Nursing care of elderly female patients is not delivered as an isolated process. Rather, it occurs within several other significant cultural, social, political, and educational spheres and is influenced greatly by each.
THE ROLE OF SOCUL CONTEXT
The Figure, which admittedly is incomplete and probably oversimplified, diagrams the basic concept of social context as it influences nursing care of elderly women.
Ultimately, nursing approaches and actions are shaped by input from many contextual layers of the surrounding society; cultural values filter through social and political systems to affect nursing education, practice, and care delivery. For example, if society values youth over age, there is social and economic emphasis on youth-oriented goals. The youth orientation then is communicated through special interest groups to elected legislators controlling federal funding. Educational institutions and practice settings vying for federal monies design their curricula or programs to satisfy legislative mandate. Therefore, options for delivery of nursing care are limited by educational preparation and the parameters of the practice setting. Nursing programs often ignore special health needs of the elderly and practice settings usually are funded poorly.2
In addition, the nurse may be influenced heavily by society's values even before they are filtered through organized institutions. In a chapter for Woman in Sexist Society, Wiesstein describes this kind of phenomenon using several well-selected examples. She cites one experiment in which 62.5% of the randomly selected subjects administered electric shocks they believed were possibly lethal because they were told to do so by an unknown "experimenter. "Wiesstein maintains that social context is the major detriment to behavior - people will act as they are expected to even if those expectations are transmitted indirectly. Nurses are not immune despite corollary pressures on them to act autonomously based on client well-being alone. If the nurse's cultural group is predominantly sexist, there is likelihood that some of the nurse's care decisions will consciously or unconsciously reflect those sexist values.
SEXISM: A FACTOR IN NURSING CARE?
About 15 years ago, this country experienced the early stirrings of feminism, dramatically evidenced by bra burnings and the first rejections of the well -en trenched feminine grooming tradition of leg shaving. These early angry actions spawned a torrent of written debate about sexism as exemplified by the 1970 publication of Sisterhood is Powerful. The opening essay of the book, authored by Brown and Seitz, is a convincing history oí thereality of sexism in this country. They review many factors that contributed to its development including British common law, puritan theology, industrialization, and the on-going economic dependence of women on their husbands and fathers.4 Further on in the same work, Gilbert points out that sexism is responsible for the undeniable sexual division in medicine: men become doctors and women become nurses.5
At the end of 1970, a TransAction article by Bell talks at length about the double standard resulting from sexism and its negative impact on aging women. She states:
"...the differential definition of age in men and women represents a palpable advantage to men at the expense of women. It multiplies the options for emotional satisfaction on his side while it diminishes them on hers. It raises his prestige and self-esteem at the expense of hers.6
Two years later, in Saturday Review, Sontag also commented on the plight of aging women in a culture that assigns them value based on physical attractiveness and reproductive capacity.7 Aging men remain eligible marriage partners, can honestly and comfortably admit to their actual chronoligical age, retain valued roles in society, and are allowed physical signs of aging. Meanwhile, post-menopausal women have outlived their culturally ascribed, traditional usefulness and face the uniquely painful and conusing process of feminine aging.
In 1973, the 26th Annual Conference on Aging was devoted to discussing the older woman in America. A subsequent publication of the proceedings indicates that aging women do, indeed, face some special problems. They are economically disadvantaged, poorly insured, socially isolated, and stereotyped in ways that are directly related to sexism. For example, on the average, women earn only 59% of the salaries of their male counterparts which, in turn, limits their ability to provide themselves with financial security and complete health insurance during their aging years.8
A subsequent conference, with a focus on women and their health, moved the discussion of sexism into the area of health and health care delivery. In one of the later-published presentations, Coser maintains that the medical profession takes a different view of men and women experiencing the same symptoms, gives examples from hospitals, and attributes that view to society's general sex-role proscriptions.9 Wiseman, another presentor at the conference, states that male domination of medical research and the sexist social context in which research occurs has resulted in a biased approach. She points out that many studies have been done with wives of alcoholics in an effort to identify cause, but that husbands of alcoholics are strangely overlooked. 10
Finally, in their 1976 text entitled Womanpower and Health Care, Grissum and Spengler outline the effects of a male-dominated, sexist society on nursing education and nursing care.11 According to these authors, society socializes women to be passive, accepting, and nurturing. The secondary socialization of nursing school reinforces those traits. Meanwhile, men are socialized to be decisive, authoritative, and remote. They enter medical school and are similarly reinforced. Then, both professionals meet to practice in a society that places more value on the male traits. Consequently, the "cure" activities of the doctor receive more public attention and monetary reward than the "care" activities of the nurse. No wonder most nurses prefer the active, cure-oriented responsibilities of acute-care settings to the care-oriented role in longterm care settings.
Sexism clearly exists and is part of the social context that shapes the lives of aged females, the definition of their problems, and the development of research projects. Those values also influence individual movement into professions, choice of practice setting within the profession, professional education and, perhaps, choice of actions within the practice setting. Unfortunately, after a review of sociological abstracts and nursing literature for the last five years, this writer was unable to find any exploration whatsoever of sexist attitudes among nurses or their impact on nursing care. Apparently, nursing does not consider sexism an important professional issue at this time. Important questions remain: Do nurses give preferential treatment to men, sometimes compromising the care of their women patients? Are men the first to be bathed, to receive pain medicine, or to be forgiven for distasteful behavior? Is there even a measurable difference? Pedrin and Brown seem to believe there is.
A GEISM: A FACTOR IN NURSING CARE
Our American culture feeds on a diet of youthful images, products promising to postpone the physical signs of aging, and activities that require the full vigor of young adulthood. Gioella says we are a ". . .highly youth-oriented culture centering its hopes, interest, and attention on the young, as well as its funds, energy, approval, and support."12 She contends that a mechanistic view of humans results in the belief that slowing down is bad. Consequently, our culture denies the aging process, and the ageism results. Palmore defines ageism as the negative attitudes and practices that discriminate against the aged.13 The elderly are stereotyped as slow, old, and useless. Most elderly people live in relative independence, but society focuses on the 5% to 7% placed in long-term care institutions, berating them for dependence and ignoring their needs.14
The literature describes numerous ramifications of ageism on health care for the elderly. Moore and Birren report that less than .25% of all doctoral dissertations over a 35-year period relate to aging, and that total is still less than the number of dissertations presented about childhood in one year.15 Spence points out that medical students see the aged as more disagreeable, inactive, dull, and withdrawn than any other patient group. It is the least preferred medical specialty.16 Rossman discusses the incredible absence of material on geriatrics in medical school curricula, then goes on to reveal his own negative bias with comments like "...the fact is that aging is an unpleasant reality of the human condition."17
Carnevali and Patrick suggest that care of the elderly is overwhelmingly a nursing task because no one else wants it. Nursing has inherited it by "default."18 They refer to a cure vs. care continuum that exists in the health care arena, similar to the concept proposed by Spengler and Grissum. Caring in the sense of providing on-going support to elderly patients who have no chance of cure is given a low priority. Most nurses prefer positions in higher-status, acute settings such as intensive care units and emergency rooms. The authors feel that nursing has not yet accepted its responsibility for care of the elderly.
However, even a cursory look at nursing literature on aging indicates that the profession is exploring the area actively. During the last decade, numerous researchers, acutely aware that ageism is a major factor in nursing's inadequate response to needs of the elderly, have studied variables influencing nursing attitudes and behaviors. Studies done by Gunter in 1971 l9 and Kayser and Minnagerod in 1975,20 hypothesized that negative stereotypes could be dismantled with education, and that this would result in increased nursing interest in geriatrics. In both cases, education successfully lowered the number of stereotypes, but the investigators reported an actual decrease in the number of subjects willing to work with aged patients. A similiar study by Robb, published in 1980 - although scrupulously designed and implemented - describes the same discouraging conclusion.21 Robb feels that development of positive attitudes toward the elderly is misleading, and urges gerontology instructors to increase clinical content of nursing courses in an effort to enhance motivation for working with the elderly.
Hogstel is the only nurse researcher claiming success with an educational approach. Although the written description of her work is too brief to assess its merit or generalizability validly, she maintains that a one-day inservice program on the nursing care of the older adult resulted in an increase in the number of registered nurses indicating interest in working primarily with older patients.22
All four studies build on the assumption that attitude affects behavior eventually as described in the second section of this paper. A 1977 paper by Hatton describes her effort to confirm a relationship between the two. Using Kogan's Old People scale and a carefully developed method of nonparticipant observation, she found that five out of seven nurse subjects demonstrated a relationship between attitude and interaction with aged patients.23 Unfortunately, her sample was too small and nonrepresentative to allow generalizations. Robb contradicts the findings with reference to an unpublished doctoral dissertation that failed to demonstrate a relationship between favorability of attitudes and counselor effectiveness with handicapped people.21
AGEISM AND SEXISM: A DOUBLE-EDGED SWORD?
Although the debate about a relationship between ageism and the quality of care for the elderly probably will continue, nursing clearly recognizes ageism as a real threat to care of the aged. As mentioned earlier, the recent literature examined by this writer does not discuss sexism among nurses or its relationship to patient care. Concomitantly, there is no literature speaking to the combined impact of ageism and sexism on the nursing care of aged women. Since both biases are prevalent in the culture and are known to affect health care as separate entities, it is not unreasonable to speculate about the significance of the two operating together. The implication for aged women is obvious: They may be the least valued and most underserved patient population subset.
The census bureau reports that over 10% of our population is over the age of 65 and projections call for that ratio to increase to 17% in the next 45 years.14 Female longevity indicates that the vast majority of elderly people are women. Is ageism exacerbated by sexism or vice versa? Theoretically, if women have less value in the culture, and most aged people are women, either could happen. A 1963 comment by Overstreet, who was then a professor of obstetrics and gynecology at the University of California in San Francisco, hints at this appalling possibility. Speaking at a symposium on the potential of women, he said ". . .When you come right down to it, perhaps women just live too long! Maybe when they get through having babies they have outlived their usefulness - especially now that they outlive men by so many years."24
It is important to note that this writer believes attitudes such as sexism and ageism originate and survive because of functional relatedness to the overall integrity of the cultural group in which they exist. Overstreet is the child of his social heritage and is voicing ideas that were, at one time, meaningful in terms of cultural group survival and functioning. However, the attitudes are outdated now and must be challenged.
Nursing professionals must consider possible consequences of Pedrin and Brown's assumption seriously. Attempts to address either sexism or ageism in isolation will fail if the two exist in a kind of synergistic symbiosis - a destructive double-edged sword chopping away at the quality of health care for older women.
Behavioral evidence of mutual sexist/ageist influence on nursing care might include any of the following:
1. Elderly women patients in acute or long-term care settings are verbally maligned by nurses more often than their male counterparts.
2. Elderly women are perceived by nurses as less productive, useful, or independent than their male counterparts.
3. Home visits or responses to call buttons of elderly women are postponed more often than they are for elderly men by the nurses responsible for their care.
Research to describe and confirm the existence of a synergistic sexist/ ageist bias must be designed and implemented carefully so that outcomes are unqualified and convincing. Feminist nurses with backgrounds in geriatrics and research are most appropriate to undertake such a project, the successful completion of which could have many benefits. The energy and resources of the women's movement could be tapped effectively to improve the plight of the elderly. Options for funding research and change projects focused on improving the health care of elderly women would increase, and the growing power of the elderly could join forces with the women's movement to maximize change that would help both groups as well as the culture as a whole. Admittedly, these are granthose and idealistic hopes. Yet, the possibility of even partial success is exciting, and nurses are in a perfect position to begin the process.
In addition, it seems time for nursing to ponder reasons for the absence of sexism conscientiously as an issue in our written and oral discussions. Our own professional functioning is still compromised as a result of the culture's sexism, but we believe apparently, perhaps naively, that we are not capable of sexist attitudes ourselves. In an effort to assure quality care for our elderly women patients, we must not hesitate to confront our feelings about ourselves as aging women.
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