Nursing homes are caring for increasingly greater numbers of physically deteriorated and cognitively impaired elderly (Rantz, 1987). The 1990 Omnibus Budget Reconciliation Act (1990) addresses the rights of nursing home residents to be involved in decision making relative to their care and life in the nursing home. Research in nursing homes regarding expectancies of control has examined the importance of control on the well-being of the elderly. Several studies examined the relationship between perceived control and morale of nursing home residents.
In a sample of nursing home residents who all rated their health as fair, Chang (1978) found that situational control, such as self-detennination in activities of daily living (ADL), was the strongest contributor to morale of aged residents. Pohl and Fuller (1980) found that choice within the institution caused the largest percent of variation in morale, followed by income, which is inherently related to control.
Other studies have found that morale is increased when the aged perceive themselves as having control in the situation (Chang, 1979) and that satisfaction decreases as the perception of constraints within the institution increases (Faucett, 1980). One researcher asked residents if they wanted to live elsewhere. The responses indicated that 46% preferred a noninstitutional setting so as to achieve greater autonomy and independence (Noelker, 1978). Jirovec and Kasno (1990; 1993) found that perceptions of the nursing home as inducing dependence were related to residents' morale and perceptions of their self-care abilities.
Studies using direct manipulation of control in a nursing home setting have shown interesting effects. Schultz (1976) studied the effect of being able to control or predict visits by a student during a 2-month period on psychologic status, physical well-being, and activity level. Groups that were able to control or predict the time and length of the visit showed a significant improvement in all measures of well-being when compared with a group that was visited randomly and a group that did not receive visits.
Langer and Rodin (1976) manipulated control using two groups of aged residents. One group was given a talk by the administrator that emphasized residents' independence and the control they had within the home. This group also was given a plant to care for. The second group was told what the nursing home would do for them and was given a plant that the nurses would water. The first group was found to be more alert, happy, and active - and were rated as significantly more improved than the second group. A follow-up study found the improvements persisted 18 months after the original manipulation by the administrator (Rodin, 1977).
Orem's (1985) Self-Care Theory provides a basis for nurses when addressing this challenge. Orem contends that accurately diagnosing an individual's self-care abilities and selfcare agency is paramount to prescribing appropriate nursing actions (Orem, 1985). The Nursing Development Conference Group identified three phases of self -care agency: estimative operations, transitional operations, and productive operations (Orem, 1979).
The estimative phase consists of the individual assessing the internal and external environments and drawing a conclusion about his or her own capabilities to perform a particular action - and the likelihood the action will achieve the desired goal within the particular situation. It is therefore important to understand nursing home residents' perceptions of their available choices within the home and their willingness to be involved in decision making if given the chance. The following research questions are addressed:
* Is there a difference between nursing home residents' perceptions of choice within the nursing home and their desired choice?
* Is the discrepancy between perceptions of actual choice within the nursing home and the desired choice related to nursing home residents' self-appraised self-care agency?
* Is the functional ability of nursing home residents' related to their desired choice within the home - and the discrepancy between perceptions of actual choice within the nursing home and the desired choice?
The study was part of a larger study that examined the relationship between several factors and self-care agency. A nonprobability sample of nursing home residents was drawn from four urban and suburban nursing homes in southeastern Michigan (N= 107). Residents who were unable to speak English or successfully complete a short portable mental status questionnaire were excluded from the sample.
The sample consisted of 69 women and 38 men. Eighty-two subjects were white and 23 were black. Sixtyfour residents were widowed, 14 separated or divorced, 14 never married, and 13 currently married. The subjects reported having from 0 to 10 children (M = 1.8, SD = 2.05). Previous occupations included blue collar or service (n = 52), homemaker (n=32), and white collar or professional (n = 19). The total numbers of years of education ranged from 3 to 20 (M = 10.26, SD = 3.07). The average age of the residents was 78.49 (SD = 9.25); their ages ranged from 58 to 99.
Self-care abilities were measured using the Appraisal of Self-Care Agency (ASA-A) scale (Evers, 1987). The ASA-A includes 24 items, both positive and negative, each scored with a 5-point Likert scale. Scores can range from 24 to 120, with high scores reflecting self-perceptions of greater self-care abilities. The scale was developed to measure self-care agency, a core concept of Orem's selfcare deficit theory. Content validity was established using an expert panel of eight nurses, who either had earned doctorates or were doctoral students, working within Orem's conceptual framework. In addition, Orem evaluated the instrument for content validity.
Construct validity, demonstrating that different methods of measuring a construct yield similar results, was demonstrated with adults from a rehabilitation center using the ASA-A and Kearney and Fleisher's Exercise of Self-Care Agency (r=.74, p<.05) (Kalter, 1987). Construct validity was further demonstrated in a Dutch elderly study using a known groups technique, with nursing home residents evidencing lower ASA-A scores as compared with elderly not living a nursing home (f(78) = 6.21, p<.001) (Courtens, 1987). In the present study, the ASA-A was found to be internally consistent (Cronbach's α = .8546).
Functional ability was measured using the Katz (1963) Index of Activities of Daily Living. This instrument has been widely used to assess activities of daily living in patients with many types of chronic illness - with much consistency in reported observer ratings. A questionnaire was developed to measure residents' perceptions of choice within the nursing home environment. Residents were asked how much choice they would like to have in 15 ADLs within the home on a scale of 1 (almost never) to 4 (almost always), and the items were summed for a total desired choice score.
After completing the items on desired choices, residents were asked how much choice they felt they actually had in the same areas on a similar 4-point scale. The scales have high face validity. To establish the testretest reliability of the perceptions of choice and desired choice, the subjects were asked to complete the two choice questionnaires 2 weeks after the first was completed and the tools were found to be reliable (r = .86, p<.01andr = .84,p<.01).
Four research assistants, who were completing graduate degree requirements in nursing, were trained by the principal investigator to participate in the study. During data collection, progress of the research assistants was monitored by the principal investigator.
Subjects did not have difficulty completing the questionnaire and expressed no concerns regarding staff reprisals related to their responses to the choice questions; confidentiality of the responses had been emphasized. Subjects were interviewed in their rooms; the short portable mental status questionnaire was administered after verbal consent was obtained (Pheiffer, 1978). Demographic data were collected, and residents were then given the ASA-A scale and the choice questions to complete. If requested, the items were read to the subjects. A few subjects needed assistance with some of the ASA-A items. Assistance usually involved clarifying the items that were negatively worded. Many of the subjects completed the questionnaire without assistance.
Residents' scores on the perceived choice available to them within the nursing home ranged from 16 to 49 (M = 33.57, SD = 8.59), with higher scores indicating greater perceptions of available choice. In contrast, the scores on the questionnaire asking the amount of choice they desired within the home ranged from 20 to 60 (M = 42.11, SD =9.45).
The first research question asked whether these scores were different. The dependent t-test showed the difference to be significant (f(106) = - 10.37, p<.01). The average difference was 8.54, with residents desiring more choice than they felt they had within the home. The second research question asked if this discrepancy between perceptions of actual choice and the amount of choice desired was related to self-perceptions of self-care abilities. A Pearson correlation showed the two were not related (r = . 07, NS).
The last research question asked whether functional ability was related to the various choice measures. Perceptions of actual choice were found to be weakly and inversely related to scores on the Katz ADL Index (r=-.23, p<.01). As functional ability scores decreased (reflecting greater independence), perceptions of choice increased. Only 5% of the variation in perceptions of choice was explained by the resident's functional abilities.
Similarly, desired choice also was weakly and inversely related to functional ability (r = -.17, p<.05). As residents' independence in functional abilities increased, desired choice increased. Less than 3% of the variation in desired choice was explained by functional abilities. Functional ability, however, was not related to the discrepancy in perceptions of actual choice and desired choice (r = -.04, NS).
Nursing home residents desired more choice than they perceived to be available to them in the home. The most likely explanation for this is that the opportunity to exercise control is limited in an institutional setting, where the work for the most part is expedited. It is much easier for caregivers not to ask for input from the patient when providing care. While nurses may talk about individualizing care plans, the bulk of actual care within a nursing home is provided by nonprofessionals.
Although research has demonstrated the value of perceptions of control on general well-being and psychologic health, nonprofessional staff members are likely to view interest in control by residents within the home as an interference that is more of an obstacle to their care. It is paramount that the professional nursing staff help their nurses' aides to see their patients as legitimate masters of their own lives.
Entering a nursing home is dreaded by the elderly. Part of this abhorrence is related to the loss of control felt by residents. The differences between perceptions of control and desired control highlight the circumstances under which nursing home residents live. Research has firmly established the value of providing control within nursing homes.
The professional nursing staff must structure the nursing home's approach to residents so that choice is maximized within the constraints of the institution. A first step in doing this is orienting all staff members to this approach. At the same time, residents must be empowered to seek control as their legitimate right when they wish.
When the elderly live at home, they are thought to be competent adults and masters of their own fates. As soon as they enter a nursing home, however, they are expected to assume the role of patient with all its submissive qualities. Unfortunately, nursing homes have been structured after the medical model, which is inappropriate if the nursing home is to be the resident's home. Aspects of what it means to live at home should be incorporated into nursing homes if appropriate care is to be provided.
This integration can be accomplished within nursing homes in a variety of creative ways. Residents can be allowed preferences that are more easily accommodated. The residents can determine if breakfast will be taken in the dining room or in their own room. Some may prefer to relax during morning coffee rather than adhering to the dining room schedule. Similarly, the bath day schedule can be established with residents' preferences in mind. While accommodating the timing of assistance for morning care may be less feasible, resident desires can be considered where possible. What the resident will wear is easily accommodated.
Ideally, resident committees can be formed to determine procedures, menus, special celebrations, and other choice-related issues. The mere existence of these committees will demonstrate to the residents that the staff wants to structure home activities according to the residents' preferences - and that the nursing home is the residents' home.
Perceptions of actual control and desire for control within the home were both related to ADL abilities. As dependency increased, perceptions of control and desired control decreased. Increased dependency may foster a sense of helplessness. Not only did more dependent residents perceive they had less control, but also they lost their desire to control aspects of living in the home. They may restructure their desires in order to be compatible with what they perceive as their abilities. An alternate explanation may be that the physical processes associated with the functional limitations may consume the majority of the resident's physical and emotional energy, and control of the external environment may become less of a priority.
It was surprising that self-perceptions of self-care abilities were not related to perceptions of control within the home. Orem (1985) posits mat living patterns can either enhance or limit self-care abilities. Loss of control as part of a nursing home life pattern can certainly limit perceptions of self-care abilities. This can occur if the resident decides not to take action because of conclusions in the estimative phase of self-care agency that a desired self-care choice is unavailable. Research is necessary to more fully understand elderly persons' perceptions of their self-care abilities, particularly elderly living in nursing homes.
Nursing home care should be structured to assess not only residents' functional abilities, physical needs, and psychosocial needs, but also preferences regarding choice within the home. Most residents, if asked, express a desire to maintain control in their lives. Assessing a resident's desire to control specific activities, such as arrangement of possessions, time with friends, ambulation, toileting, eating, and grooming, will provide essential data regarding control needs. Such an assessment also will increase the resident's perception about the availability of choices within the home.
When the nurse asks the resident about preferences, the resident will realize that the choices are available. With information about preferred choice, the resident could be provided information about the available choices within the home and the reasons for some choices not being available. For example, it may not be feasible for residents to choose the times of meals, but specific times may be arranged for afternoon snacks.
Nursing homes are institutions, and as such will never seem like the home residents left. Empowering residents to exercise control in their daily lives will be reflected in residents' behavior. Control issues should be addressed in the philosophy of care within nursing homes.
- Chang, B.L. Generalized expectancy, situational perception, and morale among institutionalized aged. Nurs Res 1978; 27(5):316323.
- Chang, B.L. Locus of control, trust, situational control, and morale of the elderly. Journal of Nursing Studies 1979; 16:169-181.
- Courtens A: De bekwaamheid van verpleegkundigen inzake het inshatten van het zelfzorgvermogen van patienten [Appraisal of acute care hospital patients' self-care agency by nurses, patients and significant others]. Unpublished master's thesis, University of Umberg, The Netherlands, 1987.
- Evers, G., Isenberg, M. Reliability and validity of the appraisal of self-care agency (ASA) scale. Paper presented at the International Nursing Research Conference, 1987, Washington, DC.
- Faucett, B., Stonner, D., Zepelin, H. Locus of control, perceived constraint, and morale among institutionalized aged, lnt J Aging Hum Deo 1980; 11:13-23.
- Jirovec, M. Predictors of self-appraised selfcare agency in nursing home residents. West J Nurs Res 1993; 15:314-326.
- Jirovec, M., Kasno, J. Self-care agency as function of patient-environment factors among nursing home residents. Res Nurs Health 1990; 13:303-309.
- Kalter, A. Betrouywbaarheid en validiteit van de aa school bij meting van zelfzorgvermagen van revalidanten [Self-care agency of the institutionalized rehabilitation patients as measured by the ESCA and ASA scales]. Unpublished master's thesis, University of Limberg, The Netherlands, 1987.
- Katz, S., Ford, A., Moskowitz, R., Jackson, B., Jaffee, M. Studies of illness in the aged. The index of ADL: A standardized measure of biological and psychosocial function. JAMA 1963; 185:94-99.
- Langer, E.J., Rodin, J. The effects of choice and enhanced personal responsibility for the aged: A field experiment in an institutionalized setting. J Pers Soc Psychol 1976; 34:191-198.
- Noelker, L., Harel, Z. Predictors of well-being and survival among institutionalized aged. Gerontologist 1978; 18:562-567.
- Omnibus Budget Reconciliation Act: Subtitle C, Nursing Home Reform (Publication No. PL:101-508). Washington, DC: US Government Printing Office, 1990.
- Orem, D. Concept formalization in nursing: Process and product, 2nd ed. New York: McGrawHill, 1979.
- Orem, D. Nursing: Concepts of practice, 2nd ed. New York: McGraw-Hill, 1985.
- Pheiffer, E. A short portable mental status questionnaire for the assessment for organic brain deficit in elderly. J Am Geriatr Soc 1978; 23:433-441.
- Pohl, J.M., Fuller, S.S. Perceived choice, social interaction, and dimensions of morale of residents in a home for the aged. Res Nurs Health 1980; 3:147-157.
- Rantz, M., Miller, T.V. How diagnoses are changing in long-term care. Am J Nurs 1987; 87:360-361.
- Rodin, J., Langer, EJ. Long-term effects of control-relevant intervention with the institutionalized aged. J Pers Soc Psychol 1977; 35:897-902.
- Schultz, R. Effects of control and predictability on the physical and psychological wellbeing of the institutionalized aged. J Pers Soc Psychol 1976; 33:563-573.