Original Manuscript
The meaning of vulnerability to older persons
Nursing Ethics 1–12 ª The Author(s) 2014 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733014564908 nej.sagepub.com
Anneli Sarvima¨ki The Age Institute, Finland
Bettina Stenbock-Hult Arcada University of Applied Sciences, Finland
Abstract Background: Vulnerability is an important concept in nursing and nursing ethics. Vulnerability and ageing have generally been associated with frailty, which gives a limited view of both vulnerability and ageing. Objective: The aim of this study was to illuminate the meaning of vulnerability to older persons themselves. Research design: A qualitative design based on interpretive description was adopted. The data were collected by interviews that were analysed by qualitative content analysis as interplay between analysis, interpretation and meaning construction. Participants and research context: In total, 14 older persons aged 70–96 years were interviewed, 2 men and 12 women. Some of the participants lived in their own homes, some in service houses and some in nursing homes. Ethical considerations: The ethical principles of informed consent, confidentiality and non-identification were respected. Findings: The core meaning was a deeper sense of vulnerability as you grow old. This was expressed in six themes: Being easily harmed, Becoming an old person, Being an old person in society, Reactions when being violated and hurt, Protection and Vulnerability as strength. Discussion and conclusion: The themes include frailty and threats to the dignity of older persons and also capacity to feel and develop. The results showed that although the frailty perspective dominated, vulnerability also had positive meanings for the older persons. Keywords Ageing, existentialism, frailty, interpretive description, personal development
Introduction Vulnerability is an important concept in nursing and nursing ethics. All people are susceptible to health problems, some persons more than others.1 Patients are, as Sellman2 puts it, more-than-ordinarily vulnerable. Thus, one fundamental function of nurses is to contribute to the flourishing of more-than-ordinarily vulnerable persons and protect them, he claims. Due to the central role of vulnerability in nursing, nursing may be characterized as a response to human vulnerability.2,3
Corresponding author: Anneli Sarvima¨ki, The Age Institute, Asemapa¨a¨lliko¨nkatu 7, FIN-00520 Helsinki, Finland. Email: [email protected]
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Vulnerability is often equalled with frailty. This can be seen especially in the literature on ageing and old age, where older persons are described as physically, psychologically and socially frail or vulnerable.4–6 However, frailty, weakness and fragility are not the sole determinants of vulnerability in old age.7,8 Exposure to harmful influence, the nature of the threat and the person’s coping capacity are important determinants of the older person’s vulnerability in addition to frailty. Furthermore, dimensions of vulnerability can be seen as resources and not only as risks or weakness.9–13 As Hoffmaster14 puts it, the recognition of our vulnerability affirms our humanity. If nursing is to be conceived as a response to human vulnerability, nurses need to recognize, acknowledge and encounter all aspects of vulnerability. This research has its philosophical roots in existentialism, which explores the conditions of human existence. Vulnerability is viewed as one of these basic conditions in addition to dependence, mortality, the frailty of relationships and existential loneliness.10,15 Existentialists make a distinction between two attitudes to life: the authentic life and the inauthentic life. The authentic life is characterized by awareness of the conditions of life. Persons who live authentically are aware of their mortality, are participants in the world and encounter others as real human beings. The authentic persons are true to themselves and involved in life. They recognize that by making choices they become responsible both for others and for themselves. Their awareness of their own freedom and responsibility evokes anguish. Furthermore, the authentic attitude is characterized by openness to life. This openness makes the persons unprotected, exposed and vulnerable. They are thus easy to hurt. The inauthentic attitude involves an escape from the freedom, responsibility and anguish that are connected with authenticity. The inauthentic persons protect themselves by not being their true selves and they pretend not to be responsible for their choices and actions. They also avoid authentic relationships by de-humanizing others. In this way, the inauthentic persons avoid pain and anguish. But at the same time, they give up the authentic life.15–18 Thus, in existentialist philosophy, vulnerability is associated not only with the risk of feeling pain and anguish but also with openness to life and awareness of the basic conditions of life. This complexity can also be seen in definitions of the concept of vulnerability. Vulnerability is often defined as susceptibility to harmful agents,19 which emphasizes the negative aspects of vulnerability. A concept analysis that includes what makes a person vulnerable also opens up for positive aspects of vulnerability.11 A person may be vulnerable because he or she is (a) frail or weak, (b) sensitive and (c) unprotected. Being vulnerable due to frailty or weakness refers to the kind of vulnerability that is usually associated with sickness, disease and decline in functional capacity. Being vulnerable due to sensitivity, on the other hand, means that a person has a propensity for noticing what is going on outside and inside him. He is tuned in to the emotional atmosphere, to his own feelings as well as the feelings of others. Unprotected, finally, refers to the person’s defence system, that is, to his own capacity to protect himself against harmful attacks or to having a protecting network. Ageing is usually associated with (a) frailty and weakness. In her narrative interviews with older persons, Heikkinen20 identified boundary conditions for the experience of ageing. The boundary conditions, which had negative connotations for the interviewees, were called vulnerability factors. The vulnerability factors included deteriorating health, deteriorating of senses, frailty, impaired memory and losses. In a Dutch study,6 older persons designated their own meanings to frailty and its Dutch equivalent vulnerability. The interviewees associated vulnerability with decline in physical functioning, psychological functioning and social functioning. This corresponds to the division of vulnerability into physical, psychological and social vulnerability found in conceptual studies.11,19 The dimensions of vulnerability interact with one another. Psychological aspects influence physical vulnerability. A negative self-perception of ageing has been shown to predict vulnerability to adverse outcomes like disability in activities of daily living (ADL).21 Social vulnerability increases physical vulnerability as well as vulnerability in care situations. In a study of the relationship between social vulnerability, frailty and 2
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mortality, social vulnerability was measured in terms of income adequacy, housing security, ability to use the telephone, ability to maintain social ties and participate in the community. The results showed that social vulnerability increased with age, correlated with frailty and was associated with increased odds of mortality.5 In an Indonesian study, vulnerability to inadequate care provision was associated with social vulnerability in terms of being an unmarried woman, widowhood, poverty, weak support networks and having a caregiver who is also vulnerable.22 Being vulnerable in terms of (c) unprotected is also a theme in ageing research. Schro¨der-Butterfill and Marianti7 use the concept coping capacity referring to assets and relationships that help people protect themselves from bad outcomes or recover from a crisis. Such protective assets include individual coping capacities, such as skills and health, supportive social networks and formal social protection in terms of pensions and health and social services. Grundy23 puts forth that people may accumulate a reserve capacity during the life-course. This reserve, including a healthy lifestyle, coping skills, supportive family ties, active interests and savings, health and social services, is a compensatory resource in old age. Being unprotected means lacking reserve capacity. There is nothing indicating that older people are necessarily unprotected, but the loss of a spouse and decline in income and health, often accompanying old age, may weaken the protection against bad outcomes. Although there is evidence supporting the view that old age is associated with vulnerability as frailness and unprotectedness, this view has also been criticized for resulting in negative stereotypical views of old age.24 This view also gives a limited picture of vulnerability. It contains nothing of the openness, sensitivity and humanity that characterize the authentic life. A study of nurses caring for older persons showed that the core meaning of vulnerability to the nurses was being human.13 This meant having feelings that exposed the nurses to harm and moral indignation and created a need for self-protection. Having the courage to confront one’s own vulnerability was seen as a way of turning vulnerability from weakness into strength. This shows a wider and deeper view of vulnerability than the one usually associated with old age. Thus, it would be important to know what older persons themselves mean by vulnerability. The aim of this study was to illuminate the meaning of vulnerability to older persons.
Methods Methodological approach A qualitative interpretive approach was adopted since the aim was to illuminate meaning. The method can be characterized as interpretive description, a non-categorical method that uses and combines techniques from more specific methods in a flexible way.25,26 The description and interpretation were guided by the existentialist-philosophical framework. Interpretation can be characterized as a process of construction; meaning is something that the researchers construct by the use of data. The researchers’ preunderstanding was based on their previous training and experiences as philosophers, nurses, teachers and researchers.
Participants The participants in the study were 14 older persons aged 70–96 years (2 men and 12 women). Some of the participants lived in their own homes, some in service houses and some in nursing homes. The purpose of recruiting participants from different settings was to ensure data variety. The method for recruiting participants was a combination of convenience and snowball sampling. The researchers contacted some older persons in their networks who then suggested additional participants. 3
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Data collection The data were collected by the use of qualitative interviews.27 Six nursing students, all women, carried out the interviews. They were all in the final stage of their studies working with their theses. They participated in the construction of themes for the interviews and used parts of the data for their own theses. The interviews started out with a few general questions related to ageing. At the end of the interviews, the questions focused more directly on vulnerability; in what kind of situations the participants had felt vulnerable and how they dealt with their own vulnerability. The interviews were audiotaped and transcribed verbatim. The total material consisted of 162 typed pages. The principle of theoretical sampling26,28,29 was partly adopted in the data collection process. The interviews were done during a period of 3 years, which allowed for alternation between data collection, preliminary analyses and complementary collection in order to arrive at a theoretical outlook. New questions were added to the interview guide during the process.
Data analysis The data were analysed by qualitative content analysis as interplay between analysis, interpretation and meaning construction. Adopting the principles of interpretive description, the researchers took their point of departure in their philosophical framework and proceeded from description towards more abstracted interpretations.25,26 Bearing in mind the question ‘What is vulnerability, how is it experienced’, the researchers (A.S. and B.S.-H.) read through the interviews, extracted relevant passages, coded and constructed themes and sub-themes. The analysis for this article was carried out by both authors. Both read all interviews, coded, compared codes, constructed themes, revised and reached consent regarding the final model.
Ethical considerations The study was conducted in accordance with The Declaration of Helsinki.30 The participants received both oral and written information about the project and signed a form stating their informed consent. They could choose the time and place for the interview. Confidentiality was guaranteed in that no names or contact details were recorded on the tapes or transcriptions, and no unauthorized persons had access to the material. The risk of identification was minimized as the sample was not described in detail and the citations were made unidentifiable. The study was approved by the ethical committee at The Age Institute. The Social Services Department gave permission to interview the participants living in a nursing home.
Results The older persons designated meaning to vulnerability from their position as ageing individuals. The meanings they gave to vulnerability were in many ways associated with ageing or old age. One meaning of vulnerability was being easily harmed and sensitive and growing old meant becoming even more vulnerable. The core meaning leavening through the themes and sub-themes was a deeper sense of vulnerability. There is a deeper sense of vulnerability that shows itself with growing old: The older you get, the more vulnerable you become. A lot in your environment disappears. You become more exposed in some way.
The six themes resulting from the analysis were Being easily harmed, Becoming an old person, Being an old person in society, Reactions when being violated and hurt, Protection and Vulnerability as a strength (Figure 1.) 4
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BEING EASILY HARMED •
Feeling hurt and violated
•
Being sensitive
BECOMING AN OLD PERSON • • •
Losses Limitations Uncertainty
REACTIONS WHEN BEING HURT AND VIOLATED • • • •
Anger Sadness Disappointment Dwelling
BEING AN OLD PERSON IN SOCIETY A deeper sense of vulnerability as you grow old
PROTECTION •
Needing help from others
•
Protecting oneself
• •
De-personalisation Exclusion
VULNERABILITY AS STRENGTH • •
Capacity to feel Personal development
Figure 1. The meaning of vulnerability to older persons.
Being easily harmed Vulnerability meant being easily harmed, the sub-themes being feeling hurt and violated and being sensitive. Feeling hurt was mainly understood as mental harm in terms of a feeling of de-valuation, misunderstanding, being tread on and being insulted. Thus, feeling hurt and violated involved an ethical aspect, being diminished and hurt as a person. This could happen in contacts with doctors, a contact that is important for many older persons. Not being able to use your mother tongue, although the country is bilingual, could be experienced as an insult: Something that really hurt me was when that doctor said . . . Then I felt hurt [ . . . ] I felt I had no value. That was a situation when I felt hurt, really. It is in a way a bit embarrassing and to a certain degree insulting that in official places it is not natural and in hospitals it is impossible to speak Swedish. [ . . . ] And they cannot say in Swedish what’s wrong. So I have to use a dictionary when I visit the doctor. I think that is insulting. 5
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Feeling hurt and violated was related to how sensitive the person was. Some people were seen as caring more about what others said about them, wondering what they meant and one could in that respect even be oversensitive: It depends on how sensitive you are. It is no fun being hurt. So it is better if you are not too sensitive. As people grow older, they were seen as becoming more sensitive and susceptible to other people’s opinions and as a consequence more easily harmed.
Becoming an old person For older persons, vulnerability was associated with becoming an old person, a process that involved many life changes. The sub-themes included losses, limitations and uncertainty. Becoming old involved a variety of losses that made the ageing person more vulnerable: Losing your abilities in different areas, both physically and mentally. [ . . . ] It is part of vulnerability that so many people disappear from one’s environment, they either die or . . . my friend has been diagnosed with Alzheimer’s [ . . . ] And that is also a disappearance, when a person disappears into this.
The losses, thus, included a loss of physical and mental abilities as well as social losses through death or illness. One mental loss that was seen as a consequence of ageing was the loss of interest and empathy, the world or other persons did not matter as before: I have thought about this many times, why one loses interest in some things. It is not as exciting or interesting (as before). [ . . . ] You become less empathetic. People in your environment also become less empathetic. [ . . . ] And you are yourself not as sensitive to other people’s vulnerability.
The losses that came with becoming an old person were seen as a natural part of ageing, something that happens when a person approaches the end of life: You have to give up a whole lot. You are more willing to give things up if you realize that it is part of life. The losses of physical and mental abilities meant that the person became more limited: Vulnerability is concrete, you know and feel your limitations when you face them. With losses and limitations life as such became more restricted: Vulnerability, in that sense that life becomes more restricted. You can’t manage things that you have managed before. [ . . . ] Life becomes smaller in that sense, a lot of things are gone.
In addition to making life more restricted, the losses and limitations made life more insecure, a feeling of uncertainty was associated with ageing and vulnerability. The loss of physical strength meant a greater risk of injury: Of course you feel more vulnerable when, with the physical things. You know when it’s slippery that you have to walk more carefully than you used to. That if you fall over, the damage is more serious than 20 years ago. In that sense you become physically more vulnerable.
Becoming an old person often means becoming dependent on other persons, spouses and children as well as care staff. The feeling of uncertainty was expressed as worrying about the children if they did not call. Staff turnover was another source of uncertainty and insecurity: It is a feeling of insecurity, that they can’t recruit permanent staff. On an existential level, life as a whole became more uncertain. The growing risk of becoming ill or being subject to injury meant that life and future could not be taken for granted: 6
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You become more exposed, ‘when it is my turn, when does it happen to me’? When does the stroke hit me so that I lie there as a package? Life is not so given anymore. [ . . . ] You become more exposed to thoughts about your future, or do you have a future?
Being an old person in society Vulnerability was associated with what it meant to be an old person in today’s society. The values and attitudes that the older persons confronted as well as their own declining capacities put them in a vulnerable position. The sub-themes were de-personalization and exclusion. The participants felt they were not treated and taken into consideration as adult persons and individuals. Rather, they were de-personalized in many ways. For example, they felt older persons were disregarded, they talk past older persons, and they were treated as a collective, a grey mass of pensioners: Older persons are treated collectively. They are all the same and here they come in big masses in buses and overflow the place. You want to be treated as an individual.
Being treated as a collective rather than as individuals also meant that personal resources and abilities went unnoticed. The participants felt that from the viewpoint of society being old meant being incompetent, diminished and less able: Vulnerability is . . . it’s when you are treated is if you’ve become a child again. It is hurting when they think that older people can’t hear well and can’t fill in forms. [ . . . ] Older persons are treated as children. You become incapacitated because you are older. That is unacceptable.
The participants did not accept this attitude from society but protested against it. They clearly wanted to be noticed, seen as individuals and competent persons: You could get more consideration in society. Being an old person in society also meant feeling excluded in social situations. Sometimes the feeling occurred as a result of others’ attitudes: If you are treated with words or shown that you are not welcome. But the feeling could also occur as a combination of the older person’s declining capacity and the lack of understanding from persons around them. Being an old person in society meant feeling left outside: I have felt redundant, that I cannot follow other people anymore, because I can’t see. I feel that they talk between themselves and I become excluded. [ . . . ] For example at parties with my children, birthday parties and so. There are so young people. And they talk and I, I cannot keep up. I have to be silent. I feel that now I am old.
Reactions when being violated and hurt In situations where the participants were vulnerable and felt hurt and violated, they reacted in different ways. Reactions when being violated and hurt had three sub-themes: anger, sadness and disappointment and dwelling. Vulnerability was by some participants seen as weakness, and feeling hurt was thus experienced as a form of weakness. Sometimes, this feeling turned into anger, even more anger than feeling hurt. When I feel hurt [ . . . ] I can become angry [ . . . ] I can be so furious. The anger was also described as going wild and crazy or losing one’s nerves. Another way of being vulnerable in the sense of being easily harmed and reacting to this was sadness: If something hurts me I can become really, really sad. Disappointment was another reaction to vulnerability, and this was seen as partly depending on oneself: 7
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The feeling of being hurt sometimes went on and on and the participants kept dwelling on insults and violations. They could not forget an insult, not swallow it even though they tried not to take the ink.
Protection For the older persons, vulnerability meant needing protection against physical as well as mental harm. The sub-themes included needing help from others and protecting oneself. The participants recognized that they needed help from others and were satisfied when, for example, transport systems were safe and easily accessible. They also appreciated getting emotional help: They (the staff) have helped me many times when I have been sad. Alarm systems were in use among those living in service houses but sometimes they had to wait for help and did not always get the help they needed: They have this alarm system. Even though you have called, it can take quite a while before someone shows up. I haven’t hurt myself, I just want to go to the loo.
The participants also protected themselves, mainly against insults and mental harm from others. Selfprotection required mental ability: As long as you are in your right senses you can protect yourself. Selfprotection meant trying to learn not to care about what others said or trying to forget harsh words and insults, to put it aside. Another way of protecting oneself was to rationalize the insulting person’s behaviour and not take it personally.
Vulnerability as strength Vulnerability also meant strength. Experiencing feelings, when being hurt or harmed, was seen as an asset initiating something positive. The sub-themes were capacity to feel and personal development. Although the feelings associated with vulnerability involved pain, sadness, anger and disappointment, they meant that the person still had an emotional capacity. The capacity to feel was a sign that the interviewee was still an active person. Feeling and locating the pain also made it easier to ask for help: It [vulnerability] is strength, otherwise you become passive, if you never feel hurt and don’t feel anything. So it is definitely strength. If you compare to physical pain, it is a good thing that you can feel this pain, you can get remedy. That you know where the pain is.
Being vulnerable and feeling pain were also seen as something that could contribute to personal development: It [vulnerability] forms and develops you. Being able to use one’s own vulnerability in the service of personal development required a process of working through feelings, putting words on feelings and talking to someone rather than swallowing one’s pain: I need to talk and then I can see it, I can see it from another perspective when I have put words on it. They [the insults] become so big if you just swallow them.
Working through having been hurt and feeling pain was seen as a learning process. The participants learned to deal with harmful situations and people: 8
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There are some things you don’t do twice. You don’t let them violate you, you avoid them or you have learned to deal with a violation or an insult.
The participants also realized what it meant to feel hurt, which could teach them to be more empathetic towards others: You turn to yourself and hope that you will never hurt anybody. Working through pain and insults and developing personally from these insights was described as a timeconsuming process: Some things take longer time to work through, longer than a lifetime.
Discussion The aim of the study was to illuminate the meaning of vulnerability to older persons. The results showed that vulnerability was associated with many aspects of ageing and old age: with ageing came a deeper sense of vulnerability. Vulnerability as frailness could be seen in the meaning Becoming an old person. This meaning involved physical, mental and social losses that made life more limited and uncertain. To this extent, the results supported previous research describing ageing in terms of frailness.4–6,19–21 The results also showed that vulnerability meant being unprotected or in need of protection. The interviewees emphasized the role of self-protection, thus relying more on individual assets than family ties and other social networks.7,23 Interviewees living in nursing homes mentioned the importance of help from the staff and mechanical alarm systems, that is, help and protection from the health and social service system.7,23 Being sensitive, an aspect of vulnerability more seldom associated with ageing, formed the category Being easily harmed together with the subcategory Feeling hurt and violated. According to the interviewees, this meaning became more evident as they grew older. They became more sensitive to harmful insults and violations from other people including doctors. In this sense, too, ageing was associated with a deeper sense of vulnerability. Moreover, vulnerability had societal meanings that rose from older persons’ position in society. The interviewees felt they were de-personalized and excluded. Both Being easily harmed and Being an old person in society involved meanings that had to do with how the interviewees were treated by other persons or what kind of attitudes they confronted in society. The specific meanings – feeling hurt and violated, being de-personalized and excluded – refer to unethical treatment and confrontation. This reveals an additional aspect of vulnerability: ethical vulnerability or vulnerability of human dignity.31 In old age, human dignity is vulnerable. Because older persons are frail, they are at risk of being badly treated and violated. This makes the older persons feel that they are not treated as individuals but as a grey mass. They are at risk of being excluded from social community and being treated unethically by health personnel. They are at risk of becoming non-persons. The violation of the interviewees’ dignity evoked emotional reactions. They became angry or sad and disappointed and kept dwelling on insults. They partly blamed themselves for these feelings. But the older persons also saw their emotional reactions as a resource emphasizing that although pain and anger were difficult feelings, they could be seen as strengths. Having mental pain meant that the person was still active and alive, and physical pain communicated information that something was wrong. These feelings could be used as resources for personal development. This can be interpreted as an authentic attitude to life.15,16,18 Having feelings was painful, but at the same time it was a sign of sensitivity as well as openness to life and personal development. Although the frailty perspective dominated, vulnerability also had a positive meaning for the older persons. A comparison of the meanings the older persons ascribed to vulnerability with those of the nurses13 shows both common and differing meanings. To both groups, vulnerability had an existential meaning. To the nurses, vulnerability meant being human, and to the older persons, vulnerability received deeper meaning as they grew old and as they became more exposed and sensitive. To both groups, vulnerability meant having feelings, being easily harmed and thus needing protection. The older persons talked about 9
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concrete protection in terms of being protected by the service system and technical devices, but they also included self-protection, that is, protecting oneself from insults and painful feelings. The nurses associated vulnerability with self-protection and they saw it as a double-edged sword. It meant concealing oneself and one’s feelings and dissociating oneself in a way that relieves pain, but at the same time results in an inauthentic attitude to life. Both older persons and nurses also saw that vulnerability could be turned into strength and serve their personal development. The meanings that were related to becoming and being an old person in society were, understandably, only found among the older persons. On the other hand, the meanings Moral indignation and Having courage were only found among the nurses. These meanings arose from situations where the nurses felt older persons had been treated unethically and they needed to speak up. The nurses also felt they needed to confront their own vulnerability in order to provide good care. The comparison shows that vulnerability has general meanings as well as meanings that stem from the persons’ viewpoints and life situations. Since few studies have previously been conducted regarding the meaning of vulnerability to older persons, it was considered important to acquire a rich variety of data. Data variation was achieved by including both men and women living in different contexts. The difference of age between the youngest and the oldest participant was 26 years. The credibility and dependability32 of the study was strengthened by the fact that both authors had a long engagement in issues concerning ageing and the care of older persons. They read and coded the interviews independently of each other, after which they interpreted and re-interpreted data in an ongoing dialogue until they reached agreement. The fact that the interviews were conducted by students could be a threat against credibility. This risk was minimized as they were instructed and supervised by the authors. Confirmability means that the findings are shaped by the interviewees’ and not by the researchers’ bias or interests.32 In interpretive research, it is neither possible nor desirable to eliminate the influence of researcher’s pre-understanding. Rather, pre-understanding is a tool in the interpretive process and it is important that the interpreter is aware of his or her pre-understanding. In this study, the authors have interpreted in the light of the existentialistic philosophy and their previous research on vulnerability. The confirmability of the interpretations is shown in the citations from the interviews. Some of the meanings of vulnerability that the interviewees expressed are closely associated with experiences of ageing in the Western world shown in previous research.6,20 Thus, the results may be transferable to other Western cultures. The results have ethical implications. Since the core of ethics in the care of older persons lies in the encounter and relationship between the nurse and the vulnerable older person, nurses need to recognize the deep sense of vulnerability associated with old age. Life in old age involves losses, limitations and uncertainty that require special sensitivity of the nurse in order not to harm the person. An old person may be more than ordinarily sensitive to physical harm as well as insults, which stresses the importance of the ethical principle Do no harm.3 Old people’s frailness often means that their human dignity also becomes vulnerable; they feel depersonalized, excluded and de-valued. In order to protect the older person’s human dignity, the nurse needs to be morally sensitive.33 The nurse needs to notice the ethical aspects of the situation and use mature empathy to support the person. Mature empathy involves viewing the vulnerable older person from an ethical viewpoint and with an altruistic aim.3 Encountering the vulnerability of an older person means protecting the person and also recognizing the person’s vulnerability as strength. The nurse should help the person to accept his or her feelings and see them as resources for personal development. People can learn and develop throughout life. Supporting vulnerability as strength is compatible with the ethical principle Do good.3 Understanding and encountering the deep vulnerability of older persons may be difficult to young nurses whose life situations differ from the old person’s. Theoretical knowledge of ageing may help, but in order to encounter another person’s vulnerability, the nurses need to allow themselves to be vulnerable human beings. They need to turn their own vulnerability into strength, which may be easier as they themselves age.13 10
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Conflict of interest The authors declare that there is no conflict of interest. Funding This work was supported by Signe and Ane Gyllenberg’s Foundation, Professor Jan-Magnus Jansson’s Fund for Gerontological Research and The Nurses’ Association in Finland. References 1. Rogers A. Vulnerability, health and health care. J Adv Nurs 1997; 26: 65–72. 2. Sellman D. Towards an understanding of nursing as a response to human vulnerability. Nurs Philos 2005; 6: 2–10. 3. Sarvima¨ki A and Stenbock-Hult B. Omva˚rdnadens etik. Sjuksko¨terskan och det moraliska rummet [Nursing ethics. The nurse and moral space]. Stockholm: Liber, 2008 (in Swedish). 4. Erlen J. The frail elderly. A matter of caring. Orthop Nurs 2007; 26: 379–382. 5. Andrew M, Mitnitski A and Rockwood K. Social vulnerability, frailty and mortality in elderly people. PLoS ONE 2008; 3(5): e2232. 6. Puts M, Shekary N, Widdershoven G, et al. The meaning of frailty to Dutch older frail and non-frail persons. J Aging Stud 2009; 23: 258–266. 7. Schro¨der-Butterfill E and Marianti R. A framework for understanding old-age vulnerabilities. Ageing Soc 2006; 26: 9–35. 8. Sarvima¨ki A, Stenbock-Hult B and Heimonen S. Ika¨a¨ntyminen ja mielen haavoittuvuus – haavoittuvuus riskina¨ ja voimavarana [Ageing and vulnerability of the mind – vulnerability as risk and resource]. Gerontologia 2010; 24: 169–178 (in Finnish). 9. Malone R. Dimensions of vulnerability in emergency nurses’ narratives. Adv Nurs Sci 2000; 23(1): 1–11. 10. Vetlesen A. Profesjonell og personlig? Legerollen mellom vellykkethet og sa˚rbarhet [Professional or personal? The significance of the doctor’s physician’s vulnerability]. Tidsskr Nor Laegeforen 2001; 121: 1118–1121 (in Norwegian). 11. Sarvima¨ki A and Stenbock-Hult B. Sa˚rbarhet som utga˚ngspunkt fo¨r etiken i a¨ldreva˚rden [Vulnerability as the point of departure for ethics in elder care]. Gerontologia 2004; 18: 153–158 (in Swedish). 12. Carel H. A reply to ‘Towards an understanding of nursing as a response to human vulnerability’ by Derek Sellman: vulnerability and illness. Nurs Philos 2009; 10: 214–219. 13. Stenbock-Hult B and Sarvima¨ki A. The meaning of vulnerability for nurses caring for older people. Nurs Ethics 2011; 18: 31–41. 14. Hoffmaster B. What does vulnerability mean? Hastings Cent Rep 2006; 36(2): 38–45. 15. Heidegger M. Being and time. Oxford: Blackwell, 1962. 16. Buber M. I and Thou. Edinburgh: T & T Clark, 1937. 17. Tillich P. The courage to be. Glasgow: Fontana Library, 1962. 18. Sartre J-P. Being and nothingness. New York: Washington Square Press, 1966. 19. Scanlon A and Lee G. The use of the term vulnerability in acute care: why does it differ and what does it mean? J Adv Nurs 2007; 24(3): 54–59. 20. Heikkinen R-L. Patterns of experienced aging with a Finnish cohort. Int J Aging Hum Dev 1992–1993; 36(4): 269–277. 21. Moser C, Spagnoli J and Santos-Eggimann B. Self-perception of aging and vulnerability to adverse outcomes at the age of 65–70 years. J Gerontol B Psychol Sci Soc Sci 2011; 66(6): 675–680. 22. van Eeuwijk P. Old-age vulnerability, ill-health and care support in urban areas of Indonesia. Ageing Soc 2006; 26: 61–80. 23. Grundy E. Ageing and vulnerable older people. Ageing Soc 2006; 26: 105–134. 11
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24. Brocklehurst H and Laurenson M. A concept analysis examining the vulnerability of older people. Br J Nurs 2008; 17: 1354–1357. 25. Thorne S, Reimer Kirkham S and McDonald-Emes J. Interpretive description: a non-categorical qualitative alternative for developing nursing knowledge. Res Nurs Health 1997; 20: 169–177. 26. Thorne S, Reimer Kirkham S and O’Flynn-Magee K. The analytic challenge in interpretive description. Int J Qual Methods 2004; 3, http://www.ualberta.ca/*iiqm/backissues/3_1/pdf/thorneetal.pdf (accessed 23 October 2009). 27. Kvale S. InterViews. London: Sage, 1996. 28. Charmaz K. Constructing grounded theory. A practical guide through qualitative analysis. London: Sage, 2006. 29. Glaser B and Strauss A. The discovery of grounded theory: strategies for qualitative research. New York: Aldine de Gruyter, 1967. 30. World Medical Association. Declaration of Helsinki, 2008, http://www.wma.net/en/30publications/10policies/b3/ (accessed 31 May 2012). 31. Sarvima¨ki A and Stenbock-Hult B. Vanhuus, haavoittuvuus ja hoidon eettisyys [Old age, vulnerability and the ethics of care]. In: Sarvima¨ki A, Heimonen S and Ma¨ki-Peta¨ja¨-Leinonen A (eds) Vanhuus ja haavoittuvuus [Old Age and Vulnerability]. Helsinki: Edita, 2010, pp. 33–58 (in Finnish). 32. Lincoln Y and Guba E. Naturalistic inquiry. Newbury Park, CA: Sage, 1985. 33. Lu¨tze´n K, Dahlqvist V, Eriksson S, et al. Developing the concept of moral sensitivity in health care practice. Nurs Ethics 2006; 13: 187–196.
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The meaning of vulnerability to older persons
Nursing Ethics 1–12 ª The Author(s) 2014 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733014564908 nej.sagepub.com
Anneli Sarvima¨ki The Age Institute, Finland
Bettina Stenbock-Hult Arcada University of Applied Sciences, Finland
Abstract Background: Vulnerability is an important concept in nursing and nursing ethics. Vulnerability and ageing have generally been associated with frailty, which gives a limited view of both vulnerability and ageing. Objective: The aim of this study was to illuminate the meaning of vulnerability to older persons themselves. Research design: A qualitative design based on interpretive description was adopted. The data were collected by interviews that were analysed by qualitative content analysis as interplay between analysis, interpretation and meaning construction. Participants and research context: In total, 14 older persons aged 70–96 years were interviewed, 2 men and 12 women. Some of the participants lived in their own homes, some in service houses and some in nursing homes. Ethical considerations: The ethical principles of informed consent, confidentiality and non-identification were respected. Findings: The core meaning was a deeper sense of vulnerability as you grow old. This was expressed in six themes: Being easily harmed, Becoming an old person, Being an old person in society, Reactions when being violated and hurt, Protection and Vulnerability as strength. Discussion and conclusion: The themes include frailty and threats to the dignity of older persons and also capacity to feel and develop. The results showed that although the frailty perspective dominated, vulnerability also had positive meanings for the older persons. Keywords Ageing, existentialism, frailty, interpretive description, personal development
Introduction Vulnerability is an important concept in nursing and nursing ethics. All people are susceptible to health problems, some persons more than others.1 Patients are, as Sellman2 puts it, more-than-ordinarily vulnerable. Thus, one fundamental function of nurses is to contribute to the flourishing of more-than-ordinarily vulnerable persons and protect them, he claims. Due to the central role of vulnerability in nursing, nursing may be characterized as a response to human vulnerability.2,3
Corresponding author: Anneli Sarvima¨ki, The Age Institute, Asemapa¨a¨lliko¨nkatu 7, FIN-00520 Helsinki, Finland. Email: [email protected]
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Vulnerability is often equalled with frailty. This can be seen especially in the literature on ageing and old age, where older persons are described as physically, psychologically and socially frail or vulnerable.4–6 However, frailty, weakness and fragility are not the sole determinants of vulnerability in old age.7,8 Exposure to harmful influence, the nature of the threat and the person’s coping capacity are important determinants of the older person’s vulnerability in addition to frailty. Furthermore, dimensions of vulnerability can be seen as resources and not only as risks or weakness.9–13 As Hoffmaster14 puts it, the recognition of our vulnerability affirms our humanity. If nursing is to be conceived as a response to human vulnerability, nurses need to recognize, acknowledge and encounter all aspects of vulnerability. This research has its philosophical roots in existentialism, which explores the conditions of human existence. Vulnerability is viewed as one of these basic conditions in addition to dependence, mortality, the frailty of relationships and existential loneliness.10,15 Existentialists make a distinction between two attitudes to life: the authentic life and the inauthentic life. The authentic life is characterized by awareness of the conditions of life. Persons who live authentically are aware of their mortality, are participants in the world and encounter others as real human beings. The authentic persons are true to themselves and involved in life. They recognize that by making choices they become responsible both for others and for themselves. Their awareness of their own freedom and responsibility evokes anguish. Furthermore, the authentic attitude is characterized by openness to life. This openness makes the persons unprotected, exposed and vulnerable. They are thus easy to hurt. The inauthentic attitude involves an escape from the freedom, responsibility and anguish that are connected with authenticity. The inauthentic persons protect themselves by not being their true selves and they pretend not to be responsible for their choices and actions. They also avoid authentic relationships by de-humanizing others. In this way, the inauthentic persons avoid pain and anguish. But at the same time, they give up the authentic life.15–18 Thus, in existentialist philosophy, vulnerability is associated not only with the risk of feeling pain and anguish but also with openness to life and awareness of the basic conditions of life. This complexity can also be seen in definitions of the concept of vulnerability. Vulnerability is often defined as susceptibility to harmful agents,19 which emphasizes the negative aspects of vulnerability. A concept analysis that includes what makes a person vulnerable also opens up for positive aspects of vulnerability.11 A person may be vulnerable because he or she is (a) frail or weak, (b) sensitive and (c) unprotected. Being vulnerable due to frailty or weakness refers to the kind of vulnerability that is usually associated with sickness, disease and decline in functional capacity. Being vulnerable due to sensitivity, on the other hand, means that a person has a propensity for noticing what is going on outside and inside him. He is tuned in to the emotional atmosphere, to his own feelings as well as the feelings of others. Unprotected, finally, refers to the person’s defence system, that is, to his own capacity to protect himself against harmful attacks or to having a protecting network. Ageing is usually associated with (a) frailty and weakness. In her narrative interviews with older persons, Heikkinen20 identified boundary conditions for the experience of ageing. The boundary conditions, which had negative connotations for the interviewees, were called vulnerability factors. The vulnerability factors included deteriorating health, deteriorating of senses, frailty, impaired memory and losses. In a Dutch study,6 older persons designated their own meanings to frailty and its Dutch equivalent vulnerability. The interviewees associated vulnerability with decline in physical functioning, psychological functioning and social functioning. This corresponds to the division of vulnerability into physical, psychological and social vulnerability found in conceptual studies.11,19 The dimensions of vulnerability interact with one another. Psychological aspects influence physical vulnerability. A negative self-perception of ageing has been shown to predict vulnerability to adverse outcomes like disability in activities of daily living (ADL).21 Social vulnerability increases physical vulnerability as well as vulnerability in care situations. In a study of the relationship between social vulnerability, frailty and 2
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mortality, social vulnerability was measured in terms of income adequacy, housing security, ability to use the telephone, ability to maintain social ties and participate in the community. The results showed that social vulnerability increased with age, correlated with frailty and was associated with increased odds of mortality.5 In an Indonesian study, vulnerability to inadequate care provision was associated with social vulnerability in terms of being an unmarried woman, widowhood, poverty, weak support networks and having a caregiver who is also vulnerable.22 Being vulnerable in terms of (c) unprotected is also a theme in ageing research. Schro¨der-Butterfill and Marianti7 use the concept coping capacity referring to assets and relationships that help people protect themselves from bad outcomes or recover from a crisis. Such protective assets include individual coping capacities, such as skills and health, supportive social networks and formal social protection in terms of pensions and health and social services. Grundy23 puts forth that people may accumulate a reserve capacity during the life-course. This reserve, including a healthy lifestyle, coping skills, supportive family ties, active interests and savings, health and social services, is a compensatory resource in old age. Being unprotected means lacking reserve capacity. There is nothing indicating that older people are necessarily unprotected, but the loss of a spouse and decline in income and health, often accompanying old age, may weaken the protection against bad outcomes. Although there is evidence supporting the view that old age is associated with vulnerability as frailness and unprotectedness, this view has also been criticized for resulting in negative stereotypical views of old age.24 This view also gives a limited picture of vulnerability. It contains nothing of the openness, sensitivity and humanity that characterize the authentic life. A study of nurses caring for older persons showed that the core meaning of vulnerability to the nurses was being human.13 This meant having feelings that exposed the nurses to harm and moral indignation and created a need for self-protection. Having the courage to confront one’s own vulnerability was seen as a way of turning vulnerability from weakness into strength. This shows a wider and deeper view of vulnerability than the one usually associated with old age. Thus, it would be important to know what older persons themselves mean by vulnerability. The aim of this study was to illuminate the meaning of vulnerability to older persons.
Methods Methodological approach A qualitative interpretive approach was adopted since the aim was to illuminate meaning. The method can be characterized as interpretive description, a non-categorical method that uses and combines techniques from more specific methods in a flexible way.25,26 The description and interpretation were guided by the existentialist-philosophical framework. Interpretation can be characterized as a process of construction; meaning is something that the researchers construct by the use of data. The researchers’ preunderstanding was based on their previous training and experiences as philosophers, nurses, teachers and researchers.
Participants The participants in the study were 14 older persons aged 70–96 years (2 men and 12 women). Some of the participants lived in their own homes, some in service houses and some in nursing homes. The purpose of recruiting participants from different settings was to ensure data variety. The method for recruiting participants was a combination of convenience and snowball sampling. The researchers contacted some older persons in their networks who then suggested additional participants. 3
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Data collection The data were collected by the use of qualitative interviews.27 Six nursing students, all women, carried out the interviews. They were all in the final stage of their studies working with their theses. They participated in the construction of themes for the interviews and used parts of the data for their own theses. The interviews started out with a few general questions related to ageing. At the end of the interviews, the questions focused more directly on vulnerability; in what kind of situations the participants had felt vulnerable and how they dealt with their own vulnerability. The interviews were audiotaped and transcribed verbatim. The total material consisted of 162 typed pages. The principle of theoretical sampling26,28,29 was partly adopted in the data collection process. The interviews were done during a period of 3 years, which allowed for alternation between data collection, preliminary analyses and complementary collection in order to arrive at a theoretical outlook. New questions were added to the interview guide during the process.
Data analysis The data were analysed by qualitative content analysis as interplay between analysis, interpretation and meaning construction. Adopting the principles of interpretive description, the researchers took their point of departure in their philosophical framework and proceeded from description towards more abstracted interpretations.25,26 Bearing in mind the question ‘What is vulnerability, how is it experienced’, the researchers (A.S. and B.S.-H.) read through the interviews, extracted relevant passages, coded and constructed themes and sub-themes. The analysis for this article was carried out by both authors. Both read all interviews, coded, compared codes, constructed themes, revised and reached consent regarding the final model.
Ethical considerations The study was conducted in accordance with The Declaration of Helsinki.30 The participants received both oral and written information about the project and signed a form stating their informed consent. They could choose the time and place for the interview. Confidentiality was guaranteed in that no names or contact details were recorded on the tapes or transcriptions, and no unauthorized persons had access to the material. The risk of identification was minimized as the sample was not described in detail and the citations were made unidentifiable. The study was approved by the ethical committee at The Age Institute. The Social Services Department gave permission to interview the participants living in a nursing home.
Results The older persons designated meaning to vulnerability from their position as ageing individuals. The meanings they gave to vulnerability were in many ways associated with ageing or old age. One meaning of vulnerability was being easily harmed and sensitive and growing old meant becoming even more vulnerable. The core meaning leavening through the themes and sub-themes was a deeper sense of vulnerability. There is a deeper sense of vulnerability that shows itself with growing old: The older you get, the more vulnerable you become. A lot in your environment disappears. You become more exposed in some way.
The six themes resulting from the analysis were Being easily harmed, Becoming an old person, Being an old person in society, Reactions when being violated and hurt, Protection and Vulnerability as a strength (Figure 1.) 4
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BEING EASILY HARMED •
Feeling hurt and violated
•
Being sensitive
BECOMING AN OLD PERSON • • •
Losses Limitations Uncertainty
REACTIONS WHEN BEING HURT AND VIOLATED • • • •
Anger Sadness Disappointment Dwelling
BEING AN OLD PERSON IN SOCIETY A deeper sense of vulnerability as you grow old
PROTECTION •
Needing help from others
•
Protecting oneself
• •
De-personalisation Exclusion
VULNERABILITY AS STRENGTH • •
Capacity to feel Personal development
Figure 1. The meaning of vulnerability to older persons.
Being easily harmed Vulnerability meant being easily harmed, the sub-themes being feeling hurt and violated and being sensitive. Feeling hurt was mainly understood as mental harm in terms of a feeling of de-valuation, misunderstanding, being tread on and being insulted. Thus, feeling hurt and violated involved an ethical aspect, being diminished and hurt as a person. This could happen in contacts with doctors, a contact that is important for many older persons. Not being able to use your mother tongue, although the country is bilingual, could be experienced as an insult: Something that really hurt me was when that doctor said . . . Then I felt hurt [ . . . ] I felt I had no value. That was a situation when I felt hurt, really. It is in a way a bit embarrassing and to a certain degree insulting that in official places it is not natural and in hospitals it is impossible to speak Swedish. [ . . . ] And they cannot say in Swedish what’s wrong. So I have to use a dictionary when I visit the doctor. I think that is insulting. 5
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Feeling hurt and violated was related to how sensitive the person was. Some people were seen as caring more about what others said about them, wondering what they meant and one could in that respect even be oversensitive: It depends on how sensitive you are. It is no fun being hurt. So it is better if you are not too sensitive. As people grow older, they were seen as becoming more sensitive and susceptible to other people’s opinions and as a consequence more easily harmed.
Becoming an old person For older persons, vulnerability was associated with becoming an old person, a process that involved many life changes. The sub-themes included losses, limitations and uncertainty. Becoming old involved a variety of losses that made the ageing person more vulnerable: Losing your abilities in different areas, both physically and mentally. [ . . . ] It is part of vulnerability that so many people disappear from one’s environment, they either die or . . . my friend has been diagnosed with Alzheimer’s [ . . . ] And that is also a disappearance, when a person disappears into this.
The losses, thus, included a loss of physical and mental abilities as well as social losses through death or illness. One mental loss that was seen as a consequence of ageing was the loss of interest and empathy, the world or other persons did not matter as before: I have thought about this many times, why one loses interest in some things. It is not as exciting or interesting (as before). [ . . . ] You become less empathetic. People in your environment also become less empathetic. [ . . . ] And you are yourself not as sensitive to other people’s vulnerability.
The losses that came with becoming an old person were seen as a natural part of ageing, something that happens when a person approaches the end of life: You have to give up a whole lot. You are more willing to give things up if you realize that it is part of life. The losses of physical and mental abilities meant that the person became more limited: Vulnerability is concrete, you know and feel your limitations when you face them. With losses and limitations life as such became more restricted: Vulnerability, in that sense that life becomes more restricted. You can’t manage things that you have managed before. [ . . . ] Life becomes smaller in that sense, a lot of things are gone.
In addition to making life more restricted, the losses and limitations made life more insecure, a feeling of uncertainty was associated with ageing and vulnerability. The loss of physical strength meant a greater risk of injury: Of course you feel more vulnerable when, with the physical things. You know when it’s slippery that you have to walk more carefully than you used to. That if you fall over, the damage is more serious than 20 years ago. In that sense you become physically more vulnerable.
Becoming an old person often means becoming dependent on other persons, spouses and children as well as care staff. The feeling of uncertainty was expressed as worrying about the children if they did not call. Staff turnover was another source of uncertainty and insecurity: It is a feeling of insecurity, that they can’t recruit permanent staff. On an existential level, life as a whole became more uncertain. The growing risk of becoming ill or being subject to injury meant that life and future could not be taken for granted: 6
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You become more exposed, ‘when it is my turn, when does it happen to me’? When does the stroke hit me so that I lie there as a package? Life is not so given anymore. [ . . . ] You become more exposed to thoughts about your future, or do you have a future?
Being an old person in society Vulnerability was associated with what it meant to be an old person in today’s society. The values and attitudes that the older persons confronted as well as their own declining capacities put them in a vulnerable position. The sub-themes were de-personalization and exclusion. The participants felt they were not treated and taken into consideration as adult persons and individuals. Rather, they were de-personalized in many ways. For example, they felt older persons were disregarded, they talk past older persons, and they were treated as a collective, a grey mass of pensioners: Older persons are treated collectively. They are all the same and here they come in big masses in buses and overflow the place. You want to be treated as an individual.
Being treated as a collective rather than as individuals also meant that personal resources and abilities went unnoticed. The participants felt that from the viewpoint of society being old meant being incompetent, diminished and less able: Vulnerability is . . . it’s when you are treated is if you’ve become a child again. It is hurting when they think that older people can’t hear well and can’t fill in forms. [ . . . ] Older persons are treated as children. You become incapacitated because you are older. That is unacceptable.
The participants did not accept this attitude from society but protested against it. They clearly wanted to be noticed, seen as individuals and competent persons: You could get more consideration in society. Being an old person in society also meant feeling excluded in social situations. Sometimes the feeling occurred as a result of others’ attitudes: If you are treated with words or shown that you are not welcome. But the feeling could also occur as a combination of the older person’s declining capacity and the lack of understanding from persons around them. Being an old person in society meant feeling left outside: I have felt redundant, that I cannot follow other people anymore, because I can’t see. I feel that they talk between themselves and I become excluded. [ . . . ] For example at parties with my children, birthday parties and so. There are so young people. And they talk and I, I cannot keep up. I have to be silent. I feel that now I am old.
Reactions when being violated and hurt In situations where the participants were vulnerable and felt hurt and violated, they reacted in different ways. Reactions when being violated and hurt had three sub-themes: anger, sadness and disappointment and dwelling. Vulnerability was by some participants seen as weakness, and feeling hurt was thus experienced as a form of weakness. Sometimes, this feeling turned into anger, even more anger than feeling hurt. When I feel hurt [ . . . ] I can become angry [ . . . ] I can be so furious. The anger was also described as going wild and crazy or losing one’s nerves. Another way of being vulnerable in the sense of being easily harmed and reacting to this was sadness: If something hurts me I can become really, really sad. Disappointment was another reaction to vulnerability, and this was seen as partly depending on oneself: 7
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The feeling of being hurt sometimes went on and on and the participants kept dwelling on insults and violations. They could not forget an insult, not swallow it even though they tried not to take the ink.
Protection For the older persons, vulnerability meant needing protection against physical as well as mental harm. The sub-themes included needing help from others and protecting oneself. The participants recognized that they needed help from others and were satisfied when, for example, transport systems were safe and easily accessible. They also appreciated getting emotional help: They (the staff) have helped me many times when I have been sad. Alarm systems were in use among those living in service houses but sometimes they had to wait for help and did not always get the help they needed: They have this alarm system. Even though you have called, it can take quite a while before someone shows up. I haven’t hurt myself, I just want to go to the loo.
The participants also protected themselves, mainly against insults and mental harm from others. Selfprotection required mental ability: As long as you are in your right senses you can protect yourself. Selfprotection meant trying to learn not to care about what others said or trying to forget harsh words and insults, to put it aside. Another way of protecting oneself was to rationalize the insulting person’s behaviour and not take it personally.
Vulnerability as strength Vulnerability also meant strength. Experiencing feelings, when being hurt or harmed, was seen as an asset initiating something positive. The sub-themes were capacity to feel and personal development. Although the feelings associated with vulnerability involved pain, sadness, anger and disappointment, they meant that the person still had an emotional capacity. The capacity to feel was a sign that the interviewee was still an active person. Feeling and locating the pain also made it easier to ask for help: It [vulnerability] is strength, otherwise you become passive, if you never feel hurt and don’t feel anything. So it is definitely strength. If you compare to physical pain, it is a good thing that you can feel this pain, you can get remedy. That you know where the pain is.
Being vulnerable and feeling pain were also seen as something that could contribute to personal development: It [vulnerability] forms and develops you. Being able to use one’s own vulnerability in the service of personal development required a process of working through feelings, putting words on feelings and talking to someone rather than swallowing one’s pain: I need to talk and then I can see it, I can see it from another perspective when I have put words on it. They [the insults] become so big if you just swallow them.
Working through having been hurt and feeling pain was seen as a learning process. The participants learned to deal with harmful situations and people: 8
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There are some things you don’t do twice. You don’t let them violate you, you avoid them or you have learned to deal with a violation or an insult.
The participants also realized what it meant to feel hurt, which could teach them to be more empathetic towards others: You turn to yourself and hope that you will never hurt anybody. Working through pain and insults and developing personally from these insights was described as a timeconsuming process: Some things take longer time to work through, longer than a lifetime.
Discussion The aim of the study was to illuminate the meaning of vulnerability to older persons. The results showed that vulnerability was associated with many aspects of ageing and old age: with ageing came a deeper sense of vulnerability. Vulnerability as frailness could be seen in the meaning Becoming an old person. This meaning involved physical, mental and social losses that made life more limited and uncertain. To this extent, the results supported previous research describing ageing in terms of frailness.4–6,19–21 The results also showed that vulnerability meant being unprotected or in need of protection. The interviewees emphasized the role of self-protection, thus relying more on individual assets than family ties and other social networks.7,23 Interviewees living in nursing homes mentioned the importance of help from the staff and mechanical alarm systems, that is, help and protection from the health and social service system.7,23 Being sensitive, an aspect of vulnerability more seldom associated with ageing, formed the category Being easily harmed together with the subcategory Feeling hurt and violated. According to the interviewees, this meaning became more evident as they grew older. They became more sensitive to harmful insults and violations from other people including doctors. In this sense, too, ageing was associated with a deeper sense of vulnerability. Moreover, vulnerability had societal meanings that rose from older persons’ position in society. The interviewees felt they were de-personalized and excluded. Both Being easily harmed and Being an old person in society involved meanings that had to do with how the interviewees were treated by other persons or what kind of attitudes they confronted in society. The specific meanings – feeling hurt and violated, being de-personalized and excluded – refer to unethical treatment and confrontation. This reveals an additional aspect of vulnerability: ethical vulnerability or vulnerability of human dignity.31 In old age, human dignity is vulnerable. Because older persons are frail, they are at risk of being badly treated and violated. This makes the older persons feel that they are not treated as individuals but as a grey mass. They are at risk of being excluded from social community and being treated unethically by health personnel. They are at risk of becoming non-persons. The violation of the interviewees’ dignity evoked emotional reactions. They became angry or sad and disappointed and kept dwelling on insults. They partly blamed themselves for these feelings. But the older persons also saw their emotional reactions as a resource emphasizing that although pain and anger were difficult feelings, they could be seen as strengths. Having mental pain meant that the person was still active and alive, and physical pain communicated information that something was wrong. These feelings could be used as resources for personal development. This can be interpreted as an authentic attitude to life.15,16,18 Having feelings was painful, but at the same time it was a sign of sensitivity as well as openness to life and personal development. Although the frailty perspective dominated, vulnerability also had a positive meaning for the older persons. A comparison of the meanings the older persons ascribed to vulnerability with those of the nurses13 shows both common and differing meanings. To both groups, vulnerability had an existential meaning. To the nurses, vulnerability meant being human, and to the older persons, vulnerability received deeper meaning as they grew old and as they became more exposed and sensitive. To both groups, vulnerability meant having feelings, being easily harmed and thus needing protection. The older persons talked about 9
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concrete protection in terms of being protected by the service system and technical devices, but they also included self-protection, that is, protecting oneself from insults and painful feelings. The nurses associated vulnerability with self-protection and they saw it as a double-edged sword. It meant concealing oneself and one’s feelings and dissociating oneself in a way that relieves pain, but at the same time results in an inauthentic attitude to life. Both older persons and nurses also saw that vulnerability could be turned into strength and serve their personal development. The meanings that were related to becoming and being an old person in society were, understandably, only found among the older persons. On the other hand, the meanings Moral indignation and Having courage were only found among the nurses. These meanings arose from situations where the nurses felt older persons had been treated unethically and they needed to speak up. The nurses also felt they needed to confront their own vulnerability in order to provide good care. The comparison shows that vulnerability has general meanings as well as meanings that stem from the persons’ viewpoints and life situations. Since few studies have previously been conducted regarding the meaning of vulnerability to older persons, it was considered important to acquire a rich variety of data. Data variation was achieved by including both men and women living in different contexts. The difference of age between the youngest and the oldest participant was 26 years. The credibility and dependability32 of the study was strengthened by the fact that both authors had a long engagement in issues concerning ageing and the care of older persons. They read and coded the interviews independently of each other, after which they interpreted and re-interpreted data in an ongoing dialogue until they reached agreement. The fact that the interviews were conducted by students could be a threat against credibility. This risk was minimized as they were instructed and supervised by the authors. Confirmability means that the findings are shaped by the interviewees’ and not by the researchers’ bias or interests.32 In interpretive research, it is neither possible nor desirable to eliminate the influence of researcher’s pre-understanding. Rather, pre-understanding is a tool in the interpretive process and it is important that the interpreter is aware of his or her pre-understanding. In this study, the authors have interpreted in the light of the existentialistic philosophy and their previous research on vulnerability. The confirmability of the interpretations is shown in the citations from the interviews. Some of the meanings of vulnerability that the interviewees expressed are closely associated with experiences of ageing in the Western world shown in previous research.6,20 Thus, the results may be transferable to other Western cultures. The results have ethical implications. Since the core of ethics in the care of older persons lies in the encounter and relationship between the nurse and the vulnerable older person, nurses need to recognize the deep sense of vulnerability associated with old age. Life in old age involves losses, limitations and uncertainty that require special sensitivity of the nurse in order not to harm the person. An old person may be more than ordinarily sensitive to physical harm as well as insults, which stresses the importance of the ethical principle Do no harm.3 Old people’s frailness often means that their human dignity also becomes vulnerable; they feel depersonalized, excluded and de-valued. In order to protect the older person’s human dignity, the nurse needs to be morally sensitive.33 The nurse needs to notice the ethical aspects of the situation and use mature empathy to support the person. Mature empathy involves viewing the vulnerable older person from an ethical viewpoint and with an altruistic aim.3 Encountering the vulnerability of an older person means protecting the person and also recognizing the person’s vulnerability as strength. The nurse should help the person to accept his or her feelings and see them as resources for personal development. People can learn and develop throughout life. Supporting vulnerability as strength is compatible with the ethical principle Do good.3 Understanding and encountering the deep vulnerability of older persons may be difficult to young nurses whose life situations differ from the old person’s. Theoretical knowledge of ageing may help, but in order to encounter another person’s vulnerability, the nurses need to allow themselves to be vulnerable human beings. They need to turn their own vulnerability into strength, which may be easier as they themselves age.13 10
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