For frail, older individuals who are unable to remain in their own homes, nursing homes provide them with medical care and assistance with daily activities. It is estimated that 43% of individuals age 65 and older will spend some time in a nursing home before they die (Kemper & Mutaugh, 1991). Although they want to maintain their independence and freedom for as long as possible, nursing home residents often must make compromises to survive. They experience fewer opportunities to engage in customary activities, fewer contacts with the outside world, and less privacy than they enjoyed outside the nursing home (Atchley, 1994).
Because many older adults have negative attitudes toward living in an institution, they face great challenges when adjusting to nursing home life. Every day, they face a carefully organized and scheduled routine, and become increasingly dependent on others for physical and financial support (Moody, 1994). Care, however well-meaning, may seem threatening and impersonal, and residents may lose a sense of control over their environment and experience a diminished sense of personal autonomy. Fearing that care may be withheld if they express their needs, some residents may become more compliant; others may refuse treatment and display an attitude of nonparticipation.
While delivering quality care, believing they are acting in the residents' best interests, and adhering to strict regulations, nursing home personnel may face ethically challenging situations. Despite a shortage of trained and well-paid workers, many overworked nursing staff cheerfully deliver quality care and are proud of their jobs. Daily, they hand-feed frail residents, clean bedpans, and possibly must cope with angry insults or accusations of mistreatment (Kearl, 1989). Nursing home personnel may efficiently perform their daily tasks and have the best of intentions. However, their behavior may be harmful to the residents' sense of autonomy (Mattiasson, Andersson, Mullins, & Moody, 1997). Residents* rights to autonomy may unwittingly be violated, as decisions are made on behalf of the institution as a whole. In this article, aspects of resident autonomy and selected organizational and nursing staff issues will be examined.
THE CONCEPT OF AUTONOMY
Personal autonomy is a complex topic that has received more attention in recent gerontological research. It can be translated into the following values: individual liberty, privacy, free choice, self-governance, self-regulation, self-rule, and independence (Collopy, J9S8). Considering the overlapping nature of these values, it is difficult to examine them independently. They must be grouped together to better understand a person's sense of self. Generally, autonomy implies that an individual has control over decision-making, has direction over one's own life, and is free of any outside interference (Collopy, 1988; Lidz, Fischer, & Arnold, 1992; Wetle, 1991). Nursing home residents may choose to exercise personal autonomy quite differently than if they were still living in their own private homes.
Autonomy is often defined in terms of personal independence. However, physical independence is not equivalent to autonomy (Kane, 1991; Lidz et al., 1992; Wetle, 1991). Severely disabled individuals are still able to make their own decisions, and it is important for nursing home staff to respect this aspect of personal autonomy. For example, a resident can decide which clothes to wear, but be unable to reach a garment hanging in the closet. While autonomy implies being allowed to make choices and to exercise some degree of control over one's own life, it does not give that individual authority over another person's life (Kane, 1991). One nursing home resident does not have the right to control the lives of other residents. For example, one resident may want lunch served at 1 1 a.m.; however, this serving time may not coordinate well with the overall schedule, or with the needs or desires of the other residents.
The scope of autonomy is quite broad and includes the freedom to develop one's short-and long-range goals and to determine one's priorities in life (Collopy, 1988). For example, a resident may decide to sit in the television room and watch a movie on the upcoming Friday, and to become more involved in the resident council discussion next month. While personal autonomy includes the ability to control one's own life on a daily basis, it does not imply that an autonomous person acts in a vacuum. Individuals interact with those around them, are influenced by others' habits and traditions, appreciate others' limitations, and are affected by social institutions (Collopy, 1988). Nursing home residents interact daily with other residents, family members, and nursing home personnel. Many are coping with an increasing number of physical and mental limitations. Plus, residents realize they belong to a community of individuals with differing levels of abilities.
_In the long-term care setting, an ethical conflict exists between a resident's self-determination and nursing home standards (MulUns, Moody, Colquitt, Mattiasson, & Andersson, 1998). From the residents' points of view, freedom of choice and action are important aspects of personal autonomy. They do not, however, have control over ail aspects of nursing home life. There are organizational imperatives as well. For the nursing home to operate efficiently, administrators are often faced with tough decisions as they determine what is "best" for all residents. The challenge for all nursing home staff is how to respect resident autonomy while adhering to mandatory regulations.
To better appreciate the ¿omplexity of autonomy, particularly as it relates to dependent older individuals in nursing homes, Collopy (1988) identified six polarities of personal autonomy. Each polarity can*- be viewed as a continuum or range of behaviors. Collopy's polarities of autonomy are as follows:
* Decisional versus executional autonomy.
* Direct versus delegated autonomy.
* Competent versus incapacitated autonomy.
* Authentic versus inauthentic autonomy.
* Immediate versus long-range autonomy.
* Negative versus positive autonomy.
A nursing home resident exhibits behavior that falls somewhere along each continuum. These polarities are shown in the Sidebar (right). Similarly, the atmosphere of a nursing home permits the expression of personal autonomy at certain points along each continuum.
SIX AUTONOMY POLARITIES
Dedslonal Versus Executional Autonomy
Decisional autonomy involves the ability and freedom to make one's own decisions without external coercion or restraint (Collopy, 1988). Executional autonomy is one's ability to implement those decisions. Ideally, autonomy should be both decisional and executional. This is not always the case, especially in the long-term care setting. As Collopy (1990) stated, doing things for older adults is not the same thing as deciding for them.
Direct Versus Delegated Autonomy
Direct autonomy is the ability to act as an independent agent, whereas in delegated autonomy, that authority is given to someone else. Some nursing home residents are able to dress themselves; other residents require the assistance of others. Legally, delegation of one's authority is sometimes mandated through the use of powers of an attorney.
In a long-term care facility, designated agents may be identified at the time of admission (Wetle, 1991). Naturally, delegated autonomy can be damaging to an older adult when the agent is not acting in the resident's best interest. A caregiver may not have the same perception as the older person on what has, or has not, been delegated.
For example, a resident's daughter visited her mother in the nursing home and, without her mother's permission, replaced the pictures on the walls. Autonomy can be enhanced when the older person has the option of delegating specific tasks and decisions to others they can trust.
Competent Versus Incapacitated Autonomy
Competent autonomy implies judgmentally coherent choice. Incapacitated autonomy reflects incoherence in judgment. Because competency is a legal issue, proper assessments should be conducted whenever competency is in question. Nursing home personnel routinely, but informally, assess the competency of residents* judgment. If the resident either makes an unpopular decision that does not conform to popular opinion, or makes a decision involving medical treatment that does not conform to the advice of health care professionals, incompetence should not be assumed. Incompetence should be determined based on an objective examination of the individual within the context of a specific situation (Mullins et al., 1998).
For example, nursing home residents may be assessed as being competent for many months. However, their rationality is questioned when they begin to refuse their daily medications, which in turn may result in a physical problem causing falls. When mental incompetence leads to choices with harmful consequences, it may signal a need for immediate intervention.
Authentic Versus lnauthentic Autonomy
Authentic autonomy involves choices consistent with a person's character (Lidz et al., 1992). Inauthentic autonomy reflects actions that are definitely out of character. Nursing home staff must exercise care when judging the authenticity of a resident's decision. Thorough knowledge of the person's life and personality prior to admission into the long-term care facility is important in determining if the person is acting as an authentic self, or from another motivation.
For example, a nursing home resident spends most of the day in his room and resents being encouraged to participate in group activities. It would be useful for his nurse to determine if this resident is displaying typical behavior or is suffering from clinical depression. Inconsistent behavior may, in fact, be the result of an impulsive whim or depression (Kane & Caplan, 1992). Moving to a nursing home is often a stressful event, and nursing home personnel should take into consideration that the resident's circumstances may affect subsequent behavior.
Immediate Versus Long-Range Autonomy
Immediate autonomy is related to a current situation that requires the individual to make certain choices. Long-range autonomy involves future freedom in decision making and requires a broader view of the impact of one's choices. Immediate autonomy protects an individual's right to decline interventions that may be seen as paternalistic and unacceptable. A doctor may have the resident's best intentions in mind when recommending a particular course of treatment; however, the resident has thè right to refuse that treatment.
If, for example, a nursing home resident refuses to participate in morning exercises and considers only the immediate result of the refusal to be the ability to sit in his or her favorite spot a while longer, the physical therapist may become frustrated with the resident's short-sighted attitude. In this case, the resident's future autonomy may be affected, particularly if the exercise could have improved muscle strength and equilibrium. Collopy (1990) recommends a balance between immediate and long-range autonomy.
Negative Versus Positive Autonomy
Negative autonomy implies that the individual does not want outside interference and does not want any invasion of personal freedom. It is a claim against invasion of rights (Mullins et al., 1998). On the other hand, positive autonomy makes a claim for support, empowerment, and entitlement. If nursing home personnel focus too heavily on negative autonomy and provide too little Coilopy (1990) warns that tHs could lead to a laissez-|aire attitude with harmful consequences.
For example, a resident may need assistance in, the shower and could become seriously injured if he or she refuses the;nursing assistant's willingness to assist. Conversely, if positive autonomjf receives tiap primary focus, this coulá result in unwelcome interventions jby providing too much care. If less frai residents receive assistance with tasks they are able to perform themselves, there may not be adequate time available to provide required assistance to more frail residents. Nursing home staff should be careful not to force their values on the residents. (Colopy1990)
Based on Collopy's definition of autonomy, the present study seeks to determine whether nursing home personnel in the,Liaitcd States understand t|ieieuro0ncept of personal autonomy. : îf nursing home staff support the autonomy of their residents, their assessments should reflect that fact. Similar research was conducted in Sweden by Mattiasson and Andersson (1995a*; P95b, 195c), who found that although fafe education and experience of long-term care workers gave them an understanding of the need for resilient autonomy this undemanding did not always affect their caregiving style.
The present study, using a sample of nursing home personnel in the Tampa Bay area, examines four sets of independent variables with respect to autonomy. Specifically, the research question was: How are the staff members' perceptions of autonomy in its various forms influenced by structural characteristics related to the staff, characteristics of the facilities and residents, sociodemographic characteristics of the staff, and the staffs' attitudes toward older adults?
Facility Identification. Fifteen homes in Hillsborough County, Florida participated in the study - seven were private, for-profit, corporately owned facilities; three were locally, privately owned nursing homes; two were private, not-forprofit facilities; and three were nursing homes affiliated with continuing care retirement communities. The facilities ranged in size from 15 to 230 beds, and the modal size was 120 beds. These 15 facilities had 1,756 of the 2,700 (61%) beds in Hillsborough County.
Sample Selection and Data Collection Procedure. Each participating nursing home provided an employee list, and three types of employees were identified - professional nurses (RNs, LPNs, and director of nursing), certified nursing assistants (CNAs), and the professional department heads. To obtain an adequate sample size, the three subgroups of employees were disproportionately sampled: 50% (n = 61) of the professional nurses (N= 121), 33% (n = 129) of the CNAs (N = 380), and 100% (N - 120) of the department heads. The research instruments were handdelivered to the respondents, and the completed instruments were collected from respondents at the facilities. The overall return was 202 of the 300 instruments and provided a 67% response rate.
Instrumentation. Two instruments were used in the study to obtain the necessary information. The first instrument was a questionnaire completed by the nursing home administrator. This provided facts about financial matters, organizational structure, usage, and staffing issues that possibly could impact the way the staff respondents assessed resident autonomy. This information identified the percentage of professional nurses and CNAs at each facility that was above the minimum required per number of beds. Additionally, they were requested to identify the turnover rates of professional nurses and CNAs during the prior 6 months. Finally, the percentages of residents who were physically restrained, chemically restrained, or on Medicare and Medicaid were computed using current nursing home census information.
REGRESSION RESULTS (BETAS) OF EACH AUTONOMY DIMENSION BY SETS OF SELECTED VARIABLES
The percentage of professional nurses and CNAs were both above minimum requirements. These two variables were measured by responses from the facility administrators to two similar questions. The general form of the question was, "The state requires a minimum number of professional nurses (or CNAs) per number of beds. If your staff number of professional nurses (or CNAs) exceed that minimum, please indicate the percentage above 100% (e.g., 110%)." "Position" was dichotomized into CNAs (!) and others (O). "Turnover rates of the professional nurses and the CNAs" were measured by two similar questions: "What is the turnover rate for professional nurses (or CNAs) for the past 6 months?"
"Percentage Medicare" was measured by calculating the ratio of the current census of Medicare residents to the total current census. Similarly, "percentage Medicaid " was measured by calculating the ratio of the current census of Medicaid residents to the total current census. "Percentage physically restrained" was obtained by calculating the ratio between the number of residents who were currently physically restrained and the total current census. "Percentage chemically restrained" was calculated in a similar manner.
The second instrument collected information from the nursing home personnel. This demographic and attitudinal information also was assumed to potentially have an impact on the autonomy assessments. The selected personnel were requested to provide their age, race, and education. Next, they were asked to describe their job satisfaction; their attitude toward older adults; and their evaluations of how, within the context of autonomy, they perceived decisions were made about how care was provided.
"Age" was the chronological age of the respondents. "Race" was dichotomized as White (1) or nonWhite (O). "Education" was categorized as fewer than 6 years (1), 7 to 9 years (2), 10 to 12 years (3), some college (4), college graduate (5), or graduate work (6).
"Job satisfaction" was measured using the question, "At this time, how satisfied are you with your job?" Response categories included very satisfied (1), moderately satisfied (2), somewhat satisfied (3), somewhat dissatisfied (4), moderately dissatisfied (5), and very dissatisfied (6). "Attitude toward older individuals" was measured using a semantic differential with 30 adjective pairs with an 8-point continuum. Higher scores indicate a more positive assessment. The statement to which the nursing home personnel responded was, "When I think of people who are old, I think of people who are...." The reliability of this semantic differential was high (Cronbach's alpha, .91).
With respect to each autonomy dimension discussed earlier, six case studies, originally developed by Mattiasson and Andersson (1995a, 1995b, 1995c) for a project in Sweden and subsequently adapted for use in the United States (Mullins et al., 1998), were used to examine nursing home personnel's perceptions of how care was provided in the facilities. These case studies are shown in the Sidebar on page 42. For each case study, the nursing staff respondents were asked the following question: "If Mr. or Mrs. X were at your facility, what would have been decided?"
Using an 8-point scale of possible scores, the response at the left side of the continuum was, "Mr. or Mrs. X would be allowed to decide totally for him or her self." Written on the right side of the continuum was, "The staff at this facility would decide totally for Mr. or Mrs. X."
Therefore, responses closer to the left side of the continuum (i.e., the resident would decide for him or her self) indicate that the respondents perceive their facility's practice would be more decisional, direct, competent, authentic, immediate, or negative autonomy of the residents, respectively. Responses closer to the right side of the continuum (i.e., the staff would totally decide for the resident) indicate that the respondents perceive their facility's practice would be more executional, delegated, incapacitated, inauthentic, long-range, or positive autonomy, respectively.
An examination of the intercorrelations between the six dimensions reveals a range from a low of r = .01 between the dimensions of direct/delegated autonomy and positive/negative autonomy, to a high of r = .37 between the autonomy dimensions of competent/incompetent and immediate/long-range.
The descriptive results are shown in Table 1. The majority of the nursing home personnel were White, an average age was 40 years old, and an average amount of schooling was somewhat more than high school (M = 3.89, SD = .91). Most staff members were quite satisfied with their work (M = 1.67, SD = .75) and held a slightly positive view of older adults (M = 149.35, SD - 26.1). The average percentage of professional nurses relative to the minimum state standard was 128. The similar figure for CNAs was 112%. The turnover rate for the professional nurses was 23%, whereas the turnover rate for the nursing assistants was 45%. These facilities averaged 13% Medicare residents and 63% Medicaid residents. On average, 9% of the residents were physically restrained, and 14% were chemically restrained.
With respect to autonomy dimensions, these respondents strongly perceived that the facilities supported the decisional (M = 2.74, SD = 1.60) and authentic polarities of autonomy (M = 2.34, SD = 1.75). The competent polarity of autonomy (M = 3.90, SD = 1.60) was seen as moderately endorsed. There was no clear directional agreement for the remaining three dimensions. The responses were essentially directionally balanced.
Multiple Regression Results
Multiple regression results are shown in Table 2. In these analyses, each autonomy dimension was regressed separately on each of the four sets of variables identified in the model. In this way, the influence of each variable within each block of variables could be examined with respect to each of the six autonomy dimensions. The standardized partial regression coefficients, Betas, reflect the relative impact of an independent variable on the dependent variable while controlling for the remaining variables in that equation. The statistical significance of a particular independent variable is based not on the beta coefficient but on an analysis of the slope, b, which is not shown in this Table. In the following discussion of autonomy dimension is examined for each of the four sets of independent variables.
Decisional/executional autonomy (D/E), A response of greater executional autonomy (i.e., the perception by these nursing home personnel that the facilities supported the view that residents should have the responsibility of implementing decisions) was related to less job satisfaction among staff and to a more negative attitude by staff about older individuals.
Direct/delegated autonomy (Di/ De). Those respondents who were non-White and those who were CNAs were significantly more likely to believe that the facilities supported the delegation of die authority for decisions to someone else - in this case, to the facility and its staff.
Competent/incapacitated autonomy (C/ In). Those staff members who were less educated, those who held more negative attitudes about older individuals, and those who were CNAs were significantly more likely to believe that the facilities would not have allowed residents to make judgmentally coherent choices.
Authentic/ in Authentic autonomy (A/la). Those individuals who were non-White, among CNAs and within facilities that had relatively higher percentages of professional nurses and relatively lower percentages of CNAs, were significantly more likely to believe facility practice was toward viewisg resident behavior as inauthentic.
Immediate/long-range autonomy (ImIL], Those respondents with less educational attainment and CNAs were significantly more likely to believe facility practice was to assume it was the nursing home, not the residents, that held the responsibility to make decisions eventually affecting the resident.
Negative/positive autonomy (N/P). Those individuals with less education, CNAs, and those facilities that had relatively smaller percentages of both Medicare and Medicaid supported residents were more likely to indicate the practice of the facility would be to intervene in decisions affecting resident welfare rather than to allow the resident to make such decisions.
It should be noted in these series of analyses, although several blocks of variables explained a significant proportion of variance (R2), the proportionate amount of explained variance was low. The greatest percentage of variance explained by any subset was 15%. The average amount of explained variance per analysis was only 5.3%.
The findings support the fact that personal autonomy is a complex concept. The nursing home staff background variables had the most effect on the autonomy dimensions. Overall, education and race were the two most influential variables. Also, the distinction between nursing assistants and professional staff was meaningful for all autonomy dimensions except for decisional/executional. While these variables provide some interesting insights into resident autonomy in nursing homes, additional research is required to uncover the complete set of variables that relate to autonomy in all of its dimensions.
The ongoing debate between personal autonomy and organizational control in nursing homes may take years to resolve. Research, such as reported in this article, is only beginning to shed light on nursing home personnel's view of resident autonomy. Expanded training of nurse's aides concerning resident freedom, self-determination, and independence would be effective in focusing on the residents' rights instead of the responsibilities of nursing homes and their staff. Management support of expanded resident autonomy will be crucial to ensure its success.
Surprisingly, staffing levels, turnover rates, and restraint usage were not related to how nursing home staff perceived resident autonomy. Apparently, the structural and procedurai issues related to operating a nursing home did not substantially affect staff members' views of autonomy. This research showed the socioeconomic backgrounds of nursing home employees had a greater impact on their opinions of resident autonomy. Future research may identify additional factors related to how nursing home staff and administrators view autonomy and what changes they would implement to improve their residents' quality of life.
In addition to the views of nursing home staff, research must examine autonomy from the perspective of the residents themselves, as well as their families and friends. Then, the complexities and dynamics of autonomy can be more effectively examined. As the U.S. population continues to live longer, well past age 90, more and more frail individuals may be dependent on nursing home care. It will become increasingly important for nursing home administrators to review their policies concerning resident rights as one step toward providing their residents with quality care.
To change the negative perception that nursing homes are total institutions, providing for residents' every needs, professional nurses and CNAs can provide residents with greater opportunities to make their own decisions concerning their care. Because CNAs have the most contact with residents on a daily basis, they would greatly benefit from sensitivity training related to resident autonomy.
Nursing home employees with less education would also benefit from training related to autonomy. In-service training sessions could focus on nursing home staff's attitudes toward older adults and could help to dispel some of the stereotypes, which unfortunately continue to persist. By retaining more of their independence and making more of the decisions related to their care, nursing home residents will become more involved in their daily routines and, in the long run, enjoy a higher quality of life. In turn, nursing home staff may experience greater job satisfaction, knowing residents are happier with the care they receive.
In-service training could explain the meaning and importance of autonomy to the physical and emotional well-being of nursing home residents. Attendees could be presented with case studies and encouraged to discuss the challenges of patient care. Participants could share personal experiences and explore how they might respond differently in the future to provide residents with greater autonomy. '
For example, related to the decisional/executional dimension of autonomy, when nursing home staff learn to exercise less control over the lives of residents, employee morale may increase. With respect to the negative/positive dimension, training programs could encourage nursing home staff to examine the frequency with which they provide assistance to residents, realizing it is often difficult to achieve a workable balance between too much and too little support. As a result, residents may not be ignored as often and, at the same time, may become more empowered to make their own decisions related to their care (e.g., residents should be encouraged to eat and to shower, but not be forced to eat or bathe on a regular basis).
Also, nursing home staff could be taught more effective ways to handle and to reduce inappropriate resident behaviors. Nursing assistants could be discouraged from verbally chastising or physically restraining residents.
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REGRESSION RESULTS (BETAS) OF EACH AUTONOMY DIMENSION BY SETS OF SELECTED VARIABLES