Constructions of self-neglect.

Abstract

Self-neglect can be understood as the failure to engage in those activities which a given culture deems necessary to maintain a socially accepted standard of personal and household hygiene and carry out activities needed to maintain health status. This failure to care for one’s self can be diagnosed as a medical syndrome. A synthesis of the Medical Model and Orem’s Theory of Self-Care provided the framework for stage one. This stage comprised a comparative survey of a group of self-neglecters and a comparison group identified by and drawn from the caseload of District Nurses. Many participating nurses practised in remote and rural settings. This geographical and cultural context may have influenced the relationships between nurses and patients and the way in which care was delivered. Self-neglecters had lower levels of self-care agency, were more likely to have a psychiatric disorder and have the nursing diagnoses of non-compliance and ineffective management of therapeutic regime. The self-neglect and comparison groups showed similar levels of independence and dependence in Activities of Daily Life functioning. The medical construction of self-neglect has come to dominate the discourse. The medicalisation of self-neglect obscures the fact that patients and professionals may have different ideas on what is and what is not self-neglect. The notion of self-neglect as a social construction was the theoretical perspective which provided the framework for stages two and three of the main study. This challenged the assumption implicit in the medicalisation of selfneglect that self-neglect is an objective a priori category. In stage two multiple-case study methods were employed to investigate other constructions of self-neglect. It was found that there were divergent views on self-neglect both between cases and across cases. A wide range of behaviours were classified as constituting self-neglect. It was concluded that self-neglect is a constructed phenomenon which is the product of social and individual normative judgements, which are themselves rooted in the dominant discourse on cleanliness, hygiene and self-care. These social judgements were investigated in a systematic way in stage three. Judgements regarding self-neglect and the degree to which individuals were perceived to have chosen to lead a neglecting lifestyle were proposed to be social judgements influenced by professional socialisation and cultural values. Stage three was a factorial survey investigating which variables or combination of variables influenced nurses’ judgements of self-neglect and choice in lifestyle. The variables investigated in the factorial survey were self- care status, functional status, gender, psychiatric illness, stated preference for lifestyle, and socio-economic status. Self-care status was the most important variable in judgements of self-neglect and a combination of functional status, stated preference for lifestyle and psychiatric status were the most important variables in judgements of choice of lifestyle. Psychiatric, general and student nurses had veiy similar patterns of judgements about self-neglect but general nurses were more likely to believe that self-neglect was an active lifestyle choice. The findings of the three stages challenge the existence of an objective medical diagnosis of self-neglect. The evidence suggests that self-neglect is a label applied to a wide range of behaviours and that there is disagreement between professionals and between professionals and patients about the existence of self-neglect in specific cases. It has also been shown that self-neglect is defined by the methods which are used to study this phenomenon. Different research methods produce a seemingly contradictory picture of selfneglect.