Journal of Gerontological Nursing

Functional Interdependence of the Social Environment and the Behavior of the Institutionalized Aged

Pamela B Lester; Margret M Baltes

Abstract

Western society has developed a value system which stresses independent behavior. Culturally, the concept of dependency is sanctioned for children; however, for the elderly who are viewed as dependent, unlike the child for whom it is "becoming," this is a sign of aging or the process of deterioration. For instance, a person needing a sheltered environment, e.g., a nursing home, is á sign of having lost the to live independently and is therefore affected by the stigma of dependency.

The effects and consequences of institutionalization have been discussed widely in the literature on child development, deprivation and stress, and gerontology. It is our intention to put forth a behavioral model which explains dependency in old age as an interaction effect hetween biological deterioration and environmental conditions. It is the intent of this paper to collect empirical data on the environmental contingencies associated with dependency in the elderly.

Theoretical Framework

Dependency is a multidimensional concept which is not innately destructive or negative. Throughout the continuum people interact with their environment and other people in a constant see-saw of independency and dependency. The dilemma for the elderly seems to be created by two major issues: (1) existing cultural value systems in which independency and competitiveness are viewed as virtuous while dependency is the admission of incompetence and worthlessness1; (2) biological changes which lead to losses which in turn affect the behavior and can lead to increased depend' ency. The only question is how many and which of the behavioral changes are main effects of the organism or interaction effects between organism and environment? There is more and more evidence from different areas that many "aging" behaviors are reversible and that environmental and ''biological conditions are at least having an interactive effect upon deterioration.2-4

The operant model, in specific, explains theacquisition of dependency with aging as a function of: (a) the presence of reinforcers following dependent behaviors; (b) the absence of punishers following dependent behaviors; (c) the presence of punishers or lack of reinforcers following independent behaviors. Thus, in order to change dependent behavior into independent behaviors, environmental conditions (consequences plus antecedents) have to be redesigned. Operant studies which have concentrated on dependent behaviors have shown high success in reversing such behaviors as nonwalking,5 noneating,6'7 non self-care,8 and nonsocial behaviors.9 It should be mentioned here that the effectiveness of the operant model in behavior change in the elderly has been demonstrated in other areas such as intellectual performance, social behaviors, and symptomatic behaviors."**'"0 All of the studies up to date, however, are manipulative microlevel short-term studies. None of the studies had as the main goal the description of the existing ecology of the elderly in the institution across subjects and time. Such descriptive data would lead to empirical findings which would allow for taxonomies of environmental conditions and behavioral events which, in turn, then would allow for large-scale interventions. We have sketchy knowledge of the arguments that institutionalization and institutional environments, in particular, seem to hasten and enhance decline in the elderly.11'12 Several researchers, for instance, Tobin,13 McDonald, Butler,5 and Lawton and Brody14 have argued that due to the custodial character of institutions, dependency is fostered and aged sick-role accepted by staff and the elderly him /herself. Independency of behavior is sought after but inadvertently extinguished. Thus, the very dependency that is deplored by the staff and others is simultaneously reinforced by them.15'16

One exploratory observational study by Mikulic16 could be found in the literature. Mikulic observing eight patients in an extended care unit found that nursing personnel more consistently reinforce dependent behaviors than independent behaviors both verbally and non verbally. No negative…

Western society has developed a value system which stresses independent behavior. Culturally, the concept of dependency is sanctioned for children; however, for the elderly who are viewed as dependent, unlike the child for whom it is "becoming," this is a sign of aging or the process of deterioration. For instance, a person needing a sheltered environment, e.g., a nursing home, is á sign of having lost the to live independently and is therefore affected by the stigma of dependency.

The effects and consequences of institutionalization have been discussed widely in the literature on child development, deprivation and stress, and gerontology. It is our intention to put forth a behavioral model which explains dependency in old age as an interaction effect hetween biological deterioration and environmental conditions. It is the intent of this paper to collect empirical data on the environmental contingencies associated with dependency in the elderly.

Theoretical Framework

Dependency is a multidimensional concept which is not innately destructive or negative. Throughout the continuum people interact with their environment and other people in a constant see-saw of independency and dependency. The dilemma for the elderly seems to be created by two major issues: (1) existing cultural value systems in which independency and competitiveness are viewed as virtuous while dependency is the admission of incompetence and worthlessness1; (2) biological changes which lead to losses which in turn affect the behavior and can lead to increased depend' ency. The only question is how many and which of the behavioral changes are main effects of the organism or interaction effects between organism and environment? There is more and more evidence from different areas that many "aging" behaviors are reversible and that environmental and ''biological conditions are at least having an interactive effect upon deterioration.2-4

The operant model, in specific, explains theacquisition of dependency with aging as a function of: (a) the presence of reinforcers following dependent behaviors; (b) the absence of punishers following dependent behaviors; (c) the presence of punishers or lack of reinforcers following independent behaviors. Thus, in order to change dependent behavior into independent behaviors, environmental conditions (consequences plus antecedents) have to be redesigned. Operant studies which have concentrated on dependent behaviors have shown high success in reversing such behaviors as nonwalking,5 noneating,6'7 non self-care,8 and nonsocial behaviors.9 It should be mentioned here that the effectiveness of the operant model in behavior change in the elderly has been demonstrated in other areas such as intellectual performance, social behaviors, and symptomatic behaviors."**'"0 All of the studies up to date, however, are manipulative microlevel short-term studies. None of the studies had as the main goal the description of the existing ecology of the elderly in the institution across subjects and time. Such descriptive data would lead to empirical findings which would allow for taxonomies of environmental conditions and behavioral events which, in turn, then would allow for large-scale interventions. We have sketchy knowledge of the arguments that institutionalization and institutional environments, in particular, seem to hasten and enhance decline in the elderly.11'12 Several researchers, for instance, Tobin,13 McDonald, Butler,5 and Lawton and Brody14 have argued that due to the custodial character of institutions, dependency is fostered and aged sick-role accepted by staff and the elderly him /herself. Independency of behavior is sought after but inadvertently extinguished. Thus, the very dependency that is deplored by the staff and others is simultaneously reinforced by them.15'16

One exploratory observational study by Mikulic16 could be found in the literature. Mikulic observing eight patients in an extended care unit found that nursing personnel more consistently reinforce dependent behaviors than independent behaviors both verbally and non verbally. No negative reinforcement of dependent behaviors was found.

The present study was conducted with two principal goals in mind: (1) to examine in a more systematic way, using a short-term longitudinal strategy, environmentbehavior interactions - specifically, to look at dependent behaviors in the elderly and their consequences in terms of staff behaviors; and (2) to outline nursing implications for more optimal environmental designs.

Methodology

Hypothesis.

The increase of dependent behaviors and the decrease of independent behaviors are directly related to positive verbal reinforcers made contingent upon dependent behaviors and negative or nonverbal contingencies upon independent behaviors.

Definition of Terms

1. Independent Behavior

Rating Scale:

a. Performance of an activity of daily living without assistance.

b. Requires equipment to be set up but then performs the activity unassisted.

c. Verbal responses of resident which focus on strengths and not weaknesses. For example, "I'm getting out of bed." "I can dress myself." "I can do it."

2. Dependent Behavior

Rating Scale:

a. Acceptance of total or partial care provided by another when such acceptance is not congruent with his demonstrated ability.

b. Verbal responses which focus on disability rather than his ability; comments about being sick, weak, unable to do things.

3. Reinforcing and Punishing Events

a. Reinforcing events include verbal approval, praise, and agreement.

b. Punishing events include verbal disagreement, verbal disapproval.

4. No response

a. Neither verbal nor nonverbal response made contingent upon statements or behaviors oí the elderly.

Population and Sample

A nonprofit skilled nursing home organized as an independent corporation with a 240-bed capacity was selected as the setting. During the study there were 234 residents. One floor with two nursing areas with 78 residents was chosen as the experimental setting. The 78 residents were stratified according to: ( 1 ) their level of physical functioning; (2) their level of mental functioning; and (3) their ability to verbally communicate, / assessed via the Functional Assessment Ability Scale17 iI in order to only pool mentally alert residents. Of the 78 residents, 56 scored in the 20-33 range (total possible score = 60). From these 56 elderly, 22 were randomly selected and constituted the final sample.

All 22 subjects had at least one diagnosed medical problem necessitating skilled nursing care. Physical disabilities ranged from severe crippling rheumatoid arthritis to residual paralysis of a nonhealing fractured wrist.

The 22 subjects ranged from 69-102 years, with a mean age of 88 years, and a standard deviation of 8.3. The five male subjects had a mean age of 89, while the 17 females had a mean age of 81.94 years. The length of residency ranged from one month to 100 months, with a mean of 40.5 months.

Design and Procedure

A repeated-measure design was used in this observational study. The observation schedule was set up as a combination of event-sampling18 and time-sampling. Event-sampling referred to such behavioral events as arising, toileting, mouth care, dressing, walking, eating, evening hygiene, undressing, and retiring. During those events, time- samples of ten-minute intervals of observation and of ten-minute nonobservation are used. During a ten-day period observations were made each day from 5:45 A.M.- 12:00 P.M. which consisted of behavioral events related to arising, dressing, personal hygiene, ambulating to the dining hall; and eating and from 6:30 P.M.-9:00 P.M. which included observations of behavioral events such as undressing, personal hygiene, and retiring. Total observation time amounted to 46.5 hours with 38.5 hours during the hours of 5:45 A.M. and noon, and seven hours observation time between 6:30 P.M.-9:00 P.M.

FIGURE 1MEAN PERCENTAGES OF BEHAVIOR OVER ALL CONSEQUENCES. OBSERVATIONS. AND SUBJECTS

FIGURE 1

MEAN PERCENTAGES OF BEHAVIOR OVER ALL CONSEQUENCES. OBSERVATIONS. AND SUBJECTS

A counter-balanced sequence of observation each day was planned but not feasible because the staff had organized a strict daily routine schedule for waking and caring for the residents. Thus, in order to secure daily observations on each subject, the staff pattern instead of a counter- balanced sequence in observing the subjects was followed.

Observations were recorded by the author. To control for experimenter bias and to test for reliability, it was planned to use a tape recorder. After trial observational sessions with a tape recorder, it was discarded because it obviously impeded resident- staff interaction. Interrate reliability was assessed two times during the morning hours between two naive observers and the author. The reliability coefficient, looking at agreements over total number of observations, was .88 and .95, respectively.

The observations were recorded by the author on a prearranged recording sheet allowing the functional description of behaviors of the elderly and the staff. Any behavior by the elderly which happened during a tenminute interval was entered on the recording sheet. A verbal consequence by the nurse was recorded verbatim when it occurred with a two^minute interval after the behavior of the elderly. A no response was recorded if nothing was said by the staff within a two-minute interval. The two-minute interval also defined whether a new behavior on the part of the elderly was recorded.

The functional observations were then classified, first into type of behavior: dependent behavior (DB) versus independent behavior (IB), and secondly into type of consequence following that behavior: reinforcement (R), punishment (P), or no response (NR.) per subject.

FIGURE 2MEAN PERCENTAGES OF CONSEQUENCES OVER ALL BEHAVIOR, OBSERVATIONS. AND SUBJECTS

FIGURE 2

MEAN PERCENTAGES OF CONSEQUENCES OVER ALL BEHAVIOR, OBSERVATIONS. AND SUBJECTS

Results

Data were analyzed by assessing the frequency of the two types of behavior followed by one of the three consequences. Because of the high intersubject variability in frequency of behaviors, a standardization method using percentages was applied; that is, the overall score of a subject's behavior was recorded as 100 percent. This allowed the expression of each sum of behaviors per consequence per subject in percentages. Figures 1 and 2 show the mean percentages for the type of behavior and the type of consequences across all subjects and observations.

FIGURE 3MEAN PERCENTAGES OF DEPENDENT AND INDEPENDENT BEHAVIORS OVER SUBJECTS AND OBSERVATIONS

FIGURE 3

MEAN PERCENTAGES OF DEPENDENT AND INDEPENDENT BEHAVIORS OVER SUBJECTS AND OBSERVATIONS

A statistical analysis using analysis of variance reveals: (a) a significant main effect for the consequences (df = 2, F = 13.5, p => .001); (b) no significant main effect for behavior df = 1, F = .7, ? =>.410); and (c) an interaction effect between behavior and consequences; specifically, dependent behaviors are most often followed by reinforcement and independent behaviors are most often followed by reinforcement and independent behaviors by no response consequences (df = 2, F= 11.8, p = <.001). Figure 3 represents the results graphically.

Discussion

The present findings support the hypothesis that the behavior of the elderly is influenced by his/her physical and social environment, including the nursing personnel in the institution. Specifically, it can be seen from the data that positive verbal reinforcers are significantly more often contingent upon the occurrence of dependent behaviors as compared to independent behaviors. Furthermore, the results demonstrate that no response as a consequence, which extinguishes behavior, most often follows independent behaviors.

Accordingly, the present results, indeed, support the notion brought forward in recent gerontological findings that elderly behavior* is at least partly determined by environmental conditions. The argument that dependency in old age is maintained and fostered, perhaps inadvertently and unknowingly by the environment itself, specifically by verbal and nonverbal actions of the nursing staff, is supported empirically by the present findings. Given the functional relationship between behaviors and environmental events, dependency is increased and independency decreased in the elderly nursing home resident. The higher frequency of no response over punishment as contingency might be due to the unique situation, in that the present setting can be described as a "better" nursing home as expressed by the residents, their family, and the staff. Indeed, it is the belief of the authors that the present results are conservative estimates of reinforcing or punishing verbal consequences used by the nursing staff. Due to the fact that the institution in the present study was unique in its implemented philosophy, emphasizing and fostering family ties and independency of their residents, we would argue that in the more typical nursing home setting the punishment category would increase for independent behaviors and the reinforcement category for dependent behaviors.

A word of caution is necessary here. In addition to the uniqueness of the sample and setting which might have tilted the data findings, methodological shortcomings diminish the generalizability of the present findings despite the statistical significance of the data. Both observation and scoring were done by the first author, allowing possible experimenter bias to go uncontrolled. In addition, a procedural question arises. A counterbalanced sequence for observation of the elderly 's behavior was not used since the author found it necessary to follow the routine of the institution in order to observe interaction between the staff and elderly. In addition, the sampling was restricted to the more dependent resident. Thus, the verbal consequences by nursing staff might very well be already a consequence upon direct situation-related expectations of the eldexly's capaci ty. In order to further substantiate our findings, the study should be replicated with a more diverse sample and heterogeneous ethnic groups in different nursing homes and with more controlled reliability procedures, utilizing an unobtrusive method of observation, such as videotaping and additional observers to allow generalization across subjects and settings.

Despite these limitations, the findings should increase the awareness in nurses that it is their behavior, their actions, verbal or otherwise, that greatly influence the functional ability of the elderly.

A conscious and active stance can be taken by the nurse in the design of the nursing home environment which would emphasize: (a) the strengths of each client in order to consciously reinforce independent behaviors instead of the problems or weaknesses of the clients; (b) a more consistent and stable interaction pattern between specific staff members and peer residents in order to establish the significant other reinforcing agent to care for and especially, acclimate the newcomer to avoid initial drop in independency; (c) awareness arising in nursing personnel that no response (NR) according to learning principles will lead to extinctions of preceding behaviors as much as punishing or aversive consequences.

In general, it seems to us that nurses have until now widely missed their role as change agent, specifically as a behavior change agent in institutions. Doubtless, they are the most logical choice to fill that role and thus help the elderly to optimize their functioning enhancing dignity and happiness of their lives in an institution.

Acknowledgment

We would like to thank Dr. Robert Burgess, Dr. Elaine Brody, and Dr. Carol Panicucci for their assistance and cooperation.

References

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10.3928/0098-9134-19780301-06

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