Background and objectives
Many nursing homes have an online presence, often in the form of a website and/or social media accounts such as Facebook and Instagram, which they use to broadcast information about their premises, staff, services and nursing-home activities (see Erlandsson, Reference Erlandsson2014; Carlstedt, Reference Carlstedt2019). Online representations of eldercare services can be studied as a documentation practice that communicates normative ideas about care – its content, relations and subject positions of those involved. As Erlandsson (Reference Erlandsson2014) suggests, this is done with the selection of content and the way various audiences are addressed. In an earlier study, one of the authors of this article found that Instagram accounts of Swedish nursing homes showed residents involved in an active and enjoyable social life (Carlstedt, Reference Carlstedt2019). This article examines how nursing-home staff account for these types of representations of old age. What is regarded as appropriate and, given the frailty of the residents, why do images of sociability and an active life predominate? Places in Swedish nursing homes are only open to those in need of extensive care, so they are facilities where people are very frail and everyday life is often dominated by care routines (Harnett, Reference Harnett2010).
Generally speaking, online representation is selective and intentional (Gibbs et al., Reference Gibbs, Ellison and Heino2006; Rosenberg and Egbert, Reference Rosenberg and Egbert2011; Smith and Sanderson, Reference Smith and Sanderson2015), and any audience, because they participate in the same online forums, may very well be aware of the levels of deception or misrepresentation involved (Ellison et al., Reference Ellison, Heino and Gibbs2006). Followers of celebrity Instagram accounts know from comparison with their own lives that innumerable everyday goings-on are left out, because they are private, uninteresting or irrelevant. In comparison, few people have first-hand experience of daily life in a nursing home, so their ability to recognise the degree of impression management in any given online representation is limited, particularly when the images are part of a soft sell that plays on their hopes, expectations or fears. This has implications for how people set about choosing a nursing home. The telephone directory and a phone call to a manager used to be the first step in obtaining information; now individuals can compare a number of nursing homes based on their ‘shop window’ online representations, and direct contact comes second.
The research problem
In the study, members of staff in Swedish nursing homes were interviewed about the form and content of their organisations’ online representations, and the logic that determined what they put online and what was excluded. The research problem of this particular article focuses on the findings from the interviews and subsequent data analysis: all interviewees described relatives as the intended audience, regardless of the type of online forum (website, Facebook, Instagram or blog). The concept of relatives could theoretically, in addition to family members, include close friends, administrators or even social workers. In the context of the interviews it was, however, clear that the concept of relatives above all referred to the adult children of residents. In a very few cases, spouses, siblings or grandchildren were mentioned.
Online representations were adjusted to suit relatives’ assumed and stated requests. In other words, representation practices built on the idea of the residents’ relatives as the customers. This constitutes a breach of official Swedish policy, which does not recognise relatives as having the right to speak for an older person in need of care, and traditionally nursing homes have tended to relegate relatives into the background (Whitaker, Reference Whitaker2009). Given what the nursing-home representatives conveyed, the aim of this article is thus to investigate nursing homes’ online representations as a practice that targets residents’ relatives. What are the motives for the choice of audience and the content of the representations? How is the breach with official policy accounted for? What images of older people and nursing-home life are produced by these online practices?
The analysis of the article draws on the field of critical gerontology (Cole et al., Reference Cole, Van Tassel and Kastenbaum1992; Featherstone and Wernick, Reference Featherstone and Wernick1995; Holstein and Minkler, Reference Holstein, Minkler, Bernard and Scharf2007) and, specifically, the research in this tradition that has analysed the interplay between the production of images of ageing, and of older people and their use in different settings. Old age is discursively constructed in a wide variety of practices, and the way old people are depicted reflects the interests of claim-makers, along with the cultural beliefs, norms and values associated with old age (see Rozanova, Reference Rozanova2010). In this study, we investigate how nursing-home representatives talk about the practices of online representation of organisational activities and nursing-home residents. The organisational practice of publicly displaying ‘what happens’ in a nursing home is interpreted as part of the practice of ‘producing’ people in ways that justify organisational features and modes of operation (see Holstein, Reference Holstein1992).
The unclear role of relatives in Swedish eldercare policies
In addressing the tension between the role of nursing-home residents’ relatives as described in official Swedish policy and as it appears in online representations, this article pays particular attention to the dynamic interplay in three respects: the frailty of nursing-home residents; the heavy emphasis on residents’ self-determination and the downplaying of their relatives’ role; and the marketisation of eldercare.
Swedish eldercare falls into two broad categories: care in the home (help getting dressed, showering, cleaning, meals, etc.) and nursing-home care (formally known as ‘special housing for the elderly’). The prospective care user applies for services and the local authority needs assessor decides on his or her eligibility (Erlandsson et al., Reference Erlandsson, Storm, Stranz, Szebehely, Trydegård, Meagher and Szebehely2013). Since the threshold for nursing-home care is fairly high, only those who need extensive care are entitled to a place. Nursing-home residents are very frail – approximately 50 per cent have dementia (Socialstyrelsen (National Board of Health and Welfare), 2011) – and more than half of the residents die within two years of admission (Socialstyrelsen, 2016). It has been argued that Swedish nursing homes are best described as palliative care contexts (Franklin et al., Reference Franklin, Ternestedt and Nordenfelt2006).
Given the frailty of nursing-home residents, the emphasis on the self-determination of older care users might seem surprising, but official Swedish policy is at pains to stress their right to decision-making autonomy, self-determination and integrity (SFS (Social Services Act), 2001:453 c 5 art 4). Sweden serves as a relatively unique example where the right to self-determination applies to all adult citizens, regardless of cognitive impairments and the like (Nedlund and Taghizadeh Larsson, Reference Nedlund and Taghizadeh Larsson2016). Nursing-home residents have the status of tenants, and their rooms are formally classed as flats and are usually furnished with their own belongings. Unlike many other countries, Swedish care providers have no formal right to overrule an adult's self-determination, even when that person has dementia (Nedlund and Taghizadeh Larsson, Reference Nedlund and Taghizadeh Larsson2016). Equally, relatives have no legal obligation to provide care for adult persons (Vingare et al., Reference Vingare, Giertz and Melin Emilssonin press). The official guidelines issued by the National Board of Health and Welfare (Socialstyrelsen, 2013) state that relatives and next of kin ‘have no legal authority to act as deputy for the individual’, and indeed ‘no right to make an application on behalf of the individual’. This is a challenge when it comes to choice and the marketisation of eldercare, and critics have questioned whether older people should be forced to act as informed customers (Meinow et al., Reference Meinow, Parker and Thorslund2011).
Eldercare in Sweden has undergone rapid marketisation. Although 75 per cent of the nursing homes in Sweden are still run by local authorities, several studies indicate that the vocabulary of the market has been embraced throughout the field of eldercare, emphasising the role of care users as customers and of competition among care providers (Meagher and Szebehely, Reference Meagher and Szebehely2013; Nilsson et al., Reference Nilsson, Jönson, Carlstedt and Harnett2018). As the health service and social services have adopted the market logic of contemporary society, they have been permeated by a consumerist discourse. Customer choice models have been implemented to guarantee freedom of choice, person-centred care and self-determination (Blomqvist, Reference Blomqvist2004; Meagher and Szebehely, Reference Meagher and Szebehely2013; Nilsson et al., Reference Nilsson, Jönson, Carlstedt and Harnett2018). Yet frailty and cognitive impairment may prohibit older people in need of care from asserting sufficient consumer agency (Gilleard and Higgs, Reference Gilleard and Higgs1998; Meinow et al., Reference Meinow, Parker and Thorslund2011). According to Nedlund and Taghizadeh Larsson (Reference Nedlund and Taghizadeh Larsson2016), Swedish legislation does not give enough guidance on how to handle this discrepancy, leaving professionals and family members in a care ‘grey area’.
The role of adult children in the eldercare context is widely acknowledged, but has been associated with ambivalence (Sandberg et al., Reference Sandberg, Lundh and Nolan2002; Hammarström, Reference Hammarström2006; Söderberg et al., Reference Söderberg, Ståhl and Melin Emilsson2012). Staff tend to view relatives as demanding ‘visitors’, intruding in the professional arena, and although they usually acknowledge them to be a resource in formal institution-based care (Holmgren et al., Reference Holmgren, Emami, Eriksson and Eriksson2013), family members may feel excluded from or constrained by the care context (Whitaker, Reference Whitaker2009). However, to acknowledge that relatives are the ‘customers’ in a ‘consumerist’ welfare system is a clear breach of Swedish law, and debates on the possibility of older care users to act as consumers do not seem even to reflect on the possibility of relatives taking on a role as a substitute decision maker (Goodwin, Reference Goodwin2011; Meinow et al., Reference Meinow, Parker and Thorslund2011). According to the National Board of Health and Welfare (Socialstyrelsen, 2013), relatives may support and advise when someone applies for a placement, but they have no right to act on behalf of the older person, and once a person has moved into a nursing home, official policy privileges the relation between the resident and the care staff. The Social Services Act (SFS, 2001:453) states that ‘staff work together with relatives if the care users want this’. Arrangements that offer relatives the right to speak on behalf of an older relative who needs care, or acknowledges that care should adapt to the needs and requests of relatives, can thus be called into question as deviating from official government policy.
Research design and methods
The first author interviewed 14 nursing-home representatives. Initially, contact was made with 31 nursing-home managers, with the aim of including representatives who were responsible for the nursing homes’ online representations. Of these, 17 declined due to lack of time. The selection thus consists of 11 managers, two nurses and one marketing manager. A limitation of the study is that it is based on a relatively small sample. All interviewees were involved in presenting the nursing homes online, e.g. by writing website content or taking photographs for Facebook or Instagram. The interviewees represented both municipal and private facilities. All interviewees have been anonymised for the present article. The study was approved by the Regional Ethical Review Board in Lund, Sweden (2015/864). For reasons of distance, three interviews were conducted by telephone. All the nursing homes had a website, about half also had a social media account and one had a blog. During the interviews, interviewees were asked to scroll through the nursing home's website, Facebook page, Instagram account or blog, and, using the representations as a point of departure, to talk about the representations’ content, purpose and function, and assumptions about the intended audience (see Jacobsson, Reference Jacobsson and Silverman2016).
All interviews centred on the general questions of what was shown, for whom, why and its potential consequences. The interviews were conducted in an open and flexible manner, with interviewees asked to talk about the perspectives and issues they perceived as meaningful and relevant to the topic. By using an active interview approach (Gubrium and Holstein, Reference Gubrium and Holstein1995), the interviewer carefully tested interviewees’ claims, offering alternative ways to understand the representation practices, on which the interviewees then commented.
All interviews were recorded and transcribed verbatim. The first author did an initial coding to sort the data and clarify the analytical themes. Both authors then read the transcripts and considered possible interpretations as part of the qualitative thematic analysis (e.g. as described by Braun and Clarke, Reference Braun and Clarke2006). From the interviews and the first-stage coding, it is clear that relatives – often specified as adult children – have a role that is central to both the form and content of the online representations. The second-stage data coding and analysis was selective, focusing on the representations’ function in targeting relatives. The results were analysed according to two functions that interviewees stressed: representations as marketing (pre-admission) and representations as assurance (post-admission).
The analysis was influenced by the sociological theory of motives and accounts. In a classic article, Mills (Reference Mills1940) made a distinction between motivation as the inner drive for action and motives as manifest expressions – the reason for action. Motives should be understood as anchored in and dependent on context, thereby revealing the systems of norms or discourses, along with the techniques for bending the rules and allowing breaches of what is morally expected. Later, Scott and Lyman (Reference Scott and Lyman1968) developed this approach by arguing that individuals tend to use different types of accounts when their actions can be interpreted as breaches of a normative framework. Vocabularies of motives and accounts are particularly useful as analytical tools in cases where human service organisations are subject to complex demands from various stakeholders, and where official policies might not correspond to the conditions on the ground. Organisations negotiate contradicting demands and logics, and exert themselves to justify their actions (see Hirsch and Bermiss, Reference Hirsch, Bermiss, Lawrence, Suddaby and Leca2009). It is clearly not in line with official Swedish policy to frame relatives of nursing-home residents as customers, but it was usually not accounted for until the interviewer challenged the interviewees’ stance. The theoretical approach points to certain vocabularies that seem to be taken for granted or regarded as unproblematic, and how professionals used them to ‘make things work’.
Findings
In the discussion of the motives behind online representation practices, two vocabularies were central: (a) marketing and (b) assurance. In interviewees’ descriptions that focused on marketing, representations assigned the role of customer to relatives, who were expected to be closely involved in the choice of nursing home. The marketing content was adjusted to attract customers by meeting relatives’ explicit and implicit requests, primarily about social activities at the facility. Assurances, meanwhile, were used to justify activity-centred content as a way of allaying relatives’ sense of guilt and concerns that nursing-home life might be passive and isolating.
Representations as marketing – to relatives
A marketing discourse was evident from the interviews, developed in the descriptions of online representations as a way for nursing homes to improve their public image and attract new residents. Even if the online representations were framed as ‘information’, rather than ‘advertising’, it was clear that the purpose of the depictions was to appeal to potential customers. All interviewees framed residents’ relatives as the target group for the online representations. The category was presumed to be made up of one particular type: adult children. Spouses and siblings were rarely mentioned. Remarks about the audience of the representations were followed by the reasons for targeting relatives: ‘They're the ones who look for information, who Google, find us, search and come to have a look at the place’ (Alice, manager). Relatives were, in this sense, defined as proxy customers, and in some cases the very reason for having a social media account was to reach this category of customer:
In the spring when we had some vacant places, that's when we set up our Facebook account. We said, ‘We have to try to market ourselves, to show that we exist!’ Because it's almost always relatives who contact us, saying, ‘Now, I'm calling on behalf of my mother; she's getting worse and home care isn't enough any more. We're thinking she might have to move.’ (Alice, manager)
Initially, none of the interviewees problematised the targeting of adult children rather than prospective residents. When the interviewer referred to the potential violation of official policy, a number of accounts were presented. Deliberately addressing younger relatives was framed as a practical issue, since those in need of nursing-home care did not have the strength or capacity to sift through the representations. One manager explained that in the past few years the health of new residents has declined drastically, and some only lived for two or three weeks in the nursing home before they died. Another manager said that because of old people's cognitive impairment, their relatives had to be the decision makers during the process. ‘Since residents are a bit confused and a bit forgetful and a bit tired, it's the relatives who decide if they should move here or not’ (Beatrice, manager).
Another way of accounting for the targeting of residents’ relatives was to refer to the digital divide, with the argument that people over a certain age are disinclined to use online services, and are thus excluded from many areas of contemporary digital society:Footnote 1
I suppose you address relatives more than you address the residents themselves. Since a lot of the information today is online. And however we try to deal with it, those who are born in the 1920s and 1930s aren't – not all of them are comfortable using computers … So the information we have online today, it primarily addresses the relatives. (Claire, manager)
When justifying the practice, interviewees described the assumption that relatives channel information for potential residents. Diana (manager) suggested that relatives might function as mediators between older people and the nursing home. ‘You would hope and think that they [older people] sit together with their relatives and look at the representations’, but she went on to add, ‘but of course that's not always the case’. The nature of digital society was also mentioned as a justification for why nursing homes presented information on platforms that were assumed to be inaccessible to older people. When asked if it might be a problem that the information provided online did not reach prospective residents, Claire (manager) responded:
I understand, I understand what you're saying. I understand exactly what you're saying. And of course, it's really … it's a Catch-22 kind of problem. I could try to get the information out in a number of ways. But the information that we have out there now – no, it doesn't target those it's supposed to be for. And that has to be a problem. But I'm not sure it's just my problem. I guess it's a social … a structural problem.
By referring to structural conditions, she accounted for her actions by disclaiming responsibility (see Scott and Lyman, Reference Scott and Lyman1968). Later in the interview, she agreed that ‘When you think about it, it doesn't look very good … that we have an organisation that targets one clientele, but they can never access the information if they don't have help and support from someone else.’ In this statement, the phrase ‘When you think about it’ indicates that although the interviewee seemed to agree with the official policy, the practice was not considered a problem outside the interview where the question had been raised.
‘Come and take a closer look!’
An issue of particular interest is whether representations were described as mirroring images of nursing-home life (see Carlstedt, Reference Carlstedt2019). Websites and Facebook and Instagram accounts were described as having the same audience, but differing in style and content. In general, websites were said to provide practical information about the premises, working methods and staff. Many of the nursing-home websites also presented a selection of results from annual user surveys to give prospective customers a sense of residents’ overall satisfaction, sense of security, activities and meals. Website representations were said to be updated less frequently, whereas social media accounts such as Facebook and Instagram were used to show ‘what it's like here day-to-day’ (Ellen, nurse). These daily doings, however, did not include ordinary tasks such as preparing meals, dispensing medicine or making beds; rather, interviewees said that they wanted to show ‘what's fun’, with residents visiting museums, playing bingo, having their nails done, participating in a traditional crayfish dinner, having Christmas or Nobel Prize parties, or marking any number of thematic days (International Women's Day, Cinnamon Bun Day, Waffle Day, etc.) that nursing homes like to celebrate (see Carlstedt, Reference Carlstedt2019).
When the interviewer raised the question of selection, several interviewees were open about the fact that nursing-home life as portrayed online was not nursing-home life in its totality. ‘Yes, this mirrors everyday life, but not everyday life as it is every day!’ (Fiona, nurse). The motive for the selection of images and texts was linked to the process of choosing a nursing home. Fiona wanted the social media images to signal ‘Come and take a closer look!’ to attract prospective customers to visit the nursing home. When asked why routine activities were not put online, Ellen (nurse), who was in charge of posting images on Instagram, agreed that in principle they could, but that was not what relatives requested:
They want to see what we are up to here, like I said. Everything revolves around activities a lot. That's the first question we get – almost always when they come and visit. ‘What do you do to keep those who live here active?’
Focusing on activities was framed as a way of showing that nursing-home life could be meaningful to residents. Fiona (nurse) reasoned that relatives were afraid that their parents would end up ‘sitting in a chair’, and that was why they wanted to make sure that there would be plenty of activities on offer. The need for these reassuring messages was attributed to the general image of nursing homes as sites associated with imminent threats of passivity, loss and boredom. Söderberg et al. (Reference Söderberg, Ståhl and Melin Emilsson2012) argue that relatives might experience shame or guilt when a parent or relative is in the process of moving to a nursing home. Such emotions may arise from a sense that enjoyment of one's own life comes at the expense of one's parent, or that one is putting one's own wellbeing first. This was also a theme in our interviews. Beatrice (manager) suggested that adult children advocated as many social activities as possible to mitigate such feelings of guilt:
‘I don't have time to take care of them any more, but then it's a good thing the nursing home, there's lots of things going on there.’ Then they don't have to worry … Because they always ask, ‘What kind of activities do you lay on?’ They want things to happen. So they don't have to have a guilty conscience for putting their mum here.
According to several interviewees, successful marketing led to a steady flow of new residents. The online representations were used to paint a picture of a meaningful nursing-home life that corresponded to the relatives’ demands, while at the same time soothing their fears by presenting events and occasions that were actually out of the ordinary.
Thus, nursing homes’ online representations were used for marketing purposes – as an entry point or shop window, primarily broadcasting that the facility existed and what activities it offered. This made it relevant to present images of residents as able to participate in social activities. Online representations targeted relatives (adult children), since they were perceived to be the real customers when it came to choosing a nursing home. The representations were thus tailored to meet the emotionally charged demands of relatives. The role that these practices assigned to relatives was not acknowledged as a problem that needed to be addressed. Neither was the content of the online representations problematised, even when interviewees admitted that the ‘everyday’ on display there was only one carefully portrayed version of reality.
Representations as assurances – for relatives
Relatives’ involvement continues after admission to a nursing home (Gaugler, Reference Gaugler2005; Holmgren et al., Reference Holmgren, Emami, Eriksson and Eriksson2013; Puurveen et al., Reference Puurveen, Baumbusch and Gandhi2018). The Swedish policy on care frames the relatives’ role as a potential source of information about the resident:
Many older people are frail due to illness, which can be an obstacle to being active and participating in choices. We may sometimes ask for help from relatives to obtain an understanding of older people's needs, but at the same time we need to be responsive to older people's own wishes. (Socialstyrelsen, 2012)
As this signals, the official policy tends to construct the role of relatives as conditional on the way staff choose to interpret the residents’ wishes and needs. Unsurprisingly, several studies have shown that relatives may view things differently, arguing that they need to act as guardians of dignity (Whitaker, Reference Whitaker2009) or to protect the identity of their loved ones from institutionalisation (Harnett and Jönson, Reference Harnett and Jönson2009). This brings us to the vocabularies used to justify the nursing homes’ online representations in relation to nursing-home life post-admission. Such vocabularies differed to some extent from representations as marketing, in that they focused primarily on mediating accountability and assurances. Starting with the themes that are absent from the online representations and the reasons for excluding some aspects of nursing-home life, we will turn to a key motive that has already been mentioned in relation to choosing a nursing home: the need to reassure relatives that residents will have a good life at the facility. By exuding confidence and legitimacy, representations continuously provide evidence for the claim that nursing-home life is active and enjoyable, and that relatives had made the right choice, thus helping to fend off criticism and avoid accusations (see Hirsch and Bermiss, Reference Hirsch, Bermiss, Lawrence, Suddaby and Leca2009).
What is missing?
Online representations consisted of a selection of daily activities at a nursing home. All interviewees claimed that care activities were usually not depicted when portraying everyday life at the nursing home, nor was death and mourning. When the interviewer raised these issues, responses were mixed. The overall impression was that interviewees had not reflected on the possibility of showing more than social activities.
A small number of interviewees referred to privacy and ethics. For instance, Alice (manager) described residents who had trouble eating, which made them quite anxious during mealtimes. She justified the lack of such content with the argument that it would be offensive to display residents in this insecure and uncomfortable situation. ‘Sensitive’ information about declining health was – if requested, and if the resident approved of the information being shared – communicated directly to the relative concerned.
Displaying only social activities seemed to be the easiest way of avoiding the risk of portraying unethical situations, while catering to the target audience. When asked about how the selection was made, Fiona (nurse) gave an answer that was typical of most interviewees:
I guess it's because we don't think there is a need to [display other situations, such as care activities]. Because as I said, from the outside it's most times the relatives who look at this, and they're not interested in how we care for a wound; they're interested in the activities.
The interviewer followed up by asking if she thought it strange that relatives were only interested in social activities, and not care. Fiona replied,
Yes. I do think that. I don't think … I mean, my work doesn't just revolve around activities; there are a lot of other things as well. But the [Instagram] account is for showing the good parts of the nursing home. And that's the activities.
Adams and Chivers (Reference Adams and Chivers2013) argue that nursing homes lie at the intersection between home and hospital. By excluding situations which might signal ‘institution’, nursing homes’ online representations are used to construct the sites as homelike in attempts to avoid criticism for being institutional.
Similarly, death and mourning were excluded from the online representations. Fiona (nurse) described how staff lit a candle whenever a resident died, and said that portraying such an event would probably be appreciated by their Instagram followers. ‘It's a nice thing to do. I'm actually going to think about that (laughter). Because I think they [the audience] would appreciate that, too – them seeing us do that.’ The quote illustrates that even if a candle is lit as a mark of respect, online representations should be tailored to what the audience would appreciate.
Representations as evidence of quality of life
Relatives can only occasionally be present in the nursing home in order to make sure that residents’ needs are met. Time away from the facility is, according to Whitaker (Reference Whitaker2009), time when relatives have no control or insight in residents’ lives, and might thus experience stress or worry. Some relatives lived far away, and most could not visit residents on a daily basis. Alice (manager) explained that relatives wanted to be reassured that there were activities for their parents, and that their parents were able to go outside. She illustrated positive reactions, such as statements from relatives such as ‘Oh, that's when mother was playing bingo’ or ‘That's when dad joined in that walk’.
The online representations were also said to complement relative–resident interaction, or even be a substitute for it. ‘Not everyone might be able to tell what they've done, or remember it. So it's a good way of seeing that “Yes, of course, we can tell you've been there and there, and done this and that”’ (Ellen, nurse). Ellen also described typical complaints from forgetful residents: ‘Nothing ever happens here; I never do anything.’ In such cases, relatives can look at the pictures on the blog and social media and show the resident that he or she did join in the activities: ‘Look, here you are!’ Social media representations, which served as proof that activities had taken place, could be used to dismiss complaints and accusations.
Reassurance was also discussed in terms of how staff were portrayed when initiating activities. Diana (manager) suggested that it was not only ‘active activities’ that were shown, but also staff reading aloud to residents or sitting and holding their hands. These images, which focused on the staff, served to reassure relatives by showing them involved and engaged. She concluded that the situation was similar to that of looking at representations of one's children in day care, but for an older generation: adult children needed to see that their loved ones were being cared for, and online representations were one way to communicate that message. Similar comparisons to day care were made in other interviews.
Managing unrealistic expectations
Feelings among professional carers towards relatives have been described as ambivalent (Hammarström, Reference Hammarström2006; Söderberg et al., Reference Söderberg, Ståhl and Melin Emilsson2012). While the practice of addressing relatives during the placement process was not perceived as problematic, their unrealistic expectations once their relatives were resident were framed as a significant challenge. Relatives’ demands for activities were by some interviewees described as putting additional pressure on staff, in cases when residents had little interest or energy to participate in activities (see Storm and Stranz, Reference Storm, Stranz, Jönson and Szebehely2018). The majority of the interviewees claimed that it was very important to get along well with relatives and to explain why the promised nursing-home life could not always be realised, in order to be perceived as trustworthy:
So we try to get them to be realistic. That we do have activities, but perhaps they don't have to be that grand … to get out and about on our excursion bus. It might be enough to just sit down and look through an old photo album or read a book together with someone. Because it should be an activity that actually gives some meaning. But they [relatives] have very high hopes. And expectations. A lot of the time. So to some extent you almost have to lower them a bit. That things don't really work like that: ‘Your mother doesn't have the energy for it.’ (Alice, manager)
Storm and Strantz (Reference Storm, Stranz, Jönson and Szebehely2018) have described relatives’ demands for social activities as a threat to residents’ actual care needs. Nursing homes may try to meet even unrealistic expectations and persuade residents to participate in activities that they do not benefit from. While official policy clearly states that care should be centred on the needs of the care user, interviewees expressed a less certain stance. Alice (manager) said, half-jokingly, that sometimes she felt that ‘we take care of relatives more than we take care of residents’. When asked what the online representations were supposed to communicate, Beatrice (manager) responded, ‘That residents have a good life, absolutely. That's the most important thing, because if residents are well, relatives can relax.’ Some managers acknowledged that their nursing home tried to comply with requests from relatives even when that was at variance with the perceived needs of the residents. Managers talked about ‘finding a mix where both groups are satisfied’ (Diana, manager), or simply said that the facility ‘frequently adheres to the relatives’ [requests]; they are often spokespersons, while the resident might not say so much.’ When asked about how her staff dealt with relatives’ requests for residents to be active, Gabrielle (manager) replied, ‘Sometimes we do things because relatives want it and not because the residents themselves want it. You end up those situations sometimes, definitely.’
Residents’ limited decision-making capacity was mentioned as a justification for such adaptions, along with a general sense that relatives were important partners and stakeholders in the care context. Relatives were also framed as having the power to affect the reputation of the facility. Satisfied customers would ensure a good reputation, which in turn would help attract new customers; here, reassuring online representations became part of the nursing home's marketing strategy. Care facilities’ reputations depended on word of mouth, although the annual user satisfaction surveys by the National Board of Health and Welfare (Socialstyrelsen, 2018) were also mentioned. Some interviewees claimed that these surveys (contrary to what was intended) were most often filled in by relatives rather than the residents themselves. This was framed as a problem, since relatives did not have full insight into daily life at the nursing home, and in some cases residents were too sick or forgetful to inform their relatives fully. Beatrice (manager) described a situation where 65 per cent of the surveys at her nursing home had been filled in by relatives. The results from the most recent survey had shown a low score for social activities, even though residents said they were satisfied with the activities currently on offer. The manager had tried to communicate residents’ needs to relatives, but the nursing home had also increased the number of social activities. ‘In December we had arranged a huge amount of activities. There were so many that they [the residents] said ‘No, that's enough!’’ Much like Storm and Strantz's (Reference Storm, Stranz, Jönson and Szebehely2018) respondents, Beatrice (manager) felt that this adaption constituted a problem. By referring to measurement results, which she said reflected relatives’ requests rather than residents’, her account served to ‘excuse’ the choice to further increase the number of activities (see Scott and Lyman, Reference Scott and Lyman1968).
Although the content of online representations was carefully selected to soothe fears, relatives tended to regard them as comprehensive reflections of the everyday life at the nursing home. In fact, having only a few social activities on display could result in worried comments. Alice (manager) described a situation where the staff member responsible for the Instagram account had quit her job, and as a result there was a period when nothing was posted:
And immediately it was like ‘Don't you have any activities any more?’ ‘Yes, we have the same activities’, but just because they [relatives] couldn't see any of them on Instagram, they felt that ‘now they aren't doing anything at the home’. So for them it's a matter of security. Even if they know, and they can see it in other ways. So it's still a good thing for them to see that ‘Yes, today they had bingo’ or ‘Today they've been out for a walk.’
What Alice (manager) indicated was that once a particular online practice had been established, the representations began to mirror reflections of the daily goings-on in the nursing home.
Interviewees thus had mixed feelings about demands from relatives to arrange social activities (see Hammarström, Reference Hammarström2006; Storm and Strantz, Reference Storm, Stranz, Jönson and Szebehely2018). This ambiguity, however, was never present in relation to online representations. Showing social activities was the right thing to do, according to the study participants, since it met relatives’ demands and needs, even in cases where those needs were described as egocentric. The practice of assuring relatives through online representations was in this sense similar to what Mahrs Träff et al. (Reference Mahrs Träff, Cedersund and Abramsson2018) observed in their studies on activities in Swedish nursing homes. According to staff, weekly lists of social activities that were posted on walls served the purpose of showing relatives that activities were planned.
Discussion and implications
The findings of this study indicate there is a need for further research on the use by nursing homes and similar organisations of online representations to manage impressions of their daily goings-on. Online representation practices descriptively ‘produce’ older people using images and short texts (see Holstein, Reference Holstein1992) in order to appeal to their adult children, who are thought of as the real customers in the nursing-home market. The question of what images of older people are produced in online representations has a clear answer: as residents, older people are displayed as content, socially active and involved, largely through the efforts of the nursing home and its staff. The online representations amount to descriptive practices by which nursing-home residents are produced as individuals, with a lifestyle corresponding to people in the third age, in order to cater to relatives’ emotional needs and so attract them as customers.
The rosy images provided in online representations thereby seem to serve a two-fold purpose. They fend off images of extreme frailty during old age that may be perceived as disturbing (see Carlstedt, Reference Carlstedt2019). Thereby, they meet the audience's emotionally charged requests. Simultaneously, they are used as evidence of the nursing homes being successful organisations providing possibilities to lead an active life. Such positive images of ‘successful’ old age may reproduce the ageist discourse of contemporary Western societies and help construct an image of nursing-home residents which further stigmatises the fourth age (see Featherstone and Wernick, Reference Featherstone and Wernick1995; Holstein and Minkler, Reference Holstein, Minkler, Bernard and Scharf2007; Adams and Chivers, Reference Adams and Chivers2013).
One finding is that the ‘reality’ constructed in the online representations is sometimes distinct from many of the everyday goings-on at the nursing home, as perceived by our interviewees. However, the line between what was on display and what interviewees perceived as the everyday nursing-home life was blurred, and the ‘reality’ of the online representations did have consequences for the organisation and practice of care in the nursing homes.
In order to post photographs of a Christmas dinner, a traditional crayfish party or a trip to the beach, these activities have to occur (see Carlstedt, Reference Carlstedt2019). Online representation practices increase the permeability of nursing homes, and may prompt them to arrange social activities, for better or worse. Even if external auditing provide a lot of information about the goings-on in the nursing homes, such as activities (Socialstyrelsen, 2018), we argue that the online depictions act as evidence and help in convincing the audience that activities did in fact occur. However, there is a risk that nursing homes become too strategic in their use of social media. The public's tendency to think online representations are accurate representations of the daily doings presents nursing homes with the opportunity to stage and display requested activities, and so fend off complaints and boost their image as a place where a lot of social activities take place. The problem, as illustrated in this article, is that important aspects of life in the nursing home may be unacknowledged or concealed. In such online representations, the function of older people is to convey appealing and reassuring images of the nursing home. Historically, the impermeable nature of nursing homes has resulted in accusations that some realities are concealed while others are brought to the fore. In 1949, the Swedish author Ivar Lo-Johansson, a member of the ‘proletarian school’, argued that the beautiful façades of some ‘old folks homes’ were Potemkin villages that served to conceal the ugly realities of ageing in the era of the Poor Law – and indeed, to conceal certain aspects of ageing itself (Lo-Johansson, Reference Lo-Johansson1949). Given the history and nature of nursing homes, the potential to use online representations to strategically orchestrate a reality that appears favourable to the public needs further attention.
A second finding concerns the position of adult children and their relation to their relatives in nursing homes when it comes to Swedish eldercare policies. Our study reveals the existence of two distinct policies on the role of relatives: one is stated in law and official documents, another is expressed in the practices of presenting nursing homes online. Could it be that the online representation of older care users under Swedish policy is in fact a Potemkin village, studiously ignoring the fact that most of the decision-making falls to relatives? An open discussion on the two policies would benefit the system of eldercare. Official policy has downplayed the role of relatives in nursing-home care in Sweden, and this tendency is also visible in research and debates about political change. In an article on customer choice in Swedish eldercare, Meinow et al. (Reference Meinow, Parker and Thorslund2011) argue that those who are most in need of eldercare services ‘are also those who have the highest prevalence rates of cognitive, physical and sensory limitations associated with the capacity to manage and carry out (on their own) informed choices of care providers’. This, combined with the lack of adequate information, means that the choice of older people in need of care is therefore a moot point. Against this, Goodwin (Reference Goodwin2011) argues that since older people wish to make choices, professionals must redouble their efforts in the areas such as patient information, patient-centred care planning and supported self-care. Are older people unable to act as customers, or could they be enabled to act in this role if they had support from the care system? What the present study shows is that the debate on whether or not older people are able to act as customers fails to acknowledge the reality of eldercare: relatives – and adult children in particular – are already involved in the admission process. So much so, indeed, that they are regarded as the actual customers. Should this be officially acknowledged and discussed?
In combination with on-going marketisation, it is likely that the greater use of online representations by nursing homes will increase the power and influence of residents’ relatives, and our study suggests that this might also influence the way residents are organisationally ‘produced’. When online representations become a shop window, the initial contact will not enable dialogue about the actual needs of residents, as perceived by nursing-home representatives, but will instead consist of snapshots of nursing-home life as it is supposed to appeal to the intended audience. Failing to present a ‘good’ shop window means there is a risk of not being contacted by relatives who are searching for a suitable nursing home.
Online representation practices may prompt nursing homes to provide social activities, thereby avoiding passivity and social isolation, but what our study shows is that such representations may also have problematic outcomes. Further research on nursing-home representation practices may prevent the development of increasingly unrealistic shop windows that market ‘third-age’ lifestyles, normally associated with the early post-retirement years, to people in the fourth age who need nursing-home care.Footnote 2
Acknowledgements
The study was carried out as part of the research programme ‘Individual Care and Universal Welfare: Dilemmas in the Age of Marketisation’. A previous version of the article was presented and discussed in the RN01 ESA Conference ‘Ageing in Europe: Agency, Citizenship and the Dynamics of Power’ in Brno, Czech Republic, 5–7 September 2018. Our thanks to Tove Harnett for reading the article at an earlier stage.
Statement of funding
This work was supported by the Swedish Research Council for Health, Working Life and Welfare (FORTE, grant number 2013-2296).
Ethical standards
The study was approved by the Regional Ethical Review Board in Lund, Sweden (2015/864).
Open access
