INDIVIDUAL AND SOCIAL IDENTITY OF RESIDENTS OF OLD PEOPLE'S HOMES IN SLOVENIA
INDIVIDUALNA IN DRUŽBENA IDENTITETA STANOVALCEV DOMOV STAREJŠIH OBČANOV V SLOVENIJI
Marija Zaletel1, Tina Levec1, Andreja Mihelič Zajec1, Lijana Zaletel Kragelj2 Prispelo: 15. 3. 2011 - Sprejeto: 29. 6. 2011
Original scientific article UDC 364.65-053.9(497.4):316
Abstract
Aim: The a^im of the study we^s to assess the de^gr^ee of individuell and social identity of the elderly in institutiona^l car^e. The f^aper analyses the data, hitherto unav^ailable in Slovenia^, in or^der to contr^ibute to the ca^r^givers' knowledge of how to help th^ir clients pr^eser^e and ma^intain th^ir dignity, self-r^espect and identity.
Methods: A cr^oss-sectional study wa^s conducted during the period Decemt^er 2005-January 2C^06. Included in the study were 164 elderly r^esidents of 20 old peop^le's homes. The study insti^ument incorpor^ated 36 statements addr^essing indi^idua^l (15), na^rr^ow social (18), and br^oad social identity (3), v^hich the r^espond^nts were as^ed to agr^ee or disagr^ee \^ith. The Mann-Whitney and Kr^uskal-Wallis tests wer^e used to facilitate data ana^lysis of the r^espond^nts' gender, ag^, education and origina^l r^esid^nce environment.
Results: The r^esults of the study showed no cor^r^ela^ion t^etwe^n the degr^^e of indi^idua^l identity a^nd the r^espond^nts' gender^, a^g^, education and originali r^esid^nce environment. The cor^r^^lation between the nar^r^ow (p=0.007) and b^r^oad (p=0.016) social identity and the r^esidents' ^ducationa^l level, h^owev^r, wa^s statistically significant. In the latter two cases identity wa^s least p^ronounced in most educated r^espondents.
Conclusion: Educationa^l level of old people's home r^esidents cor^r^elates positively with their socia^l identity cr^isis. The findings may contribute to car^egi^ers understanding a^nd recognition of their r^ole in assisting the mor^e educated elderly effectively alleviate or prevent their social identity crisis. In view of the foregoing, the residents' quality of life and their overall well-being can be improved.
Key words: individual identity, social identity, old people's homes
Izvirni znanstveni članek UDK 364.65-053.9(497.4):316
Izvleček
Namen: Vse več starostnikov v Sloveniji preživi zadnje obdobje svojega življenja v domovih za starejše občane (DSO). Stanovalcu je tam odvzeta skrb za samega sebe, to pa pomeni tudi razkroj odnosa do lastne identitete. Da bi pomagali oskrbovalcem pri premagovanju krize identitete njihovih varovancev, smo se namenili oceniti stopnjo individualne identitete ter ožje in širše družbene identitete starostnikov glede na nekatere njihove značilnosti. Metode: Presečno pregledno raziskavo smo izvedli v decembru 2005 in januarju 2006. Udeležilo se je je 164 starostnikov iz 20 DSO. Merski instrument je bil vprašalnik, sestavljen iz 36 trditev (individualna identiteta 15, ožja družbena identiteta 18, širša družbena identiteta 3), katerim so udeleženci pritrdili ali pa jih zanikali. Razlike glede na spol, starost in izobrazbo starostnikov ter izvorno socialno okolje, v katerem so živeli pred preselitvijo v DSO, smo testirali z Mann-Whitneyevim testom oziroma Kruskal-Wallisovim testom.
Rezultati: Rezultati so pokazali, da stopnja individualne identitete ni povezana s spolom, starostjo, izobrazbo niti z izvornim socialnim okoljem. Po drugi strani pa sta bili tako stopnja ožje identitete (p=0,007) kot tudi stopnja širše družbene identitete (p=0,016) statistično pomembno povezani s stopnjo izobrazbe. V obeh primerih je bila identiteta najslabše izražena pri najbolj izobraženih udeležencih raziskave.
Zaključek: Kaže, da je kriza družbene identitete pri starostnikih, ki bivajo v DSO v Sloveniji, pomembno povezana
1 Univerza v Ljubljani, Zdravstvena fakulteta, Zdravstvena pot 5, 1000 Ljubljana
2Center za javno zdravje, Medicinska fakulteta Univerze v Ljubljani, Zaloška 4, 1000 Ljubljana Correspondence to: e-mail: lijana.kragelj@mf.uni-lj.si
njihovo izobrazbo. Ti rezultati lahko pomagajo oskrbovalnemu osebju v DSO, da s primernejšim pristopom k bolj izob^r^aženim v^r^o^ancem učinkoviteje pr^emaguje izr^aženo kr^izo. Vse to lah^o pomembno vpliva na ka^oi^ost življenja obr^avnav^ne skup^ine pr^ebivalcev DSO v prihodnosti.
Ključne besede: individualna identiteta, družbena identiteta, domovi starejših občanov
1 Introduction
Identity is a fundamental concept of modern social science, and includes all the essentials of a human being. It responds to continuously present dilemmas, such as: who we are, what we are, and what our purpose is. (1).The self-concept, or the cognitive definition of one's identity (2), can be viewed as the knowledge that a person has about him/herself. This knowledge of the self may cover many different areas including knowledge of the skills one does and does not possess , knowledge of one's attitudes and values, and knowledge of one's likes and dislikes, and of what one aspires to become (3). The self is not one-dimensional or static. A person's overall self is typically represented as a set of categories, each of which represents a distinct self or identity (3-6). These distinct selves or identities are typically tied to a particular social context. This means that people can have an identity for each of the different personal and social positions or role relationships they have in specific social contexts. The development of human identity is a lifelong process of change and perception, and never ends in a stable form of the character. Although the most important period is adolescence, development does not end then, but continues until death. An individual's identity includes both personal and social aspects, and is torn between his/her individuality and sociality (1,7). Consequently, the identity is split between the individual and collective. Concurrently with the person's maturing and ageing, his/her individual and social identity (in its narrower and broader sense) also changes. Goffman argued that identity is not only subjective, but is also shaped by an individual's social experience (8). Specifically, the roles that individuals occupy affect how they age (9). Many of these roles are related to life in the primary residence environment, but also to life in institutions. Also, they are related to attitudes to the elderly in society in general and in the residential environment, including institutions caring for old people and nursing homes. The ways in which people age are affected by the social locations through which they move, by the social and cultural conditions to which they are exposed at particular ages, and by the life-course experiences of those with whom they interact as they grow older (10). The social roles that people occupy
and the transitions they experience are particularly important. The way we perceive ourselves, our self-concept or identity, has profound effects on how we feel, think, and behave, and on the things we aim to achieve (11).
Most of our lives are spent in different kinds of institutions. The most active and productive part is spent in the institutions where we work, while many people also spend their retirement period in special institutions providing professional long-term care. In Slovenia, these institutions are called Old People's Homes (OPH). Every institution has a system of written and unwritten rules, and we need to adopt them and adapt to them. In any case, this adaptation may have a huge impact on our identity, frequently without our realising it. An OPH is an institution which allows for maximum spatial coherence (common dining room, common rooms for an afternoon chat, shared recreation), but minimal privacy and independence (12). Individuals in OPH no longer need to care for themselves (eating, personal hygiene and other activities of daily living). Before their entering the OPH, all vital activities were probably their own concern; whereas afterwards, these activities are to different degrees undertaken by carers. At the same time, an old person suddenly has a lot of free time on his/her hands, and therefore feels redundant, useless, lonely and increasingly afflicted by various diseases. This more or less inevitably leads to disintegration of the self-image/concept (12). Adaptation to the residential lifestyle is a long-term process in which an old person adapts to the institution and not vice versa, and which inevitably has a huge impact on their quality of life (13). This quality can be defined as the degree to which the elderly promote and maintain their personal identity, autonomy, freedom of choice and interaction with others (14). The self, as previously stated, is highly dynamic, and the specific content of the self-concept is dependent on the situation. The self-concept of a successful student, a worker performing their chosen occupation, a parent who has successful children, or a young pensioner who lives a fulfilling life of an elderly person among their loved ones is very different from the self-concept of an old person who has recently moved to an OPH. Concomitantly, diseases that lead to increasing dependence on other people accumulate. According to Bouchard Ryan et
al. the presence of diseases can consequently mean diminished power in relationships, fewer social roles and fewer satisfying social interactions (15). All this has a huge impact on individual as well as social identity of OPH residents.
Understanding the concepts of identity in relation to institutional care of the elderly is a very important element of nursing care for elderly residing OPH. Taking into account this concept, the efforts to preserve their health and their optimal degree of autonomy in physical, psychological and social terms (a holistic approach) may be much more effective. In this way, the objectives of the healthy ageing concept (16), the concept within the broader World Health Organization healthy settings model (17), can be more easily achieved in OPH.
Slovenia has a distinctly old population. According to the latest data of the Statistical Office of the Republic of Slovenia (SORS), at the beginning of 2010 338,265 people aged 65 years and over made up 16.5% of the population (18). Such a high proportion of seniors, which is still growing, and above all the high number of people over 80 years old, raise questions about how to address their health and social problems. At present , about 4% of old people in Slovenia live in an OPH with a nursing unit, yet every year there are more applicants for OPH than places available (18, 19). In order to collect as much relevant information as possible to help plan resident-friendly environments in OPH, we undertook to assess the degree of various types of identities, which relate to the elderly residing in OPH: individual identity, and narrow and broad social identity. This classification has been used at the Faculty of Health Sciences, University of Ljubljana, Slovenia, to study the identity of the elderly for several years (20). In this context, it was assumed that the degree of all types of old people's identity observed was related to their gender, age, education and social environment from which they moved to the OPH.
2 Participants and methods
2.1	Participants
This study was conducted within the context of the broader research project entitled 'Social determinants of identity among, and communication with, the elderly'. The data for the identity part of the study were collected during the period from December 2005 through January 2006. The sampling frame was the List of the OPH in the Republic of Slovenia at the time of the study (21). According to SORS, in 2005 there were 68 public OPH caring for 13,641 senior citizens (22).Twenty institutions (about 30%) were selected at random from the list, and then, from each of the selected institutions, ten elderly residents were randomly selected to participate in the study, making a total of 200. Elderly people cared for in OPH nursing departments were not included.
2.2	Study instrument and data collection
A list of 36 statements was used as a study instrument (Table 1). The instrument intended exclusively for studying identity issues among the elderly in Slovenia was prepared by Asja Nina Kovačev, a professor of psychology at the Ljubljana University Faculty of Health Sciences, and the first author of this paper. Fifteen statements are related to individual identity, eighteen to narrow social identity, and three to broad social identity. The statements were listed in a random order (Table 1) and the participants were asked to agree or disagree with each statement. Before use, the intelligibility of the claims was tested in a pilot study, which involved seven elderly people of different gender, age and educational level. Based on this study, all the ambiguities were resolved in the text of the instrument.
Table 1. The study instrument used in the study of individual (Ind), and narrow (Soc-n) and broad social
identity (Soc-b) of residents of old people's homes in Slovenia. Tabela 1. Seznam trditev kot instrument za raziskovanje individualne identitete (Ind) ter ožje (Soc-n) in širše družbene identitete (Soc-b) starostnikov, ki bivajo v domovih za starejše občane v Sloveniji.
Type of No.of points identity ifj'yes" measured Število Vrsta točk pri identitete odgovoru "da"
Statement
Trditev
1
2
10
11
12
13
I generally trust other people. Na splošno precej zaupam ljudem.
My personal values and moral standards significantly determine my self concept. Moje osebne vrednote in moralni standardi so pomembni za moje doživljanje samega sebe.
In general I feel comfortable in the company of other people - I feel accepted and loved, which is of great importance to me.
Načeloma se dobro počutim v družbi - ljudje me spiejemajo in imajo radi, kar mi veliko pomeni.
My family and ancestors have significantly influenced the way I view myself. Moja družina in moji predniki so pomembno vplivali name in na moje pojmovanje samega sebe.
For me it is important how people react to my words and actions Pomembno zame je, kako ljudje reagirajo na moje besede in moja dejanja.
I assign a fairly great importance to my physical attributes (appearance, weight , endurance, flexibility).
Precejšen pomen pripisujem svojemu zunanjemu videzu, svojim fizičnim sposobnostim (vzdržljivost, gibčnost).
I have always pursued my personal goals and future plans.
Vedno sem posvečal veliko pozornost svojim osebnim ciljem in načrtom za
prihodnost.
Ageing has diminished my aspirations to shape my own future. Z leti se je moja osebna zavzetost za vplivanje na lastno prihodnost zmanjšala.
Religion is very important to me. Vera je zame zelo pomembna.
My feelings and emotions represent an important part of my personality. Moja čustva in občutja predstavljajo pomemben del moje osebnosti.
I have always strived to gain respect in the community and I care about other people's opinion of me.
Vedno sem se trudil/a doseči določen ugled pri drugih ljudeh in ni mi vseeno, kaj si drugi mislijo o meni.
It is important to me to be relatively independent in activities of daily living. Pomemben je občutek, da sem še vedno dovolj samostojen/na in da nisem popolnoma odvisen/na od drugih.
Sometimes I like to take the initiative, start an activity or encourage others. Včasih rad/a prevzamem iniciativo - začnem s kakšno dejavnostjo ali spodbudim druge.
Soc-n Ind
Soc-n
Soc-b
Soc-n Ind
Ind
Ind Soc-b Ind
Soc-n
Ind Soc-n
0 0 1
3
4
5
6
7
8
9
1
1
1
14	I feel responsible for my actions.	Ind Čutim odgovornost za svoja dejanja.
15	Closeness and understanding play an important role in my life.	Soc-n Bližina in razumevanje igrata pomembno vlogo v mojem življenju.
16	I am not indifferent to my social environment.	Soc-n Ni mi vseeno, v kakšnem socialnem okolju živim.
17	My thoughts and feelings are an important part of my personal identity.	Ind Svoje misli in ideje pojmujem kot pomemben del lastne osebnosti.
18	I have changed a lot with advancing age.	Ind Z leti se je pri meni marsikaj spremenilo.
19	Compared to others I am still capable of doing many things.	Ind Vprimerjavi z drugimi ljudmi moje starosti, še vedno veliko zmorem.
20	I like helping other people and have good relationships with them.	Soc-n Rad pomagam drugim ljudem in imam dobre odnose z njimi.
21	Sometimes I feel lonely and I miss the company.	Soc-n Včasih sem osamljen in si želim več družbe.
22	It bothers me when I am treated as fully dependent on the help of others.	Ind Moti me, če se ljudje vedejo do mene tako, kot da sam nič več ne zmorem.
23	I miss my home and family.	Soc-n Pogrešam svoj dom in svoje domače.
24	Retirement was a big stress, bringing substantial changes to my life.	Soc-n Upokojitev je predstavljala precejšen šok zame, saj mi je v celoti spremenila
življenje.
25	I find living in OPH pleasant.	Soc-n Bivanje v domu starejših občanov je zame prijetno.
26	I believe that I am well accepted in the new community, which means a lot to me.	Soc-n Menim, da me ljudje dobro sprejemajo in to mi veliko pomeni.
27	Sometimes I feel strong fear and anxiety which are difficult to explain.	Ind Včasih začutim močan strah in tesnobo, ki si ju težko razložim.
28	I have always been strongly attached to my family and friends.	Soc-n Vedno sem bil/a zelo navezan/a na svojo družino in na svoje .prijatelje
29	I believe that men better cope with the advanced age than women.	Soc-b Menim, da moški lažje prenašajo starost.
30	In general I am a sociable person.	Soc-n Načeloma sem družabna oseba.
31	I have a good opinion of myself.	Ind O sebi imam dobro mnenje.
32	I feel strongly committed to the community I live in, i.e. to other OPH residents.	Soc-n Občutim močno pripadnost skupnosti, v kateri živim (tj. drugim domskim
varovancem).
33	Most of the things I did in my life fulfilled me emotionally, personally and mentally.	Ind V življenju sem večinoma delal/a stvari, ki so me čustveno, osebnostno in miselno izpolnjevale.
34	I am extremely satisfied with the OPH caregivers' attitude and I think they respect me. Soc-n Zelo sem zadovoljen z odnosom domskih uslužbencev do mene in mislim, da me spoštujejo.
1 1 1 1 1 1 1 0 1 1 0
1 1 0 1 0 1 1 1
1
35	In spite of a variety of physical changes I have remained the same person.	Ind Kljub številnim fizičnim spremembam v bistvu ostajam ista oseba.
36	I am deeply hurt at the demise of a friend or a peer. Soc-n _Hudo me prizadene, če izvem, da je nekdo od mojih prijateljev ali vrstnikov umrl._
Data collection was completed on the same day in all the selected OPH. It was conducted by students of the Ljubljana University Faculty of Health Sciences (formerly the College of Health Studies). The participants completed the questionnaires with the statements voluntarily and independently. They were asked not to identify themselves on the questionnaires. The students helped them only if necessary. The study was performed within the guidelines of the Ethics Committee of the Republic of Slovenia and was approved by the Ljubljana University Faculty of Health Sciences in 2003. Permission to conduct the study was obtained from the directors and head nurses of the selected OPH.
2.3 Statistical methods
For each statement, responses with a higher degree of identity (Yes or No) were assigned a value of one point (Table 1). For each type of identity, the points from each participant were added together. The resulting sum was the score that entered further analyses. A higher score indicated a higher degree of identity.
For each type of identity, minimum and maximum values, median value, interquartile range, and average rank of score were calculated. Gender differences were tested by the Mann-Whitney test, whereas the Kruskal-Wallis test was used for age (< 70 years ; 7180 years; > 81 years), educational level (completed primary school; completed vocational school; completed secondary school, completed college or university), and differences in primary residence social environment (urban; suburban; rural) (23).
A p-value of <0.05 was considered significant in all statistical tests. SPSS 15.0 for Windows (SPSS Inc., Chicago, IL) was used for analysis.
3 Results
3.1 Description of the sample
A total of 164 (82.0%) elderly people responded to the survey and properly completed the questionnaire. The characteristics of the sample are presented in Table 2.
Table 2. Description of the sample of the respondents in a study of individual identity and of narrow and
broad social identity of old people's home residents in Slovenia. Tabela 2. Opis vzorca udeležencev v raziskavi individualne ter ožje in širše družbene identitete starostnikov, ki bivajo v domovih za starejše občane v Sloveniji.
characteristic Značilnost
N
%
Gender Spol
Men Moški Women Ženske
37
127
22.6
77.4
Age Starost
< 70
Do vključno 70 let 71-80 years 71-80 let > 81 years 81 let in več
30 58 76
18.3
35.4 46.3
Educational level
Completed primary school
79
48.2
1
1
Izobrazba
Osnovna šola
Completed vocational school Poklicna šola
Completed secondary school, college or university degree
S^i^e^c^njc^, višnja., visok^a šola
34
51
20.7
31.1
Primary residence environment I^omo bivalno okolje
Urban
Mestno
Suburban
Pi^imestno
Rural
Vaš^o
53
36 75
32.3
22.0 45.7
Table 3. The avera^ge i^ank scoi^e of inCiviCual identity of 164 p^ai^icipe^nts of the study of inCiviCual anC nai^i^ow anC bi^oaC social identity of olCpeople's home i^esiC^nts in Slovenia by genCer, age gi^oup, educational level, a^nC piima^ty i^esiCence envii^onment, anC statistical significance of Ciffei^ences between the categoi^ies.
Tab^ela 3. Povp^iečni ia^ng v^i^eCnosti ^az^lni^a inCiviCu^lne iC^ntitete pi^i 164 uC^^l^ž^encih viazis^aviinCiviCualne tei ožje in šiiše Civ^b^ene iC^n^i^ete st^i^ostni^o^, l^i tii^ajo v Comovih za st^i^ejše obča^ne v Slo^^niji po spolu, st^i^osti, izobi^azb^i in bivalnem oIoIIu tei statistična značilnost meC l^ategoi^ijami.
Characteristic Značilnost
N
Average rank Povprečni rang
p
Gender Spol
Age Staiost
Educational level Izobiazba
Primary residence environment I^omo bivalno okolje
Men Moš^i Women Ženske
< 70 years Do vključno 70 let 71-80 years 7^1-^80 let > 81 years 81 let in več
Completed primary school Osnovna šola
Completed vocational school Poklicna šola
Completed secondary school, college or university degree Si^^Cnja^, ^išja, ^iso^a šola
Urban
Mestno
Suburban
Pn'm^tno
Rural
Vaško
37 127
30 58
76 79 34
51
53
36 75
76.6
84.2
78.4
84.3
82.8
79.8
79.9
88.4
91.7
79.3 77.6
0.384
0.854
0.557
0.218
3.2 Individual identity
For individual identity, the minimum value score was 5, the maximum value 15, the median value 13, and the interquartile range 12-14. There were no statistically significant differences between genders, age groups, educational level or primary residence social environment. The details are presented in Table 3.
3.3 Narrow social identity
For narrow social identity, the minimum value score was 6, the maximum value 18, the median value 15, and the interquartile range 13-16. A statistically significant difference was found between educational level categories, while there were no statistically significant differences between genders, age groups, or different primary residence social environments. The details are presented in Table 4.
Table 4. The average rank score of narrow social identity in 164 participants of the study of individual and narrow and broad social identity of old people's home residents in Slovenia, by gender, age group, educational level, and primary residence environment, and statistical significances between the categories.
Tabela 4. Povprečni rang vrednosti kazalnika ožje družbene identitete pri 164 udeležencih v raziskavi individualne ter ožje in širše družbene identitete starostnikov, ki bivajo v domovih za starejše občane v Sloveniji po spolu, starosti, izobrazbi in bivalnem okolju ter statistična značilnost med kategorijami.
characteristic Značilnost		N	Average rank Povprečni rang	P
Gender	Men	37	84.2	0.799
Spol	Moški			
	Women	127	82.0	
	Ženske			
Age	< 70 years	30	71.2	0.312
Starost	Do vključno 70 let			
	71-80 years	58	87.2	
	71-80 let			
	> 81 years	76	83.4	
	81 let in več			
Educational level	Completed primary school	79	87.6	0.007
Izobrazba	Osnovna šola			
	Completed vocational school	34	95.6	
	Poklicna šola			
	Completed secondary school, college or	51	65.9	
	university degree	\J I		
	Srednja, višja, visoka šola			
Primary residence community	Urban	53	75.9	0.446
Izvorno bivalno okolje	Mestno			
	Suburban	36	84.3	
	Primestno			
	Rural	75	86.3	
	Vaško			
3.4 Broad social identity
For broad social identity, the minimum value of score was 0, the maximum value 3, the median value 2, and the interquartile range 1-2. A statistically significant difference
was observed between educational level categories, while there were no statistically significant differences between genders, age groups, or primary residence social environments. The details are indicated in Table 5.
Table 5. The average rank score of broad social identity in 164 participants of the study of individual and narrow and broad social identity of old people's home residents in Slovenia by gender, age group, educational level, and primary residence environments, and statistical significances between the categories.
Tabela 5. Povprečni rang vrednosti kazalnika širše družbene identitete pri 164 udeležencih v raziskavi individualne ter ožje in širše družbene identitete starostnikov, ki bivajo v domovih za starejše občane v Sloveniji po spolu, starosti, izobrazbi in bivalnem okolju ter statistična značilnost med kategorijami.
Characteristic Značilnost
N
Average rank Povprečni tang
Gender Spol
Men Moški Women Ženske
37 127
82.4
82.5
0.992
Age Starost
< 70 years Do vključno 70 let 71-80 years 71-80 let
> 81 years 81 let in več
30 58
76
90.2 83.8
78.4
0.449
Educational level Izobrazba
Primary residence environment Izvorno bivalno okolje
Completed primary school Osnovna šola
Completed vocational school Poklicna šola
Completed secondary school, college or university degree Srednja, višja, visoka šola
Urban
Mestno
Suburban
Primestno
Rural
Vaško
79 34
51
53
36 75
90.4 85.8
68.0
83.4
68.3 88.7
0.016
0.075
4 Discussion
First we need to discuss the identity terminology used for the purpose of studying the identity of the elderly. When exploring identity one encounters many problems because it is a multidimensional construct with a variety of domains (24). In the field of individual identity, options available to describe it are inexhaustible, since description may relate to different characteristics of an individual (e.g., age, physical characteristics, emotional states, attitudes toward different environments) (20). This is also reflected in the terminology. Some authors therefore use the same term, yet do not define it in exactly the same way, and others use different terms
to describe the same phenomenon (individual identity, personal identity, etc.). The situation is even more confused in the field of social identity, which can be described by a number of different terms; it is referred to as social identity, collective identity and group identity. In the literature exploring the identity of elderly people a lot of different terms can be found (7, 9, 15, 25, 26-31). In describing identities of OPH residents in Slovenia these terms have proved only partially useful, therefore special classification/terminology for social identity was developed (20) and was used in this study. Social interactions that determine social identity in the elderly have special characteristics. Social environment of the elderly increasingly narrows with time. If they stay at
home, they become increasingly confined within the four walls of their home. If they live in an OPH, their interaction is mostly limited to relationships with the staff, room-mates and relatives. This narrow social environment is associated with a social identity in a narrow sense - narrow social identity. Interactions with a wider environment (including attitudes towards society in general) are associated with social identity in a broader sense - broad social identity. The results of our study show that the degree of individual identity of elderly people residing in OPHs was not related to their gender, age, education or social environment from which they had moved to the OPH. On the other hand, both narrow and broad social identities were significantly related to the educational level.
Differences in individual identity observed between subgroups of OPH residents are worth discussing though they were not statistically significant. Firstly, individual identity, though not statistically significant, was less pronounced in men than in women. The reason may be a small number of male OPH residents participating in our study. The result is nonetheless important, because it indicates problems that may be associated with meeting the psychological and social needs of male residents. Secondly, it appears that educational level may also be related to a higher degree of individual identity (it was the highest in the most educated elderly). The result was foreseeable, since more educated people are supposed to be more independent and to have higher levels of individual initiative. In addition, education consolidates their status. As stated by Kaufman and Elder, the most salient roles shape one's identity (9). If age identity acts in a similar way, the individual's most salient roles will have the greatest impact on their age identity. Thirdly, individual identity was strongly expressed in people who had moved to the OPH from an urban environment, which may be due to the fact that in rural and suburban environments people are more closely inter-related and are therefore less individualistic. Consequently, they are less affected by moving from their original social environments to an OPH. The choice of location is often expressed as a desire to create a homely environment and family-like circumstances (32, 33). Both individual identity and the ageing process are shaped by the physical and social environments in which people live (34-36). Kaufman and Elder found that a person's current involvement in family, work, and community can be important for their identity (9). This finding can also be applied to the OPH setting. Narrow social identity in the most educated elderly was
significantly less expressed than in other educational level groups. This finding strongly indicates that keeping the need for individuality in conjunction with a higher level of education is also evident in the third life period. Other differences are less evident, but some can still be discussed. Perhaps the differences between various educational level groups are due to the fact that most intellectuals in Slovenia come from urban environments, where narrow social identity is less pronounced than in the other two social environments. In urban environments, middle-aged people are usually less interested in their surroundings; so, perhaps, in older age they do not have these links, and when moved to an OPH, have no need to form new relationships. Secondly, narrow social identity was least expressed among the youngest, recently admitted OPH residents, who were not yet adapted to the new environment. Atchley and Barusch describe one's journey through life as a "road map, offering many alternative routes to many alternative destinations" (37). The pathways that develop as we age are a result of accumulated decisions and their consequences. The timing of events over an individual's lifetime in areas, such as education, work, and the family, affects the overall course of life (35). The timing of important and specific events (completion of education, employment, marriage, birth of a child, death of a partner) in relation to social norms and cultural expectations also affects their impact on the life of an individual. Moving to an OPH is one such important event. However, the results of our study do not agree with observations on differences in narrow social identity between genders, which had been reported by other authors. Shenk et al. noted that many women of the older generation devote themselves to their homes and families, seeing their main role in adult life as wife and mother. Their identities continue to be at least partly tied to these roles (35). Similarly, Moen found that women are more likely to experience old age alone. Their gender influences the way they respond to their partner's death and to the fact that their children have grown up and they have to move to an OPH (38). Again, the reason for this result seems to be the small number of male OPH residents in our study. As for the degree of broad social identity in different subgroups of OPH residents, our study has shown that more educated people are more individualistic. Broad social identity was most strongly expressed in the least educated, and least expressed in the most educated elderly. In an OPH, this group has perhaps the largest selection of ways to spend time, and in particular, they can spend some of their time in their rooms. Because of higher incomes they can afford privacy of their own
room, reading books and entertaining themselves with electronic media. A marginally significant difference in experiencing a broader social identity also emerged among those who moved to the OPH from different social environments. It seems that people from rural backgrounds have the strongest sense of belonging to a community, and people from suburban backgrounds the weakest. In Slovenia, people from urban and rural environments, especially the better educated individuals, tend to migrate to the suburban environment as they grow older. This is reflected in their sense of belonging to that environment or social group. Carers interacting with older people in OPHs should therefore consider the location and social environment their clients come from. They should encourage them to extend their social networks in the new OPH environment, and to retain interest in social developments. The way in which old people manage to integrate their sense of home with the place where they live also influences their well-being and acceptance of ageing (32). Finally, broad social identity, though not statistically significant, was most strongly expressed in the youngest age group of study participants. Despite their staying in an OPH, old people are still interested in social developments, they feel part of the ancestral social environment, and do not want to withdraw to the margins of society. With time, however, this identity weakens because of their growing social exclusion, and is weakest among the oldest people.
This study has some potential limitations. Firstly, one could argue our use of a questionnaire that is not internationally accepted. However, as it seems that this issue has not yet been seriously investigated, no appropriate questionnaire was found in the literature. Therefore, we used an instrument designed in Slovenia. Another point that could be argued is the structure of the questionnaire; it comprises many more questions on individual and narrow social identity than on broad social identity. However, in elderly OPH residents, the most important identity is individual identity. As their social environment is mostly limited to relationships inside the OPH setting (with staff, room-mates and relatives who visit them), next most important identity is narrow social identity. Broad social identity is impoverished because of their increasing exclusion from the broader social environment. As a result, this group of elderly people has little opportunity to explore broad social identity (15). Next, our study was not focused on the comparison between different identities. Consequently, the study instrument is much more focused on individual and narrow social identity than on broad social identity. Secondly, as a good understanding of the study
instrument was at the forefront of this research, the survey was conducted only among the elderly living in residential OHP units, excluding nursing department residents. Exploring the identity of the elderly cared for in nursing units is a far more complex and difficult undertaking, yet further research in this field is planned in the future. The fact that the participants were helped by students of the Faculty of Health Sciences, University of Ljubljana, who were present while they were completing the questionnaire, could have introduced some bias into the study. However, the students were previously instructed to explain only the meaning of individual statements of the questionnaire and to avoid to influence the respondents' answers. Thirdly, the survey included only elderly OPH residents, so it was not possible to compare their identity changes with those of old people still living in the community. Again, this aspect of the issue will be addressed in the future research. Fourthly, the survey focused only on those aspects of ageing that modern societies mostly perceive as burdensome to the elderly and their surroundings, and which ultimately affect their identity. It would be useful to further expand research to include other, less salient issues. Fifthly, the number of OPHs and OPH residents included in the study is rather small. However, prior to conducting a much larger survey, an exploratory study was needed. A larger sample, with more OPHs and participants included, would allow us to use more sophisticated statistical methods, and would ensure greater reliability and validity of research results. Sixthly, one could argue that the age groups studied are not usually used in international health data databases. Elderly people aged 69 years or less was very few in number. In order to make statistical analysis more powerful we decided to change the age limits. Finally, it could be argued that some references included are rather old. However, in the bibliographic databases available we found very few studies that explored a similar issue. The previously mentioned references are still relevant.
The study has some important strenghts though. It raises important issues and therefore contributes to the improvement of old people's nursing care. It is most probably the first attempt to evaluate the factors that affect the identity of elderly OPH residents in Slovenia and thus provides the grounds for identifying identity changes in this population group. Secondly, the study is intended to encourage the OPH staff in Slovenia to re-consider the importance of their role in preventing identity crises in their clients. OPH residents should be treated holistically. This is an important aspect of quality nursing care. Nursing staff is usually more focused on
the physical than on the psychosocial needs of OPH residents. This issue is stressed in our study because of its major importance in the context of quality nursing care. The information provided by our study could thus help improve the quality of life of the elderly residing in OPHs in Slovenia. Finally, the results could be of value to countries organising old people's care in ways similar to those in Slovenia, i.e. in the countries of the Central and Eastern Europe (39). This prevailing institutional model of long-term care is characterized by top-down power structures and a medical orientation (40), and is less friendly to the elderly.
How can this new knowledge be used in practice? OPHs serve as substitutes for residents' primary homes and their families. However important they may be in addressing their problems, they are limited in their function. While being shelters, these institutions build a kind of a barrier to the outside world, which often leads to the isolation of the residents (41, 42). Even though they cannot replace primary homes, OPHs can become more or less similar to them. They can and should provide old people with feelings of security, warmth, respect, trust, and acceptance. They should be places where needs are met and dignity is maintained (43). This is extremely important, because home and family are emotionally charged concepts (32, 44). In care settings, the term 'home' signifies at least two different things: a physical space where people live, and an abstraction related to notions of identity, belonging, continuity etc. 'Home' should define and maintain the self, whereas institutions attack the self through a number of losses and the strain of indignities (44,45). Adaptation to life in an OPH is a long-term and even painful process, since institutions are seldom willing to adapt to the people who work or live in them. Staying in an OPH is a kind of a "waiting process" for old people. They, at least initially, do not know what is happening to them, who makes decisions on their behalf, or how long they will stay in the institution (12). On entering an OPH they often feel like homeless, and suffer personal deterioration and social losses. They may begin to experience a sense of loss stemming from feelings of separation and rejection. If this situation continues, they gradually become patients, people in care. At the same time, their identities change, and an identity crisis is inevitable. They are suffering from "institutional personality syndrome" (46) Nurses and other OPH staff may use the results of the study to appraise their role in preventing this crisis in OPH residents. This is extremely important, since an identity crisis always has a profound impact on health. The maintenance of appropriate relationships with one's self (individual identity), their families and significant
others, and establishing new relationships with other OPH residents and caregivers (narrow social identity), as well as with the wider environment and society as a whole (broad social identity), therefore enhance the health and well-being of OPH residents. In particular, social networks which are closely related to narrow social identity provide support in the case of illness (47). Often the support and reassurance of old-timers would be welcome by new residents and would help them cope with the new and strange environment and overcome the overwhelming sense of institutionalization. At the same time, appropriate experience of identities is a good basis for further development of the elderly, which continues in this period of life, given the suitable incentives (48, 49). The quality of institutional environments can thus be enhanced by personal interventions of specially qualified animators, i.e. andragogues. This accords with the healthy ageing concept and the healthy settings model (16, 17, 50).
5 Conclusion
For most OPH residents, this institution is their last home. They enter an OPH directly from their life course which was marked by significant events that had influenced their activities and self-esteem, as well as their attitude to self, family and the narrow and broader environments. All this has a major impact on their individual and social identity. The elderly enter the OPH with positive and negative experiences. Our aim should be to make the residents', often the last, life experience in OPH as positive as possible. The preservation of adequate degree of individual identity, and even more importantly, establishing a new narrow social identity in the community of other OPH residents and care providers are of utmost importance. This larger synthesis with incentives to bring the findings from several discrete studies into a larger interpretive perspective that could lead to ongoing practice development to enable experiences of home during residential transition, thereby informing nursing praxis in creating and shaping therapeutic environments.
Acknowledgements
The authors thank the old people's homes in Slovenia, and especially all the respondents, for their participation in the study. Its results will contribute to ensuring a coordinated approach to institutional care of the elderly and to improving its standards. The authors
also express their gratitude to Asja Nina Kovačev, Professor of Psychology at the Faculty of Health Sciences, University of Ljubljana, for her permission to use the study instrument she has developed mostly by herself to investigate the identity issues in the elderly in Slovenia. The authors also express their thanks to all nursing students who helped collect the survey data. Without their participation the study would have been much more difficult to accomplish.
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