Nursing Homes Research Paper

1. Consequences Of Institutionalization

The majority of people dread the idea of institutionalization because private homes and apartments within specific communities are strongly linked to biographies. Individual living arrangements, i.e., personal furniture, belongings, decorations, etc., can be regarded as an extension of the self and are not very easily abandoned. The move to an institution is sometimes considered as a first step towards death. Risk factors for institutionalization are high age, being female, widowhood, and childlessness. The main risk factor is impairment of functional status due to chronic, mental and/or physical diseases. Up to 50 percent of the inhabitants of nursing homes suffer from dementia. Nevertheless, people of similar vulnerability also live in communities. Therefore, the interaction between individual deficits and inadequate social support seems to be of crucial importance for the necessity of institutionalization.

Relocation is regarded as a critical life event, a major stressor which can lead to behavioral, psychological, and physical deterioration (Horowitz and Schulz 1983). Some studies, though, question this relocation-stress hypothesis and report positive outcomes of institutional living. These include better family relations, improved morale and positive alterations in lifestyles of the residents. However, there are severe methodological problems in detecting the effects of relocation. The effects of multimorbidity and various impairments are difficult to separate from effects due to institutionalization. Furthermore, it is almost impossible to realize control group designs (Kahana 1987). One important condition for positive effects seems to be that relocation is the result of the elderly person’s own decision. If the selection of the environment is under the control of the elderly individual and if the institution provides compensatory support suitable for this individual, positive outcomes are most likely (M. M. Baltes et al. 1991). Unfortunately, however, many elderly people are relocated into institutions from acute hospitals or other institutional settings, which means that they have no control over the time of relocation or the choice of institution.

Personal coping strategies are an important mediator in dealing with the stress of relocation, adaptation to new living conditions, and maintenance of a sense of control. Since Goffman’s (1961) classical study about the humiliation and deprivation of choice in ‘total institutions’, nursing homes are widely regarded as one example of violation of the basic needs for personal control. The negative impact of loss of control for elderly people has been proven in many studies (Heckhausen and Schulz 1995). It is important to note, however, that institutionalization does not necessarily lead to a total loss of control, rather to a change of certain aspects of control or differential means of expression of control. Contrary to common belief, not only active but also passive behavior can serve as having control. A resident exhibiting dependent behavior, for example, might execute control in order to secure social contact with staff members (M. M. Baltes 1996).

2. Ecological Aspects

Nursing homes are complex systems in which different ecological aspects interact and influence the residents’ well-being and behavior. Nursing home residents who suffer from physical and cognitive restrictions are particularly vulnerable with regard to these physical and social environmental conditions. Although physical and social aspects are not independent from one another, they are described here separately for reasons of clarity.

2.1 Physical Environment

Housing and nursing homes are a major issue of theoretical and empirical research efforts in ecological and social gerontology. The importance of the physical environmental appearance in nursing homes was expressed by the classical environmental docility hypothesis, which stresses the increasing importance of environmental factors when specific losses in daily functioning occur (Lawton and Simon 1968). Deficits such as visual, mobility, or cognitive impairments are extremely stressful for elderly people, and architects have designed prothetic environments in order to compensate for these problems. The competence-press model stresses the idea that environmental demands that have a manageable difficulty level can optimize residents’ performances (Lawton 1982). According to this hypothesis, high demands and low competence will result in stress and deterioration. Just manageable environmental press, however, might activate the individual’s reserve capacities.

Other lines of reasoning in ecological gerontology stresses the importance of congruence between personal preferences and needs on the one hand, and physical and social characteristics of the environment on the other hand (Kahana 1982). An optimal person–environment fit with regard to necessary assistance and respect for privacy and autonomy is extremely important for the subjective well-being of residents. Due to interindividual differences in residents, the realization of a person–environment fit for every resident is an ambitious challenge for the nursing home providers.

Regnier and Pynoos (1992) suggest a conceptual framework with 12 environmental and behavioral principles in order to structure the organization of nursing homes: (a) provision of opportunities for privacy; (b) provision of opportunities for social interaction; (c) promotion of opportunities for control, choice, and autonomy; (d) fostering a sense of orientation and wayfinding; (e) provision of a safe and secure environment; (f) accessibility and functioning of basic requirements; (g) provision of stimulation and challenge; (h) consideration of sensory aspects; (i) enhancing familiarity through personal objects; (j) consideration of esthetics and appearance; (k) provision of opportunities for personalization of the environment; (l) adaptability of environmental conditions. Along these guidelines, nursing homes should be organized according to the needs of their specific residents.

2.2 Social Environment

Important predictors for subjective well-being are social relations and social activities. Therefore, an integration into the social world of a nursing home seems an important factor for positive adaptation. Any institutionalized resident is offered opportunities for social interaction with other residents and with staff members.

2.2.1 Residents As Social Partners. Nursing homes offer a variety of possibilities for establishing social contacts which, however, are often either not taken up or do not automatically lead to increased wellbeing of the residents. Research findings report that encouragement for social activities is difficult because individual preferences in activities differ. Furthermore, admission age of residents and the prevalence of demented elderly individuals are high in institutions, which increases the difficulties of setting up new contacts and satisfactory social exchange.

Socioemotional selectivity theory provides another explanation for the difficulties of enhancing social activities. Carstensen et al. (1997) argue that for elderly people, emotional criteria are crucial for the selection of social relationships. Therefore, the quality and not merely the quantity of social contacts is the decisive criterion for positive effects of relationships. Research findings demonstrating the importance of a partner or a close person as an important predictor for well-being support this view. These findings are relevant for nursing home residents because two main predictors for institutionalization are widowhood and childlessness. In other words, the important condition of having an intimate confidant does not exist for many residents, and likewise, motivation for activities with other residents may be low because these social contacts cannot substitute the missed intimate relationship. It remains an open question whether institutions could encourage emotional satisfying relationships between residents. So far, empirical results show that outer institutional contacts contribute considerably to the life satisfaction of residents.

2.2.2 Staff Members As Social Partners. Nurses and other staff members are highly attractive and valued social partners for the residents because they represent the world outside the institution and have the means to execute emotional and instrumental power. Based on social learning theory, Margret Baltes conducted a research program which showed that cognitions and behavior patterns of staff have tremendous influence on autonomy and dependency of residents (M. M. Baltes 1996). Research findings have shown that the social reality in nursing homes can be described as overprotection and encouragement of dependent behavior. Elderly residents are regarded as incompetent and helpless by staff, who, according to the medical model, feel obliged to offer maximum assistance. Elderly residents and staff show a predictable pattern of behavior interaction: they seem to act according to a social script. This means that both staff and residents share common cognitions about appropriate role behaviors. In particular, research results from cross-cultural studies have demonstrated—on a behavior level—that dependent behavior by residents is followed by staff support behavior for dependency. In addition, independent behavior by residents tends to be ignored or even punished by staff. Consequently, the display of dependent behavior by residents ensures the desired social contact with staff members. Unfortunately, this mode of control for social contact may have negative effects on the independent functioning of the residents because abilities might get lost with time without training.

3. Intervention

Despite a substantial amount of basic gerontological knowledge, transfer of this knowledge into practice is difficult. Therefore, a considerable number of intervention studies have been conducted in nursing homes in order to assess the outcomes. The major aim of interventions is to increase the well-being of residents. In order to enhance the quality of life of residents, different means and levels of intervention have been taken up.

On the individual level, behavior modification programs are often applied in order to change residents’ behavior (Carstensen et al. 1996). First, residents’ problems like sleeping disorders or urinary incontinence are the focus of intervention. Second, rehabilitation of lost functions concerning activities of daily living like eating or dressing are addressed. Third, behaviors that disturb other residents or staff like wandering or shouting might be treated with behavior modification. Especially in this latter case, ethical principles and legitimate interests of all parties have to be carefully considered before intervening.

On the group level, interventions concerning residents and interventions focusing on staff must be differentiated. The enhancement of social activities among the elderly—such as organizing games or introducing pets into the institution—are often the target of efforts. Other changes aim at increasing the sense of control, for example, through participation in decisions. Finally, cognitive functions are a major area of interventions. Reality orientation and memory trainings are group activities offered in most nursing homes. The effects of these interventions, however, remain unclear. Some authors claim that the social activity in itself is an important factor for the wellbeing of the residents rather than effects on cognitive functioning.

Few interventions aim at changing staff behavior in order to improve a positive impact on the residents’ well-being. Maintenance or rehabilitation of everyday competence through adequate treatment by staff has been of major interest. Training programs for staff often include communicating the knowledge about normal aging, the importance of environmental conditions, and behavior modification (M. M. Baltes 1996).

On the system level, desired changes include the whole institution. Improvement of the physical environment is one key element for this kind of intervention. In particular, residents suffering from dementia need a therapeutic architecture that compensates for their deficits as much as possible (Regnier and Pynoos 1992). In order to improve orientation, different colors and noticeable symbols can be used on different floors. Low demanding elevators, simple sanitary instruments, and safe areas for physical activities like wandering are examples of matching special needs of demented patients. Moos and Lemke (1994, 1996) developed a Multiphasic Environmental Assessment Procedure (MEAP), an instrument that gathers descriptive data for different environmental dimensions. It measures physical and architectural features, institutional policy, residents’ functioning, and staff characteristics. In addition, resident and staff perceptions of the social environment and social climate of an institution are measured. This instrument has been used in many studies in order to describe nursing homes or to examine interventions (Moos and Lemke 1996).

4. Conclusions

The theoretical and empirical research described in this research paper show a variety of encouraging results in that institutions are able to offer satisfying environments for their residents. In addition, many interventions have been successfully applied. One major problem of this research, however, is the fact that most studies were conducted in the 1970s or 1980s. Since 1980, the population of nursing home residents has changed noticeably. First, admission age has raised considerably. Most residents nowadays are age 85 or above when they move to an institution. Second, the proportion of residents suffering from dementia has increased tremendously—up to 50 percent in many institutions. Third, community-based services and new living arrangements are expanding; therefore healthier people are less likely to choose an institution, and the number of residents with chronic mental illnesses in nursing homes will increase further. These changes in the characteristics of institutionalized elderly people mean a major challenge for the providers and for future gerontological research.

Baltes and Baltes (1990) proposed a general model of adaptivity to the increasing biological and social losses in old age, the model of selective optimization with compensation. The three components—selection, optimization, and compensation—are regarded as fundamental processes or strategies to ensure adaptive development (P. B. Baltes 1997). The process of selection refers to a reduction or transformation of domains of functioning in which the individual strives to perform efficiently. This involves a realistic evaluation of individual priorities, environmental demands, and biological capacity. The second component, optimization, reflects the traditional conception of development as an enrichment and augmentation of functioning with regard to quality and quantity. The third component, compensation, becomes important when losses occur (e.g., hearing loss) or behavioral capacities are reduced due to physical or mental constraints. The three processes are also operative in institutions. Nursing homes can be regarded as special worlds that alleviate adaptation to biological decline. The process of selection is realized by the provision of a less demanding environment. Compensation is offered by various means of assistance (e.g., care, prepared food) that reduce the effects of diminishing capacities, and optimization is supported by opportunities to pursue activities in those domains which are important to the individual resident (M. M. Baltes et al. 1991).

The model of selective optimization with compensation offers a valuable theoretical framework for future ecological and intervention research in institutions. It is an open question in how far the three components of positive adaptation can be supported with regard to residents suffering from dementia. Gerontological research has to generate answers concerning the balance between protection and compensation on the one hand, and stimulation and optimization on the other hand. The development of suitable offers for individuals with different levels of impairments and mental restrictions within one institution is of great importance for the well-being of the residents.

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