This qualitative study ddressed the question, "What is the nature of self-care in nursing home residents?" Maintaining self-care in the performance of activities of daily living is important to sustain dignity. Furthermore, self-care may help prevent physical and mental deterioration in nursing home residents.
Orem (1991) defined self-care as "the practice of activities that individuals initiate and perform on their own behalf in maintaining life, health, and well-being" (p. 117). Selfcare includes making choices, as well as acting on them. Self-care, thus, involves control over one's life.
Control has been the focus of much research, some of which included the elderly. That increased control is related to health of the elderly was suggested by Langer (1983) and Schulz (1980). Their conclusions were based on several studies in nursing homes showing that increased control or perceived control led to a variety of positive outcomes, including increased alertness, activity, and well-being (Banziger & Roush, 1983; Langer & Rodin, 1976; Rodin & Langer, 1977; Schulz, 1976). Interventions in these experimental studies included responsibility for care of a plant or bird feeder and control over details of visits by college undergraduates. Other nonexperimental studies have supported a positive relationship between perceived control and various measures of psychological well-being in nursing home residents (Chang, 1978; Fawcett, Stornier, & Zepelin, 1980; Pohl & Fuller, 1980; Ryden, 1984).
Research suggests that helping behaviors by staff extend beyond the actual needs of residents in nursing home settings and may be detrimental to their performance. For instance, Winger and Schirm (1989) demonstrated that nursing home residents did not function at their ability level in self-care. Similarly, several researchers reported that staff rewarded dependent, but not independent, behaviors in self-care (Baltes, Honn, Barton, Orzech, & Lago, 1983; Barton, Baltes, & Orzech, 1980; Lester & Baltes, 1978; Mikulic, 1971). Two studies reported decreased independence in activities of daily living or decreased perception of self-care capacity within one or two months of admission (Spasoff et al., 1978; Tobin & Lieberman, 1976). Furthermore, Avorn and Langer (1982) showed that "being helped" decreased speed and completeness of performance on a task by nursing home residents.
Ryden's (1985) interviews with nursing home staff revealed that they saw themselves as primary decision-makers in giving care. Although staff indicated that they preferred more control by residents, other data suggested they wanted to retain a great deal of decision-making control. The author suggested that these attitudes were influenced by caregiver perceptions that the majorìty of residents were unable to make care decisions.
Other researchers have asked whether interventions can increase self-care. For instance, Faucett, Ellis, Underwood, Naqvi, and Wilson (1990) suggested that use of Orem's theory could affect nurses' attitudes and increase residents' self-care activities. Similarly, Miller (1985) found that individualized care led to less dependency than traditional task-oriented nursing.
Nursing home residents want increased choices according to several studies (Jirovec & Maxwell, 1993; Mercer & Kane, 1979). In a nationwide study of quality of care with 457 residents of 105 homes the choice theme was evident from structured and unstructured interviews. The researchers concluded that residents wanted as much independence as possible (National Citizens' Coalition for Nursing Home Reform, 1985). Daley's (1993) interviews with six women in a nursing home setting to discover their strategies for living in that setting found that important factors included the following: 1) determining their own daily schedules, 2) being able to predict their daily routines, 3) using their potential for activity and self-care, and 4) having a calendar in their rooms.
In summary, research cited here suggests that nursing home residents do not use their full potential for self-care without specific intervention and that nurses exercise more control than is necessary to accomplish care regimens. The present research was designed to expand the picture of nursing home residents' self-care through naturalistic inquiry. The purpose of this methodology is to observe phenomena as they naturally occur. Resultant thematic understandings can be used to generate ideas for improving the situation.
Because of the intensity of the observation used in this study, the investigator believed four residents would provide an adequate sample. Thus, the sample consisted of one white male and three white female elderly residents newly admitted to a nursing home in a small town in a southeastern state. Their specific ages were 77, 86, 88, and 91. To be included residents had to be oriented and without diagnoses of Alzheimer's disease or psychiatric illness so that self-care could be exercised. Subjects came to the home from four different types of settings varying from the home of a daughter to the hospital. Each had numerous chronic health problems and entered the home because of increasing need for assistance with activities of daily living.
The setting, chosen for convenience, was a nonprofit, church-related institution that houses 120 residents. The physical environment is aesthetically pleasing, and the staff verbalize a caring, holistic philosophy of nursing. Resident rooms are occupied by two persons with the two halves of the room separable by a curtain and each having a window. Shared bathrooms are at the entrance to each room. Subjects were housed on three of the four units in the home.
Nurse staffing during the hours of observation consisted of registered nurses, licensed practical nurses, and certified nursing assistants. Most persons who gave care to the subjects during the study were certified nursing assistants. Staff were permanently assigned to a unit but some turnover occurred during the study. Staff assignments to residents changed every few days.
Subjects were identified through the admissions office. The first four residents who were admitted after initiation of the study met the criteria. Each of these persons agreed to participate and signed a consent form that explained procedures, risks, and assurances. Persons were told that the researcher wished to observe their care in the nursing home to learn ways to help older people stay as well as possible.
The investigator met with nursing staff on each nursing unit to request cooperation. The investigator explained that she was studying how to provide high quality living for nursing home residents. Staff were told that even though residents were the focus of the research, their nursing care would be observed as well. All nursing staff readily agreed to participate and signed consent forms. Participants included 3 RNs, 6 LPNs, and 36 nursing assistants, all of whom were white.
Steps in Data Analysis
Participant observation and event sampling were the data collection methods chosen. After reviewing a variety of tools for measuring functional status (see review by Moinpour, McCorkle, & Saunders, 1988), the investigator decided to specifically sample the six self-care events of feeding, bathing, dressing, toileting, transferring, and ambulating. The researcher, however, recorded any self-care that occurred during the period of observation. Although interviewing was not a planned data-collection method, the residents frequently talked to the investigator during observation periods. This was a natural occurrence as the researcher sat nearby. These data were recorded like any other observations.
Each resident was observed on one day each month for six months. With four subjects, this allowed the investigator to observe one resident per week. Data were collected during the hours from 6:30 AM until all six events were completed, usually between 9:30 AM and 11:30 AM.
During data collection the researcher sat on a chair in the resident's room or moved to another site when the resident did so. In addition to the resident's room, sites of observation included the resident's bathroom, dining room, tub room, and hallways. The investigator initiated talk with the resident when necessary to clarify the resident's intentions, desires, or understandings related to self-care. She also used some conversation to establish rapport with the resident and staff.
The researcher gathered data through hand-written field notes in order to capture the natural language and actual happenings. Names were coded to ensure confidentiality. Events were recorded as completely as possible. Immediately following the period of observation the researcher reviewed the notes and made additions if a note was incomplete. Notes included descriptions of the setting and persons, verbal communications, actions, and nonverbal behaviors. The notes were then typed in preparation for later analysis. The investigator also wrote in a journal after the observations in order to record methodological decisions, personal reactions, and theoretical ideas.
To enhance the dependability of the findings, two months after beginning the study, a second qualitative nurse researcher jointly observed with the researcher and wrote separate field notes. The two sets of notes were compared for inconsistencies. No major inconsistencies were identified.
The data were analyzed by a method established by Kahn and Steeves (1988). The method contains several steps outlined in the Table. As described in the Table, units of raw data from the field notes were written on 3x5 cards so they could be categorized. Themes were then identified from the categories.
At the conclusion of the study an expert in qualitative analysis conducted an audit of the study materials and results to establish confirmability (objectivity). The expert concluded that the data supported the themes identified by the researcher. The themes were not validated by the subjects because none lived until completion of the data analysis.
The findings presented here are the self-care themes identified from the data. The three themes reflect recurring events in the lives of all four residents. In discussing themes the term "nurse" will be used for staff members who gave nursing care, whether RN, LPN, or nursing assistant. Also, nurses will be referred to by the feminine pronoun because all but one were female.
Theme One: Asserting and Caring for Self
The residents were actively engaged in the care of self and their environments. Not only did they frequently carry out the six events sampled and make numerous choices on their own initiative or in response to staff invitation but (also) they demonstrated interest in improving their appearance; engaging in learning, religious, and recreational activities; organizing a pleasing, comfortable environment; and monitoring and caring for their own health and needs in countless ways. They repeatedly demonstrated efforts to conform to socially accepted standards of appearance and behavior related to self-care.
One particular area stood out in this setting where disorientation and confusion are common. The residents made frequent use of devices to facilitate orientation to time and place. These included sensory devices such as hearing aids and glasses, both of which they repeatedly requested be given to them when out of reach or as soon as feasible during a bath. This request was often accompanied by a comment of not being able to see or hear without the glasses or hearing aid.
Other orientation devices used included clocks, calendars, reality board, activity board, and newspapers. One resident, for instance, daily checked the date on the newspaper found in the hall on her way to the dining room. Residents frequently validated date and day of the week with a nurse.
Although residents exercised much self-care, they also received much care by nurses. Nor were choices always offered. Yet for each of the residents certain things were so important that they either initiated action toward care or insisted on certain choices. Although each coped with the nursing home environment in a different way, all were able to be assertive when they chose to pursue their preferences. Examples of assertiveness included one resident's successful protest when the nurse started to remove her underclothes prior to a trip down the hall in the shower chair to the tub room.
Asserting themselves did not always get residents what they wanted. Sometimes the nurses insisted and did not give in to the residents' desires. This could lead to strong conflicts. One example was when a nurse insisted mat a resident walk when the resident felt unable to do so because of pain in her feet. This resident expressed the belief that the nurse avoided her after this conflict.
Although residents frequently voiced their desires, they also indicated that they tried not to be a bother. In fact, they sometimes indicated that they did things for themselves to "help staff." One resident put it this way: "You come here because you need help, you're dependent. Otherwise you wouldn't be here. But then you do what you can for yourself to help staff." This attitude may have led to actions observed such as the resident laying out clean clothes, even though the nurse gave the entire bath when she arrived. In fact, one resident expressed this after laying out her clothes, "Now I got everything ready - save them time."
This idea also was expressed by nurses. They often asked residents to do a particular task "for me." For instance, a nurse asked a resident to "sit up for me." They also sometimes expressed appreciation when residents did what they could or "tried" to be independent.
Although the residents carried out many actions, such as drinking water or exercising, to improve their own health, nurses also sometimes used the "do so and so for me" language in relation to these actions. For instance, a nurse said, "We want you to drink (water) today for us." Residents did not speak of doing such actions for the nurses. Rather, they talked of doing such actions to help themselves.
The desire to be independent and care for self was expressed on many occasions. The researcher also observed, however, that generally residents did not seem to mind when the nurse provided care such as bathing. They simply accepted the care and often thanked the nurse for providing it. On the occasions when they were asked whether they wanted to act independently or have the nurse perform the task, responses varied. They sometimes chose to act independently and other times said the nurse could do it. On other occasions a resident asked a nurse for help. For instance, a resident asked for help in dressing because she was tired.
Theme Two: Unpredictability/Not "In the Know"
Unpredictability was manifested in a variety of ways. For instance, whether the resident or the nurse carried out a particular event such as combing hair, preparing food, or bathing was unpredictable. Sometimes the resident provided a certain aspect of self-care independently, and sometimes the nurse did it for the resident. The same unpredictability occurred in relation to choices offered by staff, that is, whether a choice was offered at all.
The resident's ability did not appear to be the deterrnining factor in these situations, but differences among staff members may have been one determinant. That mese differenees were part of the reason for unpredictability was supported by comments such as the following one by a resident who spent most of her time in bed due to back pain when she sat on the chair: "Some say sit up and some say do as you please."
Nor did independence in one activity predict independence in another activity. For instance, the male resident frequently shaved himself (with an electric razor) even though nurses usually washed him without his help. Residents were seen washing themselves, followed by the nurse dressing or combing them. Or the nurse would put on the resident's glasses even though the resident was encouraged to perform other self-care, such as face washing.
The researcher observed that the timing of events varied from day to day. Residents' comments also indicated that they could not make predictions about the timing of events such as bathing, whether given by the nurse or provided by the resident. For instance, one resident never knew when the nurse would come to help her transfer out of bed to the wheelchair so that she could go about self-care in bathing, toileting, and dressing. Help with transfer was all she needed to initiate these events.
Resident comments gave evidence mat they were not sure about details of routines and that they did not feel like they were "in the know." For instance, they did not always know which two days of the week they got a tub bath. One resident made repeated comments about variability and unpredictability in the size of breakfast; sometimes her tray contained only cereal and applesauce, whereas other times she also had pancakes, bacon, and yogurt. She found this puzzling. Another resident said the nurses used to wash him but "here of late you wash yourself." He did not know why the change. Nor could he explain why he had been having breakfast in bed and was now being taken to the dining room for breakfast. Another resident one day said she thought maybe she was not taken to the dining room for breakfast that day because she was to get a tub bath later. She thought the latter might be so because she usually gets a tub bath when her roommate does and she overheard the nursing assistant telling the roommate she would get a tub bath that day.
The feeling of "not knowing" often came into play as residents waited for events they thought should occur sooner than they did. For instance, while waiting for the morning bath, residents frequently wondered why the nurse was not coming. A typical comment was this one: "Maybe they're not going to give me a bath. I don't know why."
Lack of knowledge about medical treatment plans was another frequent complaint. For instance, one resident was worried that her medications were causing problems. Later she said that she thought the physician had changed her medications but she did not know how.
Unpredictability created special problems for residents in areas of great importance to them. For one resident, who experienced dribbling of urine, getting on the commode when needed was very important. But equally important was not sitting there long because of lower back pain. Sometimes nurses put her on the commode and waited the few minutes for her to be finished so she could be helped back to bed. At other times nurses put her on the commode and immediately walked out, sometimes without providing access to the call bell. Said the resident, "I don't know if they're going out or going to stay." This was a big concern to her.
Theme Three: Waiting/Permission
As implied with the previous theme, residents often were observed to be waiting for events to happen. In addition, nurse-resident interaction suggested that the nurse provided permission for residents to go ahead with events.
This behavior was particularly evident in the morning. Residents made comments that they felt unready for the day or did not feel O.K. until the bath had occurred. Yet this event could not occur until the nurse gave the go-ahead in some way, such as bringing the bath water. Until then residents made comments or gave nonverbal cues, such as fidgeting, that they were in a waiting mode.
Residents frequently expressed frustration with needing to wait for the morning bath. As an example, one resident waiting for his bath after breakfast said, "Well, I wish I could get around here. Wish now they'd come wash and dress me." Or another time: "I don't know when next shift will be on here. Maybe I'll get dressed sometime today." This resident contrasted the present setting with the home for adults where he had been earlier by implying that here he had to live by the nurses' wishes.
One resident became very assertive in order to avoid- waiting. This resident was often taken to the bathroom to begin her bath with the nurse leaving and returning later to finish the bath. The resident said she was tired of waiting for the nurse to return so she insisted that the nurse not leave. She was successful and told the researcher how she had made the nurse stay.
Language of nurses and residents indicated that the nurse was in charge or was the one to decide who did what when. For instance, nurses often used the language of "letting" the resident do a task (e.g., towel drying). Likewise, residents used this language as in this comment, "When are they going to let me take a bath?" One resident verbalized the permission idea after the nurse said, "I'm gonna let you wash your face while I go to get some soap." The resident replied, "So you're giving me permission to wash my face?" Both laughed lightly in response to this interaction.
The researcher observed that nurses frequently said, "There you go" or "Here you go" when they brought meals or did other tasks. One day when a resident commented that this was a common statement, the researcher asked why she thought this was so. The resident's response is relevant to the theme of permission: "I don't know. Maybe it means now you can go ahead."
Disagreement on how to do things was not uncommon. Typically in these situations the nurse was the one managing the situation and initiating actions. Then the resident would voice a preference for carrying out the routine in a different way. Sometimes the nurse acquiesced to the resident's desires and sometimes she did not. One incident illustrating the nurse in control occurred when a resident was told she could not go in the wheelchair to another floor to play cards unless she wore her slippers. The resident protested because of pain and swelling in her feet. This resident said she just would not be able to play cards anymore.
Locus of control shifted because of the setting. For instance, one resident wanted to call her physician about a problem she was having with her medications. According to the resident, however, the nurse told her she could not call the physician. This was something she had commonly done at home some weeks earlier before her hospitalization and nursing home admission. In the nursing home she had a telephone by her bed but now apparently calling the physician was up to the nurse. And the resident acquiesced even though she could have defied the nurse's wishes.
The setup of the environment frequently reinforced the theme of waiting /permission. Residents often were observed to be in situations where they could not exert control or act independently. Examples included having no call bell nearby, a walker not being within reach, or die bed being in a high position so a resident hardly could transfer alone.
DISCUSSION AND NURSING IMPUCATIONS
This research demonstrated that nursing home residents were active in self-care and eager to assert themselves. Yet, in spite of the ability and interest in independence demonstrated much of the time by residents, two of the three themes that emerged in this study suggested dependence for residents and emphasized nurse control. Ironically, at a time in life when ability to assert one's self is compromised because persons often move more slowly, talk more slowly, have diminished hearing and sight, and experience other similar losses, residents had to increase efforts to achieve self-care. These findings support results of earlier research showing that nursing home residents did not function at their ability level in self-care (see earlier citations).
Expressions and behavior of both residents and nurses suggested expectations of at least some dependence for nurse care on the part of residents. This in many ways seems inherent and normal in the setting. As Agich (1993) asserted, autonomy in the nursing home setting should not necessarily mean absolute independence. People in nursing homes need help; dependence is desirable and necessary.
Agich also pointed out, however, that persons in this setting need to be encouraged to express their identity, make meaningful choices, and use their full potential for self-care. So why in this study the failure to allow residents to become partners to information about scheduling? Why was there no shared routine time for rising for the resident who merely needed help to transfer into the wheelchair? Why such a circuitous route for awareness of whether today is tub bath day? Research by Daley (1993) demonstrated the importance of predictability in routines and self-determination in scheduling to persons living in this setting. Other research also underlined the importance of control and predictability (Schulz, 1976). Yet the present research suggests that routines are unpredictable and controlled by nurses.
Failure to create predictable routines or to help residents know what is happening could occur as a means of nurse control in a setting where nurses feel overwhelmed by the multitude of tasks. In other words, if residents lack specific expectations about timing of events, then nurses may feel they will not be held accountable to a schedule they may not be able to keep. Thus, perhaps inappropriate control by nurses stems from the nurses' own sense of lack of control or ability to complete all the tasks demanded of mem. This idea is consistent with the finding that both nurses and residents talked about residente doing tasks to help nurses, as well as with the idea that nurses had to give permission for tasks to proceed. Apparently, both parties saw the tasks as the responsibility of the nurse.
This research cannot answer questions of nurse motivation. What the research does is suggest the need to study this phenomenon from the viewpoint of nurses. Understanding of nurse behavior may be necessary in order to increase control and selfcare by residents.
Notwithstanding the possibility that changing resident self-care may be dependent on changing the nurses' situation, mis expanded picture of residents' self-care does allow one to generate a number of practical ideas for improving care in the nursing home. For instance, the data suggest the need to establish routine times to help selected residents transfer out of bed in the morning. Written plans could be used to create consistency in patterns of care, and residents could be included in developing and being aware of the plan. Consistency of nurse assignment over time might increase predictability for the residents. Nurses should be urged to assess individual preferences and concerns and to communicate with residents about daily happenings. As Miller (1985) showed, individualized care can lead to less dependency. Inservice discussions about power and control could be used to raise awareness about these issues and appropriate application in the nursing home. This is important because of the lack of professional preparation of most nursing home staff.
This research had some limitations. For instance, the presence of the investigator may have influenced behavior of nurses and residents. What was not anticipated was the degree to which residents talked to the investigator and shared their perceptions. The methodology deliberately employed here was observation, rather than in-depth interviewing. Yet aspects of the latter were approached as residents talked to the investigator. This became an unplanned strength of the research. At the same time the friendship that developed between each resident and the investigator created an unknown effect on the results. What seemed very clear was that residents appreciated the attention of someone listening to their concerns.
In conclusion, systematic observation suggested to the investigator that these residents were capable of much self-care and that this potential was not fully used. This finding supports prior research. Nor was the capacity for choice and a sense of control honored to the degree possible. Particularly evident was the failure to facilitate predictability in routines and to include residents in planning or at least providing information about routines. Although some dependence was expected and desired by residents, they often expressed frustration because of lack of control. Ryden's (1985) research suggested nurse perceptions that may have led to behaviors observed here, but additional research is needed to probe the reasons for these behaviors. Finally, results of this study underline the need to better prepare nursing home staff to facilitate self-care in residents.
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Steps in Data Analysis