Within moments of becoming—everyday citizenship in nursing homes

Abstract

Background

Humans are occupational beings. Our occupational choices depend on the opportunities available to us, and within nursing homes, institutional rules or structures may limit occupational engagement. An everyday citizenship lens acknowledges the importance of people’s rights as citizens as well as engagement in mundane aspects of the everyday, highlighting diverse expressions of agency.

Aims/objectives

To show how older residents living with dementia in nursing homes can realize their everyday citizenship.

Methods

A phenomenologically inspired ethnographic study was conducted in nursing home units in Norway, exploring everyday citizenship through narrative analysis.

Results

Within everyday environments of care, the narratives of May, Janne and Camilla tell stories of spontaneous initiatives towards contribution and responsibilities, highlighting their continuous occupational natures.

Conclusion

Becoming can be seen as constitutive of self and identity, through residents’ actions and contributions within the mundane and ordinary of everyday life, as an essential part of everyday citizenship.

Significance for practice

A citizenship of becoming presupposes that institutional perceptions of activities being offered ought to be broadened towards supporting residents’ natural desires to do and act within the mundane and ordinary of everyday life.

Keywords:

• Agency
• dementia
• ethnography
• narrative analysis
• occupation

Introduction

Background

Although every human being has the right to liberty, choice, privacy and freedom of movement and residence [1], some conditions or illnesses can place such autonomy under pressure in our societies. Dementia is one such condition, affecting cognitive functions and abilities in activities of daily living [2]. In Norway, the Ministry of Health and Care Services’ Dementiaplan 2020 [3] sought to promote a more dementia-friendly society, wherein people living with dementia called for inclusion in decision making, and being active participants in their own everyday life and communities. Although the overall political aspirations promote ‘aging in place’, supported by municipal services and family in own home [3], the progression of dementia may necessitate 24-h care, provided by healthcare staff at local nursing homes. Within this context, the Ministry’s strategy [3] promotes the provision of activities and social interactions, as well as autonomy, privacy and homeliness within tailored environments. However, it does not address essential dimensions of the mundane and ordinary of everyday living in this context, which is taken as a departure point for this article, aiming to explore how residents living with dementia in nursing homes can realize their everyday citizenship. The introduction presents theoretical perspectives and knowledge gaps forming the backdrop of study. This implies occupational perspectives, theories of citizenship and narrativity.

Occupational perspectives

The everyday can be seen as the mundane and familiar, the routine and rhythmic [4]; it is where life happens, and where we experience balance, or imbalance, between occupational needs and the opportunities our environments offer. Wilcock and Hocking [5] perceive humans as essentially occupational beings, with an innate need to engage in simple, complex or multiple occupations. They further argue for an inter-dynamic relationship between the things we do and our being, belonging and becoming. Doing involves active, mental or spiritual engagement, whereas being encapsules peoples’ sense of who they are as occupational and human beings. Belonging relates to the social aspects of occupation. Doing with, alongside or for other people fosters relationships and gives a sense of being at the right place, recognized by others and at home. The dimension of becoming is closely connected to our experienced being and our sense of belonging and can be seen as a continuous process of growth, development or change residing within a person through life. Becoming, as such, adds a perspective of possibilities in everyday life and activities, mediating a sense of future and hope.

The innate occupational needs of human beings have been overlooked in much scientific inquiry and theories of human nature because they are considered mundane [5]; moreover, a universally accepted definition of occupation is lacking. Carlson et al. [6] describe some typical characteristics that have received growing consensus, such as doing that is purposeful and goal directed, tending to be performed consciously and intentionally. According to Hammel [7], although dominant occupational theory might imbue planning, organizing and goal-directed behaviour with a positive value, some people living with a disease may be unlikely to hold a future time orientation in the same way; in the context of dementia, people may thus be excluded because of reduced cognitive abilities regarding intentional and goal-directed action. Hammel [8] argues that occupation may be best understood as dimensions of meaning, whereas Mello et al. [9] similarly argue that doing means being engaged in occupations that are personally meaningful, but not necessarily intentional, healthy or organized.

In this article, we understand occupation as all the things people do throughout their lives [5], both individually and collectively, encompassing the whole 24-h continuum of active, restful and sleep activities. Within such an everyday life, Wilcock and Hocking [5] argue that if people have little hope of using their potentialities in a meaningful way, the lack of recognition of their becoming needs can lead to physical, mental and social ill-health, and further: ‘A serious aspect of occupation, becoming is frequently disregarded, and is less and less considered in medical, or health fields of practice’ [5,p.256]. Hitch et al. [10,11] argue that the dimensions of doing and being have received the most comprehensive development to date, whereas becoming and belonging remain underdeveloped. In terms of becoming, Swan et al. [12] report that the use of iPads in residential care modify behaviour by leading to a decrease in challenging behaviours and supported learning new skills, enabling a sense of mastery and growth over time. Hooper and Collins [13] describe how the becoming domain can elucidate the ways that caregivers redefine themselves, their values and their priorities in becoming caregivers. Within other contexts, Ong et al. [14] argue that gardens can be a place for people to do, be, belong and to become. In their study, although doing and belonging were the most evident, the authors report that becoming was observable when participants spoke of exploring new opportunities or of being part of something bigger than themselves.

Towards a rights-based, citizenship approach

Hammel [7] argues that people’s occupational choices are dependent upon the real opportunities available for them. Thus, enhancing people’s capabilities, abilities and opportunities requires both a rights-based approach addressing the availability of real occupational opportunities, and a strengths-based approach that assesses and builds individual, collective and community strengths, assets, skills, abilities and resources. The nursing home context may hold particular challenges for such aspirations, caught between the medical logics of the hospital and the autonomy of home [15]. Rules [16] or environmental factors along with a fixed activity schedule [17] can limit engagement in activities, whereas institutional frames can decrease residents’ experience of freedom [18] and lead to experience the nursing home as boring, requiring adjustment in expectations and compliance with routines [19].

Such hospital logics, based in traditional medical and care-based perspectives, may, according to Bartlett et al. [20], limit residents’ opportunities for engagement, reducing them to inhabiting roles of those solely in need of care. The authors’ call for a broadened view of dementia towards citizenship highlights peoples’ inherent rights to the same from life as others in society. Although the concepts of human rights and citizenship may be applied less frequently and rigorously in dementia care than in other health and social care literature [21], there is increasing international debate around citizenship within the dementia field [22], highlighting the rights of people with dementia and combatting stereotypes depicting them as frail and incapable.

Within this debate, citizenship has been increasingly conceptualized as something that is beyond a stable status bestowed by others, and instead as something realized through the things we do every day [23]. Promoting micro-citizenship in long-term care, Baldwin and Greason [23] argue that citizenship can be realized through a broad spectrum of mundane activities, supported (or undermined) within relationships and physical and social environments. Ursin [24] calls for a shift in focus from care to citizenship, and from health services to an everyday life perspective, whereas citizenships’ enactment is described as both malleable and precarious by Ursin and Lotherington [25], needing continuous nourishment to be maintained. Still, Bartlett et al. [20] argue that what citizenship means—particularly in severe cognitive impairment—is unclear, whereas Baldwin and Greason [23] warn us that if citizenship is to avoid the dangers of becoming a ‘plastic’ word, void of meaning, it needs to be made specific for practice.

Exploring citizenship within narratives of everyday occupation

In response to the critiques of institutional structures and reductionist perceptions that may limit the opportunities of people living with dementia, connecting occupational theory to the international conversation of citizenship offers an opportunity to explore the needs, capabilities and rights of people living in nursing homes. Widening the canvas for examining citizenship, Nedlund et al.’s [26] way of conceptualizing everyday citizenship appears highly relevant in this regard. The way the authors acknowledge the unremarkable, routine, mundane and ordinary of human life allows us to locate citizenship in the everyday. It turns our focus towards people’s abilities for agency within every gesture, expression, action and social relation, as well as acknowledging that people living with dementia hold abilities for narrative agency, expressing themselves in forms recognizable by others.

In this study, we sought to understand aspects of everyday nursing home life from the perspective of residents living with dementia. Acknowledging their agency to tell their stories, we view narratives as performed as well as told [27], allowing us to interpret meaning in both people’s actions and vocal expressions. Baldwin [28] describes narrativity as a performative activity, articulated through action, language and joint authorship. As such, our exploration takes place in the narrative practices of the mundane and ordinary everyday life, through the question, ‘How do people living with dementia in nursing homes express and enact their everyday citizenship?’ Focussed on the immediate environment, connecting the concepts of everyday citizenship [26] with occupational dimensions [5] helps ground the narratives towards the mundane and ordinary that arose throughout the study. Through peoples’ actions and expressions, stories of meaning, purpose and identity emerged.

Materials and methods

The article is part of a PhD thesis exploring the characteristics of citizenship in the lives of people living with dementia in nursing homes, through a phenomenologically inspired [29] ethnographic study [30].

Study context

Ethnographic fieldwork was conducted at two nursing homes in the southwest region of Norway. Written invitations were sent to leaders in five municipalities of different sizes and locations within the region, and two responded positively and were included in the study. As the study did not seek to conduct general quality assessments nor had comparative ambitions, the municipalities chose which of their nursing homes to include based on two inclusion criteria: the nursing home must be intended for (1) long-term stay and (2) for persons with dementia. The included nursing homes, Sea-Crest and Sunny Hill, were located in different-sized municipalities and represented a large unit and two small-scale units.

Sea-Crest nursing home

Sea-Crest is located in a rural area in a large municipality. One large unit on the second floor was included in the study. The unit had an open door and was divided into two groups, with access to separate living rooms, terrasses and dining areas where residents gathered.

Sunny hill nursing home

Sunny Hill is located in a semi-rural area in a medium-sized municipality. Two small units were included in the study. Unit South had an open door, whereas Unit North was locked via code to prevent residents from leaving on their own—the latter unit reserved for people in need of close supervision in everyday life. The units were situated on the ground floor, equipped with a small kitchen, dining room tables and a living room area where residents gathered.

Data collection

The first author was part of an active construction of knowledge through participant observation [30] and in-context dialogue with residents and staff. In addition, individual interviews and group interviews were conducted with staff in the units (see Table 1 for an overview of the data). The ethnographic fieldwork allowed access to actions and experiences from the perspective of the residents living there. The first author participated in everyday activities and routines, in the daytime, evenings and on weekends. The majority of time was spent sitting beside residents, engaging in conversation or simply observing everyday life as it unfolded.

Table 1. Overview of the data.

	Duration of fieldwork	Number of visits	Fieldnotes	Residents involved	Interviews with staff	Group interviews
Sea-Crest	36 h	16	62 p.	10 (9 women and 1 man)	5	1 (2 participants)
Sunny Hill North	42 h	14	57 p.	9 (All women)	5	1 (4 participants)
Sunny Hill South	45 h	15	60 p.	7 (All women)	3	1 (3 participants)

The field study focussed on the everyday social and practical life of the nursing home units. For this reason, no information about residents’ illnesses, diagnosis, types of dementia or degree of cognitive decline were gathered, apart from staff confirming that the residents participating in the study had a dementia diagnosis. At the outset we intended to conduct sit-down interviews with residents as well as staff. During participant observation, the first author found that most residents did not understand or remember who she was or why she was there, and most struggled with memory, orientation or language, with some expressing anxieties or a search for home. Considering it might be easier for people living with dementia to report experiences in the present [31], because of difficulties reasoning about abstract issues and recalling past events [32], formal sit-down interviews were not conducted. Instead, in-the-situation conversations and observations throughout everyday nursing home life offered insights into the possible meanings of things that happened.

While conducting fieldwork, the first author carried a pen and paper in her pocket, regularly taking time to jot down notes. After each day of observation, diachronic fieldnotes—including a column for reflections—were written, detailing events, actions and expressions chronologically. A total of 179 pages of fieldnotes comprise the main material for analysis in this article.

Ethical approval

The Norwegian Regional Ethics Committee assessed the study as not subject to the Norwegian Health Research Act [33] and approved dispensation from professional secrecy because of its observational nature (No.2018/1324). Approval was granted by the Norwegian Centre for Research Data (No. 60972), and the study was conducted in accordance with the National Committee for Research Ethics in the Social Sciences and the Humanities’ (NESH) guidelines [34]. In line with the approval from NSD and guidelines from NESH [34], written and oral information about the project was provided, and signed consents were gathered from participants. Because of residents’ reduced capacity to provide informed consent, next-of-kin were asked to sign on their behalf; in some instances, both the resident and their next-of-kin signed the consent form. The data were stored on encrypted hard drives, separate from participants’ names and contact information, and all participants were given pseudonyms.

Narrative analysis

To enable a focus on the particular characteristics of the situations documented in the fieldnotes, as well as their significance for citizenship, we turned to narrative analysis. According to Squire et al. [35], the narrative research field lacks a common definition of ‘narrative’, as well as for rules, suitable materials or modes of investigation; with regards to the latter, the authors point to a divide between structural-, content- and context-based approaches. We chose to conduct narrative analysis as inspired by Polkinghorne’s [36] description of ‘narrative’ as a configuration of events and happenings into an emplotted story. Although narrative analysis is typically used in relation to verbal performances and first-person interview data [35], we perceive the vocal expressions, actions and behaviours of residents (as described in the fieldnotes) to be possible ways of communicating stories of meaning and identity. Viewing narratives as performed as well as told [27] offers insights into aspects of residents’ everyday stories that would not have otherwise been available, particularly for those with severe dementia; moreover, this approach offers access to the unfolding, situated and multifold character of human occupation [37].

Our analytical process, though phenomenologically seeking deeper understanding of residents’ everyday human existence [29], had an abductive design [38] and was conducted through the following four analytical steps:

Step 1—naïve and inductive reading of fieldnotes. We commenced the analysis by reading fieldnotes from all three nursing home units several times, asking ‘What stories do the fieldnotes tell, and how can they characterize citizenship?’ This analytical step is reflected in our results as ‘environments of care’.

Step 2—narrative construction. We began our narrative construction by searching fieldnotes from all three nursing home units for situations, actions or expressions that showed residents’ agency to ‘do’ within their environment, asking ‘How do residents express and enact their citizenship?’ A variety of situations were identified, in which residents expressed their desires or needs verbally or through doing. Such situations became the starting point for constructing narratives for several residents in the nursing homes, searching through fieldnotes for information that could be added to broaden their stories or shed light on contextual or relational factors that could help interpret their meaning. Within a range of such descriptions, the stories of May, Janne and Camilla were selected because they offer a broad view of some opportunities and barriers for citizenship. The three narratives are all constructed from the two nursing home units at Sunny Hill; this was not by design, but because these stories were viewed as best-suited to our purposes.

Steps 3 and 4—interpreting narratives. Our interpretation of May, Janne and Camilla’s stories started with a focus on the possible meanings that could be derived from seeing their actions and expressions in terms of the contexts in which they took place. These interpretations are reflected in the stories presented in the results section. In the next layer of analysis (as explicated in the discussion section of this article), the narratives were interpreted in terms of occupational dimensions [5] and everyday citizenship [26].

Results

Environments of care

Residents were living in nursing home environments where staff expressed deep caring about their well-being. The first author observed laughter, sit-down conversations and a quest for both calm and engagement in activities. Staff explicitly stated their aspiration for person-centred care, and constantly sought to prevent negative consequences for well-being within the social environment. The temporal aspects of the staff’s everyday were packed with things to do: they planned, prepared and served—and residents received. The staff actively upheld chronological time, on behalf of themselves and the residents, setting times for meals, activities and other appointments, as well as supporting individual needs such as toileting, sleep, anxiety, nutrition and a range of medical assessments and deliberations.

An atmosphere of waiting sometimes emerged, such as waiting for meals, waiting during meals or waiting for something to happen. Even though activities and events differed from day to day, the temporal logic of nursing home life seemed to rely on a set structure and regular themes. Meals emerged as a predictable temporal frame and seemed to act as a reference point for both staff and residents. Residents gathered at mealtimes and had their pre-determined seats, but often sat in silence beside each other. Several residents expressed joy or anticipation when invited to events and activities or receiving visits from children and others in the local community. Other times residents closed their eyes or slept on and off during the day in the common areas, mostly when there was nothing going on or no one to whom to talk.

In this study, environments of care were characterized by staff providing an attentive and caring atmosphere, including a focus on chronological time through daily activities. This implied an atmosphere of waiting and of residents’ gathering around meals and organized activities led by staff. However, the results also point to acknowledgements of the residents’ initiatives and agency. Such situations will now be explored, through the narratives of May, Janne and Camilla.

Giving back to staff—contributing through occupation

May came across as a caring woman; she often smiled and seemed to love chatting with anyone that had the time. She often fell asleep on the couch in the living room, sometimes snoring loudly, but woke up immediately if someone talked to her or something happened. She joined sing-alongs at the day centre and seemed to thoroughly enjoy visits from the local kindergarten. One day she enthusiastically expressed, ‘It’s going to be great! They’re so small and innocent’ while waiting for them to arrive. She told me she loved knitting, and once showed me a picture of a sweater she would have liked to make and give to her grandchild.

May told me that the staff had much to do and that she would like to help. One evening, she asked if they needed help preparing supper, and a staff member responded that she had just finished and did not need help. A few days later, at midday, the staff was moving around rapidly: it was a busy day. May reacted to the tempo of the staff, expressing clearly that she wanted to help. One of the staff came over and sat down with May for five minutes, before saying she had to go fold some laundry. May said she could do it—she wanted to help. The staff member retrieved a bag of clothes and brought it to the dining room table. May walked over; they emptied the bag of clothes on the table and May started folding. The staff member had to take care of something else—before leaving, she said, ‘I’ll be right back’, and May replied, ‘You don’t have to hurry, this is my work’.

May expressed, several times, being content in the nursing home. Her satisfaction with the staff and the way they cared for her seemed to motivate a desire to give back to those towards whom she was so thankful. Engaging in one of the staff’s mundane and daily everyday tasks offered the opportunity to do so, enabling her to contribute through occupation.

Embodied initiatives—restricting situationally relevant occupation

Janne often started the day early, seated at her regular place at the table, reading the newspaper, while staff made her breakfast in the kitchen. She often sang along to the music on the radio, sometimes knowing the lyrics, other times humming or tapping the rhythm with her fingers. Often falling asleep in the common areas, she would sometimes nod off but then be easily awoken; other times, when a staff member would try to wake her, she would immediately fall asleep again.

Janne was often seen taking the initiative to do. One day, entering the living room following an afternoon nap, Janne walked over to me and shook my hand. She continued towards Hanne, who was sleeping, before approaching Camilla, who hesitated. Camilla shook her hand after a short pause, while sternly stating that Janne could not take these (and she pointed to her plate and glass), because they were hers. A staff member walked over to Janne, said she could sit here, next to Magda, whereas Janne replied that she had not greeted everyone yet. The staff member gently explained that she had greeted everyone before, and that she could sit down. Janne did so.

Another day, finishing her breakfast, Janne took her plate, and said ‘I guess I’ll take this out’ and got ready to stand up. The staff member was fast—she took the plate and replied, ‘I can take that’ and walked to the kitchen with the plate. Janne said nothing but had a surprised look on her face. One afternoon, she started cleaning up after dinner. She asked me to move over so she could get past, wanting to clear her plate. The staff member sitting next to her said, ‘I can do it for you’. But Janne wanted to do it herself, and got up and walked towards the corridor (the opposite direction of the kitchen). The staff member showed her the way and followed her into the kitchen. I could hear the sounds of Janne rinsing off her plate, while her fellow residents were seated at the tables. The staff member told her they could do it later, because right now they were having dessert. Janne replied, ‘Can’t I just do it?’ Staff showed Janne to the table and she was given a bowl of dessert. She ate her dessert, and when she was finished, she picked up her bowl and walked towards the corridor.

Janne’s initiatives seemed triggered by an embodied familiarity of what to do or how to act, in specific situations. When staff led her away from engagement, this appeared part of a conscious effort to prevent negative consequences in the social environment, because of movement or noise that could influence her fellow residents. Such efforts to prevent disruptions of a vulnerable sense of calm led to a restriction in situationally relevant occupations.

Frustration as a quest for purpose—occupational responsibility

Camilla often sat with closed eyes in her regular recliner in the living room or observing conversations without participating. Other times she expressed frustration, repeating ‘Have I done something wrong?’, to which the staff would respond that she had not, and everything was fine. One day she was standing in the middle of the room, asking ‘Are we just supposed to be here? What should we do?’, while opening and closing her jacket, stating ‘I am ready to leave now’. Another morning she asked staff what she was supposed to do. When staff said she could decide for herself, she replied, ‘But that’s what I can’t do’, repeating that the door was locked and she could not leave. When Camilla would forcefully express such frustrations, the staff often promoted calm by putting on music to create a peaceful atmosphere.

Camilla was observed shouting at staff, pounding her bowl into the table, if her food was not ready the moment she wanted, and a couple of times she tried to hit staff members in frustration. The staff also explained that Camilla had a strong reluctance to change or wash her clothes. They were often dirty, as she often spilled food on them, normally eating very fast, sometimes while walking. Once, as a staff member tried to help her wipe food off her clothes, Camilla shouted, ‘Don’t touch me!’; they then encouraged her to do it herself, but this was something she could not see the point in doing.

Camilla frequently walked back and forth within the unit. One day, she expressed sternly while walking in, ‘Yeah, you’re sitting here! Yeah, we don’t do anything else’ before exiting once more. Another day, in a joint effort with other residents to fold laundry, Camilla appeared thoroughly focussed, standing by the table, efficiently folding the clothes and placing them in piles. Once, when the staff initiated a balloon game, hitting a large yellow balloon between them in the living room, Camilla immediately smiled, laughed and hit it back, participating with enthusiasm. In the group interview, the staff talked about a recent situation during the balloon game, in which a staff member had to go take care of something, and asked Camilla if she could take over the lead. She explained how Camilla took on the responsibility and this role:

Yeah, it was so fascinating, she was all sweaty in the end, and the responsibility was so strong within her. And I said, I think you’re so tired now that we should stop now. Yeah, she had to stop now, she was completely—she was so satisfied. And the result from this was, she saw in herself that she was ready to change her clothes and we went down and changed clothes. She gave me a good hug; she was filled up, she could participate—the dignity, you know, the spark came, right.

Observing Camilla over time, she appeared intent to make as many choices as she could, at the same time expressing frustration over not being allowed to do so. There seemed to be a quest for some understanding of where she was and what her purpose was, and when she became frustrated, the staff often promoted calm. However, when Camilla was deeply engaged, this sense of frustration was not observed. In such situations, a different story was created, through occupational responsibility.

Discussion

This article explores how people living with dementia in nursing homes can realize their everyday citizenship. Through narratives of occupation, May, Janne and Camilla show us how they can contribute through engagement in the occupations of staff, how embodied initiatives can be enabled or restricted within their social environment and how occupational responsibility can mediate experiences of frustration. In the first part of our discussion, these results are interpreted further in terms of occupational dimensions and identity. We continue by highlighting the significant contributions of an occupational framework for a rights-based, everyday citizenship lens, suggesting becoming as an essential aspect of everyday citizenship within the nursing home lifeworld.

Interpreting narratives through occupational dimensions and identity

The occupational dimensions of doing, being, becoming and belonging [5] offer another layer of interpreting the actions and expressions of May, Janne and Camilla. Although our observations offer insights into some of the doings of nursing home life, they do not provide direct access to the inner thoughts and deeply personal aspects of their occupational natures. Nevertheless, their stories offer an important opportunity for insight into the significance of everyday engagement.

May—contributing through occupation

Zooming in on May’s narrative, she seemed content in the nursing home where she lived. She appeared to experience belonging, through a sense of place and familiarity with the things that were done [5], engaging socially with staff and fellow residents, showing care for others in her environment, as well as actively engaging in activities provided by the staff. Her efforts to assist the staff might reflect a relationship between her being and her opportunities for becoming, whereas her occupational being emerged as closely tied to an identity as contributor and carer. Continuity of such occupation can maintain a sense of acceptable self-identity [39], and engagement in ordinary domestic tasks may be important for a sense of home in the nursing home [40–42]. The day May folded clothes was a busy day for the staff, and when she stated that she wanted to help, a staff member sat down beside her. This can be interpreted as a conscious effort from staff to communicate calm, and in some ways to free May of the responsibility she felt in that moment, perhaps viewing her expressed desire to help as stress brought on by the business of the environment. But as argued by Bartlett et al. [20], such comfort and sense of security are not enough: as human beings we also need opportunities to grow and contribute. When May instead joins the occupation of the staff, her occupational identity is recognized: she is adding to the lives of others, becoming more than a resident or receiver of care, as a contributor through occupation.

Janne—restricted occupation

Janne did not explicitly vocalize a desire or intent to help staff in everyday chores or tasks, she simply initiated doing in familiar situations that triggered situationally relevant embodied engagement. Fuchs [43] terms such embodied competence as ‘procedural memory’, in which our experiences throughout life sediments as sensorimotor habits and capabilities. As our performances are brought together as body memory, preserved as dispositions and potentialities, they become accessible through practical movements. Janne’s spontaneous doing may be interpreted as born from a sense of belonging in that moment, experiencing a familiarity with the occupations associated with meals. Such an embodied familiarity offers an opportunity for her to claim her place within the everyday occupations of that social context.

Although the staff’s restriction of Janne’s efforts to engage seemed part of an effort to prevent disruptions to a vulnerable atmosphere of calm, such restriction was also observed when none of the other resident were around. Doing for may be perceived as kindness, or, as Wilcock and Hocking [5] write, as misguided assumptions that caring for older people means doing for them. Not recognizing embodied competence as agentic potentiality may lead to an interpretation of people living with dementia as not wanting, or being able, to do. Consequently, doing the dishes may not have been acknowledged as important in terms of Janne’s occupational nature. From an occupational perspective, her doing of the dishes can be seen as an expression of an inner sense of who she is—e.g. taking on a familiar role as a homemaker—through a dialectical relationship between occupation and identity [39]. Although she may experience difficulties in executing such actions independently because of dementia, her occupational nature and being may still constitute a driving force for a need to continue such engagement. Through such moments, where she takes on an active role of responsibility in the social community of the nursing home, her belonging may be strengthened through familiar occupation, while shedding light on her continuous opportunities for becoming within embodied moments.

Camilla—occupational responsibility

According to Wilcock and Hocking [5], there is a direct interrelationship between a lack of recognition of becoming needs and ill-health, whereas becoming can be negative if doing, being or belonging through occupation is restricted or compromised. In our results, this becomes particularly evident in Camilla’s story. Her expressions of frustration can be interpreted as a lack of belonging to the nursing home, described by Wilcock and Hocking [5] as the familiarity of doing things with people you care for and share a sense of place with, or understanding the parameters and meanings of things that are done. Camilla seemed to struggle to make sense of both her place and her purpose. This can manifest as occupational alienation, the antithesis [5] of becoming, where experiencing incompatibility with the occupations associated with a place can result in feelings of despair. Within a biomedical model, such expressions of frustration or despair are interpreted through pathology, linking behaviour to dementia, resulting in strategies of redirection or distraction [44]. Often, when Camilla expressed frustration or moved about the unit in an agitated manner, staff promoted calm. This focus on generating social and behavioural changes—e.g. calming Camilla down—may lead us to lose sight of her unique perspective [44]. Turning our gaze towards situations where she participated actively in occupations, such as folding laundry or the balloon game, no such expressions of frustration were observed. Such doing seemed to strengthen her belonging, through positive collaboration with the others.

Camilla’s apparent repeated frustrations because of a lack of control and choice may reflect an inner need for occupational purpose, which she found within activities where she could move with intent. Being able to control the direction of one’s everyday life and have a meaningful effect on others are important factors affecting quality of life for people living with dementia [16]. When staff shared their responsibly for leading the balloon game with Camilla, this changed the narrative even further, telling the story of Camilla as competent, responsible and in charge. In this narrative, she holds a specific purpose, through bringing enjoyment to others, and such doing alongside others can foster her experiences of belonging and being in place [5]. When staff talked about Camilla in the group interview, through their choice of words and the enthusiasm with which they spoke, Camilla is acknowledged as belonging to the social community of the nursing home. She became different: ‘the spark came, right’. Camilla’s wanting to change her clothes and caring about her outer appearance, as well as giving the staff member a hug, speaks to the immense importance that taking on such a responsibility held for her sense of self. As in the story of May, taking on this responsibility emerges as more than simply being offered an opportunity to participate in an activity; it acknowledged Camilla’s capabilities for continued growth, becoming through occupational responsibility.

What do occupational perspectives and citizenship add to each other?

The narratives of May, Janne and Camilla took place within a context of care, where staff was responsible for meeting residents’ physical, psychological and social needs. How can such stories of occupational contribution, restriction and responsibility add to the conceptualization of citizenship and occupational dimensions? In the following section, we seek to clarify the significance of a broad understanding of everyday agency for residents’ occupational opportunities, arguing for the contributions such a perception may bring to an inclusive conceptualization of becoming. Citizenship offers a lens with which to scrutinize inequalities, through its rights-based and normative promotion of being entitled to the same from life as others [20]. Meanwhile, occupational perspectives provide a lens with which to understand the meaning and significance of those things we do through our lives [5]. Traditional notions of citizenship [23], portraying it as something stable, an aspect one has or is given, have increasingly evolved towards something realized within everyday activities and relationships. The recent conceptualization of everyday citizenship by Nedlund et al. [26] explicitly states the significance of ordinary, mundane or habitual everyday doings that can be easily taken for granted. However, how such citizenship happens within the lives of people living with dementia in nursing homes has not been properly addressed [23,26]. Considering that people living in nursing homes may be at particular risk of occupational deprivation [5], exploring the things people do and the meaning such doing may hold for both identity, belonging and growth emerges as vital in an attempt to provide such clarity.

If, as suggested in our results, people perform their identity through occupational engagement, then it follows that for residents’ expressions of self, their agency to do must be recognized. Boyle [45,p.1130] defines agency as ‘the ability to initiate social action or at least influence their own personal circumstances’, connecting it to doing, making one’s own choices or having some sense of influence over one’s everyday occupations. Such agency may go unrecognized if, as Boyle [45] problematizes, one holds on to a traditional focus on agency as rationality, language, intentional action and goal orientation, which underscores the ability of people living with dementia to influence their surroundings. As shown in our narratives, we perceive agency as emerging within social relations, embodied competence and collaboration with others, not simply as independent or consciously intentional action.

In terms of the dimension of becoming, Wilcock and Hocking [5] describe it as adding a sense of future time to the notions of doing, being and belonging, and as directed by goals and future aspirations by Hitch et al. [10]. Such a perception of the process of becoming favours people who can act consciously and intentionally, in turn excluding many people living with moderate to severe dementia in nursing homes from being perceived as able to develop and grow as occupational beings. If, on the other hand, one recognizes that doing, in terms of agency, can emerge embodied and relationally within moments when a resident acts in line with their occupational self, then we can create an environment that supports opportunities for becoming. Not through favouring perspectives of future time through aspirations, goal-directed behaviour and intentional action, but by valuing present time and future time equally [7], in turn ensuring a more inclusive perception of occupation. If we understand people as narrative agents [28], communicating who they are both through the things they say and do, then their aspirations do not need to be part of an explicit plan for growth but are communicated within every aspect of their lives.

Why are moments of becoming essential for everyday citizenship?

The grand concepts of citizenship might seem far apart from the mundane agency taking place in the nursing home context. However, if these are overlooked, the study of citizenship would be guilty of the same negligent misrecognition that it seeks to avoid. May, Janne and Camilla exemplify the everyday as the site where agency takes place [26], and show how the ordinary may be supported or overlooked, through something as minor as rinsing off one’s plate after dinner. Our results show that to ensure occupational balance, people need environments where they can express their becoming in terms of their own abilities, by acting on their natural desires to do. The lack of this may leave residents vulnerable towards alienation [5], estranged from one’s normal activities and natural lifestyles. At the same time, a vulnerable and fluctuating aspect of citizenship practices emerged. Residents depended on support for their individual needs, assistance in activities and comfort in times of anxiety, and a continuous negotiation between individual needs, concerns for the social environment, and institutional routines, structures and perceptions became evident. Within this everyday, the staff’s presence appeared crucial for residents’ physical, psychological and social well-being. Our foregrounding of moments where residents enacted their capabilities does not undervalue the importance of their immense need for care, nor does it suggests a stable condition of occupational belonging or becoming, given that a resident could seemingly express a sense of belonging in one moment while searching for home in the next. Within our narratives, becoming emerged as moments of change. Becoming was realized in moments where the vulnerable well-being of the person took a positive turn. If we recognize such fragile moments as significant, we might ensure environments where their potentialities can be given attention and realized.

Combining occupational and citizenship perspectives enable an exploration of the needs, capabilities and rights of people living with dementia in nursing homes. Nedlund et al. [26,p.93] argue that the everyday citizenship of people living in care homes requires urgent scrutiny: ‘In this living environment, everyday activities typically become either a “therapy” or a potential risk’. Such a perception, which we would term institutional understandings of activity, may limit opportunities for engagement supporting identity and the self. Kielsgaard et al. [46] show that there may be a fine line between potential engagement and occupational deprivation, underscoring a vulnerability within such everyday lives. Adherence to fixed activity schedules can in itself limit engagement in meaningful activity [17], while integrating and recognizing the significance of everyday activities to the staff’s work may lead to more positive care experiences than a focus on organized activities alone [47]. Although Norway’s Dementiaplan 2020 [3] does promote the provision of activities in nursing homes, it does not explicate how to ensure such an aspiration within the ordinary and mundane of the nursing home’s everyday life. And while the strategy asserts that such activities should be experienced as meaningful by the individual, becoming adds a perspective of growth and contribution that many older people with dementia may, implicitly or explicitly, be believed to be past.

Our results suggest that residents’ becoming requires recognition of their agency, as ways of expressing aspirations and capabilities, as well as supporting spontaneous acts of agency within the context and situations they occur. As such, becoming and everyday citizenship adds to the planning and tailoring of activities by staff, towards supporting initiatives emerging in the moment. Du Toit et al. [48,p.352] argue that, if seen as subjects rather than active agents, ‘–-residents are essentially experiencing occupational “disownment” as they are only engaging due to someone else’s initiative’. The stories of May, Janne and Camilla show that activities are not necessarily something structured or planned, but can lie within all those everyday moments where we are engaged in some way within the social context we inhabit, expressing a sense of belonging to its community. This does not undervalue the joy and meaning observed through fieldwork on days of planned events, such as visits from children or sing-alongs, but adds to it, respecting the possibilities of fragile moments for a continuous process of becoming, as a citizen in the nursing home.

Conclusion

Within everyday environments of care, the narratives of May, Janne and Camilla told stories of spontaneous initiatives and agency, towards contribution and responsibility within mundane and habitual everyday doing, highlighting their continuous occupational natures. The results of our study show how becoming, as an essential dimension of the mundane and habitual of everyday life, constitutes a part of citizenship. Becoming adds to the practical understanding of citizenship through its processual perspectives of human occupation, within repetitive and cumulative moments of change, engagement, responsibility or contribution. And within moments of becoming, residents performed their story and identity to the world around them.

Significance for practice

Our results emphasize the importance of everyday life perspectives within professional practice for persons living in nursing homes. A citizenship of becoming presupposes that institutional perceptions of activities as offered ought to be broadened towards supporting residents’ natural desires to do and act within the mundane and ordinary of everyday life.

Methodological considerations

The article explores everyday life through three constructed narratives in one nursing home. As such, the sample of our exploration is small. Considering our narrative aspirations of analysing unique narratives of unique persons [36], a broad data set would be counterproductive. We do not seek to produce general ‘truths’ about everyday citizenship. Our findings and suggested implications for practice may hold relevance within other, similar contexts, not for their direct transferability, but for their possible influence on people’s perception of the everyday as a significant site for citizenship. Only narratives from Sunny Hill Nursing home were included. This may be because the units at Sunny Hill were small-scale, leading residents to be closer to the everyday doings of the unit, in turn prompting more initiatives, although we do not have sufficient grounds to make such an assertion. In addition, only women are represented, since the majority of residents living in the nursing home units were female. We gathered no data within private areas or intimate care situations, a limitation that was deemed acceptable in order to respect the integrity and privacy of residents. We seek to understand everyday nursing home life from the perspective of residents, hoping that focussing on their capabilities and agency can bring forth positive perceptions of a life often saturated in a tragedy discourse. This is a conscious stance through our phenomenological aspiration of unveiling possible hidden and mundane aspects of everyday life [29] that may be taken for granted, towards the realization of citizenship.

Acknowledgements

The authors would like to offer our thanks to all those who participated in our study, in particular the residents and staff of the nursing home units where it took place. We are deeply grateful for being allowed to take part in their everyday life for a brief period of time.

Disclosure statement

The authors report no conflict of interest.

Additional information

Funding

The article is part of a PhD thesis, funded by VID Specialized University in Norway.