In recent years awareness has increased in the nursing profession of the importance of involving clients and their significant others in planning clients' care if compliance with a treatment plan is to be achieved. This has meant that nursing has changed its emphasis from "doing" for clients to identifying interventions that encourage their active participation in the decision-making process and in taking personal responsibility for actions that will influence health.
Although nursing has made great strides in promoting self-care within the client's capabilities in noninstitutional or acute settings, similar progress has not been associated with long-term institutional settings, specifically nursing homes. On admission to a nursing home, the resident frequently discovers that many daily activities, such as when to eat, bathe, and sleep, are no longer under personal control but are controlled by institutional policies or established routines. While some of these routines may be necessary to meet the physical and safety needs of the entire community of residents, external control (beyond that which is unavoidable) may have a negative effect on the resident's perception of the nursing home experience and ultimately his/her health.
Since the nursing staff has the more frequent and most direct contact with résidents, nursing can potentially intervene to reverse the negative effects of external control on perception. Specifically, interventions which provide residents with realistic opportunities for personal control of decisions regarding daily activities and environmental conditions could change perceptions of their living arrangement and increase their potential for optimal health.
According to Rotter, locus of control refers to the degree that the individual expects that a contingent relationship exists between one's behaviors (actions) and outcomes (reinforcements).1 Specifically, individuals who expect that reinforcements are determined by personal skills and effort tend to have an internal locus of control, whereas individuals who expect outcomes to be determined by more powerful others, chance, or luck, tend to have an external locus of control.
The individual learns what to expect for a reinforcement as a result of specific social experiences and subsequently expects that a similar reinforcement will occur in related or similar situations. Therefore, an individual's locus of control tendency is a learned phenomenon that is developed over time and, once established, is relatively stable over time and place. Because of this stability, identifying a person's control orientation serves as a predictor of behavior.
This, however, is not meant to imply that an individual's control orientation is permanent. According to Arakelian, a change in control orientation is likely to occur if reinforcements in new social experiences change previous patterns of success and failure.2 This means, then, that the potential always exists for altering a person's expectancy when there are consistent changes in reinforcements.
In order to predict behaviors appropriately, Arakelian states that a distinction needs to be made between two types of expectancies - generalized and situational. Generalized expectancy refers to an individual predicting his/her chance of success in the current situation based on past reinforcements. In contrast, situational expectancy refers to the individual judging his/her chances for success by assessing reinforcements associated with the actual situation.
Both types of expectancies influence behaviors in current situations; however, generalized expectancies exert the most profound influence in a novel or ambiguous situation because of the lack of clarity or information about the contingencies that can be expected, and the extent that the contingencies can be controlled.2 As a result, the person makes inferences and predicts what will happen based on a generalized expectancy.
Specifically, an internally oriented person is likely to judge the situation as controllable, whereas an externally oriented person will judge the same situation as uncontrollable.3 Conversely, the more information or experience that a person has with contingencies in a situation, the more likely it is that situational expectancy becomes the dominant predictor of behavior. This implies, then, that using generalized expectancy as a predictor of behavior at the time of admission to a nursing home would be appropriate if it were a new situation and had a degree of ambiguity; however, for residents of long standing, assessing situational expectancies would be the most appropriate predictor.
It is important to note that an internal orientation does not mean that it is desirable to control all outcomes or that an individual needs to control all outcomes.2 A reality of the life experience is that there are many situations where outcomes are not controllable.
In this situation, a person with an internal orientation has an opportunity to reassess goals and plans, differentiate between what can and cannot be changed, ultimately accept the unchangeable while, simultaneously, taking control of the changeable parts of the situation.
This concept also can be applied to the nursing home situation. Assuming that the older adult is admitted to a nursing home because the care provided in this setting is necessary to meet the resident's health and safety needs, admission to the nursing home is unavoidable. However, there are always some aspects ofthat living arrangement that can be controlled by the resident, such as arrangement of personal belongings and what to wear.
The Influence of Perception on Control Orientation - Several studies show that perception of control is as effective as actual control in determining expectations for influencing outcomes.4·5'6 The findings indicate, in many situations, individuals perceive that they control reinforcements when, in reality, the control is only illusionary. Furthermore, a study by Geer and Maisel indicates that prediction of an aversi ve event, while desirable, was not as effective in decreasing stress as perceived control or the illusion of control.7 This implies that when nurses are unable to permit actual control, interventions that give the illusion of control may be just as effective.
Control Orientation and Helplessness - Seligman identifies the associative relationship between locus of control and learned helplessness.8 Helplessness, according to Seligman, occurs when personal motivation to control outcomes is reduced because the individual expects outcomes to be controlled by external forces. A study by Hiroto shows that individuals perceiving that they lack control over reinforcements frequently gave up, became helpless, and passively submitted to stronger external forces.9 These passive behaviors indicated these individuals believed that they were controlled externally and any personal abilities to influence reinforcements were ineffective or nonexistent.
However, the shift in control tendency from an internal to an external focus, occurs only after the individual has been consistently exposed to noncontingent reinforcements. In contrast, random reinforcements of tasks resulted in more controlling behaviors and hope for internal control over reinforcements, and influence over desired outcomes was retained.10
These findings seem to have implications for nursing homes since nurses in these settings frequently administer policies which are implicitly or explicitly designed to control the residents' behaviors or activities, litis also implies that residents who are consistently exposed to stronger environmental forces for a prolonged period could be expected to become helpless or dependent on others.
Interventions Allowing Control Over Positive Reinforcements and the Positive Impact on Health - Several studies focus on the relationship between allowing institutionalized residents control, or at least the illusion of control, over meaningful, positive reinforcement and the impact on health. Schultz manipulated the degree of control that nursing home residents had over the frequency and length of student visits.11 The findings indicated that personal ability to predict and control meaningful, positive events improved the residents' physical and psychological well-being by either arresting or reversing a decline in functioning.
Chang studied the extent to which older adults, residing in institutions, perceived that they determined the timing and specific places of daily activities as well as their need for assistance and privacy.12 The findings showed that perceived control of daily activities was positively correlated to positive morale of older adults. Langer and Rodin hypothesized that if the deteriorating condition of residents was related to living in a decision-free, controlled environment, then returning control to the resident would improve his/her health. ,3 To test this hypothesis, certain aspects of ward routine that the resident valued were manipulated. The results showed that the treatment group members improved significantly in their level of alertness, activity, and self- reported well-being. The control group did not show significant improvement.
Finally, Mercer and Kane investigated the impact that increased personal control and choice over daily activities had on feelings of hopelessness and functioning level in a nursing home and found that the experimental group had a significant reduction in hopelessness, a significant increase in activity, and positive changes in behavior.14
Providing these options for personal control demonstrates that the potential exists for residents to improve their health status in a variety of ways. In order to have the maximum impact on health, however, it is important that choices or options for control over daily activities correspond to the resident's values. Furthermore, providing options, or the illusion of options, facilitates internals maintaining their control orientation while also promoting appropriate internalization among residents with an external-control orientation.
Independent Nursing Interventions Facilitating Control
From personal experience in practice, many older adults have stated that their greatest fear associated with becoming older is that they will live out their "final days" in a nursing home. They express the fear that going to a nursing home is positive proof that they can no longer live independently - that they have lost control. Thus, when an older adult is confronted with the reality that his/her health needs require nursing home care, a threat is experienced.
Arakelian's findings indicate that adaptation to a threat is facilitated with an internal -control orientation.2 Furthermore, as a group, older adults are more likely to be stronger internals than young adults.15 This indicates that the expectancy for internal control not only continues but becomes stronger as most individuals age. This information has important implications when planning for the care of institutionalized older adults.
It would appear that an appropriate therapeutic goal would be to utilize techniques that facilitate a person either retaining an internal orientation or promoting a balanced internal-external orientation; that is, a balance between selfreliance and seeking assistance when needed.16 This means that, in promoting personal control, older adults can be helped to retain as much independence as personally desirable and realistic considering their health limitations.
Averill has identified three types of personal control - behavioral, cognitive, and decisional.17 Behavioral control refers' to voluntary behavioral responses that directly influence or modify the objective characteristics of a stressor or threat. Cognitive control refers to processing or interpreting information in such a way that a potential threat or stressor is objectively evaluated or appraised. Finally, decisional control involves the opportunity to choose among various alternatives or to be in agreement with a course of action that must be taken anyway.18
In order to determine what the residents' needs are regarding control and what interventions would be appropriate in meeting personal control needs, an assessment is necessary. Two tools, specifically designed for older adults in nursing homes, could be used to assess the resident's perception of personal needs for control.12,19
The tool, developed by Reid, Haas, and Hawkings, would be appropriately used in the admissions process as it measures the resident's desire and expectancy for control in daily activities, arrangement of possessions, recognition and attention, doctor's visits, privacy, and time with friends. The data obtained from this instrument would indicate areas where there might be a conflict between desire for control and actual control possible in the setting. However, if the conflict can be identified, appropriate action can be taken.
In some instances, the resident may be informed about the rationale for having certain policies or rules, such as time of meals, that limit personal control. In other conflict areas, the plan of care can incorporate interventions to meet the resident's personal needs for control.
In contrast, Chang's instrument assesses the resident's perception of personal ability to control daily activities in seven specific categories.12 These categories include ambulating, dressing, eating, grooming, -toileting, group participation, and one-to-one interaction. A period of time of living in the nursing home is needed before the resident can appropriately answer this questionnaire.
The advantage of these instruments is that they are situation-specific, use lay language, and are concise. Furthermore, these tools could be used periodically to evaluate if there had been any change in either the resident's personal desire for control or in perceived ability to personally control daily activities.
Following the assessment, die nurse and resident can determine if there is loss, or potential for loss of desired control in a specific area. Once the problem has been identified, independent nursing interventions can be utilized as appropriate to promote perceived or actual control - behavioral, cognitive, and decisional - among institutionalized older adults. The interventions are as follows:
1. Promote awareness of areas of personal control. Miller states that there is a tendency for an individual to transfer feelings of loss of control in a single area to all areas of one's life.20 Within the environmental constraints inherent in the nursing home setting, the reality is that control of some daily activities, such as time to eat, has been lost. However, this does not mean that all control of the situation has been relinquished. In most settings, residents can arrange personal items in their assigned areas and select clothes they wish to wear.
Residents also need to recognize that they have the right to make their preferences known. Expressing their preference frequently influences such decisions involving their care as roommate selection and the scheduling of one's bath or hair appointments. Providing information about these choices promotes a more realistic perception of the nursing home environment while also facilitating an expectation that control or partial control over certain outcomes is still possible.
2. Provide realistic opportunities to make choices regarding personal care and daily activities when possible. Although the literature lends support for strategies that provide opportunities for residents to make choices, the available data also suggest that providing too many options may have a negative effect.21 To achieve a dierapeutic balance, an appropriate nursing intervention would be to provide options that are consistent with the individual's desire for control.
This strategy would have the dual benefit of limiting the number of options as well as meeting the resident's personal-control needs. For residents valuing experiences with music, for example, interventions providing different alternatives for musical experiences would be appropriate. This same person, however, may not be interested in books, therefore, offering reading opportuni lies would not be appropriate. While the choices in the above example might reflect an actual alternative, it is important to recognize that frequently alternatives are offered only if they are acceptable to both the institution and staff.
For instance, the resident is allowed to choose what clothes to wear each day only because the staff is comfortable with providing that option. This strategy, however, is effective in increasing the perception that the resident has personal control of certain activities when, in reality, control is only illusionary.
As cited in the literature, illusionary control can be just as effective as actual control in influencing perceptions of personal control. While studies are needed to determine the degree of control the physically dependent, but mentally alert, resident desires or expects, providing opportunities for decisional control might be even more meaningful for these people. Such opportunities could reinforce the reality that the capacity still remains to make choices about such concerns as what to wear, where to have possessions placed, and what to eat.
3. Provide opportunities to participate in activities consistent with personal talents, values, and interests. This intervention provides an opportunity for both decisional and behavioral control. Frequently the resident's unique talents and interests remain undiscovered. Yet these abilities may contribute greatly to increasing the quality of life in nursing homes. Talents may be as varied as playing the piano, gardening, or reading mail to others. It is important that these activities be presented to the resident as an opportunity rather than an expectation. To pressure or expect residents to participate does not reflect a priority for meeting the residents' needs but for meeting the needs of staff or significant others who want the resident to display his/her talents or to continue past interests or hobbies.
4. Reinterpret stressors in the situation to reflect reality. This intervention focuses on cognitive control. Through a reinterpretation of the existing situation, the resident is assisted to change personal perceptions and attitudes. For example, some residents may hold the irrational belief that there is no one to talk to in a nursing home. Interventions that provide an objective description of the situation can lead to a cognitive reappraisal of personal beliefs, values, or perceptions. Ultimately, this may result in the resident's perception changing to be more consistent with reality and decrease the threat associated with the situation.
5. Providing counseling and information. Through counseling and/or providing information, the resident is able to recognize that there is a relationship between past and present behavior outcomes. Recognizing that relationship may be helpful to the individual moving to a nursing home. Interventions might focus on the new resident reflecting on the feelings and thoughts associated with previous moving experiences, and recalling what resources and personal skills were helpful in adapting to that situation. The resident could then be assisted to recognize that similar resources and skills could be utilized to influence outcomes and behavior in the nursing home.
Additional interventions could focus on increasing the resident's awareness that he/she possesses transferable skills that can be utilized to facilitate adaptation to other potential changes he/she might encounter, such as a roommate change. In this way the resident is encouraged to become personally involved in making decisions affecting current and future reinforcements/outcomes in one's personal life.
6. Reinforce accomplishment of goals. Miller stresses the importance of reinforcing accomplishment of small daily goals.20 For instance, a male resident verbalizes the desire to increase functional mobility of his arthritic fingers and hands and, as a result, begins an exercise program that is designed to meet that goal. It is essential that any progress towards meeting this goal be reinforced by verbal comments from the nursing staff.
For example, the observation by a nurse that, "last month you were not able to close your fingers around the ball, but now you can," provides a concrete way to measure his progress towards meeting his goal. This type of positive reinforcement can have several benefits: 1) it validates the resident's accomplishment, 2) it serves as an external motivator to continue the exercise program, and 3) it enhances the resident's perception that some control over outcomes (in this case increased mobility of his fingers and hands) occurred as a result of his adherence to an exercise program.
These six categories of interventions are designed to provide residents with realistic opportunities for control of decisions affecting their daily activities. By manipulating reinforcements, the nurse can facilitate a resident's retaining an internal-control orientation, or in the case of a resident exhibiting behaviors consistent with learned helplessness, can promote an expectancy for internal control. The desired outcome, then, is directed towards influencing the resident to perceive that he/she has the ability to control, or at least partially control, reinforcements in the nursing home setting.
When an older adult is confronted with the reality that personal health needs can be best met in an institutional setting, the person's ability to personally control reinforcements is threatened. The literature also indicates that, once an individual is placed in an institutional setting, a shift to an external control orientation may occur. According to Arakelian, an external control orientation is not as likely to result in a positive adaptation to a threat.2
Therefore, the nursing staff can assist in the prevention of these changes with interventions that will facilitate a person either retaining an internal orientation or promoting a balanced internal-external orientation. Research findings support the concept that interventions that promote behavioral, cognitive, or decisional control in institutionalized older adults will maintain or improve overall physical, psychological, and social well-being, enhancing both the quality and quantity of life.
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