Social Work in Health Care, 48:597–613, 2009

Copyright © Taylor & Francis Group, LLC

ISSN: 0098-1389 print/1541-034X online
DOI: 10.1080/00981380902791267

Living in Institutional Care: Residents’

1541-034X
0098-1389
WSHC
Social Work in Health Care,
Care Vol. 48, No. 6, June 2009: pp. 1–27

Experiences and Coping Strategies

VIRPI TIMONEN, DPhil and CIARA O’DWYER, MSc

Living
V. Timonen
in Institutional
and C. O’Dwyer
Care

Social Policy and Ageing Research Centre (SPARC), School of Social Work and Social Policy,
Trinity College, Dublin, Ireland

Insights into daily living in residential care settings are rare. This
article draws on a qualitative dataset (semi-structured interviews
and recordings of residents’ council meetings) that gives a glimpse
of the experiences and coping strategies of (older) people living in
residential care. The data highlight the range of unmet needs of
the residents, similar to the categories of physiological, safety, love,
esteem, and self-actualization needs in Maslow’s hierarchy of
needs theory. Our analysis indicates that “higher” and “lower”
needs are closely intertwined and mutually reinforcing and
should therefore be accorded equal emphasis by professionals
(including social workers) employed within residential care settings.

KEYWORDS residential care, Maslow’s hierarchy of needs, quality

of life, older people

INTRODUCTION

Numerous studies have outlined the unmet physiological and psychological

needs of people in residential care facilities (Barnes, 2006; Hansebo &
Kihlgren, 2004; Kayser-Jones et al., 2003; Nelson, 2000; Teno, Kabumoto,
Wetle, Roy, & Mor, 2004; Angus, Kontos, Dyck, McKeever, & Poland, 2005;
Tuckett, 2007). It has long been recognized that the traditional structures

Received June 27, 2008; accepted December 18, 2008.

This study was supported by a grant from the Health Services Executive (Ireland). The
authors wish to thank Ms. Ana Diaz and Ms. Eileen Kelly for their help in collecting the data.
Address correspondence to Virpi Timonen, Director, Social Policy and Ageing Research
Centre (SPARC), School of Social Work and Social Policy, 3 College Green, Trinity College,
Dublin, Ireland. E-mail: timonenv@tcd.ie

597
598 V. Timonen and C. O’Dwyer

and work practices of institutional care settings are not necessarily condu-
cive to a good quality of life for residents. Research has also shown that res-
idents of care facilities attach great importance to the fulfilment of their
psychological needs. Robichaud, Durand, Bédard, and Ouellet (2006) found
that three of the most important quality of life indicators identified by a
sample of Canadian residents of care facilities were being treated with
respect, access to relationships, and positive attitudes from staff. Another
Canadian study suggested that interaction with family and friends, personal
comfort, the physical environment, and mental stimulation were among the
factors noted by residents as important for their quality of life in long-term
care (Guse & Masesar, 1999). Exploratory interviews with Dutch people
with dementia living in the community and in residential care settings
revealed that “being of use/giving meaning to life” and “self-determination
and freedom” were important quality of life domains (Droes et al., 2006).
It is only in recent years that more attention has been devoted to
improving the quality of residential care, and, in particular, ensuring that the
care provided adheres to residents’ own expectations. While there is an
extensive literature on the benefits of resident-centered care, care settings
have been slow to change, perhaps as a result of limited research outlining
what is important to older people who live in residential care settings (Kane
& Kane, 2001).
Insights into daily living in residential care settings are rare. This article
presents the analysis of interview and group discussion data collected in the
course of an evaluation of an advocacy group (residents’ council) in an Irish
residential care setting. The data give an insight into the experiences and
coping strategies of (in our sample, mostly older) people living in residen-
tial care settings. The study makes a contribution to the literature in a num-
ber of respects: it draws on a large qualitative dataset that has some
longitudinal elements; it throws light on a (still) relatively new and poorly
understood phenomenon of resident advocacy in institutional care; and it
engages with a major theoretical construct, that of Maslow’s hierarchy of
needs. From the practice and policy point of view, the article contributes to
a greater understanding of the ways in which residents’ lives in institutional
care are constrained, and can be improved, by professionals (including, and
perhaps especially, social workers) employed within such settings.
We have organized our data analysis around the framework devised by
Maslow (1943) in his hierarchy of needs theory; the reasons for adopting
this framework are outlined in the research methods and data analysis sec-
tion. Our data revealed that residents had both physical and psycho-social
(unmet) needs. The article discusses residents’ unmet physiological, safety,
love, esteem, and self-actualization needs, and reflects on the need to
devote more attention to meeting residents’ needs across the full scale of
needs from the seemingly basic (but still often unmet) to the higher needs
that are often seen as unattainable for people in care settings.
 Living in Institutional Care 599

MASLOW’S HIERARCHY OF NEEDS THEORY

Maslow’s hierarchy of needs theory, first posited in 1943, was one of the
first frameworks for understanding how individuals’ assessment of quality of
life could be related to how well their needs were being met. Maslow sug-
gested that needs were hierarchical, with physiological needs taking prece-
dence over other, psychological needs.
As illustrated in Figure 1, Maslow suggested that humans had needs on
five levels. The most basic needs of all humans were physiological, includ-
ing the need for, inter alia, oxygen, water, food, heat, sleep, and sex. Once
these needs are met, humans wish and therefore seek to have their “safety”
needs met: these include structure, order, stability, and protection. The third
set of needs, which arise once the safety needs “are fairly well gratified”
(Maslow, 1943, 380), consist of love and affection needs and belonging
needs, followed by the esteem needs, whereby humans desire self-respect
and the esteem of others, as well as independence, confidence, and
achievement.
Maslow referred to the first four lower levels of need as the “deficit”
needs to highlight their physiological nature, while the fifth, self-actualization,
he referred to as the “being” needs; these needs involve individuals’ contin-
uous desire to fulfill their full potential and do what they are fitted for.
While the term self-actualization had previously been used by other
Being needs

Self-
actualization

Esteem
Deficit needs

Love/Belonging

Safety

Physiological

FIGURE 1 Maslow’s hierarchy of needs (Source: Maslow, 1968).

600 V. Timonen and C. O’Dwyer

theorists, Maslow saw the term as having a specific and limited meaning: “it
refers to the desire . . . to become . . . everything that one is capable of
becoming” (p. 382). Maslow suggested that only approximately one percent
of all human beings were self-actualizers, whereas others were still striving
to have their lower needs met (Maslow, 1968).
Maslow’s theory is not without its critics, but as the focus of our article
is not on criticizing the theory, we can only offer a cursory summary of
some aspects of this critique. In their review of studies based on Maslow’s
theory, Wahba and Bridgewell (1976) found limited evidence to suggest that
human needs are hierarchical. Max-Neef (1991) argued that needs are
instead simultaneous and complementary with satisfaction thereof based on
trade-offs, a conclusion supported by Reiss’s research on motivation (2004,
2008). In addition, Geller (1982) questioned Maslow’s narrow definition of
the term “self-actualization,” suggesting that Maslow’s theory is unable to
offer an adequate account of the origin and nature of human needs.
In spite of its limitations, Maslow’s hierarchy of needs theory remains
popular and has been used as a framework for understanding how the
needs of vulnerable people could be met (Umoren, 1992; Zalenski &
Raspa, 2006). In this article, we are using the hierarchy primarily as an
organizing framework and a heuristic tool. We wish to emphasize that we
did not set out to test the theory, nor did we make any initial, guiding con-
jectures about life in institutional care based on Maslow’s theory. Rather,
the picture that began to emerge from our data bore such a striking resem-
blance to Maslow’s categorization of needs that we decided, at the data
analysis stage, to utilize it as a framework for organizing our discussion of
the data.

RESEARCH METHODS

The discussion presented in this article is based on data collected during the
course of an evaluation of a residents’ council established within a large,
public-sector residential care setting in Ireland, St. Anne’s.1 The facility
catered mainly for older people, many of whom had cognitive impairments
or severe physical disabilities. One unit catered exclusively for younger
people (under 65) with disabilities. The facility was located in an urban
area, approximately one kilometer from the nearest shops and other ser-
vices, making it difficult for residents to reach these without assistance.
The group was set up by staff members from within the facility who
wished to gain an understanding of the views and concerns of residents
and to bring any issues raised to the attention of the facility’s management
team. The group met with a staff member once a month, in order to high-
light aspects of life in the facility that they felt could be improved. The
group meetings were both observed and audio-recorded by the research
 Living in Institutional Care 601

team. In addition, semi-structured interviews were conducted with twelve

members of the group.2 All twelve of the original group members were
interviewed at the outset of the project. After the advocacy group had
been in operation for a one-year period, seven group members were re-
interviewed. The five others were no longer in the group for a variety of
reasons (deteriorating health, death, loss of interest). All of the individual
interviews were audio-recorded and transcribed. Ethical (human subject)
approval for the study was obtained from the researchers’ university, and
highest standards of ethical conduct of research were adhered to through-
out the research process.
The data were analyzed by the authors using both manual coding
and NVivo qualitative analysis software. The researchers read the inter-
view and group meeting transcripts several times in order to familiarize
themselves with the data. While the overall purpose of the research was
to assess the extent to which the advocacy project helped to improve the
lives of those living within the facility, the focus of this article lies in our
analysis of the content of group discussions and individual interviews
pertaining to life within the facility, and in particular those aspects of life
in institutional care that the respondents experienced as unsatisfactory.
Potentially relevant text was highlighted during a process of provisional
coding. Next, we questioned this provisionally coded data with the view
to discovering central concepts and categories (i.e., residents’ needs, how
and why these were met or not met, the role of structures, practices and
professionals in enabling or preventing the meeting of needs, and so on).
Individual cases and transcripts were then compared for similarities and
differences through a process of constant comparison. At an early stage
of this process, the resemblance between Maslow’s hierarchy of needs
theory (1943) and the themes emerging from our data became evident
and we started to utilize his theory as a framework for organizing
and presenting the findings of our analysis. In what follows, we outline
in detail how our data corroborates and contradicts aspects of Maslow’s
theory.
This project, in common with all research endeavors, had a number of
limitations that we wish to make explicit. This was a qualitative study that
cannot be argued to be representative of the institutional care population
of Ireland. However, the purpose of the study was not to yield generaliz-
able information (for that, a large-n quantitative study utilizing probability
sampling would have been necessary), but rather to explore lives in insti-
tutional care, and to make a contribution to theorizing on the (met and
unmet) needs of institutional care residents. Although the methods utilized
by us were carefully documented and are therefore replicable, our
research findings are of uncertain transferability as the context in which a
study of this kind is carried out inevitably has a strong impact on the
research findings.
602 V. Timonen and C. O’Dwyer

FINDINGS
Physiological Needs
Maslow (1943, 373) suggested that the basic, “pre-potent” needs are physiologi-
cal, including the need for, inter alia, food, hydration, sleep, sex, and oxy-
gen. Evidence from both the group meetings and the individual interviews
suggested that these basic needs were not always met:

I have to share a room with a man . . . [who is] on the suction

machine sometimes [as] he has very bad breathing. . . . I had three
hours sleep today . . . because of hearing it through the night . . . that
is why I am sleeping all through the day . . . so when he gets up . . .
to go down to the dayroom I do get in under the covers. . . . I am just
trying . . . to have a little rest but then all through the day there is
cleaners coming in and out. (Male group member in his twenties, indi-
vidual interview)

Resident 1: [Nurses and care workers] talk very, very loudly among themselves.
At that hour in the morning [six o’clock], it’s not fair.
Resident 2: In my ward one [person] snores like a motorbike. (Group discussion,
10th meeting)

As a result of poor physical facilities, residents were also at times unable to

keep warm and physically comfortable:

I came out of the bath . . . and the ward was . . . cold. . . . You are freezing.
. . . You wouldn’t get that at home. (Male group member in his fifties,
1st meeting)

Resident 1: I was in the shower now yesterday morning and it’s far too small and
they have to literally put down towels to get the water. It’s far too small
in every way, in every way. . .
Resident 2: There’s water on our unit, spilling out onto the floor when you’re having
a shower. (Group discussion, 3rd meeting)

While residents always had enough to eat, many felt that the quality of food
left a lot to be desired:

. . . the food is still just the same, sometimes you can’t even eat the
meat. Especially the so-called lamb, I think he died before he was killed!
(Female group member in her eighties, 11th meeting)

Frequent references were also made to meals being served cold, and to the
lack of variety in the food provided:
 Living in Institutional Care 603

I found that the dinner yesterday was absolutely cold . . . it was cabbage,
and cold cabbage is horrible . . . and the potatoes were horrible, really
watery, oh they were horrible. (Female group member in her eighties,
7th meeting)

. . . we never get a bit of broccoli or cauliflower, it’s carrots, carrots,

carrots, mushy peas and maybe turnip—it’s monotonous. (Female group
member in her eighties, 3rd meeting)

However, some of the remarks made by residents suggest that the poor
quality of food was not the central concern, but rather, what this and the
organization of mealtimes revealed about the attitude towards residents:

I think [staff] should sample the food themselves to see. . . . I am . . .

disabled from the neck down, not from the neck up, that’s how I know
hot from cold. (Female group member in her fifties, 6th meeting)

Resident 1: They clean the table before the meal is finished. . . . [You need] a
respectable time to eat your meals. . . . You feel like you are in school.
Resident 2: . . .when they spray that stuff [cleaning solution] it splashes onto you.
(Group discussion, 4th meeting)

Safety Needs
Using the behavior of children as an example, Maslow (1943) suggested that
human beings prefer a “safe, orderly, predictable world” (p. 378), and, more
broadly, attempt to seek safety and stability including a “preference for
familiar rather than unfamiliar things. . .” (p. 379). In this regard, residents
appeared to feel emotionally ‘safe’. The sociability of the staff ensured that
some respondents had a largely positive experienced living in residential
care settings:

This is a home from home. (Male group member in his eighties, individual
interview)

However, this perception was not shared by all. Another resident stated that
the facility did not feel like home, thus perhaps suggesting that she did not
have her safety and stability needs met within St. Anne’s:

I wouldn’t like to stay here for good. . . . I’d like my own little place. . .
(Female group member in her eighties, individual interview)

Ensuring the physical safety of residents appeared to be one of the greatest

concerns of staff, largely as a result of health and safety legislation. How-
ever, the need to adhere to the rules and regulations often inadvertently
604 V. Timonen and C. O’Dwyer

had a negative impact on residents’ lives, particularly on their sense of

independence:

We are not allowed into the kitchen any more. (Male group member in
his fifties, individual interview)

Resident 1: We have to get somebody to bring us out . . . that’s not always available.
Resident 2: And I’m not allowed to go out yet on my own in the wheelchair. I’m a
novice.
Resident 1: You’re a danger to the public! [general laughter] (Group discussion,
3rd meeting)

In his description of the need for safety, Maslow suggested that a natural
aversion to illness, being physically endangered and being in pain were
among the safety-seeking mechanisms employed by humans. In this regard,
it appeared that the care facility was not at all times meeting the safety
needs of residents:

When you are in pain there is nothing done about it. . . . I am some-
times in a lot of pain—for months in pain. (Female group member in
her fifties, individual interview)

[O]ften in our day room, a person becomes unwell and there’s no nurse
available and we keep . . . I’m not able to get up and walk and go out
for a nurse and I keep shouting for a nurse and a nurse can’t come. . .
(Female group member in her eighties, 2nd meeting)

Other comments made by the respondents indicated that they felt that
their health was somewhat under threat as a result of certain staff working
practices:

I often watch [the nurses] when they are doing the medication. They can
be awful running their hand through their hair. And another thing very
few of them have in their possession handkerchiefs. They just use the
back of their hand but I am sorry to have to bring this up but it is true
and another thing yeah they don’t bring handkerchiefs for their nose or
anything, it is not good enough. (Female group member in her eighties,
6th meeting)

The lack of privacy afforded to residents undermined their need for safety
and security of possessions:

I have a chest of drawers which I share with another lady. (Female

group member in her eighties, 8th meeting)
 Living in Institutional Care 605

The lack of safe, personal storage sometimes led to the loss of personal
clothing and meant that ensuring the safety of residents’ possessions
required handing them over to a member of nursing staff:

Resident: I looked in the wardrobe [for my] fleece and next thing . . . some
fellow just shot past me [wearing] my fleece.
Interviewer: If you wanted to keep something safe and private and secure, is there
anywhere. . .?
R: Only if it was money.
I: And . . . where would that go?
R: Into the Sister’s little safe I think.
I: OK but there’s nothing by your bed?
R: There is nowhere . . . in my room where I would be able to put
anything. (Male group member in his twenties, individual interview)

Love/Belonging Needs
Despite being surrounded by others, residents had few opportunities for
either providing or receiving affection or forming friendships:

[Living here is] an improvement [compared to previously living alone] . . .

[although I don’t] talk to anybody [except] Mary. (Female group member
in her eighties, individual interview)

Nobody communicates with anybody . . . there is no laughter. There is

no friendship, they don’t encourage that. People are vegetating. (Female
group member in her fifties, individual interview)

Residents also had to contend with difficulties in conducting a meaningful

relationship with family and friends:

I only go out on Sunday, now my daughter could take me out, but if

you could understand her husband is coming in at an awkward hour
and the children from school. And then who drives me up—they are in
work. I’d love to go out, yeah outings I don’t expect my family because
they have to wait till their husband come in, their children from school,
I’d like to go out more. . . (Female group member in her fifties, individual
interview)

Even when residents had the opportunity to spend time with family and
friends who came to visit, there was little space available to allow them to
have private conversations:

I notice when visitors come in to certain people in my unit . . . in the

day room there’s a certain lady and she listens to every word that those
606 V. Timonen and C. O’Dwyer

people . . . I think it’s very wrong. It’s very embarrassing for the visitors
to have someone listening. . . (Female group member in her eighties,
11th meeting)

Esteem Needs
Maslow (1943) suggested that every individual has a need for a stable,
firmly based (usually) high evaluation of themselves, for self-respect, and
for the esteem of others. It appeared that, at least in some cases, staff
showed little respect for residents, and even more worryingly, engaged in
threatening behaviour:

Staff can sometimes address the patients in a way they shouldn’t speak
to them, in a derogatory way . . . [or] sarcastic . . . ‘sit down and be a
good girl’ has been said to me. . . (Female group member in her fifties,
6th meeting)

It is possible that this lack of respect also led to residents lacking confidence
in their own abilities or opinions, as illustrated by the reply given by one
individual when asked her opinion on whether the facility was run like a
hospital:

Well I’m not long enough here to know. I’m just here [a few months]. So
I wouldn’t have any say on the matter or not anyway. (Female group
member in her eighties, 1st meeting)

In certain cases, residents had opportunities to improve their confidence

and use their skills to help other residents, although the extent to which
this was actively encouraged by staff was unclear. The following quote
highlights the benefits of the use of such skills for a resident’s level of self-
confidence:

There is one resident who speaks very little. One day, I told him a story,
and we got on very well, I told him my story and we laughed, then he
wanted me to tell his wife the story, she came in, and she also laughed,
I was getting him to say more words [than he normally would] and he is
still saying more words. . . (Male group member in his eighties, 2nd
meeting)

The residents recounted several occasions on which they had experienced

disrespectful treatment. Dignity was often absent from the lives of residents:

The nurse turned around and says I will give you your . . . injection,
pulled up my t-shirt . . . with visitors and other patients there. . . . I said
‘please don’t do that’. Her response was ‘who do you think you are?’
 Living in Institutional Care 607

and ‘why do you want the curtain pulled?. . . Doctors have done the
very same thing, examined me . . . in the hallway. (Female group member
in her fifties, 5th meeting)

Self-Actualization Needs
According to Maslow (1943, 382), self-actualization implies the desire for
self-fulfilment, “the desire to become . . . everything that one is capable of
becoming.” As noted earlier, much of the criticism of Maslow’s hierarchy
of needs theory has been directed at his assertion that less than two per-
cent of the world’s population are self-actualizers (Maslow, 1968), given
that the ability to self-actualize requires all of the “lower” needs to be first
fulfilled. However, as the quotes that follow show, some respondents had
great difficulties in accepting the limited opportunities for self-develop-
ment, self-fulfillment, and self-expression, in spite of having unmet “lower
needs.” This was reflected in a great deal of frustration about the lack of
mental stimulation, autonomy, and independence available to residents.
In this respect, therefore, our findings do not support Maslow’s theory as
it was evident that some of the residents aspired to, and in some cases
managed to attain, self-actualization despite also having unmet “lower”
needs.
The lack of activities available to residents resulted in a large propor-
tion of their time being spent unoccupied:

Resident: Oh I’d like to see a lot more happening. We’re sitting down all day
doing nothing in the unit. Sitting on the bed looking at television. I’d
like something else. It drives me nuts at times.
Interviewer: Right, and have you said that to [the staff]?
R: Ah sure, they won’t listen to you. (Male group member in his twenties,
individual interview)
Resident 1: Some days everything just falls flat, do you agree with me?
Resident 2: Like the days you’re just staring out the window. (Group discussion,
2nd meeting)

The following resident spoke of her despair at the lack of mental stimula-
tion provided within St. Anne’s, worrying about the effects on her morale
and cognitive abilities:

What we want here is a home life. We want a sense of normality.

Instead we are vegetating in a room, it is hard and it is not right.
(Female group member in her fifties, 5th meeting)

Even where enjoyable activities were provided, the role of residents

was sometimes confined to that of a passive observer, rather than an active
participant:
608 V. Timonen and C. O’Dwyer

TABLE 1 Current and Desired Activities Noted by Respondents

Current activities Wished-for activities

Prayers Gardening, planting flowers

Bingo Games, puzzles
Playing cards Group activities
Knitting Outings
Religious (hymns, benediction) Crafts
Cookery Computing
SONAS (sensory activity) Story-telling
Aquarium (viewing)
Current affairs

Interviewer: I think they do a bit of cooking here, do they?

Resident: Yeah, but you are only standing looking at them [cookery class instruc-
tors]. (Female group member in her eighties, individual interview)

Table 1 lists the activities currently available to and the activities wished for
by respondents, as voiced during the group meetings and individual inter-
views. The wished-for, currently unavailable activities were evidently of a
more (inter-)active, creative, and challenging nature than the activities actu-
ally available to respondents, hinting that this channel of self-actualization is
not being utilized in a way that reflects residents’ interests and wishes.
Residents also expressed a great deal of dissatisfaction with the regi-
mented lifestyle and prioritization of routine over the needs of residents that
characterized life in the facility:

Facilitator: If people want and look for a shower or a bath on a daily basis is that
ok?
Resident 1: No. We are nominated a designated specific day. Like a Tuesday.
Resident 2: Mine do it twice a week, Tuesday and Friday.
R 1: . . .if they are busy [on a Tuesday] they can’t do me. They don’t do me
until the next day.
Facilitator: [So showers are] not really available . . . on demand?
R 1: No, definitely [not]. (Group discussion, 7th meeting)

The frustration voiced by residents with regard to the lack of choice avail-
able to them resulted partly from the failure of the management to recog-
nize the ability of residents to make more of the decisions regarding their
own care. From the point of entry into the facility, to the basic day-to-day
decisions, residents had limited autonomy over their own lives:

Interviewer: [D]o you remember being part of making [the] decision to move here?
Resident: No. (. . .) I felt terrible down-hearted. (Female group member in her
eighties, individual interview)
 Living in Institutional Care 609

[. . .] staff maybe nurses and care staff talking over the people . . . almost
as if the patient is not there and . . . if they are having a change of
medication or whatever, [they should] include [us] . . . explain . . . why
they are changing it. (Female group member in her fifties, 4th meeting)

The level of frustration expressed by residents over their limited opportunities to

participate in decision making concerning their care and lives in the institution is
indicative of the value placed by residents on having their “highest” needs met.

COPING WITH THE LIMITATIONS AND CHALLENGES

OF LIVING IN INSTITUTIONAL CARE

With the exception of the advocacy initiative, the residents were largely
expected to develop their own coping mechanisms to deal with the losses
and limitations they experienced as a result of moving into and living in the
facility. They used a number of coping mechanisms, including humor:

Facilitator: John is making the point that nothing gets done unless it’s in the book
[nurses’ day book].
John: If you have to die, it has to be in the book! [General laughter] (Male
group member in his fifties, 3rd meeting)

Others appeared to “accept” the negative elements of life in St. Anne’s, by

distracting themselves or keeping busy:

I don’t mind [having no activities] so much, ’cause I knit and read and I
play my cards, I keep myself occupied, others are just staring at the four
walls. (Female group member in her eighties, 2nd meeting)

Another resident used a similar approach, displaying a great deal of resil-

ience but also resignation in the face of what she perceived to be disre-
spectful treatment.

Facilitator: So does [staff ignoring you] bother you?

Resident: No, not really. I get over it. You have to, you have to. (Female group
member in her eighties, 10th meeting)

Others tried to “rationalize” the negative aspects of their lives, suggesting

that things could be worse, or that they should not expect much more,
given their age and level of dependence:

I don’t expect too much from the time I have left. . . . I’ve done pretty
good to go as far as I have. (Male group member in his eighties, individ-
ual interview)
610 V. Timonen and C. O’Dwyer

[I am] thankful for what I have; [it] could be a lot worse. (Female group
member in her eighties, individual interview)

Others attempted to “avoid” trouble, suggesting that putting up with poor

treatment from staff and trying to “keep quiet” helped to ensure an easier
life in St Anne’s:

I have been left sitting on a commode for [a very long time]. [The staff
say] ‘what do you think I am? I have only two hands’. Well I said ‘Please,
if you are having a bad day, please don’t take it out on me’. They are
short-staffed anyway, which is totally fine but if you’re in pain it’s
another thing. So. I don’t know whether it’s worth [complaining further]’.
(Female group member in her eighties, 10th meeting)

Resident 1: I don’t like causing any trouble . . . I keep quiet.

Resident 2: [T]hat is [a way of] handling it . . . just keep quiet and that’s it . . . the
fear of causing trouble . . . that is what it is, isn’t it. Fear of causing
trouble and there is a backlash on you. . . (Group discussion, 10th
meeting)

It is possible that residents tended to desist from complaining as they were

worried about possible repercussions, as illustrated by the following quote:

One of the women in there, come four o’clock when tea is over, she
likes to go to bed you know. She keeps saying ‘Will I go down now?
Will I go down now?’ So, one of the sisters said to her, ‘If you don’t stop
that I’m going to keep you up until the night staff and you won’t go to
bed until the night staff come out’. [This] woman has a very bad leg, a
pain in her leg. That can’t be right can it? (Male group member in his
fifties, 12th meeting)

The various coping mechanisms used highlight both the difficulties associ-
ated with living in a residential care setting, the residents’ desire to be
treated with respect, and their frustrations with the lack of opportunities for
personal growth.

DISCUSSION AND IMPLICATIONS

While the residents of St. Anne’s did have concerns about basic needs, such
as food, physical comfort, and interference with sleep, the inadequacy of
these basic provisions was not the central difficulty for them. Rather, it was
lack of mental stimulation and respect shown to them and the loss of
dignity and independence that ensued. As residents were never strictly
speaking left hungry, cold, without opportunities for sleeping, nor put in
 Living in Institutional Care 611

any direct physical danger, it can be argued that this allowed residents to
focus on their “higher” esteem and self-actualization needs in accordance
with Maslow’s theory where fulfillment of higher needs is aspired to once
lower needs are satisfied. However, in contradiction to Maslow’s argument,
it is also evident from our data that some residents can, and do, aspire to
“higher” needs even where their “lower” needs remain unmet or are only
inadequately met. Furthermore, “lower” and “higher” needs are closely
intertwined: inadequate provision for lower needs (e.g., unappetizing food
served under pressure to consume it quickly) is an indicator that “higher”
needs (e.g., for respect) are also being infringed or neglected. It is therefore
important to guard against the assumption that practices pertaining to
“higher” needs (such as residents’ councils, advocacy, and consultation initi-
atives) should only be implemented when the “lower” needs have been
met. Given the central importance of “higher” needs even for residents
whose “lower” needs remain unmet, practices and policies that support the
achievement of esteem and self-actualization needs should be implemented
in parallel with, and where necessary (e.g., due to resource constrains that
prevent for instance the improvement in the physical infrastructure of the
care setting) prior to changes that pertain to “lower” needs.
One possible explanation for the frustration expressed by the research
participants may lie in their limited capacity to change their circumstances.
Abrams (1978) suggests that when patients go into hospital, they assume the
role of a passive recipient of health care. This is largely as a result of the
structured roles and work practices that allow staff to assume the role of
“guardians of knowledge” and expect patients to be compliant and depen-
dent. Similarly, residents of St. Anne’s were expected to adapt the persona of
“passive recipients” that facilitated staff working practices, but also reflected
the lack of focus on residents’ higher needs. The internalization of the role of
a “passive recipient” by some residents prevented them from shaping their
own personal development and the coping mechanisms that they used acted
as a poor substitute for progression toward meeting their esteem and self-
actualization needs. However, other residents were clearly in a position to
aspire to the “higher” (esteem and self-actualization) needs despite the inade-
quate extent to which their “lower” needs were met. We therefore noted con-
siderable variance among our respondents regarding the ability to meet, and
interest in addressing, self-actualization needs. Further study is warranted in
order to gain a deeper understanding of why some institutional care residents
are more focused on these self-actualization needs than others, and also in
order to gain an insight into how residents can be assisted in the process of
becoming aware of and striving toward meeting these needs.
Our study has indicated that Maslow’s framework can be used to gauge the
types and extent of unmet needs among institutional care residents. Although
we do not make any claims about the generalizability or transferability of the
results, we do recommend that the potential of the approach used here be
612 V. Timonen and C. O’Dwyer

explored further both by researchers and practitioners, especially social work-

ers, working with people in institutional care. In social work practice and
research, utilization of this relatively simple framework can help to gain a
better understanding of the key areas where residents’ needs remain unmet.
We expect that this framework would be particularly helpful for social work
professionals who are considering the initiation and ongoing evaluation of
residents’ councils and similar advocacy and empowerment initiatives. Ide-
ally, the qualitative approach outlined here would be used in conjunction
with ongoing collection of quantitative data on the quality of life and satisfac-
tion with care among institutional care recipients: together, these approaches
can yield a comprehensive picture and understanding of the facets of life that
are important to residents, the areas where improvement is needed, and the
ways in which residents can be more closely and meaningfully involved in
making choices and shaping their own lives in institutional care.

NOTES

1. This is a pseudonym.
2. All but one lived in the facility; due to the high level of cognitive impairment in all residents in
one unit, a volunteer who regularly visited the unit acted as the representative for that unit.

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