Scientific exploration of the impact of the institutional environment on the well-being of elderly is required if nurses are to lead institutionally and nationally in creating this environment. In her literature review, Kayser-Jones (1989) noted that most nursing research concerning the effect of the environment on health has been in the acute care setting; ie, the affects of noise levels in the intensive care unit, recovery room, and acute care unit. There is little in the nursing literature, however, that addresses the impact of the nursing home environment on the elderly. Possession of this knowledge may be essential if nurses are to claim leadership roles in creating new, health-oriented, elder care environments. From her experience with a teaching nursing home project, Donley (1985/1986) noted that, "the physical and social environments of care are untapped resources in caring for the elderly."
This study focused on the impact of the social environment. The purpose of this study was to examine the relationship of social environmental factors and functional health to well-being in elderly nursing home residents.
In the Social Ecological Theory of Moos and Lemke (1984b), the environmental and personal systems are closely related. These systems influence the appraisal and selection of coping strategies used in adaptation. Success at adapting to the environment is reflected in outcomes such as well-being. Outcomes are then fed back into the system as factors within the personal system. This study focused on the relationship of factors within the environmental system (perceived social-environmental factors) and factors within the personal system (functional health status) to outcome measures (well-being). The social-environmental factors examined in this study were independence, cohesion, organization, and resident influence. Life satisfaction served as a measure of well-being.
Independence indicates how selfsufficient residents are encouraged to be in their personal affairs and how much responsibility and selfdirection they are encouraged to exercise (Moos, 1984b). Perceived independence has been linked to wellbeing in the elderly (Ryden, 1983; Smith, 1986). One might expect institutionalized elderly to experience a lower level of perceived independence than noninstitutionalized elderly. However, Abel and Hayslip (1987) reported that elderly lowered their expectation of control over their environment following institutionalization. Slivinske and Fitch (1987) found that it is possible to enhance elderly nursing home residents' sense of well-being through interventions that increase the residents' perception of self-control.
Cohesion is the degree to which staff members of an institution are helpful and supportive toward residents and how supportive residents are with each other (Moos, 1984b). It is interesting to note that although the number of ties and frequency of social interaction have not been found to be significantly related to life satisfaction in the elderly (Conner, 1979), satisfaction with social support has been shown to be related to well-being in this population (Krause, 1987; Ward, 1984). It is important, therefore, to obtain subjective rather than objective measures of social support in this population.
Usui (1984) found that the elderly tend to form homogeneous friendship networks. Noting that there is a dearth of information on institutionalized black elderly, Usui compared whites with blacks in this setting and found that blacks tended to have less homogeneous friendship networks than whites. However, for both groups, the three closest friends described were nearly always of the same race as the subject. Further study is needed regarding the impact of the nursing home environment on black elderly.
Organization in the nursing home is reflected in the ability of the resident to predict daily events (Moos, 1984b). Although studies have demonstrated that the ability to predict negative events is related to wellbeing (Lazarus, 1984), little has been done to determine the effect of predicting positive events in relation to well-being.
Resident influence is the extent to which residents can influence the rules and policies of a facility (Moos, 1984b). Moos and Ingra (1980) examined 90 homes for the elderly. They found that facilities with heterogeneous populations tended to have less cohesive environments with little resident participation in policy formation. In a study by the National Citizens Coalition for Nursing Home Reform, residents expressed a desire to determine policies on when to get up and go to bed, when to come and go inside and outside the nursing home, and whether to participate in activities of any type (Spalding, 1985).
Functional health in this study is an individual's subjective evaluation of independence in carrying out normal activities and self-care (Yates, 1980). A meta-analysis of 104 studies was reported by Okun and associates (1984). Health and well-being were found to be positively related to subjective measures of health. Also, Stoller noted that elderly tend to rate their health higher than younger persons experiencing similar symptoms (Stoller, 1984). Stoller attributed this to reference group theory. According to this theory, elderly hold positive health perceptions when comparing themselves with others of their own age (Ferraro, 1980).
Life satisfaction is a multifaceted concept that has long appeared in the gerontological literature. It encompasses a sense of psychological well-being, meaning, achievement, a positive self-image, and a happy, optimistic attitude and mood (Neugarten, 1961).
Early studies of life satisfaction in the elderly focused on the effect of single, objectively measured variables, such as health, income, and social interactions (Casan, 1949; Kutner, 1966). More recent research has focused on multiple and subjectively measured variables, such as family life satisfaction, personal health satisfaction, and satisfaction with dwelling (Brown, 1981; Golant, 1985; Osberg, 1987; Toseland, 1980).
Golant (1985) noted no difference in the life satisfaction of blacks and whites. However, Johnson and associates (1982) suggested that because so few studies of life satisfaction among the black elderly have been undertaken, further study of this population in isolation is needed to determine similarities with and differences from whites.
1. There will be a positive relationship between perceived independence and life satisfaction.
2. There will be a positive relationship between perceived cohesion and life satisfaction.
3. There will be a positive relationship between perceived organization and life satisfaction.
4. There will be a positive relationship between perceived resident influence and life satisfaction.
5. There will be a positive relationship between perceived functional health status and life satisfaction.
Method and Sample
A purposive sample of 115 elderly living in three city-run nursing homes in a Northeastern metropolitan area were drawn from a target population of elderly, 65 years of age or older, who met the following criteria: oriented to person and place, able to speak and understand English, able to give informed consent verbally and in writing to participate in the study, and have lived in the institution for a year or longer. The demographic characteristics of the sample of the 115 subjects can be summarized as follows. There were 69 women (60%) and 46 men (40%) ranging in age from 65 to 99 years with a mean age of 75 (SD = 8.64). One hundred eight (94%) of the subjects were black and seven (6%) were white. Of the 115 subjects, 58 (51%) were widowed, 29 (25%) had never been married, 16 (14%) were married, 7 (6%) were separated, and 5 (4%) were divorced.
Means Standard Deviations, and Range of Scores for Predictor and Criterion Variables*
The number of years subjects had resided in the nursing home ranged from 1 to 26 years with the mean length of residence being 4.4 years (SD = 4.3). Residents who met the study criteria were identified by nursing home administrators in the three nursing homes. A total of 123 residents were identified. Of these, four were not interviewed because they appeared confused at the time of the interview, and four residents declined to participate. There were no significant differences among the three nursing homes for any demographic variable.
The Life Satisfaction in the Elderly Scale (LSES) was used to measure life satisfaction (Salamon, 1984). The LSES is a 40-item Likert self-report inventory that yields an overall score with a maximum score of 200 and a minimum of 40. Higher scores indicate higher levels of life satisfaction. In previous studies, the reliability coefficient for the scale was tested using Cronbach's alpha (.93) (Salamon, 1984). The Cronbach's alpha reliability coefficient obtained for the LSES in this study was .88.
The Sheltered Care Environment Scale (SCES) is a 63-item yes/ no scale that focuses on seven dimensions of the social environment of residential settings: cohesion, conflict, independence, self-exploration, organization, resident influence, and physical comfort (Moos, 1984b). Each dimension contains nine items. A raw score is calculated for each of the seven dimensions. The possible scores for each dimension range from 0 to 100. In a previous study, reliability of the seven subscales of the SCES was tested using Cronbach's alpha (.44 to .76) (Moos, 1984b). Split-half reliability of the subscales ranged from .52 to .93 (Moos, 1984b). In the present study, the reliability coefficient for the seven subscales using Cronbach's alpha ranged from .70 to .76.
Summary of Pearson's Coefficients for Predictor and Criterion Variables
Physical Functioning Index
The Physical Functioning Index (PFI), adapted from Shanus (1968), consists of three parts in which respondents are asked to rate their health as good, average, or poor and are asked if their health is worse, the same, or better than others their age. Respondents are then asked if they have difficulty bathing, dressing, and getting about indoors or out. Scores on the PFI may range from 10 to 30. Reliability measured by Cronbach's alpha in a previous study was .79 (Evans, 1979). The reliability of the PFI in this study using Cronbach's alpha was .71.
Consent was obtained from the institutional review boards of the nursing homes and from the individual subjects. To determine if the residents were oriented, the investigator asked the residents to state their own name and the name of the institution where they resided. Four residents were excluded from the study when they could not do this. A pilot study was undertaken to test the protocol for data collection. The questionnaires were all administered in an interview format by the investigator. The average length of time to complete each interview was 1 hour.
The means, standard deviations, and ranges were computed for each variable and are presented in Table 1. Pearson correlations were used to describe the relationship of each predictor variable to the criterion variable of life satisfaction. Table 2 is a summary of the corrélation coefficients for these variables.
The demographic variables of gender, marital status, and length of residence in the nursing home demonstrated no significant relationship to life satisfaction in this sample. The correlation coefficients for independence (r=.38), cohesion (r = .33), and functional health (r = .32) were positively and significantly related to life satisfaction (p<.05). Therefore, hypotheses 1, 2, and 5 were supported. Organization and resident influence were not significantly correlated with life satisfaction; therefore, hypotheses 3 and 4 were not supported.
Because of the high intercorrelation between independence and cohesion (r = .45), stepwise multiple regression analysis was performed. Regression analysis helps to determine the unique variance each individual independent variable contributes to the dependent variable. Stepwise regression is useful in studies where the phenomena have not been well examined in the past and theory does not indicate which of multiple independent variables might be more strongly related to the dependent variable than others. The results of this analysis are presented in Table 3.
Independence entered the first step, accounting for 15% of the variance in life satisfaction. Functional health entered at step 2, increasing the variance to 21%. Finally, in step 3, resident influence entered, increasing the variance accounted for to 22%. The variables cohesion and organization failed to meet the entry tolerance level criteria for inclusion at step 4. Therefore, functional health in combination with the two social environmental variables of independence and resident influence account for most of the explained variance in life satisfaction in this study.
In this study, functional health status and the social-environmental variables of independence and cohesion were significantly related to life satisfaction in elderly nursing home residents. The high levels of independence and cohesion in this sample are noteworthy. A comparison group for this study is provided by Moos and Lemke (1984a), who had interviewed a heterogeneous sample of 1,873 elderly, including those living in apartments. It was anticipated that the mean score for independence in the Moos study would be greater, as his study included noninstitutionalized elderly of varied economic status. However, the present sample of primarily lower-income, black elderly demonstrated a higher mean score on the independence scale (mean = 51 .7) than the elderly in the Moos study (mean = 47).
Because studies have linked lower socioeconomic status to lower levels of control over the environment (Larson, 1978), perhaps subjects in this study had a lower expectation of control. Their perceived level of independence would therefore be higher than that of a more economically heterogeneous group, such as in the Moos sample. Further study of perceived independence in the nursing home among both black and white residents of varying socioeconomic status is required.
Cohesion scores for this sample (mean = 69.3) were also higher than those of the Moos sample (mean = 62.0). High cohesion scores could also be a result of the homogeneity of the sample. Lemke and Moos (1980) noted that cohesion scores tended to be higher in nursing homes in which there was a more homogeneous resident population. A possible intervening variable here that was not measured and could have inflated cohesion scores was support received from others outside the nursing home. Although most residents reported little family support, many residents did mention "the ladies of the church" as people who were important to them. It may be that residents who receive support from outside the nursing home perceive an adequate level of support within the nursing home.
Summary Table for Stepwise Multiple Regression for Life Satisfaction and Social Environmental Variables and Physical Functioning*
Functional health status scores were moderately high, indicating that most of the subjects felt independent in carrying out self-care activities. The significant relationship of functional health and life satisfaction is consistent with previous findings that elderly who rate their health as high tend to have a positive sense of well-being (Okun, 1984).
The functional health status scores of this study might be reflective of the sample restrictions. Because cognitively impaired residents were omitted from the study, residents experiencing self-care deficits associated with cognitive impairments were not interviewed.
There was also a significant relationship between the variables of cohesion and functional health (r = .23). This moderately well-functioning group perceived that their environment was supportive. It may be that more functional or independent residents receive more attention from staff and, therefore, perceive the environment as supportive. Also, it might be that more functional residents are able to establish social contacts outside and within the institution more easily and are not solely dependent on the nursing home staff for their social support. Further study is needed on the contribution of nonfamily member social support to the well-being of institutionalized elderly. Study is also needed of the relationship between lower levels of functional health and well-being in the elderly.
Resident influence scores were quite low (mean = 34.1), but this variable showed no significant relationship to life satisfaction. Upon hearing of low perceived resident influence, several staff in one nursing home responded, "We encourage them to participate in residents' council, but they just aren't interested." Several residents in all three nursing homes did indicate, however, that they either were a representative on this council or were aware of the issues being addressed by their council. A study of how residents view these councils might provide insight into this lack of full participation.
An additional, related finding was that most residents seemed unwilling to be critical of the staff although they were willing to criticize the institution. For example, when subjects were asked if they received enough individual attention, many responded negatively, but went on to emphasize how hard the staff worked. Many repeated, "My nurse works so hard, but they just don't give her enough help around here." When pressed to identify who "they" were, the subjects vaguely indicated nursing home administration or city government, and one simply replied, "Well, whoever is in charge of getting more nurses for us."
This same lack of staff criticism is not found in the acute care setting. In three separate studies, many subjects were willing to criticize their caregivers (Drew, 1986; LaMonica, 1986; Ventura, 1982). Yet, other nursing home studies have shown similar findings. In their study of 60 nursing home residents, Wilkin and Hughes (1987) found only one resident willing to criticize the staff.
There are a few explanations for the lack of staff criticism. Residents may see staff working very hard and be convinced that they are doing their very best. Another explanation might indicate an understandable lack of trust in the investigator, whom the subjects had not met prior to the study. Also, because the investigator was white and the majority of the residents and caregivers were black, this may have further distanced the investigator from the subjects. Future study might use a trusted member of the nursing home staff of the same race to collect data and participate in the study.
One final explanation for the residents' lack of staff criticism deals with dependency. When a person is dependent on another for vital assistance, the dependent person may experience positive feelings toward the supportive other. Negative feelings are avoided because expression of these might lead to a withdrawal of support. The most dramatic example of this phenomena is known as the Stockholm Syndrome (Kuleshnyk, 1984). This syndrome was named after a hostage incident in Stockholm, Sweden, and refers to the unconscious development of positive feelings of attachment by hostages towards their captors. The high level of cohesion and low level of resident influence in this study indicate that the Stockholm Syndrome might be present in this sample.
A Stockholm Syndrome-like response was reported in another nursing home study in which residents who called staff by their first names were more likely to express positive views and less likely to express negative views of the staff (Bond, 1989). To determine whether this syndrome actually exists in the nursing home, residents who have recently left the institution could be interviewed. Their perceptions of the social environment of the nursing home could be compared with current residents of the home.
IMPLICATIONS FOR PRACTICE
Nurses who practice in the nursing home setting are in an excellent position to influence resident independence and functional health. They also can affect the cohesiveness of the environment by influencing resident and staff interactions. Resident independence may be strengthened through creative interventions to promote self-sufficiency among residents. If perceived resident influence is low and participation on the resident council is minimal as in the institutions in this study, perhaps the forum is too large. Smaller groups of five or six residents may be less intimidating and may even be a more manageable unit for staff to negotiate care preferences with. For example, if five residents wish to be taken off of the unit for activities at about the same time every day but transport staff is limited, residents could be assisted to come up with a plan among themselves to either alternate times at which they will be transported or even for the more able members of the group to assist in transporting the less able.
Promotion of residents' responsibility for one another in a small group may promote cohesion in the nursing home environment. Although care must be taken not to have the more able residents feel as if they are being pressed into service, praise from staff for resident assistance may increase the residents' feelings of self-worth and promote further independence.
Other interventions to promote independence and cohesiveness in the environment should focus on the staff. A nurse who is an expert in caring for the elderly should be available to provide educational programs for the staff. For example, staff could be taught about the Stockholm Syndrome. They should be aware that effusive praise from a resident may actually be a sign that the resident feels very dependent and needs more, not less, attention.
The positive correlation between functional health and cohesion noted here emphasizes the need to provide opportunities for increased interaction with other residents and staff for the residents of low functional health status. Vigilant attention to physical and occupational therapy to maximize both functional health and social interaction are indicated. Also, because this study suggests that a reference effect might increase a resident's perception of functional health, the practice of plac'mg residents of varying degrees of physical functioning together for at least part of their day is supported. Clustering residents of low functional status on separate units may further decrease their opportunities for social interaction.
Social support provided by outside visitors such, as "the ladies of the church" cited by several residents in this study, could be promoted. Staff can not only make these visitors welcome by providing them with a quiet place to visit, but also could let the visitors know when their interaction has resulted in a positive sense of well-being in the resident.
Finally, nurses working with the elderly in nursing homes could use the Sheltered Care Environment Scale and the Life Satisfaction in the Elderly Scale as evaluation tools to identify problem areas and to prioritize areas where change is needed. The SCES may also be used to evaluate the success of programs designed to improve the institutional environment for the elderly.
If nurses are to lead in the creation of healthy environments for the aged, scientific exploration of these environments must be our guide. Use of research findings and further exploration of the impact of these environments will keep us on the cutting edge of aging and health.
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Means Standard Deviations, and Range of Scores for Predictor and Criterion Variables*
Summary of Pearson's Coefficients for Predictor and Criterion Variables
Summary Table for Stepwise Multiple Regression for Life Satisfaction and Social Environmental Variables and Physical Functioning*