Father and son
I entered the apartment of a client I had never met before. He was around 80 years old, suffering from diabetes and dementia. When I approached him, he way lying in his room, in a bed which was dirty and he seemed to be unkempt. It was very cold in his room, which was also mouldy.
In order to dispense the insulin I needed a needle. There was only one needle there but no bin to drop the used needle in. For washing the client there was a bucket of water, only one washcloth and one towel. The client had only water to drink. There was no television or radio in the room and no pictures on the walls. The condition of the room the client had to live in was a shock in itself. But then I went into the small kitchen of the apartment to prepare food for the client and opened the refrigerator. It was completely empty except for baby food in cans. I was perplexed.
I decided to leave the apartment and while I was walking out I glimpsed into the room of the client’s son as the door was open. I saw modern audio-equipment, naked women on posters, new furniture and the heating was on. I couldn’t talk to the son.
I left the apartment in shock. The son kept the money he received from the state for the care of his father for himself!
When I went home I called a friend with a similar job and we talked about what had happened. Then I posted an official danger alarm / complaint within my organisation. The son had to provide towels, needles, food etc. for the father within one week otherwise officials would visit his apartment and the son would have to face consequences. Nothing changed, so the client was eventually referred to a nursing home facility.
1. Identities of the actors in the situation
The narrator was approximately 40 years old, female and an Austrian national. She was a single mother of two children. At that time, she was recently divorced and had been in mobile nursing for only four months. She had a liberal attitude in general and was especially sensitive towards “justice” at the time of the incident. She held a diploma in nursing and was working with a local service provider (NGO).
The client’s son
The son was approximately 40 years old, unemployed and an Austrian national. According to the description from the narrator he did not seem neat in terms of shaving or clothing. She perceived him to be a very simple man, who was not highly educated. She attributed a simple and even vulgar way of expressing himself to the client’s son.
An approximately 80 year old man who was bedridden, suffered from late stage dementia and was hemiplegic. He needed full time care and could no longer speak and only made noises.
Both the narrator and the client’s son were involved in care-taking activities, the narrator on a professional level and the son was taking care of a family member. They were around the same age. Deducing from the narrator’s depiction of the client’s son, he was of a lower social class than her. He was unemployed and living in social housing which is usually given to individuals and families on low income.
2. Context of the situation
The client lived in a social housing apartment in an outer district in Vienna. There were two rooms, a small kitchen and a bathroom without a window. All the floors were old, the floor in the entrance hall was broken, and there was a hole in the floor. The apartment felt gloomy, morbid and depressing to the narrator. It did not seem well taken care of. The lights were pretty dark. There was no central heating but separate heating in all rooms. There was no sign of any other person living in the apartment except the client and his son.
In the client’s room, there was mould on the walls, it was cold, the heating was off and it was crammed with stuff. In the middle of the room was a table and the bed of the client.
The room of the client’s son on the other hand appeared quite different to the narrator, with posters, entertainment technology and the heating turned on.
Mobile nurses care for clients in their own homes and usually work alone. The narrator had only been a nurse for a short time. She was going through an emotionally difficult time herself and was limited in the time she could spend on each patient – 45 minutes for this visit to the old man. She had never met that client before or been to his apartment, so she did not know what to expect.
Since she had just been divorced, she was quite wary of issues concerning justice and just distribution.
Due to demographic developments caring for the elderly has become a central issue for political and public discussions in Austria. To this date, it remains open for debate how the systems of social security are to be adapted to accommodate the growing need for care services. Organising care is furthermore a topic in many families, who need to decide whether to care for their elders themselves, make use of in-home services or find care facilities and lastly, how to afford these arrangements. At the moment there are different models relatives can choose from to receive state money for care, depending on whether they dedicate their days entirely to taking care or supplement professional services. There is also large variation among the different Austrian states on how much money is received. Yet scientific analyses generally state that the money collected by the families barely covers the use of professional care services.
Care work at home has traditionally been associated with women and is a typical example for a gendered type of activity. On a larger social level, it has been afforded very low esteem and not been considered a vital element for the functioning of society. Consequently, professional care work is often mal compensated and familial care work is done without pay predominantly by female family members. Thus, caring can be considered as “invisible work” receiving little social recognition.
3. Emotional reaction
The main shock occurred at the refrigerator which was completely empty except for baby food, but the shock evolved from room to room, from the client’s room, to the kitchen and then the son’s room as a contrast to the rest of the apartment.
The mobile nurse felt shocked, paralysed and powerless.
When she passed the son’s room in the end, she felt angry, helpless and worried for the client’s health.
4. Representations, values, norms, ideas, prejudice: The frame of references of the person who experienced the shock
Priority of needs:
- Some needs are more basic than others (i.e. hygiene, food, clean living conditions). Each person is entitled to have these needs fulfilled in every state of their being.
- Prioritising other needs, i.e. material wealth or amusement, over these basic needs is morally wrong.
- The narrator holds on to the value of personal security which was threatened by malnutrition, mould, dirt and cold in the room.
Protecting weak members of society – orientation towards social justice:
- Some members of society cannot take care of catering to their basic needs themselves – like children, the sick, the elderly. These people must be protected by the other members of society. (Being unemployed or poor does not seem to be a form of precarity that needs special attention in the narrator’s view – or is trumped by the weak physical status the client is in.)
- Social justice goes along with affording every human being with respect, protecting their right for dignity. There is no legitimising certain forms of living (without social contact, without heating, in unclean conditions). Basic rights are ineluctable and they come with specific protections as well.
Family as shelter:
- Family members are supposed to take care of each other and respect each other.
- Familial ties stand for emotional closeness, not just biological relation.
- Children are supposed to take care of their relatives, not necessarily doing the work of a professional, but caring emotionally.
- Maltreating and abusing family members is especially disdainful, because of the close personal relationship.
Social contract / system of welfare:
- Money is distributed for specific purposes; how the resources are allocated is not be changed by the recipients as they see fit.
- The distribution of money between father and son should at least be just; the son heating his room while not heating the father’s is scandalous.
- Trust in officials and the state that distributes money to the son for health care is shaken here.
Strong orientation towards professional identity as a mobile nurse:
- Being a caretaker means showing empathy for the client and not just fulfilling tasks, i.e. dispensing insulin. The narrator feels responsible for the people she cares for and takes her work seriously.
- Due to the living conditions she felt that quality of care was threatened. Thus, she adheres to a specific notion of care, not only as a professional task, but an activity linked with emotional components that are – amongst other things – expressed by the fashioning of the material surroundings in which someone is taken care of. Good care looks a certain way.
- Living up to her standards of care seems to be a question of moral character.
- Preference for acting in the face of injustice and taking action as professional responsibility: Since her standards of care were not met, she got active in order to help the client and wanted to make a meaningful change. Not being able to adequately influence the patient’s care situation made her feel helpless.
- The nurse was quite new to the nursing profession when she experienced this case, and she had not seen many poor homes / social housing yet. She could have experienced a poverty-shock (e.g. due to the lack of more towels, the lack of more food). This might correspond to her professional identity and the standards of care she believes in, and that social housing is not a place in which to be taken care of. However, there is no cultural obligation to how many towels someone possesses.
Nurses are requested to report certain behaviour of patients and relatives, if patients are at risk. According to the Austrian Law – if the patient’s health or life is at risk – the nurse can report this and then the court decides whether or not the father can stay in these care arrangements or other arrangements have to be made. The nurse was trying to act obedient of the law and to assess the degree of risk here.
5. What image emerges from the analysis of point 4 for the other group (neutral slightly negative, very negative, "stigmatized", positive, very positive, real, unreal) etc?
Negative; not a trustworthy person; a redneck who does not care for his father
6. Representations, values, norms, prejudice: The frame of references of the person or group that is causing the shock / that caused the shock in the narrator
- Insecurity: The son might not possess relevant information on how to take care of his sick father according to professional standards of care. Since the father is attended to by the care system, he feels that his father is cared for professionally.
- Caring for a very sick person, who is not able to verbally express himself, can be overwhelming – for a lay person, but especially for a son who experiences his father deteriorating.
- He cooperates with the professionals in the sense that he supplies all the materials necessary for an external caretaker to use: a needle, a towel, water to wash his father etc.
Caring in a familial sense is shown by being present, living together.
- Since his father is bedridden, he has very different needs than the son himself. Catering to his father’s needs is expressed by buying the type of food he can eat as well as by the fact that is living at home, not being sent to a care facility.
- Individual orientation towards material wealth, enjoyment, entertainment: His room is furnished according to his needs, which might not be shared by his father, but are an expression of his culture and age.
- Relativity of needs depending on social situation: A person’s needs are constituted by their general state of being. While a young man needs to participate in society through consuming relevant goods (limited opportunities for unemployed persons to participate through consumption), a sick old man maybe does not need wall decoration or television.
- Caring for his father at home might be a financial burden for the unemployed son, which shows in the condition of the apartment. It might be testimony to his prioritising being able to care for his sick father in his own home as well as fulfilling his own needs, while the up-keeping of the apartment has a lower priority.
- Basic needs are considered as having a roof, a bed and any sort of food and drink. These needs of his father are taken care of.
- Fastness – the son did not want to spend a lot of time preparing food for his father, so he bought baby food to save time.
Familial hierarchy: The son has legal and formal responsibility for the father since he pays bills and signs papers for his father.
- Notion of head of family being the one in charge: setting of priorities, making decisions
Caution towards institutions:
- It could be speculated that he is on bad terms with Austrian institutions and representatives of institutions, having made bad experiences before or having been abandoned himself – with his requests (as member of a lower social class).
In case he did use the money for the care of his father for himself, as the narrator alleges, he could have been trying to beat a system, he is not fond of. By spending the money received on his terms, he could exercise control, not giving in to institutional regulation.
7. Does the situation highlight any problem concerning the professional practice, or in general about the respect of cultural differences in intercultural situations?
Standards of care
- At the heart of this incident are questions regarding standards of care. Care work is at the intersection of professional activities as well as private, familial ways of family members relating to each other: What counts as good care? How does a loving home look like? And who gets to decide whether one towel suffices or is considered an expression of neglect?
- Since many nursing and care services have to cooperate with relatives, professional standards and familial ways need to be synchronised. At the same time approaches to care vary considerably. While the narrator of this story judges the client’s son to be of bad character, she might actually be experiencing a poverty shock. The signs of neglect she identifies might be a consequence of social difference and the general living conditions of the client rather than individual deficiency.
- On the other hand caring for her client is the narrator’s professional responsibility. Thus, she needs to be able to address her concerns – either in the realm of professional supervision or in a moderated discussion with the client.
Mobile nurses as clients’ advocates?
- By working within the homes of their clients mobile nurses witness many things the departments giving out money for supporting family care have no knowledge about. They are afforded a very intimate view on the patients’ living arrangements, they are taking care of and their general health. In this way they might play an important part in patients’ advocacy when they realise lack of care or problems with the living conditions. This also applies when home care might no longer be sufficient for a certain patient.
- In this way, observing and assessing the living and care conditions of a patient should be part of the training of mobile nurses. They should learn how to critically observe in detail what they see in different apartments. When they are not sure about a possible danger for a person, they should seek professional advice within their team or colleagues.
- On the other hand, this might constitute an overextension of what nurses can and should do, since they are not trained social workers, nor did they decide to be. In this way communication and cooperation between different service providers and types of services should be facilitated so that nurses know where to turn to in case of noted danger for the patient.
Training of relatives
- Caring for relatives can be very hard on the family members. On the one hand, they might lack knowledge and feel overwhelmed. On the other hand, they tend to be very emotionally affected by their relatives being sick.
- Service providers could train and inform relatives once they start working with clients – on the medical procedures, caring at home, designing beneficial care environments as well as on the emotional challenges.
Private care force
- The incidents also speaks to a tendency exhibited by Austrian welfare institutions. While the social system hinges on family members to care for their relatives, they are often times perceived as nuisance or even as trying to beat the system, unnecessarily collecting money.
- It also shows that caring can be considered a familial obligation – either because family members feel morally obliged to take care of their relatives at home or because they simply cannot afford sending them to specialized facilities. Consequently, there are people very much involved in care activities who might not have chosen this path, if it had not been (financially or socially) imperative.
- Lack of efforts to treat family members as allies trying to empower them