Ethical aspects of institutional care for seniors “The signs of human fragility, which are most clearly manifested in old age, in this light become a call for mutual dependence and necessary solidarity, which links generations to one another. Every person needs another person and becomes richer through the gifts and charisma of others.” (John Paul II: Letter to older persons, October 1, 1999, point 10)

Old age (in Latin, senium) is the last stage of human development in the course of life. Social work with seniors brings many challenges and daily difficulties to helping professionals, especially in institutional care. In the context of this article, we refer to helping professionals and especially social workers, but also caregivers, nursing staff, and management of the institution providing social services for one of the most vulnerable social groups—seniors.

Each stage of human development is a very complex process that is reflected in four aspects: the physical, psychological, social, and spiritual domains, and with regard to the uniqueness of each person's personality. Four-dimensional understanding of the person is also derived from empirical work in the area of human needs, where needs are considered physiological, psychological, social, and spiritual. Such an understanding of the person, which captures the whole spectrum of an individual's life, is also emphasized by B. Balogová (2005). In old age, sensory perception and intensified emotional experiencing come to the fore. Seniors have a lot of free time and some, to a greater extent, pay increased attention to themselves and their health issues. In seniors' experiences, fear of possible abandonment, hospitalization, loneliness, dependence, and reliance on another person often comes to the forefront. Some seniors may also perceive negatively the threat of temporary or even permanent placement in a social services institution. As their health status deteriorens and possible family support or home caregiving service is exhausted, institutional placement comes.

With the move to a new social environment—a social services institution for seniors—the life of the senior changes dramatically. The necessity of permanent placement in an institution providing social and health services primarily affects the senior, and equally their immediate circle—the family. Family social roles, lifestyle, and the senior’s space change significantly; there may be a reduction in life opportunities, threats to privacy, and even dehumanization and dishonouring of human dignity. Based on conversations with seniors and family members entering our institutions, we encounter similar thoughts and concerns.

Helping professionals need to be able to evaluate all available options with the aim of eliminating the negative consequences of a senior’s adaptation to the new social environment. Encouraging the client toward self-determination, self-care, active participation in the social life of the institution, supporting their healthful potential, and also seeking individualized solutions to seniors’ suffering and difficulties is part of our work and our full responsibility. It is important for us to be able to receive the client as they are, without prejudice, without our assumptions about their need to become something else. With each senior it is necessary to live their own value, the value of existence “here and now,” the value of the very moment being experienced. Building an authentic human relationship is the most essential element in helping professions. We believe that seniors in institutional care need to trust social workers as much as caregiving and nursing staff. Many naturally expect from the staff human concern for their person, for their positive experiences and negative experiences. In addition to trust and interest, clients also expect acceptance, understanding, and concrete help from us. We believe that if we want to meet seniors’ needs and respond to them, we need to get to know them more closely. Medical reports, expert assessments, or social investigations about a senior are not enough. Information about the previous way of life, interests, hobbies, preferred foods, bad habits, rituals, and the course of employment or education are relevant for preserving dignity, respect, and regard. For helping professionals, this means choosing a communication style with the senior and being helpful in everyday institutional life. Each of us has come into this world as an unrepeatable original, and it is not possible to generalize work procedures and methods for all clients of the same age. If we want in our work to not only declare but especially to fulfill individual approach on a daily basis, there is no doubt that we must know the client—the senior—as comprehensively as possible. According to E. Böhma, work with the client biography belongs to modern social work and care: “meaningful care of an older person is based primarily on the revival of the psyche and only then on the somatic dimension” (In Procházková, 2008, p. 17).

Especially in work with seniors, one of the most important activities of helping professionals is listening to life stories, which clients bring with them when they enter social services institutions. It depends on the skill of helping professionals that, through patient listening, they can analyze the client’s needs and answer the following questions:

  • What is the client able to do alone without help?
  • Is this inability temporary or permanent?
  • Is there a possibility to teach the client something so that they can manage on their own? (Grayová, 2009, p. 11)

After establishing a relationship with the client, and after careful observation and mapping of their abilities and previous situation, it should not happen that a helping professional carries out only delegated authority without deeper engagement. However, the work of the helping professional does not end there... Seniors’ needs change, especially with regard to their health condition. Our words are echoed by the Czech specialists in social work with seniors, Klevetová and Dlabalová (2008), who state that the most valuable contribution of professionals is to give their time in the service of another person, to create space for trust and understanding of a concrete senior in a concrete situation, and to help them find meaning in everyday life. If a senior has support from others, they can overcome life crises and cope with their limitations. Our most important task in working with seniors is to create a loving and supportive environment full of responsiveness, a pleasant atmosphere, and at the same time clear rules. In a safe environment, seniors will feel better; with strengthened self-confidence, they will discover new possibilities of life and their own potential for living in a new environment.

Awareness of each person’s originality (uniqueness), vulnerability, and mortality, and at the same time insight into one’s own limits through self-knowledge should motivate us to continue our work and improve care. Yet it is very difficult in the established routine of individual social services institutions to introduce an absolute individualized approach, for example during waking up or serving meals. In practice, we very often encounter that kitchen or laundry staff hold more power, because “they” decide when meals are served and when dirty laundry is sent away. Regardless of whether the client is finished eating or not. This is most common in large-capacity institutions. In institutions with smaller capacity it is possible to accommodate individualized requests. Likewise, in practice caregivers sometimes decide on so-called “shower days” regardless of whether this need is currently relevant or suitable for the clients. Preventing such stereotypes is sometimes beyond the ability of institutional leadership, because caregiving and nursing staff make up the majority of employees and are therefore in the majority. A major future challenge is to work more consistently with employees, for example through further education with emphasis on implementing basic ethical principles in everyday work. Our experience confirms that especially caregivers’ and care assistants’ knowledge “boundaries” and their unwillingness to continue learning are strongly reflected in the normal operation of institutions. Even the syllabi in requalification training for caregiving do not meet and do not reflect the requirements of caregiving as a profession. Realizing that in everyday contact with clients—seniors—the caregiving staff is in fact the one most present, it is very difficult to intervene from social work given social workers’ working hours. Few people reflect on the fact that if a senior’s morning hygiene takes place in a tense, hostile, or nervous atmosphere created by the attending caregiver, it is very difficult and sometimes practically impossible to offer, for example, activation activities for seniors. It is no surprise then that clients become uncooperative, apathetic, or their overall health, especially psychological health, rapidly deteriorates, and so on. Social workers record in individual plans that the client refuses, does not respond, or is not willing to cooperate. Many times care is provided at a basic level and professional work is carried out only with difficulties. If seniors have impaired communication abilities, we do not even learn what happens during our absence or during early mornings or late evenings. All responsibility lies with helping professionals and their self-reflection on carried out activities and on their approach toward each client.

Helping professionals seem, in their daily routine, to “forget” basic ethical principles in helping professions as stated by Mahrová and Venglářová (2008):

  1. The principle of beneficence – acting for the greatest good of the specific client.
  2. The principle of non-maleficence – excluding any intentional or unintentional harm.
  3. The principle of autonomy – respecting the client’s shared decision-making about themselves.
  4. The principle of justice – making no distinctions between clients.

Reasons for this “forgetting” are varied, from the low status of our profession, through financial remuneration, time pressure and other stresses, to the risk of burnout. Yet in the center of our attention are people—seniors—who may not care about our arguments as to why we cannot give them enough time. Have we sometimes reflected on whether we as professionals, through our behavior and demands on seniors, contribute to the deterioration of their health? On the one hand, the most effective form of help for seniors lies in collaboration among professionals—helping professionals (geriatrics, psychiatrists, social workers, nurses, caregivers, and family members)—and on the other hand, each helping professional may have a specific motive and goal they want to achieve in cooperation with the senior. Sometimes a senior may feel frustrated or confused by the demands and rules brought by the institutional regime and by the overall change of environment and worsening health status. Paradoxically, while helping professionals make every positive effort, they observe seniors mentally deteriorating, slipping into depression, or developing new illnesses. Changes in behavior such as demanding behavior, wandering, aimless roaming, helplessness, dissatisfaction, and despondency should be a challenge for helping professionals, not merely a statement that something is happening to the senior client. Let us admit: how many of us actively seek causes of behavioral changes in seniors living in social services institutions?! Very often we simply state that a senior’s health is worsening, and few of us investigate the causes deliberately. The worsening of health conditions may be due not only to the adaptation process, but for example also to our high demands for adaptation, side effects of medications, or long-term family distress of the senior.

Conclusion

Currently, social service institutions strive to adapt clients’ life conditions—seniors—so that they resemble as closely as possible the so-called normal life conditions to which the client has been accustomed through their previous way of life. This trend has entered a path of getting to know the client—a senior. Through our concrete actions, we can fulfill clients’ ideas about their own life and their own way of aging. Remember, therefore, that seniors place their life in our hands, and our hands—the hands of helping professionals—must be both a firm support and, at the same time, a gentle touch for a senior dependent on our help.

Author: PhDr. Miroslava Tokovská List of bibliographic references

[1] BALOGOVÁ, B. 2005. Seniori. 2. vyd. Prešov : Akcent Print, 2005. 158 s. ISBN 80−969274−9−3. [2] GRAYOVÁ, C. 2010. Ako opatrovať chorých. 2. vyd. Martin : Príroda, 2010, 192 s. ISBN 978-80-07-01835-8. [3] KLEVETOVÁ, D., DLABALOVÁ, I. 2008. Motivační prvky při práci se seniory. 1. vyd. Praha : Grada, 2008, 208 s. ISBN 978-80-247-2169-9 [4] MAHROVÁ, G., VENGLÁŘOVÁ, M. a kol. 2008. Sociální práce s lidmi s duševním onemocněním. 1. vyd. Praha : Grada, 2008, 176 s. ISBN 978-80-247-2138-5 [5] PROCHÁZKOVÁ, E. 2008. Důstojná péče o seniora. In: Sestra a lekár v praxi. Č. 5-6/2008, ISSN 1335-9444

The lecture was delivered at the international scientific conference Applied ethics in social work and other helping professions, held on October 20–21, 2010, in Piešťany, and was published in the proceedings from that conference: MÁTEL, A. – SCHAVEL, M. – MÜHLPACHR, P. – ROMAN, T. 2010. Aplikovaná etika v sociálnou práci a ďalších pomáhajúcich profesiách. Zborník z medzinárodnej vedeckej konferencie. Bratislava : VŠZaSP sv. Alžbety. 413 s. ISBN 978-80-89271-89-4.