For nearly two decades, environmental psychologists (Kahana, 1982; Lawton, 1982) have advocated the use of environmental modifications in the care of frail elderly individuals. Specifically, they suggest titration of the amount of environmental press or demand so that it "fits" with the elderly individual's level of functional capacity. The person-environment fit model has underpinned a wide range of gerontological nursing research during the past decade (Buckwalter et al., 1999; Gerdner, Hall, & Buckwalter, 1996; Neelon, Champagne, Carlson, & Funk, 1996).
The conceptualization was expanded and tailored in Hall's progressively lowered stress threshold (PLST) model in relation to the care of older adults with cognitive impairment by nurses. The PLST model identifies for nurses that individuals with dementia-causing illness need environmental demands modified because of their declining abilities. Most applications of the person-environment fit models have been developed for elderly individuals in hospital or nursing home settings to achieve care goals such as decreasing the use of restraints (Rader, 1991).
For older adults in the community, however, it is the family caregiver who provides 80% of the medically related and nearly all of the general supportive care. Thus, the family member's ability to understand the fit of their elderly relative within their specific environment, and to tailor the environment to the elderly individual's competence is critically important - yet unstudied. The purpose of the study reported in this article was to describe family caregivers' use of environmental modifications. The following research question was addressed: What are the factors that affect family caregivers' use of environmental modifications?
PERSON-ENVIRONMENTAL FIT MODELS
Person-environment fit models describe an interactive relationship between the person and the environment. The environment may be defined as the totality of circumstances surrounding an individual and includes a combination of the external physical and complex of social and cultural conditions affecting one's behavior. According to Lawton (1982), behavior is a function of the individual and the environment.
Environmental press includes aspects of the environment that demand something of the individual. The individual is defined in terms of a set of competencies. An individual's competence is determined by the upper limit of their functional capacity in the areas of biological health, sensory-perception, motor behavior, and cognition. The model suggests there is a specific and linear relationship between individuals' total competencies and the amount of press they can stand. The point where environmental press matches competency is called the adaptation level. Press above or below this level within a certain range is tolerable. Beyond these ranges press can have negative impacts. Competent individuals can handle a greater range of press than people with less competence before they reach the point of negative affect and maladaptive behavior. The PLST model (Hall, 1994) builds on this aspect of Lawton's theory to explain why older adults with cognitive impairment oscillate between baseline adaptation level behaviors and anxious and dysfunctional behaviors. Dysfunctional and problematic behaviors are more likely to occur when a cognitively impaired individual's environment provides too much press without opportunity to relax or avoid stimuli.
According to Kahana (1982), it is not the capabilities of the elderly individual per se that lead to variability in adaptation outcomes but the fit or lack of fit between the individuals' capabilities or needs and their environmental conditions and demands. Environments can do more or less in compensating for existing losses. Most home environments of community-dwelling older adults do not directly accommodate the special needs associated with chronic functional loss, nor do they support remaining capabilities.
A nurse using a person-environment fit framework views the environment as a source of active intervention rather than as passive background. Because older adults are more susceptible to environmental stress (Kahana, 1982; Lawton, 1982), any action taken by the caregiver to reduce the gap between an elderly individual's personal competencies and living arrangements should make caregiving easier.
Person-environment fit models have been used for developing recommendations for managing geriatric syndromes such as falls (Hogue, 1992; Hollinger & Patterson, 1992), incontinence (Pearson & Larson, 1992; Smith, Newman, McDowell, & Burgio, 1992; Wy man, 1992), and cognitive impairment (Beck, Heacock, Mercer, & Walton, 1992; Foreman, 1992). Environmental press variables such as type of unit (Swanson, Maas, & Buckwalter, 1993), privacy provided (Ryden, 1985; Ryden, Bossenmaier, & McLachlan, 1991), personal control (Ryden, 1985; 1990), and interaction between staff and residents (Burgener, Jirovec, Murrell, & Barton, 1992) have been examined as potential mediators of resident behavior. Several maladaptive behaviors such as aggression, agitation, screaming, and weeping have been linked to manifestations of excess disability created by an overdemanding environment (Kolcaba, 1992). Ryden (1992) and Negley and Manley (1990) have identified environmental stimuli as antecedents of aggression. Meddaugh (1990) found that change from a comparatively active life to the inactive environment of a nursing home can result in aggressive behavior. The importance of therapeutic milieu (Taft, Delaney, Seman, & Stariseli, 1993) and the culture of long-term care institutions (Kayser-Jones, 1992) have also been explored.
In community settings, improved person-environment fit has been identified as a goal for several inhome interventions for individuals with Alzheimer's disease and their caregivers (Corcoran & Gitlin, 1992; Hall et al., 1995; Pynoos, Cohen, & Lucas, 1989). In addition, some researchers have examined family caregiver's use of environmental modification strategies in the community setting (Calkins & Namazi, 1991; Olsen, Ehrenkrantz, & Hutchings, 1993). However, no studies have specifically examined the factors affecting caregivers' ability to effectively use such strategies.
Environmental modifications have typically been defined from the professional's perspective and include such factors as structural changes, special equipment, behavioral changes, and assistive device use (Régnier & Pynoos, 1987). The main purpose of environmental modifications is to adapt the environment to the diminishing capabilities of the older adult. Environmental modifications can be viewed as a means of reestablishing a balance between environmental demands and individual competencies. However, evidence suggests that families do not adequately modify the environment of the older adult's home to optimize independent functioning. Struyk (1987), using data from the 1978 Annual Housing Survey, estimated that of households headed by an individual 65 years of age and older and in which at least one elderly member had health or mobility limitations, only approximately 10% had been modified in some way. Wister (1989) found that only 15% of individuals 74 years and older living in Ontario had modified their homes in the past 5 years to facilitate their activities.
From the elderly individual's perspective, the reasons why environmental modifications are or are not implemented are not clear. The older adult's decreased competency as measured by a reported increase in activity restrictions, particularly those associated with problems with mobility, according to some researchers, does predict an increased use of environmental modifications (Struyk, 1987; Trickey, Maltais, Gosselin, & Robitaille, 1993; Wister, 1989). However, other researchers have found that as disability progress and competence declined, environmental modifications such as assistive devices were not as effective (Mann, Karuza, Hurren, & Tornita, 1992).
Environmental modification recommendations that were easy to implement (Devor, Wang, Renvall, Feigal, & Ramsdell., 1994) were more likely to be adopted. Older frail households that lacked resources and informal support were less likely to make environmental modifications (Reschovsky & Newman, 1990). In some studies, income had little (Wister, 1989) or no (Struyk, 1987) influence on the likelihood of adopting home modification recommendations, while in others, high income had a negative influence (Gosselin, Robitaille, Trickey, & Maltais, 1993). Study of the use of outside services in the home, also produced contradictory results. In some cases, the use of outside services seems to decrease the use of environmental modifications, because personal assistance makes them unnecessary (Struyk, 1987). Alternatively, the use of outside services may promote more use of environmental modifications because service providers act as a resource for ideas and help persuade the elderly individual that the modification would be helpful (Gosselin et al., 1993; Wister, 1989). The elderly individual's perceived need for a modification is perhaps the most consistent predictor of the use of environmental modifications (Gosselin et al., 1993; Trickey et al., 1993)
FACTORS AFFECTING CAREGIVER'S USE OF ENVIRONMENTAL MODIFICATIONS
FACTORS AFFECTING CAREGIVER'S USE OF ENVIRONMENTAL MODIFICATIONS
Little is known about family caregivers' perspectives about what either constrains or facilitates their use of environmental modifications. The purpose of this study therefore was to examine factors affecting caregivers' ability to use environmental modification strategies
A qualitative approach was used to explore caregivers' perceptions of what enabled or constrained their use of environmental modification strategies. Environmental modifications were defined broadly and included actions taken to organize the home, protect the elderly individual, structure the elderly individual's day, supplement the elderly individual's function with devices and environmental cues, work around the limitations of the environment to provide care, and make the home more pleasing (Messecar, 1997; 1998).
The unique strengths of a qualitative descriptive research design are its assumption of the value of context and setting, the search for a deeper understanding of the participant's lived experiences of the phenomenon, and the recognition that it is essential to know how participants define their situations (Marshall & Rossman, 1995). The goal for using a descriptive exploratory design was to document the strategies of interest, to discover and identify important conditions affecting these strategies, and to generate ideas for further research. The design strategy (Marshall & Rossman, 1995) was carefully matched with the data collection techniques of intensive interviewing and participant observation (Lofland & Lofland, 1995; Merton, Fiske, & Kendall, 1990; Morse & Field, 1995) to discover the salient behaviors, beliefs, attitudes, and processes occurring in the phenomenon.
Sample and Participant Recruitment
The focus of the study was on factors that affect the caregiver's use of environmental modifications in the home setting. Therefore the sampling strategy employed was purposive sampling to achieve maximum variation of the target phenomenon (Sandelowski, 1995) that the research question was intended to address. Initial sampling was guided by the desire to meet family caregivers and older adults who, by virtue of their engagement in caregiving activities, were likely to have used environmental modification strategies. The older person had to be 65 years or older and eligible for skilled home health care (e.g., wound care, diabetic care, IV therapies). Caregiver participants for this study had to be the self-identified primary caregiver for the older person eligible for skilled home health, at least 18 years of age, and able to speak English.
Throughout the study, maximum variation in the type of impairment of the care receiver, the caregiver-care receiver relationship, and demographic variation found to be germane in quantitative caregiving studies such as gender and race were sought in the sample. Of 27 participants who were eligible to participate, 2 refused because the caregiver was too sick to complete the interview and 1 refused because the care receiver had recently died in the hospital. Of the total sample of 24 primary family caregivers, 4 were recruited from hospital discharges, 8 from Alzheimer's disease and Parkinson's disease clinic nurse referrals, 5 from snow ball sampling referrals, 6 were participants in a previous environmental modifications study, and 1 was self-referred from an advertisement. The Institutional Review Board (IRB) for the university reviewed and approved the sample recruitment and study protocols. As modifications were made to accommodate the changes needed for theoretical saturation, IRB approval was obtained.
The sample consisted of 24 caregivers that ranged in age from 33 to 88. Most of the caregivers were female 71% n = 17) and White 92% (n = 22). All had completed high school, 67% (n=16) had at least some college education, and among the college-educated caregivers, nearly one third (n - 7) held advanced degrees. Half of the caregivers were spouses or spouse-surrogates, 6 were husbands, 4 were wives, and 2 were female livein partners. The remaining half of the caregivers were children or grandchildren, 10 were daughters, 1 was a granddaughter, and 1 was a son. Two thirds of the caregivers lived with the elderly individuals (n = 16): 12 were spouses and 4 were daughters. Caregivers' experience ranged from new to caregiving (1 to 2 years, ? = 7), more established (3 to 4 years, ? = 8), and very experienced (more than 4 years, n = 9).
Elderly individuals ranged in age from 65 to 91. Nearly half of the older adults (n = 11) in this sample were 80 years or older. In national databases, the 80 to 85, and 85 years and older age categories are associated with the highest percentages (31% and 50%, respectively) of individuals needing assistance with activities of daily living (Hobbs & Damon, 1996). The elderly individuals were mostly female 58% (w = 14) and White (92%) (n = 22). More than half (54%) (n = 13) had a college education or better. Half of the elderly individuals (n = 12) had both physical and cognitive or mixed impairments, 33% (n = 8) had physical impairments only, and 17% (n = 4) had cognitive impairments only.
Data Collection Procedures
Intensive interviews focused on use of environmental modification strategies. The interview guide used caregiving activities to help family caregivers describe the environmental modification strategies they had used. For example, questions such as, "Do you now use any help for an activity that has now become difficult for the person you care for to do, such as cutting with a knife, buttoning shirts, or opening jars?" were used to prompt caregivers to describe the nature and effectiveness of the environmental modification strategies they used and how these changed over time.
Interviews ranged in length from 1 to 3 hours (mean = 2 hours). During 8 interviews, the elderly individual was present and contributed information. The purpose of participant observation in this study was to observe the physical setting in which caregiving activities took place and those who were involved as they performed various caregiving activities (Spradley, 1980). Participant observation data was collected on 12 caregivers and care receivers; the period of observation ranged from 1 to 2xh hours (mean = 1 hour and 40 minutes). The caregivers and elders who participated in the participant observation portion of the study were observed performing various caregiving tasks for the elderly individual, escorted the investigator on tours of the home, and showed the investigator artifacts that were important in the older adult's environment.
Interviews were taped and transcribed verbatim and all identifying information was eliminated from the transcripts. Demographic data were collected to describe the sample and were recorded on the interview guide. Fieldwork notes were transcribed from dictation (Lofland & Lofland, 1995; Morse & Field, 1995) to document participant observations of the environment, people, and activities. Three concurrent flows of activity directed the data analysis: data reduction, data display, and conclusion drawing/verification (Miles & Huberman, 1994). Data analysis was begun following each interview and episode of observation.
INTERVENTIONS TO STRENGTHEN CAREGIVER'S ABILITY TO USE ENVIRONMENTAL MODIFICATIONS
In the initial part of the analysis, coding (data reduction) was done by hand in the margins of the transcripts. The inductive coding technique known as open line-by-line coding described by Strauss and Corbin (1990) and referred to in Miles and Huberman (1994) was used. Coded interviews and field observations were entered into NUD*IST (nonnumerical unstructured data indexing searching and theorizing software) (Scolari, Sage Publication Software, Thousand Oaks, CA) (Richards & Richards, 1994). The command functions in NUD*IST were used to create printouts of coded data organized according to the major pattern codes (data display). NUD*IST search and retrieve functions were used to examine the relationships between the pattern codes (conclusion drawing/ verification).
Analysis of data from caregivers led to the identification of six interrelated factors that influence the caregivers' use of environmental modifications as part of their care for their elder care recipient. These factors are discussed in Table 1 . Because a caregiver's ability to use modifications is multidimensional and impacted by a variety of factors, it is useful to evaluate their ability using the depicted framework. Each of the factors will be described. Quotes from the participants in the study are also included in Table 1.
Characteristics of the Elderly Individual
Characteristics of the elderly individual were identified by a number of caregivers as being critical in exploring possible environmental modifications. Failure to address characteristics could cause a strategy to not fit the older adult. For example, the elderly individual's size and anthropometric dimensions made some equipment or adaptive equipment unusable. Current and projected functional status affected the fit of modifications for elderly individuals. A lack of strength and mobility were frequent impediments to the use of some strategies. Changes in the elderly individual's personality or their view of themselves hindered caregivers' efforts to make suitable modifications.
The elderly individual's view of independence and autonomy sometimes interfered with the caregiver's efforts to make environmental modifications. It was difficult to introduce either environmental modifications that would threaten older adults' autonomy or those that would compel elderly individuals to be more independent than they were prepared to be. For example, one daughter caregiver found that her mother always changed the subject when she or her sisters tried to talk about her possible future need to use a wheelchair.
Attributes of Modifications
Qualities of the environmental change that facilitated or impeded their adoption included cost, availability, ease of installation, and ease of use. Cost was affected by whether or not caregivers could obtain reimbursement from Medicare or insurance. Some items, such as wheelchairs, were very expensive unless reimbursed. Modifications varied in how easy they were to obtain. In some instances, caregivers used materials at hand to make a modification. In other cases, they had to conduct a search in specialty stores that were difficult to find. When the caregiver had limited time for shopping, modifications that were not available in the local familiar stores were difficult to obtain.
Ease of installation was another important factor. When installation of the modification required special skills, tools, or physical strength, caregivers had to depend upon other family members or hired help to install the modification. This help was not always readily available. Several caregivers described difficulty in using a modification, because the caregiver needed training to use the modification, but received none.
Elderly Individual/Caregiver Relationship
The quality of the relationship between the caregiver and the elderly individual indirectly influenced the caregiver's ability to make environmental modifications. The relationship quality depended on their history dealing with one another, the impact of the elderly individual's functional decline, present closeness in terms of the amount of time they spent together, how enjoyable or unpleasant that time was, and the caregiver and elderly individual's ability to communicate around disability issues.
Caregivers described several critical skills that enabled them to make and use environmental modifications successfully. First, caregivers had to be able to accurately assess the elderly individual's functional status, identify functional limitations, and recognize changes in functional status. They then had to have the capability to understand the impact of the functional limitations on the older adult's performance of activities. Third, caregivers had to understand how aspects of the physical environment affected the functioning of the elderly individual. Fourth, they had to be able to assess the cognitive and affective responses of the elderly individual to changes in functional status and use this knowledge to discern the elderly individual's thinking, feelings, and wishes.
Caregivers' emotional and physical energy, the time they had available to work on environmental solutions, the financial resources they could devote to purchase modifications, and the resources they had to install the modifications affected their ability to successfully use environmental modifications.
The amount of time the caregiver had available to work on environmental modifications also affected the caregiver's ability to implement and refine environmental modifications for the older adult. The amount of time available depended on the caregiver's other family obligations and the ease of getting to and from the elderly individual's home.
Several factors that affect the caregivers' ability to implement modification strategies were identified in the analysis. These factors included characteristics of the elderly individual, attributes of the modification, the elderly individual/caregiver relationship, caregivers' characteristics, caregiver resources, and the situational characteristics of caregiving. The findings of the study were compared to the existing literature and several similarities were found. Similar to previous findings (Devor et al. 1994), this study demonstrated that the attributes of the modification influence the likelihood of their adoption.
Prior research also supports findings of this study that access to resources and social supports are critical (Strauss & Corbin, 1992; Schulz & Williamson, 1993). Smith (1994) found that caregivers of technologically dependent adults, whose financial resources and personal health or emotional energy was low, had difficulty providing implementing caregiving strategies effectively. Caregivers that lived separately spent more time in daily travel, more time working, and consequently had less time available for helping the elderly individual than caregivers who lived with the impaired person (Moss, Lawton, Kleban, & Duhamel, 1993).
Conflict in the relationship between the parties jointly managing an illness trajectory has also previously been identified as a condition that impedes effective illness management (Strauss & Corbin, 1992) and alters the impact disability in older adults (Schulz & Williamson, 1993). Parentadult child historical relationship quality in the present study seemed to be more likely to be problematic. This finding is consistent with empirical evidence that supports the hypothesis that parental divorce and memories of family problems adversely affect the quality of parentchild relationships later in life (Webster & Herzog, 1995).
This was a descriptive exploratory study that focused on caregiver's perceptions of their ability to use environmental modifications. The study procedure did not include direct assessment of the elderly individual's functional status, but instead relied on the caregiver's report for this important information. The impact of the specific type of impairment on the factors that affect the caregiver's ability to use environmental modifications, for example cognitive versus physical or mixed impairment, was not explored in the interview format used in this study. The consequences of the elderly individual's type of impairment should be more thoroughly studied in the future. Another limitation of the study was that the relationship of one factor to another was only preliminarily described. Whether all factors are essential for caregiver's ability to use and make modifications should be explored. Further research is needed to determine how the factors work in combination to predict caregiver's ability to implement and use environmental modifications.
The use of nursing interventions to facilitate caregiver's use of environmental modifications were not the purpose of this study, but specific interventions were identified for future research. Future research should examine if spouse and child caregivers have special intervention needs, given the differences in relationship to the older adult. Another limitation of the sample was the limited ethnic diversity of the participants. Future studies should examine other ethnic groups.
IMPLICATIONS FOR NURSING PRACTICE
Using a person-environment framework, the purpose of this article was to contribute to research on the use of environmental modifications by family caregivers. Patient teaching for family caregivers is accomplished in a variety of settings, but the ideal venue for interventions teaching the caregiver how to modify the environment is in the home of the elderly individual for whom they provide care. Even in the relatively brief time span of a 1-hour home visit, the nurse can assist the caregiver in performing a home safety assessment and identifying the means to strengthen their ability to modify the home. Table 2 displays a variety of interventions to strengthen the caregiver's ability to use environmental modifications.
Use of a person-environment fit framework dictates that an environmental assessment should always take place in conjunction with an observed functional assessment. The existence of a hazard depends in large degree on the functional status of the person in whose home the potential hazard exists. Home hazard assessment that ignores the functional status of the individual living in the assessed home is meaningless. Tideiksaar (1989) described the most useful assessment developed tJius far. He recommends observing elderly individuals in their usual living environment walking from room to room over different surfaces; climbing and descending stairs; transferring to and from beds, chairs and toilets; getting in and out of the bathtub and shower; and reaching and bending to get objects from shelves. Intervention should be based on a collaborative approach that ensures the caregiver and care receiver's needs and preferences are respected (Corcoran & Gitlin, 1992; Harvath et al., 1994; Hasselkus, 1988; 1989). Any environmental change must be carefully negotiated with the older person. In addition, nurses should explore with the caregiver what additional resources or support they may require to implement desired home modifications.
The caregiver's ability to use environmental modifications is a complex phenomenon influenced by several factors. Using a person-environment fit framework provides nurses with insight into elderly individual and environment interaction that might otherwise go unnoticed. The desired outcome of an environmental modifications training intervention should be an increase in the caregiver's sense of competence in making changes in the home that improve the caregiver's sense of mastery. This in turn should improve the elderly individual's functioning.
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FACTORS AFFECTING CAREGIVER'S USE OF ENVIRONMENTAL MODIFICATIONS
FACTORS AFFECTING CAREGIVER'S USE OF ENVIRONMENTAL MODIFICATIONS
INTERVENTIONS TO STRENGTHEN CAREGIVER'S ABILITY TO USE ENVIRONMENTAL MODIFICATIONS