Customarily, nursing home residents have been excluded from participating in making decisions about their own care. According to the medical model and the concept of the sick role (Parsons, 1958), residents hove been expected to be helpless and to comply with nursing service routines. Nursing's official document, Standards for Gerontological Practice (American Nurses Association, 1987), reflects the position that residents should be greatly involved wifh an interdisciplinary team to determine goals of care. In 1 974, the Social Security Administration issued ftrtf'enfe' Rights in Skilled Care Nursing Facilities, emphasizing resident involvement in care planning and daily activities. Gerontological nurses have demonstrated that giving residents choices about their daily activities enhances resident independence and self-esteem (Langer, 1976; National Citizen's Coalition, 1985; Ryden, 1982).
In a majority of long-term care facilities, care is currently delivered by certified nurse assistants (CNAs) with unit charge nurses who are often licensed practical nurses (LPNs) and supervised by nursing administrators who are registered nurses (Almquist, 1980). Medications and treatments are administered by LPNs and all other daily care is usually administered by CNAs. Most RNs working in long-term care facilities are in supervisory positions (Beck, 1983; Cox, 1991; Ryden, 1982). Therefore, LPNs and CNAs were chosen as the participants in this study.
The purpose of this study was to determine the incidence of choicegiving behaviors of LPNs and CNAs about daily activities, specifically dressing, and group participation for geriatric residents in long-term care facilities.
Data were collected in two longterm care facilities that met the following criteria: licensed by the state as a skilled nursing care facility; within commuting distance of Chicago; a minimum 150-bed capacity; and a majority of residents over 65 years of age. Only state licensed facilities were considered as study sites to ensure that the state-required minimum standard of care was met.
A minimum of 150 beds ensured there would be enough day shift staff to include in the study. The sites had to have a majority of elderly residents due to the focus of the study. Both facilities selected were nonprofit institutions. One had 275 beds, was religiously affiliated, and in a suburban location. The other had 330 beds, was associated with an acute care institution, and was located within the city limits. Two facilities were used to include participants from a variety of backgrounds.
Demographic Characteristics of Participants
The director of nursing at each facility was contacted by phone, and the study was explained. A follow-up letter describing the study and asking permission to collect data at the facility was sent. The directors of nursing discussed the study with the facility administrators and the investigator was notified of their willingness to participate by phone. The director of nursing at each institution designated a contact person to provide any needed assistance.
Thirty CNAs and 10 LPNs were selected randomly from lists of nursing caregivers assigned to the day shift. Every participant selected agreed to participate in the study, although two participants asked to postpone the time of participation. All participants worked full time, provided direct care to residents, were employed in the current facility for at least 2 months, spoke English fluently, and were willing to participate in the study.
Participants were observed in interactions with residents and then were interviewed to complete the demographic questionnaire. Observations began approximately 30 minutes after the start of the shift and continued for 2 consecutive hours. Each participant was told that the investigator was conducting a research project that involved a 2-hour observation period followed by a short interview. Potential participants were told that participation was voluntary and they could withdraw at any time; they were also assured that administration would not see the data and that the data would be reported for groups, not individuals. When the potential participants consented to be in the study, observation commenced immediately.
Each participant was observed once for a 2-hour period between 7:30 and 10:30 AM. The investigator accompanied caregivers during this period and recorded observations on the Observer Recording Form. The participant was asked to introduce the investigator to each resident as a nurse-investigator and explain to the resident that a study was being done about the nature of the caregiver's activities. The resident was asked if the nurse-investigator could stay. Only one resident asked that the investigator leave the room while the caregiver assisted her to dress.
Thirty CNAs and 10 LPNs were selected randomly from lists of nursing caregivers assigned to the day shift at two long-term care facilities. Participants were predominantly women (95%) and ranged in age from 22 to 66 years with a mean age of 40.4 years (Table 1). Participants were predominately black (65%) with a representation of other cultural backgrounds including Filipino, Polish, German, Irish, and Indian.
Thirty-five (87.5%) participants had a minimum of a high school education. Four (10%) of these had general education diplomas. Four (10%) participants employed as CNAs held baccalaureate degrees in nursing; they had not yet been successful on the NCLEX exams. Eighteen (45%) of the participants had attended college-level classes.
The majority of participants (87.5%) reported having had some course content in gerontology. Participants were unable to specify how many hours of gerontological content had been included in their programs of study. However, 33 (82.5%) reported clinical and classroom gerontological content and 2 (5%) reported only clinical gerontological content.
Twelve (40%) participants had been employed in nursing for 10 or more years (Table 2). Twenty-eight (70%) had 5 or more years of experienee. The mean years of practice for all participants was 6.5 years.
Work History of Participants
Nine (22.5%) participants had practiced in a gerontological setting for 10 or more years. Twenty-six (65%) had 5 or more years of gerontological practice. The mean number of years in gerontology for all participants was 7.8 years.
Participants had been employed at their current facility for a mean of 6 years. Twenty-two (65%) participants had been in their current facility 5 or more years. Six (15%) had been employed at the same institution for 10 or more years.
Participants were responsible for delivering care to a range of 7 to 61 residents, with a mean of 16.6 residents. Licensed practical nurses were responsible for overseeing and delivering care to a range of 28 to 61 residents, with a mean of 34.3 residents. The CNAs were responsible for the daily care of 7 to 21 residents, with a mean of 10.4 residents.
The average number of choicegiving behaviors related to all daily activities was 10.7 per participant with a range of 2 to 26 (Table 3). Sixteen (40%) participants provided 4 to 9 opportunities for choices about daily activities. Certified nursing assistants had an average number of choice-giving behaviors related to all daily activities of 11 with a range of 3 to 24. Licensed practical nurses had an average number of choice-giving behaviors related to all daily activities of 9.9 with a range of 2 to 26.
The daily activity for which residents were most frequently given a choice was eating. There were an average of 5.5 choice-giving behaviors about eating by all caregivers. When the f-test was used for comparison, the types of daily activities for which there were significant differences in choice-giving behaviors between LPNs and CNAs were dressing, group participation, and toileting.
Incidence of Choice-Giving Behaviors for Daily Activities, Dressing, and Group Participation
Frequently observed behaviors regarding providing choices to residents about eating included:
* CNAs were responsible for delivering breakfast trays to residents eating in their rooms. At that time, CNAs determined how much assistance residents needed in setting up breakfast trays. CNAs opened containers and mixed foods. As one CNA prepared a resident's tray she asked, "Do you want salt on your eggs?"
* Another CNA asked a resident "How many sugars do you want in your coffee?"
* LPNs were responsible for administering medications. When administering medications, LPNs had the opportunity to ask residents what type of fluid they wanted with their medication. One LPN asked a resident, "Do you want juice or water with your pills?"
* Another LPN, while administering medications, asked a resident, "Do you need prune juice today?"
The average number of choicegiving behaviors about dressing was 1.1 per participant with a range of 0 to 6 (Table 3). Twelve (30%) participants did not provide any choice to residents about dressing, and 19 (47%) participants gave residents a choice about dressing only once. CNAs were observed having the most opportunities to provide choices to residents about dressing because CNAs were involved with assisting residents with dressing more often than were LPNs.
The t-test demonstrated that CNAs had significantly more choice-giving behaviors about dressing than LPNs. The average number of choicegiving behaviors observed of CNAs in relation to dressing was 1.4 with a range of 0 to 6. Twenty-four (80%) CNAs gave residents opportunities to make choices about dressing, although 15 (50%) CNAs demonstrated only one choice-giving behavior related to dressing. LPNs were observed providing choices to residents about dressing an average of 0.4 times. Observation data revealed that during the morning routine, LPNs usually administered medications and treatments and did not provide assistance with dressing. Six (60%) LPNs did not give residents an opportunity to make choices about dressing and four (40%) LPNs were observed giving residents a choice about dressing only once.
Examples of giving residents choice about dressing included:
* CNAs usually went from one resident to another for bathing and dressing according to either resident schedules or getting the "hard ones" out of the way first or saving the "hard ones" for last. One CNA gave a resident choice in the time to get dressed by stating, "When you are ready I'll get you dressed."
* CNAs often went to the resident's closet and decided what the resident would wear. One CNA held up a dress and asked the resident, "Do you like this dress?" The resident said, 'Tes." The CNA then brought the dress over to the resident to assist with dressing.
* One CNA walked to the closet and asked the resident, "What do you want to wear?" The resident described the dress she wanted and the CNA looked in the closet and pulled out a dress. The resident said, "No, that isn't it" and described it again. The CNA then took the correct dress from the closet and handed it to the resident.
* A resident was sitting in a wheelchair in the hall. The CNA noticed that the resident was hugging herself and rubbing her arms. The CNA asked the resident, "Are you cold? Do you want a sweater?" When the resident said '?ß5," the CNA went to the resident's room and brought a sweater and assisted the resident to put it on.
There were few behaviors observed related to giving choices to residents about group participation (Table 3). An average of 0.2 incidents per participant were observed with a range of O to 3. Thirty-five (87.5%) participants gave residents no choice about group participation. Four (10%) were observed giving residents a choice about group participation only once and one (2.5%) participant was observed three times giving residents a choice about group participation. Twenty-eight (83%) CNAs were never observed giving residents a choice about group participation and only two (7%) were observed once each giving residents a choice about group participation.
Licensed practical nurses had a mean occurrence of 0.5 choicegiving behaviors regarding group participation during the 2-hour observation period. Seven (70%) LPNs were not observed giving a choice to residente about group participation. Two (20%) LPNs were observed giving one opportunity for a resident to make a choice about group participation and one (10%) LPN was observed twice giving residents an opportunity to have a choice about group participation. It was determined using the f-test that LPNs demonstrated significantly more choicegiving behaviors than CNAs about group participation.
Examples of observations of behaviors allowing residents to have choice about group participation included:
* While LPNs administered medications, they spoke to residents about group activities scheduled in the facility. One LPN asked a resident if she wanted to go on a trip to a retirement apartment building affiliated with the long-term care facility. The LPN said, "Some residents are going on a trip to the apartment building. Do you want to go?" The resident refused because she thought it would entail too much walking. The LPN explained that there would be a place to sit. Even with this information, the resident decided not to go.
* The recreation department was planning a shopping trip for residents. An LPN, while administering medications, asked a resident "Are you going shopping tomorrow?" The resident knew about the trip and was planning on going.
* An LPN knew that a particular resident enjoyed watching baseball games. The LPN told the resident about a planned trip to a ball game and asked, "You are going to the baseball game today?" The resident was excited about the game and was planning on going.
It was not always possible to determine when a participant missed an opportunity to give choice to a resident. The resident's cognitive ability, daily routine, previous discussions, physical ability, and family requests were unavailable to the observer at the time of observation. Therefore, no attempt was made to identify missed opportunities for giving choices to residents. Only absolute, rather than relative, values for choice-giving behaviors have been reported thus far.
Observation data included information about participants going to the closet and choosing what to wear without any input from the resident. This is not to say that these actions were the only missed opportunities for giving choices to residents about dressing. However, what is of interest is that participants more often chose clothing for residents than gave residents the opportunity to choose their own clothing.
For all participants, there were 75 incidents of choosing clothing for residents as compared with 57 incidents of giving a choice to residents about dressing. Only CNAs chose clothing for residents. Of the 57 incidents of giving a choice to residents, 53 were by CNAs whereas 4 were by LPNs.
Not giving a choice about dressing was the only daily activity where frequencies of missed opportunities were reported. Another daily activity where the data supported missed opportunities was toileting. Examples of a missed opportunity to give choice about toileting included:
* While a CNA assisted a resident with dressing, the resident told the CNA he had to go the bathroom. The CNA said, "You don't have to worry about that, you have a diaper on."
* Another CNA walked into a resident's room and said to the resident, "It's time to go to the bathroom now." The CNA then walked the resident to the bathroom and put the resident on the toilet. There was no dialogue about whether the resident wanted or needed to go to the bathroom and the resident was not on a bowel or bladder program.
The findings provided evidence that CNAs and LPNs in long-term care facilities seldom provided choices for residents concerning daily activities, dressing, and group participation. Certified nursing assistants provided a significantly greater number of incidents of choice-giving behaviors concerning dressing than did LPNs. However, the job responsibilities of LPNs did not include assisting residents with dressing. Licensed practical nurses provided a significantly greater number of incidents of choice-giving behaviors concerning group participation than did CNAs. However, LPNs had more opportunities to provide choices for residents concerning group participation.
The results are congruent with the types of responsibilities given these two groups of caregivers by nursing administrators in long-term care facilities. Certified nursing assistants are responsible for residents' physical care: grooming, toileting, and dressing. Certified nursing assistants were observed giving information to each other about a resident's selfcare ability.
Licensed practical nurses were observed asking CNAs what residents could and could not do for themselves. CNAs had a higher incidence of giving choices about dressing than did LPNs because differences in job descriptions provided CNAs with more opportunities to give a choice about dressing.
The Role of IPNs in Long-lerm Care Facilities
The job responsibilities of LPNs did not include bathing and dressing residents. Because LPNs had fewer opportunities to give choices about dressing, LPNs had fewer incidents than CNAs of giving choices about dressing. Observations of incidents of giving choices about dressing demonstrated that LPNs and CNAs have different job responsibilities regarding residents.
LPNs as charge nurses are responsible for supervising CNAs in completing their tasks. Therefore, they can influence the behavior of the CNAs. However, the differences in the job descriptions does explain the LPNs' lack of choice-giving behavior related to activities of daily living.
Results of the study provide implications for nursing administration and nursing practice in long-term care facilities. There are also implications for health policy.
Nursing Administration and Practice
The results demonstrated that residents in long-term care facilities are not receiving opportunities to make choices about their daily activities as often as choices are made for them. These results of actual incidence of choice-giving behaviors were obtained from field observation. Nursing administrators need to have professional nurses on the units to observe and document what type of care is being provided to their residents. These professional nurses can serve as role models and onsite educators to provide the resources needed by nursing caregivers.
Many of the choice-giving behaviors observed did not take any more of the nursing caregiver's time. When assisting residents with dressing, the caregiver could ask what the resident would like to wear or hold up two items of clothing and ask which the resident prefers. When setting up the breakfast tray, the caregiver could first ask how the resident wanted the food prepared. On occasion, the observer noted CNAs mixing eggs, cereal, and toast all in one bowl and feeding it to residents. This type of behavior does not allow residents to experience the unique taste sensations of each food. It also decreases the human quality of the care, and the food may not taste very good. Other CNAs were observed adding sugar and cream to coffee without asking how the resident preferred the coffee. These CNAs may have known how the resident preferred food prepared, but it did not give the resident an opportunity for variety or a change of mind. Those CNAs who asked the residents what they wanted to wear or how they wanted their breakfast prepared did not appear to take more time in assisting residents.
The content of orientation and inservice programs must focus on the psychosocial aspects of the residents' care. Nursing caregivers know what physical care needs to be completed, but not that they should involve or how to involve the resident in daily activities. Nursing administrators responsible for hiring can include these expectations for giving choice to residents in job interviews and job descriptions.
Nursing administrators need to look at caregivers' workloads along with patient classification and quality assurance data. If the goal is giving more choices to residents, then it may be determined that increasing the number of nursing caregivers is the answer. Another solution may be providing incentive programs for LPNs and CNAs to give more choices to residents.
Implications have focused on staff and nursing administration. However, residents can play an important role in increasing opportunities for offering choices. They are sometimes afraid to ask nursing caregivers to do things differently and fear that if they speak up they may not get the care needed. Therefore, residents should also attend regular classes where nursing representatives orient them to the role and expectations of the longterm care facility resident. Included in this orientation would be suggestions of how to tell nursing caregivers what the resident wants and how it should be done. Facilities have resident councils that serve as a means of communication to administration and other facility departments. Obtaining choices about daily activities could be discussed at these council meetings.
Federal and state governments provide regulations for the longterm care industry. In 1987, new federal legislation mandated that all CNAs complete a minimum of 75 hours of course work before working as a CNA. The Omnibus Budget Reconciliation Act regulations also mandated 24-hour facility coverage by a licensed nurse and that a registered nurse be on duty at least 8 hours a day (National Citizens' Coalition, 1987).
Continuing to increase the educational preparation of nursing caregivers is one step toward increasing quality care for the elderly. Nursing educators in LPN and CNA programs need to increase the amount of curriculum time that focuses on meeting the psychosocial needs of residents. Legislating changes in education of caregivers does not reduce the responsibility of professional nurses to provide the training necessary for CNAs and LPNs to deliver quality care to residents. Professional nurses can function as educators, administrators, caregivers, and consultants in long-term care facilities. However, one RN in a facility is not enough to provide guidance and support for nursing caregivers. Nurses also need to educate other professional nurses to the benefits of working in long-term care.
The findings of this study also suggest several areas where additional investigation is needed. The recommendations for additional study include surveying residents, investigating additional behaviors in the caregiver /resident interaction, observing caregivers at other times of the day, attempting to change caregivers' behavior, and increasing the incidence of choices for residents.
In this study, it was assumed that choices about daily activities, dressing, and group participation were important to the residents. Future study should include a survey of residents to determine what type of choices are important to them. Residents could be asked to prioritize activities about which they would most like to have a choice.
Intentions about three behaviors were included in the study. Studies looking at other behaviors that occur in the nursing caregiver/ resident interaction also should be studied. Examples of other behaviors could include toileting, eating, solitary activities, and one-to-one activities.
- Almquist, E., Bates, D. Training program for nursing assistants and LPNs in nursing homes. Journal of Gerontological Nursing 1980; 6:622-627.
- American Nurses Association. Standards ofgerontological nursing practice. Kansas City, MD Author, 1987.
- Beck, J.C. Unique learning experiences in longterm care. In Creating a career choice for nurses: Long-term care. New York: National League for Nursing, 1983.
- Cox, C.L., Kaeser, L., Montgomery, A.C., Marion, L.H. Quality of life nursing care: An experimental trial in long-term care. Journal of Gerontological Nursing 1991; 17(4):6-11.
- Langer, E.J., Rodin, J. The effects of choice and enhanced personal responsibility for the aged: Field experimentation in an institutional setting. JPersSoc Psychol 1976; 34:191-198.
- National Citizen's Coalition for Nursing Home Reform. A consumer's perspective on quality care: The resident's point of view. Washington, DC: Author, 1985.
- Parsons, T. Definitions of health and illness in the light of American values and social structure. In E.G. ]aco (Ed.), Patients, physicians, and illness. New York: Free Press, 1958, pp. 165-187.
- Ryden, M. Perception of situatianal control, climates for autonomy, and morale in institutional elderly. Unpublished doctoral dissertation, University of Minnesota, Minneapolis, 1982.
Demographic Characteristics of Participants
Work History of Participants
Incidence of Choice-Giving Behaviors for Daily Activities, Dressing, and Group Participation