Neugarten calls "the young old." If so, it is not surprising tnat they are mentally and physically active. Such a portrayal may represent reality more than a stereotype. To determine if this image of the elderly as mentally and physically active is dominant on television, we would need representative samples of dramas as well as news stories and documentaries from which to draw conclusions. According to a recent "My Turn" observation in the popular press by Eli Rubinstein (1991), researchers should also look at advertisements to determine the image of aging presented by television:
Only with a more complete sampling of television portrayals can we speak to the dominant image on television, if there is indeed one. The reality is that "the elderly" may be too diverse a group about whom to measure attitudes and too diverse a category to use in monitoring television coverage. What may be a stereotype for one group within the old may not be a stereotype for another. If we want the public and the media to abandon the oversimplifying generalities they often make about age and aging and look instead at the diversity among older people, then gerontologists must stop asking attitudinal and factual questions about "the elderly" as if they were a homogeneous group. Where does this leave us as researchers, practitioners, and policymakers? First, we need to develop measures of attitudes and beliefs about older persons that allow respondents to make greater differentiations than past measures often allowed. Thus, we can begin to diminish the discrepancy between what we know about the heterogeneity among older persons and what we measure through our surveys. Second, because ageism is a colorful term, we probably do not want to abandon
Fay Lomax Cook, PhD Graduate Program in Human Development and Social Policy School of Education and Social Policy Northwestern University Evanston, IL References Bell, J. (1992). In search of a discourse on aging: The elderly on television. The Gerontologist, 32, 305-311. Butler, R. N. (1987). Ageism. Encyclopedia of Aging. New York: Springer. Butler, R. N. (1989). Dispelling ageism: The cross-cutting intervention. The Annals of the American Academy of Political and Social Science, 503, 138-147. Ferraro, K. F. (1992). Cohort change in images of older adults, 1974-1981. The Gerontologist, 32, 296-304. Neugarten, B. L. (1974). Age groups in American society and the rise of the young-old. The Annals of the American Academy of Political and Social Science, 415, 187-198. Palmore, E. B. (1990). Ageism: Negative and Positive. New York: Springer. Rubinstein, E. A. (1991). The not so golden years. Newsweek, October 7,13. Schonfield, D. (1982). Who is stereotyping whom and why? The Gerontologist, 22, 267-272.
TOWARD SECOND-GENERATION NURSING HOME RESEARCH Although few organizations so profoundly affect their clients' lives, very little is known about what makes nursing homes tick. Nursing home research has typically been conducted at the extremes of macro and micro levels of analysis. Analyses of survey data from the National Center for Health Statistics and state regulatory bodies have documented the structure of the nursing home industry but provided little guidance for those who seek to improve the quality of nursing home care. Rich qualitative case studies have described life and work in particular nursing homes, yet the question of generalizability remains. What is now needed is research at the meso level that sheds light on how nursing home corporations, organizational structures, and individual providers interact with a diverse resident population to produce care. From knowledge obtained from other settings, very little can be assumed about the organizational behavior of nursing homes as they simultaneously serve as formal health care delivery systems and primary group substitutes (Litwak, 1985). Nursing home residents are a diverse population, not easily sorted into functionally meaningful "departments." Organizational goals reVol. 32, No. 3,1992
flect the ambivalence of society at large regarding custodial versus restorative care for dependent elders. This makes the nursing home an awkward social system. Attempts to delineate characteristics of good and bad facilities have been hampered by lack of consensus regarding appropriate outcome measures and the predictive impotence of structural characteristics available from secondary data sources (e.g., ownership). Although the organizational properties of other health service organizations, most notably hospitals, have been thoroughly researched and organized into various taxonomies, nursing homes remain relatively unexplored territory for the organizational sciences. Whether this is explained by researchers' assessments of nursing homes as uninteresting or as unpleasant research sites can only be speculated upon. The result, however, is that much of the vast unevenness in quality among nursing homes in the United States remains unexplained. More to the point, the public's interest in supporting quality improvement in this largely proprietary industry remains stifled. The recent implementation of a standardized resident assessment system (Morris et al., 1990), however, creates the real possibil-
293
Downloaded from http://gerontologist.oxfordjournals.org/ at University of Bath Library & Learning Centre on June 18, 2015
Advertisers trying to capture the growing market of affluent senior citizens underscore some of the problems of aging. On TV, June Allyson sweetly assures her viewers about the joys of hugging their friends again while wearing protective undergarments.. . . immediate assistance is promised after "I've fallen and I can't get u p " — as long as you're wearing a radio transmitter (Rubinstein, 1991, p. 13).
it. But at the same time we should not use it so casually that we diminish its meaningfulness. For example, if we label attitudes as ageist if they are either overly negative ("negative ageism") or overly positive ("positive ageism"), the term could come to signify very little (Palmore, 1990). The reason that ageism (as Butler defines it) is a problem similar to racism and sexism is not only that a single characteristic is used to devalue an entire group but also that we assume a link exists between systematic stereotyping on the basis of age and discrimination against people over 65. It is this linkage that warrants further study. Because older persons are so heterogeneous, we must be prepared to learn that links between stereotyping and discrimination — to the extent they exist — are complexly determined, exist in some domains (for example, employment) but not others, and are stronger toward some elderly groups than others as measured by such factors as functional capacity or work status or appearance of fraility.
staff; and the prominence of rules and procedures over negotiated relationships as guides for behavior. Yet, some nursing homes feel less bureaucratic than others. Examples of autonomy-enhancing organizational strategies have been cited (Kane & Caplan, 1990) and innovations within the industry are apparent. The challenge for second-generation nursing home researchers is to simultaneously look within and across facilities to identify patterns of organizational design, work design, and human resource strategies that enhance resident well-being. This will require crossdisciplinary thinking, which results in studies of individual behavior framed in organizational context variables and studies of institutions attending to individual differences. Diane Brannon, PhD Health Policy and Administration The Pennsylvania State University University Park, PA References
Bowers, B., & Becker, M. (1992). Nurse's aides in nursing homes: The relationship between organization and quality. The Gerontologist, 32, 360-366. Chapped, N. L , & Novak, M. (1992). The role of support in alleviating stress among nursing assistants. The Gerontologist, 32, 351-359. Kane, R. A., & Caplin, A. (1990). Everyday ethics: Resolving dilemmas in nursing home life. New York: Springer. Kruzich, J. M., Clinton, J. F., & Kelber, S. T. (1992). Personal and environmental influences on nursing home satisfaction. The Gerontologist, 32, 342-350. Litwak, E. (1985). Helping the elderly: The complementary roles of informal networks and formal systems. New York: Cuilford. Morris, J. N., Hawes, C , Fries, B., Phillips, C , Mor, V., Katz, S., Murphy, K., Drugovich, M., & Friedlob, A. (1990). Designing the National Resident Assessment Instrument for Nursing Homes. The Gerontologist, 30, 293307. Sheridan, J. E., White, J., & Fairchild, T. J. (1992). Ineffective staff, ineffective supervision, or ineffective administration? Why some nursing homes fail to provide adequate care. The Gerontologist, 32, 334-341. Smyer, M., Brannon, D., & Cohn, M. (1992). Improving nursing home care through training and job redesign. The Gerontologist, 32, 327-333.
GERONTOLOGY AND CRITICAL THEORY Gerontology can claim great success in its struggle to be a science. It is an achievement to be celebrated, both because knowledge itself is good and because the application of science and technology promises benefits. But, as in the case of environment and ecology, the advance of technology can and must be criticized from a broader perspective. The challenge is how to mount that critique in a spirit that is reflective but not polemical. The important article by Lars Tornstam in this issue offers a helpful contribution to this challenge. Tornstam's article underscores the need for a selfcritical spirit in gerontological theory and practice. But what is a "self-critical spirit" and where will we find the intellectual resources for it? The answers aren't clear, but the source of the problem can at least be defined. American academic life has been damaged by uncritical worship at the altar of "value-free" empiricism. Ironically, that pose of uncritical detachment in recent years has given rise, particularly in the humanities, to fashionable trends of politicization and relativism: a belief that objective truth is not attainable or that truth is less important than advancing a political agenda. So the question becomes more pressing: Where can we find a model of rational criticism that reinforces liberal values of civility and free public discourse?
294
Help is to be found in the tradition of Critical Theory associated with figures like Adorno, Horkheimer, Marcuse, and, more recently, the philosopher Jurgen Habermas (Braaten, 1991; Horkheimer, 1972; Horkheimer & Adorno, 1972; Ingram, 1990). That European tradition is alien to American social scientists, just as Tornstam's argument will seem alien to many. But the message needs to be heard by American gerontologists, and there are some signs that the message may be getting through (Moody, 1988). For example, a new volume on "critical gerontology" edited by Thomas Cole (in press) will be published later this year. All the contributors are Americans, including some well-known names in the mainstream of gerontology. These steps toward a "critical gerontology," including the ideas of Critical Theory, could help remedy some serious deficiencies in the mainstream of American gerontology. Critical Theory throughout its tradition has stood in opposition to the conventional positivism and empiricism long dominant in gerontology. It stands equally in opposition to domination by bureaucracy and marketplace, whose characteristic modes of thought indirectly inspired the positivist regime. On the political plane, Critical Theory is suspicious of the pragmatic liberalism so congenial to mainstream geronThe Gerontologist
Downloaded from http://gerontologist.oxfordjournals.org/ at University of Bath Library & Learning Centre on June 18, 2015
ity of meaningful measures of outcomes of nursing home care. Thus it is timely for social gerontologists to embark on a new generation of process-outcome research focused on variations in the internal workings of the nursing home and its parent corporation. The symposium in this issue includes a collection of articles that indicate a transition from the current slate of the art in that they address nursing homes as organizations. Methodologically, they range from the qualitative case study to cross-sectional to longitudinal; none is definitive. They are, rather, early chronicles from the frontier of the analysis of nursing homes as caregiving systems within bureaucratic organizations. Chappelt and Novak, and Smyer, Brannon, and Cohn evaluate approaches and obstacles to improving the ability of nursing assistants — the primary caregivers — to cope with and effectively manage resident behavior problems. Bowers and Becker specify institutional barriers to providing primary group care in the nursing home setting. Sheridan, White, and Fairchild link institutional failure in a sample of nursing homes to organizational climate, and Kruzich, Clinton, and Kelber identify resident functional status and nursing unit factors that moderated the influence of organizational characteristics on resident satisfaction. Each of these research reports complicates our simplistic view of the nursing home as the black hole of the health services system, into which people go to experience the inevitable, if mysterious, shattering of their lives and from which they never return. From the viewpoint of the student of organizations, nursing homes are paradoxes. Although organizational size is usually positively associated with levels of bureaucratization, nursing homes are small organizations that exhibit decidedly bureaucratic structures. Families and residents experience bureaucracy in a variety of ways including: the routinized, sometimes "assemblyline" nature of care routines; the highly regulated hierarchy of information exchange and authority within the
Only with a more complete sampling of television portrayals can we speak to the dominant image on television, if there is indeed one. The reality is that "the elderly" may be too diverse a group about whom to measure attitudes and too diverse a category to use in monitoring television coverage. What may be a stereotype for one group within the old may not be a stereotype for another. If we want the public and the media to abandon the oversimplifying generalities they often make about age and aging and look instead at the diversity among older people, then gerontologists must stop asking attitudinal and factual questions about "the elderly" as if they were a homogeneous group. Where does this leave us as researchers, practitioners, and policymakers? First, we need to develop measures of attitudes and beliefs about older persons that allow respondents to make greater differentiations than past measures often allowed. Thus, we can begin to diminish the discrepancy between what we know about the heterogeneity among older persons and what we measure through our surveys. Second, because ageism is a colorful term, we probably do not want to abandon
Fay Lomax Cook, PhD Graduate Program in Human Development and Social Policy School of Education and Social Policy Northwestern University Evanston, IL References Bell, J. (1992). In search of a discourse on aging: The elderly on television. The Gerontologist, 32, 305-311. Butler, R. N. (1987). Ageism. Encyclopedia of Aging. New York: Springer. Butler, R. N. (1989). Dispelling ageism: The cross-cutting intervention. The Annals of the American Academy of Political and Social Science, 503, 138-147. Ferraro, K. F. (1992). Cohort change in images of older adults, 1974-1981. The Gerontologist, 32, 296-304. Neugarten, B. L. (1974). Age groups in American society and the rise of the young-old. The Annals of the American Academy of Political and Social Science, 415, 187-198. Palmore, E. B. (1990). Ageism: Negative and Positive. New York: Springer. Rubinstein, E. A. (1991). The not so golden years. Newsweek, October 7,13. Schonfield, D. (1982). Who is stereotyping whom and why? The Gerontologist, 22, 267-272.
TOWARD SECOND-GENERATION NURSING HOME RESEARCH Although few organizations so profoundly affect their clients' lives, very little is known about what makes nursing homes tick. Nursing home research has typically been conducted at the extremes of macro and micro levels of analysis. Analyses of survey data from the National Center for Health Statistics and state regulatory bodies have documented the structure of the nursing home industry but provided little guidance for those who seek to improve the quality of nursing home care. Rich qualitative case studies have described life and work in particular nursing homes, yet the question of generalizability remains. What is now needed is research at the meso level that sheds light on how nursing home corporations, organizational structures, and individual providers interact with a diverse resident population to produce care. From knowledge obtained from other settings, very little can be assumed about the organizational behavior of nursing homes as they simultaneously serve as formal health care delivery systems and primary group substitutes (Litwak, 1985). Nursing home residents are a diverse population, not easily sorted into functionally meaningful "departments." Organizational goals reVol. 32, No. 3,1992
flect the ambivalence of society at large regarding custodial versus restorative care for dependent elders. This makes the nursing home an awkward social system. Attempts to delineate characteristics of good and bad facilities have been hampered by lack of consensus regarding appropriate outcome measures and the predictive impotence of structural characteristics available from secondary data sources (e.g., ownership). Although the organizational properties of other health service organizations, most notably hospitals, have been thoroughly researched and organized into various taxonomies, nursing homes remain relatively unexplored territory for the organizational sciences. Whether this is explained by researchers' assessments of nursing homes as uninteresting or as unpleasant research sites can only be speculated upon. The result, however, is that much of the vast unevenness in quality among nursing homes in the United States remains unexplained. More to the point, the public's interest in supporting quality improvement in this largely proprietary industry remains stifled. The recent implementation of a standardized resident assessment system (Morris et al., 1990), however, creates the real possibil-
293
Downloaded from http://gerontologist.oxfordjournals.org/ at University of Bath Library & Learning Centre on June 18, 2015
Advertisers trying to capture the growing market of affluent senior citizens underscore some of the problems of aging. On TV, June Allyson sweetly assures her viewers about the joys of hugging their friends again while wearing protective undergarments.. . . immediate assistance is promised after "I've fallen and I can't get u p " — as long as you're wearing a radio transmitter (Rubinstein, 1991, p. 13).
it. But at the same time we should not use it so casually that we diminish its meaningfulness. For example, if we label attitudes as ageist if they are either overly negative ("negative ageism") or overly positive ("positive ageism"), the term could come to signify very little (Palmore, 1990). The reason that ageism (as Butler defines it) is a problem similar to racism and sexism is not only that a single characteristic is used to devalue an entire group but also that we assume a link exists between systematic stereotyping on the basis of age and discrimination against people over 65. It is this linkage that warrants further study. Because older persons are so heterogeneous, we must be prepared to learn that links between stereotyping and discrimination — to the extent they exist — are complexly determined, exist in some domains (for example, employment) but not others, and are stronger toward some elderly groups than others as measured by such factors as functional capacity or work status or appearance of fraility.
staff; and the prominence of rules and procedures over negotiated relationships as guides for behavior. Yet, some nursing homes feel less bureaucratic than others. Examples of autonomy-enhancing organizational strategies have been cited (Kane & Caplan, 1990) and innovations within the industry are apparent. The challenge for second-generation nursing home researchers is to simultaneously look within and across facilities to identify patterns of organizational design, work design, and human resource strategies that enhance resident well-being. This will require crossdisciplinary thinking, which results in studies of individual behavior framed in organizational context variables and studies of institutions attending to individual differences. Diane Brannon, PhD Health Policy and Administration The Pennsylvania State University University Park, PA References
Bowers, B., & Becker, M. (1992). Nurse's aides in nursing homes: The relationship between organization and quality. The Gerontologist, 32, 360-366. Chapped, N. L , & Novak, M. (1992). The role of support in alleviating stress among nursing assistants. The Gerontologist, 32, 351-359. Kane, R. A., & Caplin, A. (1990). Everyday ethics: Resolving dilemmas in nursing home life. New York: Springer. Kruzich, J. M., Clinton, J. F., & Kelber, S. T. (1992). Personal and environmental influences on nursing home satisfaction. The Gerontologist, 32, 342-350. Litwak, E. (1985). Helping the elderly: The complementary roles of informal networks and formal systems. New York: Cuilford. Morris, J. N., Hawes, C , Fries, B., Phillips, C , Mor, V., Katz, S., Murphy, K., Drugovich, M., & Friedlob, A. (1990). Designing the National Resident Assessment Instrument for Nursing Homes. The Gerontologist, 30, 293307. Sheridan, J. E., White, J., & Fairchild, T. J. (1992). Ineffective staff, ineffective supervision, or ineffective administration? Why some nursing homes fail to provide adequate care. The Gerontologist, 32, 334-341. Smyer, M., Brannon, D., & Cohn, M. (1992). Improving nursing home care through training and job redesign. The Gerontologist, 32, 327-333.
GERONTOLOGY AND CRITICAL THEORY Gerontology can claim great success in its struggle to be a science. It is an achievement to be celebrated, both because knowledge itself is good and because the application of science and technology promises benefits. But, as in the case of environment and ecology, the advance of technology can and must be criticized from a broader perspective. The challenge is how to mount that critique in a spirit that is reflective but not polemical. The important article by Lars Tornstam in this issue offers a helpful contribution to this challenge. Tornstam's article underscores the need for a selfcritical spirit in gerontological theory and practice. But what is a "self-critical spirit" and where will we find the intellectual resources for it? The answers aren't clear, but the source of the problem can at least be defined. American academic life has been damaged by uncritical worship at the altar of "value-free" empiricism. Ironically, that pose of uncritical detachment in recent years has given rise, particularly in the humanities, to fashionable trends of politicization and relativism: a belief that objective truth is not attainable or that truth is less important than advancing a political agenda. So the question becomes more pressing: Where can we find a model of rational criticism that reinforces liberal values of civility and free public discourse?
294
Help is to be found in the tradition of Critical Theory associated with figures like Adorno, Horkheimer, Marcuse, and, more recently, the philosopher Jurgen Habermas (Braaten, 1991; Horkheimer, 1972; Horkheimer & Adorno, 1972; Ingram, 1990). That European tradition is alien to American social scientists, just as Tornstam's argument will seem alien to many. But the message needs to be heard by American gerontologists, and there are some signs that the message may be getting through (Moody, 1988). For example, a new volume on "critical gerontology" edited by Thomas Cole (in press) will be published later this year. All the contributors are Americans, including some well-known names in the mainstream of gerontology. These steps toward a "critical gerontology," including the ideas of Critical Theory, could help remedy some serious deficiencies in the mainstream of American gerontology. Critical Theory throughout its tradition has stood in opposition to the conventional positivism and empiricism long dominant in gerontology. It stands equally in opposition to domination by bureaucracy and marketplace, whose characteristic modes of thought indirectly inspired the positivist regime. On the political plane, Critical Theory is suspicious of the pragmatic liberalism so congenial to mainstream geronThe Gerontologist
Downloaded from http://gerontologist.oxfordjournals.org/ at University of Bath Library & Learning Centre on June 18, 2015
ity of meaningful measures of outcomes of nursing home care. Thus it is timely for social gerontologists to embark on a new generation of process-outcome research focused on variations in the internal workings of the nursing home and its parent corporation. The symposium in this issue includes a collection of articles that indicate a transition from the current slate of the art in that they address nursing homes as organizations. Methodologically, they range from the qualitative case study to cross-sectional to longitudinal; none is definitive. They are, rather, early chronicles from the frontier of the analysis of nursing homes as caregiving systems within bureaucratic organizations. Chappelt and Novak, and Smyer, Brannon, and Cohn evaluate approaches and obstacles to improving the ability of nursing assistants — the primary caregivers — to cope with and effectively manage resident behavior problems. Bowers and Becker specify institutional barriers to providing primary group care in the nursing home setting. Sheridan, White, and Fairchild link institutional failure in a sample of nursing homes to organizational climate, and Kruzich, Clinton, and Kelber identify resident functional status and nursing unit factors that moderated the influence of organizational characteristics on resident satisfaction. Each of these research reports complicates our simplistic view of the nursing home as the black hole of the health services system, into which people go to experience the inevitable, if mysterious, shattering of their lives and from which they never return. From the viewpoint of the student of organizations, nursing homes are paradoxes. Although organizational size is usually positively associated with levels of bureaucratization, nursing homes are small organizations that exhibit decidedly bureaucratic structures. Families and residents experience bureaucracy in a variety of ways including: the routinized, sometimes "assemblyline" nature of care routines; the highly regulated hierarchy of information exchange and authority within the
