The Presentation of Paradise: Impression Management and the Contemporary Nursing Home
Jason S. Ulsperger and John Paul

The Qualitative Report, Volume 7, Number 4 December, 2002


This report discusses dramaturgical perspectives, organizational impression management, and the history of the nursing home industry. Through participant observation, it uses a critical dramaturgical analysis to examine social interaction in three for-profit nursing homes. It explores how employees in these facilities create impressions of affective care in the face of negative publicity and long-term care competition. Specifically, the article examines four impression management tactics related to nursing home environments, concluding with suggestions for future research relating to organizational deviance.

Key Words: Dramaturgy, Impression Management, Nursing Home, and Long-term Care

Friends and family provide health care at intermediate levels for a majority of the elderly. However, portions of the population 65 and over need intense supervision due to cognitive impairment and severe health problems. Family members are likely to place these individuals in long-term care facilities. These facilities provide nursing care to sick or disabled people that do not need hospital services, but cannot use assistance from home health care (Sahyoun, Pratt, Lentzner, Dey, & Robinson, 2001). With estimates that 70 million Americans will be 65 years of age and older by 2030, long-term care will remain an essential component of the U.S. health care system (Strahan, 1997).

Long-term care involves a range of health services, personal care, and social services delivered to individuals who lack the capacity for self-care. Nursing homes often provide these services (Kane & Kane, 1987). With a rise in the number of elderly in the population, nursing homes are caring for more clients. In the early 1970s, there were slightly more than one million residents in nursing homes, while there are currently 1,608,700 residents in 1,700 facilities (National Center for Health Statistics, 2000). Estimates indicate that over 40 percent of Americans who turned 65 in 1990 will spend time in a nursing home before they die (Kemper & Murtaugh, 1991).

Considering these trends, economic competition for clientele is intense in the long-term care industry. Though the decision to institutionalize a family member is complex, it is important for nursing homes to create a satisfactory image of caring to pull in prospective residents. Images of elder care as paradise make the decision to place a loved one in a specific facility more feasible. In addition, impressions of affective care are essential in that they counter negative images historically associated with nursing homes.

This report discusses dramaturgical perspectives, organizational impression management, and the history of the nursing home industry. Through participant observation, it uses a critical dramaturgical analysis to examine social interaction in three for-profit nursing homes. It explores how employees in these facilities create impressions of affective care in the face of negative publicity and long-term care competition. Specifically, the article examines four impression management tactics related to nursing home environments, concluding with suggestions for future research relating to organizational deviance.

Conceptual Framework

Dramaturgy has been a central theme in the social sciences for decades. Various analysts discuss micro-level action in terms of theatrical analogies (Burke, 1945; Cochran, 1986; Combs & Mansfield, 1976; Goffman, 1959; Hare, 1985; Hare & Blumberg, 1988; Harre, 1979; Lyman & Scott, 1975; Manning, 1982; Perinbanayagam, 1982). These examinations create a general conception that dramaturgy is the study of how humans accomplish meaning through interaction (Brissett & Edgley, 1990).

In the dramaturgical perspective, social interaction is akin to a theatrical performance. Individuals engage in scripted behavior in order to persuade a desired mode of action from those with whom one is interacting (Holstein & Gubrium, 2000). With this perspective, people gauge the responses of behavior and alter it to create a desired impression for an audience. As Goffman (1959) states, "when an individual plays a part he implicitly requests his observers to take seriously the impression that is fostered before them. They are asked to believe that the character they see actually possesses the attributes he appears to possess…" (p. 17).

In the dramaturgical framework offered here, social action is viewed as a process wherein actors play parts, manage their actions, and seek to develop impressions crafted in the backstage to generate favorable images. Implied by this statement is the perception of the dramaturgical actor as one who is consistently scheming to deceive others with illusionary manipulations (Wilshire, 1982). The field of critical dramaturgy exemplifies this position the best (Young, 1990). It implies that actors in capitalist societies promote their interests, which usually relate to profit, with impression management strategies. However, this is not to say that all dramaturgical conceptions take this stand.

Some analysts argue that impression management is not the consequence of dramaturgical awareness, but merely a process inherently connected to the actor (Brissett & Edgley, 1990). Such a view insinuates that in social transactions a priori motivation is lacking -- meaning the actor does not constantly seek to control the impressions of others for calculated advantage. Regardless of this debate, there is little dispute that impression management occurs in the process of various interactions and milieus. For example, many analysts have explored the role of impression management in terms of organizational face work using qualitative methods.

Maines (1977) argues that social organizational processes transcend individuals and constrain their behavior. In terms of organizational analysis, dramaturgy involves the negotiation of image and meaning through individual members of the organization. Individual members of a group build social order through impression creation. Using observations from fifteen mortuaries, Turner and Edgley (1976) contribute to organizational impression management literature with their examination of funeral home directors. With categories based on front and backstage activity, they explore the manner in which funeral home directors create impressions to control ceremonies, organizational reputations, and the legitimacy of death work.

Boles, Davis, and Tatro (1983) further justify dramaturgical application in their work on fortunetelling as a con game. Using in-depth interviews as a source, they imply that in various occupations and organizations "everyday deception" occurs "in which actors manage their impressions to control the perceptions of others for profit" (1983, p. 375). Using thick descriptions, they conclude that to exploit potential clients, fortunetellers construct misrepresentations in the backstage.

Kolb (1985) uses dramaturgical insight in an examination of federal negotiators. She argues that explicit impression creation legitimizes the negotiator. Since mediators have limited formal authority, they must establish credentials through expressive tactics. These tactics help to shape the daily interpretations of what it means to be a negotiator in their organizational environment. Other studies examining organizational environments and dramatic themes include Haas and Shaffir's (1977) study of doctors, Booth-Kewley, Rosenfeld, and Edwards' (1992) study of impression management and Hispanic Navy recruits, and Hooghiemstra's (2000) review of corporate image creation.

This article expands on dramaturgical literature focusing on organizations by analyzing the dynamics of impression management in the contemporary nursing home. The existing literature on organizational impression management does not provide an understanding of image creation in long-term care environments. Using a critical dramaturgical perspective, this research explores this theoretical gap by examining for-profit nursing homes in which the use of face work to create positive images of care is evident.

Background: History and Research

In 1966, the U.S. government began subsidizing old-age institutions through Medicare and Medicaid funding. From that point forward, the move from county maintained poor farms to institutionalized nursing home care took place. Private businesses and corporations started caring for the elderly population needing long-term care. As early as 1968, approximately 77 percent of nursing homes existed for-profit, while only 23 percent were nonprofit (Manard, Kart, & Gils, 1975).

Public watch groups began criticizing privatized institutionalization for the aged starting in the 1970s and early 1980s (Mendelson, 1974; Townsend, 1971; Vladeck, 1980). They urged policymakers to realize that corruption was rampant in the long-term care industry, and many nursing homes had turned into second-rate living environments. Media sources pointed out poor living conditions were due to financial cut backs intended to increase revenue (Hess, 1976). Regardless, in the early 1980s, President Reagan felt pressure from interest groups supported by for-profit corporations to deregulate the nursing home industry, and substandard levels of care continued (Harrington & Carrillo, 1999). Recent reports show the continued dominance of privatized nursing home care in the United States. They reveal 70 percent of nursing homes exist as for-profit facilities (Gabrel, 2000; Strahan, 1997).

With reports of poor living conditions in long-term care, researchers in various fields started focusing on nursing homes. Gubrium's (1975) landmark work is a significant study concentrating on the nursing home industry. His examination of a nonprofit Midwest nursing home he calls Murray Manor provides useful information pertaining to organizational dynamics based on staff position. Using exchange theory, the work of Kayser-Jones (1981) contrasts a for-profit institution in California with a National Health Service institution in Scotland. She discusses how the nonprofit Scottish home enhanced the quality of care for its residents. Primarily, the Scottish facility had more regard for its residents' personal rights such as privacy. In terms of the for-profit home, she discusses dehumanizing situations, such as staff bathing men and women simultaneously in the same room, and residents freely defecating on floors.

Vesperi's (1987) work assesses her employment as a nurse's aide concentrating on how expectations of peers and residents shaped day-to-day practices in nursing homes. She finds that habitual institutional processes impeded the ability to meet expectations of those with which she interacted. Powers (1988) gained employment as a nurse in a New York nursing home. Her work uses network analysis to reveal strategies elderly residents use to construct support systems. O'Brien (1989) reviews a nonprofit church facility in the eastern United States and notes how the institutional orientation toward morality and faith influenced the resident's worldview as well as the caregivers.

Timothy Diamond's (1992) research is of particular importance in terms of nursing home analyses. He gained a formal education in nursing home work by becoming a certified nursing aide. Following his training, he entered the field without revealing himself as a sociologist. He explains that initial overt disclosure was necessary because he could not get himself hired otherwise. As he asserts, the study "was forced increasingly to become a piece of undercover research" (1992, p. 8). Regardless, using Marxist conceptions he concludes from his observations that "caretaking has been turned into a commodity and managed as a capitalist industry" (1992, p. 169).

Paterniti (2000) reviews identity construction by residents in nursing home environments. In her study of a for-profit nursing facility, she points out that habitual actions by the staff of a nursing home develop into embedded routines contributing to a common stock of knowledge concerning operations in the facility. When the staff operates from these ritualized practices, they take for granted the residents, whose presence originally defined the necessity of their routines. Other qualitative studies focusing on nursing home environments reveal the many levels of social reality existing in long-term care surroundings; however, they fail to address issues related to impression management (Foner, 1994; Gubrium, 1993; Henderson, 1981; Savishinsky, 1991; Shield, 1988).


The primary data for this paper involves information collected from participant observation in three nursing homes. The facilities were located in areas in close proximity to the researchers. As such, we used purposive sampling methods. In qualitative research, purposive sampling involves researchers using their special knowledge in intentionally selecting research environments (Berg, 1995). It was necessary to intentionally target certain nursing homes since the focus of this research involves only for-profit facilities. This article refers to the institutions studied with the pseudonymous names Mills Healthcare, South Haven Estates, and Stanville Nursing Home. Through observations in each institution, the first author gained knowledge of patterns relating to images of care by taking on differing roles with various strategies used in qualitative research.

Data Collection

The first author initially worked as a volunteer at Mills Healthcare. Mills Healthcare is a for-profit facility with 113 beds and 94 residents located in the southeast United States. It is part of the one of the largest nursing home chains in America (Forrest, Forrest, & Forrest, 1993). Following a meeting with the executive director, a discussion emerged concerning the first author's interest in nursing home life. The executive director agreed to be shadowed over the course of the next few months and served as a gatekeeper from that point forward. In addition to observations, the director believed any attempts to understand her facility should involve volunteer work. In order to observe social interaction at Mills Healthcare, assisting administrative staff on a weekly basis was a requirement. Berg (1995) describes this process as a research bargain.

Observations and volunteer work at Mills Healthcare lasted from January 1999 until June 1999. Supervision from two executive directors during that period yielded access to staff meetings and resident records. Volunteer work involved task support for the executive director, social service director, activity director, and nursing staff.

The data from the first wave of observations inspired a second wave focusing on another home. This involved gathering information at South Haven Estates, a 125-bed facility with 58 residents in the southwestern United States. The social service director of South Haven Estates was approached and discussions ensued pertaining to the possibility of performing observations and volunteer work. She agreed, but limited access to organizational activities outside of the managerial sphere. As such, while at South Haven Estates, observations were restricted to interaction between residents and lower level staff members. Volunteer employment at South Haven Estates lasted approximately six months, ranging from August 1999 to December 1999.

Additional observations occurred at Stanville Nursing Home, a 105-bed facility with 96 residents. As with Mills Healthcare, this facility is located in the southeast United States. Observation at this facility was less intense. It involved visits with five residents only during weekends from August 1999 to December 1999. During several observation periods, unstructured interviews with staff took place. Modeling the work of Diamond (1992), field notes were predominately drafted during the hours following volunteer work and visitation.

Data Organization

The organization of information involved typing field notes onto a word processing program. The first author directly typed information into the program on afternoons following observations. Utilization of a word processor for field notes provides compact storage and the ability to move rapidly from one location in the notes to the next during the process of analysis. This creates the ability to move quickly from one event to the next expanding on the ability to reconstruct events following observation periods (Berg, 1995).

Using open coding techniques, we initially read all field notes to systematically extract themes. With both researchers reading and rereading the field notes to extract themes, each researcher had a chance to render judgements about the dependability of the notes. This process was necessary to ensure a sense of credibility in relation to our findings. Following separate reviews of the information, we categorized notes as theoretical, methodological, and reflexive. Theoretical notes concentrated on observations concerning impression management. Methodological notes related to observation strategies and data recollection. Reflexive notes involved thoughts concerning the research process.

Following the open coding of observations, we focused our attention on entries from the theory category. Again, we each read and reread each entry finally coming to a consensus on patterns in the conversations and activities of people depicted in the notes. The patterns pointed to four salient subdivisions relating to dramaturgical practices in for-profit nursing homes. They included issues focusing on the labeling of facilities, the construction of physical environments, the management of problems, and the reconstruction of resident narratives. In relation to our findings, we provide quotations from conversations to build confidence in the accuracy of the theoretical subdivisions presented (for elaboration see Berg, 1995).

Impression Management and Nursing Homes: A Comparison of Four Tactics

Diamond (1992) points out, businesses and corporations in the long-term care industry are making gray gold. Following his research, we use a critical dramaturgical perspective to propose for-profit nursing homes turn images of paradise into monetary gain with high-quality impression management. In concurrence with Turner and Edgley (1976), this research implies organizations provide a dramaturgical front to enhance their reputation. Following the work of Boles et al. (1983), this research concludes organizations use impression management techniques to increase profits. While cutting costs and providing inadequate care, some nursing homes encourage employees to present the organization in a favorable light. This serves to counter negative stereotypes and increase revenue by pulling in more clientele. This section examines four impression management strategies relating to nursing homes.

Labeling and the Organization

As previously discussed, in the 1970s and early 1980s, many nursing homes were under attack for placing profits ahead of quality care (Mendelson, 1974; Townsend, 1971; Vladeck, 1980). However, organization members report that label shifts occurred to counter negative reputations tied to elder care facilities. Staff members indicate that in the long-term care industry it is hard to tell if a facility is a nursing home or is not. As an executive director at Mills Healthcare stated,

"The last place I worked at had the phrase nursing home in the name. Now when I tell people where I work, they ask me what kind of business it is. I have to explain to them that health and rehabilitation center now means nursing home."

Forrest et al. (1993) point out decades ago you could look for a nursing home in a local phone book and find several organizations under that listing. The typical yellow page listing under nursing home now refers you to sections labeled convalescent home. Under this listing, you can find organizations labeled health care facilities, skilled nursing facilities, or nursing centers. Forrest et al. (1993) explain that many of these terms overlap and few have real meaning in today's health care delivery system. Though the federal government now refers to Medicare or Medicaid certified organizations as skilled nursing facilities, many government agencies still describe long-term care institutions as nursing homes (Giacalone, 2001).

An examination of government policy partly explains the renaming of nursing homes (Giacalone, 2001). However, many workers interviewed believe these name changes allow many facilities to elude degrading stigmas related to the industry. In Goffman's terms, many of these organizations explicitly alter their "front" (1959, p. 22). Through a sense of dramaturgical awareness, certain facilities in the industry seek to create a different impression relating to nursing homes. As indicated by upper-level staff interviews from Mills Healthcare, many facilities stage name changes to manage negative stereotypes and increase their level of clientele. It appears that the industry uses renaming tactics specifically in cases of ownership change or the reopening of a home following a state mandated closure.

Impression management tactics relating to labeling also occur to control impressions inside nursing homes. As Gubrium (1975) discusses, owners and administrators struggle with attempts to label the structures within the nursing home environment. In the early years of formal long-term care, staff members called floors units instead of wards. Gubrium (1975) explains that administrators wanted the atmosphere characterized as a comfortable home habitat and the word ward was inappropriate. On the contrary, the use of the word unit helped to shift resident thoughts away from any association with a medical context, specifically hospitalization.

Constructing the Set

In terms of set construction, the importance of impression management in the contemporary nursing home is obvious. As Goffman explains, a set is part of the front produced for a performance. The set involves "physical layout," "furniture," and "decor" (1959, p. 22). This section focuses on impression management efforts relevant to set creation in nursing homes. It discusses the physical layout of each facility with a focus on impression management relating to security systems and reception areas.

Contrary to the design of Gubrium's Murray Manor (1975), the facilities this research examines do not exceed one story, nor do they have a design that the label of home implies. The designs of the facilities are extremely functional in terms of long-term care. A central desk area exists in the center of each facility. This area serves as the hub of activity for staff. This is the location of data and charts describing resident characteristics. Resident halls exist as appendages that emerge from the central station. In each facility, a room behind the nursing station serves as the cafeteria. The kitchen is located in close proximity to this room. Staff offices are on halls connected to the center of the structure.

Each facility provides an image of protection with a security system. A box with buttons assigned a numerical value is located on doors leading to the outside grounds of the facility. With these systems in place, the impression is given that access to the home is limited without the correct code. In terms of the front stage, staff interviews indicate that the systems exist to keep individuals out. After providing an entrance code to a family member, a certified nursing aide at South Haven Estates once exclaimed,

"We can't just let anyone in here! You know, we have to make sure everyone is safe. It may seem stupid to punch those numbers every time you come in, but it is important."

Once relationships with inhabitants of each facility developed, we realized clients believe the systems exist to keep them confined. One South Haven Estates resident believed she was being held against her will. She was living on her own when she attempted to retrieve a slipper from under her bed. She stated that as she bent over, she heard her back "snap." With an injury impairing independent living, her son desired nursing supervision. Her injury healed while she was in South Haven Estates, but she said her son had not mentioned returning home. In turn, this resident reported feelings of discomfort. Specifically, she "felt trapped and missed friends."

In addition to impressions of protection, more signs of set construction relate to social areas that resemble middle-class living rooms. There is often foliage, a television, and several comfortable chairs in this area. Goffman classifies these areas as a "dressed up room" that reminds individuals of the outside world (1961, p. 102). As Goffman (1963) points out, individuals often try to fight off discreditable reputations leading to stigmas. This room is another example in this work that indicates an organizational attempt to combat institutional stigmas. It creates the impression of an environment where aging residents are not confined by medical problems, but watch world events unfold on television and socialize with peers. Regardless, the manipulation of the physical environment in nursing homes indicates intentional set construction. It allows a nursing home to create an image of secure elder care paradise in which residents merely relax in the grasp of retirement. However, staff and resident narratives imply a different reality. To counter the explicit discussion of backstage happenings, often members of the top staff intentionally direct employees to only provide favorable information to others.

Staging Talk

Based on observations, staff meetings in nursing homes involve multiple components. General issues discussed at daily meetings include a census of the residents, an examination of progress notes relating to critical care patients, a count of decubiti, a computation of residents on psychotropic drugs, and unresolved complaints. In addition, upper level staff members use these meetings to deal with concerns oriented toward administrative functioning problems.

As discussed by Gubrium (1975), addressing administrative functioning problems involves the examination of resident care plans. For example, immobile residents require frequent rotations in bed so decubiti, also known as bedsores, do not form. In Stanville Nursing Home, one resident had not been rotated frequently. She developed a bedsore on her heal that evolved into gangrene. Doctors amputated her leg because of decay. Her grandson stated,

"There is no reason some of the nursing staff did not realize something was wrong. The smell that went along with her rotting skin filled the room for weeks. My family asked about the smell several times. I don't know why they did not do something instead of spending all of their time covering it up."

Regardless of functioning problems, based on observations at Mills Healthcare it appears that the primary role of staff meetings involves the executive director managing excuses for potential problems in the organization. This process fits into Goffman's (1959) notion of staging talk -- what to present the audience during a performance. It involves conversations of organizational dirty work that is "cruel" and "degrading" but necessary for the development of a positive impression (Goffman, 1959, p. 44). In terms of nursing homes, the social service director at Mills Healthcare continuously had problems with money delegated by the front office for cigarettes. One resident's money disappeared. The executive director quickly told the social service director,

"Call the family and tell them that Mr. Wallace has been smoking more than usual and that he needs more money each month to keep up his habit. Maybe they won't ask any questions. If they do, tell them to call me."

In another instance at Mills Healthcare, a nursing aide brought a Halloween mask to work to frighten other employees. A nurse checking vital signs in the room of a frail resident did not know the aide was hiding behind a door preparing to scare her. The executive director stated,

"The aide jumped out at Louise and nearly scared her to death. She threw her hands in the air and fell back on Ms. Tabby's legs. We soon found out that Ms. Tabby had several breaks in her leg bones."

The executive director admitted erroneously failing to discipline the aide. She implemented the impression management tactic of staging talk. She attempted to organize conformity in relation to stories at the staff meeting the following day. The plan was to present the damage as the result of a fall. The family was not fooled by the disguise created for this potential problem and a lawsuit followed. The use of staging talk often influences the actions of employees outside of staff meetings. Specifically, certain staff members have the ability to redefine social interaction.

Rewriting the Script

An important member of the administrative staff in a nursing home is the activity director. The activity director assures clients and residents that living in a nursing home environment is advantageous. Specifically, the activity director plans events designed to hinder resident social disengagement. At Mills Healthcare, the first author worked for the activity director for several months. The activity director had recently gained an undergraduate degree in social work and began employment at Mills Healthcare. While observing at Mills Healthcare, she never obtained the required license for her position. This did not stop her from participating in the image creation inherent in the Mills Healthcare system.

As previously mentioned, the activity director controls recreation in the home. When residents are absent during activities, the activity director's job is to explore resident decisions for truancy. This process involves visiting isolated individuals and filling out a programming form. Programming forms explain reasons for continuous lack of participation in activities from a resident's perspective. While at Mills Healthcare, it was common for programming forms to reflect images that counter illusions of nursing homes as palaces of paradise. For example, residents reported that they disapproved of the activity director and that the home did not offer an adequate variety of recreation.

Upon returning negative reports to the activity director, she would state that resident replies were not satisfactory. She stated that clients should try to "give the correct answers." During the period the state survey team was scheduled to visit the home, the first author recorded a negative response given by a resident on a programming form. The activity director examined the response and stated, "I will dispose of these improper programming forms and fill out some correct forms for the files." She distorted resident views of nursing home life by rewriting the script they had provided.

The process of rewriting scripts helps to maintain dramaturgical facades of consistent social interaction. This ensures that state inspectors will interpret satisfactory views of the nursing home during the examination of facility files. Another practice related to rewriting the script includes orders given by upper level administration that imply that lower level staff should provide special attention to coherent residents. As described by the Mills Healthcare activity director, if you keep the "ones who know what goes on happy" they will give positive reports to state survey teams looking for deviations from Health Care Financing Administration regulations.


With predicted increases in the elderly population, there will be an escalating need to focus on social interaction in long-term care. One thing long-term care environment analysts have frequently dealt with is the nursing home (Diamond, 1992; Gubrium, 1975; Paterniti, 2000). Previous qualitative studies focusing on nursing homes reveal multiple levels of social reality, but fail to address issues of impression management. This article provides a unique view of nursing home interaction to enhance previous studies. It illustrates the presence of dramaturgical awareness in nursing homes at the organizational level.

The findings of this analysis add to dramaturgical research in that they critically examine social interaction from perspectives relating to front stage and backstage regions. However, there are ways that they specifically build on literature focusing on impression management in organizations. First, the findings show that nursing homes are organizations that use impressions to pull in prospective clients for an increase in revenue. Monetary gain is not a paramount motive for all actors in the for-profit facilities examined, but certain individuals in these organizations seem to be driven by a profit oriented organizational logic. Second, the findings reveal that impression management can assist in the deception of state organizations monitoring specific industries. Again, it is possible that the organizational logic of for-profit nursing homes influences staff member activity. In relation to deception, it influences unethical activity in order for the organization to avoid penalties from state agencies. Regardless, the overall findings suggest that image creation does exist in nursing home settings to overcome negative stigmas relating to the organizational environment.

Limitations of the Study

A major limitation of this study involves its focus on for-profit facilities. An understanding of impression management tactics in for-profit nursing homes is clearly essential to literature pertaining to organizational interaction; however, research should also consider impression management tactics used by nonprofit facilities.

A related limitation involves the sampling methods used. Problems involving generalizability exist with the use of purposive sampling. However, we felt the use of purposive sampling was necessary in order to target specific types of facilities close to the researchers. This allowed for convenient, yet intensive research environments. As Lincoln and Guba (1985) contend, the use of concentrated, qualitative observations can outweigh the use of diluted generalizations provided by other methodological paradigms.

Another limitation of this research concerns the conceptual framework used. For example, some analysts believe the dramaturgy is too simplistic. They insist that everyday life is not the same as theater (see for example Ryan, 1978; Wilshire, 1982). However, supporters of dramaturgy stand firm on its place as a legitimate form of social thought (see Burke, 1945; Combs & Mansfield, 1976; Manning, 1982; Perinbanayagam, 1982). As Brissett and Edgley (1990) explain, many social scientists still see dramaturgy as a "long sought clear window into human reality" (p. 32).

Directions for Future Research

Researchers need to examine impression management in multiple long-term care environments. Consider the popularity of new services for the elderly such as adult day care, home health care, and assisted living (Riekse & Holstege, 1996). Though organizations such as these may not provide intensive supervision for the aged, they are still in competition with the nursing home industry. It is possible that they could be using impression management techniques similar to those discussed in this analysis.

In addition, if organizational logics focusing on monetary gain and deceptive activity influence actions in for-profit nursing homes, it may be essential to focus on ritualized practices in these facilities (see Knottnerus, 1997). Unaware to staff, taken-for-granted actions routinely performed in for-profit nursing homes may provide a script for action that promotes deviant behavior in the name of financial earnings. An analysis of these practices would not only be beneficial to the field of dramaturgy, but to a field such as organizational deviance as well.


      Berg, B. (1995). Qualitative research methods for the social sciences (2nd ed.). Boston: Allyn & Bacon.

      Boles, J., Davis P., & Tatro, C. (1983). False pretense and deviant exploitation: Fortuntelling as a con. Deviant Behavior, 4, 375-394.

      Booth-Kewley, S., Rosenfeld, P., & Edwards, J. (1992). Impression management and self-deceptive enhancement among Hispanic and non-Hispanic white Navy recruits. The Journal of Social Psychology, 132, 323-329.

      Brissett, D., & Edgley C. (Eds.). (1990). Life as theater: A dramaturgical sourcebook (2nd ed.). New York: Aldine de Gruyter.

      Burke, K. (1945). A grammar of motives. New York: Prentice Hall.

      Cochran, L. (1986). Portrait and story: Dramaturgical approaches to the study of persons. New York: Greenwood.

      Combs, J. E., & Mansfield, M. (1976). Drama in life: The uses of communication in society. New York: Hastings House Publishers.

      Diamond, T. (1992). Making gray gold: Narratives of nursing home care. Chicago: University of Chicago Press.

      Foner, N. (1994). The caregiving dilemma: Work in an American nursing home. Berkley, CA: University of California Press.

      Forrest, M. B., Forrest C., & Forrest, R. (1993). The complete nursing home guide. Dallas, TX: Taylor Publishing Company.

      Gabrel, C. (2000). An overview of nursing home facilities: Data from the 1997 National Nursing Home Survey. Advanced Data for Vital and Health Statistics No. 311. Hyattsville, MD: National Center for Health Statistics.

      Giacalone, J. (2001). The U.S. nursing home industry. Armonk, NY: M.E. Sharp.

      Goffman, E. (1959). The presentation of self in everyday life. New York: Doubleday.

      Goffman, E. (1961). Asylums. Chicago: Aldine Publishing Company.

      Goffman, E. (1963). Stigma. Englewood Cliffs, NJ: Prentice-Hall, Inc.

      Gubrium, J. F. (1975). Living and dying at Murray Manor. New York: St. Martin's.

      Gubrium, J.F. (1993). Speaking of life: Horizons of meaning for nursing home residents. New York: Aldine de Gruyter.

      Haas, J., & Shaffir, W. (1977). Taking on the role of doctor: A dramaturgical analysis of professionalization. Symbolic Interaction, 5, 157-203.

      Hare, A. P. (1985). Social interaction as drama: Applications from conflict resolution. Beverly Hills, CA: Sage.

      Hare, A. P., & Blumberg, H. (1988). Dramaturgical analysis of social interaction. New York: Praeger.

      Harre, R. (1979). Social being: A theory for social psychology. Oxford: Basil Blackwell.

      Harrington, C., & Carrillo, H. (1999). The regulation and enforcement of federal nursing home standards, 1991-1997. Medical Care Research & Review, 56, 471-494.

      Henderson, J. N. (1981). Nursing home housekeepers: Indigenous agents of psychosocial support. Human Organization, 40, 300-305.

      Hess, J. L. (1976, January 12). News analysis: Nursing homes show progress. New York Times, p. 32.

      Holstein, J. A., & Gubrium, J. (2000). The self we live by. New York: Oxford University Press.

      Hooghiemstra, R. (2000). Corporate communication and impression management - new perspectives: Why companies engage in corporate social reporting. Journal of Business Ethics, 27, 55-68.

      Kane, R. A., & Kane, R. (1987). Long-term care: Principles, programs, and politics. New York: Springer.

      Kayser-Jones, J. (1981). Old, alone, and neglected: Care of the aged in Scotland and the U.S. Berkley, CA: University of California Press.

      Kemper, P., & Murtaugh, C. (1991). Lifetime use of nursing home care. New England Journal of Medicine, 324, 595-600.

      Knottnerus, J. D. (1997). The theory of structural ritualization. Advances in Group Processes, 14, 257-279.

      Kolb, D. (1985). To be a mediator: Expressive tactics in mediation. Journal of Social Issues, 41, 11-25.

      Lincoln, Y., & Guba, E. (1985). Naturalistic inquiry. Newbury Park, CA: Sage Publications.

      Lyman, S. M., & Scott, M. (1975). The drama of social reality. New York: Oxford University Press.

      Maines, D. (1977). Social organization and social structure in symbolic interactional thought. Annual Review of Sociology, 3, 235-259.

      Manard, B., Kart C., & Gils, D. (1975). Old-age institutions. Lexington, MA: Lexington Books.

      Manning, P. K. (1982). Producing drama: Symbolic communication and the police. Symbolic Interaction, 5, 223-241.

      Mendelson, M. (1974). Tender loving greed: How the incredibly lucrative nursing home industry is exploiting America's old people and defrauding us all. New York: Alfred Knopf.

      National Center for Health Statistics. (2000). National nursing home survey: 1995. Hyattsville, MD: National Center for Health Statistics.

      O'Brien, M. (1989). Anatomy of a nursing home: A new view of residential life. Owings Mills, MD: National Health Publishing.

      Paterniti, D. A. (2000). The micropolitics of identity in adverse circumstance: A study of identity making in a total institution. Journal of Contemporary Ethnography, 29, 93-119.

      Perinbanayagam, R. S. (1982). Dramas, metaphors, and structures. Symbolic Interaction, 5, 259-276.

      Powers, B. (1988). Social networks, social support, and elderly institutionalized people. Advances in Nursing Science, 10, 40-58.

      Riekse, R., & Holstege, H. (1996). Growing older in America. New York: McGraw-Hill.

      Ryan, A. (1978). Maximizing, moralizing, and dramatizing. In C. Hookway & P. Petit (Eds.), Action and interpretation: Studies in the philosophy of the social sciences (pp. 65-81). Cambridge: Cambridge University Press.

      Savishinsky, J. S. (1991). The ends of time: Life and work in a nursing home. New York: Bergen & Garvey.

      Sahyoun, N., Pratt, L., Lentzner, H., Dey, A., & Robinson, K. (2001). The changing profile of nursing home residents. Aging Trends No. 4. Hyattsville, MD: National Center for Health Statistics.

      Shield, R. R. (1988). Uneasy endings: Daily life in an American nursing home. New York: Cornell University Press.

      Strahan, G. (1997). An overview of nursing homes and their current residents: Data from the 1995 National Nursing Home Survey. Advanced Data for Vital and Health Statistics No. 280. Hyattsville, MD: National Center for Health Statistics.

      Townsend, C. (1971). Old age: The last segregation. New York: Grossman Publishers.

      Turner, R., & Edgley, C. (1976). Death as theatre: A dramaturgical analysis of the American funeral. Sociology and Social Research, 60, 377-392.

      Vesperi, M. D. (1987). The reluctant consumer: Nursing home residents in the post-Bergman era. In J. Sokolovsky (Ed.), Growing old in different societies (pp. 225-237) Littleton, MA: Copley.

      Vladeck, B. (1980). Unloving care: The nursing home tragedy. New York: Basic Books.

      Wilshire, B. (1982). The dramaturgical model of behavior: Its strengths and weaknesses. Symbolic Interaction, 5, 287-297.

      Young, T. R. (1990). The drama of social life: Essays in post-modern social psychology. New Brunswick, NJ: Transaction Publishers.

Author Note

+Jason S. Ulsperger is a doctoral student and instructor of sociology at Oklahoma State University. He obtained a master's degree from Arkansas State University. He has published research concerning nursing homes in several gerontology and sociology journals. He can be contacted at the Department of Sociology, 006 Classroom Building, Stillwater, OK 74078-4062, USA; Telephone: 405/744-9455; Email:

+John Paul is a doctoral student and instructor of sociology at Oklahoma State University. He earned a master's degree from the University of North Texas. His research interests include the areas of social psychology and inequality. He can be contacted at the Department of Sociology, 006 Classroom Building, Stillwater, OK 74078-4062, USA; Telephone: 405/744-9360; Email:

Article Citation

      Ulsperger, J. S., & Paul, J. (2002, December). The presentation of paradise: Impression management and the contemporary nursing home. The Qualitative Report, 7(4). Retrieved [Insert date here], from

Jason S. Ulsperger and John Paul
2002 copyright

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