Journal of Gerontological Nursing

Living Arrangements for the Elderly

Margaret R Grier

Abstract

Institutional care for the elderly is a topic of major concern. Some facilities are excellent and provide a high quality of care, but many are badly managed and provide poor care for their residents. Institutional care is needed, and will continue to be needed for a small proportion of the elderly population; consequently, nurses must become more involved in caring for the elderly and in improving nursing home conditions. About 100 years ago much the same thing was being said about hospitals as is being said today about nursing homes. Dr. Ashley's historical analysis of nursing indicated that nurses contributed greatly to making hospital care desirable for the sick,1 and nurses also have the potential to make nursing home care exceptable for the aged.

A problem in providing care for elderly people in any setting is that many older people are in environments incongruent with their needs. One reason for this problem may be that nurses are not adequately involved in the selection of living arrangements for the aged. Nursing's holistic approach, considering all facets of a person's life, can be invaluable in selecting living arrangements for the elderly. But if a living arrangement conducive to maintaining well-being during the aging process is to be chosen, the nurse must have· knowledge of what living situations are available to the older person, of what is expected to happen in those living situations, and of what is desirable in living arrangements.

Two descriptive studies concerning the choosing of living arrangements were conducted to gain understanding of how both nurses and elderly people go about choosing a living situation for the elderly. The process of decision making2 was studied since this process focuses on variables pertinent to choosing living arrangements and also provides a means for selecting living arrangements.

Subjects were given a written description of a patient situation (Figure 1), that of Mr. Thomas, and were to make choices between three living arrangements for him: his own apartment, his son's home, or a nursing home. Twenty-one visiting nurses, 26 hospital nurses, and 16 elderly people ranked the three living situations according to which living arrangement was best for Mr. Thomas. This decision was considered to be intuitive. After ranking the living situations, subjects gave the probability (0-100%) of each of seven needs (activity, dietary, environmental, health care, medication, selfcare, and social) being met in each of the three living situations, and assigned a value to each need (0-100) according to its importance. The quantitative decisions were computed by the investigator from the probabilities and values Σ (Ρ χμ) for each alternative, and the living situation having the highest number was the quantitative choice.

Findings

The data indicate that visiting nurses disagree with hospital nurses, and both groups of nurses disagree with the elderly, when intuitively choosing a living arrangement for Mr. Thomas (Table I). Intuitively, visiting nurses choose the patient's own home, hospital nurses choose the nursing home, and the elderly are divided between these two living situations. The subjects agree remarkably, however, when quantitatively choosing a living arrangement for Mr. Thomas (Table II); about three-fourths of the subjects quantitatively choose the nursing home.

Analysis of the data in Tables I and II reveals that hospital nurses and the elderly have some agreement between their intuitive and quantitative decisions-visiting nurses do not. The intuitive decision of the visiting nurses is in keeping with the actual choice of living arrangement, however, according to the VNA patient record. The patient upon whom the Thomas description was based remained in his own apartment.

A personal and organizational reason for an irrational choice of living arrangement…

Institutional care for the elderly is a topic of major concern. Some facilities are excellent and provide a high quality of care, but many are badly managed and provide poor care for their residents. Institutional care is needed, and will continue to be needed for a small proportion of the elderly population; consequently, nurses must become more involved in caring for the elderly and in improving nursing home conditions. About 100 years ago much the same thing was being said about hospitals as is being said today about nursing homes. Dr. Ashley's historical analysis of nursing indicated that nurses contributed greatly to making hospital care desirable for the sick,1 and nurses also have the potential to make nursing home care exceptable for the aged.

A problem in providing care for elderly people in any setting is that many older people are in environments incongruent with their needs. One reason for this problem may be that nurses are not adequately involved in the selection of living arrangements for the aged. Nursing's holistic approach, considering all facets of a person's life, can be invaluable in selecting living arrangements for the elderly. But if a living arrangement conducive to maintaining well-being during the aging process is to be chosen, the nurse must have· knowledge of what living situations are available to the older person, of what is expected to happen in those living situations, and of what is desirable in living arrangements.

Two descriptive studies concerning the choosing of living arrangements were conducted to gain understanding of how both nurses and elderly people go about choosing a living situation for the elderly. The process of decision making2 was studied since this process focuses on variables pertinent to choosing living arrangements and also provides a means for selecting living arrangements.

Subjects were given a written description of a patient situation (Figure 1), that of Mr. Thomas, and were to make choices between three living arrangements for him: his own apartment, his son's home, or a nursing home. Twenty-one visiting nurses, 26 hospital nurses, and 16 elderly people ranked the three living situations according to which living arrangement was best for Mr. Thomas. This decision was considered to be intuitive. After ranking the living situations, subjects gave the probability (0-100%) of each of seven needs (activity, dietary, environmental, health care, medication, selfcare, and social) being met in each of the three living situations, and assigned a value to each need (0-100) according to its importance. The quantitative decisions were computed by the investigator from the probabilities and values Σ (Ρ χμ) for each alternative, and the living situation having the highest number was the quantitative choice.

Findings

The data indicate that visiting nurses disagree with hospital nurses, and both groups of nurses disagree with the elderly, when intuitively choosing a living arrangement for Mr. Thomas (Table I). Intuitively, visiting nurses choose the patient's own home, hospital nurses choose the nursing home, and the elderly are divided between these two living situations. The subjects agree remarkably, however, when quantitatively choosing a living arrangement for Mr. Thomas (Table II); about three-fourths of the subjects quantitatively choose the nursing home.

Analysis of the data in Tables I and II reveals that hospital nurses and the elderly have some agreement between their intuitive and quantitative decisions-visiting nurses do not. The intuitive decision of the visiting nurses is in keeping with the actual choice of living arrangement, however, according to the VNA patient record. The patient upon whom the Thomas description was based remained in his own apartment.

FIGURE 1DECISION SITUATION FOR CHOOSING LIVING 5 FOR MR, THOMAS "

FIGURE 1

DECISION SITUATION FOR CHOOSING LIVING 5 FOR MR, THOMAS "

The probabilities given for the needs being met in the son's home and in the nursing home are similar for all three groups of subjects (Figure 2). Hospital nurses, visiting nurses, and elderly people all see Mr. Thomas's needs as most likely to be met in the nursing home and least likely to be met in the son's home. For own apartment, however, the three groups of subjects tend to differ in their expectations. The probabilities given for Mr. Thomas's needs being met in his own apartment are lowest for hospital nurses and highest for the elderly.

An interesting feature of the data in Figure 2 is the apparent pessimism of all three groups of subjects regarding Mr. Thomas's needs being met in any of the living arrangements. On the average, both the nurses and older people see the chances of Mr. Thomas's needs being met as only about 50 percent or less.

Analysis of the values assigned to the needs according to their importance reveals no significant differences between the three groups of subjects. Nurses and elderly people both hold similar values for the needs listed, and adjust their values in asimilar manner when choosing living arrangements for Mr. Thomas.

Discussion

Differences between visiting nurses, hospital nurses, and the elderly in choosing living arrangements for Mr. Thomas are probably due to irrational choices, since examination of the probabilities and values of importance does not reveal sufficient variance to account for the differences in decision making. There are three reasons for failing to make rational choices: (a) failure to make the best choice because of personal or organizational reasons, (b) failure to consider all the relevant factors, and (c) failure to use an objective and systematic process in making a decision.2

Table

TABLE INURSES' AND ELDERLY PEOPI.E'STNTUITIVE -CHOICE OF LIVING ΛRRANGEMENT'S FOR MR. THOMAS

TABLE I

NURSES' AND ELDERLY PEOPI.E'STNTUITIVE -CHOICE OF LIVING ΛRRANGEMENT'S FOR MR. THOMAS

Table

TABLE IINURSES' AND ELDERLY PEOPLES QUANTITATIVE CHOICE OF LIVING ARRANGEMENTS: FOR MR.THOMAS

TABLE II

NURSES' AND ELDERLY PEOPLES QUANTITATIVE CHOICE OF LIVING ARRANGEMENTS: FOR MR.THOMAS

FIGURE 2PROBABILITIES (if VEN FOR OCCURRENCE OF OUTCOMES IN CHOOSING LIVING ARRANGEMENTS FOR MR. THOMAS

FIGURE 2

PROBABILITIES (if VEN FOR OCCURRENCE OF OUTCOMES IN CHOOSING LIVING ARRANGEMENTS FOR MR. THOMAS

A personal and organizational reason for an irrational choice of living arrangement may be a societal influence. Society does not view nursing homes as desirable living situations for older people, and attitudes of the elderly parallel that of the society. Shanas reported that to older people an institution was associated with the poor house, senility, and physical decline.3

A common belief about institutions is that they have undesirable effects caused by their "dehumanizing" and "depersonalizing" environments. This view can be supported by a variety of research studies, although Lieberman drew the tenative conclusion that the stereotype of the institution as a destructive setting for the elderly is overdrawn, that many of the psychological effects of institutionalization could be characteristics of the patient prior to admission to the institution, and that some effects could result from changing the patient's environment.4

Nurses also have attitudes that coincide with society's stereotype of institutions, even though these attitudes clash with the nurse's professional knowledge. In choosing living arrangements in this study, several nurses were disturbed about choosing the nursing home as the desirable situation. These nurses seemed to believe the patient's needs could best be met in the nursing home, but experienced conflict about making such a choice.

The conflict between society's stereotyped view of institutions, and knowledge of what is best for Mr. Thomas, could be a factor in the lack of agreement between the visiting nurses' intuitive and quanitative decisions and could contribute to differences in decisions between the three groups of subjects.

Stereotyping may also be reflected in visiting nurses choosing "own apartment" for Mr. Thomas, as opposed to hospital nurses choosing "the nursing home." Visiting nurses are probably more exposed to society's beliefs about institutions since their work setting is the community, while hospital nurses are probably more protected from such influences.

Nurses need to recognize their own attitudes toward various living arrangements for older people. If conflicting views of these situations are held, the conflict must be resolved if reasonable or rational nursing actions are to be chosen. The nurse must recognize the existence of stereotyping and identify how such bias effects patient care.

The goal or objective of living arrangements could also produce differences in the intuitive choice of a living arrangement. A decision maker chooses the action which appears most useful for accomplishing an objective. Different people could hold different goals for living arrangements, and thus could differ in their decisions.

Nichol's study of patient benchmarks in an extended care facility provided evidence that patients and nurses differed in their objectives. In the extended care facility attainment of independence was the goal held by the nursing staff for all patients. Independent functioning was required for discharge, and to the nurses the key to this independence was mobility. Patients' goals were broader and more functional in nature. For instance, patients' goals were to walk in order to garden; to go home in order to eat. Patients' objectives were related to tasks the patients felt were necessary for home functioning and these tasks were not necessarily related to mobility.5

Failure to consider all relevant factors could also explain differences in the data. Knowledge of a given living arrangement can lead a decision maker to choose the familiar situation without giving adequate thought to other alternatives. Thus, visiting nurses tend to choose own home for the elderly person, and hospital nurses choose the institutional setting.

A study in Great Britian indicated that hospital personnel lack information about patients' home conditions and domestic arrangements. According to the findings, patients needed information about aftercare, and hospital staff and the public needed information about community resources.6 Nichol's study reported that patients' homes had different meanings to patients than to nurses; to patients home was a resource for meeting needs and to nurses it was a helpful environment, but potentially hazardous.7

These studies indicated that hospital nurses lack knowledge of patients' home situations, and hospital nurses in the studies being reported may have given little realistic consideration to Mr. Thomas's own apartment or the son's home. Visiting nurses and the elderly could likewise have given little consideration to institutional alternatives with which they were not familiar. The lack of agreement between visiting nurses' intuitive and quantitative decisions indicate this is more likely with the visiting nurses than with the elderly.

Failure to make choices in a systematic and objective manner can also lead to irrational decisions. Choosing living arrangements for elderly people can be improved if a decision making process is used (i.e., if alternative living arrangements are specified and outcomes of the situations are identified, if the likelihood of the outcomes for each situation are estimated, and if the importance of the outcomes are assessed). The choice is based on the probabilities of outcomes occurring and on the importance of outcomes. Living situations should be chosen by a systematic evaluation of what is apt to occur in alternative living arrangements, and not by intuition or rule of thumb.

The process of decision making is valuable for choosing living arrangements since alternatives and their outcomes are identified and assessed. Such a procedure provides a framework for choosing living arrangements in keeping with older people's needs. Identification of discrepancy between expected and desired outcomes leads to effective use of resources for older adults. Assessment of the relationship between possible living arrangements and their expected and desired outcomes facilitates the planning and implementation of care in the chosen environment. The agreement between all three groups of subjects in the choice of living arrangement when quantification is used for decision making is a striking feature of the studies presented. Health care would undoubtedly have more impact if 75 percent of the patients, nurses, and other health care workers agreed with the actions chosen.

References

  • 1. Ashley J: Nursing and early femanism. Amer J Xurs 75:14651467. 1975.
  • 2. Kast F. Rosenzweig J: Organization and Management. New York, McGraw-Hill, 1974, pp 340-434.
  • 3. Shanas E: Living arrangements and housing of old people. In Busse and Pfeiffer (eds); Behavior and Adaptation in Late Life. Boston, Little Brown. 1969, pp 129-149.
  • 4. Lieberman M: Institutionalization of the aged. J Geront 240:330-340. 1969.
  • 5. Nicholas E: Benchmarks of the status passage of elderly persons from institutionalized to noninstitutionalized status. Unpublished Dissertation. Ann Arbor, Michigan, Michigan University Microfilms, 1974.
  • 6. Hardy S: Home from hospital. Nurs Mirror, pp 13-14, Jan 22. 1971.

TABLE I

NURSES' AND ELDERLY PEOPI.E'STNTUITIVE -CHOICE OF LIVING ΛRRANGEMENT'S FOR MR. THOMAS

TABLE II

NURSES' AND ELDERLY PEOPLES QUANTITATIVE CHOICE OF LIVING ARRANGEMENTS: FOR MR.THOMAS

10.3928/0098-9134-19770701-06

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