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Exchange Theory — Theoretical Interpretation

The preceding three chapters have analyzed those factors that may in part be responsible for the lower quality of care at Pacific Manor. However, this analysis does not fully reveal why the United States, a country that prides itself on excellence in acute care, will tolerate such low standards (and sometimes even inhumane care) in the care of the institutionalized aged. I should like to propose that exchange theory might offer some insight into the problem and perhaps explain on a theoretical level the difference in the care of the elderly in the two institutions.^[1]

Exchange refers to the transaction of labor, resources, and services within a society and plays a vital part in the social life of all societies. "Exchange is not limited to economic markets: social exchange is ubiquitous" (Blau 1968:453). Malinowski (1922), in his description of the kula, and Mauss (1925), in his analysis of gift exchange, were the first anthropologists to observe this phenomenon, and they have greatly influenced the development of exchange theory. In addition to Malinowski's analysis of the Trobriand kula ring, anthropologists have examined other social institutions, such as bridewealth in African societies and the pot-

[1] Some readers may suggest that the data could be analyzed using other theoretical frameworks such as social organization, social class, or network theory. I have chosen to limit the theoretical discussion to exchange theory because I believe that the principles of exchange theory more than any other theoretical framework help to explain the interpersonal relationships and other phenomena observed in this research.

latch of the North American Indians. These institutions illustrate reciprocity, which is the prevailing and characteristic mode of exchange, and demonstrate the essentially social nature of a reciprocal exchange of valued goods. Sociologists and social psychologists such as Homans (1961), Emerson (1962, 1972), Blau (1964), and Ekeh (1974) have also made major contributions to exchange theory.

Dowd (1975), drawing upon the work of Emerson and Blau, has put forth a view of aging as a process of social exchange; he sees the problem of aging as one of decreasing control over power resources. As power resources decline, the aged, unable to engage in balanced exchange relations, are forced to exchange compliance for their continued sustenance.

Major Propositions of Exchange Theory

Some of the major propositions of exchange theory as set forth by Emerson (1962, 1972) and Blau (1964) include:

1. People enter into social relationships because they expect them to be rewarding.

2. A person who derives benefits from another is under obligation to reciprocate by supplying some benefit in return.

3. When an individual fails to reciprocate, there is no incentive to continue to befriend him and he is likely to be accused of ingratitude.

4. When the person does reciprocate, both parties benefit from the association, a social bond develops between them, and the interaction between the two will probably be continued.

5. In every interaction, costs are inevitably incurred. Cost is defined as the resource one gives to the other party. If one perceives the cost to be equal to the reward, the exchange relationship is in balance.

6. If one participant values the rewards more than the other, an imbalance results and the latter person has power over the former—a unilateral dependence develops.

Power is the ability of persons or groups recurrently to impose their will upon others, despite resistance, through deterrence either in the form of withholding regularly supplied rewards or in the form of punishment (Blau 1964:117). By supplying regularly needed services to others who cannot reciprocate, a person establishes power over them and they are forced to comply with his wishes. In power-dependence relations, individuals who need services have the following options: (1) they can supply a service in return, (2) they may obtain the service elsewhere, (3) they can use coercion to obtain the service, (4) they may choose to do without the service. If they are uanble to choose any of these alternatives, they must comply with the wishes of the one in power since he can make the continuing supply of the needed service contingent upon compliance.

Application of Exchange Theory to the Institutionalized Aged

The propositions of exchange theory cited above are especially relevant to the care of the institutionalized aged.^[2] Owing to their physical disability, mental impairment, and (for some) lack of friends and relatives, many are dependent upon staff for multiple services. But since they have few resources with which to reciprocate, they are forced to comply with the wishes of the staff. Mrs. Lundgren, for example, is dependent on the staff for bathing. She objects to being placed in the shower room with male patients. "I don't know how the men feel," she averred, "but I find it disgusting! But what can I do?" None of the options mentioned above is open to her. She is too disabled to perform a return service for staff, she cannot obtain the service elsewhere, she has no power of coercion, and she cannot do without the service. Her only alternative is to comply with their wishes because she realizes that if she complains they can withhold the service.

The institutionalized aged are clearly dependent on staff for services. Staff can render these services promptly, willingly, and respectfully; or they can use the situation to exercise power over the aged. I found, for instance, that at Pacific Manor there are more examples of staff exercising power over patients than at Scottsdale. I submit that this occurs because the American patients have fewer resources and are more dependent: they are unable to engage in balanced social relationships.

[2] This theoretical analysis will necessitate repeating previously discussed descriptive data.

Dependency of the Aged at Pacific Manor

The atmosphere of an institution and the quality of its care can either maximize one's level of functioning, thereby promoting independence; or conversely, it can mimimize one's level of functioning and make one dependent upon others. At Scottsdale, for example, a portable telephone at wheelchair level can be placed in patients' rooms (every room has a telephone jack); patients can independently and privately talk with friends and relatives. But at Pacific Manor the only telephone is in the hallway at a level unreachable for those confined to wheelchairs; they must depend upon staff to dial the phone and they cannot talk privately.

The quality of medical and nursing care also contributes to patients' dependence or independence. At Scottsdale medical problems are given prompt attention, yet at Pacific Manor they may go untreated for weeks. On one occasion the director of nursing service at Pacific Manor asked me to visit Mrs. Edwards, who was depressed and had not left her room for days. While visiting with me, she confided that she had been troubled with diarrhea and urinary frequency for weeks but that she could get no attention from the nurses or doctor. This patient had only one kidney, she had repeated urinary tract infections, and she was frightened about her condition. A very proud woman, she was not going into the lounge for coffee and activities because she was afraid she would not get back to the bathroom in time and would wet herself. "I've told the nurses," she said, "but they don't do anything about it. If I had the courage, I would go to the telephone and call my doctor myself." "What do you mean?" I asked. "I'm afraid to walk that far because I might not get back to the bathroom in time," she explained. Even though she stayed in her room, she was sometimes incontinent and then dependent upon the staff to change the bed linens. Also, she could no longer independently get her morning coffee. As I walked into the lounge to get some for her, the activity director said, "I would rather that you not take coffee to Mrs. Edwards. She is just too lazy to come out of her room." I explained the situation and added, "I would like to take coffee to her; she's such a lovely woman." "I think she's obnoxious," the director replied. "She doesn't like the programs I have arranged for the patients and has been complaining that they are not as good as they used to be." This incident provides a clear example of staff exercising power over a patient who had become dependent upon them for a service.

At Pacific Manor some patients were restrained in chairs (forced depen-

dency), were incontinent because they were not taken to the bathroom, and were made to wait several hours before their clothes were changed (compliance). At Scottsdale, by comparison, I never observed patients restrained in chairs. The nurses made rounds every 2 to 3 hours, offered bedpans to some, and walked those who were able to the bathroom.

Lack of Resources

A lack of resources also creates dependence and contributes to an imbalance in social exchange relations. Resources are essentially anything perceived by the exchange partner as rewarding; it may be a skill, money, or food—anything that someone has and the other values or wants. Resources enable one to reciprocate in an exchange relationship; they serve as an inducement for staff to furnish service and protect patients from dependency and compliance (Blau 1964:119).

The patients at Scottsdale have more resources than do patients at Pacific Manor. As mentioned in Chapter 3, they make items in diversional therapy that are valued by the staff and others. Mrs. Frazer, for example, knits beautiful sweaters and scarves (she can hardly keep up with the demand) that she sells at a reasonable price to staff and friends. Others make lovely trays, padded coat hangers, and children's toys, which they sell or give to staff and relatives. These items provide patients with resources they can give in exchange for services. This in turn enables them to engage in balanced exchange relationships. It is unlikely that a nurse will treat Mrs. Frazer unkindly when she is knitting a sweater for that very nurse. These exchanges also contribute toward the establishment of social bonds.

In addition to making products for exchange, the Scottish patients have money and access to a shop where they can purchase articles to give to others. Most have only a basic government pension as income, which must go toward the payment of their care. Nevertheless, patients are permitted by law to keep £3.05 per week (approximately $6.00) for personal use. By American standards this may seem like a small amount, but because they are provided with virtually everything ("they want for nothing," remarked one of the nurses), it gives them considerable purchasing power. On several occasions I observed patients giving treats to a "special nurse," and I, too, was the recipient of such gifts. Patients valued my lengthy visits. On some days, in fact, I began to feel guilty as I collected chocolate bars, biscuits, coat hangers, and homemade marmalade. The marmalade

provides an interesting example of a successful exchange system. The minister of one of the Scottish women made delicious orange marmalade. Each time he came she ordered several jars, which he delivered on his next visit and which she in turn gave to staff who were especially kind to her. "I am good to people who are good to me," she smiled.

By contrast, patients at Pacific Manor have few resources. Since they are not able to engage in any productive activity, they have no products that they can exchange for services. Additionally, many are without money; 50 percent of the Pacific Manor patients, who were formerly private patients, are now on Medicaid. They have become impoverished through their long-term illness. Although Medicaid stipulates they be permitted to keep $25.00 per month for personal use, the likelihood of theft keeps them from having money in their rooms. Some keep a small amount in the business office, but there is no shop in the facility where they can purchase food and sundry items.

It was intriguing to observe that, despite the restrictive environment at Pacific Manor, some of the elderly managed, through their ingenuity, to develop balanced social relations with certain staff members. Mrs. O'Sullivan has no family and her closest friend, an 84-year-old woman, lives fifty miles away. Her needs are small; she likes potato chips and mints for snacks and a little wine now and then. Fortunately, she has a skill that she can exchange for service. Mrs. O'Sullivan alters and mends clothes for one of the nurse aides, who in turn shops for her. "Of course, I wouldn't charge her for it," she said. "When I can do her a bit of a favor I do, and when she goes to the store and I need something, she shops for me."

Mrs. Levine is one of the more fortunate patients. She has an attentive daughter and numerous friends who visit frequently and provide her with money and food, which she carefully hides and uses to purchase favors. She does not like to go to the hair dresser, for example, who charges $6.00, and she does not like to wait in line. So she has arranged for one of the aides to wash her hair, and she in turn pays $1.00 for this service. Mrs. Levine always has resources available and carefully reciprocates. When I took her some of her favorite cheese, she immediately offered candy in return.

Mrs. Crawford, a 93-year-old woman with no relatives but many friends, has been one of the most resourceful and successful in establishing balanced exchange relations. I was in her room one day when a nurse

aide came and asked for some food. "I always come in for something to eat when I go on my coffee break," she explained. "Mrs. Crawford always has nice things in her room." Mrs. Crawford said she had received four big boxes of candy and many homemade Christmas cookies. "There was plenty for everyone," she beamed, "and I share it with all the girls." Her favorite nurse aide was Mrs. Lee. "She is so good to me," Mrs. Crawford went on. "When anything is bothering me, I always tell Mrs. Lee; she is like a sister to me." When Mrs. Lee's son was in the hospital, Mrs. Crawford sent him a box of candy. A strong social bond has developed between these women, and Mrs. Lee (a powerful woman because of her long tenure at the nursing home) will not permit anyone to speak unkindly of Mrs. Crawford. On one occasion staff members were saying how mean Mrs. Crawford had been because she had attacked a male orderly and scratched his arm. Mrs. Lee immediately went to her defense: "He tried to 'manhandle' her," she corrected them, "so she scratched him."

Mrs. Crawford is an outgoing person who likes people and needs companionship. The food she keeps in her room provides an incentive for staff to come in for a brief visit. Because of her generosity, furthermore, she has made many friends among the staff and appears to be somewhat exempt from the theft problem. Although other articles have been stolen from her, the food, which she keeps in large tin boxes right at the head of her bed ("most things get taken at nighttime," she said) usually is not disturbed.

Negative Exchange

Although social exchange by and large concerns a reciprocal giving and receiving of goods and services, some theorists have included negative exchange as an element of social exchange. Homans (1961:57–61) speaks of exchanging punishment, Blau (1964:227–30) and Kiefer (1968:225–44) refer to offenses that call for retaliation, and Sahlins (1965:148–49) and Price (1978:339–50) discuss "negative reciprocity." Although our conceptualization of negative exchange lags behind that of positive exchange (Befu 1977:259), I believe it may explain some of the negative staff-patient interaction seen at Pacific Manor. For example, there are many elderly persons at Pacific Manor with few resources who require long-term care. In our culture they are seen by the productive members of

society as useless, dependent, and nonproductive; they are a burden and a nuisance. Clark (1972:267) discusses how one who becomes a burden is seen as having nothing of value to exchange; he is in a nonreciprocal role. If an individual is arbitrarily defined as having nothing of value to exchange, moreover, he is expecting something for nothing, and in our culture, with its strong emphasis on self-reliance, negative sanctions are usually brought against such persons (Clark 1972:270). The infantilization, depersonalization, dehumanization, and victimization described earlier illustrate the negative sanctions brought to bear against those who are in nonreciprocal roles.

Negative Reciprocity

Sahlins (1965:148–49) defines negative reciprocity as "an attempt to get something for nothing with impunity." Haggling, gambling, chicanery, and theft are some of the various means used by some to profit by another's expense. This concept of negative exchange may explain the theft of patients' belongings that occurs at Pacific Manor. The poorly paid staff, who have no social bonds with the patients, victimize them for personal gain because punishment is highly unlikely. The elderly cannot retaliate; their families may complain but their complaints are not acted on, and the administration does not see theft as an important problem. Thus it is advantageous for staff to steal from patients; they can do so without recrimination.

Retaliation

Some of the punitive behavior discussed earlier in the infantilization, depersonalization, dehumanization, victimization process suggests that the staff may retaliate in their treatment of the elderly. In both institutions staff commented on the dependency of patients. "They want us to do everything for them; they come in here and forget they have hands and feet," said one nurse. A staff member at Pacific Manor clarified, "They have been catered to for so many years; they become dependent and think we are here to provide services for them." Although the importance of encouraging the elderly to be as independent as possible (most prefer this) is widely recognized, it must also be understood that, because of unavoidable circumstances, many are dependent on others for some of their care. I believe that staff do resent the work involved in the care of

dependent patients and further resent that they are poorly paid to perform difficult work; at Pacific Manor, many approach their work sullenly as a result.

Resentment on the part of the staff may be caused by their poor working conditions. The personnel at Pacific Manor are exploited by the institution. They are among the lowest paid health care workers in the U.S., and their salaries compare unfavorably with those of similar workers in acute-care institutions. Blau (1964:229) suggests that "exploitation and oppression are punishing experiences which arouse anger, disapproval, and antagonism." If a person is severely deprived, he feels a strong desire to retaliate by harming those who have harmed him. In this situation, however, employees cannot retaliate against the proprietor, who controls their salary; predictably, they take out their resentment on the patients. For example, an incontinent patient may be considered difficult and uncooperative. The incontinence creates more work for the staff, and they punish the patient for this "extra" work by not changing the linens promptly.

Because many of the elderly at Pacific Manor do not have resources, it would be beneficial for them if social bonds could be established in other ways. Functions wherein staff, patients, and their friends and family interact on a social level is one suggestion. Staff would begin to see patients as individuals and treat them more kindly; it is more difficult to be unkind to those whom one knows personally. But it must be kept in mind that the depersonalization of patients by the staff may be a protective mechanism. It is emotionally taxing to care for people who will not get well; the mortality rate is high at Pacific Manor. If staff become personally involved with patients, it may be painful to see them die.

The behavior observed on a staff-patient level must also be examined on the societal level; for, broadly speaking, exchange theory is also applicable within the socio-cultural context of each country. Every society, after all, determines what is a fair exchange, and there is common agreement on the terms of exchange. For example, for more than 30 years (since the beginning of the NHS) the British people have agreed that they will pay taxes in exchange for health care services. This is considered by virtually all of the people to be a fair and equitable exchange. Hence, the elderly are not receiving any special consideration. Like everyone else in the society, they are entitled to health care; one government-financed system exists for all.

In the United States, by contrast, the prevailing attitude toward medical care is that one is individually responsible and must pay privately for health care through an insurance program or from personal funds. Those who cannot pay in exchange for health care services are thought to be unworthy of receiving high-quality care. They may procure care through government-financed programs, but these programs are considered welfarism by many Americans, and those who must participate in such programs are considered second-class citizens. Many people in our society (which stresses individual responsibility for health care) feel such individuals receive something for nothing; hence, they should rate lower-quality care and they must accept what is offered without complaint. Unfortunately, many of the elderly, who have become impoverished through long-term illness, fall into this classification.

This attitude of what is fair exchange on a socio-cultural level exerts a subsequent impact on an institutional and individual level. For example, as reported in Chapter 6, physicians at Pacific Manor, products of our society, often provide only minimal care to the institutionalized elderly in exchange for Medicare and Medicaid payments. Taking his cue from the attitude of society in general and physicians in particular, the owner of the institution knows that he need provide only minimal care to the elderly in exchange for payment. He will not be held accountable by professionals or society. Subsequently, the poorly paid nonprofessional staff observe this behavior on the part of those who should be responsible for care. They are fully aware that the elderly are seen by others as undeserving of a high standard of care and conclude that they need provide only minimal service in exchange for their substandard pay. Consequently, the elderly become the victims of the system, whereas the nursing home industry, owing to a lack of professional responsibility and an absence of effective public pressure realizes tremendous profits.