The Importance of Friendships To Elderly Nursing Home Residents

Friendship is an important form of social support for people of all ages. As various studies have shown, friendship is especially significant for elderly people and specifically elderly women (Stevens and van Tilburg, 2000). Unfortunately, friendship research is often criticised for being methodologically weak due to factors such as: a lack of a standardised definition of friendship, small non-representative samples, and cross-sectional research designs. This research into six residents and three staff in a Manchester, UK nursing home investigates the importance of friendships for institutionalised elderly women and whether nursing home management should address the friendship formation of its residents.

Factors Affecting Friendship

Most researchers concur that friendship is a voluntary, informal, reciprocal and personal relationship between equals (Allan, 1989; Jerrome, 1984). Researchers feels that an individual’s opportunity to make and maintain friends over their life course is linked to factors such as age, sex, physical status, class, disability level, living environment, cultural background, socio-economic status and psychological characteristics (Johnson and Troll, 1994). Kahn and Antonucci’s theoretical model entitled the Convoy of Social Support Model explains how the aforementioned factors affect one’s social network over their life course (Antonucci, 1985). A discussion of the effects of age, gender, and living environment follows. In relation to age, Allan (1989) feels that friendship characteristics vary according to the social and physical circumstances related to the ageing process and not age per se. As Johnson and Troll’s 1994 study determined, increasing age is associated with a decrease in the number of friends a person has and reduced motivation to make new ones. They felt that this could be partially explained by the decline in one’s physical condition as one ages and the resultant reduction in mobility and capacity to socialise.

Differences between male and female friendships are also apparent in society. It has been speculated that men’s friendships are more activity-oriented and are based on shared experiences rather than the intimate, emotionally intense, self-disclosure based friendships held by women. No further discussion of the gendered nature of friendships will be discussed in this article as this study deals with female friendships only. The last friendship-influencing factor to be discussed in this article, living environment, will be discussed in relation to the friendships of elderly people.

The Friendships of Elderly People

Adams (1989) explains that friends tend to be from the same age, sex, race, religion, geographic area and status level. People’s likelihood to form friendships is commonly influenced by more than one of these factors. A discussion of the friendships of elderly people is perhaps the ideal forum to explain the cumulative influence of factors such as age, status, disability level and geographic area on a person’s convoy of friendships.

Elderly people form a heterogeneous population whose quantity and quality of friendships are affected by many factors such as gender, marital status, material resources, economic position, relative health or infirmity (Allan and Adams, 1989). It is difficult to predict whether these factors will be deleterious or beneficial to the friendships of elderly people. For instance in Adams’ 1986 study of age-segregated housing, as explained in Allan and Adams (1989), it was found that marital status did not affect friendship patterns although it did elsewhere in the community. Thus some factors (e.g. institutional settings) can de-emphasise the relevance of other friendshipinfluencing factors such as status (Allan and Adams, 1989).

The debate over whether institutional life has a positive or deleterious effect on older adults’ opportunities to make and maintain friends is a complicated one. Noelker and Poulshock (1984) claim that social similarity, physical proximity, and frequency and length of association enhance friendship formation. Perkinson and Rockemann (1996) also feel that residents of age-homogeneous settings experience higher rates of social interaction and integration than older adults in age integrated settings. They feel that friendships flourish in these settings due to age density and frequency of contact between residents. However not all friendship researchers support the belief that group living environments are conducive to friendship formation.

Noelker and Poulshock (1984) explain that in nursing home study it was found that although the home included several characteristics associated with friendship formation, such as proximity, and social similarity - these factors were nullified by staff and residents’ stereotypical perceptions of elderly people. These perceptions hindered friendship formation and generated management procedures that had a negative effect on resident behaviour (Noelker and Poulshock, 1984). In one study by Bennett (cited by Reed and MacMillan, 1995) it was found that the staff at the nursing home did not value the residents as people and would therefore dismiss their friendships as unimportant. Thus although age segregated homes for elderly people may seem to be friendship forming environments, many deleterious factors may hinder the process.

Other research has shown that even when friendships form within an institution they may lack intimacy (Reed and MacMillan, 1995). Gutheil (1991) noted a lack of intimacy in her study of friendships in two New York City nursing homes. Similar results were found by Shea et al (1988), as explained in Perkinson and Rockemann (1996), in their study of friendships between females in a newly opened retirement community. They found that residents engaged in intimate conversations with their non-resident friends but information exchanged amongst friends within the retirement community was more impersonal.

Gutheil (1991) speculated that the lack of intimacy in institutional friendships might be due to 1) a lack of privacy in the nursing home, 2) lack of development time, 3) selflimitation or 4) the involuntary nature of nursing homes. As Gutheil (1991) explains:

1. Residents cannot be assured total privacy in an institution. Residents eat, sleep, toilet and bathe amidst people that they may want to impress and therefore they are unable to keep their real and social selves separate - this may affect their desire to form intimate friendships in the institution.
2. Friendships in nursing homes are new compared to those with old friends outside the institution. Intimate relationships often take time to develop and therefore may not develop in the short amount of time people may be in an institution.
3. Residents may restrict themselves from forming relationships if they feel that they do not have the resources to maintain the friendship. Alternatively, they may keep their friendships on a more casual level in order to protect themselves from being in a friendship with someone whose needs are great (Gutheil, 1991). Residents may also limit their friendships if they feel they will be leaving the institution soon or are hoping to leave the institution soon.
4. Residents are living together involuntarily and have therefore lost all control of their social situation. This forced association robs the friendship of the spontaneity and voluntarism that is so beneficial to the participants (Reed and MacMillan, 1995).

However, as Gutheil (1991, pp.71) concludes, ‘although friendships among these residents [in her study] are limited in depth and intensity, they clearly provide companionship and support’. She feels that although friendships in nursing homes are potentially less intimate than those outside of nursing homes they are still an important addition to the lives of elderly people.

The Significance of Friendship for Older People

The Convoy of Social Support Model proposes that social support is an important determinant of well-being, and much research supports this (Crohan and Antonucci, 1989). Evidence has shown that social support can reduce morbidity and mortality, buffer the effects of stress on mental and physical health, and aid adaptation to and recovery from physical illness (Crohan and Antonucci, 1989). Researchers have also found that social support is related to low levels of depression, high morale and the performance of preventive health behaviours (Crohan and Antonucci, 1989). Thus social support can have a significant effect on one’s health.

Friends are key participants in the convoy of social support of most elderly people. Therefore, as would be expected, research has also proven that friendship has a positive effect on the mental and physical well-being, morale, and life satisfaction of elderly people in particular (De Vries et al, 1996; Crohan and Antonucci, 1989). Jerrome (1981, pp. 177) supports this when she says, ‘There are certain periods of life when friends are particularly important, and old age is one of them.’

Both Jerrome (1981) and Allan (1989) feel that friendship takes on more importance when other roles are diminished, as is often the case as one ages. Many researchers feel that friends provide a means of social integration and belonging. They also feel that friendships provide both practical and emotional support in coping with stressful life transitions and adapting to the physical, personal, and social changes associated with ageing (Allan, 1989; Duck 1983; Stevens and van Tilburg, 2000). Allan states that ‘friends help one another to come to terms with old age and provide a continuing validation of self, at a time when other indicators of individual worth are less prominent’ (1989, pp.92). Lastly, Stevens and van Tilburg (2000) also believe that friendship provides sustainment of identity and meaning for elderly people. They discuss how the companionship that friends provide and the stimulation caused by socialising with friends has a positive effect on the well-being of elderly people.

The significant effect of friendship on the well-being of elderly people inspired my research. The remainder of this article will report on my study into the friendships of elderly people living in an institutional setting and: a) whether friendship is important to institutionalised elderly women and, b) if nursing home management should address the issue of resident friendship.

Methodology

Subjects/Site

This study involved a group of 6 mentally aware older women (age range of 58-88) living in a private nursing home in Manchester, UK and 3 staff members (the general manager, activities director and a nursing manager) working in the home. All research participants had been working or living in the home for at least two months and the nursing manager was the only male in the study. Male residents were excluded from the study in order to reduce the variability in the sample, enhance the comparability with the research literature (as it focuses on elderly women’s friendships) and increase the feasibility of the study (women tend to have larger networks of friends). The nursing home was 28 months old, contained a 50 bed residential unit for elderly people and units for mentally infirm and young physically disabled people (total capacity of 75 residents and 70 staff). The nursing home was part of a chain of similar homes across the UK.

Data Collection

All research participants were interviewed and interviews were taped, transcribed and analysed. Staff and residents were asked separate sets of questions with an overall goal to answer the two research questions. Staff and residents were all asked to define a ‘friend’ and some basic demographic questions. Only staff were asked their feelings on the importance of friendship to the residents and what practices staff used to maintain, enhance or create friendships in the home. Only residents were asked about the quality, quantity and satisfaction with their friendships and confidants. They were also asked what importance friendship held for them and whether the nursing home helped friendships to be formed. The transcripts of residents and staff were then compared and contrasted in order to answer the two research questions.

Findings

More differences than similarities were found between staff and resident interviews. The two groups did reach one consensus – the definition of a friend. They defined a friend as someone they could confide in and someone that would help them when they needed assistance. As one elderly woman said:

‘A friend is someone who is there for you, to be helpful to you, to confide in and for you to be a friend to them also, it is a two way thing.’

The communal definition was surprising because researchers claim friendship research to be overly subjective and often find it difficult to create a standardised definition of friendship. Although all friendship methodology must be regarded critically, this study was strengthened by the common definition of friend provided by the research participants themselves.

Resident Findings

It was found that many residents named family members as their closest friends and confidants. Only one claimed to have a close friend in the home itself and she did not feel that the relationship was intimate. All residents said that friendship played a role in their lives but only two claimed that friendship was important to them, the remaining residents seemed indifferent to friendship and one was confused by the question. All residents, even those without confidants, were satisfied with the quality and quantity of their friendships.

When residents were asked about the manner in which they made friends in the nursing home as opposed to the community, some suggested that the mental deterioration of other residents made it difficult to communicate and form relationships with them. The residents’ own physical deterioration also hindered their friendship formation because they did not want to burden others. All were content with the home management’s level of involvement in their social life – for example the home would arrange transportation to church, or indirectly help them to maintain their friendships by allowing visitors 24 hours a day and not requiring residents to be home at a specific time. Responses were mixed about whether residents wanted to form friendships in the home at all.

Staff Findings

Staff felt friendship was very important to the residents and that resident/staff friendship was especially influential on the care of the residents. They felt that residents need to maintain links with the past and the outside world by having friendships external to the nursing home in which they live. Staff believed that residentresident friendships were necessary because residents should have friends in a similar situation to their own.

The home did not have any policies relating to friendship formation for residents but they did have many practices that were perceived to enhance the social interaction of residents. The practices include: high staff to resident ratios, planned social activities, social seating at meals, 24 hour visitation, and staff who take residents out after their shift. No formal evaluation of the friendship enhancing practices has been conducted - instead the staff merely gauge the success of the social care by the number of complaints they receive.

Discussion

The findings support the literature. However, the staff views about residents’ friendships do not match the residents’ views about whether:

1. They need friends in the nursing home itself
2. They want staff to assist them in forming and maintaining friendships.

The staff’s view that friendship is important in the lives of the residents and that residents should make friends with other residents simply because they are in the same position were not opinions that were shared by residents. Although research does support the need for friends in an elderly person’s life there is much debate as to whether the friends of an institutionalised elderly person need to be within or outside of the nursing home and whether the friendships must be intimate in order to positively affect the individual’s well-being. Gutheil’s (1991) research supports the development of friendships in the nursing home as it shows that they provide companionship and support even if they are not intimate. As was found in the current study it seems that many researchers have not only noticed the lack of friendships between residents of nursing homes but also a lack of intimacy in resident-resident friendships (Gutheil, 1991; Noelker and Poulshock, 1984). Residents in this study mentioned length of time, self-limitation and the involuntary nature of the nursing home as reasons for their lack of intimate friendships.

Interestingly, although residents did not claim to have many friendships, nor any intimate friends in the nursing home, they were all satisfied with the quality and quantity of their friendships.

Surprisingly, the residents did not seem to feel strongly that friendship was important to them. Many listed family as friends and confidants and seemed indifferent to having friends in the nursing home. Residents were satisfied with the home management’s level of involvement in their friendships therefore, the home must be doing something positive to support the residents’ friendships or at least not having a negative influence on existing ones. Either way, the overall effect on residents’ friendships was positive.

Lastly, nursing home staff must not devalue friendships that are external to the nursing home. All friendships, intimate or not, positively affect one’s well-being and the staff should play a facilitating role by offering transportation, 24 hour visitation, easy access to telephones, and perhaps even friendship training such as Stevens and van Tilburg’s innovative educational friendship programme (2000). The goal of the programme was to ‘help older women reduce their loneliness by developing the friendships that they desire, either by improving existing relationships or developing new ones’ (Stevens and van Tilburg, 2000, pp. 18). The programme consisted of twelve lessons focussed on topics such as setting goals in friendships and making new friends. An evaluation of the programme showed that the participants were successful in reducing their loneliness and had developed new friendships of varying degrees of closeness and increased their social network (Stevens and van Tilburg, 2000). Education, involvement of residents in the planning and creation of their own social activities, and formal evaluation of residents’ satisfaction with the quality and quantity of their friendships may have a positive influence on residents’ friendship levels and feelings of control over their social support.

Conclusion

It is clear that friendship has an important positive influence on the well-being of elderly people and women in particular - thus it should be a concern for many nursing homes and their residents. Although, as Antonucci (1985) suggests, it may be residents’ beliefs about the adequacy of their social network that are most essential to their well-being. In this study all residents were satisfied with the quality and quantity of their friendships even if they had minimal friends overall and no intimate friends in the nursing home. Nursing homes are best to ask residents what level of involvement they want staff to take in assisting them to maintain and form friendships and what form that assistance should take. The methodological strength of this study is the selfdefined common definition of a friend but limitations such as the small sample and age of the nursing home may have affected the conclusive nature of the results. An older nursing home, a larger sample, and a longitudinal study would have greatly enhanced the accuracy and generalisability of the research.