Introduction
Recent decades have witnessed a growing number of patients with dementia, attributed with heightened dependency, as well as an increase in the complexity of their care (Baillie et al. Reference Baillie, Ford, Gallagher and Wainwright2009; Cohen-Mansfield, Garms-Homolová and Bentwich Reference Cohen-Mansfield, Garms-Homolová and Bentwich2013; Kada et al. Reference Kada, Nygaard, Mukesh and Geitung2009; Örulv and Nikku Reference Örulv and Nikku2007). Patients with an advanced stage of dementia often cannot recognise others and therefore are reluctant to co-operate with them (Simard and Volicer Reference Simard and Volicer2010). Accordingly, The World Health Organization (WHO 2012) has declared, as a public health priority, attending to these patients in a professional manner that is respectful of their personhood and dignity.
The employment of multicultural care-givers who are responsible for older adults in need of care is increasingly prevalent. In Europe and Canada, for example, the population of home attendants is comprised mainly of labour immigrants from Africa, Eastern Asia, the Middle East and Eastern Europe (Cohen-Mansfield, Garms-Homolová and Bentwich Reference Cohen-Mansfield, Garms-Homolová and Bentwich2013; Ireland Reference Ireland2011; Martin et al. Reference Martin, Lowell, Gzodziak, Bump and Breeding2009; O'Shea and Walsh Reference O'Shea and Walsh2010; WHO 2012). Yet, much of the literature on the human dignity of older adults and of older adults with dementia has either overlooked possible cultural differences between formal care-givers or denied the existence of such differences (Ariño-Blasco, Tadd and Boix-Ferrer Reference Ariño-Blasco, Tadd and Boix-Ferrer2005; Tadd, Vanlaere and Gastmans Reference Tadd, Vanlaere and Gastmans2010; Woolhead et al. Reference Woolhead, Tadd, Boix-Ferrer, Krajcik, Schmid-Pfahler, Spjuth, Stratton and Dieppe2006).
Against this backdrop, we have already published a mixed-methods study that probed whether or not formal care-givers from a range of cultural backgrounds differ in their respect for the dignity of patients with dementia. The study emphasised the potential Arab formal care-givers may have for demonstrating care of patients with dementia that is more respectful of these patients’ human dignity, especially compared with care-givers from the former Soviet Union (Bentwich, Dickman and Oberman Reference Bentwich, Dickman and Oberman2016). It was argued that stronger support for the different attributes of human dignity and autonomy reflected a more holistic viewpoint of patients with dementia, depicting them as whole human beings by acknowledging their personhood, manifested in their own wishes, perceptions and emotions, which should be respected to the greatest extent possible. We have, therefore, suggested that Arab care-givers’ emphasis on the dignity and personhood of patients with dementia may be interpreted as reflecting a person-centred approach, thus laying the groundwork for person-centred care (PCC).
Thus, personhood, particularly in patients with dementia, was presented by Tom Kitwood as ‘imply[ing] recognition, respect and trust’ (Reference Kitwood1997: 8), which has much to do with acknowledging the uniqueness of persons (Reference Kitwood1997: 20). In a similar vein, based on a recent literature review regarding PCC, its six main components were identified, amounting to setting the focus of care on the person being treated, thereby necessitating the need to know and empower, as well as forming a relationship of trust and respect with this person (Sharma, Bamford and Dodman Reference Sharma, Bamford and Dodman2015). These components also imply the need for giving primary attention to the subjective perspective of the person living with the disease, by establishing a therapeutic relationship based on shared power and responsibility between the care-giver and the patient, which is achieved through open communication between them (Edvardsson, Fetherstonhaugh and Nay Reference Edvardsson, Fetherstonhaugh and Nay2010). Therefore, PCC, setting the focus on the person being taken care of and his or her subjective perspective, is based on respecting the patient's personhood. In other words, PCC is based on a person-centred approach, placing the patient with dementia's personhood at the centre of the care-giver's attention and focus of care.
However, in our previous study, we were unable to suggest explanations for the differences between the care-givers from different cultural backgrounds. Furthermore, in the absence of possible explanations, our ability to identify differences in the conceptualisation of dignity among these care-givers is rather limited. In contrast, the ability to understand the possible source underlying the more robust perception of Arab care-givers regarding the human dignity of their patients with dementia, which is manifested by an emphasis on their personhood, may apply to all care-givers of people with dementia.
A possible source for the differences we found between the varied ethno-cultural groups of care-givers could be related to the link between the use of figurative language and empathy. Some studies associated the existence of an imaginative capacity and the ability to enhance the capacity to imagine with the use of figurative language, both of which are mainly manifested in the use of metaphors and similes (el-Aswad Reference el-Aswad2014; Lakoff and Johnson Reference Lakoff and Johnson1980; Nelson Reference Nelson2012; Ryman, Porter and Galbraith Reference Ryman, Porter and Galbraith2009). A metaphor is ‘the application of a word or a phrase to an object or concept it does not literally denote, in order to suggest comparison with another object or concept’ (Urdang and Flexner Reference Urdang and Flexner1969: 840). The imagination in human thought provides a fertile breeding ground for the evolution of stable knowledge structures (i.e. metaphors, similes), thereby depicting the use of figurative language as reflecting the capability to imagine (Lakoff and Johnson Reference Lakoff and Johnson1980). Similarly, the capability to imagine has been found to be enhanced through the use of figurative language, as in the case of using similes and metaphors while writing essays, which has been shown to kindle a writer's imagination (Nelson Reference Nelson2012).
At the same time, the ability for empathy may be related to an enhanced imaginative capacity. Empathy is the ability to genuinely understand someone else's personal experiences, emotions and view of the world; the ability to empathise is thus grounded in cognitive and emotional competencies (Davis Reference Davis1994). The care-giver should have empathy for the patient by understanding the situation, perspective and feelings of the patient, communicating that understanding and verifying its accuracy with the patient, as well as acting on that understanding toward the patient in a helpful way (Hojat Reference Hojat2016; Mercer and Reynolds Reference Mercer and Reynolds2002). In other words, the empathetic care-giver of patients with dementia may be said to respect the personhood of each of those patients. What is common to most definitions of empathy is the focus on the empathiser's ability to imagine either the patient in another mental and/or medical condition or him- or herself in the patient's situation. This view corresponds to the teachings of Titchener, the British psychologist who introduced the term ‘empathy’ to English (Titchener Reference Titchener1909). Hence, an enhanced capacity for imagination among care-givers of patients with dementia may be an important tool that enhances the ability of these care-givers to empathise with and respect the personhood of patients with dementia, manifested by a person-centred approach, leading to PCC.
Purpose and scope
In the current study, we returned to the qualitative portion of the research, in which 20 care-givers from a variety of ethno-cultural backgrounds were interviewed (in Hebrew; see further details in the Design section that follows): immigrants from the former Soviet Union (IFSU), Jews born in Israel (JBI) and Arabs. We searched the care-givers’ verbal patterns for potential links between respect for the personhood of patients with dementia and the care-givers’ use of figurative language.
The focus on these particular ethno-cultural groups of care-givers stems from two reasons. First, the three ethno-cultural groups we chose to focus on constitute the majority of care-givers within institutional settings in Israel. Second, and no less important, these groups appear to exhibit different cultural attributes potentially pertaining to the current study. A culture consists of sets of values, beliefs and habits constructed and reconstructed in social interaction, which form the worlds of ideas, perceptions and decisions, as well as how individuals act. Hence, each care-giver has his or her own collection of cultural values, which is brought into the caring interaction with the patient (Doswell and Erlen Reference Doswell and Erlen1998; Rassin Reference Rassin2008). Notice that this definition does not imply that the cultural values a care-giver carries with him or her are static. Indeed, culture is regarded as a dynamic construct that changes with time, whether on the macro- or micro-level (Boyd and Richerson Reference Boyd and Richerson1985; Henrich and McElreath Reference Henrich and McElreath2003; Inglehart and Baker Reference Inglehart and Baker2000; Kashima Reference Kashima2008, Reference Kashima2014).
Historically, the Arab community in the country is a traditional society based on the principles of kinship and respect for older adults as wise and valuable community members (Al-Haj Reference Al-Haj1995). In contrast, Israeli Jews are characterised by Western individualistic values that tend to marginalise older adults (Al-Haj Reference Al-Haj1995; Lavee and Katz Reference Lavee and Katz2003). Indeed, it seems that the important familial role and the satisfaction of older adults with their status and care in this sector are still more pronounced than in the Jewish society (Katz and Lowenstein Reference Katz and Lowenstein2012). A more recent study, regarding nursing students in Israel, revealed that, in comparison with their Israeli-Jewish counterparts, Arab nursing students are more willing to take care of older adults in need of care (Zisberg, Topaz and Band-Wintershtein Reference Zisberg, Topaz and Band-Wintershtein2015). Finally, another interesting study, with respect to hospital nurses caring for older adults who were bedridden, revealed that Israeli-Jewish nurses who immigrated from the former Soviet Union reported using more physical restraints than other Israeli-Jewish nurses (Iecovich and Rabin Reference Iecovich and Rabin2013). Hence, nurses who immigrated from the former Soviet Union were less concerned with respecting the autonomy of these older adults, entailed in acknowledging their humanness.
Design and methods
Design
We embarked on a qualitative research study that explored the attitudes of informants toward the human dignity of patients with dementia using semi-structured interviews (Lincoln Reference Lincoln1995; Miller and Crabtree Reference Miller and Crabtree1994). The informants were presented with two vignettes about care-givers and asked to express their opinions about the behaviour of those care-givers. We used the ‘one shot case study’ in which ‘a group is studied only once, after some agent or treatment presumed to cause change’ (Campbell and Stanley Reference Campbell and Stanley1966: 6–7). All interviews, which were conducted in Hebrew, were audiotaped and transcribed; however, the interviewers also spoke the native language of their informants. This way, if the informant did not understand some sentences or words in the interview guide, the interviewer could immediately translate them into the informant's first language.
It should be emphasised, though, that in general, the interviews did not require translations, i.e. there were few instances in which the translation was required, and even then, it was mainly regarding a single phrase/word. In this respect, it should also be noted that the interviewers were specifically instructed to probe for implied difficulties in language expression by the informants. In cases where the interviewers sensed such difficulties, they were directed to encourage the informants to express their thoughts using their native language, and the interviewer will also serve as a translator. However, as noted above, there were only scarce instances where the informants wished to use this option and, even then, mainly with respect to a single phrase/word. Furthermore, as Table 1 shows, most of the interviewed care-givers had more than five years of work experience, with the majority having tten years or more. This fact is particularly important regarding care-givers who were immigrants from the IFSU, most of whom had ten or more years of experience (with only one having eight), as it means that they were hardly ‘new immigrants’ to the country. Finally, turning to the Arab care-givers, as our results show, despite the fact that Hebrew is not their native language, their use of figurative language surpassed the Jewish care-givers who were born in Israel (JBI) and for whom Hebrew was actually the native tongue.
Table 1. Occupational/cultural background of informants
Notes: 1. Arab care-givers who are Christians; the rest are Muslims. IFSU: immigrants from the former Soviet Union. JBI: Jews born in Israel.
Sample
We applied stratified purposeful sampling (Onwuegbuzie and Collins Reference Onwuegbuzie and Collins2007), by which we divided the sampling frame into strata of types of persons providing patient care, in order to obtain relatively homogeneous sub-groups. We recruited 20 experienced care-givers attending to patients with dementia. These care-givers were nurses, nurses’ aides, occupational therapists and physiotherapists, employed either in nursing homes or hospitals in the northern region of Israel. The ethno-cultural background of the informants was diverse: seven were Arabs, six were IFSU and seven were JBI. Table 1 presents their demographic and professional information.
The process of recruiting these care-givers included two stages. First, either the head nurse or the facility's manager was asked to provide a list of care-givers who fit the professional and ethno-cultural profile we were looking for and have had at least three years of experience in the job (and preferably above five years of experience). In the second stage, we approached these care-givers directly, without the presence of any administrator or other authority figure, and asked for their permission to be interviewed, after explaining our research goals. Overall, we reached approximately 25 potential informants, of whom 20 gave their consent to participate. While the interviews were conducted at the workplace and during the working hours of the care-givers, they took place in a private room that was designated for this purpose, so that, during the time of the interview, only the interviewer and the informant were present.
Method
This study offers a secondary analysis of the data gathered in the interviews, focusing on the figurative language employed by the care-givers in the course of the interviews, in order to reveal possible differences in their narration styles. Accordingly, the data analysis technique used here is based on discourse analysis. Discourse is conceptualised here as a set of meanings, metaphors, similes, representations, images and stories (Burr Reference Burr2015). Discourse analysis offers a way to scrutinise the ‘orderly ways of talking, with which individuals account for and make sense of themselves and their social worlds’ (Shotter Reference Shotter1993: 35). A key concept of discourse analysis is that human beings use language to build versions of their social world. This language does not merely revolve around neutral means by which people express themselves but is constitutive (Davies and Harré Reference Davies and Harré1990; Wetherell Reference Wetherell1998). Hence, by focusing on discourse components such as metaphors and similes, discourse analysis may reveal how complex identities are constructed and reconstructed through the use of language. In other words, discourse analysis may reveal more hidden layers of identity that are not communicated in an explicit verbal manner but rather in an implicit manner through the particular use of lingual expressions chosen by the speakers (or interviewees in our case).
The interviews were designed to assess the care-giver's perspective on human dignity indirectly, to minimise the chances of social desirability. Hence, each informant was presented with two typical but detailed vignettes describing everyday situations faced by care-givers of patients with dementia (e.g. bathing patients or helping them to do so, administering medicines to patients, taking them to the dining hall). This method also follows previous research aimed at exploring the concept of autonomy among formal care-givers of older adults in need of care (Collopy Reference Collopy1988; Mattiasson and Andersson Reference Mattiasson and Andersson1994; Mattiasson et al. Reference Mattiasson, Andersson, Mullins and Moody1997). After each vignette was presented, the informant was requested to share his or her impression of the hypothetical care-giver and to express an opinion based on one's own experience. Subsequently, the informant was asked to reflect about everything that the care-giver in the vignettes had said and done.
To expose the metaphors and similes in the transcribed interviews, as well as extract key themes expressed by these metaphors and similes in a trustworthy manner, a two-layer interactive interpretation exchange process between the researchers was applied. The first layer revealed the metaphors and similes through a constant mutual scrutiny regarding the interpretation offered by the researchers, so that any personal bias of a single researcher would be minimised. When the researchers disagreed over whether or not a certain expression indeed constituted figurative language, the researchers discussed it until they arrived at an agreement. The second layer revolved around examining whether key themes of the figurative language expressions (FLEs) exposed in the first layer could be extracted. In this stage, once again, a mutual scrutiny process was applied. When there was disagreement over the thematic interpretation of the FLEs, the researchers engaged in discussions until an agreement was reached.
Ethical approval
The study was approved by the research ethics committee at the Faculty of Medicine in which the first author is employed (approval #61-2013) and by the research ethics committee of the hospital involved in the study (approval #2013-5671). Ethical standards of conducting social sciences research involving human subjects were followed. We presented the potential informants with an informed consent form, prior to the interview, and verified their willingness to undergo an interview, together with an emphasis that they may refuse to do so, without giving reason for their refusal. We ensured the confidentiality of the informants by using fictional names in the transcriptions and in this paper, by removing any identifying information that could jeopardise the confidentiality of our informants, and by refraining from disclosing the names of nursing homes and hospitals that participated in this study.
Results
Our results show substantial differences among Arab, JBI and IFSU care-givers. In what follows, we highlight the main differences. We begin by asserting the quantitative differences in the use of FLEs among the Arab, IFSU and JBI care-givers and then proceed to the thematic aspects of these differences. The thematic aspects of the differences are then further interpreted in the Discussion section that follows.
The number of utterances reflecting the use of FLEs proved highest among Arab care-givers. Twenty FLEs were found in the narratives of the seven JBI care-givers, 11 appeared in the narratives of six IFSU care-givers but there were 48 among the seven Arab care-givers. As Table 2 shows, among JBI care-givers, the instances of FLEs per care-giver range from one to three, and the highest number of FLEs per care-giver reached five (in the case of Shoshana). Among the IFSU care-givers, the number of FLEs per care-giver ranges from one to two, with only one care-giver (Oxana) having six FLEs. In contrast, among Arab care-givers, except for a single care-giver (Jasmin), all of them had at least five FLEs; four care-givers had six or more. Hence, four of the seven Arab care-givers exhibited at least as many FLEs as the single-most-expressive care-giver in each of the other groups.
Table 2. Number of figurative language expressions (FLEs) and number of FLEs in the three domains per informant
Notes: 1. Militaristic language, small children and family. IFSU: immigrants from the former Soviet Union. JBI: Jews born in Israel.
These quantitative disparities are most pronounced when attention turns to the uncovered themes of FLEs. Hence, our analysis shows that almost all FLEs used by immigrant care-givers and nearly half of the FLEs employed by their Jewish colleagues are limited to three domains of discourse: militaristic language, small children and family (10/11 and 9/20, among IFSU and JBI care-givers, respectively). In contrast, while two of these domains (small children and family) are shared by the Arab care-givers, they articulate FLEs that mostly go beyond the three domains (43/48 FLEs).
Accordingly, Table 3 shows key examples of FLEs within each of three domains, as they are employed by care-givers from each group. Table 4 displays key examples of FLEs articulated by Arab care-givers as well as examples of such expressions used by JBI care-givers, which are beyond the domains of family, small children and militaristic language. While JBI care-givers, except for Noa and Shosha, used fewer expressions beyond these domains, all Arab care-givers extensively used expressions beyond the domains of family, small children and militaristic language. These extensively used expressions by Arab care-givers covered themes as varied as food, blue-collar workplaces, flora, fauna and anthropomorphism.
Table 3. Examples of use of figurative language expressions (FLEs) in the three main domains by all cultural groups
Notes: IFSU: immigrants from the former Soviet Union. JBI: Jews born in Israel. PWD: patient with dementia.
Table 4. Examples of use of figurative language expressions (FLEs) outside the three main domains
Notes: JBI: Jews born in Israel. PWD: patient with dementia.
For example, Ahmed, referring to the care-giver behaviour described in the vignette, says, ‘You cannot treat him [the patient] as if he was a sack of potatoes’, while Amir uses another simile related to food when reflecting on the concept of human dignity for patients with dementia, as he equates the latter to ‘the food, the bread and water of these patients’. When Amir and Rulla reflect upon the environmental nature of the institution they work in, they contrast it with blue-collar workplaces such as a factory and construction site, while Rulla also uses metaphors related to flora, when she states that ‘I tried to survive under the rain drops’. Muhammad, on the other hand, refers to the animal world (fauna) in order to stress the humanness of a person with dementia, by stating that ‘it is not a dog! He is a human being!’
In other words, the FLEs used by Arab care-givers mainly go beyond the ‘regular’ expressions of figurative language used by their colleagues, thus intensifying the imaginative nature of the metaphors and similes used by this group of care-givers. Moreover, as will be further elaborated upon and discussed in the next section, the intensified imaginative nature of the FLEs used by Arab care-givers seems to express an emphasis on the individuality of their patients. In contrast, their IFSU and JBI colleagues, mainly focusing on FLEs that are limited to three domains of family, small children and militaristic language, tend to capture persons with dementia in a collectivist manner.
Discussion
Our results show that Arab care-givers’ narration style is characterised by highly figurative language, reaching beyond the usual domains of FLEs, as identified among their colleagues. In the current section, we discuss further the Arab care-givers’ narration style in comparison with their IFSU and JBI colleagues, and explain how the use of figurative language by Arab care-givers reflects a more person-centred approach, emphasising the personhood of patients with dementia. Then, by linking our findings to the relevant literature, we propose that the use of figurative language by these care-givers may be understood as (a) having cultural underpinnings among Arabs, in general, and Muslims, in particular; and (b) forming the foundation for their person-centred approach due to the theoretical linkage among figurative language, imagination capacity and empathy. We also suggest that the Arab care-givers’ emphasis on a person-centred approach may be understood as laying the grounds for PCC.
Thus, Arab care-givers not only tend to use the most extensive and varied FLEs, but the latter emphasise the individuality and uniqueness of patients with dementia. As shown in Table 4, Rulla uses the metaphor of a ‘construction site’ to emphasise the privacy of the patients with dementia, while Amir uses a similar metaphor (factory) to reiterate the importance of personal treatment. Amir compares the human dignity of the individual patient to a necessity like bread and water. Three of the Arab care-givers (Amir, Muhamad and Juwaher) cited the need not to treat patients like objects, thereby affirming their humanity. In a similar vein, Muhamad was appalled by the treatment given to one patient in the vignettes, declaring that the patient ‘is not a dog. He is a human being!’ Finally, Jasmin referred to a patient with dementia as a ‘wiped-out person’; she complained about the care-giver in the vignette who raised her voice toward the patient with dementia only because the patient wished to pray, instead of bathing as the care-giver planned. Commenting on the fictional care-giver described in the vignette, Jasmin says: ‘She treated him [the patient with dementia] as if he were a person who knows everything.’ Hence, Jasmin shows an awareness for the mistreatment of the patient with dementia in the vignette, while emphasising the humanness or personhood of this patient.
In contrast, as Table 3 shows, JBI and IFSU care-givers’ use of figurative language when referring to patients with dementia depicted the latter in a group-wise manner, thereby circumventing the personhood of the patient with dementia. They depicted patients with dementia as if they were their grandmothers or other relatives. Some spoke about these patients as if they were small children, while others mentioned not treating them like in a kindergarten or infantilising them by calling them ‘sweetie’, yet again reflecting on these patients collectively rather than individualistically. When using metaphors reminiscent of a militaristic language, it is not to emphasise the individuality or privacy of patients with dementia (as used by the Arab care-givers with similar ‘civil’ metaphors like ‘construction site’ and ‘factory’). Instead, militaristic language is used as a rhetorical vehicle that relegates patients with dementia to a group. Merav (a JBI care-giver) said that patients with dementia should not be forced to take a shower or submit to other non-medical procedures, rhetorically commenting: ‘Are they currently in a military boot camp?’ Neta (also JBI) says: ‘I fight, I fight every day … for the old persons to feel good.’ Even Oxana, the care-giver who is an immigrant from the former Soviet Union with the highest number of FLEs in her ethno-cultural group, repeatedly uses para-militaristic language (police, prison, ghetto) to make the same point that Merav does: not forcing patients with dementia as a group. Similarly, Noa and Shoshana, the only JBI care-givers referring to FLEs outside the main three domains, used such FLEs solely with respect to patients with dementia as a group (see Table 4).
In fact, note that, even when these care-givers had presumably presented opposite stances regarding people with dementia, these care-givers nonetheless referred to the patients in a collective manner rather than individualistically. One example for such opposite stances while sharing a similar collectivist approach to people with dementia concerns whether or not they should be treated as small children. Another example relates to the use of militaristic language. While content-wise, Neta (JBI care-giver) uses such language in order to stress her devotion to patients with dementia (‘I fight, I fight every day … for the old persons to feel good’), Inna (IFSU care-giver) employs militaristic language to emphasise the hardship in coping with resistive patients (‘It's a war’). Yet in both care-givers’ use of militaristic language, the reference to people with dementia is done in a collective manner, namely group-wise instead of individually focused.
Differently from JBI and IFSU care-givers, then, Arab care-givers tend to employ a more extensive and varied figurative language, in which the personhood and the uniqueness of patients with dementia are reflected precisely by these care-givers’ use of individualised references to their patients. In doing so, the Arab care-givers express a more holistic and person-centred approach acknowledging the patient's personhood, manifested in the patient's own wishes, perceptions and emotions. Such emphasis also appears to echo Kitwood's definition of personhood specifically in the context of caring for persons with dementia as stressing the acknowledgement of the uniqueness of persons (Kitwood Reference Kitwood1997: 20).
At the same time, such an extensive use of figurative language by Arab care-givers appears to be aligned with past studies emphasising the cultural underpinnings of FLEs among Arabs, in general, and Muslims, in particular. Thus, it has been claimed that the Qur'an's narrative is charged with many metaphors, and the Muslims commonly accept the belief that typically language fails to express the essence of God. Therefore, much metaphoric imagery is used in order to convey the nature and essence of God (Ahammed Reference Ahammed2010). Consequently, the Arabic language is made up of metaphors, and the Qur'an verses include many metaphoric directives (Hourani Reference Hourani1983, Reference Hourani1991). Dwairy (Reference Dwairy2006) also calls attention to the unique Muslim thinking style, which is characterised by imaginary language, symbols and metaphors termed Qeyas. Hence, it is customary among Muslims to utilise indirect and figurative language when describing and evaluating problems. Finally, a more recent study found that most Arab women use metaphors extensively in as varied realms as marriage, food and nourishment, rootedness and authenticity, covering and protection, as well as patience (el-Aswad Reference el-Aswad2014: 39). Therefore, our study's findings regarding the extensive use of figurative language particularly by Arab care-givers may not be a mere coincidence but rather a reflection of deeper cultural context embedded in this ethno-cultural group.
Interestingly, previous research depicted figurative language as reflecting the capability to imagine and enhancing this capability. On the one hand, research suggests that human imagination is the basis for conceptual metaphors because the imagination is a fertile breeding ground for the evolution of stable knowledge structures (i.e. metaphors, similes) (Lakoff and Johnson Reference Lakoff and Johnson1980; Ryman, Porter and Galbraith Reference Ryman, Porter and Galbraith2009). On the other hand, the use of figurative language may enhance the capacity to imagine. For instance, Nelson (Reference Nelson2012) found that using similes and metaphors while writing essays kindles the writer's imaginative capability. Another study suggests that figurative language is based on imagination and creativity, and recommends the development of students’ imagination by encouraging them to think of new metaphors (Ryman, Porter and Galbraith Reference Ryman, Porter and Galbraith2009). It follows that one may interpret the extensive and varied use of figurative language by the Arab care-givers as both reflecting a higher imaginative capacity and perhaps as enhancing this capacity.
Moreover, the idea that the use of figurative language may enhance the imaginative capacity is further supported, once the extensive use of figurative language by Arab care-givers is linked to empathy and personhood. Recall that empathy is the ability to understand someone else's experiences, emotions and worldview; hence, the ability to empathise is grounded on cognitive and emotional competencies (Davis Reference Davis1994). As already noted in the Introduction, what is common to most definitions of empathy is the focus on the empathiser's ability to imagine either the patient in another mental and/or medical condition or him- or herself in the patient's situation. In fact, some later studies, focusing on family care-givers of patients with dementia, showed that these care-givers tend to use metaphors to make sense of their loved one's health (Golden, Whaley and Stone Reference Golden, Whaley and Stone2012; Mastergeorge Reference Mastergeorge, Kovarsky, Duchan and Maxwell1999). Hence, by using metaphors, which can be seen as reflecting an imaginative capability, family care-givers were able to empathise with what their relatives with dementia were going through.
Yet the ability to empathise with patients with dementia requires acknowledging their personhood and uniqueness, in other words a person-centred approach. That is, in either version of empathy (cognitive or emotional), the care-giver is required to relate to the individual and specific experience that the patient with dementia undergoes. In the cognitive version, the care-giver needs to understand this experience from the outside; in the emotional or affective version, he or she is supposed to join the patient's experience, at least up to a point. In fact, one study precisely found that ‘achieving person-centred dementia care is dependent upon health practitioners’ imagination to recognize that selfhood persists despite the presence and progression of cognitive impairment’ (Kontos and Naglie Reference Kontos and Naglie2007: 565).
Therefore, from this perspective, if the Arab care-givers in our study were found to exhibit an extensive use of FLEs, associated with imaginative capacity, and these FLEs mainly stress the individuality of patients with dementia, then these results may be interpreted as possibly depicting the imaginative capacity of these care-givers as being enhanced by the extensive use of FLEs. Hence, by stressing the individuality of these patients, Arab care-givers may be understood as fostering an empathic stance to these patients, which is associated, in turn, with an enhanced imaginative capacity supposedly triggered by the extensive use of FLEs.
Finally, PCC in the context of dementia is particularly geared toward shifting the focus from the disease to the person and from the objective interests of medical and nursing professions to the subjective perspective of the person suffering from the disease (Edvardsson, Fetherstonhaugh and Nay Reference Edvardsson, Fetherstonhaugh and Nay2010; Kitwood Reference Kitwood1997; Sharma, Bamford and Dodman Reference Sharma, Bamford and Dodman2015). Furthermore, implementing PCC is particularly significant in nursing homes, as the idea of PCC had been contemplated due to the observed tendency among long-term care facilities to de-humanise their residents (Chenoweth et al. Reference Chenoweth, Stein-Parbury, Lapkin and Wang2015; Cornelison Reference Cornelison2001; Kitwood Reference Kitwood1993, Reference Kitwood1997; Ronch Reference Ronch2004; White, Newton-Curtis and Lyons Reference White, Newton-Curtis and Lyons2008). Consequently, emphasis on the personhood of persons with dementia, as it was reflected and possibly enhanced through the extensive use of FLEs by Arab care-givers, may be depicted as potentially laying the grounds for PCC; the latter setting the focus on the person with dementia as being first and foremost a person, thereby acknowledging this person's humanness and uniqueness.
Theoretical and practical implications
The above discussion reveals a possible tool assisting Arab care-givers to foster a more person-centred approach, as demonstrated by their stress on the personhood of the patient with dementia. This tool is the extensive use of figurative language, which, according to the analysis, may be related to a greater ability to empathise. Based on this interpretation of the data, we propose that a more extensive use of figurative language may provide a tool assisting care-givers of different cultural backgrounds in offering the much-desired PCC for patients with dementia.
Researchers from several disciplines recommend the incorporation of metaphors in training programmes for care-givers and therapeutic counselling (cf. Ahammed Reference Ahammed2010; Berdes and Eckert Reference Berdes and Eckert2007). Such recommendation introduces the potential importance of incorporating figurative language within the training of care-givers. Our results and their discussion, in turn, suggest that figurative language may be a tool assisting care-givers of patients with dementia to show empathy and implement a person-centred approach toward these patients. Based on the aforementioned recommendation, together with the suggested insights from our study, one possible practical implication might relate to the training of care-givers for patients with dementia. Such training programmes may encourage figurative thinking in order to provide these care-givers with a more fruitful ground for showing empathy and implementing PCC toward patients with dementia.
Conclusions and limitations of the study
The study revealed substantial differences in the narration style of Arab, JBI and IFUS care-givers attending to patients with dementia. Our study found that, in comparison with their JBI and IFSU colleagues, Arab care-givers of patients with dementia tended to use a more figurative language. The study also showed that the figurative language of Arab care-givers especially emphasised the personhood of these patients. Against this backdrop, further literature ascribing the use of figurative language to a greater capacity for imagination and associating this latter capacity with the ability for empathy was presented as well. Based on the study's results and the presented literature, we suggest that Arab care-givers’ stronger emphasis on figurative language may have enabled them to empathise more with patients with dementia, subsequently leading them to stress a person-centred approach. Future studies should explore the extent to which these findings are found in other cultural groups and whether programmes for care-givers of patients with dementia may be enhanced by the introduction of figurative language as one tool that is expected to improve the quality of the care given to these patients.
Some study limitations bear mentioning. The first is the undefined generalisability of the findings to other ethno-cultural groups. It is reasonable to suspect that care-givers working in other countries and originating from different ethno-cultural backgrounds may have different ideas about personhood and human dignity, which may correspond to different levels of figurative language usage than those employed by the care-givers in our study. Therefore, we hope our study will lead to future research in other countries, both qualitative and quantitative, which can further corroborate or alternatively dispute or test our findings. Such future research may also widen the thematic scope of the current study by presenting and examining additional perspectives regarding the use of figurative language by care-givers of persons with dementia. These perspectives may include (but are not limited to) issues such as which dominant discourses of dementia and ageing are reflected in the care-givers’ narration as well as how do the FLEs reflect or contribute to negotiate counter-discourses of dementia and ageing?
The generalisability of the study's finding is also limited due to its qualitative nature, which by design is not supposed to demonstrate statistically significant causality between relevant variables. As such, the study did not include examining alternative factors that may explain our results, other than FLEs. Future quantitative studies may wish to do so, thereby either further corroborating our findings or refuting them.
We are also aware that a social desirability effect might have been at work, where care-givers tried to appear more ethical and more devoted to their job in their responses to the interviewer. Understandably, most studies that use face-to-face interviews are vulnerable to this bias. However, it is precisely due to the social desirability factor that we have used vignettes, as have other studies in the health domain.
Finally, it might be argued that, because the interviews were conducted in Hebrew, the results are biased in favour of native speakers of this particular language. Nevertheless, as discussed already in the Design section, this concern appears to be less substantiated. To begin with, overall, there was (almost) no need for translations, even though the interviewers were specifically instructed to probe for implicit difficulties in language expression by the informants and to offer them the option to speak in their own native language in such cases. In fact, when retrospectively going through the audiotaped interviews, the authors did not find any spots in the interviews in which the informants seemed to have difficulties in expressing themselves without being given the opportunity to use their own native language by the interviewers. We explained this lack of need for translation by the fact that the IFSU informants were hardly ‘new immigrants’, given their years of work experience in the country. In addition, Arab care-givers whose native language is not Hebrew actually exhibited the most extensive use of FLEs, thereby suggesting that these care-givers also apparently did not have significant difficulties in expressing their thoughts in Hebrew. Still, we acknowledge the possibility that, theoretically, there might have been a few instances in which neither our interviewers nor the authors (retrospectively) had been sensitive enough to implicit difficulties in language expression experienced by informants for whom Hebrew was not their native language.
Acknowledgments
Above all, we are indebted to all the participants in the study. We are also grateful for the very helpful comments and suggestions for improvements offered by the two anonymous reviewers who read the previous versions of the manuscript. An initial draft of the study's findings was presented at the 2015 Oxford-Mt. Sinai Consortium on Bioethics Meeting. The helpful comments offered by the participants of these conferences, particularly the comments and suggestions made by Professor Michael Weingarten and Professor Rosamond Rhodes, have likewise significantly contributed to the study.
Funding
We wish to express our gratitude to the Israel National Institute for Health policy research for its funding of the research.
Ethical approval
The study was approved by the research ethics committee at the Faculty of Medicine in which the first author is employed (approval #61-2013) and by the research ethics committee of the hospital involved in the study (approval #2013-5671).
