The literature suggests that one-third of all people admitted to nursing homes die within one year.1 Concern about the "forgotten two-thirds" led to the development of this exploratory study. The purpose of this investigation was to provide information concerning the factors characierizing adjustment Of older individuals who survive in nursing homes. Knowledge of adjustment factors as perceived by residents potentially can help nursing home personnel improve resident care. Existing nursing care patterns can be altered according to factors correlated with adjustments
In spite of the negative image of nursing homes, the number of older people entering these institutions is increasing. According to Wershow, the number of institutionalized elderly over the age of 70 years is closer to 23% rather than the often quoted 4%.2 Entry intoan institutional setting generally is related to assuring survival through maintenance of residual capacities and restoration of lost function. In a limited study, Spasoff and others found that only about 3% of nursing home residents would be able to continue living at home. The remaining 97% were institutionalized because of serious health problems and mandatory nursing care.3
In the view of many gerontologists and health care providers, nursing homes are considered to have profound negative effects on older persons. Few attempts have been made to systematically determine positive effects. As noted in the study by Tobin and Lieberman, many elderly people fear the possibility of ending their years in an institution.4 Various studies indicate higher mortality rates among people moving to nursing homes as compared with people who have not moved.5"9 Other studies report minimal change in death rate after relocation. Although the positive effects of residing in nursing homes is not addressed in these investigations, questions are raised about the validity of the mortality figures in the relocation literature.10-14
In addition to mortality, the effects of institutionalization have been stated in terms of self-esteem and life satisfaction. According to Schwartz, the linchpin of quality of life for the institutionalized aged is self-esteem.15 In an investigation of the psychological and social correlates of life satisfaction, Wölk and Teilen support the importance of selfesteem.16 High levels of correlation between life satisfaction, adjustment, and morale also were established by Lohmann.'7 Further investigation into the specific effects of institutionalization, however, are necessary in order to obtain a realistic and comprehensive picture of the needs of older people who survive in nursing homes.
Key Study Questions
Key questions were developed as the result of an earlier pilot study involving intensive interviews of nursing home residents and conversations with directors of nursing in the nursing homes. The following questions guided the investigation:
1. What are the correlates of adjustment in nursing homes?
2. What is the pattern of interaction among the key variables?
3. What are the levels of adj ustmen t?
A purposive sample of 50 individuals was selected from two licensed nursing homes, one a sectarian rural home and the other a nonseetarian urban home. Nurses in the facilities were asked to identify residents who fulfilled the following criteria: at least 60 years of age, mentally competent to respond to questions, English speaking, and able to hear. Both men and women were included. After explaining the nature of the study, potential participants were asked to sign a consent form. Confidentiality was assured by utilizing a number coding system on the questionnaires. Names were not linked to the answers and individual questions were not shared with staff in any form that could identify the residents.
Data were collected by utilizing a 122item questionnaire. The items were developed as a result of an earlier pilot phase involving eight selected nursing home residents. The interviews involved open-ended questions that reflected Lawton's definition of adjustment/ morale.18 As a result of the literature search, the questions were categorized as follows: length of time in the particular facility, comfort experience in living there, former residence, extent of involvement both in activities within the facility and activities outside thefacility, change in self-care ability since admission, self-expectations, and value of life.
After the interviews were completed, the tapes were transcribed. Two nurse reviewers closely scrutinized the transcripts and the following categories evolved:
Decision to enter home
Perception of nursing home
Response to relocation
Adjustment to relocation
Perception of health
PERCENTAGE IN EACH ADJUSTMENT LEVEL BY AGE
Proximity to acute care resources
Satisfaction with nursing home
Futurity of goals
Based on these categories and the literature review, a questionnaire was developed that included forced-choice and open-ended questions.
Design and Data Collection
This study was exploratory in design. Data were collected over a two-month period by nurse-administered questionnaires. The two interviewers were masters-prepared nurse gerontologists who were able to review medical records and assess functional ability.
The interviewers interacted with the residents suggested by nursing home nurses and directors of nursing. Only persons who were willing to participate in the study were interviewed. The data were collected in the residents' rooms or in settings where the respondents' privacy could be maintained and one-toone interactions were possible. The interviews lasted an average of 60 minutes. Following the interviews, the participants' medical records were reviewed for relevant data regarding birthdate, date of admission, place transferred from, availability of transfer notes, admission and current mobility, and medical diagnosis.
Although 50 persons were interviewed, only 49 of the questionnaireguided interviews were completed and yielded usable responses. The responses to forced-choice questions were tabulated. Categories were developed for responses to open-ended questions. A panel of four nurses reviewed the categories and assigned the responses to the designated categories. A discrepancy in the placement of responses was resolved after a discussion and consensus was obtained among the four reviewers.
Variables were designated and a data dictionary was developed. The data were placed into the MTS/MIDAS system. The variables identified as being representative of environmental adjustment were derived from the following questions: Since you moved here, how do you feel? (feelings since move to nursing home); Since you came to live here, are you happy? (happiness); Are you pleased - do you sometimes feel good - about having moved here? (pleasure); Are you satisfied with your life here? (satisfaction); and Are you comfortable living here? (comfort).
Since the correlation among the environmental adjustment variables was significant, an environmental adjustment scale was designated as consisting of the selected variables. The possible overall adjustment scores ranged from 1.00 to 2.40. Scores of 1.001.49 indicated high adjustment; scores of 1.50-2.40 were indicative of low adjustment. To identify the variables significantly associated with environmental adjustment, ANOVA and Twoway Cross Tabulations were done.
Results and Discussion
The major portion of the residents in this study were 80 years of age and older and predominantly female. Seventy-two percent were widowed. Immediately prior to moving to the nursing home, the majority of the residents were in the hospital or another nursing home. Very few came from their own homes. About half of the residents lived in the nursing home two or more years with a surprising number (22%) in residence more than five years. (See Table 1.)
Of the 49 participants, 51% received a high adjustment score. As indicated in the Figure, a greater percentage of highly adjusted persons were in the young-old (62-69 years) category. The greatest number of low adjustment scores was obtained by persons in the old (70-79 years) category.
The correlates of adjustment were determined by doing a Twoway Cross Tabulation. A chi-square with a p value of less than .05 was considered significant. As indicated in Table 2, adjustment was correlated with the following variables:
* Çxperience difficulty in living with unrelated others
* Find humor in everyday happenings
* Have desired qualities in present nursing home
* Think present living is best suited for now
* Had no change in amount of sleep in last 3-4 weeks
* Wish doctor were more available
* Have enough to do
* Have many visitors
* Satisfied with life now
* Feel doctor is concerned
* Feel useful as a person
* See life as being worthwhile
Key Indicators of Adjustment
Perception of Nursing Home
Residents' perceptions of the nursing home seemed to influence their adjustment. When the present living situation was viewed as being the best suited for now and the desired qualities were present in the nursing home, the residents were better adjusted. The factors most commonly cited as influencing the desirability of a nursing home included the necessary provision of care and personnel characteristics. The concern and availability of the physician also seemed to be critical for adjustment. Of the persons interviewed, at least 60% felt that their expectations of the physician were fulfilled. The most highly adjusted residents felt that their physician was both concerned and available.
Adjustment to Relocation
While the study showed that highly adjusted persons found no difficulty in living with unrelated others, this finding must be interpreted cautiously. Other factors may make living with unrelated others easier. Persons with many visitors, for example, may not depend as much on other residents to meet their affiliative needs.
A lack of change in the amount of sleep seemed to characterize the highly adjusted persons. No data was obtained to determine the exact amount of sleep for each person. Residents' statements regarding their usual sleeping patterns, however, revealed that 37% slept soundly all night, 33% sometimes awakened but( went right back to sleep, and 30% sometimes awakened and could not go back to sleep. Reasons given for interrupted sleep included noise, urge to void, and dreams. In order to prevent awakening during the night, several residents noted that they took sleeping medication or went to bed later at night.
Finding humor in everyday happenings seemed to be associated with high adjustment. While some residents found humor in interactions with the staff, others perceived humor in the actions of other residents. Residents noted that the following situations elicited humor: listening to the complaints and jokes of other residents, teasing younger people and the staff, hearing comments that nurses make to each other, doing things that the nurses are not aware of, observing the behavior of other residents, and reading funny incidents in the newspaper.
Interaction and Activity
Since highly adjusted persons reported many visitors, adjustment seemed to be enhanced by interaction with visitors. Family and friends were cited as the most frequent visitors. Of the residents interviewed, 80% reported having visitors at least monthly.
Highly adjusted persons indicated that they had enough to do. Of the interviewees, 63% stated that they participated in the planned activities available in the nursing home. The desire to participate in "meaningful" activities frequently was expressed by the residents. While activity seemed important, 78% noted that they also had enough time to be alone.
DEMOGRAPHIC CHARACTERISTICS OF RESIDENTS
CORRELATES OF ADJUSTMENT
Perception of Own Life
Self-perception seemed important for high adjustment. Highly adjusted persons saw life as worthwhile, felt useful as persons, and found satisfaction with their current life. Factors contributing to positive self-percepdons included positi ve feelings about past accomplishments, interactions with significant others, ability to get around, participation in meaningful tasks, helping others, and ability to do things for self.
The findings of this study emphasized the importance of thoroughly assessing nursing home residents. Special attention needs to be given to the residents' expectations regarding the nursing home, perceptions of the physician's concern and availability, feelings about living with unrelated others, usual amount of sleep, self-expectations in relation to activities, type of humor, interactions with family and friends, and perceptions of own life. Incorporation of this assessment information into the plan óf care potentially will contribute to the residents' adjustment to the nursing home.
Not only is assessment of needs important, but attention should be given to matching activities with individual needs to produce the outcome of adjustment. It is not enough to formulate care plans for meaningful activities - they must be created. These activities need not be expensive. Some of the most frequently described meaningful activities in this study were delivering the paper or messages, assisting with light tasks, and participating in patient care councils.
Primary nursing is not possible in most homes but it is possible to have a key contact nurse. The same nurse or nurse assistant who communicates with the same group several times a week may be involved in direct care some days and only conversation on others. This contributes to better relationships between residents and staff. The importance of casual conversation especially was noted in this study.
The recognition of humor was found to be extremely important, yet in many homes it is neglected sorely. Find out what makes residents laugh. If nobody in your particular nursing home ever smiles or laughs, you need to know why. This is a difficult response to encourage unless staff members are happy. Perhaps there are implications for the kind of staff hired as well as the kind of activities planned.
Rest and comfort in the form of sleep contributed to adjustment. There are many implications - attention to elimination patterns, control of noise, and planning sleep schedules to allow for periodic naps. Some patients prefer to have wakeful periods during the night. Adherence to former sleep patterns, if possible, appears to contribute to the residents' adjustment to the nursing home.
Again and again, the project nurses became aware of the importance of selfesteem and recognition of individualism. Friendliness and attention to requests contributed to positive feelings about nursing home personnel. It is possible to make residents feel useful in a variety of ways, many of which are not costly or demanding of time. This might include keeping favorite items from home that require special attention by the resident.
Everything cannot be changed in a given nursing home nor does it need to be. The findings in this study imply that it is important to identify those quality activities that seem important to residents and concentrate on emphasizing and reinforcing them. If particular staff activities seem to be more rewarding than others, they should be promoted.
The size and composition of the sample were major limitations in this study. Fifty residents were nonrandomly selected from two nursing homes. Only coherent and verballycommunicative persons were interviewed. No attempt was made to identify the adjustment characteristics of other residents. The findings of this study, therefore, cannot be generalized to other populations.
Implications for Future Nursing Research
The findings suggested several areas for future investigations. Studies could focus on improving the image of nursing homes through a variety of demonstration projects testing flexible options in nursing care. Identifying the correlation between adjustment and the problems of impaired mobility, incontinence, and confusion could provide the framework for useful investigations. Other studies could measure the effects of humor and meaningful activities on mobility and cognition.
An unexpected finding during this study was the interest shown by nursing home personnel. They were very interested in improving nursing care and in contributing to a positive focus for care. Collecting data from nursing personnel, therefore, could provide additional useful information.
Overall, the investigators were impressed that the elderly interviewees generally were positive about their living situations. In spite of the dismal view of nursing homes portrayed by the media, this study showed that institutional living is not necessarily negative for all residents. The characteristics of highly adjusted persons indicated that factors both within the environment and inherent in the individual residents contributed to adjustment.
The complexity of health problems exhibited by the nursing home residents emphasized the need for quality comprehensive nursing care. Consideration of physical and mental functional abilities needs to be incorporated in each resident's plan of care. Furthermore, modification of the care plan needs to be made as alterations occur in functional status.
Research and practice based on the need for improvement of nursing home care have been neglected sorely by professional nurses. The findings of this study reiterated the importance of continuing the search for developing strategies to enhance optimal care in nursing homes. Stimulating, creative nursing home environments need to be developed whereby both nursing personnel and residents can benefit.
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DEMOGRAPHIC CHARACTERISTICS OF RESIDENTS
CORRELATES OF ADJUSTMENT