What ’ s in a name? Address practices in Swedish residential care facilities

.


Introduction
In Shakespeare (2014) Romeo and Juliet, Juliet applies the metaphor of a rose to Romeo.His surname, associated with a long history of conflict between his family and her own, is the enemy, not the man.Neither is her own name of importancelove is all that matters.
Is this view of names applicable to other settings, one might wonder?Is there really something to a name or not?This is an empirical question that will be investigated in a decidedly different time and setting than medieval Italy: address forms in 21st century Swedish residential care for people with dementia who have culturally and linguistically diverse backgrounds and their care-providing staff.

Cultural and linguistic perspectives on address forms
Not surprisingly, forms of address are culture and language bound.In a comparative study on human relationships, researchers investigated styles of address across four European languages: English, French, German, and Swedish (Clyne, Norrby, Warren, & Warren, 2009).Those data consist of interviews, participant observation, focus groups, and chat groups in various settings, such as families, workplaces, and among students.The results revealed well-established address practices not requiring choices, as well as those established by hierarchy or imposition, particularly in the workplaces.Clyne et al. (2009) investigated the way that speakers of the respective languages choose the pronominal and nominal modes of address available to them to express common ground, social distance, and group boundaries.The choice of address mode was demonstrated to be a spontaneous, or reasoned, response to how much of themselves speakers discover in their interlocutor; in other words, the extent to which speakers share common ground (See also Clark, 1996).For this reason, it has been argued that the choice of address mode is an act of identity (Clyne et al., 2009; see also La Page & Tabouret-Keller, 1985).
Based on established values in a culture, different languages offer a restricted range of address modes.For example, in the Swedish context, following egalitarian values dominating in the 1960s and 1970s, hierarchical relationships in address practices were abolished through a linguistic reform that is known as the du-reform (Bratt Paulston, 1976;Clyne et al., 2009).Following the du-reform in Sweden, using a title and avoidance of direct address related to hierarchy as well as using second person plural pronoun ni (V) indicating polite or distant address form for singular addressee have been abolished and hereafter people have been using direct address with their first names and second person singular pronoun du (T), implying a simple or intimate address form for singular addressees (Bratt Paulston, 1976;Clyne et al., 2009).The abbreviations T and V are derived from Latin tu and vos, respectively second person singular and second person plural, and are suitable for languages with a contrast of two pronominal variants such as French tu/vous, German du/Sie, Persian to/ Šoma, Swedish du/ni, etc. (Braun, 1988).Although using the V pronoun was largely abolished in Sweden after du-reform, Mårtensson (1986) argues that the V pronoun ni was restored in some contexts such as service encounters to signal respect rather than hierarchy.In a classical investigation of address forms, Brown and Gilman (1960) argued that reciprocal and non-reciprocal use of either the T or the V pronoun indicate respectively solidarity and power.
Since the 1960s, cultural and linguistic diversity in Sweden has multiplied, and many people with diverse backgrounds have arrived in Sweden after spending considerable amounts of their lives in other cultures with different addressing conventions and systems.One example of another system of address is English, wherein at least in some situations, using first names for unfamiliar older persons is deemed problematic (Wood & Kroger, 1993).For instance, in Dickey (1997), a few older English-speaking informants reported their preference for using title and last name at least until a personal acquaintance was established.A more recent study with American English, Australian English, and British English in academic settings found that in Australian English reciprocal first names were the default pattern of address, whereas in American English asymmetrical use of titles, honorifics, and first names were noted (Formentelli & Hajek, 2016).In British academia, usage of first names and titles between lecturer and students was non-reciprocal, which usually, after extended contacts and collaboration, evolved into a more reciprocal use of first names (ibid).In addition, some English kinship terms have been borrowed as address terms by Akan of Ghana (Sekyi-Baidoo, 2020).In some languages, age becomes a decisive factor in choosing forms of address (Keshavarz, 2001).For example, in Persian, deferential pronouns can be a preferred choice in addressing senior people even in informal encounters (ibid).
Both differences and similarities between various systems of address might become tangible when culturally and linguistically diverse people come across each other in contexts with close and lengthy social contacts, for example, such as in residential care homes.This goes for encounters between the residents themselves, visitors like family members, and especially the daily interaction with care-providing staff.Therefore, it becomes important to raise awareness about address practices especially in education programs for those who aspire to provide care for people with dementia.These programs provide trainings that prepare students for the dilemmas of daily work such as handling residents' affective stance and expressions of distress (Jansson & Majlesi, 2020).Interpersonal skills training is reported to be effective in other branches of healthcare (e.g., Gleber, 1995).

Address practices in residential care
There are few studies that focus on address practices in residential care that explicitly deal with either resident's preferences or the thoughts of staff on their own use of terms of address (cf.Wood & Kroger, 1993;Wood & Ryan, 1991) and even less that focus on people with dementia (cf.Backhaus, 2017).The findings in Wood and Kroger (1993) are based on constructed examples, and they call for more studies based on examples of naturalistic talk.In particular, research involving culturally, and linguistically diverse informants is rare.For monolingual settings, there are studies of communication in geriatric wards that have focused on nurses' speech style when addressing older residents (Grainger, 2008; see also Lanceley, 1985a).These styles have been dubbed "secondary baby talk" (Caporael, 1981, p.746) or "elderspeak" (Cohen & Faulkner, 1986, p.91) with implications of being nurturing, patronizing, or even insulting (Grainger, 1993;Small, Huxtable, & Walsh, 2009).Discussing elderspeak, Williams, Herman, Gajweski, and Wilson (2009) considers terms of endearment as diminutive when directed towards people with dementia.
Based on observation, and previous research, certain behaviors have been categorized as controlling (Grainger, 2008; see also Lanceley, 1985b), including using the third person singular as a means of directing speech, addressing, or talking about/for the residents in their presence.Residents also tend to be addressed by their first names despite claims that these types of practices represent an impersonal and disrespectful attitude towards them (Wood & Kroger, 1993).Another feature includes the use of "I" versus "we" as in "we'll just stand you up", which is described as a refusal of the nurse to treat the resident as an individual (Grainger, 2008;Lanceley, 1985a).In contrast to the findings of Grainger (2008), addressing the residents by their first names is not always well-received.In an ethnographic study, Fairhurst (1981) identified naming practices as a feature of nurses' talk to institutionalized older people.From a critical perspective, addressing residents with first names as well as nicknames might convey affection and intimacy that, if not actually felt or desired, may be perceived as disrespectful (Fairhurst, 1981).In Backhaus (2006), fictive kinship terms such as Gran or Pop are used for addressing people who are not related to the speaker.Backhaus (2006) found that a care-provider in a residential home in Manila used a fictive kinship term as a strategy for establishing the asymmetrical power relations with the resident.Yet, using first names is not universally disrespectful (Grainger, 2008;Ryan & Cole, 1990) but dependent on contextual factors, such as perceived social distance and the social status of the interlocutors (Grainger, 2008).
As mentioned, the above studies have been conducted in monolingual contexts, mostly in Anglophone societies.However, in the Japanese context, Backhaus (2009) conducted a quantitative study of address and the use of honorifics in a residential care facility.Although the default way of addressing non-familiar adults in the Japanese context involves using a person's last name plus the person honorific -san, care-providing staff sometimes addressed the residents by their first name plus the person honorific -san.This would be an uncommon way of addressing non-familiar adults in Japan.Backhaus (2009) also reported an imbalance in knowledge between care-providing staff and residents concerning naming practices; the results indicated staff addressing the residents by their names, rather than the residents' addressing the staff by their names.In a more recent study in the Japanese context, Kavedžija (2015) highlighted the factor of respect in addressing residents.For instance, care-providers may be discouraged from displaying excessive familiarity and diminutives in addressing older residents; they are treated as ladies and gentlemen, who need to be respected; they are regarded as otoshiyori rather than kōreishaseniors (those older than us, warranting respect), rather than "elderly".

Address practices, sense of self and identity in dementia
Another dimension that needs to be considered is the fact that a considerable number of residents in care facilities may have a dementia diagnosis or display symptoms associated with dementia.Some studies have investigated the impact of different stages of dementia on identity as based on autobiographical memory (See also Addis & Tippett, 2004;Caddell & Clare, 2010).
A systematic review of thirty-three studies investigating self and identity in people with dementia showed evidence of persisting self and identity in both mild and moderate to severe stages of dementia, although many studies record some degree of deterioration in these aspects (Caddell & Clare, 2010).Of relevance for the present study is that one thing that is well preserved for most people living with dementia is their ability to identify their names (Gross et al., 2004).
Highlighting the significance of name as an element of identity for people, Kitwood (1997) refers to an account of a person with dementia whose descriptions indicate that there is a link between her positive feelings in the residential care home and being greeted by name.The idea that choice of address form is an act of identity is supported by Clyne et al. (2009) and La Page and Tabouret-Keller (1985).While different forms may be used to address a person, they often invoke one particular aspect of a person's identity (Backhaus, 2020).Studying the function of names from different biographical stages of a character's life in a literary work, Backhaus (2020) uses the concept of onomastic layering to refer to the coexistence of a person's older and newer names that are given or gained throughout her/his life often due to transitional stages that s/he experiences.Accordingly, there is always a preference for one particular name among onomastic layering depending on different situations; for example, using an older name may reinforce recall of an identity associated with the past accomplishments of the person in question.Calling the older name may recall relevant memories associated with emotions that can be felt even in the present time.This mechanism can be raised in discussions about communication in the framework of person-centered care, where the aim, among other things, is optimization of remaining capacities to support sense of identity and well-being for people with dementia.
Identity in relation to language choice as well as talking about the use of a specific language in multilingual older people's care have been addressed in two studies: one in Ireland (Müller, 2017) and another in Finland (Lindholm, 2017).These studies both show that raising awareness and adapting to the remaining linguistic and communicative competencies of persons living with dementia may facilitate the maintenance of self and identity, especially in multilingual settings.Lindholm (2017) highlights the importance of staff having some knowledge of the residents' language habits prior to moving into residential care.A care environment characterized by intergenerational language shifts and limitations in staff sharing the residents' language may lead to mislabelling a resident as noncommunicative (Müller, 2017).This, in turn, may result in a lack of a sense of belonging or increasing a sense of alienation and social isolation for a person with dementia (ibid).Since most people with dementia need increasing cognitive and communicative support, this may involve encouraging multilingual people with dementia to use their linguistic and communicative resources to their fullest (ibid).This may be challenging if members of staff and residents do not share many linguistic resources (Plejert, Lindholm, & Schrauf, 2017), and multilingual people with dementia are at risk of experiencing more loss in their latter learned languages (Vega-Mendoza, Alladi, & Bak, 2019).In Lindholm's (2017) study, people with dementia who are bilingual Swedish-speaking Finns are positioned by staff relative to their language background and time of dwelling in the ward (see Davies & Harré, 1990;Moghadam & Harré, 2010;Mühlhäusler & Harré, 1990).Lindholm (2017) distinguishes between reflexive positioning (i.e., how individuals position themselves) and interactional positioning (i.e., how people are positioned by others).Her study demonstrates that the choice of language in conversation seems to be involved in identity formation and maintenance in complex and important ways.
The idea of investigating address practices by care-providing staff and residents' preferences emerged when I was doing fieldwork in a residential home in a mid-sized city in Sweden.I found myself in three different situations where residents with dementia, who were not of Swedish descent, in various ways displayed preferences for how they wished to be addressed.The first case was Seyed Pasha,1 an older man of Iranian background.When introduced to him, I realized that he previously had mainly been addressed with the second part of his first name, coming after a Persian title that literally means "master".The title had to do with his expertise as a plasterer before he retired.So, although he used to be called Oos Pasha (i.e., "master Pasha") even by some of his relatives during most of his life, in the residential home in Sweden, he was called Seyed Pasha by members of staff.Seyed Pasha was thus his complete first name.His son reported that in the early days of moving in the residential home, Oos Pasha was bothered when he was addressed with his first name.Whereas he appreciated when he was called uncle by an Arabic speaking care-provider.I also heard him complain to a member of staff when she used a nickname and called him Pishi.
The second instance occurred when I was walking with an older Armenian woman, Anni.When we arrived at the entrance of her room in the residential home, I read the family name written on the plate hanging next to her door aloud.Disrupted, Anni immediately turned to me and asked me to repeat what I had just read.Repeating the family name written on the plate, Anni seemed very uncomfortable.She asked me why they had written her ex-husband's family name on the plate; she did not use that name any longer.
Finally, I met an older man with a Kurdish background, Sherko, who had late-stage dementia.When I was talking to Sherko's son, it turned out that Sherko used to be addressed with a title before his first name.He used to be called Malaa2 Sherko, both when he was living in Iraq and after immigrating to Sweden.
These instances led to the emergence of the following study questions: 1) What are care-providers' address practices with residents?2) What is the function of address forms for residents and care-providing staff in multilingual residential care settingsis there anything in a name?If so, what is it?3) What are the residents' preferences for being addressed?4) What are the care providers' viewpoints on their practices of addressing residents?

Data, participants, and method
This study is based on three types of data: 1) ethnographic observations and field notes, 2) interactional data consisting of video-and audio recordings, and 3) interview data with members of staff and residents.The observations, field notes, and a major part of the recordings3 were collected in a residential home that will be referred to as Cedar.Interviews also included informants from a residential home that will be referred to as Oak.The fieldwork, including observations and collecting interactional data in Cedar, stretched from June 2014 until May 2016.Interview data in Cedar and Oak was collected from August 2018 to March 2019.

Participants in observational and interactional data
Participants in the observational and interactional data were 23 in all, consisting of five residents and 18 members of care-providing staff (Table 1).All names are replaced by pseudonyms.
During fieldwork, I also had many conversations with the residents, their relatives, and care-providing staff.Those conversations, especially with the residents and their relatives, were essential for understanding the address forms that the residents identified with prior to moving into a residential care facility.The conversations differ from the formal interviews, described below, in the sense that they were not planned and were not recorded.Persian, as a shared linguistic background, was used in both conversations and interviews with residents, their relatives, and some of the care-providers.

Management of observational and interactional data
The first step of data analysis consists of reviewing the field notes made during the ethnographic observations, with a focus on instances of mismatches between seven staff members' address practices and three residents' preferred forms of address.Although observations as well as field notes were central to the present study, they need to be complemented with more detailed instances available in the video-and audio-recordings, as well as additional information gained from interviews.
After the analysis of the field notes, 14 h of video-and audiorecordings of interaction with five residents were examined to identify care staff's practices of addressing the residents.The video-based search results in 427 instances of staff addressing the residents in everyday interaction.All instances are subsequently analyzed linguistically and divided into 21 categories.These categories are presented in Table 3 in the result section of this article.

Participants in the interview data
Although interactional data primarily drew my attention towards address practices in residential homes, the research questions required knowledge that could not be gained from interactional data alone.Thus, both staff and residents were interviewed.The interview data consisted of 30 semi-structured, open-ended interviews recorded in Cedar and Oak, as well as informal conversations during the first data-collection period.The participants of Cedar include a combination of people without any reported symptoms of dementia, people diagnosed with dementia, and residents who display symptoms of dementia.Oak specialized in providing care for people who have a formal diagnosis of dementia.In Oak, I interviewed four residents: Sara, Amir, Ellena, and Fanny.The interview data was used for developing a corpus.The corpus consisted of examples from interviews with 21 members of staff and five residents (Table 2).

Management of interview data
While listening to and transcribing the interviews, the goal was to identify instances dealing with address practices.Initially, seven interviews were transcribed verbatim in their entirety.However, subsequently, I chose to transcribe only those parts of the recordings that were related to address practices and preferences.This is because the interviews contain many other subjects not relevant to the issue of addressing.The collection of these transcriptions of expressions to addressing was turned into a corpus of 76 excerpts in 44 pages.Further analyses led to a division of the material into eight different "themes" within the overall framework of forms of address.A theme here is the classification of discrete examples compared against each other and assessed as relevant for a certain phenomenon (Ryan & Bernard, 2003).Thus, in this study repetitions of similar examples were the major criterion for identifying themes, but not the only criterion.For example, there was only one example in the case of the theme addressing with idioms expressing taarof,4 which belongs to a "cultural domain" (Ryan & Bernard, 2003, p.89).Since multicultural/multilingual communication is an important feature of the data, I decided to keep the theme despite having only one example (See Table 4 in the result section).

Ethical considerations
Verbal and written information about the study were distributed to potential informants.In the case of residents, the information was given to their relatives or guardians as well.Although the participants had already given their written consent, I verbally asked for permission prior to any recording.
The study was approved by a Regional Committee for Research Ethics in Sweden (Dnr 2013/2211-31).There are no special directives when it comes to conducting research involving people with dementia, but several things need to be considered.Apart from involving the residents' relatives or guardians in obtaining informed consent, it was crucial to consider the individual situation of participants before carrying out any interviews or video recordings.For instance, there were cases where, despite booked appointments, I changed the schedule at the participants' request.Especially in the case of the residents, interviews were sometimes postponed to another day or even cancelled due to issues such as residents feeling tired or distressed, which most often happened at the first meeting.This highlights the fact that a researcher can hardly safeguard ethical aspects of fieldwork just by following a set of general rules (Brinkmann & Kvale, 2005;Levine, 1998).

Results
In the methods section, three datasets for this study were presented.Analyses of the different data contributed to findings that are not identical; however, they address different research questions, and findings in the observational and interactional data elaborate the findings of interview data regarding the care staff's practices.

Address practices identified in the interactional data
The findings based on the interactional data are presented in Table 3 below, representing all types of displayed practices by the careproviders when addressing the residents (Table 3).

Address practices in the interview data
As mentioned, a thematic analysis generated eight different themes.The themes are presented in Table 4, below.
After triangulating the reported categories in interviews (Table 4) interaction was being conducted, a few cases were recorded, where the careproviding staff participating in the project, addressed three residents who are not in the study.These address forms as a part of the staffs' practices are included in the corpus, however the above-mentioned residents are not listed as participants.with displayed practices in interactional data (Table 3), four themes were represented in both tables.The qualitative analyses below will deal with these four identified themes: (1) Mismatch between staff's practices and residents' preferences (2) addressing residents with nicknames, (3) endearment terms, and (4) use of fictive kinship terms.The former is from the residents' perspectives and the latter three are from the staff interviews.

Mismatch between staff's practices and residents' preferences
This theme reflects a mismatch between the residents' preferred forms of address related to various identification information about the residents that is accessed and used by staff.
In the excerpt below, resident Sara says that in the residential home she is addressed by a name other than the one she prefers.Sara migrated to Sweden in her middle age, so Swedish became her later learned language.After being diagnosed with dementia, she moved into a special ward for people with dementia.During my encounters with Sara, she introduced herself as Sara, but in the residential home, she was called Farnaz, and henceforth she will be referred to as Sara.
It should be mentioned that I knew about her preferred name prior to the interview.When I met her the first time, I asked how I should address her.The answer was Sara.According to Sara, although her name is Farnaz in her identification documents, she was never called Farnaz before coming to the residential home.In the interview she maintained that throughout her life from childhood to adulthood she was called Sara by all including her parents, siblings, classmates, colleagues, and husband.However, when her husband was diagnosed with cancer and consequently, she had to move to the residential home, Farnaz became the name used by the residential home while Sara remained only to herself.When I asked if she had tried to remind the people in the residential home that her name is not Farnaz, Sara became silent and held her gaze on me.The same question was repeated for the second time in the interview and this time Sara said when the staff call her Farnaz she only says okay, and she had never argued for it.On one occasion, I was walking side by side with Sara along the corridor leading to her apartment and she told me that Farnaz is after all a beautiful name and she likes it, but her name is Sara.Last, but not least, Sara also said in the interview that if she were to choose between the styles of being addressed, she would like to be addressed with deferential you pronoun/ Šoma/rather than the familiar you pronoun/to/in Farsi.The transcription of excerpts is verbatim in the native tongue, and translations are idiomatic.In the interview, Sara implied the name Farnaz was imposed on her.However, it seems that the residential home did not have the knowledge that Sara did not like to be addressed with the name Farnaz.This observation is based on the information from informal conversations as well as interviews with Sara where she said that she had never talked about her preferred name to the care-providers.In addition, the staff referred to Farnaz and Sara was never used in the staff's interviews.In regard to Sara's name, we can see a contrast between reflexive and interactional positioning.On the one hand, Sara positions herself as Sara with all her life history including positive feelings and accomplishments associated with her family, friends, and career.On the other hand, in interactions she is positioned as Farnaz, a name which is not as resonant as Sara is to her memories and life history except insofar as it is printed in her identification documents.Choice of address form is an act of identity (Clyne et al., 2009).Previous studies on identity and dementia suggest that inconsistencies between the identity bestowed by others and the view of identity held by oneself can create a loss of social identity for an individual with dementia (Beard & Fox, 2008;Gilles & Johnston, 2004;Harris & Keady, 2009).Inconsistency between reflexive and interactional positioning is probably due to lack of knowledge about Sara's preferred form of address as a part of her life history.The residential care home's lack of awareness about Sara's preference for her name may have contributed to Sara's frustration since she claimed to have been called Sara for most of her life.
In sum, at least three factors are important in Sara's being a person  with dementia from a multilingual background.A major potential impact of dementia is the gradual loss of language and communicative abilities.For multilingual people with dementia, they are likely to experience more loss in their later-acquired language (Vega-Mendoza et al., 2019).A second factor is that many multilinguals may acquire a less balanced competence in their various languages.Thirdly, these residents are very likely to experience encounters with care-providers with whom they share very limited or no verbal language (Plejert et al., 2017).These three factors probably are valid in the case of Sara as they may shape false presumptions of dementia as a major blow preventing Sara and staff from achieving mutual understanding.Such presumptions arguably prevent staff from being aware of Sara's preferred form of address.In addition, the force majeure situation of her husband's health condition leading to his admission to a hospital is another important contextual factor.These facts might explain why the residential care home perhaps was not informed about Sara's name and might also explain why, despite her preference for Sara, she had never argued for it.
Another example of mismatch is presented in resident Seyed-Pasha, whose preferred style of being addressed differs from his name in the identification documents.After a few meetings with Seyed-Pasha during fieldwork, the disparity between his preferred form of address and a name in his identification documents became clear.Therefore, it seemed relevant to interview him and ask a few questions about his preferred style of being addressed.Although I had several encounters with him, sometimes we could not understand each other clearly, likely due to a number of factors.Seyed-Pasha's speech had been affected by a stroke, had been diagnosed with hearing impairment, and unfortunately had lost his hearing aids.In addition, although we both spoke Persian, we spoke different dialects.While I asked questions mostly in formal Farsi, he answered in his Isfahani Farsi dialect.Therefore, his daughter Assieh joined the conversation to help ensure mutual understanding.It was after lunch when I interviewed resident Seyed-Pasha.He introduced himself as Seyed-Pasha, but when I asked how I should address him, he requested a constellation consisting of the title Oos5 + second part of his first name (Pasha).Titles are either bestowed or achieved by appointment (such as doctor, major) or are inherited (such as Count, Duke) (Braun, 1988).That address pattern for Oos Pasha had been established and remained unchanged for decades before he migrated to Sweden.It should be emphasized that the title started to be used as a form of address because of its lexical meaning.However, it was changed in accordance with the Swedish system of address when he was admitted to a residential care home in Sweden.It was unclear whether the residential home was aware of his prior address form or not.
Oos Pasha, according to his son, in the early days of moving in the residential home, was complaining about being addressed by the staff with his first name.Thus, since moving to the new place, Oos Pasha experienced a sudden change in the form with which he was addressed, which communicated devaluing (e.g., Beard & Fox, 2008;Vittoria & Cortland, 1999).That pattern is applied by most people addressing him as Seyed-Pasha both verbally and in written form and the name plate hanging next to his doorway was listed as such.
In discussing forms of address and their social meaning, Braun (1988) claims that address forms are ambiguous in the sense that they include a potential of more than one social aspect.For example, the V pronoun, in languages with a contrast of two pronominal variants such as French tu/vous, can express distance, high status of addressee, irony etc.It is the actual situation of the address that determines which one of these aspects predominates (Braun, 1988).In the case of Oos Pasha, the age factor in choice of forms of address for speakers of Persian is also important.Keshavarz (2001) concluded that in addressing older people, among speakers of Farsi, deferential pronouns are preferred even in informal familial contexts.It is not uncommon, therefore, for family members, in a formal context, to switch to deferential styles of addressing.
Reviewing the historical development of Mr./Mrs.-variants in European languages, Braun (1988) maintains that although they were introduced to express superiority with the help of literal meanings, their use was more and more extended throughout history until finally the link between lexical origin and social meaning was severed.As another example, one can refer to the historical development of affix 'khan' originally meaning emperor (See Shiratori, 1926).The affix entered Farsi around the 13th century as a result of language contact with Mongolian.Furthermore, for centuries the power connotation of the affix was downgraded until the Iranian Land Reforms (1959)(1960)(1961)(1962), with the aim of distributing farming lands of rural areas, erased the superiority connotation (See Lambton, 1953).Braun's argument refers to the development of address forms across several generations.Arguably, the same argument could be valid in discussions of address form of an individual with an eye on his/her life history.The title Oos, because of its lexical meaning, was used in addressing Oos Pasha only after he became a well-known master of his occupation; however, the connection of lexical and social meaning seems to have loosened over time.The preference for being addressed as Oos Pasha is likely connected to the aspect of respect and Oos Pasha's expectation of being addressed respectfully with a name that has been his addressing name for many years.
In the third excerpt, resident Amir highlights the importance of respectfulness in addressing.The excerpt is chosen from a longer interview with Amir, who lives in a special ward for people with dementia.The interview was conducted when Amir was eating breakfast.Amir was diagnosed with dementia in his early nineties, almost two years prior to the interview.He migrated from Iran more than three decades ago.He used to work as a pharmacist in drugstores before moving out of Iran.In addition, he had conducted a considerable number of studies and published works in classic as well as modern literature, including translations of some literary works before and after migrating.Pharmacists in medical universities of Iran normally receive a five-year training program before becoming a doctor pharmacist.Therefore, they are usually called doctor, especially in the workplace.Amir is multilingual and there were a couple of instances in which I switched to English; however, the interview was mostly conducted in Farsi.Amir confirmed that he used to be addressed as doctor in his workplace.Furthermore, when asked about his preferred style of address, he stated that the important factor is showing respect.However, it remains unclear in his answer how respect in address is to be shown.According to his son, Amir's acquaintances still address him with the title doctor + last name, i.e., doctor Diba.Furthermore, in the social media, there are a couple of Iranian-Swedish pages that have acknowledged Amir's endeavors and his contributions to the Farsi literature.These pages refer to him doctor Diba rather than Amir.These facts confirm that until he was admitted to the residential care home, Amir was addressed by the Iranian-Swedish network around him even in Sweden with the title doctor.At the care home, he suddenly started being addressed by his first name in accordance with the Swedish address system that has been established after the du-reform.From Amir's perspective, there is an inconsistency between the way he is positioned in residential care home interactions and the way he was positioned before being admitted.Thus, the environments provide two different versions of interactional positioning that are based on respective systems of address.Furthermore, we know that address form is an act of identity (Clyne et al., 2009; see also La Page & Tabouret-Keller, 1985).Amir's emphasis on the element of respect regarding address forms suggests his awareness of the inconsistency between reflexive positioning and interactional positioning in the residential care home.This may have been experienced by doctor Diba as a "social demotion" whereby he felt relegated from his previously held identity associated with autonomy and expertise (e.g., Beard & Fox, 2008).While dementia presents a great challenge to the certainty about one's identity, many traits persist in both mild and moderate dementia to severe dementia (e.g., Beard & Fox, 2008;Caddell & Clare, 2010;Gilles & Johnston, 2004;Harris & Keady, 2009;Kitwood, 1997;Sabat, 2002;Usita, Hyman, & Herman, 1998;Vittoria & Cortland, 1999).The loss of certainty about one's identity begins when the identity bestowed by others is inconsistent with one's own view of her/ his identity (Gilles & Johnston, 2004).
Throughout the interview, Amir addresses the researcher by the deferential you pronoun/ Šoma/rather than the familiar you pronoun/ to/in Farsi.Keshavarz (2001) claims that one use of the deferential you/ Šoma/in Persian is reserved for equals in formal encounters as well as for showing a high degree of respect.The key element here, highlighted in resident Amir's interview, is the significance of showing respect in address terms.Reference to his accomplishments suggests his preferred address form among his onomastic layering.Perhaps Amir's consistency in using the deferential/ Šoma/was intended to be recycled, 6 which according to Keshavarz (2001) would signal respect.Recycling the deferential pronoun/ Šoma/through accommodation could also eventually increase the possibility for establishing solidarity.In the literature, it is argued that reciprocal use of either T or V pronoun is intended as a solidarity act (Brown & Gilman, 1960; see also Clyne et al., 2009).

Themes in the accounts of care-providing staff
The second set of the results report three themes identified in analyzing care-providers' accounts, including addressing residents with nicknames, endearment terms, and use of fictive kinship terms.

Addressing residents with nicknames
The two data excerpts in this theme demonstrate the use of nicknames for addressing the residents.On the one hand, Huvik describes how they address a resident with a nickname.On the other hand, Elin reflects about a resident who wants to be addressed with his first name, rather than with a nickname.
Huvik, who speaks Swedish as a second language, has extensive experience working as a care-provider in residential homes.In the interview, which was conducted in Swedish, Huvik reflects on the fact that sometimes residents want to be addressed with their nicknames rather than with their first names.Huvik emphasizes that it is important to call the residents by their first names.However, sometimes residents prefer nicknames.Huvik refers to a resident in the dementia ward whose name is Ingrid and speaks Swedish as her mother tongue; yet Ingrid does not want to be addressed with her first name.Instead, she prefers to be addressed with a nickname, which is Ingse.Huvik says that Ingse protests whenever she is addressed with her first name by new staff and/or substitutes.If residents should be addressed according to their preferences, it seems Ingse does not consider her nickname as a sign of patronizing (cf.Williams et al., 2009).Tensions arise when staff come up with nicknames for residents without considering the individual's chosen address.In some cases, it might even be disliked by residents, such is the excerpt below.
Elin is a native Swedish speaker who has been working in the residential care home for several years.I interviewed her during one of her breaks and she described the form of address she uses in communicating with the resident Seyed-Pasha (excerpt above).While Elin speaks Swedish as her native language, Seyed-Pasha speaks Farsi and Arabic, so they have a limited amount of shared verbal language, which mostly consists of a few English words.

E: Elin E:
m och sedan ibland brukar han säga att till mig så här e:: jag kan m and then sometimes he says to me like this when I E: säga pishi pishi då säger han SEYED-PASHA say pishi pishi then he says SEYED-PASHA 6 Recycling here refers to partial or exact repetition of prior utterance by interlocutors in the progression of interaction (see Anward, 2015).

M. Yazdanpanah
Elin describes that sometimes when she comes up with the nickname Pishi to address resident Seyed-Pasha, he objects and clearly directs Elin to say his first name Seyed-Pasha.It should be noted that the word Pishi in Farsi means kitten and Elin is aware of this fact.Based on my observations, Elin and Seyed-Pasha have developed a friendly relationship in the sense that Elin sometimes starts joking with him and Seyed-Pasha laughs and/or responds both verbally and non-verbally.Although they have developed a friendship, Seyed-Pasha's objection to being addressed with the nickname Pishi is in line with previous findings that the use of nicknames, if undesired, may be perceived by residents as disrespectful (Fairhurst, 1981;Grainger, 2008).

Terms of endearment
The third theme involves addressing residents with terms of endearment.The first excerpt is from the interview with Kajsa, a new care-provider at the home.Kajsa speaks Swedish as a second language and the interview was conducted in Swedish.Although the aim of the interview was clarified beforehand, just before the beginning of the interview, it turned out that Kajsa was not comfortable with being audio recorded because she said that she was not confident enough in her Swedish skills.After making it clear that the interview was part of a separate academic project with no connections to the bureaucracy of the residential care home, and not any type of language assessment, she allowed the interview to be recorded.
At that time, Kajsa had been working several months in the residential care home for people with dementia.K: Kajsa, R: researcher K: ja när jag säger till dem älskling någonting jag blir nånting känsla yeah when I call them love something, I get some feeling K: ja jag älskar dem that I love them R: a: okej men ingen aning om vad den här personen tycker om? yeah okey but any idea whether what that person thinks about it?K: e: jag vet inte till exempel jag jobbar mest med de förstår e:: I do not know for example I work mostly with those who do not K: ingenting () man kan kalla deras namn eller älskling de realize anything () one may call them love or their name they K: förstår ingenting do not realize it According to Kajsa, she usually addresses the residents with terms of endearments such as "little man" and "love".Discussing forms of address in general, Braun (1988) reports that terms of endearment are mostly used in addressing small children or persons to whom the speaker feels close.
Kajsa says that she sometimes addresses the residents with their names.Answering the follow up question about residents' responses to different styles of addressing, Kajsa says that it does not make any difference to them (i.e., They do not realize, presumably due to their dementia).Since she believes it is impossible to access residents' thoughts about their preferred style of being addressed, Kajsa, instead, focuses on her own thoughts and feelings when she chooses a particular form of address.She maintains that when she chooses the term of endearment "love" to address a resident, she gets a feeling of liking the resident.It might be a valid claim that Kajsa's unilaterally choosing a term of endearment contributes to establishing connection for her.On the other hand, it may also generate frustration if residents feel how they are addressed is not based on their personal preference linked to their preinstitutional identity.
One constituent feature of a person's identity is her/his name.Kitwood (1997) refers to a person with dementia living in a residential care home, who describes the facility as if it were her home.In hearing her account, one can recognize that the resident's positive feelings are partly rooted in being known by staff and being greeted by name in the home (Kitwood, 1997).The resident's need for supporting her identity is probably met by the staff's practice of addressing the resident by her name.However, Kitwood's (1997) account does not provide details about the form of addressing the resident by name; in other words, we do not know whether it is the resident's first name, a nickname, or constellation of titles and names.The participants' accounts in Clyne et al. (2009) and also in Kitwood (1997) come from monolingual experiences with people of similar linguistic and cultural backgrounds.However, in the case of the multilingual context of the residential care home where Kajsa works, it is a different story.Here, Kajsa, expresses a lack of confidence in her command of Swedish.This might hinder her from discovering features of residents' identities throughout their lives.Discovering the pre-institutional identity of a resident might pose a challenge for care-providers regardless of their linguistic background yet it is not an issue solely for those who speak the language of the workplace as a second language.
In addition, Kajsa considers the residents with dementia, who are also from different linguistic backgrounds, incapable of distinguishing between various forms of address.Despite the best of intentions, Kajsa's choice of form of address may be distasteful to residents.
In sum, Kajsa's opinion was that she could offer more kindness to the residents through addressing them with terms of endearment such as "love."Yet, the residents' perspectives, preferences and identities -as key elements in forms of address -are missing in Kajsa's approach.The aim of having awareness of the residents' perspectives and identities can hardly be achieved unless in-depth and close dialogue between interlocutors takes place.However, being multilingual may mean having different degrees of competency in different languages, which may result in less having confidence in initiating dialogue in non-native languages.

Fictive use of kinship terms
The last theme selected from the care-providers' interviews is the fictive use of kinship terms.As an example, Monir speaks Swedish as a second language and the interview was conducted in Farsi.She reflects on addressing practices of a resident's name in everyday interaction with him.Just prior to this excerpt, Monir emphasized that she had never addressed Seyed-Pasha with his first name, but instead as "baba", meaning papa in Persian.According to Braun (1988) when a kinship term is used for addressing someone who is not related to the speaker in one way or other, it is called a fictive use of a kinship term.Studying communication in nursing homes, Backhaus (2006) reports a case fictive kinship usage by a staff member addressing a resident in a Filipino-care home for older adults in Manila.According to Backhaus (2006), his example of the fictive use of kinship term represents a strategy for making the asymmetrical power relations acceptable from the resident's point of view.So, while the care-provider addresses the resident with a kinship term, the resident does not entitle himself to recycle a fictive kinship term but replies in a formal and respectful way.However, according to Monir, in the above excerpt, Seyed-Pasha recycles the fictive use of kinship term through calling Monir "papa" or "my dear."This form of address, where a speaker inverts an address form usage which is, or could be, directed to himself, has been referred to as address inversion (Braun, 1988).Furthermore, it is a fictive use of address inversion, because Seyed-Pasha is not related to Monir in the same way as the kinship term implies.
Yet, there is at least one other aspect to be analyzed in Monir's use of the fictive kinship term "papa" in addressing Seyed-Pasha.By calling him this, Monir not only implies that there is an age difference between them, but also perhaps that there is an intergenerational gap between them.In fact, age impacts the degree of social distance when a participant chooses one address form over another (Clyne et al., 2009).However, according to Monir, the kinship term is recycled by Seyed-Pasha when he uses a fictive address inversion.Research shows that verbal recycling may indicate an accommodation practice, and eventually, it can contribute to establishing alignment between participants.We also know from earlier research that speech adaptations towards older people are often discussed in terms of elderspeak (Caporael, Lukaszewski, & Culberston, 1983;Samuelsson, Adolfsson, & Persson, 2013).Although Monir's use of fictive kinship term towards the resident here does appear to be elderspeak, in contrast to the example in Backhaus (2006) where the use of a fictive kinship term serves as a mean of controlling the resident, Monir's practice represents not only alignment, but also solidarity between the participants when it is recycled by Seyed-Pasha.It is claimed that elderspeak may have different effects in a continuum from controlling to supporting.Based on Monir's interview, it appears that Seyed-Pasha does not protest when he is addressed with the fictive kinship term "papa," at least by Monir.

Discussion and concluding points
"What is called 'distortion' or 'misunderstandings' arise precisely from the lack of equivalence [in terms of meanings] between the two sides […]" (Hall, 1973, p.4) So, what's in a name?There are some interesting comparisons that might be made between the classic telling of Romeo and Juliet and the study at hand.For both, time, change, identity, and norms are at play.A difference is that Romeo and Juliet decided by themselves to abolish their names, whereas for the residents, the above quote by Hall appears more applicable; misunderstandings may arise from the lack of equivalence in regard to carers' address practices and residents preferred forms of address.
In the present study, there is mismatch between residents' preferred address forms and terms used by care staff.This is despite the staff's wide variety (21 types) of practices identified and displayed in Table 3.These differences seem primarily to be due to the information available to staff, but perhaps also to cultural norms and habitsfor Swedish natives, being addressed by one's first name out of potentially several names is customary in the 21st century.Previous studies investigating self and identity in persons with dementia show that there is evidence for persisting identity in both mild and moderate to severe stages of dementia (e.g., Beard & Fox, 2008;Caddell & Clare, 2010;Harris & Keady, 2009;Kitwood, 1997;Sabat, 2002;Usita et al., 1998;Vittoria & Cortland, 1999).One element of identity that remains intact for most persons with dementia is their ability to recognize their names (Gross et al., 2004).We see in the opening excerpts that the residents emphasize their pre-residential identities, namely through the use of their names.This is reflected especially when Sara, Oos Pasha, and Ingse express their preferences for names that are different from those on their identification documents, respectively; Farnaz, Seyed Pasha, and Ingrid.Comparing the preferred forms of address by Ingrid and Seyed Pasha, we see while on the one hand, Ingrid prefers to be addressed by her nickname Ingse, Seyed Pasha does not like the nickname Pishi.This supports the claim made by Clyne et al. ( 2009) that address practices are relative insofar as they may be deemed respectful behavior if this is what recipient prefers, while the same form could be disrespectful in an encounter with other actors or if interlocutors are from diverse backgrounds.
In the case of Amir, although he does not express any preferred name, in the interview, he acknowledges that he used to be called doctor + last name when he worked as a pharmacist.Public data reveal that he used to be addressed by his Iranian-Swedish community accordingly before being admitted to the residential care home.Furthermore, when asked how he would like to be addressed, he emphasized his achievements as an outstanding author.Referring to the concept of onomastic layering as the coexistence of older and newer names, Backhaus (2020) argued that for a person there is usually a preferred name that is associated with her/his past accomplishments.Although Amir's response may sound ambiguous in relation to the question about his preferred form of address, perhaps it is related to his struggle to preserve his cherished pre-institutional identity; that is, arguably he is resisting social demotion (e.g., Beard & Fox, 2008).A major social obstacle for those living with dementia is maintaining a valued sense of self and identity in the eyes of others, or "resisting relegation" (Beard & Fox, 2008, p.1513).Perhaps Amir uses his past, as a resource, to counter the way he is positioned by others (e.g., Beard & Fox, 2008;Gilles & Johnston, 2004).
Identity is maintained in the way people present themselves to the outside world and communicates differences in characteristics such as culture, age, gender, social status, etc. Identity and sense of self is also based on a lifetime of affirmation and acknowledgment of self-attributes conferred by others (Gilles & Johnston, 2004).This contrast between presenting identity to the outside world vis-a-vis conferred identity by others has also been discussed within the framework of positioning theory in the context of multilingual interaction and dementia (Lindholm, 2017).Accordingly, there is sometimes a contrast between interactional and reflexive positioning, when culturally and linguistically diverse people with dementia are involved.This discrepancy between reflexive positioning (i.e., how a person positions him/herself) and interactional positioning (i.e., how a person is positioned by others) is observed in the data.On the one hand, the residential care home identifies the residents with the first names in their identification documents; a practice which is in accordance with the agreed address form in Sweden after the du-reform.On the other hand, the residents have their preferred forms of being addressed, which are among the few remaining traits of their pre-residential identities.In interviews with Oos Pasha and doctor Diba cultural systems of address, which differ from Swedish norms, are important.Residents, in interviews with Sara and doctor Diba, show their preference for being addressed with a deferential pronoun rather than an intimate pronoun.In interviews with Oos Pasha and doctor Diba we see that residents' pre-residential address forms are constellations of titles and names.Interviews with Elin, Kajsa, and Monir demonstrate that care-providers prefer to address residents with nicknames, terms of endearment, and fictive kinship terms.While this may reflect care-providers' preference for addressing the residents intimately, the analysis suggests discrepancies between the care-providers' choice of forms of address, which are chosen with the best of intention, and the residents' preferred forms of being addressed.
Previous studies on identity and dementia demonstrate that when social others bestow an identity that is inconsistent with one's view of self, it can cause a threat to identity (e.g., Beard & Fox, 2008;Gilles & Johnston, 2004;Harris & Keady, 2009).This inconsistency between one's own view and the institution's view of name is well expressed here: "Sara is only for myself and Farnaz is for the residential care home".

Practical implications
In dementia care, staff duties are both mentally and physically challenging (Jansson & Majlesi, 2020).There are education programs that aim to prepare those who aspire to work as care-providing staff.Students in these programs receive trainings that prepare them for possible work dilemmas, such as handling residents' affective stance (Jansson & Majlesi, 2020).The findings of this study might be useful in education of care providers with respect to encounters with residents from diverse linguistic and cultural backgrounds.
Effectiveness of interpersonal skills trainings has been reported in numerous fields of care.A study that examined a 20 h interpersonal communications skills training in dental hygiene curriculum found that the experimental group demonstrated considerable differences in knowledge, but not behavior, after the intervention.Follow ups with the students who received the trainings, however, revealed that after oneyear they showed significant improvement in both knowledge and behavior when compared to the control group.This highlights the potential effectiveness of training in interpersonal communications skills for staff.
In care that aims to be person-centered, it is central to attend to the details of life histories of people with dementia, including the way residents were addressed throughout their lives and what they currently prefer to be called.This can be done by asking the residents and/or their relatives and friends if necessary.Paying attention to the way a certain address forms is reacted tolooking for non-verbal responses that perhaps reveal something about a person's preferenceis also vital.Through learning and using the names that are preferred, staff can optimize the maintenance of residents' identities, which would arguably contribute to higher quality of life for residents.
The results indicate that paying attention to forms of address in care for people with dementia is an important contribution in support of their identity irrespective of language but especially in multicultural encounters.Furthermore, cultural sensitivity in choice of forms of address becomes an especially vital factor for culturally and linguistically diverse residents.Lack of a shared verbal language and cultural understanding are potential barriers to staff awareness of the residents' preferred forms of address.Addressing these misunderstanding and obstacles potentially helps all parties, since having residents who are more satisfied and positive may increase the job satisfaction of staff as well.
Future studies should consider other aspects of address forms, such as prosodic features: the pitch, loudness, rhythm, melody, and intonation.It would be interesting to compare, for example, resident and careprovider interactions when the preferred forms of address are used versus where the care-providers do not have knowledge of residents' preferred address forms.After all, when asking what is in a name, the answer is everything.

Declaration of Competing Interest
The author declares no conflict of interest.

Table 1
Participants in observations, field notes, and interactional data.The participants are five residents and 18 caregivers.
a While in the fieldwork audio/video recordings with a focus on participants'

Table 2
Participants in the interview data (N = 26): five residents and 21 members of staff.

Table 3
21 types of address practices in the interactional data, based on analysis of linguistic features.

Table 4
Presentation of the eight themes concerning address forms in the interview-data.