The 20th century has seen a rapid growth in the percentage of the population aged 65 and older in the United States. Projections indicate the elderly will comprise 12% of the general population by the year 2000 and 17% by 2030.1 Concurrently, there has been a dramatic increase in the number of long-term care facilities. While the number of individuals 65 and older increased 23% between 1960 and 1976, the number of nursing homes increased 140%, and nursing home beds increased 302% during the same time period.2
If current trends continue, the older population in nursing homes will double in 35 years from 1.3 million in 1985 to 2.8 million in 2020.3 In the United States, approximately 5% of the population over 65 reside in long-term care facilities, and one fifth of all older persons over 85 live in nursing homes.3 Twenty-five to 30% of deaths in individuals 65 and older occur in these extended care facilities.4
These statistics suggest that it is important for nurses and other health - care providers to be aware of and investigate the psychosocial, as well as physical, needs of residents in long-term care facilities. This article describes results of a study designed to explore the relationship between residents of long-term care facilities and the nursing staff. Residents' perceptions of the nursing staff and the association to their life satisfaction is also examined.
Although institutionalized care has improved in recent years, negative effects of institutionalization are well documented. Some of these effects include; depersonalization of the individual, loss of identity, and development of docile behavior.5 Life in an institution can strip away the very essence of a person - his/her dignity and self-worth.6 Humane living, a positive self-image, and morale come from opportunities for meaningful personal contact that are frequently not met in the regimentation and impersonal care of total institutions.
Placement of the elderly in a longterm care facility at a stage of life characterized by physical, psychological, and social losses, to which long-term institutional confinement can contribute, may have devastating effects.7,8 Comparison of mortality rates for individuals who were institutionalized and those on a waiting list demonstrated that mortality rates were apparently related to impact of institutionalization - not age or physical condition on admission.9 Moreover, an increased number of deaths has been shown to be related to the social and psychological stresses of relocation rather than to physical condition.10
Improvement in quality of care in institutions usually implies better medical treatment, upgraded facilities, and improved physical care,11 but quality of care also depends on the attitude of the nursing home staff. Loving and caring attitudes and interaction between staff and residents can create an atmosphere that fosters self-esteem and satisfaction. Maslow12 stressed the importance of interpersonal relationships, love, affection, belonging, self-esteem, and the esteem of others to achieving self-actualization. These needs are met through social interaction.
How people interact with the elderly is in part a result of how society perceives the elderly. "Ageism" views the elderly in negative and Stereotypie ways, regarding them as different rather than unique individuals.13 Health professionals also tend to overemphasize behaviors (eg, dependency and incapacity to meet their own needs), which fosters the attitude that others know better than the elderly what is good for them.
In nursing homes, staff attitudes influence behavior and care.14,15 The majority of staff in nursing homes have been found to view the elderly as dependent, which results in the loss of the adult status role for the elderly, and to make considerable effort to avoid becoming involved with residents.16 If improving the quality of life in institutions is a priority, it appears that attention needs to be focused on resident/ staff relationships.
There have been few studies investigating residents' perceptions of the nursing staff. Dorm'nick, et al17 found that only 19% of nursing home patients reported free and open communication with nurses. Millerand Russell18 found that "aloneness" was a major factor in life satisfaction of the subjects they evaluated. Their subjects felt "comfortable" with the nursing staff, but the nature of resident/staff relationship was not investigated.
Walsh and Kiracofe19 found that the presence of a significant other was a positive factor in the life satisfaction of institutionalized elderly and that changes in significant other occurred following institutionalization. Prior to institutionalization, most elderly reported that a relative was their significant other. However, after a period of residence, an institutionalized friend was designated as their significant other. Nursing staff were not included in this study as a possible choice.
Significance to Nursing
The nature of long-term care makes it imperative that a holistic philosophy be a hallmark of care. Social and psychological well-being increases the ability to cope with health problems and functional limitations, and ability to still maintain autonomy despite increased age.
Nurses are the most numerous health-care providers within long-term care facilities and must take responsibility for reversing the damaging effects of institutionalization and improving the quality of residents' lives. Nursing recognizes the importance of interpersonal relationships between nurse and client. Nurses' expectations and beliefs are conveyed to the elderly and may have a significant impact on how they feel about themselves.20 In longterm care facilities, this relationship has added significance. Institutional living contributes to the social isolation that often occurs with aging, and nursing staff may be the residents' friends, significant others, and confidants, as well as caretakers.
This descriptive study examined the relationship between life satisfaction and perceptions of the nurse/resident relationship. Elderly residents were interviewed in an attempt to identify the association between life satisfaction and perception of the nursing staff. The interview schedule developed for this study consisted of six sections:
1. Demographic data were collected and used to provide a descriptive profile of the sample.
2. The Life Satisfaction Index developed by Neugarten et al21 measures life satisfaction independent of level of activity and social participation. Following this subjective testing, the Life Satisfaction Index A (LSIA), consisting of 20 items, was developed. The instrument has been used extensively with the elderly population in its original and modified form.22,23 The form used in this study is the result of modifications recommended by Adams.22
3. The nurse/resident relationship tool was adapted from an instrument developed by Risser24 to evaluate patient satisfaction with nurses and nursing care in primary care settings. Risser's tool consists of three content areas. This study used the items from the third area entitled "Trusting Relationship Area."
4. Social isolation has been shown to have a negative effect on life satisfaction. Therefore, the short HRCA Social Contact Inventory was used to identify residents who were content with their interactions with individuals other than staff. This tool was developed for institutional use and combines subjective and objective measures.25 The subjective measure was consistent with the premise of this study, which was to evaluate the elderly individuals' lives from their individual perspective.
5. Individual Perception of Health Status. Self-rating of health represents a summary statement about the ways in which numerous aspects of health, both subjective and objective, are combined with the perceptual framework of the individual respondent. Studies have supported the assumption that self-rated health is consistent with physician ratings, and is a useful measure of health status.26,27
6. Activities of Daily Living. The amount of physical assistance a resident requires may influence his or her perception of the nursing staff in that more disabled residents report a close relationship with the staff more frequently than less disabled residents. The Barthel Index was used to assess the functional status of subjects.
Thirty subjects were interviewed from two intermediate care facilities. The care facilities were proprietary institutions in a midwestern city with inpatient capacities of 89 and 91 persons respectively. The sample was comprised of 23 (76.7%) females and seven (23.3%) males. The mean age of subjects interviewed was 85 with a range of 67 to 97 years of age. The largest number, 43.3%, were in the 81 to 90 age group. The age of the subjects is not unusual for a long-term care facility. Compared to the general elderly population, those in nursing homes are disproportionately over 75 years of age. Statistics have shown that 8 1 % of residents in long-term care facilities are 75 years or older.28
Twenty-five (83.3%) of the subjects were widowed, four (13.3%) subjects had never married, and one (3.3%) subject was divorced. Currently married individuals were not included in the study. The mean length of residence was 35 months with a range of six to 97 months. Seventeen (56.67%) of the subjects were in the institution for longer than two years. Residency of this duration denotes the importance of long-term care facilities being modeled on normal home life roles rather than on medical models.
This study posed the following three research questions:
Question I. Do residents who report positive feelings about the nursing staff have higher levels of life satisfaction?
To determine if a relationship existed between life satisfaction and residents' perception of the nursing staff, a correlation matrix for the variables of Life Satisfaction Index (LSI), Independent Perception of Health Status (IPHS), Nurse-Resident Relationship (NRR), Presence of a Confidant, and Activities of Daily Living (ADL) was used.
The correlation between life satisfaction and perception of nursing staff was not statistically significant. A positive view of the nursing staff does not appear to be related to life satisfaction. The strongest correlation was found between life satisfaction and perception of health status (r= . 72 , p< .00 1 ). There was a moderate negative correlation between life satisfaction and presence of a confidant. Since the scales for life satisfaction and presence of a confidant are ranked in opposite order, this inverse relationship can be interpreted as residents who report the presence of a confidant have higher levels of life satisfaction.
The only other statistically significant correlation was the moderate relationship between residents' perception of the nursing staff and activities of daily living. It appears that residents who report a higher opinion of the nursing staff also are able to perform a greater number of their activities of daily living. Interestingly, this study did not find a significant relationship between ability to perform activities of daily living and residents' perception of their health.
To evaluate the simultaneous effects of the nurse/resident relationship, the presence of a confidant, perception of individual health status, and activities of daily living on life satisfaction, a multiple regression analysis was performed. The four independent variables had a strong relationship to life satisfaction (Multiple R=, 81). Independent perception of health status had the strongest relationship and was the most important contributor in explaining life satisfaction scores. The second best predictor of life satisfaction was presence of a confidant. The third variable entered, according to strength of its relationship to life satisfaction, was the nurse/resident relationship. The final variable, activities of daily living, had a minimal relationship to life satisfaction.
Question 2. Is there a difference in life satisfaction for residents who report having a confidant and those who do not?
T-tests were calculated to determine differences in life satisfaction scores between subjects who had a confidant and those who did not. Results indicate a significantly higher life satisfaction score for subjects who reported having a confidant. This result is consistent with findings reported by Lowenthal and Haven,29 suggesting individuals who have confidants exhibit higher morale.
Question 3. Do residents who name a nurse as a confidant have higher levels of life satisfaction?
For analysis purposes, four groups of confidants were established. Group 1 consisted of subjects who reported children and grandchildren; Group 2 consisted of friends, other relatives, and others; Group 3 consisted of nurses; and Group 4 were subjects who reported having no confidant. Life satisfaction scores for Group 2 and Group 3 were significantly higher than the scores for Group 1 and Group 4. Also, the group mean for residents (Group 4) with no confidant was significantly lower than the means of any of the other groups. The finding that residents who named children as confidants had lower levels of life satisfaction was unexpected. Why children as confidants do not have as positive an effect on life satisfaction as other individuals is an area for further research.
In summary, the combined independent variables of health status, nurse/ resident relationship, presence of a confidant, and activities of daily living had a strong relationship to life satisfaction. Health status was the most important contributor in explaining life satisfaction.
The correlation between life satisfaction and nurse/resident relationship was not statistically significant. Elderly residents who reported the presence of a confidant had significantly higher life satisfaction scores. Nurses contributed to higher life satisfaction scores through their roles as confidant.
Discussion: The Nurse as Confidant
This study supported the premise that it is the quality of relationships that have a significant effect on morale.29 The presence of a confidant was associated with increased life satisfaction scores. It has been shown in previous research that a significant dyadic relationship is a vital personal resource throughout old age.30 This close relationship can change in relation to the events in a person's fife. For example, the role of a confidant can shin from a spouse to a same-sex friend following the death of a husband,31 or from a relative to a friend following insti tutionalization. 19
The presence of a confidant has a definite buffering effect, such that loneliness is decreased and adaptation to loss is easier in older bereaved persons if a confidant is present.32-33 As women outlive men, there are fewer elderly males available to act as confidants and thus fewer widowers in whom to confide. Warner34 recently supported the classic work of Lowenthal and Haven32 which found that elderly females are most likely to have a confidant. She suggests that the availability of a confidant may explain why widows in her sample were better able to accomplish grief work than widowers.34
There are a wide range of people described as confidants. For example, Lowenthal and Robinson30 found that barbers, bartenders, delivery boys, and nurses were all perceived as confidants in a community dwelling population. Confidants reported in this study were children, grandchildren, daughter-inlaw, niece, former neighbor, a friend in the institution, and nurses. Yet, in this study, the nurse/resident relationship per se did not have a significant relationship to life satisfaction. This does not mean that nurses cannot influence the morale of residents.
Indeed, when nurses were named as confidants by some institutionalized elderly, this nursing role had a significant influence on the residents' life satisfaction scores. This suggests that, more than just giving good physical care, nurses must also have a close interpersonal relationship with their clients to be most effective. That is, nurses must serve in the role of confidant. Regrettably, there were residents who did not feel they had anyone to confide in or with whom they could discuss their problems. Staff often distance themselves and relate to residents as a disease or thing, rather than a human being.35 One reason may be that the psychological needs of nursing staff postulated by Maslow ' 2 must be identified and met in order for them to interact in ways that facilitate meeting the higher level needs of residents.
Comprehensive training of nursing staff in psychosocial relationships can bring about intimacy in therapeutic interactions because the nurse fosters the development of a supporting, accepting atmosphere. "It is worth noting that it is the way in which attitudes and procedures are perceived which makes a difference to the client and that it is this perception which is crucial. "30 Based on this study, empathy is an important attribute for nurses employed in long-term care facilities, and is a vital characteristic underlying the important role of nurse as confidant.
The nursing profession is responsive for the holistic care of individuals and must consider interventions that have a positive effect on life satisfaction of the elderly. In view of the strong relationship between life satisfaction and perception of health, nurses must implement preventive and health maintenance measures. Counseling in the areas of diet, exercise, emotional adjustment, and how to make use of rehabilitative techniques can assist in maintaining independence and promoting the health concept.
Nurses also should promote interventions that facilitate the development of therapeutic relationships between nursing staff and residents. Scheduling of time that allows for communication opportunities and sharing between nurses and residents can result in relation-building experiences. It may be helpful to educate nurses in techniques for communicating good feelings through touch, which has a high potential for breaking through interpersonal baniers. Programs that assist nursing staff to learn how to listen may promote the feeling and correspond with the finding that "being listened to has a way of restoring an older person's sense of worth."36 Therapeutic relationships may facilitate nurses in their roles as confidants, which can promote the total well-being of institutionalized elderly and enhance their life satisfaction.
The nurse/resident relationship did not correlate significantly with life satisfaction in this study. However, nurses did have an effect on residents' life satisfaction when they were in the role of a confidant. Seven residents (23.3%) named nurses as their confidants, and residents who reported having a confidant had higher levels of life satisfaction. This finding is in keeping with the geropsychiatric literature which suggests that, "one of the keys to avoiding psychopathology, especially depression, in later life is the maintenance of a confidant relationship."32,38 The role of the nurse as confidant becomes even more important for the elderly in longterm care settings, where age-related declines may operate as constraints on the friendship activities of residents,39,40 and where personal devaluation may occur.41
The variable that appears to have the highest impact on life satisfaction is the residents' perception of their health status. Residents who rated their health as good or excellent had higher levels of life satisfaction. Health status was the best predictor of life satisfaction in this sample, accounting for 52% of the variance in life satisfaction alone. Ways in which nurses can promote residents' perceptions of health and serve as confidants were set forth. Health-promotion activities and therapeutic relationships are among the best strategies nurses have to combat Buckelew's42 dire prediction, "If the aged person isn't dead physically, the social death of being in a nursing home may be all that is needed to hasten the process."
- 1. Fact Book on Aging: A Profile of America's Older Popuiaiion. Washington. DC, National Council on Aging, Inc. 1979.
- 2. Moss F, Halamandares V: Too Old, TooSick, Too Bad: Nursing Homes in America. Germantown, Maryland. Aspen Systems Co, 1977.
- 3. A Profile of Older Americans. Washington, DC, American Association of Retired ftrsons. 1986.
- 4. Lesnoff-Caravaglia G: The five percent fallacy. IM J Aging Hum Dev 1978-1979; 9:187-192.
- 5. Felton G. Kahana E: Adjustment and situationally-bound focus of control among institutionalized aged. J Gerontol 1973; 29:295-301.
- 6. Goffman E: Asylums. Chicago, Aldine Publishing Company, 1961.
- 7. Lieberman M: Institutionalization of the aged: Effects on behavior. J Geroniol 1969; 24:330-339.
- 8. Kasl SV, Rose p field S: The residential environment and its impact on the mental health of the aged, in Birren S, Sloane RB, (edsy. Handbook of Menial Health and Aging. Englewood Cliffs, NJ, Prentice-Hall. Ine, 1980, pp 468-501.
- 9. Lieberman M: Relationship of mortality roles to entrance to a home for the aged. Geriatrics 1961; 16:515-519.
- 10. Aldrich C, Mendkoff E: Relocation of the aged and disabled; a mortality study. J Am GeriatrSoc 1963; 11:185-194.
- 11. Brady E: Long-term care of the aged. Health Sue Work 1979; 4:29-59.
- 12. Maslow A: Motivation and personality. New York, Harper and Row, 1954.
- 13. Butler R: Life review: An interpretation of reminiscence in the aged. Psychiatry 1963; 26:65-76.
- 14. Hatton J: Nurse's attitudes toward the aged: Relationship to nursing care, J Gerontol Nurs 1977; 3:21-26.
- 15. Taylor K, Hamed T: Attitudes toward old people: A study of nurses who care for the elderly. J Gerontol Nurs 1978; 5:43-47.
- 16. FaIk U, FaIk G: The Nursing Home Dilemma. San Francisco, R and E Research Association. 1976.
- 17. Dominick J, Greenblatt D. Stotsky B: Adjustment of aged persons in nursing homes. I. The patients' report. J Am Geriatr Sec 1968; 16:63-77.
- 18. Miller, Sister P, Russell D: Elements promoting satisfaction as identified by residents in the nursing home. J Gerontol Nurs 1980; 6:121-129.
- 19. Walsh J, Kiracofe N: Change in significant other relationships and life satisfaction in the aged, lnt J Aging Hum Dev 1979; 10:273-281.
- 20. Bell J: Disengagement versus engagement - A need for greater expectations. J Am Geriatr Soc 1978; 26:89-95.
- 21. Neugarten B, Havighurst R, Tobin M: The measurement of life satisfaction. J Gerontol 1961; 16:134-143.
- 22. Adams D: Analysis of a life satisfaction index. J Gerontol 1969; 24:470-474.
- 23. Edwards N, Klemmack L: Correlates of life satisfaction: A re-examination. J Gerontol 1973; 28:497-502.
- 24. Risser N: Development of a tool to measure patient satisfaction with nurses and nursing care in primary care settings. Nurs Res 1975; 24:45-52.
- 25. Kane R, Kane R: Assessing the Elderly. Lexington. Massachusetts, Lexington Books, 1980.
- 26. Ferearo KF: Self-ratings of health among the old and the old-old- J Health Soc Behav 1980; 21:3777-383.
- 27. Linn BS, Linn MW: Objective and selfassessed health in the old and very old. Soc Sci Med 1980; 14:313-315.
- 28. Vldek B: Unloving care: A Nursing Home Tragedy. New York, Basic Books, 1980.
- 29. Lowenthal M. Haven C: Interaction and adaptation intimacy as critical variable, in Atehley R, SeKzet M (eds); Sociology of Aging: Selected Readings. Belmont, California, Woodsworth Publishing, Inc. 1976.
- 30. Lowenthal M, Robinson B: Social networks and isolation, in Binstock R7 Shanas E (eds): Handbook of Aging and the Social Sciences. New York, Van Nostrand Reinhold Co, 1976.
- 31. Blau ZS: Structural constraints on friendships in old age. American Sociological Review 1961; 26:429-439.
- 32. Lowenthal MF, Haven C: Interaction and adaptation: Itinerary as a critical variable, in Neugarten BL (ed.): Middle Age and Aging. Chicago, University of Chicago Press, 1968, pp 390-400.
- 33. Richter J: Crisis of mate loss in the elderly. Advances in Nursing 1984; 6:45-54.
- 34. Warner SL: Grief and support in early spousal bereavement. Archives of Psvchiatric Nursing 1987; 1(4):241-250.
- 35. Kramer J: What is a nice girl like you doing here, in Pfeiffer E ted): Successful Aging. Durham, NC, Duke University Press, 1973.
- 36. Rogers C: On Becoming a Person. Boston, Houghton Mifflin Co, 1961; p 44.
- 37. Keller J, Hughston G: Counseling the Elderly. New York. Harper & Row, 1981.
- 38. Brink TL: Geriatric Psychotherapy. New York, Human Sciences Press, 1979, p 28.
39. Adams RG: Patterns of network change: A longitudinal study of friendships of elderly women. The Geronlologist 1987; 27(2):222-228.
- 40. Adams RG: Friendship and aging. Generations 1986; 10:40-43.
- 41 . Storlie FJ: The reshaping of the old. J Gerontol Nurs 1982; 8(10):555-559.
- 42. Buckelew B: Health care professionals versus the elderly. J Gerontol Nurs 1982; 8(10): 560-564.