While my specific career goals have somewhat shifted, I think my heart is still in the same place it was a year ago (if not more earnestly so). I was relieved to stumble across this essay and be reminded of that today. There are a few thoughts I might amend if I were to write this again, but overall it still sits as a good reminder for me of why I am doing this. One of my biggest fears of working in this field is that it will become "just a job." I always say that if that ever happens, both I and my residents would be better off if I found another career.
For those who don't know, I have a BA in Theology/Philosophy (and a minor in English - woo!), because when I started school I intended to be a pastor. Through a series of encounters and realizations regarding the elderly, my ambitions changed over time, and by my last semester I found myself trying very hard to force pastoral-minded classes to fit into the mold of my new-found ambitions. It was too late to change my major at that point, but with the help of incredibly supportive and creative professors and peers, I was able to use my last semester to somehow tie together the applications of pastoral thinking and ministry to the need I was encountering in elder care. This essay is the result of one such mash-up.
And I should probably give a shout-out to all my Turabian/Chicago formatting peers out there. The blog format restructured the footnotes' appearance a little bit, but I'm sure you can still appreciate the oh-so-recognizable citation style we all love to hate and hate to love. Enjoy!
EASTERN NAZARENE COLLEGE
IDENTIFYING THE SOCIAL AND SPIRITUAL NEEDS OF
NURSING HOME RESIDENTS FROM A PASTORAL PERSPECTIVE
A PAPER SUBMITTED TO
PROFESSOR JEFFREY BARKER
IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR TH399 NATURE OF GOD, CHURCH & MINISTRY
BY
ANNA COUSINS
QUINCY, MA
April 28, 2011
Identifying the Social and Spiritual Needs of
Nursing Home Residents from a Pastoral Perspective
Most people do not long for the day they will be considered “old.” American society runs rampant with negative stereotypes about the elderly, believing them to be “frail, useless, inactive, unattractive and unimportant.”[1] We see more beauty and strength in the productiveness of youth.[2] Unfortunately, these stereotypes can often lead to neglect of the elderly. Even if people’s consciences do not allow them to ignore the elderly entirely, there are often at least some needs that go unfulfilled.
The elderly, as with any people, are well-rounded, holistic, and unique people that have needs spanning a vast variety of components. This essay will argue that two of those components, the social and the spiritual, could be better addressed in some ways by increased involvement from pastoral figures. There are admittedly other needs to be addressed (physical, psychological, etc.), but the heart that makes a pastor puts a person in a very unique position to address the social and spiritual concerns of nursing home residents. Also, the religious scope that a pastoral figure can inspire has the potential to lead to a larger, communal, church-inspired “shared life together” among nursing home residents.
Before delving into these concepts, it is important to note that I refer to a “pastoral figure” rather than simply saying “pastor” with great intention. Nothing in this essay is meant to imply that local church pastors have failed to take on this responsibility. This role is more than a visiting pastor can supply when his or her energies are already focused on a home congregation. I instead speak only of a pastoral figure, one who has the heart of a pastor, and may be licensed as such, but does not necessarily pastor a physical church. Essentially, I may be speaking of a nursing home chaplain, but given the rarity of that position and the limited funds that could allow for it, I care more about inspiring those who already are in positions to work frequently and consistently with nursing home residents to learn what it means to have this heart and dedication of filling the void of “pastor” for those who can no longer attend church.
In order to address what roles this pastoral figure should take on for the elderly, it is necessary to identify some of their specific needs. Though they often overlap (or at least they should), we will first discuss social needs, followed by spiritual. Social needs may often be misunderstood to be as simple as having organized chess games and trivia sessions. If only it were that simple! There are much more serious social issues at play that have a direct impact on the well-being of nursing home residents and the elderly in general. One such influence arises out of some of the previously mentioned stereotypes about the elderly. Many of these stereotypes label the elderly as being useless, which for obvious reasons cannot be good for their self esteem.[3] The elderly must also deal with the void that comes from weakened, estranged familial ties.[4] They must learn to find peace at a stage when loss and changes occurs with intense regularity.[5] Finally, our tendency to define the elderly by their social category is severely misguided. This fault lies with society, because our cultural perception that old age means wrinkles and retirement says more about our societal condition than it actually does about the elderly.[6] This neglect must be corrected.
A certain degree of neglect has also allowed room for various spiritual voids and crises for the elderly. Branching from their social needs, the elderly still need to have a sense of belonging and meaning. Even to points of extreme frailty, they often still feel a need to make a difference in their community and world, and spiritual nourishment is needed to encourage that in healthy ways.[7] When an older person’s faith or hope is not nurtured, whether pre-existing or not, it can lead to periods of great despair.[8] Many of the elderly in nursing homes rely on media religious leaders, a personal relationship with God, and/or independent Bible study to fill their spiritual needs.[9] This is partly because of the limited availability of local clergy. In one survey, 54 percent of surveyed nursing home residents reported that they never received pastoral visits. Of those that had, the visits usually lasted fifteen minutes or less.[10] With these statistics and their “back-up” means of nourishment, it is evident that a consistent, community-inspired source of spiritual encouragement is severely lacking. While an independent relationship with God and a discipline for devotions is good, no elder, especially those with a history of church participation, should ever be so isolated that they can no longer tap into the resources of a reliable clergy person and the richness that comes with a community of faith.
Before forming a pastoral response to these needs, it is important to recognize that there are solutions to these issues that do not necessarily have to be pastoral. Many of the issues are widespread societal flaws, and a pastoral response can only help lessen the effect of that rather than eliminate it entirely. Unfortunately, much of what a pastor does is intended to inspire healing as a response to already troubling situations. While a pastor’s work is preparatory in nature at times, it often seems to be focused on reacting positively in the face of hardship. This is no different in a nursing home setting. Much of the influence a pastor has is only applicable because systems of care have fallen short in other ways. For instance, family and friends can play a large part in a resident’s spirituality; all of that influence does not (and should not) fall on the pastor.[11] Families need to supplement institutional care with love and attention.[12] When it comes down to it, “the elderly can tolerate aging, illness, grief and dying far better than they tolerate prejudice, protectionism, neglect, deprivation of choice, and dishonesty.”[13] One pastoral figure, no matter how valuable, is not enough to single-handedly fight those levels of neglect. Others in society still need to take accountability for this need. Even something as simple as using therapy dogs is one way society can help relieve some of the neglected needs of nursing home residents, connect with residents and inspire forgotten memories.[14]
The reality of the situation is, however, that whatever changes society needs to make will not happen overnight. Because of this, it is necessary for a pastoral figure to be one type of buffer that lessens the hurt in the midst of this process, but at the same time he or she needs to be cautious not to act as such a forceful replacement that people no longer see the need for that change. Therefore, the work of a pastoral figure in a nursing home setting must be deeply personal. Rather than trying to fight the “big picture” and overarching flaws in the care system, it is more natural for one with a pastoral heart to take situations as they come, catering to the needs of individuals as unique people, not as a part of a neglected minority.
There are many practical ways for pastoral figures to express this personal care. In order to do anything, however, they must confront any phobias that they themselves might have about working with older people.[15] This is a common angst in society, probably because we fear working with what we do not understand and with what we dread becoming. As Melvin Kimble puts it, “Pastors sometimes prove to be ill-equipped and uninformed in responding to opportunities for individual and congregational pastoral care with older adults. Their inadequacy appears to be rooted, in part at least, in the pastors’ own anxieties and attitudes about the aging process, a problem shared with most people in our society.”[16] Pastors are not naturally exempt from this tendency, but they need to be willing to confront it and learn to understand what scares them so that they can overcome the uncomfortable parts. Otherwise, any work they do will likely be in vain because it will not be genuine.
Secondly, a pastoral figure should reassure residents of basic Christian truths that may not seem so natural in a nursing home environment. For instance, God’s covenant promise at baptism does not end when a person turns 65, and some elderly people may need to be reminded of this.[17] In a time where it may feel as if everyone else is turning their backs, it is comforting to know that God still cares. Verses like Isaiah 46:4 need to be shared: “Even to your old age and gray hairs I am he, I am he who will sustain you. I have made you and I will carry you; I will sustain you and I will rescue you.”[18] Also, senior citizens can be reminded that God’s love is not conditional upon sex, age, or race.[19] In these reminders, however, it is important for the pastoral figures to not be too forceful. They must remember that they are not there to “give” faith; their primary responsibilities involve initiating contact, practicing sensitivity, and offering services (such as communion, prayer, Scripture reading, etc.).[20]
A major part of being sensitive involves giving respect. This can be done by recognizing a resident’s wishes (even if their wish is to not be visited right now)[21] and by listening and being concrete.[22] Being concrete and genuine should not be taken lightly. It is not enough to just show up and spend time with residents because “somebody has to.” There must be genuine concern for the resident as a unique individual, for “the pastor who finds a conversation with an elderly person boring and repetitious may be tempted to attribute the problem to the other person’s age (or ‘senility’).”[23] One must care about the resident so deeply that surface-level conversations are not enough. Without being forceful, a pastoral figure needs to be in a position that allows for natural, concrete conversations about the resident’s concerns. For example, talking about being lonely is very vague, but talking about how sexually frustrating it is to be a single elderly person is very concrete.[24] It is conversations like these, if the resident is willing, that can foster a relationship of trust that begins to restore a sense of worth. This trust can allow for situations that offer a chance to see the graciousness of God at work through some of the resident’s deepest concerns, regardless of if they seem mundane to everyone else or not.[25]
This genuine care is also essential when it comes to prayer. Prayer can often be a default comfort device that we turn to when we do not know what else to say but want to show we care. For an elderly person, this may make them feel severely patronized. Prayer as a result of intimate conversation and care, however, can be very moving. It is much more meaningful when the resident can see how mindful the pastoral figure is of his or her personal needs.[26]
Two common resources for pastoral figures in these endeavors are Scripture and Christian tradition. Both of these aids provide guidance and inspiration for pastors working with the elderly, but it is important to remember that they are not limiting rules or standards. Instead, they are more inspiring of goals and creative means rather than universal principles.[27] As previously mentioned, every resident is unique and individual. They have different pasts, different beliefs, different concerns, and different joys. It is impossible to come up with exact guidelines that declare what is best for every person over the age of 65. Instead, Scripture and tradition are meant to provide motivation and inspiration for those who work with the elderly. We can be reminded of why it is our responsibility to care for them and why they are still valuable. The practical ways in which we live this out leave much room for ingenuity and passion.
In addition to a very individual, one-on-one approach, however, it is worth considering the possibility of seeing a nursing home as a community of faith participating in shared life together. According to Kimble, “in a Christian community an older person should never have to fear dying isolated and alone.”[28] There is no reason a nursing home cannot serve as this Christian community. Also, given how individual and unique each resident is, the “body of Christ” mentality at work in most churches could also be applied here. Their unique needs and gifts can lead to a very healthy, inter-dependent lifestyle.[29] When we plan activities, we absolutely cannot have a mindset as if we are just trying to “keep them busy.” Instead, we can utilize their experience and wisdom in practical ways.[30] In doing so, it becomes easier to make plans with consideration of direct input from the elderly and their own perceived needs (a practice we should be doing anyway).[31]
A system like this within a nursing home starts to mirror the church in other ways as well. After a while, the “pastoral role” might start to be taken on by more than one member of that particular environment. To quote Ralph Underwood, “pastoral care is a shared reality among the people of God when they rejoice before God in each other as persons and when they seek to respond to each other’s concerns.”[32] In this way, residents can begin to find the selfless meaning and purpose that they often do not find when living in a care facility. When we start to develop care for those around us, we can more freely encourage the elderly to participate in praise, celebration, and servanthood as a community.[33]
Another key practice best done within community is the idea of narrative. A wide-known concept within the field of geriatric counseling is termed “life review.” This practice is a way for residents to share their story, which gives them a sense of purpose. In sharing, they are able to recall memories and shape their identity, opening it up for new interpretations.[34] This process is also beneficial to younger generations and the community at large. As it gives a sense of purpose to the elderly, it provides inspiration and guidance for the youthful. This type of inter-generational exchange is invaluable, especially in a communal gathering of faith and worship. Narrative has always been a significant part of church history, and it seems fitting that it should be practiced within not only a Christian community but a Christian community made up primarily of elderly people.
One particularly moving example of how “life review” and narrative can be carried out practically and sincerely is in a poem written by Julian Lamb, the son of Winifred Wing Han Lamb (co-author with Heather Thomson of ‘Wholeness, Dignity and the Ageing Self’: A Conversation Between Philosophy and Theology). Julian wrote an incredibly moving poem entitled “Grandpa’s Biscuits.” It is exemplary of the form of continuity that sharing one’s story can grant to both the teller and the hearer. Recording stories and poems like this can open up the possibility of the continuity inspiring countless others. Below is Julian’s poem as it appears in the article written by Lamb and Thomson:
Grandpa’s Biscuits
At South Granville Retirement Home
wrinkles are admitted quite
openly, if noticed at all.
A flurry of branches is observable
through a window.
Grandpa likes the view.
He wonders why he cannot
see it at night time.
He often has the curtains open in the afternoon
to allow the sun set to put
him to sleep
with its pink half light
blushing on his wrinkled cheeks.
It seems to please the
tired sun to drowse
upon his face.
He says things that nobody knows the
meaning of, as if reason had
let him go,
and that was his pension.
He always remembers to let
you go first through a doorway
or sitting down,
but he can’t (for the
life of him) remember how the buttons go on
his shirt. “Go ahead,” he says and motions
to the door,
letting the buttons slip.
Grandpa had become the
dry husk of the person he had always
been: he does all the things that
he has done all his life,
but without the reasons.
There are lines in his skin,
there's a spot on his forehead,
his hair is grey and white.
His eyes are sometimes red.
His hands clutch their histories–
or a crumbling digestive biscuit
which always has a bite taken out of it,
but rarely any more than that.
Come to think of it,
I don’t think I’ve
ever seen him finish one.
Occasionally,
when looking around his room
at all the things–
the shoe horns, the hats,
the photographs of relatives
that he no longer recognizes–
you will find a forgotten,
half-eaten biscuit
forming a puddle of crumbs
where it sits.
All attention is on the present
biscuit, and if that one was lost
he gets another from the tin
beside his bed.
The irregular, inimitable
unrepeatable bite marks
stretch out like tiny
headlands into space,
whilst the air laps round
in waves
persuading the crumbs from the precipice.
Whether they came
directly off the biscuit or from
the wrinkly edges of his mouth,
the crumbs would always
find their way to
the ground. And it never mattered.
In fact, it was good.
They say that God took
seven days to make the world. It was
as if, after eighty years in that
world, Grandpa had decided that it needed
a new floor.
And that floor was being
made with the silence
and subtlety of dew
dripping amongst the grass.
You hardly noticed that
a life was crumbling in front
of you because it was doing so
without protest,
without tragedy or
without complaint,
but with the quietness and humility
of a dry biscuit becoming
the air.
Most of the phone
calls we have got at three o’clock in
the morning have been accidents.
There is one coming that won’t be.
But, although the biscuit tin would be empty,
I’m sure there’ll be a half-eaten one,
lurking secretively in that room,
amongst the shoe-horns,
beside a lost watch,
or maybe making dust behind a photo of Grandma.
In the rooms and down the
corridors, Grandpa’s peers
are learning how to walk again.
Because, you know,
After eighty or so years of walking
without thinking,
you tend
to forget
which foot
goes
first.[35]
by Julian Lamb, Canberra
Julian’s poem “illustrates dialogical communion in which wholeness is achieved not through agency and strength of the obvious kind but through love and the mutual appreciation of our finitude and the demonstrative value of our being.”[36] This kind of respect is brought about most powerfully through true community, as well as through familial support as is shown in the case of the Lambs. The reverence involved here is astounding. It is not even as simple as just recording facts about his story. It is about describing his essence – the very being that makes him “Grandpa” even when his daily motor skills begin to fail him. A community of faith would be not nearly as adequate without some sort of practice of narrative, even if only orally passed down. We must pay attention to the stories of those for whom we care.
This entire system is admittedly idealistic. Transforming an entire nursing home into some sort of monastic-style faith community may not be practical or well received. But without ideals, what hope can we have for these citizens? Shutting them in and presuming occasional, one-on-one, ten-minute visits is not enough. If we preach a lifetime of community and shared life, how can we expect people to live without it in their final years simply because it is no longer convenient? It is our duty to do whatever it takes to provide a sense of community for Christians in nursing homes. While it may not be possible to convert an entire nursing home into a totally Christian environment, it is surely possible to at least create ties between people of similar traditions in the same care facility and provide an ordained leader to officiate communion and opportunities for worship and service.
That is why the idea of a nursing home chaplain is absolutely captivating and valuable. This is a position that should be taken just as seriously as the role of “activities coordinator.” While many homes try to include spirituality in that spectrum of needs that are filled by various activities, the most they are sometimes able to do from a religious perspective is bring in a minister or priest once a month to host a service. There is little to no community in that. Having a constant face, like a chaplain or other pastoral figure, creates the possibility for real, genuine community that just may be even more “successful” in these regards than typical churches are. People in a nursing home do, after all, already live in a sort of communal, shared life together. If we could add deliberateness to that for the people who share similar passions about their faith, their experience there could be truly transforming for all involved.
An essay about the proper pastoral response to the needs of the elderly could not be complete without a biblical motivator as to why this work is so important. It was already mentioned that Scripture can be a great resource for pastoral figures working with the elderly. Psalm 71:9-18 is one such passage:
9 Do not cast me away when I am old;
do not forsake me when my strength is gone.
10 For my enemies speak against me;
those who wait to kill me conspire together.
11 They say, “God has forsaken him;
pursue him and seize him,
for no one will rescue him.”
12 Do not be far from me, my God;
come quickly, God, to help me.
13 May my accusers perish in shame;
may those who want to harm me
be covered with scorn and disgrace.
do not forsake me when my strength is gone.
10 For my enemies speak against me;
those who wait to kill me conspire together.
11 They say, “God has forsaken him;
pursue him and seize him,
for no one will rescue him.”
12 Do not be far from me, my God;
come quickly, God, to help me.
13 May my accusers perish in shame;
may those who want to harm me
be covered with scorn and disgrace.
14 As for me, I will always have hope;
I will praise you more and more.
I will praise you more and more.
15 My mouth will tell of your righteous deeds,
of your saving acts all day long—
though I know not how to relate them all.
16 I will come and proclaim your mighty acts, Sovereign LORD;
I will proclaim your righteous deeds, yours alone.
17 Since my youth, God, you have taught me,
and to this day I declare your marvelous deeds.
18 Even when I am old and gray,
do not forsake me, my God,
till I declare your power to the next generation,
your mighty acts to all who are to come.[37]
of your saving acts all day long—
though I know not how to relate them all.
16 I will come and proclaim your mighty acts, Sovereign LORD;
I will proclaim your righteous deeds, yours alone.
17 Since my youth, God, you have taught me,
and to this day I declare your marvelous deeds.
18 Even when I am old and gray,
do not forsake me, my God,
till I declare your power to the next generation,
your mighty acts to all who are to come.[37]
This verse could almost be considered a sort of “anthem of the elderly.” It acknowledges many valuable points: 1) God does not abandon people in their old age, 2) the world does see the elderly as weak and vulnerable, 3) that it is worth having hope in spite of neglect, 4) that God is faithful and worthy of praise, and 5) narrative is a valuable tool for sharing God’s power. These verses can provide a good template for a pastoral figure to determine his or her message regarding the connection between the needs of the elderly and the will of God. What a beautiful harmony!
Working with the elderly is no easy task. Well, perhaps it is not really that difficult, but mustering the courage to care in the face of such a public fear is a valid challenge. From countless philosophical interpretations of aging, it is evident that caring for the elderly takes more than just a “do-gooder” attitude. There are many deep-seeded social and spiritual systems at play that affect each and every older person in different ways. Without people willing to have genuine concern and a responsible approach, these influences could increasingly become crippling to nursing home residents. A holistic, genuine, and faith-based approach may be what many nursing home residents really need in order to rediscover their feelings of hope and purpose, and someone with a pastoral heart may just be the right person to help inspire and foster that.
BIBLIOGRAPHY
Carlson, Robert. “Step One: Who Are the Elderly?” Journal of Religion, Spirituality and Aging (2005). Vol. 17 No 3/4. http://www.haworthpress.com/web/JRSA (accessed February 2011).
Hannigan, Candice. “Community of Faith Dunwoody United Methodist Ministers with Canine Friends: Dogs Cheer the Elderly.” The Atlanta Journal-Constituion (2005): page nr.
Harris, J. Gordon. Biblical Perspectives on Aging: God and the Elderly, Second Edition. Philadelphia: Fortress Press, 1987.
Kimble, Melvin. 1987. Pastoral Care of the Elderly. Journal of Pastoral Care 41, no. 3: 270-279.
Lamb, Winifred Wing Han and Heather Thomson. 2000. “‘Wholeness, Dignity and the Ageing Self’: A Conversation Between Philosophy and Theology.” Journal of Religious Gerontology 12, no. 3: 57.
Uhlman, Jerry, and Paul D. Steinke. “Pastoral Care For the Institutionalized Elderly: Determining and Responding to Their Need.” The Journal of Pastoral Care 39, no. 1 (1985): page nr.
Underwood, Ralph L. “Pastoral Care with the Elderly.” Austin Seminary Bulletin (Faculty ed.)96, no. 3 (1980): page nr. http://ehis.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=9&hid=101&sid=e40eb0d9-ff45-419f-b7a8-c5cff9c9764f%40sessionmgr111(accessed February 2011).
Yeager, Carolyn M. 2006. Five Steps to Senior Life Assessment: Reflection on Past and Current Decisions and Relationships. Vol. 41.
[2] Ibid.
[3] Robert Carlson, “Step One: Who Are the Elderly?” Journal of Religion, Spirituality and Aging (2005): Vol. 17 No 3/4, http://www.haworthpress.com/web/JRSA (accessed February 2011), 8.
[4] J. Gordon Harris, Biblical Perspectives on Aging: God and the Elderly, Second Edition (Philadelphia: Fortress Press, 1987), 109.
[5] Kimble, 274.
[6] Ralph L. Underwood, “Pastoral Care with the Elderly,” Austin Seminary Bulletin (Faculty ed.) 96, no. 3 (1980): page nr., http://ehis.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=9&hid=101&sid=e40eb0d9-ff45-419f-b7a8-c5cff9c9764f%40sessionmgr111 (accessed February 2011), 16.
[7] Carlson, 10.
[8] Carolyn M. Yeager, 2006, Five Steps to Senior Life Assessment: Reflection on Past and Current Decisions and Relationships, Vol. 41, 1.
[9] Jerry Uhlman and Paul D. Steinke, “Pastoral Care For the Institutionalized Elderly: Determining and Responding to Their Need,” The Journal of Pastoral Care 39, no. 1 (1985): 25.
[10] Ibid., 27.
[11] Uhlman, 25.
[12] Harris, 108.
[13] Underwood, 16.
[14] Candice Hannigan, “Community of Faith Dunwoody United Methodist Ministers with Canine Friends: Dogs Cheer the Elderly,” The Atlanta Journal-Constituion (2005): page nr., 1.
[16] Ibid., 270.
[17] Ibid., 274.
[18] NIV
[19] Underwood, 16.
[20] Ibid., 17.
[22] Underwood, 20.
[23] Ibid., 21.
[24] Ibid., 20.
[25] Ibid., 17.
[26] Uhlman, 29.
[27] Underwood, 15.
[28] Kimble, 275.
[29] Carlson, 9.
[30] Harris, 10.
[31] Underwood, 17.
[32] Underwood, 15.
[33] Ibid., 16.
[34] Kimble, 275.
[35]Winifred Wing Han Lamb and Heather Thomson,"'Wholeness, Dignity and the Ageing Self': A Conversation between Philosophy and Theology," Journal of Religious Gerontology 12, no. 3 (09, 2000): 64-67.
[37] NIV.
