Perceived autonomy refers to perceived personal self governance, or the perception that a person is free from external constraint to determine his or her own actions and behaviors. Autonomy is linked to quality of life among those with critical mental capacities, such as understanding, intending, and voluntary decision-making capacity (Beauchamp & Walters, 2003). The autonomy of older adults is especially at risk in health care settings because they are often not given the opportunity to fully understand their diagnosis and treatment choices and are thus unable to make truly informed choices about their care (Lothian & Philp, 2001). Within the context of the nurse–patient/client relationship, autonomy can be potentially threatened or inhibited by a variety of circumstances, either real or symbolic, intrinsic or external to the person (Horowitz, Silverstone, & Reinhardt, 1991).
However, the current trend toward person-centered care assumes the informed role of patients in health care decisions. The nursing practice literature differentiates various interventions to promote patient autonomy, such as actively encouraging patients to participate in decisions about their care (Davies, Laker, & Ellis, 1997). For example, advance directives provide an opportunity to document a person’s preferences for potentially life-saving medical treatment in the event he or she is unable to communicate. In the United States, a considerable amount of research regarding advance directives has been conducted since the Patient Self-Determination Act was enacted in 1991 (Fried, Redding, Robbins, O’Leary, & Iannone, 2011; Resnick, Hickman, & Foster, 2012). Older adults are encouraged to make their preferences known to trusted friends, family, and health care providers so that their future treatment choices will be respected (Malcomson & Bisbee, 2009). On the other hand, despite the fact that Japan has the oldest population in the world, few studies examining advance care planning have been conducted in Japan. A survey among Japanese adults demonstrated that more than 70% of respondents would want to express treatment preferences (Miyata, Shiraishi, & Kai, 2006). Similarly, another study that focused on community-dwelling older adults found that 72.9% reported positive preferences for executing living wills (Matsui, 2007). Respect for older adults’ autonomy in decision making is an important ethical requirement, and without advance directives, it is difficult for health care providers to make decisions in accordance with patients’ wishes when they lack the capacity (Aw et al., 2012).
Several studies describing antecedents and correlates of autonomy among older adults have been conducted in the United States (Hertz, 1996; Hertz & Anschutz, 2002; Matsui & Capezuti, 2008) as well as other countries (Hwang & Lin, 2003; Hwang, Lin, Tung, & Wu, 2006; Scott et al., 2003). Factors associated with autonomy among older adults include: (a) sociodemographic characteristics (i.e., age, marital status, educational level, and place of residence); (b) perception of health status; (c) functional abilities (i.e., functional autonomy and physical function); (d) anxiety level; (e) ability to cope; (f) self-image; (g) social support; and (h) one’s personal attitude toward life (Hwang et al., 2006).
One conceptualization of autonomy, perceived enactment of autonomy (PEA), has been reported to have three attributes: voluntariness, individuality, and self-direction (Hertz, 1991, 1996). Voluntariness is described as “the perception of the presence of choice, freedom from coercion, access to information and other recourses, unrestrained thought or movement, and unconstrained decisions or behaviors” (Hertz, 1991, p. 31). Individuality is “the perception of having distinguishing characteristics, possessing a human uniqueness, being a distinct entity, and having a sense of self and knowledge of one’s own needs and goals” (Hertz, 1991, pp. 31–32). It includes the idea that people can recognize their own need for maintaining social bonds and privacy. Self-direction is the perception of “guiding or controlling one’s own destiny, moving toward self-determination goals, and conducting one’s own affairs” (Hertz, 1991, p. 32). Through self-direction, needs for both dependence and independence can be met, either separately or simultaneously. These definitions indicate that the notion of autonomy is both multidimensional and context-dependent (Collopy, 1988).
Several studies have used a tool based on Hertz’s conceptualization known as the Hertz Perceived Enactment of Autonomy Scale (HPEAS). Among respondents of senior centers, PEA was positively correlated to perceived control, high morale, and life satisfaction (Hertz & Anschutz, 2002). Hwang et al. (2006), in a study of Taiwanese older adults, found that PEA was related to satisfaction with social supports, higher functional ability, positive life attitudes, and higher levels of education. The measurement of PEA was modified in the Hwang study, with some items from the HPEAS tool being deleted; therefore, comparison of these studies is not possible.
PEA is based on the Modeling and Role-Modeling (MRM) nursing theory (Erickson, Tomlin, & Swain, 1988). PEA assumes that people can sense their own ability to act autonomously in meeting their needs for both dependence and independence (Hertz, 1996). The current study is based on MRM theory, which provides a framework for understanding self-care practices that facilitate health by incorporating older adults’ views. This theory assumes that older adults know what is interfering with their health and what is needed to restore health (Hertz & Anschutz, 2002). Self-care action is thus the result of PEA, or “a state of sensing and recognizing the ability to freely choose behaviors and course of action on one’s own behalf and in accordance with one’s own needs and goals” (Hertz, 1991, p. 15). The MRM model describes the aspect of self-care as internal and external resources. Internal resources include the client’s physical functioning, age, attitudes, and values, whereas external resources include social supports, living arrangement, and access to materials to meet basic needs (Hertz & Anschutz, 2002).
Although used in the United States and Taiwan, this conceptualization of autonomy has not been evaluated in older Japanese adults. Japan has also been influenced by American health care’s focus on the bioethical principles of respect for persons (i.e., autonomy), non-maleficence, beneficence, and justice (Japanese Bioethics Editorial Committee, 2012).
Culture has a powerful influence on one’s interpretation of, and responses to, health care. For example in one study, Japanese-Americans reported significantly higher trust in their physician than Japanese living in Japan (Tarn et al., 2005). In terms of autonomy, there are fundamental differences in the perspectives of Japanese and Americans. Autonomy in relation to medical ethics has been mostly studied from a Western view, which emphasizes individualism, whereas in Japanese culture, the individual is considered connected to others, so the social unit has priority over personal needs (Karasawa et al., 2011). However, little is known about cultural differences in perceived autonomy among older adults.
This study examines perceived autonomy among older adults in the United States and Japan and investigates factors associated with autonomy. It also describes the relationship between perceived autonomy and self-care resources, both internal (i.e., age, race, and educational level) and external (i.e., social support, marital status, living arrangements, and cultural aspect).
A correlational design was used to compare self-reported views of perceived autonomy among American and Japanese older adults. This study was approved by The New York University Committee on Activities Involving Human Subjects.
Setting and Sample
Respondents were recruited from senior centers in the United States and senior citizens clubs in Japan. There are 6.7 million members, generally ages 60 and older, in the nearly 100,000 senior citizens clubs in Japan. The purpose of these senior clubs is to provide both social and health promotion activities (Japan Federation of Senior Citizens Clubs, n.d.).
Six senior centers in Manhattan, New York City and two senior clubs in Fukuoka City and Hiroshima City, West Japan, were invited to participate. More than 1.5 million people live in Manhattan (New York City Department of City Planning, 2012), with 12.1% ages 65 and older, and more than 60% are non-White (United States Census Bureau, 2014). Both Japanese cities of Fukuoka and Hiroshima are ordinance-designated cities, with populations of 1,492,254 and 1,181,410, respectively. Those ages 65 and older are 17.8% and 20.8% of the population, respectively (Statistics Japan, Statistics Bureau, n.d.).
In the study conducted in Manhattan, senior center staff advertised the study in their newsletter and with a flyer posted on the events calendar bulletin board. One hundred thirty eight older adults consented to participate. Of these, 132 completed surveys (95.7%) were received; however, 12 contained missing data that brought the final sample to 120 respondents (valid rate 87%) for the analysis. Most respondents filled out the surveys by themselves, but several respondents received help from a family member or research assistant. In Japan, each senior club director instructed staff on how to conduct this study, and 400 self-administered questionnaires were distributed. Of these, 290 (144 in Fukuoka and 146 in Hiroshima) were returned (72.5%), but only 220 respondent surveys were completely filled out (valid rate 55%) for final analysis.
Respondent characteristics, including demographics (i.e., age, gender, and marital status), living arrangement, and educational level were obtained. Additionally, race/ethnicity and functional status assessed by the Barthel Index were included in the American version of the survey. Instead of functional status, health status was added to the Japanese version because senior club members in Japan are all functionally independent.
Perceived autonomy was quantified with the HPEAS. The HPEAS contains 31 items, and total scores can range from 31 to 124, with higher scores indicating a higher level of PEA. There are three subscales: voluntariness (9 items), individuality (13 items), and self-direction (9 items). Content and construct validity were obtained through expert judgments, factor analysis, and testing of hypothesized relationships (Hertz, 1991), and Cronbach’s alpha for the total scale is reported as 0.87, with subscale alphas of 0.71, 0.76, and 0.74, respectively (Hertz & Anschutz, 2002). The 31-item questionnaire was translated into Japanese by a bilingual researcher and native Japanese speaker. The Japanese version was then reviewed and edited by a native Japanese speaker researcher. To check the accuracy of the Japanese version, it was back-translated by another bilingual researcher. Cronbach’s alpha for the 31-item Japanese HPEAS version is reported as 0.93, with subscale alphas of 0.75, 0.86, and 0.78, respectively (Matsui, 2009).
Perceived social support was assessed with the 12-item Multidimensional Scale of Perceived Social Support (MSPSS), which has three categories: family, friends, and significant others. Item scores range from 1 to 7, with responses averaged to create total and subscale scores; higher scores indicate greater perceived social support. The MSPSS has demonstrated high internal reliability; Cronbach’s alpha for the entire scale is reported as 0.88, with subscale alphas of 0.87, 0.85, and 0.91, respectively (Zimet, Dahlem, Zimet, & Farley, 1988).
MSPSS is not translated into Japanese; therefore, a different scale was used to assess social support for the Japanese sample. The Social Support Scale for the Elderly, developed by Noguchi (1991), was used for Japanese respondents and has 12 items with three categories: emotional support (4 items), instrumental support (4 items), and negative support (4 items). Each category was assessed in terms of three categories of support based on living arrangement: living with family members (except spouse), living separately from children or other relatives, and living alone and with support extending beyond family to friends and neighbors. The scores were calculated to indicate if the respondent has support (1) or no support (0), and then each category was summed.
Data were analyzed using SPSS version 21.0. Descriptive and correlation statistics were used to examine the relationship between perceived autonomy and the internal and external self-care resources in each group. Statistical significance was set at p < 0.05. Significant predictors of perceived autonomy were assessed using linear regression analysis.
Three hundred forty older adults consisting of 220 Japanese and 120 Americans recruited from senior centers participated in this study. Table 1 presents respondent characteristics. The mean age of U.S. older adults was 76.4 (SD = 8.79 years), and 32.5% were men who mostly lived alone (74.3%). The mean age of Japanese older adults was 74.2 (SD = 6.2 years), and 67.7% were men with the majority married and living with a spouse.
Comparison of Perceived Autonomy
Perceived autonomy measured by HPEAS in both groups is shown in Table 2. The total score of PEA was significantly higher in the American respondents (mean = 109.5, SD = 10.2) than in the Japanese respondents (mean = 86.98, SD = 9.4). Moreover, scores of each of the three subscales were also significantly higher in the American respondents compared to the Japanese respondents. All items, except “The way my home is furnished keeps me from doing what I want to do,” were higher in the American versus the Japanese respondents.
Comparison of Perceived Enactment of Autonomy (PEA) Items
Factors Related to Perceived Autonomy
Relationships between social support and PEA are presented in Table 3. Significantly, correlations were observed between social support and PEA, except the subscale of self-direction, in the American respondents. Each of the three relationships of emotional and instrumental support, except negative support, was examined in Japanese respondents because negative support refers to disagreements between the provider and receiver regarding the support. As a result, slightly partial correlations were shown between PEA and children living separately/relatives (instrumental support). PEA was not associated with demographic characteristics such as marital status and living arrangements in both groups.
Relationships Between Perceived Enactment of Autonomy (PEA) and Internal/External Self-Care
Factors associated with perceived autonomy in each group are illustrated in Table 4. The linear regression with social support was examined using family in the American sample and children living separately/relatives (instrumental support) in the Japanese group. Among the American respondents, White race (β = −0.464, p < 0.001) and social support (β = 0.340, p = 0.001) were significantly related to perceived autonomy. In Japan, health status (β = −0.409, p < 0.001) and social support (β = 0.191, p = 0.018) were significantly linked to perceived autonomy.
Linear Regression Analysis Exploring Factors Related to Perceived Enactment of Autonomy (PEA)
Older Americans living in Manhattan reported higher levels of perceived autonomy than older Japanese adults living in Fukuoka and Hiroshima. The American respondents demonstrated similar levels of PEA compared with previous surveys among community-dwelling American older adults (Hertz & Anschutz, 2002; Mowad, 2004). Although informed consent is required and more autonomous and independent patient decision making is now encouraged, PEA scores were significantly lower among Japanese respondents. Japan is culturally different from Western countries. Many definitions of culture have been proposed, and one definition is that culture is “the totality of socially transmitted behavioral patterns, arts, beliefs, values, customs, life ways, and all other products of human work and thought characteristics of a population of people that guide their worldview and decision making” (Purnell & Paulanka, 2003, p. 3). Similar to the United States, in the decision-making process of the Japanese health care setting, the importance of informed consent is emphasized (Takimoto et al., 2007), and self-determination is valued. Even among older adults, much attention has been paid to promoting autonomy and independence in health care, especially since public long-term care (LTC) insurance was implemented in 2000. This insurance covers both home and institutional services, and older adults’ views, including their preferences for services independence, are given high priority. A study of older adults related to the LTC insurance found that the ability to collect service information and the level of knowledge about service content was highly linked to perceived autonomy (Kutsumi, Ito, & Mikami, 2004).
In both the American and Japanese respondents, social support was significantly related to PEA. It has been recognized that social support is an important factor, which may affect the general well-being of individuals living with chronic and life-threatening health conditions (Cohen & Syme, 1985). Another study using an adapted version of the PEA in older adults living in a senior citizen home also reported that social support was significantly related to autonomy (Hwang et al., 2006). In this U.S. sample, 50% were divorced or single, and more than 70% lived alone (reflecting the living arrangements of those in U.S. metropolitan areas), which seems to support their high PEA. Although marital status and living arrangements were different in both countries, the findings from this study suggest that social support from family or friends is extremely important to PEA among older adults. Autonomy is maintained and fostered in supportive relationships (Moser, Houtepen, Spreeuwenberg, & Widdershoven, 2010).
In Japan, living arrangements among older adults are changing, and older adults will more likely be living alone in the future. Therefore, social support from family may be less, whereas support from friends and neighbors may increase. Consideration of the changing demographic patterns, such as fewer available adult children, on autonomy of older adults needs to be addressed in future research.
The relevance of this study to clinical practice is that the findings emphasize the importance of nurses assessing not only internal self-care resources but also external resources, which are related to autonomy among older adults. Social support was especially related to autonomy in both groups; therefore, nurses working in home-care and community-based settings need to consider this when caring for older adults.
This study has several limitations. First, the cities that were selected for the study are categorically different; New York is a metropolitan and multiethnic area, whereas Fukuoka and Hiroshima in Japan are ordinance-designated cites but not metropolitan. Second, although senior centers were used for the study setting in both countries, the organizational characteristics (e.g., staffing, services, activities for older adults) are different between the two countries. In Japan, senior centers are administrated by older adults and led by men. The questionnaires were distributed by a man in each senior club, and this may have led to more male respondents participating. Third, social support was not assessed using the same scale in both countries, and health status was asked only in the Japanese group. Although similar categories were included in both scales, the results need to be interpreted with caution.
This study investigated PEA among community-dwelling older adults in the United States and Japan. The findings showed that the American respondents demonstrated higher PEA, including scoring higher on the three subscales of voluntariness, individuality, and self-direction, than Japanese respondents. Factors associated with PEA were different in both countries; however, social support as an external self-care resource was significantly related to PEA in both groups of older adults. These results suggest that supportive relationships are important for both American and Japanese older adults to maintain autonomy.
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|Variable||United States (n = 120)||Japan (n = 220)|
|Age (mean [SD], range)||76.4 (8.79), 60 to 101||74.2 (6.2), 60 to 91|
|n (%)||n (%)|
|Sex (male)||39 (32.5)||149 (67.7)|
| Married||21 (17.5)||162 (73.6)|
| Widowed||39 (32.5)||45 (20.5)|
| Divorced, single, other||60 (50.0)||4 (1.8)|
| Missing data||0 (0)||9 (4.1)|
| Spouse or partner||21 (17.5)||126 (57.3)|
| Children or parents||8 (6.7)||40 (18.2)|
| Alone or other||84 (70)||47 (21.4)|
| Missing data||7 (5.8)||7 (3.2)|
| Elementary/junior/high school||49 (40.8)||147 (66.8)|
| College/university/graduate school||71 (59.1)||59 (26.8)|
| Missing data||0 (0)||14 (6.4)|
Comparison of Perceived Enactment of Autonomy (PEA) Items
|Mean (SD), Range|
|Scale/Subscale||United States||Japan||p Value|
|Autonomya||109.5 (10.2), 78 to 124||86.98 (9.4), 59 to 108||< 0.001|
|Voluntarinessb||31.4 (4.2), 20 to 36||26.1 (3.7), 17 to 35||< 0.001|
|Individualityc||45.4 (5.1), 34 to 50||34.6 (4.7), 21 to 46||< 0.001|
|Self-directiond||32.3 (3.8), 22 to 36||26.7 (3.1), 18 to 34||< 0.001|
Relationships Between Perceived Enactment of Autonomy (PEA) and Internal/External Self-Care
|Self-Care Resources||Autonomy (PEA)||Voluntariness||Individuality||Self-Direction|
| Functional status (Barthel Index)a||0.044||<0.001**||0.171||0.109|
| Marital statusc||0.898||0.951||0.645||0.767|
| Living arrangementd||0.440||0.779||0.506||0.087|
| Social supporta,e|
| Significant other||0.031*||<0.001**||0.018*||0.995|
| Health statusa||<0.001**||<0.001**||<0.001**||0.076|
| Marital statusc||0.086||0.002**||0.646||0.145|
| Living arrangementd||0.688||0.302||0.924||0.891|
| Social supporta, e|
| Family living together|
| Emotional support||0.810||0.638||0.851||0.165|
| Instrumental support||0.389||0.898||0.730||0.013*|
| Children living separately/relatives|
| Emotional support||0.102||0.043*||0.207||0.352|
| Instrumental support||0.044*||0.029*||0.171||0.129|
| Emotional support||0.332||0.055||0.370||0.241|
| Instrumental support||0.704||0.899||0.814||0.899|
Linear Regression Analysis Exploring Factors Related to Perceived Enactment of Autonomy (PEA)
|ß||p Value||ß||p Value|