"The most important thing for me right now is to have a good time and enjoy myself." This observation was made by a study participant How many nursing home residents would make similar statements?
Because the majority of the elderly and the majority of residents of nursing homes are women, it seemed appropriate for this study to focus on women's strengths. Not much data is available about older women's lives. Thus, studying elderly women's life management strategies and applying the findings to nursing practice has significance for geriatric nursing.
Qualitative research methods were used to identify the personal attributes or qualities of elderly women who effectively managed their lives in a nursing home setting. To be eligible to participate in the study, subjects had to be over 70, cognitively intact, and able to reminisce and to think about their lives in the present. Six women who met the criteria were selected for the study. The women ranged in age from 77 to 98, with an average age of 89; all participants had been residents of the same 96bed nursing home for a minimum of 8 months.
All participants of the study were functionally impaired and required much assistance with activities of daily living. One participant was a quadriplegic, one a paraplegic, and three were limited because of arthritis. Their diagnoses included diabetes, heart disease, and history of stroke. All were mobile with assistive devices (walkers or wheelchairs).
The atmosphere of the home was friendly. Each resident was asked on admission how he or she would like to be addressed; most were called by their first names. Many members of the staff and administrators had worked at this nursing home for several years. Their mission was maintaining a comfortable, friendly environment that is "home" for the residents.
Each participant in the study was interviewed three times during a 6month period and was asked to describe her life in the nursing home. Each interview lasted 30 minutes and was tape-recorded. Data analysis resulted in the identification of 10 strategies used for living in a nursing home by these six women. The strategies are described below.
All the participante clearly communicated their opinions. 'T speak my piece when I have it to speak. I let people know how I feel about things," Corinne said. The women believed that their opinions counted; they were straightforward in communicating their thoughts and feelings.
The women also communicated their wants and needs. They did not apologize for insisting that their needs be met; if they had a complaint they communicated it. "I like it here. Of course, there are some things I do not like," Betty stated. The women knew the proper channels to use when making a complaint. If there was a problem with the care she was receiving, Dot said, she asked to speak to the charge nurse.
They knew how to negotiate the system. They knew what they needed or wanted, and to what they were entitled.
Following a Routine
Each participant talked about her daily routine; having a routine and following it seemed important to the women. For example, walking out to the hall with her walker to sit in her chair every day was important for Alice. There she was able to observe activity; she enjoyed the social interaction. Watching "Wheel of Fortune" on television with roommates was part of the evening routine for several participants.
In regard to her routine, Alice said, "The 'girls' (certified nursing assistants) decide my routine. [However,] they let me sleep as long as I want." It was important for the women to deterrnine their own daily schedules.
Betty's adopted son came at lunchtime to feed her, often bringing the cat for a visit. He would take Betty for a ride through the grounds in her wheelchair on warm days. Betty spent as much time as possible outdoors on the patio during the summer
The predictability in having one's own routine seemed important. Each woman knew what she could look forward to each day. In addition, because she had determined her schedule herself, she felt a sense of control over her life.
Each woman maximally used her potential for activity and self-care. Despite the necessity of using a walker, Corinne considered herself self-reliant. "I go everywhere on my own steam using my walker," she said. "There's no place I can't go with my walker."
"Nobody helps me do anything," Corinne noted. "I like to be able to do what I have to do myself." Each woman insisted on performing certain aspects of her care herself. Each was proud of her abilities and capacity to perform self-care. Dot considered herself self-reliant even though her activity was severely limited by arthritis. She said, "They tell me here that I'm no trouble at all. No trouble at all."
The subjects participated in personal activities (eg, watching television and reading newspapers or books). In addition, five of the six subjects attended the activities provided for the residents. Betty, who is quadriplegic, said, "I go to everything. I get into all the activities. I go to bowling and Beano; I go to everything that I can watch. All I can do is sit and watch." Corinne said she attended the monthly birthday party because others came to her party.
In addition to the bowling and birthday parties, there was entertainment: gospel singers, bluegrass music, and piano playing. Trivia, word, and other games were played. Current events and other discussion groups were held. An exercise class that was held twice a week was popular.
The women said that as long as they were residents of the nursing home, they planned to take advantage of the activities that were offered. There were more activities available for them in the nursing home than in the community - where many had felt isolated.
Keeping Mentally Alert
Being mentally alert was important to the participants. Dot spoke clearly and with pride; "My mind is pretty good," she said. The women worked actively at staying mentally alert. Each had a calendar in her room to which she referred and on which she noted events of interest. "If I get stuck [determining the date on the calendar] I ask someone for help," Corrine said.
When asked how she was able to maintain her alert mental state at the age of 98, Alice answered, "You have to be that way all your life. I was always interested in everything. You've got to be that way." Alice saw her interest in "meeting the public" as contributing to her alert mental status. She did this in various ways, which included working in her younger years and greeting people in the hall within the nursing home in more recent years.
The women read newspapers and books, and watched favorite television programs regularly. Their rooms were personalized with photographs and belongings. "I try to keep up with the news," Corinne said. "1 go down once a week to [the] current events [discussion group] and find out what's going on down at town hall." They knew what was happening in the outside world and in their own worlds - namely in their families, nursing home, and communities. They were oriented to date, year, and time of day - as well as to person and place.
The participants in the study were proud of what they were still able to accomplish at their advanced ages. It was clear to the women that these abilities did not come about by chance. The women worked at maintaining all their skills.
Being sociable and interacting with others was important to the participants. "I go out there to sit in the hall quite a lot," Alice said. "And I get to see people. Most everyone stops to speak, and if they don't, they say, 'Hello"
Flossie said she enjoyed sitting in her wheelchair near the entrance of the facility to observe the activity. From this vantage point she could greet old friends from the community, regular visitors to the facility, and staff. Several residents interacted with children from the nursery school who visited regularly.
Making friends with the other residents and with the staff was another aspect of being sociable for the women in the study. They visited with one another while seated in the hall in easy chairs, which were conveniently arranged to form "neighborhoods." They also chatted in one another's rooms and in the dining room.
All of the participants in the study had family who were geographically and socially close. Corinne said, "We're a lovable family. All of them." The closest attachment for most subjects was with their children, but this also included grandchildren and others beyond the nuclear family.
Support for these women was reciprocal. They were still providing some kinds of support for family members according to their abilities. "I have a beautiful family," Alice said. "I have 14 great-grandchildren. I always remember their birthdays and Christmas with a card and a little money."
Visits, especially regular visits, were enjoyed and eagerly anticipated by residents. Telephone conversations were important to many residents. Having a telephone in their room contributed to a feeling of connectedness for several subjects.
The one participant who had never married had nieces and former neighbors who visited regularly.
On admission the participants assessed their situations. Although they preferred to remain at home, they were realistic about the situation. To deal with it, they looked at the move from a positive perspective. Emma spoke for the group when she said, "Of course I'm glad to be here and get the care I need and all, but there's no place like home."
Based on her positive perspective, each woman decided to accept the move and the new living arrangements. Alice said, "This isn't home, but they're good to me, very good."
Even though the participants in the study would have preferred to be living in their own homes, they decided to make the best of the situation by accepting the changes and losses associated with life. Some ascribed their losses to "God's will"; this explanation possibly made accepting the losses easier. Alice said, "I knew at my age I'd gone my limit . . . God's got His plan. You can't change that. I don't believe in making a big fuss."
Corinne's attitude also exemplified acceptance. She said, "Sometimes when I go to sleep, I pray to the Lord I won't wake up in the morning - but it hasn't happened yet, so I've had to be content."
Determination was apparent in the behaviors and attitudes of these women. It was manifested in the toughness and resilience that enabled them to maintain their position in a determined way once they made a decision. This approach could be seen in many of their life decisions.
Betty, when referring to the aftermath of the tragedy that left her quadriplegic, said, "I finally gave myself the date of October 6 - the day my husband died. If I didn't die by then, I was going to live, turn over a new leaf, and make myself get along. I was going to change my way of life ... I was going to laugh and joke and have a good time. I've made myself change. Now I want to get down to the dining room where everything is going on. I just made up my mind."
The strategy of determination was also manifested in the women's capacity to keep active despite overwhelming odds. As Flossie said, "I'm not ready to give up yet. I may some day, but not yet."
All of the subjects in the study were assertive; they clearly expressed their wants and needs. All had a daily routine that they determined themselves. The women insisted on being self-reliant and in engaging in as much self-care as possible. They kept themselves active as well as mentally alert. Sociability, including family interaction, was important. In addition, each woman experienced acceptance, had determination, and maintained a positive perspective. These 10 strategies were used by the subjects for effective management of their lives.
This study shows how important it is for the elderly to be in control of their lives. Langer (1983) studied the role of control in the lives of nursing home residents; the participants in her studies were given increased opportunities for decision-making in their daily lives. Langer found a positive correlation between increased decision-making for residents and improvement in their overall condition. They demonstrated more active participation and involvement, and increased mental alertness. They also reported feeling happier.
Langer (1989) used the term "mindful" to describe people who are actively involved and engaged in meeting challenges on a day-to-day basis. Her studies showed that, for the elderly, mindfulness can be rejuvenating. Nursing home residents, however, often find themselves in a state of mindlessness (the opposite of mindfulness) when they watch others doing activities for them that they were accustomed to doing for themselves. They then begin to believe that they are no longer capable of performing these tasks. Langer believes nursing home residents should have the opportunity to be "mindful" by being involved in more of the day-today decisions that affect their lives. In addition, she recommends that instead of giving residents too much help, the staff should encourage residents to be active and involved (Langer, 1989).
The women in this study were "mindful." They were active and mentally alert, and they continued to seek out challenges and new experiences.
The participants all had strong support networks. Other studies also confirm the importance of social support that "facilitates the development of coping strategies that help people .. . meet the requirements of new situations and prepare for the future" (Ryan, 1989). This may be a significant variable in adaptation of the elderly. Lack of social support is associated with both cognitive and emotional deficits in elders.
IMPLICATIONS FOR NURSING PRACTICE
The study identified specific strategies used by some older women, who, even as nursing home residents, are effectively managing their own lives. This information can be applied to help support the capable older woman as she lives her life as a nursing home resident. In addition, these findings can be used to assist other nursing home residents achieve this optimal level of functioning.
When planning their work days, the nursing home staff should consider the residents' need for control over their own lives. This may, however, be difficult due to time and other constraints. Instead of giving residents too much help, the staff must encourage residents to be active and involved in their own care. Nursing home residents' statements quoted in this article indicate how important activity and self-reliance are to them. Exercise, visiting, trips, and other planned activities are all enjoyed by nursing home residents. Because of physical limitations, however, many need assistance from the nursing and activities department staffs when planning and participating in these activities.
In addition to providing assistive devices, the elderly may be empowered to successfully manage their own lives by being given certain tools (eg, telephone, radio, and television) as they engage in activities and maintain their mentally alert status. Newspapers, magazines, calendars, books, and writing paper also were helpful tools.
Providing opportunities for making friends with other residents is important - as are family visits. Nurses can encourage family members to include their elderly member in family activities. The family can be instructed on the care the resident may require when away from the facility; many families are too intimidated to bring the resident out.
Lastly, the nursing home staff should be alert to the needs of those residents who have not learned how to be heard, and to assist them in finding a voice. The staff should encourage their residents to be assertive and not to view the assertive woman who is requesting her due as being demanding or ornery.
- Langer, E. Mindfulness. Reading, MA: Addison-Wesley,1989.
- Langer, E. The psychology of control. Beverly Hills, CA: Sage, 1983.
- Ryan, M., Austin, H. Social supports and social networks in the aged. Image 1989; 21(3):176-179.