons who have been unjustly labeled. This new perspective of the nurse's role with aged clients should be introduced to students of nursing, so that nurses can be taught to be change agents, who are able to look beyond the presenting problems of one aged person to the similar needs of his counterparts, and then to societal conditions that produce and exacerbate the group's problems. The degree of support that society gives to this stance of the nursing profession will depend on the dedication and enthusiasm we bring to the effort-the effort of helping the aged to redefine their social roles and as a result, decrease the possibility of societal allegations of deviance based on old age.
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