Journal of Gerontological Nursing

Institutionalized Older Adults' PERCEPTIONS OF Nurse Caring Behaviors: A PILOT STUDY

Barbara Marini, MSN, RN

Abstract

ABSTRACT

The purpose of this article is to identify which behaviors performed by nursing staff were important indicators of caring as perceived by older adults residing in institutional settings. Using Watson's Theory of Transpersonal Care as the framework for the study, the Caring Behavior Assessment (CBA) instrument, which is congruent with Watson's carative factors, was used to interview residents. A convenience sample of 21 residents residing in long-term care and assisted-living facilities answered the 63-item CBA. Descriptive statistics were used to analyze the importance of each identified behavior. The analyses revealed that the highest indicator of nurse caring focused on the nurses' technical competency (instrumental activities). This study noted a significant gender-specific perception of caring. This may reflect differences in gender communication styles and interpersonal processes which may affect connotations of caring expressions. Humanistic caring (expressive activities) was the second most important indicator of care. Older adults desired care which preserved and enhanced individual dignity.

Abstract

ABSTRACT

The purpose of this article is to identify which behaviors performed by nursing staff were important indicators of caring as perceived by older adults residing in institutional settings. Using Watson's Theory of Transpersonal Care as the framework for the study, the Caring Behavior Assessment (CBA) instrument, which is congruent with Watson's carative factors, was used to interview residents. A convenience sample of 21 residents residing in long-term care and assisted-living facilities answered the 63-item CBA. Descriptive statistics were used to analyze the importance of each identified behavior. The analyses revealed that the highest indicator of nurse caring focused on the nurses' technical competency (instrumental activities). This study noted a significant gender-specific perception of caring. This may reflect differences in gender communication styles and interpersonal processes which may affect connotations of caring expressions. Humanistic caring (expressive activities) was the second most important indicator of care. Older adults desired care which preserved and enhanced individual dignity.

People are living longer, and many of them are being cared for in institutional environments. "In 1993, there were approximately 17,500 nursing homes in the United States, with more than 1.7 million beds in service. This figure is predicted to increase almost 30% to approximately 2.2 million beds by the year 2000," according to Pillari and Zeuschner (1994, p. 17). Adding to this number of older adults living in institutional environments is the rapid expansion oí assistedliving residences throughout the United States. Although institutional care has improved during the past several years, primarily because of the enactment of the 1987 Omnibus Budget Reconciliation Act (OBRA '87, Public Law No. 100-203), numerous physical and psychological detrimental effects remain. Many older adults experience loneliness, disorientation, hopelessness, loss of identity, and dehumanization (Ebersole & Hess, 1990). Gerontological nurses are in a position to change the nature of caring in institutional environments. If nurses are to meet the caring needs of this ever-growing population, nurses need to know what caring means from the older adults' perspectives.

The purpose of this study was to identify which behaviors performed by nursing staff were important indicators of caring as perceived by older adults residing in institutional settings. For the study, the nursing staff included RNs, licensed practical nurses, and nurse aides. Nurse aides were included because they are the primary caregivers in the majority of geriatric institutions.

THEORETICAL FRAMEWORK

The theoretical framework for the study was Watson's (1988) Theory of Transpersonal Care. According to Watson:

Transpersonal human care and caring transactions are those scientific, professional, ethical, yet esthetic, creative, and personalized giving-receiving behaviors and responses between two people (nurse and other) that allows for contact between the subjective world of the experiencing persons (through physical, mental, or spiritual roots, or some conbination thereof) (1988, p. 58).

Watson balances science with humanism and describes 10 carative factors nurses can use to incorporate caring into practice (see Sidebar on this page). Transpersonal care involves both instrumental activities (such as giving medications and treatments) and expressive activities (such as listening and providing emotional support) (Watson, 1988).

LITERATURE REVIEW

The literature review revealed a wealth of information on the importance of human caring and the advancement of caring knowledge in nursing. Much of the empirical research involved perspectives of care from both patients and nurses (Keane, Chastain, de Rudisill, 1987; Larson, 1987; Mayer, 1987; Von Essen & Sjoden, 1991; Wolf, Giardino, Osborne, & Ambrose, 1991). Some studies were conducted solely from the patients' perspectives (Brown, 1986; Cronin & Harrison, 1988; Huggins, Grady, & Kohut, 1993; Larson, 1984; Parsons, Kee, & Gray, 1993; Rieman, 1986). The findings of the research studies supported the importance of caring, and many studies identified instrumental and expressive behaviors as caring indicators.

Little gerontological research on caring has been conducted. Only three references involved studies of caring as viewed by institutionalized older adults (Aventuro, 1991; Hutchison & Bahr, 1991; National Citizens' Coalition for Nursing Home Reform, 1986). The National Citizens' Coalition for Nursing Home Reform (1986) study involved more than 400 nursing home residents in 10 states. A series of focus groups identified three critical elements of quality care for nursing home residents:

* The ability to make choices and exercise control over their lives.

* Being treated with dignity.

* Positive attitudes of the staff.

Friendliness and caring enhanced the quality of care.

Aventuro (1991) interviewed 120 older adults in a private, long-term care institution. These older adults perceived that their needs for being cared for were not met if they were not cared about. Meeting psychosocial and spiritual needs were as important as physical needs. With this group of institutionalized older adults, expressive nurse caring behaviors were identified as more essential than instrumental nurse caring behaviors.

Hutchison and Bahr (1991) interviewed and observed 20 nursing home residents, which resulted in the identification of four properties of caring:

* Protecting.

* Supporting.

* Confirming.

* Transcending.

Caring was a significant means by which these nursing home residents maintained their personal identity and sense of value. Both of these studies used qualitative methods and revealed the importance of holistic caring.

Numerous quantitative investigations of caring with different patient populations revealed that instrumental activities are the most important indicators of caring (Cronin & Harrison, 1988; Huggins et al., 1993; Keane et al., 1987; Larson, 1984; Mayer, 1986; Parsons et al., 1993; Von Essen & Sjoden, 1991). Several studies that measured both patients* and nurses' perceptions of caring demonstrated a difference in perceptions, with nurses identifying expressive nurse caring behaviors as the highest indicators of caring (Larson, 1987; Mayer, 1987; Von Essen & Sjoden, 1991). However, a study of rehabilitation patients and nurses by Keane et al. (1987) revealed agreement between nurses' and patients' perceptions of caring. The most important nurse caring behaviors were instrumental behaviors. This agreement was attributed to the fact that rehabilitation nurses emphasize patient participation and self-care before affective behaviors.

METHODOLGY

This study was conducted at two suburban care communities for older adults. Assisted-living residents (19%) and long-term care residents (71%) were targeted for the study. A convenience sample of 21 older adults, 15 women and 6 men, participated in the study. Older adults who met the following criteria were included in the study:

* Age 60 or older.

* Cognitively aware.

* No severe hearing or speech impairment.

Older adults with the diagnosis of Alzheimer's disease, multi-infarct dementia, senile dementia, psychoses, and confusion were not included in the study. To increase the sample size, four boarding residents (10%) who met the inclusion criteria and who resided on the assisted-living unit of one of the facilities were included in the sample. These residents interacted with the same nursing staff as residents on the assistedliving unit.

Table

TABLE 1SUMMARY OF OLDER ADULTS' PERCEPTIONS OF THE MOST IMPORTANT NURSE CARING BEHAVIORS

TABLE 1

SUMMARY OF OLDER ADULTS' PERCEPTIONS OF THE MOST IMPORTANT NURSE CARING BEHAVIORS

Table

TABLE 2SUMMARY OF OLDER ADULTS' PERCEPTIONS OF THE LEAST IMPORTANT NURSE CARING BEHAVIORS

TABLE 2

SUMMARY OF OLDER ADULTS' PERCEPTIONS OF THE LEAST IMPORTANT NURSE CARING BEHAVIORS

The subjects ranged in age from 97 to 74. The mean age of the subjects was 87.95 (SD = 5.87). The largest percentage of subjects, 71% (n - 15), lived in the long-term care unit. The total length of stay of all subjects in the study ranged from 6 months to 16 years. The mean length of stay of all subjects was 3.30 years (SD - 4.47). Educational level of subjects ranged from 10 years to 18 years. The mean educational level was 13.31 years (SD = 2.41).

A college Research Review Committee reviewed and approved the research proposal to ensure protection of the human subjects. The Directors of Nursing at both research sites granted permission to conduct the study, and informed consent was obtained from the older adults and their guardians.

Table

TABLE 3RANKING OF THE CARING BEHAVIOR ASESSMENT SUBSCALES WHICH ARE CONGRUENT WITH WATSON'S CARATTVE FACTORS

TABLE 3

RANKING OF THE CARING BEHAVIOR ASESSMENT SUBSCALES WHICH ARE CONGRUENT WITH WATSON'S CARATTVE FACTORS

Instrument

The Caring Behavior Assessment (CBA) was used for the study. The CBA lists 63 nurse behaviors ordered in seven subscales congruent with Watson's carative factors and measures both instrumental and expressive behaviors. A panel of four content specialists familiar with Watson's (cited in Cronin & Harrison, 1988) conceptual model established face and content validity. Internal consistency reliability was determined by using the first study sample responses to calculate Cronbach's alpha for each of the seven subscales. Reliability coefficients ranged from .66 to .90 (Cronin & Harrison, 1988). The CBA also includes a question at the end of the 63 items. The question asks, "Is there anything else that nurses do to make you feel cared for or about?". This question is used to elicit additional indicators of caring not included on the CBA instrument.

A prior small pilot study was conducted to assess readability, comprehension, length of the questionnaire, and appropriateness of the questions on the CBA instrument for the population under study. The CBA instrument previously was used only for studies in acute care. As a result of the assessment of the instrument, the print of the questionnaire was enlarged to improve readability, and question 39 was changed from "Help me plan for my discharge from the hospital" to "Help me plan for my day." This question was more appropriate for the population being studied. Several subjects required short rest periods during the administration of the questionnaire, but all were pleased to share their perceptions of caring.

Data Collection

Descriptive statistics were used to describe the study sample. Mean scores and standard deviations were calculated for each of the 63 items to rank the items. Mean scores ranged from 4.57 for the most important item ("Know what they are doing") to 2.76 (Talk to me about my life before coming to the facility"). Summaries of the behaviors rated as most important and least important are presented in Tables 1 and 2.

Responses to the 63-item CBA were analyzed using each of the seven subscales. The overall item mean scores for each of the seven subscales were calculated. The highest ranked subscale was "Human needs assistance," which included such items as "Know when it's necessary to call the doctor," "Give my treatments and medications on time," and "Check my condition very closely." A summary of the ranking of the CBA subscales is presented in Table 3. The Pearson product-moment correlation coefficient was used to reflect the direction and degree of linear relationship between the total population means of each subscale compared to gender means of each subscale.

The Pearson correlation coefficients by gender for each subscale ranged from the highest correlation (r = .89 for women; r = .85 for men) for the subscale, "Humanism/faithhope/sensitivity" to the lowest correlation (r = .96 for women; r = .42 for men) for the subscale "Human needs assistance." Women revealed a consistent pattern of high correlation with the total population for the seven subscales. The Pearson correlation for the men was less correlated and reflected that the men were more varied in their responses. The difference in sample size (women ? = 15; men ? = 6) also attributed to the lower correlation for the men.

INTERPRETATION OF FINDINGS

The study results revealed that the most important indicator of caring for institutionalized older adults was nurses' technical competency in meeting physical needs. "Human needs assistance" was the subscale ranked the highest. Although the sample size was small and there was relative homogeneity, these results are consistent with findings reported by Cronin and Harrison (1988), Huggins et al. (1993), and Parsons et al. (1993).

The highest-scoring CBA item was "Know what they are doing," followed by "Know when it's necessary to call the doctor." The third-highest and fourth-highest ranked items were equally ranked: "Treat me as an individual" and "Treat me with respect." The subscale "Humanism/faithhope/sensitivity" was ranked second in importance. This indicated that, for older adults, being treated with respect and dignity is an essential component in caring. This study demonstrated the importance of delivering competent care with interpersonal processes which enhance individuality and human dignity.

Pearson correlation coefficients for the subscales showed weaker correlation for the men, which may have been because of the smaller number of men in the study. However, there was a remarkable difference in the subscale "Human needs assistance." Another notable difference in Pearson correlation was with the subscale "Supportive/protective/corrective environment." Many of the items in these two subscales used the words "helping," "understanding," "encouraging," "checking with me," and "telling me." The way the items were worded may have been a threat to the men's ego strength. Differences in gender communication styles and interpersonal relating may affect the connotation of caring expressions, and it also may reflect differences in gender caring needs.

LIMITATIONS

Significant study limitations were the sample size (N = 21), length of the instrument, and the CBA instrument's prior use only in acute care. Slight modification of question 39, "Help me plan for my discharge from the hospital" to "Help me plan for my day," make the instrument more appropriate for this population.

CONCLUSIONS

* Older adults residing in residential health care settings ranked nurses' technical competencies in meeting physical care needs as the highest expressions of care.

* A second significant indicator of care was treatment that demonstrated respect and enhanced individuality.

* Nurse caring behaviors of prime importance in making older adults "feel cared for and cared about" combined the competencies of nurses (instrumental activities) with an emphasis on interpersonal processes (expressive activities) that preserve and enhance an individual's dignity.

* Differences in nursing behaviors perceived as indicators of caring may be gender specific.

NURSING IMPLICATIONS

The character of a society and the state of civilization are said to be measured by the way in which older adults are treated (Ebersole & Hess, 1990). Knowledge gained from continued studies of what caring means to institutionalized older adults can The second significant care indicator identified by older adults was care that enhanced human dignity. This was unique to this population compared to the studies conducted in acute care settings. Watson (1988) identifies a

transpersonal caring relationship as a special kind of human care relationship where there is high regard for the whole person and their beingin-the-world. Caring, in this sense, is viewed as the moral ideal of nursing where there is the utmost concern for human dignity and preservation of humanity (p. 63).

Moral caring creates a quality of caring that touches the human spirit and promotes health and growth in both patients and caregivers. Moral caring transforms, heals, comforts, and promotes higher levels of growth and health in all humans. According to the late Maggie Kuhn, founder of the Gray Panthers, "The goal of old age is to be continuing, maturing, and developing adults reaching out to others until the very end of life" (Ebersole & Hess, 1990, p. 1). Older adults in health care institutions reach out to nurses for such caring. Caring as an attitude and activity is critical for gerontological nursing practice. Nurses working with older adults can improve their health and well-being. The ethic of caring as a moral ideal must be taught and practiced by nurse clinicians and educators because quality of care and quality of life are created by caregivers.

RECOMMENDATIONS

Caring as an essential human need and the core of the nursing profession requires extensive study, and older adults are important resources of caring knowledge. It is recommended that this study be replicated using a larger, more diverse sample to validate the nurse caring behaviors identified in this study. Different caring assessment instruments such as the Caring Behavior Inventory (Wolf et al., 1991) or the Patient Satisfaction Instrument (Risser, 1975) could be used in studies with older adults and compared with the results of this study. In particular, shorter caring assessment instruments would be advantageous in assessing older adults. Instrument development for this population is of prime importance.

This study revealed the possibility of gender-specific caring, and research to identify gender differenees in caring behaviors warrants further exploration. Additionally, nursing studies related to moral caring and higher-level needs gratification for older adults would be beneficial.

REFERENCES

  • Aventuro, B. (1991). The meaning of care to geriatric persons living in a long-term care institution. Ann Arbor, MI: Bell & Howell.
  • Brown, L. (1986). The experience of care: Patient perspectives. Topics in Clinical Nursing, 8(2), 56-62.
  • Cronin, S., & Harrison, B. (1988). Importance of nurse caring behaviors as perceived by patients after myocardial infraction. Heart and Lung, /7(4), 374-380.
  • Ebersole, P., & Hess, P. (1990). Toward healthy aging. (3rd ed.). St. Louis: Mosby.
  • Huggins, K., Grady, W., & Kohut, C. (1993). Emergency department patients' perception of nurse caring behaviors. Heart and Lung, 22(4) 356-364.
  • Hutchison, C, & Bahr, R-Sr. (1991). Types and meaning of caring behaviors among elderly nursing home residents. Image, 23(2), 85-88.
  • Keane, S., Chastain, B., & Rudisill, K. (1987). Caring: Nurse-patient perceptions. Rehabilitation Nursing, /2(4), 184-187.
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  • Risser, N. (1975). Development of an instrument to measure patient satisfaction with nurses and nursing care in primary care settings. Nursing Research, 24(1), 45-52.
  • Von Essen, L., & Sjoden, P. (1991). The importance of nurse caring behaviors as perceived by Swedish hospital patients and nursing staff. International Journal of Nursing Studies, 28(3), 267-281.
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  • Wolf, Z., Giardino, E., Osborne, P., & Ambrose, M. (1991). Dimensions of nurse caring. Image, 26(2), 107-111.

TABLE 1

SUMMARY OF OLDER ADULTS' PERCEPTIONS OF THE MOST IMPORTANT NURSE CARING BEHAVIORS

TABLE 2

SUMMARY OF OLDER ADULTS' PERCEPTIONS OF THE LEAST IMPORTANT NURSE CARING BEHAVIORS

TABLE 3

RANKING OF THE CARING BEHAVIOR ASESSMENT SUBSCALES WHICH ARE CONGRUENT WITH WATSON'S CARATTVE FACTORS

10.3928/0098-9134-19990501-09

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