“Lillian” is a fictitious 90-year-old in transition from decades of living at home independently to living in a new assisted living facility. Lillian’s story is not unique. Since the 1980s, the population of individuals older than 90 has tripled (U.S. Census Bureau, 2011). An assisted living industry has developed in response to demand for alternative living situations (e.g., http://www.alnursing.org). For nonagenarians, 2.9% live in assisted living facilities or other forms of residential care, whereas 22.7% live in some form of nursing home setting (U.S. Census Bureau, 2011). Lillian’s transitional experience is filtered through three philosophical paradigms: contemporary empiricism, critical theory, and post-modernism. The underlying assumption of each paradigm gives way to new meaning about Lillian’s transition. As the domain of nursing practice develops a deeper understanding of transitional care for the older individual moving from independent living to assisted living, a new language, affirming in nature, is created (Meleis, 2012).
Lillian’s Transition Through the Lens of a Contemporary Empiricist
A contemporary empiricist approaches transition as phenomena to be measured. Through a systematic assessment, empirical data are collected to deduce a probable plan for success (Weiss, 1995). The contemporary empiricist meets Lillian at a point when she has lost most of her family and friends. Her cognitive abilities are intact, although she admits that it takes a bit longer to grasp new information. She has independently decided that a move to another living situation is overdue. She can no longer shop for food or manage her garden. Arthritis has taken over her entire body. Lillian has also lost many reliable neighbors over the past years, and some of the new neighbors are not to her liking.
Lillian needs to sort through the options available for her next living situation, so she relies on the Area Agency on Aging community worker for assistance. When the worker arrives at her home, the assessment process begins with data collection about functional status, illness, mental health status, social support system, and finances. The worker objectively collects information to help determine the best possible living alternative. This information includes subjective data from Lillian such as feeling unsafe in the neighborhood and suffering bouts of loneliness (Lincoln & Guba, 1994; Weiss, 1995). Lillian’s complexities have thus been reduced to a descriptive profile of disability level and psychosocial impairments, mirroring the profile of a perfect candidate for residency in an assisted living facility. After a few weeks of deliberation, Lillian agrees to meet with an admissions nurse in a recently opened facility, and the transition is planned.
Lillian’s Transition Through the Lens of a Critical Theorist
To view Lillian’s transition through the lens of a critical theorist, the historical, socio-cultural, and political world for care of older people in the United States is a necessary starting point. The critical theorist helps Lillian gain awareness about these influences on her current situation to make a decision that serves her best interest (Guess, 1981).
Americans value autonomy, and the growing cadre of nonagenarians cling to their autonomy in the face of many physical, social, emotional, and financial losses. Without the ability to remain autonomous, their value to society diminishes (Becker, 1994). In fact, as the question looms about where the burgeoning population of older adults will live, they become a problem to be managed.
The proliferation of nursing home institutions during the 1970s proved to be too expensive for the system to sustain. In-home support is difficult to manage, and funding the various combinations of services is complicated. The growth of continuing care retirement communities, assisted living centers, memory care units, and adult foster homes has been a response. Hence, government and private businesses scramble to secure scarce financial resources to “fix” the problem (Carder, Wright, & Jenkens, 2005).
The critical theorist is concerned that Lillian has been deluded into thinking of herself in terms of being a problem to be managed (Guess, 1981). At this point, Lillian’s self-talk reflects the following: “Now that I am old and frail, I am no use to society. In fact, I am a burden to my family and community. The best thing to do is pack up my life and move into an institution. I’ll be taken care of by a parade of strangers until I die.”
Through a process of self-reflection and dialogue with the critical theorist, Lillian begins to understand the historical, political, and sociocultural roots of her thinking. She concludes that the pressures of society that have molded her thinking are unacceptable. Subsequently, her self-talk is redirected to the following: “I may be old and frail, but my self-worth is not diminished. I am still the person I have always been. I expect my family and community to support me in a lifestyle that is respectable and enjoyable.” Hence, Lillian is empowered to seek a new lived experience.
Lillian’s Transition Through the Lens of a Post-Modernist
A post-modernist recognizes that multiple truths and realities exist simultaneously, acknowledging that long-held definitions of truth do not always sync with changing times (Rogers, 2005). Lillian is at a surprising moment in her life as she packs up her house, puts a sale sign in the ground, and moves into a one-bedroom apartment in an assisted living facility. Within weeks, she meets a new friend named Bill and they fall in love.
Thinking about Lillian in a love relationship at the age of 90 in her new living situation requires the post-modernist to transcend the traditional discourse around intimacy, sexuality, and relationships to construct new definitions. A belief that marriage follows love and includes a commitment to one another is deconstructed to make way for new language of intimacy for nonagenarians. Two people in love are allowed to hold hands, kiss, and express themselves sexually. But what if you are 90? Is the warmth of a body next to you the only definition of sexuality allowed? Can individuals so physically changed by the process of aging be sexually attracted to one another? Is a sexual relationship at the age of 90 cute, genuine, or repulsive? Do rules about cohabitation exist in an assisted living residence? In a world where the very old are rarely considered “sexy” beings, the post-modernist thinker rejects a single truth and attempts to reconstruct a new language for love at age 90 (Watson, 1999).
In an article by Phillips and Drevdahl (2003), it is stated that “the language of vulnerable populations may seem innocent, but it is marked by racial difference and carries with it historical and linguistic baggage” (p. 27). The language of vulnerable older adults is marked by ageism instead of racism and carries historical and linguistic baggage, as well.
In the first philosophical paradigm applied to Lillian’s transition, the contemporary empiricist uses assessment tools to determine her level of cognitive functioning, disability, maladaptation, and emotional despair. Aging is historically described in terms of human failing and decline. This leaves a linguistic void for words of hope and quality of life. Through a contemporary empiricist’s lens, assessment tools could be formulated to measure ability—not disability—to help individuals realize new goals. For example, Lillian is opened to exploring new social opportunities. The assessment language becomes more affirming when “communication strengths” and “degree of interest in new friendships” replaces “communication difficulties” and “degree of social isolation.”
Within the critical theorist’s paradigm, language surrounding this vulnerable older population carries the baggage of ageism, marginalization, and oppression that hides a new language of self-worth and empowerment. This can be changed, as well. For example, Lillian’s decision-making capacity has served her all these years, and transition to an assisted living facility must not diminish this capacity. Nurses can foster an environment where the language of ageism, either overt or veiled, does not exist. All members of the assisted living community are encouraging, empowerment is celebrated, and decision-making capacity is supported at every level of ability.
Finally, Lillian’s new life is devoid of descriptive language for fresh and surprising possibilities. Through a post-modernist lens, the language of love and intimacy is reconfigured for older adults. A nurturing climate in assisted living facilities allows for new patterns of relationships to blossom in countless ways. Nurses adopt a language of respect for newfound intimacy among residents, and the descriptor of “cute” is replaced with “sincere” or “cherished.”
An entirely new language of affirmation needs to be woven into the lived experience of the growing number of nonagenarians. Nurse leaders must model the use of this affirming language that is rooted in our profession’s philosophical underpinnings. This is an important preoccupation for nursing practice, because Lillian in transition from independent living to assisted living, even at age 90, deserves a chance for growth and the discovery of new joys.
- Becker, G. (1994). The oldest old: Autonomy in the face of frailty. Journal of Aging Studies, 8, 59–76. doi:10.1016/0890-4065(94)90019-1 [CrossRef]
- Carder, P., Wright, B. & Jenkens, R. (2005). Making quality assisted living an affordable community-based care option. Retrieved from the Center for Excellence in Assisted Living website: http://www.theceal.org/assets/whitepapers/001~Making%20Quality%20Assisted%20Living%20an%20Affordable%20Community-based%20Care%20Option,%202005.pdf
- Guess, R. (1981). The idea of a critical theory: Habermas and the Frankfurt School. Cambridge, UK: Cambridge University Press.
- Lincoln, Y. & Guba, E. (1994). Competing paradigms in qualitative research. In Denzin, N.K. & Lincoln, Y.S. (Eds.), Handbook of qualitative research (pp. 105–117). Thousand Oaks, CA: Sage.
- Meleis, A.I. (2012). Theoretical nursing: Development and progress (5th ed.). New York: Wolters KluwerHealth/Lippincott Williams & Wilkins.
- Phillips, D.A. & Drevdahl, D.J. (2003). “Race” and the difficulties of language. Advanced Nursing Science, 26, 17–29.
- Rogers, B.L. (2005). Developing nursing knowledge: Philosophical traditions and influences. Philadelphia: Lippincott Williams & Wilkins.
- U.S. Census Bureau. (2011). Census Bureau releases comprehensive analysis of fast-growing 90-and-older population. Retrieved from http://www.census.gov/news-room/releases/archives/aging_population/cb11-194.html
- Watson, J. (1999). Postmodernism and knowledge development in nursing. In Polifroni, E.C. & Welch, M. (Eds.), Perspectives on philosophy of science in nursing: An historical and contemporary anthology (pp. 471–477). Philadelphia: Lippincott Williams & Wilkins.
- Weiss, S.J. (1995). Contemporary empiricism. In Omery, A., Kasper, C.E. & Page, G.G. (Eds.), In search of nursing science (pp. 13–26). Thousand Oaks, CA: Sage doi:10.4135/9781452225753.n2 [CrossRef] .