To the Editor:
The concept that people will feel homeless after giving up their home is hardly novel. What is unique is the way that Judith Carboni used what was primarily literature research of homelessness as another vehicle for bashing nursing homes (Carboni JT. Homelessness among the institutionalized elderly. Journal of Gerontological Nursing. 1990; l6(7):32-37). Her field study seemed negatively biased and lacked the usual safeguards of a random sample, adequate sample size, and objective tool. She goes so far as to suggest that nursing homes have no useful existence if they cannot be home and family to their patients.
Nursing homes are not the reason that elderly people lose their friends, family, or home. When basic needs can no longer be met at home, elders or their families may choose the services of a nursing home. This choice is usually made only after every effort has been made to keep the elder at home.
At admission, most patients have a background of life-threatening behaviors, such as repeated stove fires, lying for hours on the floor after falling, and poor nutritional status. Strong elders with dementia often threaten their families with violent behavior.
It is generally accepted that before higher needs can be met, we must address basic physiological and safety needs. This is the primary mission of the nursing home. However, gerontological nurses address higher needs, such as belonging and creativity, as well. We are active advocates of the elder's right to privacy and selfdetermination.
Ms Carboni dismisses all positive behaviors of the nursing home patient as games of pretense. I have cared for the elderly in nursing homes for more than 20 years, and I can state that mere are now many positive experiences mat the elderly have - yes, even in an institution.
Donna Lee Johnson, RN, BS, C
South Portland Nursing Home
South Portland, Maine
The Author Responds:
Qualitative research, such as the field study on which my article is based, does not require the use of quantitative research methodologies such as random sampling and '"adequate sample size," and, as is known, it is clearly not "objective" in nature. The very subjectiveness of this research is what makes it valuable, for when using this research, we go to the original source, in this case, the institutionalized elderly themselves. What better resource can we have than the people who must endure institutionalization? The review of the literature was one small portion of the research and was used to understand the data and to gain focus in examining the material. The concept of homelessness as it is described in the article emerged primarily from the data obtained in the field study, that is, from the elderly institutionalized persons who shared their feelings with me.
There is no doubt that many elderly people who are in nursing homes require nursing care to meet their basic physiological and safety needs. However, to describe this as the primary mission of the nursing home is both naive and dangerous; it leaves us content with providing the inadequate custodial care of which nursing homes have been accused for far too long. Clearly, more is needed than this simplistic approach to the complex and painful experiences that emerge when the elderly are institutionalized; lack of meaning in life and deep existential pain cannot be alleviated via a bedbath, or raised side rails.
I have spent 21 years working in nursing homes as a nurse aide, staff nurse, director of nursing services, and clinical specialist in gerontological nursing. For many years I have functioned as primary therapist for psychogeriatric groups, and I have witnessed again and again the intolerable pain that the institutionalized elderly endure. As director of nursing, I have likewise witnessed the difficulty that gerontological nurses working in longterm care frequently encounter in acknowledging this pain - it is deeply felt and strikes at the core of our existence. It takes courage to look beyond the institutionalized elders' protestations of "acceptance" and search their hearts, where one discovers the pain of homelessness. Hundreds of nursing home residents have shared their feelings with me and the message is always the same. It is a message of pain, hopelessness, and deeply felt loss; a message to which both nursing and society ought to pay heed.
I will continue to pursue this message. If nursing homes cannot provide a loving, nurturing environment that supports a sense of home and family, then the value of their existence is truly questionable. It is my belief that nursing homes, as they are structured now, encounter a great difficulty in providing an environment that involves significantly more than "TLC" provided by well-meaning and caring nurses. The nursing profession needs to seriously think about this situation and provide direction by suggesting humanistic alternatives to a rather poor solution to caring for our frail, chronically ill elders.
Judith T. Carboni, RN, MSN, CS
University of Rhode Island
School of Nursing