Social isolation in old age: a qualitative exploration of service providers' perceptions

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Social isolation in old age: a qualitative exploration of service providers'perceptions

CHERRY RUSSELL and TONI SCHOFIELD

Ageing and Society / Volume 19 / Issue 01 / January 1999, pp 69 - 91DOI: null, Published online: 08 September 2000

Link to this article: http://journals.cambridge.org/abstract_S0144686X98007181

How to cite this article:CHERRY RUSSELL and TONI SCHOFIELD (1999). Social isolation in old age: a qualitative exploration of service providers'perceptions. Ageing and Society, 19, pp 69-91

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Ageing and Society, , , –. Printed in the United Kingdom# Cambridge University Press

Social isolation in old age: a qualitativeexploration of service providers’perceptions

CHERRY RUSSELL and TONI SCHOFIELD*

ABSTRACTThis paper presents findings from a qualitative study of social isolation in thecontext of service provision to older people. It draws on in-depth interviewswith Australian aged care practitioners about their perceptions of socialisolation among their clients. The findings show that service providersexperience significant levels of concern and frustration and a sense ofpowerlessness in meeting the needs of such clients. In analysing these accounts,the identification and management of isolation is conceptualised as a socialpractice which occurs in specific relational settings. The provision of care tolonely, isolated old people is structurally constrained in two ways. First,because of inadequate public resource allocation, the relationship betweenpractitioners and older clients is dominated by time pressure and in-strumentality. Secondly, the organisational and professional rules whichservice providers are required to follow shape the interpersonal relationsbetween practitioner and client in ways which negatively impact on theoutcomes of care for both.

KEY WORDS – Ageing, social isolation, sociology, public policy, serviceproviders, qualitative research.

Introduction

Lonely, isolated, depressed people…are the hardest to reach. How to get themout of the woodwork is the most difficult question.

The physiotherapist who expressed this view was part of a sample ofAustralian service providers whom we interviewed in the course of aqualitative investigation into social isolation in old age. While there isan extensive body of gerontological literature devoted to isolation as asocial problem confronting old people, we know remarkably littleabout the experiences and perspectives of professional workers whoseroutine, everyday practice entails repeated encounters with it.

* School of Behavioural and Community Health Sciences, The University of Sydney.

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Cherry Russell and Toni Schofield

This paper begins with a brief overview of the public policy contextof aged care in Australia and its associated structure of service delivery.Next, we explore the literature on social isolation and professionalpractice and identify some important gaps in the existing research data.We propose a sociological framework for the analysis of isolation as asocial practice which occurs in specific relational contexts, and describethe research project which developed from it. Finally, we draw on in-depth interviews with practitioners in aged care. These accountsreveal that service providers experience significant levels of concernand frustration and a sense of powerlessness in relation to socialisolation among elderly clients. Finally, we discuss the implications ofthe findings in relation to prevailing structures of public resourceallocation, policy formulation and professional practice.

The policy context

In Australia care policy to older people has, since , explicitlysought to effect change in the balance between residential andcommunity care services. A central objective here, as in comparableother countries, has been to maximize the extent to which frail anddisabled older people can remain, with support, in their own homes(Dalley ; Fine and Thomson ; Giles ; Lingsom ). Aswell as stemming the flow of nursing home admissions, this goal was tobe achieved by improving and expanding those community-basedservices which provide an alternative form of care.

A range of basic home-delivered services are now funded under theHome and Community Care (HACC) Program. It is estimated that atany one time, some per cent of the population aged and overreceives HACC services (Giles : ). The range of services has beenincreased from the original core (home help, delivered meals anddomiciliary nursing) to include additional respite and day care,personal care, transport, home maintenance and modification, in-formation and training, and paramedical services. The balance offunding, however, continues to favour core activities.

Eligibility for all HACC services is defined in relation to residentialcare. Services may only be provided to persons who are at risk of‘ inappropriate ’ nursing home admission. The task of deciding whetheror not such admission is appropriate is performed by Aged CareAssessment Teams (ACATs). Recent figures show that ‘one in five ofthose assessed are recommended for nursing home care with the greatmajority being recommended for community care’ (Giles : ).



Social isolation in old age

While the reforms to aged care of the past decade have generallyreceived widespread approval, they have not remained uncontested.One challenge has come from researchers who have argued that themain burden of providing ‘community care’ actually falls on informalcarers, mainly female relatives (see, for example, Dalley ; Finchand Groves ; Lingsom ; Qureshi and Walker ). Othercritics refer to problems associated with home care for older peoplethemselves, particularly those living alone. Apart from physical dangers(falls, scalds, and so on), being ‘at home’ may mean being lonely,isolated and afraid. It has been suggested that the assistance receivedby many frail older people may ensure their basic survival but couldscarcely be seen to offer a ‘quality ’ life. One British study, for example,reported that ‘ the proportion of people who sat for hours on end doingnothing in residential care was almost identical to the proportion ofpeople who did so before admission’ (Baldwin et al. : ).

In , nearly one-third of clients referred to ACATs were reportedto be socially isolated (Price et al. : ). In this context,Australian commentators have pointed to the massive fundingimbalance between core ‘maintenance’ services and those which couldbe seen to have a more socialising function, such as transport (Healy ; Minichiello et al. ). In New South Wales, for instance,approximately per cent of the HACC budget goes to the Home CareService, which provides household cleaning and personal care, andonly three per cent to community transport (Minichiello et al. :).

It was against this background that we decided to pursue researchinto the phenomenon of social isolation in old age. As sociologists whoteach in professional education programmes for health and welfarepractitioners, we were particularly interested in exploring its impli-cations in relation to the provision of supportive services.

The literature on social isolation

A vast gerontological literature has accumulated on the topic of socialisolation (e.g. Duncan and Kivett ; Creecy et al. ; Thompsonand Heller ; Berg et al. ; Page and Cole ; Mullins andDugan ). That old age is characterised by a generalised decreasein social participation, in both collective and individual terms, hasbecome a ‘given’ in the field. Declining social involvement is seen toresult from the cumulative effects of multiple role loss throughwithdrawal from the workforce, death of spouses and friends, caring




responsibilities, and the effects of chronic illness and disability. All theselosses, together with low levels of retirement income, are factors whichreduce opportunities for social interaction.

As a recent review of the empirical literature (Wenger et al. )makes clear, this enterprise has focused on identifying the range ofsocio-demographic and epidemiological correlates of the phenomenon.In particular, studies have sought to specify the main predisposing orrisk factors for isolation in the elderly population. The main reason fordoing so, the authors of this review point out, is because isolation is seenas a significant problem associated with old age insofar as it hasdetrimental effects on the health and quality of life of older people. Thisin turn creates a problem in social policy terms because sick andunhappy old people consume more public resources than well andcontented ones. Risk factors widely agreed to be of significanceinclude such things as poor health, low income, widowhood, caringresponsibilities and ethnicity.

Significant questions, however, remain unresolved. One of the mostimportant of these is the nature of the relationship between ‘objective ’and ‘subjective ’ dimensions of isolation. Wenger and her associatesargue that the term social isolation should be reserved for ‘ the objectivestate of having minimal contact with other people ; while lonelinessrefers to the subjective state of negative feelings associated withperceived social isolation, a lower level of contact than that desired orthe absence of a specific desired companion’ (Wenger et al. : ).But no direct link between isolation and loneliness has been established:while many of the same factors are associated with both ‘ interpretationsare not always consistent so that no unified model of isolation orloneliness exists ’ (Wenger et al. : ).

From their own study of elderly people in North Wales, the authorsconclude that social isolation in old age ‘appears to arise from factorswhich are largely beyond the control of the individual and which are,therefore, not obviously susceptible to amelioration’ (Wenger et al. : –). These objective factors were widowhood, living aloneand a privatised or household-focused social network. Two othersubjective factors – self-assessed poor health (leading to restrictedmobility) and low morale – were identified as correlates of lonelinessand as likely to exacerbate social isolation (Wenger et al. : –).

If isolation is ‘not obviously susceptible to amelioration’, what arethe implications of this for the role of service providers who are chargedwith the care of older people? In broad terms, of course, the concernof practitioners in aged care ‘ is to provide helpful and productiveassistance to older adults ’ (Polkinghorne : ). The Welsh study




did not set out to explore social policy and practice options associatedwith the management of social isolation in old age. The authors advisethat ‘practitioners should be aware of the predisposing factors andmaintain closer monitoring and surveillance of those recognised to beat risk of social isolation’ (Wenger et al. : –). Beyond this, theimplications for practitioners are not elaborated.

Yet service providers are expected in practice to play a central rolein the identification and management of social isolation. Publicpolicies, programmes and services are not designed or implemented byolder people. Their needs are identified (‘assessed’) by professionalexperts, and appropriate interventions are planned and delivered byothers on their behalf. As Lingsom ( : ) points out,

needs are not facts but judgements and, as such, are part of policy. Needs, aswell as obligations to respond to needs, are subject to continual negotiation byparticipants within the aged care system…Patterns of interactions between‘people-processors ’ and clients limit demand and shape needs in the categoriesemployed by service providers.

In such negotiations, relations between service provider and client havebeen characterised as inherently asymmetrical, since the balance ofpower rests ultimately with the former (Estes ; Healy ;Minichiello et al. ). This is likely to be the case, Lingsom ( :) suggests, even when the formal care worker does not belong to apowerful professional group:

…what occupations such as nurses’ aids and home helpers may lack inprofessional esteem and authority, they make up for by their control over theallocation of resources and autonomy in daily practice. There is great leewayfor service provider discretion in deciding who needs care the most and howthe day-to-day interactions with clients are organised.

As recent Australian research has shown, the assessment procedureemployed in community service provision is

essentially subjective and discretionary, depending greatly on the experienceof the assessor. Judgements about need [are] made…on the basis ofprofessional knowledge, experience, ‘gut feelings ’ and the feedback fromsubsequent visits. (Fine and Thomson : )

In other words, the characteristics and behaviours of older peoplethemselves are not the only logical source of research data about thephenomenon of social isolation. The situations in which isolation isidentified, and from which outcomes ensue, take the form of face-to-face interactions between individual service providers and their elderlyclients. It follows that it is not enough to know what older people bringto such encounters in the way of objective characteristics or even in




terms of their subjective perceptions. We also need to know about howproviders themselves construct the reality of social isolation and toidentify the salient features of its negotiation.

As we have seen, the literature offers service providers at best aninconclusive body of research-based knowledge on which to draw whenthey assess older clients and their needs in relation to social isolation. Atthe same time, their expected practice is minimally guided by explicitservice rules and procedures. What, then, is the nature of theseproviders ’ experience as carers of such people? What do they actuallydo to provide ‘helpful and productive assistance’, and how do they

interpret what they do?

A sociological framework

While there is a body of social-psychological research on aspects ofclinical decision-making in aged care (dela Cruz ; Clark ;Polkinghorne ; Saveman et al. ), such work has tended tofocus on cognitive and, at most, micro-level social factors. But

provision of formal assistance to people in their own home takes place withina larger system of government policy and funding, over which those in thelocal community have little direct control…With only limited resources attheir disposal, the staff of community support services [are] faced with the taskof interpreting broader policy objectives and developing practical strategieswhich would enable them to identify and assist their clientele. (Fine andThomson : )

In other words, what is required is a sociological framework which can‘address the relationship between micro and macro levels of analysis,the nature of the links between agency and structure, and focusespecially on the notion of social hierarchies ’ (Bury : ). There isan extensive literature devoted to the relationship between structureand human agency or action. One of its most influential contributorssuggests that social structure refers to social rules and resources whichboth impose constraints on and create opportunities for human action(Giddens ). But they do so through ‘specific relational settings ’(Somers and Gibson : ). As Bob Jessop ( : ) comments :

Structures do not exist outside of specific spatial and temporal horizons ofaction pursued by specific actors acting alone or together and in the face ofopposition from others. Likewise, actors always act in specific action contextswhich depend on the coupling between specific institutional materialities andthe interaction of other social actors.




Human action or practice, in other words, is always subject to factorsbeyond individual control or, in sociological terms, social structure(Bourdieu ; Giddens ; Calhoun ; Somers and Gibson ; Connell ; Jessop ).

We have adopted such a conceptual framework in the design of ourresearch project. In this framework, social phenomena are understoodas human practice undertaken by social agents or actors located withinspecific relational settings. The nature of such practice is multi-facetedor multi-layered and includes, among other dimensions, the symbolicor interpretive. What people do, and how they interpret or make senseof what they do, are social practices fundamental to understandingsocial phenomena (Silverman ).

Research design and methodology

Conceptualising social isolation in this way has important methodo-logical implications. Because the focus of inquiry is on issues of humanexperience, interpersonal interactions and meanings, a qualitativeresearch design is required. Qualitative research, of course, does notaim to yield statistically generalisable results. It is particularly valuablewhen (as here) the topic of inquiry has been minimally investigatedand its key dimensions remain unidentified.

Our aim, then, was to obtain service providers’ accounts of theireveryday practice in relation to social isolation among their elderlyclients. Given the qualitative, exploratory nature of the study, weadopted a purposive sampling strategy. We wanted informants whowould be able to generate a rich body of talk about the phenomenonout of their own experience and from a diversity of professionalbackgrounds and occupational roles. Although such a sample does notlend itself to internal statistical analysis nor to external generalisation,it maximises the extent to which a wide range of potentially relevantthemes and issues can emerge.

The sample of service providers was drawn from several sources.It comprised eight students enrolled in postgraduate courses at TheUniversity of Sydney who were currently employed in aged careservices, five professional colleagues of some of these participants, andfive hospital-based workers recruited through personal contacts. Teninterviews were individually conducted with providers ; in two cases, atthe respondents’ request, two workers were interviewed together andone session involved four community nurses.




The interviews were semi-structured, guided by four broad topic areas :

E providers’ overall work context and roleE their definition of social isolation, its causes and consequencesE specific practices adopted in relation to social isolation among

clients, especially strategies for assessment and interventionE actual examples or case studies from their own experience of (i)

clients whom they have perceived to be socially isolated and (ii)clients they would describe as not socially isolated. For ethicalreasons, these were requested (if not already volunteered) asanonymised accounts of past or present clients.

Most of these interviews were tape-recorded and transcribed. In twocases (actually one interview with two providers), permission to do sowas not given so, in accordance with ethical requirements, shorthandnotes were taken.

A method of analysis based on the techniques associated with thegrounded theory approach was employed (Glaser and Strauss ).Essentially, these entail the inductive generation of explanatorycategories through continuous interplay between data collection andanalysis. In this constant comparative method, ‘data collection,analysis and theory stand in reciprocal relationship with each other ’(Strauss and Corbin : ). This process generates emergentcategories which can be ‘checked out ’ in subsequent interviews. Forexample, in relation to the guiding question about ‘causes of socialisolation’, early interviews produced (in addition to the expectedchecklist of physical deficits) the substantive code ‘ life-long loner’.Similarly, questions about how providers ‘knew’ when they weredealing with a case of social isolation yielded expressions such as‘hanging on to you’ or ‘wanting to talk about their past lives ’ whichwe coded into a category of ‘ interactional evidence’. Where suchconcepts did not emerge spontaneously in later interviews (and, for themost part, they did), a specific question was asked.

The service providers and their work

The service providers we interviewed, all of them women, comprisedseven community nurses, a clinical nurse consultant in aged care, threephysiotherapists, one occupational therapist, three social workers, two(untrained) community care workers and one coordinator of adementia home support programme. Five (a physiotherapist, the




clinical nurse consultant, occupational therapist and two socialworkers) were hospital-based and two of these (the OT and one socialworker) saw only in-patients. Another physiotherapist worked in alarge retirement village}hostel complex, and the third managed acommunity team providing services to people with an intellectualdisability (few of her clients were older people).

Typically, community nurses and care workers were assigned agroup ( to ) of clients whom they visited on a regular basis,sometimes daily. The community nurses provided ‘hands on’ assistance(e.g. medications, treatment of wounds, palliative care, help withpersonal hygiene) to clients in their own homes. The untrained careworkers performed domestic (e.g. house cleaning, making breakfast)and personal care (e.g. showering) tasks. Respondents who worked ata more senior level identified their main role as other than hands oninvolvement (such as service coordination, staff supervision and}ortraining) ; however, all reported that they were also in direct contactwith clients on a regular basis. A senior social worker, for instance, saidthat she would ‘see about or people a month’.

Providers’ constructions of social isolation

All respondents provided a definition of social isolation when asked andidentified socially isolated individuals. All definitions began with somereference to an ‘objective state of having minimal contact ’. Forexample:

I would define it in terms of not being physically able to go out. That wouldbe the first criterion. Number two, they may not have any member of thefamily or friends able to or willing to visit them. That would be the secondcriterion. Those two are the most important. (community nurse u )

At the same time, all indicated that such an objective definition was notsufficient. How people felt about contact with others (or lack thereof),its subjective meaning or relational significance, was seen to becritical :

For someone to be socially isolated, it would have to be something that theysee is happening, because there are different levels of how much contact eachof us wants in life. (home nursing service coordinator u )

To no longer feel isolated, you need more than a presence. There can bepeople around and you can still be terribly isolated…It is a lack of ameaningful relationship that makes you feel lonely. (hospital-based physio-therapist u )




To a degree, it is subjective. How they respond to circumstances is, really, inthe end, what matters. How they feel about their circumstances will determinewhether they feel isolated or not. (community nurse u )

Clearly, then, practitioners’ definitions of social isolation reflected thedichotomised model which prevails in research literature. Theydistinguished between objective and subjective aspects of the phenom-enon. It was the latter, however, which they emphasised. In thelanguage of research, the critical factor was loneliness or ‘perceivedsocial isolation’.

Practitioners described isolation as a widespread and significantsocial problem among older people generally and their own clients inparticular. In identifying the causes of social isolation, they mentioneda range of individual deficits associated with old age. Factors reportedby all respondents (and usually in combination) were decliningphysical health status (particularly impaired mobility) and loss offamily and}or friends. Relatively few providers identified structuralfactors, such as inadequate income (four respondents) or being of non-English speaking background (two) as additional contributing factors.

At the same time, half of all respondents differentiated this kind of‘externally imposed’ isolation from what they saw as isolation ‘bychoice’. They saw some people as having a particular type of‘personality ’ which had led them to become life-long isolates. For suchpeople, isolation did not carry the same negative consequences forwellbeing, since they were ‘quite satisfied with their own company’. Asthe clinical nurse consultant expressed this dichotomy:

From my point of view, the main cause of social isolation is either choice or amedical condition making them housebound. (clinical nurse consultant u )

For those perceived as having age-related deficits, on the other hand,the consequences of social isolation were seen to include a range ofphysical and mental health problems:

…depression, focus on the self. Their conversation – the little they have – isentirely focused on themselves. It is as if the rest of the world no longerexisted…They will keep you with them for an hour just talking about theiraches and pains, the sadness of growing old, the loneliness of being old.(community nurse u )

…the psychological problems from not having stimulation, hygiene problems,further medical problems, the despair of loneliness. (clinical nurse consultantu )

Some of them are so lonely and so depressed that they’d rather be dead.(hospital-based physiotherapist u )




Loneliness, continuing bad health, reaching out to doctors by numerousreferrals for pain and other things that are pseudo complaints, easy crying ordepression, living in the past. (community social worker u )

Discovering and encountering isolation

How did providers identify cases of social isolation? They cited bothobjective and subjective kinds of evidence about the presence orotherwise of social isolation. The main objective indicator wasfrequency of contact with other people :

We do a full data base about our clients and we have included in that aquestion about contacts people have…if they see anyone outside of the houseor coming to visit them. (home nursing service coordinator u )

The appearance of the premises and}or person could also provideevidence:

One can usually tell how well they are coping with the daily tasks. The placeis often quite dirty, there is no or little food in the house, there is no house pridein the place, their self esteem is eroded, they don’t carry themselves with anysense of presentation, they don’t show the insight to be able to reflect abouttheir own needs. (community social worker u )

As the previous discussion has shown, however, objective levels ofcontact were perceived as necessary but not sufficient indicators ofsocial isolation. Rather, it was the absence of ‘meaningful relationship’which rendered old people at risk. When specifying the kinds of socialcontacts which constitute, actually or potentially, those ‘meaningfulrelationships ’ which protect against isolation, providers universallyidentified the classic gerontological social support network of familyand same-age friends. Other forms of contact, including that withservice providers, was not ascribed such potential.

Indeed, only having contact with service providers was often includedin the definition of social isolation itself. One worker, for example,identified a widower in his s as one of her socially isolated clients.This man lived alone, suffered impaired mobility and had a restrictedincome. His family, she reported, did not visit him frequently and hisfriends had died, ‘ so that the only people he sees are us and meals onwheels ’. Others echoed this construction:

From my perspective, a person who is socially isolated is a person who is losinghis or her confidence to go out anywhere at all, has no rapport with her family,




only sees carers like me and meals on wheels. Such a person is not interactingwith society. I would call her socially isolated. (community nurse u )

Isolated means – not necessarily physically, although it could be physically –but it also could be emotionally, mentally, from things or people or events theyhave been associated with at some point in time…With our service, they arenot so much physically isolated – they are not completely isolated, put it thatway – because we are coming in. But many are still lacking in something.(community care worker u )

When you have a person who is living alone, she may be isolated, she can’t goout, she can be day after day without speaking to anyone except the carers orus. That’s not conducive to quality of life. (community nurse u )

Providers identified several sources of subjective evidence of theabsence of meaningful relationships. One obvious source was clients’self-reports :

They tell me that they are sad and unhappy and they just want to stay in theirown rooms and they don’t want to go where people congregate. (seniorphysiotherapist, retirement village u )

People sometimes also volunteer the information when we ask them whatproblems do they see, what would they like to have help with. ‘I feel lonely’,or ‘No-one ever comes to see me’ – these are the sort of things people who areisolated may say. (home nursing service coordinator u )

However this source was also perceived as problematic. Here acommon theme in providers’ accounts was that many older people werereluctant to admit to being isolated or lonely:

Not all of them will say so. (community care worker u )

Some are very private about their own feelings and they don’t want pity.(clinical nurse consultant u )

The principal explanation advanced for this reluctance to self-identifyas isolated}lonely was the perceived centrality of independence to anolder person’s construction of their identity :

…because if you express it and admit that you can’t do anything about it, youfeel that you have lost something in your life. You have already lost a lot ofyour independence if you need nursing or other services, and feeling lonely isanother failure for them to deal with. (community nurse u )

It is often a problem that some people mask their coping abilities…With theelderly, there is always a fear that their independence will be taken away andthat they will be removed from their environment, even though they are notcoping well in that environment. (community nurse u )

It is true that most people whom you ask, ‘Do you feel lonely? ’, most peoplesay, ‘No, I’m not’. Among these, some may never have been keen to have




more contacts than they have now, while others may cover up their lonelinessto outsiders. (home nursing service coordinator u )

Hence, neither objective nor subjective sources of information about orprovided by older people themselves was perceived as adequatelyidentifying all socially isolated individuals. Rather, providers’ accountsdisclosed, such identification occurred within the specific context orsetting of their professional relationship with individual clients, andthey themselves were key agents or actors in its negotiation. From theperspective of senior staff, their own professional experience was the keyto recognising isolation when they saw it :

When you have been in the community for a long time as I have, you recognisepeople who are socially isolated. (community nurse u )

[Interviewer] Do you use a checklist or form which guides you in yourassessment?

No, it is purely from experience, I don’t have a set format that I follow. At thebeginning I used to, but not now. (clinical nurse consultant u )

All providers in fact interpreted a specific type of professional-clientinteraction as constituting, for them, the most telling evidence of socialisolation. What they talked about here was the client who tried to usethe provider’s visit as an opportunity for social interaction:

You recognise people who are socially isolated because the majority of thosewho want to keep you longer than you should, talking about their past lives.You just know…The lonely clients do the same with everyone. They need totalk and keep you there as if you were a friend. (community nurse u )

I assume that they miss someone to talk to intimately, and you can guess byhow much they want to tell you. Their enthusiasm and their need to talk toyou are symptoms of the fact that they are lonely. They don’t want you toleave, they try to keep you longer even after the physio treatment is finished.(hospital-based physiotherapist u )

When we come in and we are the only visitor they are going to have all day,they are going to try and keep you there as long as possible. They either talk,talk, talk and some are very crafty at manipulating and they will do their bestto keep you in the house as long as they can…That will be for me anindication of some sort of isolation. (community care worker u )

People [who are socially isolated] like to feel that someone is listening to themand that they are getting someone’s attention. (community nurse u )

One of the major [signs of social isolation] is that they grasp for you. Theyreally want you there and will go in some cases to extraordinary measures tomaintain you in their environment, or will make sure that you are coming




back. I don’t think they would admit it openly, but they use a lot of tactics tomaintain you in close contact. Some are direct, others don’t even know thatthey are doing it. One can see their great pleasure in having you withthem…They are so happy to have you there and they appear pleasured by thesheer fact of you being there. (clinical nurse consultant u )

In other words, service providers interpreted some elderly clients asattempting to engage in the construction of a personal relationship withthem: ‘They treat you like a friend’. Moreover, they reported that sucha construction assisted their own professional practice insofar as itfacilitated the task of assessing whether the client was isolated. This isbecause the client was believed to be more willing to disclose how they‘really ’ feel about his or her state :

Some [hostel] residents will tell you [they are lonely], because with them therelationship became very strong because they saw you every day over theyears. (community care worker u )

Not many just come out and say ‘I am terribly lonely’ when you just meetthem. Sometimes they admit directly that they are lonely when you get toknow them better. (hospital-based physiotherapist u )

Several respondents further suggested that the actual nature of theirwork practices sometimes led clients to ‘open up’ to them. These wereworkers who provided intimate physical services during which, theyobserved, some older clients disclosed highly personal details abouttheir lives :

When you are showering someone they are in a very vulnerable situation, andI often find that they expose their lives much more. Not only their bodies, buttheir lives. And they talk about things they did with their husband, thingsfrom their childhood – not so much what they did yesterday or what they’ll dotomorrow, but personal experiences and feelings. Normally, it’s in the shower.I just noticed that association. And then they carry on when you sit down andhave a cup of tea. (community care worker u )

Sometimes people feel that a nurse can listen to something intimate to whichthey have been holding on for a long time. (community nurse u )

While you are dressing a wound, all sorts of memories are triggered thatsurface when you feel vulnerable. Sometimes it happens because there is noone else to talk to all day and for days, and sometimes it just happens in thatfleeting moment when you feel the weight of the whole world on yourshoulders because you are in pain. (community nurse u )

You do such personal things, showering and things like that. First it is sort oftricky, you know, the clients get a bit embarrassed, and you can actually pickup when you are getting closer to them emotionally. (community care workeru )




Intervening in social isolation

What strategies did providers believe were available to them to addressthe social isolation of their clients? Many of those with managementresponsibilities commented in one way or another on the inadequacy ofthe resources at their disposal to meet clients’ needs. For example:

For the government, community services are a cheap way to opt out fromproviding the services that people really need and are not getting. Whenpeople can’t cope any more in their own homes, someone has to pick up thetab and it is generally the community or their relatives. It is cheaper to do thatif you give people only the strict minimum they need to survive at a physicallevel. Forget about quality of life ! (senior social worker u )

Oh, the funding’s OK but this is because there are needs that are not met !(home nursing service coordinator u )

There is a high demand for the support services to carers [of dementiasufferers], but there is a shortage of people willing to work in that area becauseof the burnout stress…It is not particularly well paid – they get $. anhour, the wage an untrained person like a cleaner would be getting. (dementiahome support group coordinator u )

Within this context of limited resources, providers described onlylimited service options : they could offer clients socialising communityservices for the frail elders, such as day care or (much less frequently)home visiting or telephone contact. At the same time, however, theyreported that this often proved completely ineffective. For example, aphysiotherapist working in a retirement village described how herfacility had had a project running for the last two years which was‘ trying to tap into those very people ’ but which had met with littlesuccess :

It has been very difficult. None of the things we have put on in such socialintervention programs with the hope of attracting these people have beensuccessful in getting them out of their rooms. (senior physiotherapist, retirementvillage u )

Providers identified a range of factors which they believed contributedto the inadequacy of such an approach. Some referred to theinappropriateness of the service itself for some of their clients :

It would be good if there were more activities for people who are mentallyalert. A lot of day care centres cater almost exclusively for people withdementia and they are marvellous for these people and their carers but theydo not suit those who are mentally alert, and there aren’t many outings forpeople like that who live by themselves – I mean, concerts and things like that.(community nurse u )




I have encouraged one person to go to day care and he’s been several times,but he said that people go to sleep there while he is talking to them. He is quitegood mentally. He did not have the mental stimulation at home, but it was nobetter at day care. (community nurse u )

Aged care outings are other activities that may not be particularly ‘bonding’,but people like them because they are driven around and see other places thantheir own. But you have to be reasonably fit to join it, because you have toclimb in and out of those buses. And you have to have a reasonable level ofEnglish otherwise you are going to be isolated from the other people and thatwill make the older person feel even worse. (community nurse u )

People who hate playing games like bridge or scrabble or bingo would find nosolace in these activities even with other people around them. (dementia homesupport group coordinator u )

Most respondents, however, emphasised the inability of formallyorganised services to provide a genuine solution to the kind of lonelinessthey believed characterised the lives of many of their clients :

But often with an adult who is not demented and who may be lonely, theyactually don’t want to use anything like that. What they are missing is thesorts of contacts that you and I enjoy, where you select who you are with. Theyusually don’t want to go out to a club. (home nursing service coordinatoru )

It is not that services can’t be implemented. There are day care centres theycould go to. We try to encourage them to be involved in that. But I think theunderlying problem that these people have is that they have outlived theirloves and their support network, so what they are left with is day care! Sowhat? They can go along and be ‘social ’, but that does not meet theirunderlying need for meaningful interaction. (community nurse u )

Of all the things we look at in the planning of health, social isolation stilldoesn’t get addressed. We can try with our resources to address some of thephysical things, but how do you solve an isolation problem – that need somepeople have for meaningful relationships? They won’t find it in a day carecentre, even if they accept going there! (hospital-based physiotherapist u )

Practitioner-client relations in the context of social isolation

One of the particular strengths of qualitative research is its capacity togenerate unexpected findings. In the present study, this occurred inrelation to the ways in which practitioners talked about the relationalqualities of their own interaction with isolated clients. As we notedearlier, aspects of this interaction played an important role in the actualprocess of assessing whether an elderly person was isolated or not. At




the same time, some providers observed that, in contrast to theineffectiveness of organised socialising services in generating‘meaningful relationships ’ for many isolated people, some clientswished to develop such a relationship with them :

These are usually people who may form an attachment to the nurse who visitsevery day but who refuse to see anyone else. (community nurse u )

When you think [clients] may be [isolated], that is when I suggest that thereare some services out there that they may want to try. ‘No’, they say, ‘I don’twant that. It is just that I’ve got to know you and I feel comfortable talkingto you. I don’t want to go to places where there are crowds of people I don’tknow. I’m okay’. But I often feel uneasy, because I know that our services aregoing to stop once nursing is no longer needed and that they will have no-oneto talk to. (community nurse u )

From the providers’ perspective, however, the development of suchrelationships was simply not possible. They advanced two main reasonsfor this. First, they did not have the resources which would permit themto spend time with their clients :

They generally don’t want to go out and mix with groups, but they are quitehappy generally in their own environment. But they’d just love to have a one-to-one contact.

[Interviewer] Can you help meeting that need?

Not really, because I usually have to rush off to my next appointment.(community nurse u )

I think in some cases it [holding on to you] is definitely because they are lonelyand it is very hard to go away without appearing rude. They always tell youtheir life story just when time comes and you have to rush to your nextappointment. (community nurse u )

We spend about one-and-a-half to two hours per day with a client. That leaveslittle time to chat…We travel a lot and often we are late and get held up andthen some of the clients don’t understand why we are running late…We tryto get all the showers done in the morning and when people need houseworkdone, someone may call later during the day or I go back later in the day.(community care worker u )

[Working with elderly people] can be frustrating if I am in a hurry becausethere is so much to do. My timetable is very tight and they are very slow. Ican spend up to two hours with a client. (community care worker u )

Another constraint identified by several practitioners was the existenceof an organisational policy which requires them to rotate their clientbase. This policy was attributed to two factors. The first of these, in thewords of one community care worker, was ‘related to workloads’ since




some areas were known to be ‘more demanding’ than others. Thesecond is bound up with the code or ‘rules ’ regarding the need forprofessional objectivity or detachment. Commenting on this practice, anurse observed that the clients themselves ‘don’t like it because they getattached to their nurse ’ but, she went on to say, it is actually ‘good for ’the client because s}he will be seen with ‘ fresh eyes ’ :

It only takes them a couple of months or so before they get used to their newnurse, and it is good for us because there will be more than one nurse whoknows about the case…We can discuss whatever needs to be discussed.(community nurse u )

A community care worker echoed the view that emotional attachmentwas to be avoided in the best interests of both the provider and theclient :

We are in the process of changing carers. The supervisor has decided that weshould not become too dependent on our clients and they should not becometoo dependent on us. Some of the carers are very upset about that and someclients are too. It will take time for some of our clients to get to trust a newcarer. (community care worker u )

Providers’ responses and the paradox of ‘choice’

It was clear from the accounts of many providers that they were notimmune to personal feelings of sadness about the loneliness of theirclients and expressed frustration at the limitations on their capacity toalleviate it. What, then, was their response to this dilemma? Whilereference to inadequate levels of funding were common, no specificsuggestions were forthcoming as to how increased resources might moreeffectively be deployed. It was evident from their own accounts thatthey did not see ‘more of the same’ as a solution. Even if existingservices were more widely available, they would still remain un-acceptable to many old people, and inaccessible to the frail and sick.Given the limited contribution to practice provided by availableresearch and policy literature, it should hardly be surprising thatservice providers find social isolation a problem which is ‘not obviouslysusceptible to amelioration’.

At the same time, the interviews suggest that the philosophy of client‘ independence’ and ‘choice’ which underpins the provision of careservices for older people may be having a paradoxical effect. The rightof client ‘choice ’ is embodied in the core values of Australian aged carepolicy (Fine and Thomson : ). Our interviewees made frequent




reference to the importance which their own service attached to thisimperative and to the ways in which, in turn, it had come to informtheir interpretation of older people’s needs and of their own professionalpractice. For example:

There could well be people within these [group] homes who choose to beisolated and the Disability Services Act now overrides everything we do. Wemust ensure that all the clients have a choice in what they do. So they canchoose to be isolated or choose to take part. That is not only the philosophyof the standards, but it is the law now. Choice is central to any service we areproviding. (physiotherapist, community team manager u )

It is very common that you really don’t know what is best for yourclient…You learn after a while that you, as a nurse, and we, as serviceproviders, can only do that much. We are there to help and advise, but we arenot there to make decisions on our clients’ behalf…In nursing you learn togive and to accept that you are not responsible for people’s choices. I learn toaccept that sometimes there is nothing else I can do. (community nurse u )

In other words, the concept of ‘choice ’ is interpreted in a highly specificand limited way. It entitles those whom providers have identified as‘ loners ’ to be ‘ left alone’, and others to refuse a service they do not like.Even when a service, such as day care, is demonstrably – in the eyes ofprofessionals themselves – unable to meet a client’s needs, rejection isinterpreted as evidence that the older person is exercising their right tomake decisions for themselves. Within prevailing policy guidelines, theservice provider can only fulfil her professional responsibilities byrespecting that right.

Discussion

The service providers we interviewed described social isolation amongtheir clients and their own professional role in some considerable andobservant detail. Our analysis has demonstrated the explanatorypower of a theoretical framework in which the provision of services toisolated old people is conceptualised as an interpretive social practice.Within the relational setting between practitioner and client, ‘ isolation’is identified and, within structural limits, acted upon.

Clearly, this particular study can lay no claim to statisticalgeneralisability. Such was not its intention. The sample of serviceproviders was relatively small and non-representative. Nonetheless, theextent to which their responses converged around a common set ofthemes and issues was striking and suggests that further research along




these lines is warranted. Future work, for example, could providecomparative data with respect to different occupational groupings,service delivery settings and socio-demographic characteristics ofpractitioners (such as gender, work history, education and so on). Also,of course, we need to know how older clients themselves perceiveisolation and their own relationships with service providers. This is infact the focus of a related project which we are currently pursuing.

On the basis of these data, we would propose that the work practicesof service providers who deal with isolated clients are structured orconstrained in two main ways. First, because of inadequate publicresource allocation, the relationship between practitioners and olderclients is dominated by time pressure and instrumentality. At a time ofcontracting public welfare expenditure, tightly rationalised timemanagement regimens have been adopted in the organisation ofpublicly administered health services.

At the same time, the organisational and professional rules whichservice providers are required to follow, directly contribute to theprocess and outcomes of service provision. They shape the interpersonalrelations between practitioner and client as ‘properly’ characterised bydetachment and lack of continuity: whatever practitioners or clientsmay feel about it, ‘emotional care…is not part of what explicitly isoffered by formal services ’ (Andersson : ).

Furthermore, the policy construction of the client’s right to ‘choice’and its implementation in service provision has a paradoxical effect onthe agency accorded to older people. It does not extend to the right tochoose a worker whom one knows and likes, or to spend non-instrumentally oriented time with her or him. The policy in this contextprecludes the notion that older people have the right to participate in thedesign and execution of services that suit them.

From the perspective of service providers, it is clear that the existing‘ structures of practice ’ (Connell ) within aged care offer nosolution to the problems of their frail, isolated clients. Providersreported widespread dissatisfaction and resistance among older peopleto organised day care. For the needs of the very frail – that is, preciselythose housebound elderly people whom providers identify as most atrisk of social isolation – such ‘away-from-home’ programmes (evenwhen transport is provided) are largely irrelevant.

Nor do the prevailing structures of practice offer providers themselvesa means of addressing their own feelings of powerlessness to offer‘helpful and productive assistance’. They will continue to confront asuccession of lonely, isolated and depressed older people for whom‘there is nothing else I can do’. The faces will change. Some clients will




no longer need nursing or other instrumental assistance, the servicewill stop, and ‘they will have no-one to talk to’. Others will be rotatedout of their care, and they will begin the whole process anew, with‘ fresh eyes ’ but an unchanging and apparently unchangeable problem.Their sense of frustration is eminently understandable : their role inaddressing isolation, as they see it, is limited to identifying the optionsavailable to clients for other, explicitly ‘ social ’ services, yet they knowthat these services are often neither appropriate nor acceptable.

Clearly, without a radical departure from prevailing thinking withinpolicy and research, the problem of social isolation among the very oldand frail will continue to languish in the ‘no-care zone’ of serviceprovision (Wallace ). Equally clearly, any major challenge toexisting structures of practice within older people’s care would not onlyrequire considerably enlarged public resource allocations, but alsomajor shifts in policy discourse around the clients’ needs andentitlements. To reconstitute publicly funded service providers andolder people as inter-subjective agents engaged in an enterprise of‘dismantling’ isolation and making sociability, would require athorough-going recasting of ideas about citizenship, about sociallyisolated older people, and about the nature of professional care. Itwould entail, as Estes () has proposed, replacing the presentapproach with an ‘empowerment imperative’ at three levels ofintervention: the everyday life of frail older people, professionalpractice and organisation, and social structure.

Acknowledgements

The research reported here was funded by an Australian Research CouncilInstitutional Grant administered by the University of Sydney. The interviewswere conducted by Dr Vera Sauran, whose invaluable contribution to theproject is gratefully acknowledged.

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Accepted �� May ��Address for correspondence:

Cherry Russell, Senior Lecturer, School of Behavioural andCommunity Health Sciences, Faculty of Health Sciences, TheUniversity of Sydney, PO Box , Lidcombe, NSW ,Australia.


Social isolation in old age: a qualitative exploration of service providers' perceptions

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