PRACTICE DEVELOPMENT – USER INVOLVEMENT

Conceptualizing place in the care of older people: the contributions of

geographical gerontology
Janine Wiles PhD
Assistant Professor, Department of Geography, McGill University, Montreal, QC, Canada

Submitted for publication: 1 April 2005

Accepted for publication: 15 May 2005

Correspondence: WILES J. (2005) International Journal of Older People Nursing in association

Janine Wiles with Journal of Clinical Nursing 14, 8b, 100–108
Department of Geography Conceptualizing place in the care of older people: the contributions of geographical
McGill University
gerontology
805 Sherbrooke St W.
This paper introduces the subdiscipline of geographical gerontology to the readers
Montreal
QC H3A 2K6 of International Journal of Older People Nursing, and the ways in which geogra-
Canada phers and others have conceptualized place in relation to the experiences of older
Telephone: þ1 514 398 4953 people and their health and well-being. Particular attention is paid to place as a
E-mail: janine.wiles@mcgill.ca process; its role in the exertion and negotiation of power; and as an experience open
to interpretation; and how these relate to clinical practitioners. This review sets the
scene for the following papers on practice and the future research agenda.

Key words: place, older people, geographical gerontology, health, well-being

their health and well-being? And what is the relevance of this

Introduction
Broadly defined, geographical gerontologists are interested in
the spatial and environmental contexts of ageing; the ways
that space and place are related to the experiences and needs
of older persons. Specifically, they seek to understand both
how ageing affects specific places and spaces, and the
influence that specific contexts or places have on issues
related to ageing and older persons. Not all geographical
gerontology is focused on older people’s health, indeed as a
subfield of social geography, it branches out increasingly to
consider positive and less problematized ageing contexts and
older peoples’ broader social and cultural lives. Nevertheless,
older people do still represent a significant proportion of the
population with health conditions and as such a substantial
proportion of the literature is, and probably always will be,
focused on their health and health and social care. As such,
this is the literature that I draw on most.
In this paper I outline the concepts of space and place, and
why they matter with respect to older people, to provide a
context for the next two papers which are focused on nursing
practice and future research. I will cover three main ideas:
how do geographical gerontologists conceptualize space and
place? How can we do so with respect to older people and
to a clinical/nursing audience?
How do geographical gerontologists
conceptualize space and place?
Over time, human geographers have conceptualized space and
place in a variety of ways. These include a regional approach, in
which researchers tried to describe and thus understand
different regions in their social and physical complexity
(Andrews, 2003). Later, a more analytical ‘space as container’
approach became prominent, as researchers thought about
space as a kind of geometric grid of co-ordinates, in which
various phenomena are distributed or in which processes occur
(Hartshorne, 1958). Following the parent discipline of human
geography, early work in geographical gerontology included
the quantitative mapping of the distribution of ageing popu-
lations, often at the ‘macro’-scale of countries and interna-
tional regions. Documenting the proportion of older people in
different areas and the patterns of their migration enabled an
analysis of international demographic changes, such as the
rapid ageing of some populations and changing kinship
relations and possibilities (McCracken & Phillips, 2004). Such
work revealed migration patterns of ‘young-old’ (65–75 years)

100 Ó 2005 Blackwell Publishing Ltd


moving to areas rich in amenities and with warm climates,
contrasted with a pattern of ‘older-old’ (75þ) people migrating
back to their original areas, probably to live closer to their adult
children and established communities as they begin to think
about becoming more dependent on care (Al-Hamad et al.,
1997; Moore et al., 1997). This kind of work is important in
understanding which regions and countries are ageing demo-
graphically, and the consequences of these patterns for
population health, health policies, and health economics. For
example, it helps to identify inequalities in access to healthcare
services and appropriate distributions of healthcare services for
older people (Phillips, 1995).
More recently, geographers have begun to think of place as
a kind of process (Massey, 1999; Crang & Thrift, 2000). This
has influenced contemporary work in geographical gerontol-
ogy, with calls for critical thinking about the significance of
changing social and physical contexts of ageing and older
persons (Estes, 1991; Laws, 1993, 1995; Harper & Laws,
1995). For example, qualitative research using in-depth
interviews and participant observation reveals how political
emphases on ‘ageing in place’ and care at home for older
people affect the meaning of individual homes as places as
well as the recipients and providers of that care (Teeland,
1998; Twigg, 1999, 2000; England, 2000; McKeever, 2001).
Notably, receiving care at home impacts on the daily rhythms
of all members of a household. Many older persons grieve the
loss of their home as a place in which they could socialize
with family and friends, as well as changing their homes
physically to meet the needs of care (Wiles, 2003a). This kind
of research is particularly important in understanding the
shift of care for older persons from institutions to ‘commu-
nities’ (mostly, to unpaid female family members), and
addressing ways in which community-based care could be
provided to most effectively enhance the independence and
autonomy of older persons and help the ‘lay’ and professional
caregivers who support them (Guberman & Maheu, 2002;
Wiles, 2003b). In this paper, I focus on this latter approach,
of place as a process, because this more contemporary
approach to the concept of place underpins the following
papers on practice and research. I emphasize, nevertheless,
that there are still many other ways that geographers
conceptualize space and there is by no means a universal
consensus on the best way to think about space or place.
Although this issue of International Journal of Older People
Nursing focuses on the idea of place, the relationship between
‘space’ and ‘place’ should be examined. While these terms are
often used almost interchangeably, geographers do distinguish
between them to mean different, if nuanced, concepts. The
concept of ‘space’ refers to more universal and abstract ideas
such as geometric distance. Place, however, is more specific-
Ó 2005 Blackwell Publishing Ltd, International Journal of Older People Nursing in association with Journal of Clinical Nursing, 14, 8b, 100–108
Conceptualizing place in the care of older people
ally a portion of space, a setting which is experienced and
which holds meaning, and which shapes the intimate relations
between people as well as the bigger social relations and
processes that make up society. The influential humanist
geographer, Yi Fu Tuan, for example, describes place as ‘space
with meaning attached’ (Tuan, 1977). Hence, a ‘sense of
place’ is the resulting human experience. In exploring the idea
of place, however, we are also interested in how general
processes (such as ageing) vary in the context of specific places.
Places are the contexts in which we live, settings to which we
feel attached but which also shape our experience of social
processes, such as the provision of health care, the process of
ageing, or social and economic restructuring.
Older people and place as process
For the remainder of this paper, I will elaborate on this
concept of place and its’ relevance for older people. I will do
so by discussing some of the ways in which geographical
gerontologists conceptualize place as a process (see Table 1),
showing how these ideas relate to older people and their
health and well-being. I will use examples of places in which
health professionals deal with the health and well-being of
older people such as the homes of older people, and long-
term institutional care settings to show how these ideas are
relevant to nurses and other clinical practitioners. In covering
these key discussion points, I will provide a general review of
contemporary research in this field.
Process
In thinking about place as a process, geographers recognize
that place is not static or a simple ‘background’ to events, but
is very much a part of social relations. Many geographers talk
about the ‘mutually constitutive’ relationship between society
and place (Valentine, 2001), meaning that just as societies
shape the spaces and places in which they live, societies in
turn are shaped by those spaces and places. Improved housing
Table 1 How do geographical gerontologists conceptualize place?
Places are processes
Place are subject to ongoing negotiation
The many different experiences and contested
interpretations of places (some of these may compete or conflict)
Power relations are expressed through, and shape, places
Places are interrelated – to other places, at different scales,
at different times
Places are simultaneously material/physical AND symbolic
and social
All the above features of place overlap and interact.
101
J. Wiles
and infrastructure design leading to better air quality and
standards of sanitation, for example, are among many factors
leading to increased life expectancies, and greater numbers of
older people as well as more successful ageing. This mutually
constitutive relationship is ongoing, it is a process in which
there are changes over time and space. Increased life
expectancies, population ageing and greater numbers of
relatively healthy and independent older persons, mean
society needs to develop new ways to accommodate older
persons in communities in ways which recognize, support,
and enhance their independence and autonomy. These
processes are ongoing and mutually reinforcing.
In the context of the care of older people, an example of
this mutually constitutive and ongoing process is the role that
family members play in providing care to frail, ill, or disabled
older people in the community. Many studies have shown
that geographical proximity is a factor shaping the experience
of care (Keating et al., 1999). Family/lay caregivers who live
with an older person requiring care tend to provide more
hours of assistance, and undertake a more diverse range of
caregiving tasks, than those who live apart from care
recipients (Parker, 1992; Twigg & Atkin, 1994; Moore
et al., 1997). Indeed, even those family members who live
near to an older person are more likely to provide care, and
more hours of care, than those who live further away (Joseph
& Hallman, 1998). Other factors that predict which family
members provide care, and the extent to which they provide
care, are gender and relationship. Women are more likely to
provide care, to provide more hours of care, and more
personal care (Montgomery & McGlinn Datwyler, 1990;
Miller & Cafasso, 1992; Morris et al., 1999; Armstrong &
Kits, 2001). However, the closer the relationship a family
member has to the older person, the more likely they are to
provide care, especially if they are a woman (Qureshi &
Walker, 1989). Further factors that seem to shape who
provides care include employment status, marital status, and
degree of frailty of care recipient.
While there is some debate as to which of these factors is
most likely to determine who provides care, it is likely that
the explanation for who provides care is a combination or
process of several of these social and spatial factors, which
not only shapes who provides care but also the potential
impacts of providing care on the caregiver/s. Such decisions
(where people live in relationship to each other, and how
much support they provide), are part of the ongoing and
intimate process of family life as well as broader social
processes. For example, living with an older care recipient
may decrease the likelihood of paid employment (Ettner,
1995). Decisions to live near or with an older person may be
precipitated by expectations of increased dependence, as
102 Ó 2005 Blackwell Publishing Ltd, International Journal of Older People Nursing in association with Journal of Clinical Nursing, 14, 8b, 100–108
older people and their children make migration decisions on
the basis of their expectations of their future frailty and
health needs (Silverstein, 1995; Silverstein & Angelelli, 1998;
Shelton & Grundy, 2000; Walters, 2002). Broader social
processes such as the differential life expectancy of men and
women and traditional age gaps in marriage, moreover, mean
that women are more likely to be living with a spouse who
needs care, but when they themselves require care they are
often living alone and require support from family members
(Arber & Ginn, 1995). At the micro-level of the home as a
place for care, gender roles, experiences and skills (such as
running domestic affairs for many older women, or managing
household financial affairs for many older men) are likely to
be implicated in the skills and knowledge they bring to
caregiving (Rose & Bruce, 1995; Davidson et al., 2000).
As processes, places are complex, they are subject to ongoing
negotiation between different groups who may view and
experience places in quite different ways at different times.
Places are subject to ongoing negotiation
Rather than being somehow fixed, static or immutable, places
are constantly in negotiation. As individuals age, their
relationship to the places around them are constantly
renegotiated. In the example of proximity above, decisions
made about where to live based on an older person’s
potential need for support from family, new skills people
learn to adapt to new situations such as providing care, or the
physical and social changes that people make to a household
where an older person is receiving care, are all illustrations of
how homes as places for care are constantly in negotiation.
Furthermore, they are also examples of how individuals’
personal ‘geographies,’ (where they live, where they go and
how, how they experience and understand those places) are
constantly negotiated.
Not only do places change physically, but ideas and
associations with place are always changing. For example,
the ways that we think about the appropriate location for
care of older persons have changed over time, in accordance
with developments in health philosophies and treatments, but
also with social transformations. These include changing
attitudes towards seniors and elder care practices including a
gradual recognition and acceptance of public responsibility
for care (Braithwaite, 1990; Health Canada, 1997), com-
bined with increasing numbers of women (who are ‘tradi-
tionally’ the unpaid carers for older persons) in the paid
workforce (Doty et al., 1998; Watson & Mears, 1999), and
greater geographic dispersion of families (Moore et al., 1997;
Smith, 1998). In the past, the most appropriate place for care
for older people was seen as the home (Hareven, 1991a,b).

However, as institutional care and practice developed over
the last century, nursing homes came to be regarded as the
best site for dependant older people.
More recently however, in a partial turnaround, new
technologies, political and financial imperatives to cut
healthcare costs, and social ideas about the importance of
ageing in place, have all combined to contribute to a growing
perception that home, or at least more ‘home-like’ places are
more appropriate sites for care for older people (Rubenstein,
1989; Rowles, 1993; Health Canada, 1997; Anderson,
2001). This has led to a proliferation of new places for the
care of older persons, including smaller public or private
residential homes (Andrews & Kendall, 2000; Andrews &
Phillips, 2000, 2002) as well as more families taking on the
care role in their own homes (Arber et al., 1988; Stoller,
1988; Parker, 1992; Baldock & Ungerson, 1994; Hirst,
2001). Demographic and socio-economic changes, including
increasing proportions of older people in general populations,
greater life expectancy, and improved health and independ-
ence amongst older people, have also contributed to a
growing emphasis on community-based care and care in
homes (Teeland, 1998).
People have different experiences and contested
interpretations of places
As well as there being many places to experience social life
and care, there may be conflicting and even competing
interpretations of the same places, as shown in the previous
discussion about contested interpretations and negotiations
about which places are best to care for older people,
institutional settings or homes. For example, the increasing
emphasis on homes as places for the care of older persons has
quite different impacts on individual care recipients, as well
as continual alterations to the position of other family
members, and consequences for evolving relationships with
healthcare workers (Noelker & Bass, 1989; Johansson, 1991;
McKeever, 1999; Hellström & Hallberg, 2001) as well as
others. Adult children who are caring for a parent often find
they are juggling their caregiving role with the needs of their
own spouse and children and there may be conflict over these
different groups’ needs of the home as a place (Gelfand,
1989; Pruchno et al., 1993; Remennick, 1999).
In addition to conflict over place amongst household
members, there are additional viewpoints to consider with
respect to needs and perceptions of homes as places as they
become places for the provision of health care. Health
professionals entering a home as ‘outsiders’ to provide care to
an older person need work spaces that are hygienic, efficient,
clean and safe (England, 2000; Ward-Griffin & McKeever,
Ó 2005 Blackwell Publishing Ltd, International Journal of Older People Nursing in association with Journal of Clinical Nursing, 14, 8b, 100–108
Conceptualizing place in the care of older people
2000; McKeever, 2001). Safe workplaces mean safety from
abuse, safe working conditions (e.g. clean air, unpolluted by
second-hand smoke, dust, or pet dander), and safety in
travelling to and from work places. Older persons receiving
care and their families, however, do not necessarily see homes
as clinical work spaces, and instead may place value on the
home as a place that is private, comfortable, aesthetically
pleasing, full of memories and dreams and personal belong-
ings, a place where they have the privacy to carry out their
personal habits, enjoy the company of a loved and loyal pet,
and an affordable place. This is also a good example of how
places are subject to ongoing negotiation, as home care means
that these different groups have to continually negotiate the
physical as well as the symbolic nature and meaning of the
home as a place for the provision of care and other activities.
In institutional settings, we can observe similar competing
experiences and needs of place. For example, while paid care
workers may have to juggle clinical demands in the context of
being understaffed and overworked and hold a broad clinical
knowledge, lay or family caregivers see the place as holding
the potential to meet the needs and interests of their loved ones
and have a deep knowledge of that particular person and their
characteristics and well-being (Raudonis & Kirschling, 1996).
Moreover, older people themselves may express need for a
place that provides them with some autonomy and privacy as
well as high standards of clinical care and safety (Rubenstein,
1989). While some of these experiences and demands of the
place are overlapping, some of them may also be competing,
leading to conflict and dissatisfaction on the part of various
parties, particularly the aged person.
Power relations are expressed through, and shape, places
All of the examples above suggest that not all people can have
equal abilities or opportunities to shape places, and that the
different ways people experience places are partly related to
their differing positions in society. Social relations structure
and characterize our society, and similarly structure and
characterize places. For example, gender and power relations
are such that women are typically paid less than men for
similar work, and that jobs characterized as ‘women’s work’
are typically paid less than those characterized as ‘men’s
work’ (Angus, 1994; Gardiner, 1997). By far the majority of
those providing care to older people, both on a paid and
unpaid basis, are women (Graham, 1985; Aronson, 1990;
Abel, 1991). The majority of those older people receiving
care also tend to be women, partly because of longer life
expectancy but also because of traditional age gaps in
marriage which mean women are often younger than their
spouses (Arber & Ginn, 1993; Wyn & Solis, 2001).
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J. Wiles
This extreme and consistent gender imbalance in care for
older persons means policies that influence the nature and
location of care for older people, such as cutbacks to
funding for community-based care, or increased privatiza-
tion of care for older people, have a disproportionately
negative effect on women (Armstrong & Armstrong, 1999,
2002, Morris et al., 1999; Watson & Mears, 1999). One
of the most troubling aspects of the increasing provision of
care for older persons at home is that as places, homes are
less ‘visible’ than more public institutional places such as
hospitals, so these power imbalances and inequities are
hidden. Community-based nurses are sometimes paid less
than their hospital-based colleagues, and often occupy
more precarious positions, with long distances to travel and
high staff turnover. Despite this extensive research
completed on the financial, physical and social costs for
‘lay’ or family caregivers involved in home-based care,
there has been very little redress. It is difficult enough to
mobilize action amongst organized health professionals in
an institutional setting, but trying to organize across the
fragmented spaces of different homes presents additional
and considerable challenges.
Places are interrelated
Places do not exist in a vacuum, but are always connected to
other places. The relative location of a home in which an
older person receives care matters because it directly affects
their access to resources such as parks, shops, and medical
services, as well as to social relationships such as family
members and other potential caregivers. Whether the home is
in a relatively wealthy or poor area may also have an effect
on their relative health outcomes, as wealthier neighbour-
hoods may be likely to have better resources and amenities.
While we can think of places on many different scales (we
might think of a ‘place’ at any scale from a favourite
armchair, a room in a house, a home, an institution,
neighbourhood, city, region, or even a country, for exam-
ple), these are also interconnected. Policy decisions on care
for seniors made at national level, or at the urban and
regional level for community-based care, have a direct effect
on the health and well-being of older people at home.
Decisions about whether and how to provide publicly
funded community-based care, or whether to provide a
general service or directly fund older people (who are then
able to purchase healthcare services on an individual basis)
will effect the spatial distribution and power dynamics of
care provision for older persons (Glendinning et al., 1997;
Ungerson, 1997). Similarly, government policies about
benefits for residential care might impact on other policy
104 Ó 2005 Blackwell Publishing Ltd, International Journal of Older People Nursing in association with Journal of Clinical Nursing, 14, 8b, 100–108
goals to promote older persons’ independence by influencing
decisions about institutional care vs. home support (Clark-
son et al., 2005).
The example of care of older people from visible ethnic
minorities is illustrative of many of the complex aspects of
place discussed thus far, including place as an ongoing
process and negotiation, the way different people may
experience the same places, the role of power relations in
place, and how place is interconnected to other places.
Power relations connected to culture and ethnicity are
important in shaping the healthcare experiences of older
people. Older people from visible ethnic minorities are
reported to be likely to seek formal health care later than
those from non-minority groups, but also to receive less
support (Gelfand, 1989; Reijneveld, 1998; Buchignani &
Armstrong, 1999). At the level of individuals and homes as
places, cultural norms about the role of family in providing
care and the need to maintain autonomy, may lead to
resistance to seeking formal care and especially having care
workers come in to the home (Ebrahim, 1996; Pang et al.,
2003). In other potential places for the care of older
persons, whether hospitals or residential care, the lack of
culturally appropriate services catering to language or
dietary requirements may prove barriers that reinforce the
need to provide care at home instead (Bellamy, 1993;
Baxter et al., 2001). Barriers within healthcare systems may
create this difference in use of healthcare services at home
or in institutions (Neufeld et al., 2002). To speculate,
healthcare professionals may believe that older people from
visible ethnic minorities have more extensive informal
support networks and therefore do not need formal
support. They may consequently be less likely to offer
care, even though there is little evidence to suggest that
there are more extensive support networks amongst immi-
grant or ethnic minority families. Finally, the effect of
being in a new place may itself be important. For example
immigrant elders may wish to return to their ‘homeland’ to
die and this prospect of returning home may delay their
engagement with formal support services (de Graaff &
Francke, 2003). The combination of values about home
and family, and barriers to access to alternative places for
the care of older persons, combine to contribute to
inequities in the use of support services for older persons
from visible ethnic minority groups in both homes and
institutional sites for care.
Places are simultaneously material, social and symbolic
Places are not only physical but also have social and symbolic
meaning. As discussed above, people may have quite different

social experiences and expectations of a particular place,
whether a home or an institutional setting. While homes or
institutions are physical tangible entities, they are also imbued
with symbolic meaning. Home is itself a powerful symbol of
autonomy and independence for many older people, for
example, whereas institutions are symbolically associated
with the loss of autonomy and independence. The actual
social experiences of these may concur with these symbolic
ideas, or be quite different. For example, homes are not
always havens of tranquility and warmth but may be the site
of conflict. Complex interrelations of power and relationships
shape the experience of older persons in the home as a place,
as the growing literature on elder abuse suggests (Whittaker,
1995). Even beyond these problematic extremes, many
caregivers in the ‘sandwich generation’ may find themselves
constantly negotiating the competing social, emotional and
physical needs that their children and their older parents have
of their home, such as one group needing a quiet, clutter-free
space while children need spaces for leisure and play.
None of these aspects of place (social, physical and
symbolic) is necessarily more ‘real’ or important than any
other. Instead, they are interconnected and directly depend-
ent on each other. The way that people symbolically
understand a place, such as a hospital bed, will shape their
social experiences of that place and their physical use (or not)
of it. If a place such as a hospital bed is associated with ideas
of fear or with negative past experiences, further experiences
are likely to be tinged with those ideas and memories. A new,
positive experience with the same kind of place will, in turn,
influence perceptions and future expectations about that
place. An example of this is older Maori (the indigenous
people in New Zealand), who often want to bring their own
sheets and bedding with them to hospitals or care facilities.
This is in case someone has died on the sheets they might be
given by the institution. Many Maori believe that the wairua
(spirit) of that dead person might be in the sheets, which
would therefore be tapu (forbidden or restricted, but also
sacred). This example is illustrative not only of cultural ideas
about the symbolic, social and physical experiences of place,
but also richly illustrative of the way that places always have
an historical context and are related to power and relations.
In the preceding discussion I have separated out various
ways in which geographical gerontologists conceptualize
place, but it is obvious that these are all very much
overlapping and interactive conceptualizations. The exam-
ple of formal care workers, family members, older people
and others and their sometimes conflicting views on the
way that homes should be organized where an older person
is receiving care there shows how many of these aspects of
place overlap.
Ó 2005 Blackwell Publishing Ltd, International Journal of Older People Nursing in association with Journal of Clinical Nursing, 14, 8b, 100–108
Conceptualizing place in the care of older people
Relevance of place to health professionals caring
for older persons
Geographical gerontologists emphasize the importance of
context and that place matters in the experience of older
persons receiving support from health professionals. The
increasing importance of ‘ageing in place’ and the subse-
quent emphasis on communities and homes as places for
the care of older persons, means that it is important we do
not simply see these as straightforward sites for care. As
places, homes and communities are not all equally suited to
the provision of care, nor will all users of the same places
experience or understand them in the same way. Instead,
places are linked to other places and times and through
many scales, and have historical, political, social and
economic contexts.
Understanding the place as a dynamic, negotiated, contes-
ted, contextual and complex process rather than as simply a
series of neutral ‘containers’ or locations for care has
implications for health carers and professionals. Recognition
that broad social processes, such as cultural differences or
gender relations, are manifested through and shaped by
particular places influences how care for older persons should
be organized in those places. For example, an approach
attentive to the nuances of place suggests the need to consider
the economic and political organization of health care for
older persons and ‘ageing in place.’ This would mean
developing communities, as well as community care, in ways
that help older persons to maintain their autonomy, and
assist those family members who choose to directly support
them in ways that are flexible and appropriate and sensitive
to difference. Recognition that places are also shaped by, and
shape, the intimate relations between people also has
implications for care at all scales from the regional to the
most intimate. Understanding place as a process emphasizes
the importance of building and maintaining relationships, for
example by having the same district nurse come as often as
possible, rather than fragmented care by a number of people.
The importance of continuity of care as a part of the process
of place has implications not only for individual healthcare
professionals, but also for the political and economic need to
fund health professionals adequately so that they are able to
do the job at which they are so effective.
Acknowledgements
My thanks especially to Jan Wiles and Robyn Lazarovitch,
and well as two anonymous referees for their valuable
comments on this article. All shortcomings remain my
own.
105
J. Wiles
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