Healthcare in the West has also been changing over the past few decades. As more people survive serious disease and live longer, families are being expected to shoulder more of the burden of care. Patients have shorter hospital stays, but they leave quicker and sicker. It is ironic that, as medical technology improves, there are more ill people in the community being care for by their families. However, as the proportion of older and ill people in the community continues to increase, there are growing numbers of people living on their own, and less traditional family stability or an extended family structure to support people being cared for at home. Consequently there is greater reliance on nursing homes and other forms of institutional care (Brennan, 2004).
Nursing homes provide care for longer periods under more home-like conditions. In Sweden, three general types of nursing homes gave developed. Central nursing homes are usually attached to a geriatric department and function essentially as an annex. These seem to be diminishing in importance. Local nursing homes are usually independent of hospitals and come under the organizational auspices of the primary care system, with the district physician usually having referral authority. At present the number of beds in such local nursing homes is being increased. Finally, 4% of all beds in long-term care are to be found in private nursing homes (Lesemann & Martin, 1993).
Although many people identify long-term care with nursing homes, the predominant provider of long term care in the United States is the family. The elderly express strong preferences for remaining in their own homes as long as possible and for being cared for by relatives. Only about 21 percent of the disabled elderly were in nursing homes in 1985. The rest were in the community, mostly in their own homes. Those with more severe disabilities were more likely to in institutions, but even among the severely disabled considerably less than half were in nursing homes (Harris, 2002; Rivlin & Wiener, 1988).
Issues in the Nursing Home
Age. Much of the pain literature has called attention to the problem of inadequate pain assessment and management in the elderly in a palliative care setting. Elderly patients suffer disproportionately from chronic painful conditions and have multiple diagnoses with complex problems and accompanying pain. Elders have physical, social, and psychological needs distinct from those of younger and middle-aged adults, and they present particular challenges for the pain assessment and management. Pain assessment may be more problematic in elderly patients due to their increased detachment. Elderly people often present with failures in memory, depression, and sensory impairments that may hinder history taking: they may also underreport pain because they expect pain to occur as a part of the aging process. Moreover, dependent elderly people may not report pain because they do not want to bother the nurse or doctor and are concerned that they will cause more distress in their family caregivers. (Coyle & Ferrell, 2006)
Gender. Research has consistently demonstrated that gender is an important variable in depression. Studies have shown that there is a higher incidence of depression in women and also that the actual experience of depression differs for men and women. However, there has been little work on gender differences in depression in the elderly. In one student that examined depression in nursing homes, W.D. Hale (1982) found that depression was correlated negatively with financial well-being, loneliness, and reports of insufficient informal contact for women, but not for men. For men, depression was related to measures of physical health and reports of pain (Aiken, 1999; Padgett, 1995).
Ethnicity. Despite controversies and uncertainties, the relationship between ethnicity and pain is vital. The term ethnicity refers to one or more of the following: (1) a common language or tradition, (2) shared origins or background, and (3) shared culture and traditions that ate distinctive, passed through generations, and create a sense of identity. Ethnicity may be predictor of pain expression and response. While assessing pain, it is important to remember that certain ethnic groups and cultures have strong beliefs about expressing pain and may hesitate to complain of relieved pain. Other studies also have reported that members of the minority groups are at risk for untreated pain (Coyle & Ferrell, 2006).
Race. On the whole, Whites and Asian Americans are healthier that Blacks and more likely to view their health as good. The better health status of Whites than Blacks is underscores by statistics on life expectancy. In 1996, the life expectancy of White Americans was 73.8 years for males and 79.6 for females, but it was only 66.1 years for Black males and 74.2 years for Black females. These life expectancy figures are all- highs for White men, Black men, and Black women in the US (Aiken, 1999).
If I get to be employed in a nursing home, a lesson that I may learn is how rich lives can be even as my subjects suffer from pain, are severely restricted by disabilities, have lost most if not all of their loved ones, and have little or no chance for recovery. Theirs are faces with stories, which under the most trying bodily conditions are still able to make meaning, to link together semblances of explanation and understanding for life and living. Their stories may have taught me that, even with dreadful insults to one’s body or being near death, varied horizons communicate meaningful; differences. Experience does not necessarily combine around immediate afflictions, their cares, their trials, or dying.
I could learn about the many residents who readily spoke of their lives, who in many instances with breathing difficulty or aching from pains in their backs, chests, legs, and elsewhere as we conversed. Most went on, wanted to go on, despite the difficulties. Their will and stamina amazed me. In a few cases, it was more than I could bear, knowing that they were succeeding in presenting to me what their lives had been like, what life had become, and, perhaps most significantly, what a life could still be.