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Looking after our old: who cares?

Christine Smith
Director of Primary Care and Community Nursing
University of Cardiff

Care of older people features regularly in the news. For example, just recently there were reports on "dignity nurses" employed to care for older people.(1) But why is there a need for dignity nurses? Surely it is the responsibility of all nurses to maintain the dignity of our older patients?
Much concern about care of the elderly centres around standards and quality of care, whether in a nursing home, hospital or living at home. However, what is rarely reported on is the day-to-day care provided by ordinary people, and the constant burden on these carers of having to cope with a failing older relative.
This article takes a look at informal care of older people from the older person's perspective. It also examines how families report on informal care of older people, drawing on published research,(2) and the potential role of the nurse in an area that allows innovative ways of working with both the older person and their carer.

Have a life
To start with, it's worth taking note of people's feelings and attitudes as to how they would like to be cared for when they are older. A recent policy study funded by the King's Fund as part of its care service inquiry did just that.(3)
The study explored the attitudes of people in their 50s from a range of backgrounds to find out how they would like to be cared for, and where they would like to live, when they got older. It became very clear that most people wanted to "live their own lives", "have a life" and remain independent when they were older. They didn't want to be cared for by their children, and they didn't want to stop enjoying themselves just because they were old. Most people were not worried about personal care or nursing care; however, they did feel that they would need help with domestic work and heavy lifting.

Help with daily activities
According to Carers UK, there are 6.8 million carers in the UK - that is, one in every seven adults.(4) In the UK, a great deal of care of older people is informally provided by spouses, children, friends and voluntary organisations, at little financial cost to the government. Care assistance includes social, emotional, physical and often technical care. As the older person becomes more dependent, help with activities of daily living (ADL), such as bathing, dressing, mobility, using the toilet or eating become necessary. Successful living in the community also requires assistance with ADL such as shopping, cooking, housework, banking, transport and management of medications. All of these activities are time intensive and can add significantly to the stress generated by caregiving, regardless of the age of the informal caregiver.

Research study exploring attitudes
In a research study, the attitudes of both men and women towards the care of dependent older people were explored.(2) The sample (n=174) was drawn from age cohorts 20-39 years and 40-59 years in South Wales. The aim of the study was to explore the willingness and attitudes of a sample of the general public to provide care for their older parents and/or relatives in the future. The questionnaire comprised three sections:

  • Exploration of demographic data and whether those questioned were currently providing informal care of an older person.
  • Questions regarding their views on current policies and issues that placed the focus of care in the community, rather than in institutional care.
  • Male and female attitudes towards caring and whether they saw the day-to-day care as someone else's responsibility.

The key factors included:

  • Whether they had made plans for their old age.
  • Whether they were already providing care to an older person.
  • Whether they would care for an elderly person in their own home.
  • Whether they regarded the care of an older relative as being their duty.
  • Whether they would give up paid employment.
  • Whether they were able to identify problems or benefits from providing care.
  • Whether they were concerned about the effects of caring on their lifestyle or partners.

It isn't surprising that more women said they would be willing to provide care. The 40-59-year-olds were more willing than the 20-39-year-olds. However, 49% of females and 66% of men said that they were not prepared to care for an older relative.
If the UK is all set to encourage a more primary care-led service then there needs to be more support and practical help for family carers.(5) The National Service Framework for Older People highlighted the fact that carers needs and views must be taken into consideration and respected.(6) Future carers need to be involved in planning and service provision.(5)
Ninety-three percent of those questioned felt that personal, intimate care of an elderly person was a major stressor because of the embarrassment it may cause them. Information and "knowing what to do" was seen as a major hurdle, and this could be an area where nurses could be more proactive and provide more innovative teaching programmes for informal carers.

"Working with the elderly has no benefit to one's career"
Studies have reported that nurses do not view working with older people as beneficial to their career pathway and choose to work in the more technical areas, such as emergency nursing or intensive care nursing. There seems to be a stigma attached to working with older people. Care of older people is seen as an unpopular choice for students and is not viewed as being an academic area to study or to work in. It is also not seen as requiring specialist knowledge despite the common issues of falls, dementia, wound care and continence. The nursing literature is replete with reports of nursing negativity and attitudes in relation to older people.(7,8)
This creates what Tudor Hart describes as "inverse care", where older people have the greatest need for nursing and medical services and yet care of older people is low on nurses' priorities.(9)
Informal care of older people in the community involves even more complex care than secondary care, but with less help from the NHS and social care. If the patient is in hospital they have all the services readily available 24 hours a day, but when at home the family is often left to cope with little help or teaching on how to best provide care. Often, informal carers cannot go out to work, their families and lives get disrupted for months and years, and they may become socially isolated and exhausted. Often they are sick or old themselves. Innovative nursing care of older people can challenge negative attitudes and nurse-led services can result in greater autonomy and expert practice in older care nursing. Nurses can develop their practice by having a strong commitment to education, research and developing new ways of engaging with carers to make a real difference to the care of older people.


Future opportunities
There are great opportunities to study and develop nursing practice in caring for older people, working across boundaries with health- and social care staff and indeed working with families and relatives.(10,11) Management of long-term care is identified as a key area in the health and social policy agenda, and major opportunities have been created for us as nurses to take the lead and to work innovatively with families and at a community public health level.


  1. Pledge to end NHS elderly abuse. BBC Website. 20 April 2006. Available from:
  2. Smith C, Snelgrove S, Armstrong-Esther, Clarke J. Is there a future for the informal homecare of older people in a changing society? Qual Aging Policy Pract Res 2003;4(1):12-21.
  3. King's Fund. Care service inquiry: looking forward to care in old age - expectations of the next generation. London: King's Fund; 2005.
  4. Carer's National Association. Ignored and invisible: report on caregiving. London: Carers National Association; 1998.
  5. Welsh Assembly. Designed for life: creating world class health and social care for Wales in the 21st century. Cardiff: Welsh Assembly; 2005.
  6. Department of Health. National Service Framework for older people. London: DH; 2001.
  7. Murray K. Poor quality of elderly care deterring students. Nurs Standard 2002;29:7.
  8. Herdman E. Challenging the discourses of nursing ageism. Int J Nurs Stud 2002;39:1105-14.
  9. Tudor Hart J. A new kind of doctor.  London: Merlin Press; 1988.
  10. Smith C. From theory to practice: capturing the uniqueness of nursing. Nursing Older People 2006;18:1.
  11. Welsh Assembly. The review of health and social care in Wales (Wanless Report). Cardiff: Welsh Assembly; 2003.

King's Fund
Carers UK