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Latitude of choice among the institutionalized elderly : resident and staff perceptions Jang, Gail 1990

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LATITUDE OF CHOICE AMONG THE INSTITUTIONALIZED ELDERLY: RESIDENT AND STAFF PERCEPTIONS. by (BRENDA) GAIL JANG B.Sc.N., The University of B r i t i s h Columbia, 1985 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in THE FACULTY OF GRADUATE STUDIES The School of Nursing We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA A p r i l 1990 © (Brenda) G a i l Jang In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department The University of British Columbia Vancouver, Canada DE-6 (2/88) A b s t r a c t The establishment of i n t e r m e d i a t e care f a c i l i t i e s i n B r i t i s h Columbia, as w e l l as the establishment of s i m i l a r f a c i l i t i e s throughout the r e s t of Canada, was and s t i l l i s a w e l l - i n t e n t i o n e d approach t o meet the long term care needs of the e l d e r l y . The p r a c t i c e s and procedures adopted by long term care f a c i l i t i e s , however, tend to i n h i b i t the p e r s o n a l autonomy of r e s i d e n t s (Thomasma, 1985). S p e c i f i c a l l y , a f a c i l i t y ' s p r a c t i c e s and procedures tend to i n h i b i t r e s i d e n t s ' l a t i t u d e of c h o i c e r e g a r d i n g d a i l y l i v i n g a c t i v i t i e s . R e s i d e n t s ' l a t i t u d e of c h o i c e may a l s o be l e s s e n e d when nurses implement w e l l - i n t e n t i o n e d h e l p i n g i n t e r v e n t i o n s based on t h e i r own m o t i v a t i o n s and g o a l s , r a t h e r than those of e l d e r l y r e s i d e n t s . L a t i t u d e of c h o i c e measures the extent to which an i n d i v i d u a l ' s p e r c e i v e d degree of c h o i c e i n c l u d e s a c t i v i t i e s of importance t o him/her. At present, t h e r e i s l i m i t e d r e s e a r c h a d d r e s s i n g both r e s i d e n t and s t a f f p e r c e p t i o n s r e g a r d i n g the autonomy (freedom of choice) of r e s i d e n t s , p a r t i c u l a r l y i n r e l a t i o n t o t h e i r d a i l y a c t i v i t i e s . A c c o r d i n g l y , t h i s study's purpose was t o determine the i n s t i t u t i o n a l i z e d e l d e r l y r e s i d e n t s ' and t h e i r c a r e g i v e r s ' p e r c e p t i o n s of r e s i d e n t s ' l a t i t u d e of c h o i c e r e g a r d i n g a c t i v i t i e s of d a i l y l i v i n g . From determining these s p e c i f i c s t a f f and r e s i d e n t p e r c e p t i o n s , s i g n i f i c a n t d i f f e r e n c e s were i s o l a t e d . T h i s study was conducted i n two i n t e r m e d i a t e care f a c i l i t i e s l o c a t e d i n a l a r g e c i t y w i t h i n the p r o v i n c e of B.C. The data c o l l e c t i o n instruments i n t h i s study i n c l u d e d s e l e c t e d questions from Hulicka et a l . ' s (1975) revised Importance, Locus and Range of A c t i v i t i e s Checklist, as well as a demographic data sheet developed by the researcher. Forty-five intermediate care 1 residents and f o r t y - f i v e nurses (Registered Nurses, Licensed P r a c t i c a l Nurses and Nurses' Aides) completed the study questionnaire and the demographic data sheet. The researcher studied the residents' and s t a f f ' s responses to the Importance, Locus and Range of A c t i v i t i e s Checklist by using non-parametric techniques for s t a t i s t i c a l analysis. The researcher used these techniques to determine the existence and location of differences i n perceptions among the residents and s t a f f . S i g n i f i c a n t differences exist i n residents' and s t a f f ' s perceptions when each group's importance ratings are combined with choice ratings. Isolation of the above importance and choice components for i n d i v i d u a l analyses indicate that the residents and s t a f f had s i g n i f i c a n t l y d i f f e r e n t response patterns regarding a) the importance residents attach to d a i l y l i v i n g a c t i v i t i e s and b) the degree of choice residents associate with d a i l y l i v i n g a c t i v i t i e s . The above findings indicated that residents' l a t i t u d e of choice may not be r e a l i z e d to a greater extent i f the s t a f f do not attach a degree of importance to a p a r t i c u l a r a c t i v i t y ( i e s ) s i m i l a r to that attached by the residents. Residents' latitude of choice may not be recognized to a greater extent i f s t a f f do not perceive that residents associate "some" or "no choice" with an a c t i v i t y of p a r t i c u l a r importance to them. i v Table of Contents Abstract i i Table of Contents i v L i s t of Tables v i i Chapter One: Introduction 1 Background to the Problem . 1 Statement of the Problem 6 Purpose of the Study 7 Research Questions 7 Foundation of the Study 8 D e f i n i t i o n of Terms 11 Assumptions 12 Limitations 13 Significance of the Study 14 Conceptual Framework 15 Definitions of Freedom of Choice and Latitude of Choice 15 Latitude/Freedom of Choice and the Need for Achievement 18 Latitude/Freedom of Choice and the Need for Self-esteem 19 Nursing Care and the Relationship Between Latitude of Choice and Freedom of Choice . 20 Chapter Two: Review of Related Literature 23 Autonomy and Aging 23 Freedom of Choice and the Long Term Care F a c i l i t y Environment 25 V Freedom of Choice and P s y c h o l o g i c a l W e l l - b e i n g i n the I n s t i t u t i o n a l i z e d E l d e r l y 28 I n s t i t u t i o n a l i z e d E l d e r l y R e s i d e n t s ' P e r c e i v e d L a t i t u d e of Choice 32 Resident and S t a f f P e r c e p t i o n s of I n s t i t u t i o n a l i z e d E l d e r l y R e s i d e n t s ' L a t i t u d e of Choice 33 Summary 35 Chapter Three: Methodology 37 Design 37 S e t t i n g 37 Sample 38 Instrumentation 39 Importance, Locus and Range of A c t i v i t i e s C h e c k l i s t . . . . . . . . . 40 Demographic Data Sheet 43 E t h i c s and Human Righ t s 44 Data C o l l e c t i o n Procedures 45 Data A n a l y s i s 46 Chapter Four: P r e s e n t a t i o n of F i n d i n g s 49 D e s c r i p t i o n of the Study Sample 4 9 Residents 4 9 Age and Sex 4 9 M a r i t a l Status 49 Prev i o u s Residence 50 Length of Stay i n the Intermediate Care F a c i l i t y 50 Nurses 52 F i n d i n g s . 53 v i Summary 61 Chapter Five: Discussion of Findings 63 Findings Regarding Importance and Choice 64 Sig n i f i c a n t Differences Between Residents' and Staff's Perceptions 68 The Conceptual Framework as a Basis for Analysis . . 72 Summary 7 6 Chapter Six: Summary, Conclusions, Implications and Recommendations 7 9 Summary 7 9 Conclusions 85 Implications for Nursing Practice and Education . . 86 Recommendations for Further Research . . . . . . . . . 90 References . 93 Appendices Appendix A Importance, Locus and Range of A c t i v i t i e s Checklist (Resident form) . 89 Appendix B Importance, Locus and Range of A c t i v i t i e s Checklist (Staff form) . . . 91 Appendix C Demographic Data Sheet (Residents) . . 93 Appendix D Demographic Data Sheet (Staff) . . . . 95 Appendix E Resident Information Letter 97 Appendix F Staff Information Letter . . 99 Appendix G Permission to Use the Research Tool . 101 v i i List of Tables Table Page I. Resident's Age 50 I I . Length of I n s t i t u t i o n a l i z a t i o n 51 I I I . D a i l y L i v i n g A c t i v i t i e s Rated as being Very Important By a M a j o r i t y of Residents, S t a f f and Residents and S t a f f Combined 55 IV. D a i l y L i v i n g A c t i v i t i e s A s s o c i a t e d With Free Choice By a M a j o r i t y of Residents, S t a f f and Residents and S t a f f Combined 56 V. D a i l y L i v i n g A c t i v i t i e s A s s o c i a t e d With No Choice By a M a j o r i t y of Residents, S t a f f and Residents and S t a f f Combined 57 1 Chapter One I n t r o d u c t i o n Background t o the Problem With the s t a t i s t i c a l p r o j e c t i o n s of an i n c r e a s i n g l y aging p o p u l a t i o n i n Canada, t h i s group i s becoming the o b j e c t of i n c r e a s i n g a t t e n t i o n (Thomasma, 1985). Indeed, i f the e l d e r l y are i n d i v i d u a l s age 65 and over, t h i s group w i l l comprise 27% of the Canadian p o p u l a t i o n by the year 2031 ( H a l l , 1987). The most recent census data from S t a t i s t i c s Canada (1987) i n d i c a t e s t h a t i n d i v i d u a l s over age 65 c o n s t i t u t e 10.7% of the t o t a l p o p u l a t i o n . Of t h i s e l d e r l y p o p u l a t i o n , 10% are i n s t i t u t i o n a l i z e d . Moreover, of the e l d e r l y who were 75 years and o l d e r , 17% are i n s t i t u t i o n a l i z e d ( S t a t i s t i c s Canada, 1987). Intermediate care f a c i l i t i e s r e p r e s e n t one of f i v e l e v e l s of i n s t i t u t i o n a l long term care i n B r i t i s h Columbia. T h i s study f o c u s s e d on long term care f o r i n s t i t u t i o n a l i z e d e l d e r l y r e s i d e n t s as i t i s p r a c t i c e d i n i n t e r m e d i a t e care f a c i l i t i e s . The a d j e c t i v e " i n t e r m e d i a t e " r e f e r s to the l e v e l or amount of i n s t i t u t i o n a l care r e s i d e n t s r e c e i v e . T h i s l e v e l i s i n c o n t r a s t t o "personal care", r e p r e s e n t i n g the lowest l e v e l of i n s t i t u t i o n a l care, and t o "extended care", r e p r e s e n t i n g a r e l a t i v e l y heavy l e v e l of care (Kane and Kane, 1985). I n s t i t u t i o n a l i z a t i o n i s one means through which Canada's e l d e r l y p o p u l a t i o n can r e c e i v e long term care. D e s p i t e the number of i n s t i t u t i o n a l i z e d e l d e r l y , i n s t i t u t i o n a l i z a t i o n i s not 2 n e c e s s a r i l y the s o l e o p t i o n f o r the e l d e r l y who p r e s e n t l y or i n the f u t u r e w i l l r e q u i r e long term care. Many e l d e r l y i n d i v i d u a l s can be a s s i s t e d to l i v e i n t h e i r own homes or with r e l a t i v e s . Nonetheless, i t i s c e r t a i n t h a t long term care i n s t i t u t i o n s w i l l continue t o operate i n Canada because "... i n s t i t u t i o n a l care f o r some i n d i v i d u a l s may be the most a p p r o p r i a t e and c o s t - e f f e c t i v e o p t i o n " (Forbes, Jackson and Kraus, 1987, p. x i ) . Moreover the demand f o r long term care i s such t h a t , a c c o r d i n g t o a study conducted by the Canadian Med i c a l A s s o c i a t i o n (1987), an a d d i t i o n a l 138,000 long term care beds w i l l be needed i n Canada by the year 2000. I t seems l i k e l y , then, t h a t long term care w i l l f i g u r e c e n t r a l l y i n the l i v e s of the e l d e r l y i n t o the t w e n t y - f i r s t century. Although the term " i n s t i t u t i o n a l i z a t i o n " w i t h i n the context of care of e l d e r l y i n d i v i d u a l s may r e f e r t o any number of l e v e l s of l ong term care, i t i s o f t e n used i n r e f e r e n c e t o i n t e r m e d i a t e care f a c i l i t i e s (or " n u r s i n g homes") p r o v i d i n g long term care. W i t h i n these f a c i l i t i e s , long term care r e f e r s to p r a c t i c e s and procedures t h a t are " g e n e r a l l y intended to p r o v i d e 24 hour accommodation, food s e r v i c e s and v a r i o u s degrees of care and treatment" (Forbes, Jackson and Klaus, 1987, p. x i ) . Moreover, the o v e r a l l emphasis i s t o "... meet p h y s i c a l , s o c i a l and p e r s o n a l needs of ( e l d e r l y ) i n d i v i d u a l s whose f u n c t i o n a l c a p a c i t i e s are c h r o n i c a l l y impaired or at r i s k of impairment" (Ontario H o s p i t a l A s s o c i a t i o n , 1980, p. 1 ) . 3 The establishment of i n t e r m e d i a t e care f a c i l i t i e s i n B.C., as w e l l as the establishment of s i m i l a r f a c i l i t i e s throughout the r e s t of Canada, was and s t i l l i s a w e l l - i n t e n t i o n e d approach to meet the long term care needs of the e l d e r l y . The p r a c t i c e s and procedures of long term care as d e s c r i b e d above, however, tend t o i n h i b i t the p e r s o n a l autonomy of r e s i d e n t s (Thomasma, 1985). There are two reasons f o r t h i s s i t u a t i o n . F i r s t , long term care w i t h i n i n s t i t u t i o n s i s f r e q u e n t l y a d m i n i s t e r e d i n a s t a n d a r d i z e d environment. Meal times are e f f i c i e n t l y s t r u c t u r e d so t h a t a l l r e s i d e n t s are served t h e i r meals at r e g u l a r times, r e c r e a t i o n a l programs are conducted to meet r e s i d e n t s ' s o c i a l and sensory needs, v i s i t i n g hours are e s t a b l i s h e d , and so f o r t h . Presumably, i n s t i t u t i o n a l programs are i n v a r i a b l y developed and conducted i n accordance with what the i n s t i t u t i o n ' s s t a f f and/or a d m i n i s t r a t i o n p e r c e i v e to be the r e s i d e n t s ' best i n t e r e s t s . However, c o n s t r a i n t s due to the number of s t a f f , and the l i m i t e d time t h a t s t a f f have to spend with r e s i d e n t s may a f f e c t how the i n s t i t u t i o n ' s programs are conducted. With such c o n s t r a i n t s f r e q u e n t l y e x i s t i n g i n long term care f a c i l i t i e s , t h e r e i s o f t e n d i m i n i s h e d o p p o r t u n i t y f o r c a r e g i v e r s t o enhance the autonomy of r e s i d e n t s . Second, the problem of m a i n t a i n i n g e l d e r l y r e s i d e n t s ' autonomy i n long term care s e t t i n g s i s i n t e n s i f i e d by the r e a l i t y t h a t many r e s i d e n t s have marked p h y s i c a l d i s a b i l i t y and/or c h r o n i c i l l n e s s ( E u s t i s , Greenburg and P a l l e n , 1984). Often the e l d e r l y become dependent on the c a r e g i v e r (e.g. the 4 nurse) for accomplishing a c t i v i t i e s of d a i l y l i v i n g that the e l d e r l y themselves cannot complete. There i s the p o t e n t i a l danger that dependency on the caregiver w i l l extend to choices i n d a i l y a c t i v i t i e s that the e l d e r l y are capable of making themselves. Maintaining the c l i e n t ' s autonomy when the c l i e n t ' s energy l e v e l i s low and dependency i s great can be a considerable challenge to caregivers (Ryden, 1985). Compounding t h i s challenge i s the application of the moral p r i n c i p l e of beneficence. This p r i n c i p l e d i r e c t s the caregiver "to promote and protect the best interests of the patient by seeking the greater balance of good over harm i n treatment and care" (Hofland, 1988, p. 4). Because i t i s often the caregiver who defines the patient's best interests, t h i s p r i n c i p l e tends to be applied i n a strongly p a t e r n a l i s t i c manner. Consequently, caregivers often adopt a p a t e r n a l i s t i c , maintenance approach which purports to meet the needs of the e l d e r l y residents (Emery, 1989). Hence, the autonomy of the e l d e r l y resident i s often undermined by the well-intended acts of the caregiver. Indeed, the e l d e r l y resident may also contribute to the i n h i b i t i o n of autonomy by acquiescing to the caregiver's determination of the elderly's best i n t e r e s t s . Whereas the p r i n c i p l e of beneficence i s quintessential i n acute care settings, "the p r i n c i p l e of beneficence i s less powerful i n long term care and requires much greater concern for and consideration of autonomy" (Hofland, 1988, p. 4) . Although a number of caregivers i n long term care acknowledge that the 5 e l d e r l y are e n t i t l e d to the maximum amount of autonomy and dignity, caregivers' e f f o r t s to enhance the elderly's autonomy often are based more on t h e i r own perspective rather than on the el d e r l y c l i e n t ' s perspective. Autonomy i n t h i s study refers to "... the freedom to manage the short range ad hoc aspects of l i f e , the mundane r e a l i t i e s that measure self-determination on a day-to-day basis" (Collopy, 1988, p. 10). Autonomy occurs when an i n d i v i d u a l has freedom of choice over "ad hoc aspects of l i f e " that are important to him/her. As a value that upholds an individual's right to make s e l f - d i r e c t e d choices, freedom of choice i s a prominent value among i n s t i t u t i o n a l i z e d e l d e r l y . "Latitude of choice", on the other hand, i s a concept r e f l e c t i n g the extent, as perceived by an i n d i v i d u a l , to which freedom of choice i s r e a l i z e d . An i n d i v i d u a l can determine t h i s perceived extent by the degree of importance and the degree of choice he/she attaches to, for example, a c t i v i t i e s of d a i l y l i v i n g . It should be noted that within the context of an individual's freedom of choice, the "autonomous person i s not a lone, isola t e d , atomistic agent making decisions without t i e s to other people, s o c i a l i n s t i t u t i o n s , and t r a d i t i o n s of thought and action" (Collopy, 1988, p. 10) . Furthermore, a person having freedom of choice i s not omnipotent or wholly unaffected by outside influence or constraint. Rather, such a person, as characterized by the i n s t i t u t i o n a l i z e d e l d e r l y residents i n t h i s study, believes that he/she has freedom of choice, as 6 e x e m p l i f i e d by t h e l a t i t u d e o f c h o i c e he/she has r e g a r d i n g a c t i v i t i e s o f d a i l y l i v i n g . However, e l d e r l y r e s i d e n t s ' l a t i t u d e o f c h o i c e r e g a r d i n g d a i l y l i v i n g a c t i v i t i e s t e n d t o be i n h i b i t e d as a r e s u l t o f t h e p r a c t i c e s and p r o c e d u r e s adopted by l o n g term c a r e f a c i l i t i e s . R e s i d e n t s ' l a t i t u d e o f c h o i c e may a l s o be l e s s e n e d when n u r s e s implement w e l l - i n t e n t i o n e d h e l p i n g i n t e r v e n t i o n s based on t h e i r own m o t i v a t i o n s and g o a l s , r a t h e r t h a n t h o s e o f e l d e r l y r e s i d e n t s . T h i s can be a p r o b l e m a t i c s i t u a t i o n f o r r e s i d e n t s i f t h e s e " h e l p i n g " i n t e r v e n t i o n s supersede t h e c h o i c e s d e s i r e d by r e s i d e n t s . The e x t e n t o f c h o i c e over a c t i v i t i e s i m p o r t a n t t o r e s i d e n t s i s e s s e n t i a l t oward m e e t i n g t h e i r needs f o r achievement and s e l f - e s t e e m . Statement of the Problem E n t r y i n t o a l o n g term c a r e f a c i l i t y o f t e n exposes t h e e l d e r l y t o a r e d u c t i o n i n l a t i t u d e o f c h o i c e r e g a r d i n g a c t i v i t i e s o f t h e i r d a i l y l i v i n g . F r e q u e n t l y , such a c t i v i t i e s become r e g u l a t e d by t h e f a c i l i t y and a r e d e t e r m i n e d by t h e nu r s e s who p r o v i d e o r a s s i s t w i t h c a r e . F u r t h e r m o r e , p r e c i s e l y when c a r e i s (meant t o be) b e n e f i c e n t , i n t r u s i o n s upon autonomy can go unchecked, u n s c r u t i n i z e d , even unobserved b e h i n d t h e c u r t a i n o f good i n t e n t i o n s . H e l p i n g i n t e r v e n t i o n s a r e o f t e n judged by t h e m o t i v a t i o n s and g o a l s o f t h e h e l p e r s , not by t h e p r e f e r e n c e s and l i f e p r o j e c t s o f o t h e r s ( C o l l o p y , 1988, p. 10) . 7 When a nurse's h e l p i n g i n t e r v e n t i o n s are p r i m a r i l y based upon h i s / h e r p e r c e p t i o n s of what i s "best" f o r a r e s i d e n t , the l a t t e r ' s l a t i t u d e of ch o i c e i s at r i s k . I f i n p l a n n i n g h i s / h e r i n t e r v e n t i o n s , the nurse does not take i n t o account the r e s i d e n t ' s p e r c e p t i o n s , the i n t e r v e n t i o n s may impede the r e s i d e n t ' s c h o i c e over a c t i v i t i e s of d a i l y l i v i n g t h a t are of importance t o him/her. Purpose of the Study The purpose of t h i s study was to determine the i n s t i t u t i o n a l i z e d e l d e r l y r e s i d e n t s ' and t h e i r c a r e g i v e r s ' p e r c e p t i o n s of r e s i d e n t s ' l a t i t u d e of c h o i c e r e g a r d i n g a c t i v i t i e s of d a i l y l i v i n g . From determining these s p e c i f i c s t a f f and r e s i d e n t p e r c e p t i o n s r e g a r d i n g a c t i v i t i e s of d a i l y l i v i n g , s i g n i f i c a n t d i s c r e p a n c i e s were i s o l a t e d . Research Questions Given t h a t t h i s study p r i m a r i l y addresses the components of l a t i t u d e of choice, the f o l l o w i n g q u e s t i o n s were addressed i n t h i s study: i ) To what extent are s p e c i f i c a c t i v i t i e s of d a i l y l i v i n g important t o e l d e r l y r e s i d e n t s ? i i ) To what extent do the s t a f f view s p e c i f i c a c t i v i t i e s of d a i l y l i v i n g as be i n g important t o e l d e r l y r e s i d e n t s ? 8 i i i ) Are there s i g n i f i c a n t differences, between s t a f f and resident perceptions, regarding the importance residents attach to s p e c i f i c a c t i v i t i e s of d a i l y l i v i n g ? iv) Are there s i g n i f i c a n t differences between resident and s t a f f perceptions regarding residents' perceived l e v e l of choice over these a c t i v i t i e s ? Foundation of the Study The studies of Hulicka et a l . (1975) and Morganti et a l . (1980) provided the foundation for t h i s research. The concept of l a t i t u d e of choice as developed by Hulicka et a l . (1975) i s a primary concept i n t h i s study. Additionally, Morganti et al. ' s study, which i s an expansion of Hulicka's (1975) work, adopts the perspective of resident and s t a f f perceptions. This study r e p l i c a t e s a portion of Morganti et a l . ' s study. S p e c i f i c a l l y , t h i s study adopted Morganti et al.'s questions regarding resident and s t a f f ratings of the importance and choice that residents associate with d a i l y l i v i n g a c t i v i t i e s . There are differences, however, between t h e i r study and t h i s one. The foremost difference i s that Morganti et a l . ' s (1980) study focussed not only on comparing resident and s t a f f perceptions of a resident's l a t i t u d e of choice regarding da i l y l i v i n g a c t i v i t i e s , but also on the relat i o n s h i p of resident's l a t i t u d e of choice scores to two measures of well-being ( i.e. 9 self-concept and l i f e s a t i s f a c t i o n scores). This present study focusses primarily on the components comprising l a t i t u d e of choice, that i s , the importance and the degree of choice that residents attach to s p e c i f i c a c t i v i t i e s of da i l y l i v i n g , as perceived by both residents and s t a f f . Other differences between t h i s study and Morganti et al.'s (1980) warrant mention. The conceptual framework which guides t h i s present study contains two elements d i s t i n c t from the framework of Morganti et a l . ' s (1980) study. S p e c i f i c a l l y , the conceptual framework of the present study relates the concept of lat i t u d e of choice to the concept of freedom of choice, a relati o n s h i p not found i n Morganti et a l . ' s (1980) study. Secondly, both these concepts are developed i n the framework within the context of the U.B.C. . Model for Nursing (1980), p a r t i c u l a r l y with respect to the ego-valuative subsystem (need for self-esteem) and achieving subsystem (need for achievement). These two concepts are of p a r t i c u l a r significance to residents of a long term care environment. Their needs for achievement and self-esteem frequently may go unnoticed by caregivers i n i n s t i t u t i o n s where p o l i c i e s and procedures often determine a large extent of the elderly's d a i l y a c t i v i t i e s . For t h e i r part, caregivers must act i n accordance with standardized procedures, procedures which invariably may not recognize and/or include opportunities for a s s i s t i n g residents i n meeting t h e i r needs for achievement and self-esteem. The U.B.C. Model, therefore, helped the researcher i n formulating an appropriate 10 fo u n d a t i o n f o r t h i s study's conceptual framework. As such, t h i s context i s d i s t i n c t from t h a t of Morganti et a l . ' s (1980) study. D e s p i t e the d i f f e r e n c e s i n the conceptual frameworks, t h i s study i s s i m i l a r t o Morganti et a l . ' s (1980) study i n r e s p e c t to the nature of the study s e t t i n g and the study sample. L i k e Morganti et a l . ' s (1980) study, t h i s study s e t t i n g c o n s i s t s of l o n g term care f a c i l i t i e s , and the study sample c o n s i s t s of e l d e r l y r e s i d e n t s w i t h i n these f a c i l i t i e s . These are not exact s i m i l a r i t i e s , however. Whereas the above study i n c l u d e d American long term care f a c i l i t i e s , t h i s study i n c l u d e s e x c l u s i v e l y Canadian long term care f a c i l i t i e s . Moreover, Morganti et a l . ' s (1980) study s e t t i n g was an American veterans' a d m i n i s t r a t i o n d o m i c i l i a r y . T h i s d o m i c i l i a r y i s more s i m i l a r t o a community d w e l l i n g r a t h e r than an i n s t i t u t i o n a l d w e l l i n g , i n t h a t r e s i d e n t s of the former have access t o the t o t a l community, and by and l a r g e are.not r e s t r i c t e d by i n s t i t u t i o n a l schedules (Morganti et a l . , 1980). In t h i s present study, however, Canadian i n t e r m e d i a t e care f a c i l i t i e s were used as the study s e t t i n g . Such f a c i l i t i e s are i n v a r i a b l y i n s t i t u t i o n a l by nature, where r e s i d e n t s are s u b j e c t t o i n s t i t u t i o n a l programs and schedules. Furthermore, u n l i k e Morganti et a l . (1980) who i n c l u d e d e x c l u s i v e l y male s u b j e c t s i n t h e i r study, t h i s present study w i l l i n c l u d e both male and female s u b j e c t s . An a d d i t i o n a l m e t h o d o l o g i c a l d i f f e r e n c e i s t h a t the above study i n c l u d e d H u l i c k a et a l . ' s (1975) o r i g i n a l v e r s i o n of the Importance, Locus and Range of A c t i v i t i e s C h e c k l i s t i n i t s 11 e n t i r e t y , whereas t h i s study i n c l u d e s s e l e c t e d q u e s t i o n s from the r e v i s e d v e r s i o n of t h i s c h e c k l i s t . T h i s study's s e t t i n g i s thus d i s t i n c t from Morganti et a l . ' s (1980) American study s e t t i n g s . There i s no known study, conducted i n e i t h e r B r i t i s h Columbia or the r e s t of Canada, s i m i l a r t o t h i s present study. The r e s u l t s from t h i s study would then r e f l e c t a Canadian p e r s p e c t i v e , s p e c i f i c a l l y a B r i t i s h Columbian p e r s p e c t i v e , h i t h e r t o unexplored. D e f i n i t i o n o f Terms Freedom of c h o i c e : A concept r e p r e s e n t i n g "... the freedom t o choose g o a l s , and t o r e l a t e means to g o a l s " (Thomasma, 1984, p. 908). Freedom of ch o i c e can be measured by l a t i t u d e of c h o i c e . L a t i t u d e of c h o i c e : A measure r e p r e s e n t i n g the extent t o which the e l d e r l y p e r c e i v e t h a t they can make ch o i c e s r e g a r d i n g s p e c i f i c a c t i v i t i e s , a c t i v i t i e s t h a t are important t o them and t h a t o f f e r a degree of c h o i c e . L a t i t u d e of ch o i c e w i l l be measured i n t h i s study through a d m i n i s t r a t i o n of H u l i c k a , Morganti and Cataldo's (1975) r e v i s e d Importance, Locus and Range of A c t i v i t i e s C h e c k l i s t . S e l e c t e d items from the c h e c k l i s t w i l l be used t o assess p e r c e i v e d l a t i t u d e of ch o i c e r e g a r d i n g the s e l e c t i o n or t i m i n g of a c t i v i t i e s of d a i l y l i v i n g . A c t i v i t i e s of d a i l y l i v i n g : A c t i v i t i e s of the e l d e r l y w i t h i n an in t e r m e d i a t e care f a c i l i t y which i n c l u d e d r e s s i n g , e a t i n g , 12 grooming, s o l i t a r y a c t i v i t i e s , one-to-one a c t i v i t i e s and group a c t i v i t i e s . Included i n t h i s d e f i n i t i o n i s the environment i n which the a c t i v i t i e s take place. I n s t i t u t i o n a l i z e d e l d e r l y : Males and females age 65 years and over who reside i n an intermediate care f a c i l i t y . Caregivers: Staff comprised of Registered Nurses, Licensed P r a c t i c a l Nurses or Nurses Aides who provide d a i l y professional care and/or supervision as well as moderate assistance with d a i l y l i v i n g to i n s t i t u t i o n a l i z e d e l d e r l y residents. Intermediate Care F a c i l i t y : A f a c i l i t y that "recognizes the person who i s independently mobile with or without mechanical aides, requires moderate assistance with the a c t i v i t i e s of d a i l y l i v i n g , and who requires d a i l y professional care and/or supervision" (Long Term Care Program: Policy Number: 3.2.3, 1983, p. 1). Perception: "A mental image of a place, person, object or event, interpreted i n l i g h t of one's own experiences" (King, 1971). Assumptions These are the assumptions of t h i s study: (1) Both e l d e r l y residents and nurses are cognizant of what they perceive and w i l l respond to the research questionnaire t r u t h f u l l y . 13 (2) Both e l d e r l y residents and nurses w i l l be able to d i s t i n g u i s h between importance and range of choice regarding a c t i v i t i e s of d a i l y l i v i n g . (3) Selected questions from the revised Importance, Locus and Range of A c t i v i t i e s Checklist'(Hulicka et a l . , 1975) w i l l r e t a i n the v a l i d i t y and r e l i a b i l i t y of the o r i g i n a l measurement t o o l . Limitations This study has the following l i m i t a t i o n s : (1) the use of a convenience sample consisting of nurses and i n s t i t u t i o n a l i z e d e l d e r l y residents from two intermediate care f a c i l i t i e s (2) the i n c l u s i o n of individuals who are English speaking and oriented to person, place and time (3) the administration of selected questions from the revised Importance, Locus and Range of A c t i v i t i e s Checklist (Hulicka et a l . , 1975) which thus may not f u l l y represent l a t i t u d e of choice regarding a c t i v i t i e s of d a i l y l i v i n g (4) the revised measurement t o o l not having been retested for v a l i d i t y and r e l i a b i l i t y 14 (5) data c o l l e c t e d from study s u b j e c t s r e p r e s e n t i n g t h e i r p e r c e p t i o n s at a p a r t i c u l a r p o i n t i n time Significance of the Study The knowledge generated from t h i s study can p r o v i d e nurses wi t h a b a s i s upon which t o p l a n meaningful i n t e r v e n t i o n s towards p r e s e r v i n g the autonomy of i n s t i t u t i o n a l i z e d e l d e r l y r e s i d e n t s . Nurses have the o p p o r t u n i t y t o f o s t e r the r e s i d e n t s ' l a t i t u d e of cho i c e t o the f u l l e s t extent p o s s i b l e which can r e s u l t i n the enhancement of the r e s i d e n t s ' s u b j e c t i v e sense of freedom of ch o i c e . Development and maintenance of a broad l a t i t u d e of cho i c e i s in h e r e n t i n the value " r e s p e c t f o r the r i g h t of choice h e l d by c l i e n t s " as s t a t e d i n the Canadian Nurses A s s o c i a t i o n (CNA) Code of E t h i c s (1985) . Furthermore, the Canadian n u r s i n g p r o f e s s i o n ' s mandate t o pre s e r v e c l i e n t autonomy i s expressed i n the CNA's Code of E t h i c s standards: I l l n e s s or other f a c t o r s may compromise the c l i e n t ' s c a p a c i t y f o r s e l f - d i r e c t i o n . Nurses have a c o n t i n u i n g o b l i g a t i o n t o value autonomy i n such c l i e n t s , f o r example, by c r e a t i v e l y p r o v i d i n g them with o p p o r t u n i t i e s f o r ch o i c e s , w i t h i n t h e i r c a p a b i l i t i e s , thereby a i d i n g them t o main t a i n or r e g a i n some degree of autonomy (Canadian Nurses A s s o c i a t i o n , 1985, p. 5). Hence, the s i g n i f i c a n c e of t h i s study can be expressed i n terms of nurses' p r o f e s s i o n a l mandate towards p r e s e r v i n g c l i e n t autonomy. A r e s i d e n t who i s meeting the need f o r achievement 15 and s e l f - e s t e e m i s b e t t e r able t o maintain or r e g a i n a degree of autonomy, and p s y c h o l o g i c a l w e l l - b e i n g (Schwartz, 1974) . Cognizant of t h i s r e l a t i o n s h i p , the r e s e a r c h e r i s attempting through t h i s study t o determine the extent t o which long term care r e s i d e n t s have o p p o r t u n i t i e s f o r ch o i c e s , c h o i c e s e n a b l i n g them t o meet t h e i r need f o r achievement and s e l f - e s t e e m . When s t r i v i n g t o a s s i s t r e s i d e n t s i n meeting these b a s i c human needs, nurses are i n f a c t c r e a t i n g o p p o r t u n i t i e s f o r cho i c e s which enhance r e s i d e n t s ' degree of autonomy. R e s u l t s of t h i s study can p r o v i d e nurses with a b a s i s f o r a s s e s s i n g an e l d e r l y r e s i d e n t ' s f e e l i n g s of achievement and se l f - e s t e e m . F u l f i l l m e n t of these two b a s i c human needs i s l a r g e l y determined by a c l i e n t ' s degree of ch o i c e over a c t i v i t i e s of p a r t i c u l a r importance t o him/her. R e s u l t s of t h i s study a l s o can p r o v i d e nurses with an awareness of t h e i r impact upon a r e s i d e n t ' s l a t i t u d e of choice and, by exte n s i o n , f e e l i n g s of achievement and s e l f - e s t e e m . Conceptual Framework Def i n i t i o n s of Freedom of Choice and Latitude of Choice Concepts c e n t r a l t o t h i s t h e s i s are those of freedom of ch o i c e and l a t i t u d e of c h o i c e . Freedom of ch o i c e r e f e r s t o "... the freedom t o choose g o a l s , and t o r e l a t e means t o g o a l s " (Thomasma, 1984, p. 908). T h i s type'of freedom i s d e r i v e d from an i n d i v i d u a l ' s s u b j e c t i v e p e r c e p t i o n , a p e r c e p t i o n based upon 16 his/her b e l i e f that he/she has choice over a c t i v i t y ( i e s ) of p a r t i c u l a r importance to him/her. Latitude of choice measures the extent to which an individual's perceived degree of choice includes a c t i v i t i e s of importance. In viewing la t i t u d e of choice i n terms of choice and importance, Hulicka et a l . (1975) suggest that: Free choice on an a c t i v i t y (perceived) to be important would contribute more to perceived l a t i t u d e of choice than to free choice on an a c t i v i t y (perceived) to be less important; and conversely no or l i m i t e d choice on an a c t i v i t y (perceived) to be important would represent a greater r e s t r i c t i o n on perceived l a t i t u d e of choice than i f the a c t i v i t y were (perceived) to be unimportant (p. 29). The above conception of l a t i t u d e of choice concurs with that of Perlmuter, Monty and Chan (1986) i n t h e i r writings on control and aging. Indeed, a considerable portion of the psychosocial research focuses on aspects of autonomy with respect to the i n s t i t u t i o n a l i z e d elderly, but usually under the rubric of "control" (Hofland, 1988). Perlmuter et a l . (1986) appear to be writing under t h i s rubric and t h e i r conception of increasing perception of control strongly p a r a l l e l s the c h a r a c t e r i s t i c of l a t i t u d e of choice. Perlmuter et a l . (1986) argue that, "... neither the e x p l i c i t awarding of the opportunity for choice nor the mere exercise of choice i s s u f f i c i e n t to strengthen the perception of control" (p. 115) . Rather, the choice must be perceived to be meaningful for the 17 i n d i v i d u a l , t h a t i s , i t must be p e r c e i v e d t o be m o d e r a t e l y d e s i r a b l e o r i m p o r t a n t ( P e r l m u t e r e t a l . 1986). L a t i t u d e o f c h o i c e e x p r e s s e d i n t h e s e terms i n c l u d e s not o n l y t h e a v a i l a b i l i t y o f c h o i c e but a l s o c h o i c e s t h a t a r e m e a n i n g f u l , i . e . i m p o r t a n t , t o t h e i n d i v i d u a l . B oth o f t h e s e a t t r i b u t e s o f c h o i c e a r e l a r g e l y d e t e r m i n e d by an i n d i v i d u a l ' s s u b j e c t i v e p e r c e p t i o n o f r e a l i t y . Hence, an i n d i v i d u a l ' s p e r c e i v e d degree o f c h o i c e , and t h e importance he/she a t t a c h e s t o h i s / h e r c h o i c e s , c u l m i n a t e t o produce h i s / h e r l a t i t u d e o f c h o i c e . T h i s l a t i t u d e can r e p r e s e n t t h e e x t e n t t o which e l d e r l y r e s i d e n t s p e r c e i v e t h e y can make c h o i c e s on a c t i v i t i e s o f d a i l y l i v i n g t h a t a r e i m p o r t a n t t o them and t h a t o f f e r a degree o f c h o i c e . Moreover, l a t i t u d e o f c h o i c e can be a b a s i s from which an e l d e r l y r e s i d e n t can det e r m i n e h i s / h e r freedom o f c h o i c e . The r e s i d e n t ' s freedom o f c h o i c e r e p r e s e n t s c h o i c e over a c t i v i t i e s o f s p e c i f i c i m p o r t a n c e t o her/him; a c t i v i t i e s t h a t a r e w i t h i n t h e r e s i d e n t ' s l a t i t u d e o f c h o i c e . F u r t h e r m o r e , t h e nurse can view t h e above d e f i n i t i o n s o f l a t i t u d e o f c h o i c e and freedom o f c h o i c e w i t h i n a c o n t e x t d e r i v e d from t h e U.B.C. Model f o r N u r s i n g (1980). A c c o r d i n g t o t h i s model, an i n d i v i d u a l i s a b e h a v i o u r a l system c o m p r i s e d o f n i n e subsystems. Each subsystem i s r e s p o n s i b l e f o r meeting a b a s i c human need. F o r t h e purpose o f t h i s s t u d y , t h e f o c u s w i l l be on t h e r e s i d e n t ' s a c h i e v i n g and e g o - v a l u a t i v e subsystems. 18 The a c h i e v i n g subsystem has t h e g o a l o f f e e l i n g s o f and s a t i s f a c t i o n w i t h accomplishments. The e g o - v a l u a t i v e subsystem has t h e g o a l o f s e l f - e s t e e m . F o r t h e purpose o f t h i s s t u d y , t h e g o a l s o f t h e s e two subsystems w i l l be viewed as b a s i c human needs c e n t r a l t o t h e c o n t e x t o f t h i s c o n c e p t u a l framework. The r e s i d e n t ' s need f o r achievement and s e l f - e s t e e m i s t h e most d i r e c t l y a f f e c t e d by one's p e r c e i v e d l a t i t u d e o f c h o i c e and r e s u l t a n t p e r c e p t i o n s o f freedom o f c h o i c e ; however, o t h e r b a s i c human needs may a l s o be a f f e c t e d . Because o f t h e i n t e r d e p e n d e n t r e l a t i o n s h i p between b a s i c human needs, t h e e f f e c t o f p e r c e i v e d l a t i t u d e o f c h o i c e and freedom o f c h o i c e on t h e above two human needs may r e s u l t i n r e p e r c u s s i o n s f o r o t h e r human needs. Latitude/Freedom o f Choice and the Need f o r Achievement I t i s germane f o r t h e nurse t o view l a t i t u d e o f c h o i c e w i t h i n t h e c o n t e x t o f t h e c l i e n t ' s need f o r achievement. By h e l p i n g t h e c l i e n t t o d e v e l o p and use s u i t a b l e c o p i n g b e h a v i o u r s t o meet h i s / h e r need f o r achievement, t h e nu r s e i s , i n e f f e c t , a s s i s t i n g t h e c l i e n t t o a c t on h i s / h e r c h o i c e s . By p r o v i d i n g t h e c l i e n t w i t h o p p o r t u n i t i e s t o make c h o i c e s and t a k e a c t i o n (s) on them, t h e nurse can f o s t e r c o p i n g b e h a v i o u r s t h a t t h e c l i e n t can adopt i n o r d e r t o e x p l o i t t h e s e c h o i c e s . I n v e r s e l y , t h e c o p i n g b e h a v i o u r s t h e m s e l v e s can c r e a t e more p o s s i b l e c h o i c e s f o r t h e c l i e n t . When t h e nu r s e promotes s u i t a b l e c o p i n g b e h a v i o u r s and a l l o w s l a t i t u d e o f c h o i c e , he/she i s c r e a t i n g " o p p o r t u n i t i e s f o r r e s i d e n t s t o make c h o i c e s and t o t a k e a c t i o n s 19 t h a t w i l l enhance t h e i r sense of mastery" both over the environment and the events t h a t a f f e c t him/her ( G e r o n t o l o g i c a l Nursing A s s o c i a t i o n , 1987, p.9). With o p p o r t u n i t i e s t o make cho i c e s and take a c t i o n on ch o i c e s as w e l l as t o develop s u i t a b l e coping behaviours, the c l i e n t can b e t t e r a d j u s t t o d e c l i n i n g h e a l t h and/or a b i l i t i e s as w e l l as a d j u s t t o a long term care environment. Latitude/Freedom o f Choice and the Need f o r Self-esteem J u s t as a c l i e n t ' s l a t i t u d e of ch o i c e i s w i t h i n the context of meeting the need f o r achievement, so too i s a c l i e n t ' s freedom of ch o i c e w i t h i n the context of approaching s e l f - e s t e e m i n the e g o - v a l u a t i v e subsystem. As p r e v i o u s l y mentioned, the c l i e n t ' s freedom of ch o i c e r e p r e s e n t s c h o i c e over a c t i v i t i e s of s p e c i f i c importance t o him/her, a c t i v i t i e s t h a t are encompassed by l a t i t u d e of c h o i c e . S i m i l a r l y , the need f o r achievement, although only one of a number of b a s i c human needs, nonetheless i n v a r i a b l y has a d i r e c t e f f e c t upon an i n d i v i d u a l ' s s e l f - e s t e e m (Schwartz, 1974). Because, by d e f i n i t i o n i n the U.B.C. Model (1980), the a c h i e v i n g subsystem and the e g o - v a l u a t i v e subsystem (self-esteem) are two of nine interdependent subsystems, and because l a t i t u d e of ch o i c e i s d i r e c t l y r e l a t e d t o the need f o r achievement, i t f o l l o w s t h a t l a t i t u d e of ch o i c e and freedom of ch o i c e are interdependent as well.. By h e l p i n g the c l i e n t t o extend h i s / h e r l a t i t u d e of ch o i c e towards r e a l i z i n g freedom of 20 choice, the nurse i s a s s i s t i n g the c l i e n t t o meet the need f o r achievement, as w e l l as the need f o r se l f - e s t e e m . A r e s i d e n t ' s goal of freedom of ch o i c e w i t h i n an i n s t i t u t i o n a l environment i s p e r c e i v e d (by the w r i t e r ) t o be a r e f l e c t i o n of the need f o r se l f - e s t e e m . An e l d e r l y r e s i d e n t ' s p e r c e i v e d freedom of choice i s l a r g e l y c ontingent upon the re s p e c t he/she r e c e i v e s from others, ( i . e . n u r s e s ) , p a r t i c u l a r l y i n r e g a rd t o the r e s i d e n t ' s c h o i c e s i n a c t i v i t i e s of d a i l y l i v i n g . Secondly, the e l d e r l y r e s i d e n t ' s p e r c e i v e d freedom of cho i c e enhances h i s / h e r f e e l i n g s of r e s p e c t f o r s e l f . Hence, the e l d e r l y r e s i d e n t ' s r e a l i z a t i o n of freedom of ch o i c e w i l l i n v a r i a b l y c o n t r i b u t e t o h i s / h e r r e a l i z a t i o n of s e l f - e s t e e m . Nursing Care and the Relationship Between Latitude of Choice and Freedom of Choice How does the r e l a t i o n s h i p between l a t i t u d e of ch o i c e and freedom of ch o i c e a s s i s t the nurse i n c a r i n g f o r e l d e r l y r e s i d e n t s ? I f the nurse allows l a t i t u d e of ch o i c e so t h a t r e s i d e n t s can experience freedom of cho i c e , the aforementioned r e l a t i o n s h i p s t i p u l a t e s t h a t the nurse p r o v i d e s o p p o r t u n i t i e s f o r the c l i e n t t o develop coping behaviours toward meeting the need f o r achievement. Moreover, the r e s i d e n t who develops such coping behaviours e n l a r g e s h i s / h e r r e p e r t o i r e of coping behaviours t o the extent t h a t he/she i s b e t t e r able t o c r e a t e more c h o i c e s r e g a r d i n g a c t i v i t i e s of d a i l y l i v i n g . With such coping behaviours, the r e s i d e n t has the p o t e n t i a l f o r g r e a t e r self-esteem; these coping behaviours allow the residents to augment his/her l a t i t u d e of choice toward experiencing freedom of choice. As previously mentioned, freedom of choice, combined with respect of s i g n i f i c a n t others and respect for s e l f , w i l l invariably contribute to the enhancement of an individual's self-esteem. In other words, the resident's r e a l i z a t i o n of freedom of choice and la t i t u d e of choice are indicators of an individual's sense of achievement and feelings of self-esteem, basic human needs that are otherwise d i f f i c u l t for the nurse to d i r e c t l y observe. In fostering the development and use of the above coping behaviours, the nurse should determine the c l i e n t ' s perceptions of freedom of choice (for example, regarding a c t i v i t i e s of d a i l y l i v i n g ) . By being aware of residents' perceptions of what constitutes freedom of choice, the nurse can better a s s i s t residents with developing and using coping behaviours toward that end. The nurse, however, i s unable to d i r e c t l y observe the eld e r l y resident's perceptions as only the resident can. Instead the nurse must use alternate means to determine the eld e r l y resident's perceptions of freedom of choice. By di r e c t i n g questions to residents regarding t h e i r l a t i t u d e of choice over a c t i v i t i e s of d a i l y l i v i n g , the nurse may gain an impression of the resident's freedom of choice-related perceptions. 22 The nurse would then c o l l e c t i n f o r m a t i o n from e l d e r l y r e s i d e n t s i n regard to (a) the degree of importance of an a c t i v i t y of d a i l y l i v i n g (an a c t i v i t y t h a t i s meaningful f o r the r e s i d e n t ) and (b) the p e r c e i v e d degree of c h o i c e r e g a r d i n g the p a r t i c u l a r a c t i v i t y of d a i l y l i v i n g . Such data would a s s i s t the nurse i n determining what a c t i v i t i e s are meaningful to the e l d e r l y c l i e n t and i n determining the extent of a f o r c e (e.g. the degree of choice a v a i l a b l e t o r e s i d e n t s ) upon a r e s i d e n t ' s a c t i v i t i e s of d a i l y l i v i n g . Combining such data on importance and c h o i c e would p r o v i d e the nurse with a t a n g i b l e measure (p e r c e i v e d l a t i t u d e of choice) of the e l d e r l y r e s i d e n t ' s p e r c e i v e d freedom of c h o i c e r e g a r d i n g a c t i v i t i e s of d a i l y l i v i n g . 23 Chapter Two Review of Related Literature The l i t e r a t u r e review i s comprised of f i v e s e c t i o n s , each with theory and/or r e s e a r c h components. S e c t i o n one reviews l i t e r a t u r e p e r t a i n i n g t o autonomy and aging. S e c t i o n two reviews l i t e r a t u r e r e g a r d i n g freedom of c h o i c e (autonomy) w i t h i n the long term care f a c i l i t y environment. S e c t i o n t h r e e reviews l i t e r a t u r e p e r t a i n i n g t o freedom of c h o i c e and p s y c h o l o g i c a l w e l l - b e i n g of e l d e r l y r e s i d e n t s i n a long term care f a c i l i t y . S e c t i o n f o u r reviews l i t e r a t u r e d i r e c t e d at e l d e r l y r e s i d e n t s ' p e r c e i v e d l a t i t u d e of c h o i c e r e g a r d i n g d a i l y l i v i n g a c t i v i t i e s . S e c t i o n f i v e reviews l i t e r a t u r e r e l a t i n g t o s t a f f and r e s i d e n t p e r c e p t i o n s of i n s t i t u t i o n a l i z e d e l d e r l y r e s i d e n t s ' l a t i t u d e of c h o i c e r e g a r d i n g a c t i v i t i e s of d a i l y l i v i n g . The study problem, purpose and the f o u n d a t i o n f o r the study are p r e s e n t e d f o l l o w i n g the l i t e r a t u r e review. A d d i t i o n a l l y , the terms used i n the study are d e f i n e d , and the study's assumptions and l i m i t a t i o n s are o u t l i n e d . Autonomy and Aging In western s o c i e t i e s , freedom of c h o i c e i s a value h e l d t o be i n t e g r a l t o human f u n c t i o n i n g . For the e l d e r l y i n p a r t i c u l a r , freedom of c h o i c e becomes i n c r e a s i n g l y germane to t h e i r l i v e s as they f e e l the e f f e c t s of aging (Hofland, 1988). Freedom of c h o i c e as d e f i n e d e a r l i e r r e f e r s t o "the freedom to choose g o a l s , and to r e l a t e means t o g o a l s " (Thomasma, 1984, p.908). T h i s type of freedom i s u s u a l l y enjoyed by a d u l t s i n the conduct of t h e i r d a i l y l i v e s . Thomasma (1984) i n d e f i n i n g freedom of ch o i c e i n d i c a t e s t h a t t h i s type of freedom i s c l o s e l y r e l a t e d t o "... the freedom from o b s t a c l e s t o c a r r y out ones's d e s i r e s ... and the freedom t o know one's o p t i o n s " (p. 908). Furthermore, Thomasma (1984) views freedom of ch o i c e as being contingent upon the "freedom t o a c t " . The e l d e r l y o f t e n experience r e d u c t i o n s i n freedom of choice f o r a v a r i e t y of reasons. Such reasons i n c l u d e p h y s i c a l d i s a b i l i t i e s , mandatory r e t i r e m e n t and r e s i d e n t i a l moves from s e l f - c o n t a i n e d households t o r e l a t i v e s ' households or t o long term care f a c i l i t i e s (Rowe and Kahn, 1987). Goldman (1971) r e l a t e s reduced autonomy a s s o c i a t e d with aging t o l o s s of b e h a v i o u r a l c h o i c e . B e h a v i o u r a l c h o i c e s u b j e c t to such l o s s i s a s s o c i a t e d with p h y s i o l o g i c a l and s o c i a l aging. Goldman (1971) concludes t h a t p h y s i o l o g i c a l aging occurs when th e r e are r e s t r i c t i o n s on choice (regarding p h y s i o l o g i c a l a c t i v i t y ) , which "... repr e s e n t aging only when (the l o s s of choice) i s i r r e v e r s i b l e " (Goldman, 1971, p. 158). A l t e r n a t i v e l y , Goldman (1971) views s o c i a l aging i n terms of an aging i n d i v i d u a l ' s r e s t r i c t e d c h o i c e s r e g a r d i n g s o c i a l a c t i v i t i e s . Goldman (1971) i d e n t i f i e s c u l t u r a l and environmental f a c t o r s as w e l l as i n t e r n a l f a c t o r s ( p h y s i o l o g i c a l and p s y c h o l o g i c a l ) which c o n t r i b u t e t o an i n d i v i d u a l ' s reduced c h o i c e i n s o c i a l a c t i v i t y . He f u r t h e r s t a t e s t h a t t h i s 25 r e d u c t i o n o f c h o i c e r e f l e c t s a g i n g o n l y i f t h i s r e d u c t i o n i s i r r e v e r s i b l e . T h i s i r r e v e r s i b i l i t y i s due t o t h e i n d i v i d u a l ' s i n a b i l i t y t o t a k e c o r r e c t i v e a c t i o n s a g a i n s t t h e a f o r e m e n t i o n e d f a c t o r s t h a t c o n t r i b u t e t o t h e l o s s o f s o c i a l c h o i c e s . Hence, " l o s s o f c h o i c e o r t h e t h i n g s which a p e r s o n ( i s a b l e to) do i s th e most s i g n i f i c a n t measure o f a g i n g , whether s o c i a l o r p h y s i o l o g i c a l " (Goldman, 1971, p. 158). Freedom of Choice and the Long Term Care F a c i l i t y Environment D e s p i t e any l o s s o f c h o i c e a s s o c i a t e d w i t h a g i n g , P r o s h a n s k y , I t t e l s o n and R i v l i n (1976) argue t h a t t h e r e i s a g e n e r a l need f o r humans t o maximize b e h a v i o u r a l o p t i o n s , so t h a t t h e y can maximize t h e i r freedom o f c h o i c e i n g i v e n s i t u a t i o n s . In t h i s r e g a r d , P r o s h ansky e t a l . (1976) view an i n d i v i d u a l ' s p e r c e i v e d freedom o f c h o i c e as a c r i t i c a l d e t e r m i n a n t o f h i s / h e r b e h a v i o u r i n r e l a t i o n t o h i s / h e r p h y s i c a l environment. Moreover, Proshansky e t a l . (1976) suggest t h a t , " i n any new s e t t i n g o r where a f a m i l i a r s e t t i n g changes, t h e p e r s o n w i l l i n some i m p l i c i t f a s h i o n r e o r g a n i z e h i s r e l a t i o n s h i p t o t h e p h y s i c a l environment so t h a t h i s freedom o f c h o i c e i s maximized" (p. 172) . Hence, p a r t i c u l a r l y w i t h i n a new environment, man experiences the need t o maximize h i s / h e r freedom o f c h o i c e . A l o n g t erm c a r e f a c i l i t y i s o f t e n , a t l e a s t i n i t i a l l y , a new environment f o r most r e s i d e n t s . I t i s l i k e l y , t h e n , t h a t t h e e l d e r l y w i l l e x p e r i e n c e t h e need t o maximize t h e i r freedom of c h o i c e because o f t h e f a c i l i t y ' s r e l a t i v e l y u n f a m i l i a r n a t u r e 26 (due to i t s physical and organizational structures). E l d e r l y residents w i l l invariably make adjustments, i m p l i c i t l y at least, to t h e i r new environment i n order to maximize t h e i r freedom of choice; t h i s freedom arguably being of high value to eld e r l y residents. Indeed, i n a 1989 study conducted by a mu l t i d i s c i p l i n a r y team of researchers, nursing home residents' problems appeared to be centered on maintaining freedom of choice over a c t i v i t i e s of d a i l y l i v i n g i n the nursing home environment (Kolata, 1989). Even aft e r the i n i t i a l relocation period to a long term care f a c i l i t y , e l d e r l y residents often w i l l continue to experience the need to maximize t h e i r autonomy (freedom of choice). By virtu e of i t s organizational and physical structure, the long term care f a c i l i t y " . . . i s the almost exclusive environment for many residents, and has the poten t i a l to exert a powerful influence on perceived [autonomy]" (Ryden, 1985 p.363). Ryden (1985) conducted a study exploring aspects of the "nursing home" (long term care f a c i l i t y ) environment i n terms of interpersonal, organizational and physical aspects r e l a t i n g to residents' autonomy. The study sample was selected from four proprietary nursing homes i n the Minneapolis area. The sample included 113 residents, 137 caregivers (registered nurses, licensed p r a c t i c a l nurses, nurses' assistants), and 10 administrative personnel. 27 The study f i n d i n g s i n d i c a t e d t h a t nurses c o n s t i t u t e the dominant i n t e r p e r s o n a l aspect of the long term care f a c i l i t y environment/ an aspect a f f e c t i n g the c l i m a t e f o r r e s i d e n t s ' autonomy (freedom of c h o i c e ) . S p e c i f i c a l l y , study r e s u l t s i n d i c a t e d t h a t nurses p e r c e i v e themselves as the major decision-makers r e g a r d i n g r e s i d e n t s ' d r e s s i n g , e a t i n g , grooming and t o i l e t i n g . Nurses' responses a l s o i n d i c a t e d t h a t they p e r c e i v e themselves engaging i n j o i n t decision-making with r e s i d e n t s r e g a r d i n g c l i e n t ambulation and group a c t i v i t i e s . With r e s i d e n t s ' 'one-to-one and s o l i t a r y a c t i v i t i e s however, nurses p e r c e i v e r e s i d e n t s as the decision-makers. Nonetheless, even with these two types of a c t i v i t i e s , nurses' mean scores i n d i c a t e d nurses' input r a t h e r than independent d e t e r m i n a t i o n (freedom of choice) by r e s i d e n t s . The above study r e s u l t s emphasize t h a t nurses are major f o r c e s w i t h i n the r e s i d e n t s ' long term care environment, f o r c e s t h a t can g r e a t l y i n f l u e n c e the r e s i d e n t s ' autonomy (freedom of choice) r e g a r d i n g a c t i v i t i e s of d a i l y l i v i n g . A spects of the o r g a n i z a t i o n a l environment found to ( p o s i t i v e l y ) a f f e c t r e s i d e n t s ' autonomy i n c l u d e mechanisms such as a Resident's C o u n c i l , membership on f a c i l i t y committees, and r e s i d e n t p a r t i c i p a t i o n i n care p l a n n i n g . Such mechanisms can enable r e s i d e n t s t o e x e r c i s e t h e i r r i g h t s w i t h i n the f a c i l i t y . The study f i n d i n g s a l s o i n d i c a t e d c h a r a c t e r i s t i c s of the p h y s i c a l environment r e l e v a n t to r e s i d e n t s ' autonomy (freedom of c h o i c e ) . L i m i t e d amount of p e r s o n a l space i s one example of the 28 major c h a l l e n g e s a f f e c t i n g autonomous f u n c t i o n i n g of r e s i d e n t s with wheelchairs or walkers, or r e s i d e n t s with v i s u a l problems. Although the g e n e r a l i z a b i l i t y of t h i s study's f i n d i n g s i s l i m i t e d due to the s e l e c t i o n of only the most competent n u r s i n g home r e s i d e n t s , the study's f i n d i n g s do i n d i c a t e t h a t "a s i g n i f i c a n t aspect of a c l i m a t e f o r autonomy i s the atmosphere c r e a t e d by the i n t e r a c t i o n s of s t a f f with r e s i d e n t s " (Ryden, 1985, p. 368) . As the predominant c a r e g i v e r s i n the e l d e r l y r e s i d e n t ' s immediate i n t e r p e r s o n a l environment, nurses have the op p o r t u n i t y t o i n f l u e n c e both the r e s i d e n t ' s l a t i t u d e of choice and h i s / h e r s u b j e c t i v e p e r s p e c t i v e of freedom of c h o i c e . Freedom o f C h o i c e and P s y c h o l o g i c a l W e l l - b e i n g i n the  I n s t i t u t i o n a l i z e d E l d e r l y Given t h a t an e l d e r l y r e s i d e n t ' s freedom of ch o i c e i s undermined, t o v a r y i n g extents, by the e f f e c t s of aging and r e s i d i n g i n the long term care environment, i t i s h a r d l y s u r p r i s i n g t h a t the p s y c h o l o g i c a l w e l l - b e i n g of a r e s i d e n t i s i n v a r i a b l y undermined by such l o s s of autonomy (freedom of c h o i c e ) . Saup's (1986) study on the l a c k of r e s i d e n t autonomy i n o l d age homes i n d i c a t e d t h a t l o s s e s of b e h a v i o r a l o p t i o n s are l a r g e l y due t o " u n c o n t r o l l a b i l i t y of p h y s i c a l and s o c i a l f e a t u r e s of the old-age home environment" (p.32). Saup (1986) f u r t h e r concluded t h a t the e l d e r l y r e s i d e n t s ' l o s s of autonomy (due to s t a n d a r d i z a t i o n of room f u r n i t u r e , no 29 possession of house key for inhabitants, meal times at fixed times, etc.) appeared to be a prime source of the residents' subjective stress. Saup (1986) suggests that "the actual u n c o n t r o l l a b i l i t y of the old-age environment i s experienced as a s t r e s s f u l loss of autonomy by [residents]" (p.34). Study results indicated that residents' mean stress scores p a r a l l e l an increase i n lack of autonomy. Saup (1986) organized residents' perceived sources of stress by c l a s s i f y i n g i d e n t i f i e d sources thematically and noting t h e i r frequency of occurrence. Certain s t r e s s - r e l a t e d aspects were most noticeable: "most prominent were a reduction of privacy (66%) and the i n s t i t u t i o n a l control upon the resident's l i f e s t y l e through [regulating the start of the day] (49%) and of the d a i l y routine i n i t s entirety (43%)" (Saup, 1986, p. 31). Saup's (1986) study results c l e a r l y indicate the stress induced by el d e r l y residents' reduced autonomy. Indeed, the results of t h i s study concur with those of other studies i n d i c a t i n g a relat i o n s h i p between autonomy-reducing aspects of long term care i n s t i t u t i o n s and residents' decreased psychological well-being (Wolk and Telleen, 1976; P h i l l i p s and Wright, 1980; Pohl and F u l l e r , 1980). Many authors have noted that r e s t r i c t i o n s on personal autonomy have a probable negative impact on an individual's psychological well-being. In his book, Why Survive ? Being Old i n America, Butler (1975) argues that cumulative losses of behavioural options may culminate i n dependency, anxiety and depression among the eld e r l y . 30 Additionally, a number of researchers studying residents' autonomy i n long term care settings suggest that r e s t r i c t i o n s i n freedom of choice contribute negatively to morale (Elias, P h i l l i p s and Wright, 1980; Pohl and F u l l e r , 1980). Conversely, residents' higher degree of freedom of choice within the nursing home setting has been p o s i t i v e l y correlated with psychological well-being (Hulicka, Morganti and Cataldo, 1975; Morganti, Hulicka and Nehrke, 1980) . The above co r r e l a t i o n i s consistent with other psychosocial research i n d i c a t i n g personal autonomy as enhancing psychological well-being. There i s a considerable body of such research focussing on aspects of autonomy (freedom of choice), a l b e i t usually under the rubric of "control" (Hofland, 1988). P a r t i c u l a r l y notable within t h i s body of research are the intervention studies. They were directed at analyzing the effe c t s of increasing the eld e r l y residents' control or independence over a c t i v i t i e s of da i l y l i v i n g . In Langer and Rodin's (1976) study, e l d e r l y residents were encouraged to make a greater number of choices and to exercise more control over a c t i v i t i e s of da i l y l i v i n g . Immediately a f t e r the intervention was terminated, and during the study follow-up 18 months l a t e r , Rodin and Langer (1977) reported that the experimental group of 47 subjects reported f e e l i n g happier and more a l e r t than the control group of 43 subjects who were encouraged to have s t a f f care for them and meet t h e i r needs. Additionally, physicians' evaluations of residents' medical records during the 18 month 31 follow-up indicated that the experimental group had s i g n i f i c a n t l y improved i n t h e i r health as compared to the residents who were i n the comparison group. The above studies were b u i l t upon by Avorn and Langer (1982) who contrasted control-enhancing interventions with control-reducing experimental interventions. The researchers c a r r i e d out these interventions by involving nursing home residents i n the completion of a simple jigsaw puzzle. Avorn and Langer (1982) concluded that the dependence i n the elde r l y can be augmented inadvertently by nursing home s t a f f performing helping a c t i v i t i e s for residents, which, i n turn, may reduce the resident's a b i l i t y to carry out the task(s). Nurses' acts of assistance that exceed the resident's c l i n i c a l requirements may impart a message to the resident that he/she i s incapable of performing the task. The study's findings indicate that residents' perceived lack of control has negative effects on th e i r psychological well-being. Conversely, the study's findings indicate that residents' perceived control p o s i t i v e l y corresponds with t h e i r psychological well-being. The results from the controlled intervention studies support the conclusion that increased opportunity for control and personal e f f i c i e n c y can p o s i t i v e l y a f f e c t nursing home residents' psychological well-being. 32 Institutionalized Elderly Residents' Perceived Latitude of  Choice The above authors and researchers have focussed on research directed toward determining the psychological outcomes of having freedom of choice. There i s li m i t e d research, however, concerning e l d e r l y residents' perceived freedom of choice over a c t i v i t i e s of d a i l y l i v i n g . There i s also correspondingly li m i t e d research on the importance eld e r l y residents attach to making choices over such a c t i v i t i e s . Accordingly, Hulicka, Morganti and Cataldo (1975) conducted a study to assess the i n s t i t u t i o n a l i z e d elderly's perceived l a t i t u d e of choice regarding a c t i v i t i e s of d a i l y l i v i n g . Hulicka et a l . (1975) designed the Importance, Locus and Range of A c t i v i t i e s Checklist to assess e l d e r l y residents' perceived l a t i t u d e of choice. The researchers also used a " l i f e s a t i s f a c t i o n " scale and a "self-concept" scale i n an e f f o r t to measure the relat i o n s h i p between perceived l a t i t u d e of choice and psychological well-being. The checklist and the scales were administered to 25 n o n i n s t i t u t i o n a l i z e d e l d e r l y females and 25 i n s t i t u t i o n a l i z e d e l d e r l y females. Results of the study indicated that, " i n s t i t u t i o n a l i z e d respondents, l i v i n g i n a r e l a t i v e l y r e s t r i c t e d environment, earned s i g n i f i c a n t l y lower l a t i t u d e of choice scores than did n o n i n s t i t u t i o n a l i z e d e l d e r l y " (Hulicka et a l . , 1975, p. 27 ) . Moreover, there were s i g n i f i c a n t correlations between la t i t u d e of choice scores (L.O.C. scores) and self-concept scores between the two subject groups. There 33 was a product moment c o r r e l a t i o n of 0.62 (p < 0.01) between L.O.C. scores and s e l f - c o n c e p t scores combined. This c o r r e l a t i o n suggests t h a t e l d e r l y females with h i g h e r p e r c e i v e d L.O.C. scores a l s o tend to have hi g h s e l f - e v a l u a t i o n s . T h i s c o r r e l a t i o n a p p l i e s more s t r o n g l y t o i n s t i t u t i o n a l i z e d s u b j e c t s (r=0.60, p > 0.01) than f o r n o n i n s t i t u t i o n a l i z e d s u b j e c t s (r=0.29, p < 0.05). L i f e s a t i s f a c t i o n scores a l s o v a r i e d d i r e c t l y with L.O.C. scores (r=0.42, p < 0.01). However, when the scores of the two groups were t e s t e d i n i s o l a t i o n from each other, the c o r r e l a t i o n s between l i f e s a t i s f a c t i o n scores and L.O.C. scores w i t h i n each group were not s i g n i f i c a n t . Resident and Staff Perceptions of Institutionalized  Elderly Residents' Latitude of Choice Morganti, Nehrke and H u l i c k a (1980) used the same methodology as H u l i c k a et a l . (1975) but extended the study p o p u l a t i o n t o i n c l u d e s t a f f . Hence, t h e i r study addressed both r e s i d e n t and s t a f f p e r c e p t i o n s of the r e s i d e n t s ' l a t i t u d e of c h o i c e over a c t i v i t i e s of d a i l y l i v i n g . The study p o p u l a t i o n came from a Veteran's A d m i n i s t r a t i o n Centre (V.A.C.) and i n c l u d e d 99 i n s t i t u t i o n a l i z e d males s e l e c t e d e q u a l l y from t h r e e age groups (50-59, 60-69, 70-79), as w e l l as 100 s t a f f s e l e c t e d from the v a r i o u s s e r v i c e areas of the V.A.C. Both s t a f f and r e s i d e n t s were asked t o complete H u l i c k a et a l . ' s (1975) Importance, Locus and Range of A c t i v i t i e s C h e c k l i s t . S t a f f were 34 asked to respond to the questionnaire by estimating how a t y p i c a l resident might respond. The study results indicated that " i n comparing s t a f f attributed and resident perceived l a t i t u d e of choice s i g n i f i c a n t patterns were found. Examination of response patterns to the s p e c i f i c a l l y l i s t e d a c t i v i t i e s of d a i l y l i v i n g also revealed s i g n i f i c a n t s t a f f - r e s i d e n t differences" (Morganti et a l . , 1980, p. 367). Moreover, these perceptual discrepancies suggest that there i s a potential danger to the e l d e r l y residents' freedom of choice i f the s t a f f misperceive the importance the e l d e r l y attach to having choice over a given a c t i v i t y (ies) . A subsequent study conducted by Smith and Olson (1984) compared s t a f f and resident perceptions regarding the residents' recreational a c t i v i t i e s i n a r e s i d e n t i a l care f a c i l i t y . Study results indicated considerable congruence between s t a f f and residents' perceptions i n terms of the residents' s p e c i f i c l e i s u r e i n t e r e s t s . There were discrepant sta f f - r e s i d e n t perceptions, however, with regard to broader issues related to recreational planning within the f a c i l i t y . The above findings regarding re s i d e n t - s t a f f perceptual differences suggest there i s pot e n t i a l danger of developing i n s t i t u t i o n a l programs or p o l i c i e s based primarily on the s t a f f ' s notions of what a c t i v i t i e s are or are not important to residents. In cases such as the above, differences i n perceptions are important to note insofar as the elderly 35 r e s i d e n t s ' p e r c e p t i o n s of importance/choice of a c t i v i t i e s may be e c l i p s e d by the p e r c e p t i o n ( s ) h e l d by the s t a f f . Summary S o c i e t i e s w i t h i n western c i v i l i z a t i o n h o l d freedom of cho i c e as a value of p a r t i c u l a r s i g n i f i c a n c e . The l i t e r a t u r e r e f l e c t s the r e d u c t i o n i n freedom of choice as a r e s u l t of the e f f e c t s of aging. With the onset of p h y s i o l o g i c a l and s o c i a l aging, the i n d i v i d u a l has a corres p o n d i n g l o s s of b e h a v i o r a l c h o i c e s . An e l d e r l y i n d i v i d u a l may a l s o experience l o s s of b e h a v i o r a l c h o i c e s upon becoming a r e s i d e n t of a long term care i n s t i t u t i o n . There i s l i m i t e d r e s e a r c h r e g a r d i n g e l d e r l y r e s i d e n t s ' p e r c e i v e d freedom of cho i c e , p a r t i c u l a r l y i n r e l a t i o n t o a c t i v i t i e s of d a i l y l i v i n g . There i s a l s o l i m i t e d r e s e a r c h r e g a r d i n g s t a f f and r e s i d e n t p e r c e p t i o n s of the r e s i d e n t s ' l a t i t u d e of c h o i c e . D i s c r e p a n t p e r c e p t i o n s between the two groups may pose a p o t e n t i a l danger t o the long term care environment, i n s o f a r as one group's p e r c e p t i o n (e.g. the s t a f f ' s ) may overshadow t h a t of the other. Consequently, the s t a f f ' s p e r c e p t i o n , no matter how w e l l - i n t e n t i o n e d , may or may not encompass the f o l l o w i n g r e s i d e n t p e r c e p t i o n s : (a) the importance the r e s i d e n t s a t t a c h t o cho i c e s of d a i l y l i v i n g and (b) the importance the r e s i d e n t s a t t a c h t o the r i g h t t o make ch o i c e s r e g a r d i n g s p e c i f i c a c t i v i t i e s . 36 Should these p e r c e p t i o n s not be encompassed, the s t a f f may u n w i t t i n g l y c o n t r i b u t e t o the r e s i d e n t ' s l a c k of autonomy. The u n c o n t r o l l a b i l i t y of the old-age environment can be experi e n c e d by the r e s i d e n t s as a s t r e s s f u l l o s s of autonomy. Nurses, on the other hand, are i n a p i v o t a l p o s i t i o n t o reduce such s t r e s s , because they c o n s t i t u t e a dominant aspect i n the r e s i d e n t ' s immediate i n t e r p e r s o n a l environment. A c c o r d i n g l y , nurses have the o p p o r t u n i t y t o i n f l u e n c e both the r e s i d e n t ' s l a t i t u d e of cho i c e and s u b j e c t i v e p e r s p e c t i v e of freedom of c h o i c e . Hence, i t i s a p p r o p r i a t e f o r nurses t o conduct r e s e a r c h t h a t w i l l c o n t r i b u t e t o the enhancement of r e s i d e n t s ' autonomy (freedom of c h o i c e ) . Research on both r e s i d e n t and s t a f f p e r c e p t i o n s r e g a r d i n g the autonomy (freedom of choice) of e l d e r l y r e s i d e n t s should p r o v i d e nurses with i n f o r m a t i o n t h a t they can use i n enhancing such autonomy. As i t i s , the l i m i t e d amount of r e s e a r c h cannot adequately address the i s s u e of r e s i d e n t autonomy i n a manner u s e f u l t o the n u r s i n g p r o f e s s i o n . A c c o r d i n g l y , t h i s study addressed r e s i d e n t and s t a f f p e r c e p t i o n s of the r e s i d e n t ' s l a t i t u d e of c h o i c e r e g a r d i n g a c t i v i t i e s of d a i l y l i v i n g . 37 Chapter Three Methodology This chapter provides a description of the methodology used to conduct t h i s study. Accordingly, the study's design, setting, sample, instrumentation, e t h i c a l considerations, data c o l l e c t i o n and analysis procedures are presented. Design A descriptive survey design was used i n comparing resident versus s t a f f perceptions of residents' perceived importance and degree of choice regarding a c t i v i t i e s of d a i l y l i v i n g (Brink and Wood, 1978) . Demographic data from the nurses (registered nurses, licensed p r a c t i c a l nurses, nurses aides) and residents were also c o l l e c t e d for descriptive purposes. Setting The setting for t h i s study was two intermediate care f a c i l i t i e s , one located i n Vancouver B.C. and the other located in Burnaby B.C. These f a c i l i t i e s were b u i l t i n 1974. They are owned and operated by a non-profit society. There are 152 residents i n each f a c i l i t y . Of these residents, 64 are intermediate care l e v e l 1 residents i n the Vancouver f a c i l i t y and 68 are intermediate care l e v e l 1 i n the Burnaby f a c i l i t y . There are 40 s t a f f members, comprised of f u l l time, part time and casual nurses employed by each f a c i l i t y . There i s also a 38 Director of Nursing within each f a c i l i t y . There i s also one Administrator and one Assistant Administrator who oversee both f a c i l i t i e s . Sample Because p r o b a b i l i t y sampling could be used, the researcher determined t h i s study's sample size by considering the number and type of study variables to be measured. To ensure s u f f i c i e n t data for analysis, at least f i v e observations (subjects) for each category of each variable i s necessary (Brink and Wood, 1978) . This study has two variables, namely choice and importance, each divided into three categories of ordinal data that pertain to two groups of subjects (staff and residents). Since both variables each require three categories, and each category needs at least f i v e subjects, i t was then necessary that there be at least 45 subjects i n each group (3 x 3 x 5 ) . Ideally, the s t a f f sample w i l l have a mix of Registered Nurses (professional staff) and Licensed P r a c t i c a l Nurses and Nurse's Aides (non-professional staff) that r e f l e c t the s t a f f i n g r a t i o s recommended i n the Long Term Care Non-Profit F a c i l i t y S t a f f i n g Guidelines (1979), guidelines to which the study f a c i l i t i e s adhere. Based upon these guidelines, the r a t i o of professional s t a f f to non-professional s t a f f i s 5:19 for every 100 residents within a 24 hour period. Based upon t h i s r a t i o , a sample size of 45 s t a f f i d e a l l y should include at least 9 professional s t a f f and 36 non-professional s t a f f . 39 The f o l l o w i n g c r i t e r i a must be met by r e s i d e n t s f o r e l i g i b i l i t y i n t h i s study: (1) able t o speak, read and w r i t e E n g l i s h ; (2) age 65 years or o l d e r ; (3) o r i e n t e d t o person, p l a c e , and time; (4) assessed as i n t e r m e d i a t e care l e v e l 1 by a long term care (LTC) as s e s s o r of the p r o v i n c e ' s LTC program; (5) have r e s i d e d i n the in t e r m e d i a t e care f a c i l i t y f o r at l e a s t s i x months. C r i t e r i o n #4 r e f e r s t o the r e s i d e n t s who are (generally) independently mobile with or without mechanical a i d s , but r e q u i r e some h e a l t h s u p e r v i s i o n and a s s i s t a n c e with a c t i v i t i e s of d a i l y l i v i n g . A d d i t i o n a l l y , such i n d i v i d u a l s need a p r o t e c t i v e housing environment as w e l l as s o c i a l / r e c r e a t i o n a l program(s) (Kane and Kane, 1985). C r i t e r i o n #5 i s i n c l u d e d because the i n i t i a l adjustment phase of r e l o c a t i o n i s noted by Rosswurm (1983) and S t e i n , L i n n and S t e i n (1986) t o be a major f a c t o r i n f l u e n c i n g p e r c e p t i o n i n the f i r s t s i x months of i n s t i t u t i o n a l i z a t i o n . In order f o r a nurse t o be e l i g i b l e f o r p a r t i c i p a t i o n i n t h i s study, she/he must meet the f o l l o w i n g c r i t e r i a : (1) has the p o s i t i o n of e i t h e r a R e g i s t e r e d Nurse, L i c e n s e d P r a c t i c a l Nurse or Nurses' Aide, (2) p r o v i d e s n u r s i n g care t o i n t e r m e d i a t e care 1 r e s i d e n t s and (3) i s able t o speak, read and w r i t e E n g l i s h . Instrumentation The data c o l l e c t i o n instruments i n t h i s study i n c l u d e d s e l e c t e d q u e s t i o n s from H u l i c k a et a l . ' s (1975) r e v i s e d 40 Importance, Locus and Range of A c t i v i t i e s Checklist, as well as a demographic data sheet developed by the researcher. Importance, Locus and Range of Act iv i t i e s Checklist  (Revised Version) Hulicka et al . ' s (1975) revised version of t h e i r checklist " i s designed to allow for a more profound measure of lati t u d e of choice and to increase i t s a p p l i c a b i l i t y for d i f f e r e n t categories of respondents" (P. 37) . In t h i s revised design, new items have been added to the scale to determine pot e n t i a l contributors to perceived l a t i t u d e of choice among persons i n various age groups and l i f e circumstances. In addition to these items, Hulicka et a l . (1975) included the es s e n t i a l content of the o r i g i n a l instrument i n the revised instrument, because t h i s content provided "a v a l i d estimate of perceived l a t i t u d e of choice (among i n s t i t u t i o n a l i z e d elderly) with respect to a c t i v i t i e s of d a i l y l i v i n g " (p. 37). The essen t i a l content of the o r i g i n a l instrument was maintained i n a condensed form i n the revised instrument because " e s s e n t i a l l y the same information was obtained from two items" i n the o r i g i n a l instrument (Hulicka et a l . , 1975, p. 37). As a result of such revisions, 25 items from the o r i g i n a l scale were retained i n the revised scale. For the purpose of t h i s study, 20 of these 25 items were administered to el d e r l y residents. Five items were not included because they are not applicable to intermediate care settings 41 and/or they do not c l e a r l y meet t h i s study's d e f i n i t i o n of a c t i v i t i e s of d a i l y l i v i n g . Despite the revisions i n Hulicka et al.'s (1975) Importance, Locus and Range of A c t i v i t i e s Checklist, the intent for administering i t remains the same as that of the o r i g i n a l instrument: "to assess an individual's perception of his own lati t u d e of choice or personal autonomy with respect to a c t i v i t i e s of d a i l y l i v i n g " (p. 28) . Latitude of choice i s a derived score based j o i n t l y on perceived degree of importance regarding a d a i l y a c t i v i t y and perceived degree of choice available for that a c t i v i t y . The o r i g i n a l Importance, Locus and Range of A c t i v i t i e s Checklist i s comprised of 37 statements. As i n t h i s o r i g i n a l instrument, statements i n the revised instrument generally address the "... selection or timing of a c t i v i t i e s and the selection of associates or surroundings" (Hulicka et a l . , 1975, p.29). Sim i l a r l y , subjects completing the revised instrument are to rate each a c t i v i t y with regard to the personal importance and the l e v e l of choice available to them with each l i s t e d a c t i v i t y (Morganti et a l . , 1980, p. 369). Perceived importance i s rated by using one of the following rating responses: very important, somewhat important and unimportant. Choice-related responses include free choice, some choice and no choice. Responses for the importance dimension were scored as follows: very important=3; somewhat important=2; unimportant=l. Choice responses were scored as: free choice=3, some choice=2; no 42 choice=l". A lati t u d e of choice score for each a c t i v i t y i s formed by multiplying the scores of choices and importance with each other. "The resultant l a t i t u d e of choice scores can range from a value of nine for the p a i r i n g of very important and free choice, i n d i c a t i n g high degree of personal autonomy, to a score of one for very important and no choice, r e f l e c t i n g a low degree of personal autonomy" (Morganti et a l . , 1980, p. 369). As with the o r i g i n a l instrument, there are two forms of the revised instrument. There i s one for residents and one for s t a f f (Appendix A, B). The two forms are i d e n t i c a l except for the required perspective of the s t a f f when completing the chec k l i s t . That i s , the s t a f f ' s perceptions should be based upon how an eld e r l y resident might t y p i c a l l y respond to the importance and choice dimensions of the c h e c k l i s t . Hulicka et a l . (1975) report two v a l i d i t y checks for the o r i g i n a l version of the Importance, Locus and Range of A c t i v i t i e s Checklist. A preliminary measure for v a l i d i t y involved 10 young men i n the armed services and a group of 20 peers i n an educational setting. Although Hulicka et a l . (1975) report t h i s small sample size, the m i l i t a r y group's l a t i t u d e of choice scores were s i g n i f i c a n t l y lower than those of the non-military group. These results suggest that the scale provides a v a l i d measure of la t i t u d e of choice. Moreover, data c o l l e c t e d from Hulicka et al. ' s (1975) study indicate that i n s t i t u t i o n a l i z e d e l d e r l y females have lower l a t i t u d e of choice scales than n o n - i n s t i t u t i o n a l i z e d e l d e r l y females. This data also suggests that the Importance, Locus and Range of A c t i v i t i e s Checklist provides a v a l i d estimate of la t i t u d e of choice regarding a c t i v i t i e s of d a i l y l i v i n g . F i n a l l y , Hulicka et a l . (1975) assessed t h i s instrument's t e s t - r e t e s t r e l i a b i l i t y by administering i t to a sample of 36 college students and re-administering i t a week l a t e r . Test-retest r e l i a b i l i t y was moderate, Hulicka et a l . (1975) report 0.84 for the la t i t u d e of choice scores. The r e l i a b i l i t y and v a l i d i t y have not been evaluated i n the revised instrument; however, as alluded to e a r l i e r , t h i s instrument has maintained the esse n t i a l content of the o r i g i n a l instrument. One may expect, therefore, the revised instrument to have sim i l a r levels of r e l i a b i l i t y and v a l i d i t y to that of the o r i g i n a l instrument. Demographic Data Sheet To describe the two study samples the researcher developed demographic data sheets to c o l l e c t information. The data sheet regarding the residents indicated t h e i r age, sex, marital status, previous residence and duration of stay i n the i n s t i t u t i o n . The data sheet pertaining to nurses who pa r t i c i p a t e i n the study included t h e i r nursing education background, years of nursing experience, and length of time working i n the study setting as well as i n sim i l a r i n s t i t u t i o n s (Appendix C, D). 44 Ethics and Human Rights P r i o r to conducting t h i s study, the researcher obtained approval for t h i s study from the University of B r i t i s h Columbia Behavioural Sciences Screening Committee for e t h i c a l review. Approval was also obtained from the two intermediate care f a c i l i t i e s where the study was conducted. So that they could make an informed consent, residents of the i n s t i t u t i o n were provided with a verbal explanation of the purpose of the study as well as a l e t t e r of information regarding the study (Appendix E) . Nurses also received a sim i l a r l e t t e r (Appendix F) . There was a statement i n the study l e t t e r s that i f the study questionnaire was completed and returned, i t would be assumed that consent had been given. Residents' or nurses' refusal to p a r t i c i p a t e i n the study was respected by the researcher. Residents' were informed that non-participation i n the study would i n no way aff e c t t h e i r medical or nursing care. Furthermore, s t a f f were also informed that non-participation i n the study would i n no way aff e c t t h e i r status as employees. The research subject's right to c o n f i d e n t i a l i t y was maintained by the use of code numbers i n place of names on the questionnaire. During data analysis, data was group analyzed so that individuals would not be recognized by t h e i r responses. 45 Data C o l l e c t i o n Procedures Data c o l l e c t i o n proceeded i n the following.manner. The researcher met with the Director of Nursing from each intermediate care f a c i l i t y so that both directors could i d e n t i f y p o t e n t i a l subjects (residents) for the researcher. With a l i s t of p otential subjects from each f a c i l i t y , the researcher made a random selection of 23 subjects from one f a c i l i t y and 22 subjects from the other. After having i d e n t i f i e d 45 subjects, the researcher met with residents i n d i v i d u a l l y to explain the purpose of the study. If the resident was interested i n pa r t i c i p a t i n g i n the study, the researcher then reviewed with the resident the contents of the study information l e t t e r . After receiving t h i s explanation, residents were asked to complete the study questionnaire at the present time, or at a la t e r prearranged time convenient for the resident. The researcher provided residents with instructions for completing the questionnaire at that time. The residents completed the questionnaire and demographic data sheet within available areas of the i n s t i t u t i o n , areas where the resident believed she/he had a considerable measure of privacy and comfort. After authorizing the researcher's memo to the s t a f f regarding the study, the two Directors of Nursing sent t h i s memo to the nursing units within the two f a c i l i t i e s . Upon reading the memo, the nurses were met by the researcher at pre-arranged times so that the researcher could explain the study and 46 encourage s t a f f p a r t i c i p a t i o n . For nurses not ab l e t o a t t e n d these meetings, the r e s e a r c h e r met with these s t a f f at pre-arranged times convenient t o them. While meeting with n u r s i n g s t a f f , the r e s e a r c h e r p r o v i d e d the study i n f o r m a t i o n l e t t e r . The r e s e a r c h e r then reviewed the contents of t h i s l e t t e r with the s t a f f . S t a f f . members i n t e r e s t e d i n the study were asked t o complete the q u e s t i o n n a i r e by a p r e s c r i b e d date and then t o p l a c e i t i n t o a d e s i g n a t e d box w i t h i n the n u r s i n g u n i t . The r e s e a r c h e r p r o v i d e d i n s t r u c t i o n s f o r completing q u e s t i o n n a i r e s when i s s u i n g them to n u r s i n g s t a f f p a r t i c i p a n t s . A l l p a r t i c i p a n t s were gi v e n two weeks t o complete the q u e s t i o n n a i r e s and r e t u r n them t o the de s i g n a t e d boxes. Upon the end of the p e r i o d , the r e s e a r c h e r r e t r i e v e d the q u e s t i o n n a i r e s from the two boxes. Data A n a l y s i s The r e s e a r c h e r used c r o s s - t a b u l a t i o n s of the data i n order t o r e v e a l r e l a t i o n s between v a r i a b l e s , and t o arrange the data i n t o a convenient s t r u c t u r e f o r s t a t i s t i c a l a n a l y s i s (Brink and Wood, 1978). The v a r i a b l e s i d e n t i f i e d i n the study purpose were used t o c r o s s - t a b u l a t e the data. A c c o r d i n g l y , t h r e e c r o s s - t a b u l a t i o n s were used t o examine each s p e c i f i c a c t i v i t y of d a i l y l i v i n g : (1) p e r c e i v e d l e v e l s of importance c r o s s - t a b u l a t e d w i t h r e s i d e n t and s t a f f p e r c e p t i o n s ; (2) p e r c e i v e d l e v e l s of c h o i c e c r o s s - t a b u l a t e d with r e s i d e n t and s t a f f p e r c e p t i o n s ; (3) 47 p e r c e i v e d l e v e l s of importance and l e v e l s of choice c r o s s - t a b u l a t e d with r e s i d e n t and s t a f f p e r c e p t i o n s . The r e s e a r c h e r used " m a j o r i t y o p i n i o n " c r i t e r i a whereby the study q u e s t i o n n a i r e item should have a minimum of a 50% response by e i t h e r r e s i d e n t s or s t a f f (Morganti et a l . , 1980). I f the item has met t h i s c r i t e r i a , i t can be r a t e d as being "very important" or "unimportant" and/or as having " f r e e c h o i c e " or "no c h o i c e " . Having determined the r a t i n g s , the r e s e a r c h e r o b t a i n e d a ge n e r a l i n d i c a t i o n of a c t i v i t i e s c o n s i d e r e d by r e s i d e n t s and s t a f f t o be "very important" or "unimportant" and a c t i v i t i e s a s s o c i a t e d with " f r e e c h o i c e " or "no c h o i c e " . In a d d i t i o n t o the above a n a l y s i s , the r e s e a r c h e r a l s o used chi - s q u a r e a n a l y s i s " . . . t o determine the s i g n i f i c a n c e of d i f f e r e n c e s between two independent groups" ( S i e g e l and C a s t e l l a n , 1988). S p e c i f i c a l l y , c h i - s q u a r e a n a l y s i s was used t o determine s i g n i f i c a n t d i f f e r e n c e s i n s t a f f and r e s i d e n t p e r c e p t i o n s r e g a r d i n g the aforementioned c r o s s - t a b u l a t e d v a r i a b l e s and s p e c i f i c a c t i v i t i e s of d a i l y l i v i n g . With ch i - s q u a r e a n a l y s i s , "the d i f f e r e n c e s found are r e l a t e d t o d i f f e r e n c e s among a l l the c a t e g o r i e s of the f i r s t v a r i a b l e and a l l the c a t e g o r i e s of the second v a r i a b l e " (Burns and Grove, 1987, p. 490) . The above a n a l y s i s , however, cannot i d e n t i f y p a r t i c u l a r d i f f e r e n c e s among v a r i a b l e s and c a t e g o r i e s of v a r i a b l e s , t h a t i s , d i f f e r e n c e s i n response p a t t e r n s . A c c o r d i n g l y , the re s e a r c h e r a l s o used approximate p a r t i t i o n i n g of chi- s q u a r e t o 48 examine any d i f f e r e n c e s between r e s i d e n t s ' and s t a f f ' s response p a t t e r n s r e g a r d i n g the 20 q u e s t i o n n a i r e items. Approximate p a r t i t i o n i n g was used t o determine the e x i s t e n c e and l o c a t i o n of d i f f e r e n c e s i n p e r c e p t i o n s among the r e s i d e n t s and the s t a f f ( H a l p e r i n et a l . , 1976). A d d i t i o n a l l y , s t a f f and r e s i d e n t demographic data are pre s e n t e d i n the form of d e s c r i p t i v e s t a t i s t i c s . 49 Chapter Four Presentation of Findings This chapter i s divided into three sections. The f i r s t section describes the two groups comprising the study sample. The second section presents the findings pertaining to the four study questions. The t h i r d section provides an analysis of the study findings. Description of the Study Sample The study subjects included 45 intermediate care l e v e l 1 residents and 45 nursing s t a f f (Registered Nurses, Licensed P r a c t i c a l Nurses and Nurses' Aides) from two intermediate care f a c i l i t i e s . Residents Age and Sex The resident group consisted of 7 men (15.6%) and 38 women (84.4%). The residents' ages ranged from 65 years to 98 years with a mean age of 81.18 years (see Table I ) . Marital Status The marital status of the residents included 7 (15.6%) who were single, 1 (2.2%) who was married, 4 (8.9%) who were divorced and 33 (73.3%) who were widowed. 50 Table I Re s i dent's Age Age (years) f Percent 65-69 3 6.7 70-74 6 13.3 75-79 13 28. 9 80-84 8 17.8 85-89 8 17.8 90-94 5 11.1 95-99 2 4.4 Total 45 100 Previous Residence P r i o r to residing i n the intermediate care f a c i l i t y , 16 residents (35.6%) had l i v e d alone i n t h e i r own houses, 22 (48.9%) had l i v e d alone i n an apartment and 5 (11.1%) had l i v e d i n a house or apartment with a spouse or other family member. Only one resident (2.2%) had been ho s p i t a l i z e d p r i o r to residing i n the intermediate care f a c i l i t y . Length of Stay in the Intermediate Care F a c i l i t y Residents' length of stay i n the f a c i l i t y ranged from 6 months to 11 years (see Table I I ) . The residents' mean length 51 of stay was 2.8 years with a standard d e v i a t i o n of 2.4 years and a median of 2.0 years. Table II Length of Institutionalization Year f Percent 0-1.5 16 35.6 1.5-3.0 17 37.8 3.0-4.5 4 8.9 4.5-6.0 4 8.9 6.0-7.5 2 4.4 7.5-9.0 0 0 9.0-10.5 1 2.2 10.5-12.0 1 2.2 T o t a l 45 100 The r e s i d e n t group i n t h i s study sample predominantly c o n s i s t e d of female and widowed r e s i d e n t s . The m a j o r i t y of r e s i d e n t s had l i v e d alone i n t h e i r own apartments p r i o r t o l i v i n g alone i n the in t e r m e d i a t e care f a c i l i t y . Most of the r e s i d e n t s had l i v e d i n the f a c i l i t y f o r at l e a s t s i x months but l e s s than t h r e e years. 52 N u r s e s Of the n u r s i n g s t a f f who p a r t i c i p a t e d i n t h i s study, 15 (33.3%) were R e g i s t e r e d Nurses, 6 (13.3%) were L i c e n s e d P r a c t i c a l Nurses and 24 (53.3%) were Nurses' A i d e s . These study p a r t i c i p a n t s had an average of 17.78 years employment i n nu r s i n g , ranging from 2.0 years t o 45 years employment with a median of 17 years and a mode of 17.5 ye a r s . P a r t i c i p a n t s ' average l e n g t h of employment i n long term care s e t t i n g s was 11.62 years, ranging from 2 years t o 30 years with a median of 11 years and a mode of 15 years. The p a r t i c i p a n t s ' average l e n g t h of employment i n the study s e t t i n g was 9.33 years, ranging from 1 year t o 16 years with a median of 10 years and a mode of 14.5 years. The s t a f f i n t h i s study was comprised of nurses with one of the above t h r e e l e v e l s of n u r s i n g e d u c a t i o n . T h i s study i n c l u d e d 15 p r o f e s s i o n a l s t a f f ( R e g i s t e r e d Nurses) and 30 n o n - p r o f e s s i o n a l s t a f f (Nurses' Aides and L i c e n s e d P r a c t i c a l Nurses). The study's sample s i z e exceeded the s t a f f i n g r a t i o s recommended i n the Long Term Care N o n - P r o f i t F a c i l i t y S t a f f i n g G u i d e l i n e s (1979). The nurses i n t h i s study had worked i n long term care s e t t i n g s f o r s e v e r a l years. These nurses' p e r c e p t i o n s of what c o n s t i t u t e s long term care n u r s i n g t h e r e f o r e , i n a l l l i k e l i h o o d , are l a r g e l y r e f l e c t i o n s of t h e i r r e l a t i v e l y e x t e n s i v e work experience i n these s e t t i n g s . 53 F i n d i n g s Data are presented on the importance that residents and s t a f f attached to the residents' d a i l y l i v i n g a c t i v i t i e s , as well as on the choice both groups respectively associated with these a c t i v i t i e s . Staff perceptions were based upon how important the a c t i v i t y i s perceived to be to the t y p i c a l intermediate care l e v e l I resident and how much choice the resident has with respect to the a c t i v i t y . Data are also presented regarding s i m i l a r i t i e s and differences i n resident and s t a f f perceptions of the aforementioned variables. As discussed under "Data Analysis" i n Chapter 3: Methodology, the data were f i r s t analyzed by using "majority opinion" c r i t e r i a . This c r i t e r i a was used to obtain a general in d i c a t i o n of a c t i v i t i e s that residents and s t a f f perceive to be important or unimportant, as well as a c t i v i t i e s associated with free choice or no choice. Of the 20 items i n the study questionnaire, 16 items were rated as "very important" by a minimum of 50% of the residents. In p a r t i c u l a r , "personal privacy", "personal possessions" and "when to go out" (items 15, 16 and 19) were rated as very important by more than 70% of the residents. In contrast, the majority of s t a f f viewed 11 items as being "very important" to residents. The following items, "when and where to see v i s i t o r s " , "having someone to confide i n " , "personal privacy", "personal possessions" and "who to l i v e with" (items 5, 14, 15, 16, 17) were rated as "very important" 54 by more than 70% of the s t a f f . There was concurrence among the s t a f f ' s and residents' ratings of items 1, 9, 10, 12, 14, 15, 16, 17, and 19 (see Table I I I ) . The d a i l y l i v i n g a c t i v i t i e s associated with "free choice", as selected by a minimum of 50% of the residents and s t a f f , are depicted i n Table IV. The concurrence i n s t a f f and resident majority opinion regarding l e v e l of choice was somewhat stronger than s t a f f and resident concurrence on the importance rating. There was concurrence among the residents' and s t a f f ' s responses of "free choice" regarding the following 10 items: #5, 7, 8, 9, 10, 11, 12, 14, 19, 20. The majority of the residents indicated "free choice" for four additional items (#3, 13, 15, and 18) . The s t a f f indicated "free choice" for one additional item (#6) (see Table IV). The majority of residents indicated "no choice" for the items "when to take a bath" and "who to l i v e with" (#4 and 17). There was concurrence i n resident and s t a f f responses of "no choice" for item 2, "what time to eat meals" (see Table V). The study data were also analyzed to determine any s t a t i s t i c a l l y s i g n i f i c a n t differences i n resident and s t a f f ratings, that i s , differences regarding the perceived importance and c h o i c e each group associated with i n d i v i d u a l questionnaire items. Accordingly, a chi-square test was run at a significance l e v e l of .01 using a two (resident and staff) by nine (the three choice and three importance combinations) design. 55 Table III Daily L i v i n g A c t i v i t i e s Rated as Being Very Majority of Residents, Staff and Residents and Important By a Staff Combined Items Rated as "Very Important" Item No. Item Residents Residents Staff and Staff 1 What i s served at meals X 2 What time to eat meals X 4 When to take a bath X 5 When and where to see v i s i t o r s X 7 8 How to spend l e i s u r e time With whom to spend l e i s u r e time X X 9 Who to have for friends X 10 What clothes to wear X 11 Pursuing hobbies or a c t i v i t i e s X 12 How to spend your money X 13 Whether to of f e r suggestions X 14 Having someone to confide i n X 15 Personal privacy X 16 Personal possessions X 17 Who to l i v e with X 18 Color of walls, etc. - X 19 When to go out X 20 Whether to p a r t i c i p a t e i n group a c t i v i t i e s X 56 Table IV Daily Living Act iv i t i e s Associated With Free Choice By a Majority of Residents, Staff and Residents and Staff Combined Item No. Item Items Associated With "Free Choice" Residents Residents Staff and Staff 3 What time to get up and to go to bed 5 When and where to see v i s i t o r s and friends 6 What T.V. programs to watch 7 How to spend l e i s u r e time 8 With whom to spend le i s u r e time 9 Who to have for friends 10 What clothes to wear 11 Pursuing hobbies or a c t i v i t i e s 12 How to spend your money 13 Whether to of f e r suggestions 14 Having someone to confide i n 15 Personal privacy 18 Color of walls, etc. 19 When to go out 20 Whether to pa r t i c i p a t e i n group a c t i v i t i e s x x x x x x x x x x x x x x x 57 Table V Dally Living Act iv i t i e s Associated With No Choice By a Majority of Residents, Staff and Residents and Staff Combined Items Associated With "No Choice" Item Residents No. Item Residents Staff and Staff 2 What time to eat meals x 4 When to take a bath x 17 Who to l i v e with x The chi-square analyses revealed 14 of the 20 questionnaire items as having s i g n i f i c a n t differences. Chi-square analyses were not s i g n i f i c a n t for the following six items: when to take a bath, how to spend l e i s u r e time, with whom to spend l e i s u r e time, who to have for friends, how to spend (one's) money, what personal possessions to have. The researcher also used the s t a t i s t i c a l method of approximate p a r t i t i o n i n g for complex contingency tables developed by Halperin, Nehrke, Hulicka and Morganti (1976). This method was used to determine s i g n i f i c a n t differences between residents' and s t a f f ' s response patterns regarding the questionnaire items, that is,items that had s i g n i f i c a n t chi-square t e s t s . S p e c i f i c a l l y , the above form of analysis allowed the researcher to examine each item with respect to res i d e n t - s t a f f differences on both importance "collapsed" over the three choice categories, and on choice "collapsed" over the 58 three importance categories. The former form of collapsing allowed for s p e c i f i c , more exclusive examinations of the differences between residents' and s t a f f ' s response patterns among the three importance categories. The l a t t e r form of collapsing allowed for s p e c i f i c examinations of the differences between residents' and s t a f f ' s response patterns for the three choice categories. The researcher used a stringent p r o b a b i l i t y l e v e l (p < .01) to compensate for the increased p r o b a b i l i t y of s i g n i f i c a n t results, that i s , results that may occur because of the separate analysis of each questionnaire item (Morganti et a l . , 1980). Approximate p a r t i t i o n i n g i s intended for the analysis of items that have a s i g n i f i c a n t chi-square t e s t . Accordingly, the researcher used the technique to analyze response pattern differences (between residents and staff) regarding the 14 questionnaire items having s i g n i f i c a n t chi-square t e s t s . A l l of the fourteen items i n which approximate p a r t i t i o n i n g was used had s i g n i f i c a n t differences i n residents' and s t a f f ' s response patterns. These items indicate strong evidence of discrepancies between resident and s t a f f perceptions of the importance and/or choice associated with the residents' d a i l y l i v i n g a c t i v i t i e s . Of these items, six items i n p a r t i c u l a r (# 2, 5, 6, 13, 17, 20) indicated a r e l a t i v e l y wide gap of perception between residents and s t a f f . With item 2, "what time to eat meals", the collapsing of choice over importance indicated s i g n i f i c a n t differences between s t a f f and resident perceptions regarding importance: 53% of the s t a f f and 29% of the residents perceived item 2 as "very important". In contrast, 49% of the residents as compared to 9% of the s t a f f viewed the item as "not important". When importance was collapsed over choice, there were no s i g n i f i c a n t differences i n residents' and s t a f f ' s perceived l e v e l of choice regarding item 2. With item 5, "when and where to see v i s i t o r s and friends", the collapsing of choice over importance indicated s i g n i f i c a n t differences between resident and s t a f f perceptions of importance. A larger number of s t a f f (73%) than residents (33%) perceived the item to be "very important". In contrast, a larger number of the residents (44%) as compared to the s t a f f (9%) perceived the item as "not important". When importance was collapsed over choice, the researcher found no s i g n i f i c a n t differences between residents' and s t a f f ' s perceived l e v e l of choice regarding item 5. With item 6, "what T.V. programs to watch", the collapsing of choice over importance indicated that the majority of s t a f f (67%) perceived the item as "somewhat important", whereas a large proportion of residents' responses were divided between "very important" (40%) and "not important" (42%) . When importance was collapsed over choice, there were also s i g n i f i c a n t differences found with regard to residents' and s t a f f ' s perceived l e v e l of choice. A larger number of s t a f f (57%) than residents (31%) associated the item with "free 60 choice". In contrast, a larger number of residents (38%) than s t a f f (8%) associated the item with "no choice". With item 13, "whether to of f e r suggestions about how things should be done", the collapsing of choice over importance indicated that there were s i g n i f i c a n t differences regarding residents' and s t a f f ' s perceived importance. The most notable difference was between the residents' and s t a f f ' s ratings of "very important" and "somewhat important". More than half the number of s t a f f (58%) responded i n the "somewhat important" category whereas more than half the residents (53%) responded to the "very important" category. When importance was collapsed over choice, there were also s i g n i f i c a n t differences found between the residents' and s t a f f ' s perceived l e v e l of choice. A larger number of residents (71%) than s t a f f (40%) associated the item with "free choice", whereas a larger number of s t a f f (53%) than residents (22%) associated the item with "some choice". Although item 17 "who to l i v e with" had a s i g n i f i c a n t chi-square analysis, there were no s i g n i f i c a n t differences regarding perceived importance when choice was collapsed over importance. There were, however, s i g n i f i c a n t differences i n residents' and s t a f f ' s perceived l e v e l of choice. The greatest differences were between s t a f f ' s and residents' ratings of "free choice" and "no choice". S l i g h t l y more than half the s t a f f (51%) associated the item with "some choice", whereas 73% of the residents associated the item with "no choice". 61 With item 20, "whether to p a r t i c i p a t e i n organized group a c t i v i t i e s (games, sports, educational meeting ecetera)", the collapsing of choice over importance indicated that s l i g h t l y more than half the residents (58%) perceived the item as "very important". The majority of the remaining residents perceived the item as "not important". In contrast to the residents, almost hal f the s t a f f (49%) viewed the item as "somewhat important" and the majority of the remaining s t a f f perceived the item as "very important". When importance was collapsed over choice, there were no s i g n i f i c a n t differences found between residents' and s t a f f ' s perceived l e v e l of choice regarding the above item. Summary In t h i s chapter, the researcher has presented the data obtained from 45 intermediate care 1 residents and 45 nursing s t a f f (Registered Nurses, Licensed P r a c t i c a l Nurses and Nurses' Aides) from two intermediate care f a c i l i t i e s . Most of the residents were female and widowed. The majority of the residents had l i v e d i n the f a c i l i t y at least six months but less than three years. The majority of nursing s t a f f possessed a depth of experience i n nursing, p a r t i c u l a r l y i n long term care settings. Majority opinion ratings of item importance and item choice indicated s i m i l a r i t i e s and differences between the residents' and s t a f f ' s perceptions. The above ratings indicated that a 62 minimum of 50% of the residents rated 16 of the 20 questionnaire items (daily l i v i n g a c t i v i t i e s ) as being "very important". In contrast to the residents' ratings of the items, the s t a f f perceived 11 of the questionnaire items as being "very important" to the residents. There was concurrence i n residents' and s t a f f ' s responses of "very important" for nine items. The residents and s t a f f also concurred on the l e v e l of choice associated with ten of the questionnaire items. The residents indicated "free choice" for four additional items and "no choice" for three items. The s t a f f indicated "no choice" for one item. The chi-square analyses revealed that 14 of the 20 questionnaire items indicated s i g n i f i c a n t differences between the residents' and s t a f f ' s perceptions. Approximate p a r t i t i o n i n g indicated s i g n i f i c a n t differences in residents' and s t a f f ' s response patterns for the fourteen questionnaire items with s i g n i f i c a n t chi-square analyses. A discussion of the above findings i s presented i n the following chapter. 63 Chapter Five Discussion of Findings T h i s study's r e s e a r c h f i n d i n g s w i l l be d i s c u s s e d i n th r e e s e c t i o n s . S e c t i o n 1 w i l l address the d a i l y l i v i n g a c t i v i t i e s t h a t the r e s i d e n t s p e r c e i v e d as be i n g "very important", as w e l l as the a c t i v i t i e s t h a t the s t a f f p e r c e i v e d as be i n g "very important" t o the r e s i d e n t s . The r e s e a r c h e r w i l l a l s o d i s c u s s the f i n d i n g s r e g a r d i n g the choice t h a t r e s i d e n t s and s t a f f a s s o c i a t e d with r e s i d e n t s ' d a i l y l i v i n g a c t i v i t i e s . In the second s e c t i o n , the r e s e a r c h e r w i l l address the s i g n i f i c a n t d i f f e r e n c e s i n r e s i d e n t and s t a f f p e r c e p t i o n s r e g a r d i n g (i) the importance r e s i d e n t s a t t a c h t o s p e c i f i c d a i l y l i v i n g a c t i v i t i e s and ( i i ) the p e r c e i v e d l e v e l of ch o i c e r e s i d e n t s a s s o c i a t e with the a c t i v i t i e s . The t h i r d s e c t i o n c o n t a i n s a d i s c u s s i o n of t h i s study's conceptual framework i n terms of i t s u t i l i t y toward i d e n t i f y i n g the r e s i d e n t s ' l a t i t u d e of ch o i c e and freedom of cho i c e , as w e l l as i n a s s e s s i n g the r e s i d e n t s ' needs f o r achievement and se l f - e s t e e m . The d i s c u s s i o n f u r t h e r i n c l u d e s an i n t e r p r e t a t i o n of t h i s study's f i n d i n g s , with the conceptual framework as the b a s i s f o r t h i s i n t e r p r e t a t i o n . W i thin the context of the conceptual framework, the r e s e a r c h e r w i l l a l s o make i n f e r e n c e s from the study f i n d i n g s f o r the assessment of the r e s i d e n t s ' needs f o r achievement and se l f - e s t e e m . 64 Although t h i s study replicates a portion of Morganti et al. ' s (1980) study, the present study findings w i l l not be compared with those of Morganti et al's (1980) for the following three reasons. F i r s t , the present study included a majority of females whereas Morganti et a l . ' s (1980) study included solely males. Second, the present study i s predominantly, i f not en t i r e l y , comprised of c i v i l i a n s , whereas Morganti et al.'s (1980) study included only veterans. Third, the present study was conducted i n two Canadian long term care f a c i l i t i e s which tend to be i n s t i t u t i o n a l i n nature and design, whereas Morganti et a l . ' s (1980) study was conducted i n an American veterans' domiliciary. This domiliciary i s more sim i l a r to a community dwelling rather than an i n s t i t u t i o n a l dwelling, i n that residents of the former have access to the t o t a l community, and by and large are not r e s t r i c t e d by i n s t i t u t i o n a l schedules (Morganti et a l . , 1980). Findings Regarding Importance and Choice The importance and choice that residents attach to the da i l y l i v i n g a c t i v i t i e s (in the study questionnaire) provide an ind i c a t i o n of the residents' l a t i t u d e of choice. As mentioned e a r l i e r , l a t i t u d e of choice includes not only choices that are available but also choices that are meaningful to the in d i v i d u a l . This study's data indicate that, of the d a i l y l i v i n g a c t i v i t i e s l i s t e d i n the study questionnaire, the . residents 65 perceived most of the a c t i v i t i e s as being "very important". In p a r t i c u l a r , majority opinion ratings of item importance indicated that residents percieved 16 items (80%) of the d a i l y l i v i n g a c t i v i t i e s l i s t e d i n the questionnaire as being "very important". Although majority opinion ratings provide only a general i n d i c a t i o n of item importance, these ratings do s i g n i f y that residents perceived items concerning the selection and timing of d a i l y l i v i n g a c t i v i t i e s , the selection of associates, and the selection of surroundings as being of p a r t i c u l a r s ignificance to them. In contrast, the majority opinion ratings indicate that the s t a f f viewed 11 items (55%) of the questionnaire items as being "very important" to the residents. The residents may have rated a higher number of items as important because the residents are the "best judge" of t h e i r own perceptions, and therefore are i n a better p o s i t i o n than the s t a f f to determine what i s important to themselves as residents. The s t a f f , on the other hand, i s not wholly privy to such knowledge i n making t h e i r selections. Further, the s t a f f rated the study questionnaire items i n r e l a t i o n to the " t y p i c a l intermediate care 1 resident" rather than i n r e l a t i o n to the s p e c i f i c residents who p a r t i c i p a t e d i n t h i s study. The discrepancy between the number of items rated as being "very important" (11 items as opposed to 16) by s t a f f and by residents can be attributed to two factors. The s t a f f may have chosen only 11 items because they represent either a c t i v i t i e s common to every person i n t h e i r d a i l y existence (for 66 example, who to have for friends), or the items represent d a i l y l i v i n g a c t i v i t i e s i n which the s t a f f have dir e c t involvement with the residents. The l a t t e r factor i d e n t i f i e d above may largely account for the s t a f f ' s perceptions. Indeed, a study by Kahana and Koe (1969) indicated that whereas the i n s t i t u t i o n a l i z e d e l d e r l y resident had " w e l l - d i f f e r e n t i a t e d self-conceptualizations" based on both past and present s o c i a l roles, the s t a f f ' s view of residents tended to be "depersonalized" and based upon the s t a f f ' s perspective of t h e i r work roles. Similarly, the s t a f f i n t h i s present study may have i d e n t i f i e d items as being "very important" to the residents based upon the s t a f f ' s perspective of i t s own work roles. These are roles i n which the s t a f f ' s work routines require involvement i n the residents' d a i l y l i v i n g a c t i v i t i e s , and therefore are roles i n which the s t a f f have direc t involvement with the residents. Examples of such roles include a s s i s t i n g residents at meal times, a s s i s t i n g residents to dress and coordinating arrangements for residents who want "to go out" with family or friends. A study conducted by Brown (1988) indicates that requirements for i n s t i t u t i o n a l e f f i c i e n c y often r e s u l t i n the majority of nursing s t a f f ( i . e . nursing assistants) predominantly focussing on tasks related to residents' d a i l y l i v i n g a c t i v i t i e s . In Brown's study (1988), she notes that "on a daily, basis, a nursing assistant's tasks usually consist of continuously giving baths, changing s o i l e d clothes, and feeding 67 those i n t h e i r c a r e " (p. 15) . Given the demands of such a workload, as i n d i c a t e d by t h i s study, i t would not be s u r p r i s i n g i f a l a r g e number of n u r s i n g home s t a f f (that i s , L i c e n s e d P r a c t i c a l Nurses and/or Nurses' Aides and R e g i s t e r e d Nurses) p e r c e i v e d such a c t i v i t i e s , with which they have v a r y i n g degrees of involvement, as b e i n g most important to the r e s i d e n t s . W i t h i n the f i n d i n g s i n t h i s present study, t h e r e was concurrence i n s t a f f and r e s i d e n t responses of "very important" f o r nine items. T h i s concurrence i n r a t i n g s suggests some "g e n e r a l " evidence t h a t s t a f f p e r c e p t i o n s are s i m i l a r t o r e s i d e n t p e r c e p t i o n s with r e g a r d to p a r t i c u l a r l i v i n g a c t i v i t i e s , a c t i v i t i e s with which s t a f f (as mentioned p r e v i o u s l y ) have e i t h e r d i r e c t involvement or b e l i e v e to be common t o human e x i s t e n c e . In f a c t , the s t a f f and r e s i d e n t s agree most s t r o n g l y i n t h e i r importance r a t i n g s of item 15, "how much p e r s o n a l p r i v a c y i s a v a i l a b l e " and item 16, "what p e r s o n a l p o s s e s s i o n s to have". In examining the r e s i d e n t and s t a f f data r e g a r d i n g p e r c e i v e d l e v e l of c h o i c e , the r e s e a r c h e r noted t h a t t h e r e was concurrence i n r e s i d e n t s ' and s t a f f ' s m a j o r i t y o p i n i o n r e g a r d i n g the l e v e l of c h o i c e a s s o c i a t e d with t e n (50%) of the q u e s t i o n n a i r e items. Morganti et a l . (1980) ob t a i n e d s i m i l a r r e s u l t s i n t h e i r study i n which they a d m i n i s t e r e d the o r i g i n a l 37 item Importance, Locus and Range of A c t i v i t i e s C h e c k l i s t . In t h e i r study, t h e r e was concurrence i n V.A. d o m i c i l i a r y r e s i d e n t s ' and s t a f f ' s m a j o r i t y o p i n i o n r e g a r d i n g 50% of the 68 questionnaire items. Among these items were those either the same or similar to the ten items associated with "free choice" by the present study's s t a f f and residents. The conclusion drawn (by the researcher) from the present study findings coincides with the conclusion reached by Morganti et a l . : residents' and s t a f f ' s concurrence concerning the l e v e l of choice available to residents suggests that both groups are aware of the regulations and p o l i c i e s governing a long term care f a c i l i t y . The majority opinion ratings indicated that the residents associated "no choice" with the following three items: "what time to eat meals", "when to take a bath" and "who to l i v e with". These items may have been associated with "no choice" because they are subject to the f a c i l i t y ' s procedures and p o l i c i e s . Significant Differences Between Residents' and Staff's  Perceptions As discussed e a r l i e r , chi-square analysis was used to determine any s i g n i f i c a n t differences regarding the perceived importance and choice each group associates with i n d i v i d u a l questionnaire items. There were s i g n i f i c a n t differences i n resident and s t a f f perceptions regarding 14 (70%) of the questionnaire items. Two factors may have contributed to these discrepancies i n perceptions. F i r s t , t h i s study focussed on s p e c i f i c e l d e r l y residents' perceptions, whereas the s t a f f ' s 69 perceptions were based upon what i t s members considered to be " t y p i c a l " of intermediate care 1 residents. Second, despite any e f f o r t s on the s t a f f ' s part to be as objective as possible when choosing t h e i r responses, the s t a f f ' s personal biases may have affected t h e i r choice of responses. Approximate p a r t i t i o n i n g was also used to determine any s i g n i f i c a n t differences i n residents' and s t a f f s ' response patterns regarding the questionnaire items, that i s , items that had s i g n i f i c a n t chi-square t e s t s . Although a l l of the 14 items indicated discrepancies i n resident and s t a f f response patterns to varying degrees, only items with a r e l a t i v e l y large discrepancy w i l l be discussed. With the items "what time to eat meals" and "when and where to see v i s i t o r s and friends" (items 2 and 5), a larger number of s t a f f than residents perceived these items to be "very important". In contrast, a larger number of residents than s t a f f perceived these items, as "not important". Despite t h i s discrepancy of importance attached to these items, there were no s i g n i f i c a n t differences i n residents' and s t a f f ' s perceived l e v e l of choice regarding items 2 and 5. The residents' and s t a f f ' s response patterns regarding importance strongly indicate discrepancies i n residents' and s t a f f ' s perceptions of importance. As discussed e a r l i e r , the s t a f f may have perceived the above items as being very important to the residents based upon the s t a f f ' s perspective of i t s work rol e s . 70 The residents, however, did not perceive the two a c t i v i t i e s as being p a r t i c u l a r l y important or meaningful to them. Hence, even though the majority of the residents and s t a f f associated item 2 with "no choice" and item 5 with "free choice", the range of choice available neither diminishes nor enhances the residents' l a t i t u d e of choice because neither of the above a c t i v i t i e s are p a r t i c u l a r l y important to the residents. With the items "whether to off e r suggestions about how things should be done" and "whether- to p a r t i c i p a t e i n organized group a c t i v i t i e s (games, sports, educational meetings)" (items 13 and 20), the majority of s t a f f perceived these items as "somewhat important", whereas the majority of residents' perceived the items as "very important". These results indicate s i g n i f i c a n t discrepancies i n residents' and s t a f f ' s perceptions of importance regarding these items. Despite the above discrepancies regarding perceived importance, the residents l a t i t u d e of choice over these two a c t i v i t i e s i s for the present intact because the residents associated "free choice" with these a c t i v i t i e s . Although residents' l a t i t u d e of choice may remain intact, there i s s t i l l the p o t e n t i a l for t h e i r l a t i t u d e of choice over these a c t i v i t i e s to diminish because of the s t a f f ' s discrepant perceptions. Indeed, i f the s t a f f are not f u l l y aware of the importance that the residents attach to these two a c t i v i t i e s , the s t a f f may inadvertently lessen the residents' l e v e l of choice regarding 71 these a c t i v i t i e s , for the s t a f f perceived these a c t i v i t i e s to be only "somewhat important" to the residents. With the item "what T.V. programs to watch" (item 6), the majority of s t a f f perceived the item as "somewhat important", whereas a large proportion of the residents' responses were divided between "very important" and "not important". Clearly, there were discrepancies between residents' and s t a f f ' s perceptions regarding the importance of t h i s item. There were also discrepancies i n the l e v e l of choice that residents and s t a f f associated with t h i s item. Indeed, more than hal f the s t a f f associated t h i s item with "free choice", whereas one t h i r d of the residents associated the item with "no choice". The above results suggest that residents may or may not have l a t i t u d e of choice regarding the above item. For many of the residents, the above a c t i v i t y i s perceived as being unimportant. Residents' perceived l a t i t u d e of choice, therefore, may be unaffected by the lack of choice associated with t h i s a c t i v i t y . However, for the residents who perceive t h i s a c t i v i t y to be "very important" and associate i t with "no choice", the residents' l a t i t u d e of choice i s lessened by the lack of choice over t h i s a c t i v i t y . With the item "who to l i v e with" (item 17), there were no s i g n i f i c a n t differences i n residents' and s t a f f ' s perceptions of importance regarding t h i s item. The majority of residents and s t a f f perceive t h i s item as being "very important". There were s i g n i f i c a n t discrepancies, however, regarding residents' and 72 s t a f f ' s perceived l e v e l of choice: 51% of the s t a f f associated the item with "free choice", whereas 73% of the residents associated the item with "no choice". The discrepancy of perceptions regarding t h i s p a r t i c u l a r a c t i v i t y i s an example of how mixed st a f f - r e s i d e n t perceptions can be p a r t i c u l a r l y detrimental to the residents' la t i t u d e of choice. The majority of residents perceived the a c t i v i t y as being very important, while associating i t with no choice. The s t a f f , who are i n a p o s i t i o n to influence the residents' lat i t u d e of choice to varying extents, believe that residents enjoy free choice with t h i s a c t i v i t y , an a c t i v i t y of p a r t i c u l a r importance to the residents. When s t a f f members operate under t h i s erroneous assumption, t h e i r misperception unwittingly may resu l t i n s t a f f procedure(s) that lessen the residents' l a t i t u d e of choice regarding t h i s a c t i v i t y . The Conceptual Framework as a Basis for Analysis The conceptual framework developed for t h i s study incorporates l a t i t u d e of choice, a concept which encompasses not only available choices but choices that are important or meaningful to an i n d i v i d u a l . An individual's l a t i t u d e of choice regarding an a c t i v i t y ( i e s ) provides a tangible measure of his/her perceived freedom of choice. The researcher's analysis of the study's findings indicates that the importance and choice components of the conceptual framework were useful i n determining the residents' perceived 73 freedom of choice. In t h i s study, the items, "when to take a bath" and "who to l i v e with" each represented an a c t i v i t y that residents perceived as being "very important" and that they associated with "some or no choice". These perceptions provided a tangible i n d i c a t i o n of the residents' freedom of choice most l i k e l y being lessened with regard to these a c t i v i t i e s . The study findings regarding the above two items s i g n i f y d i s s a t i s f a c t i o n among the residents because they are not afforded the opportunity to enjoy an a c t i v i t y that i s important to them. Conversely, the residents' freedom of choice i s most l i k e l y to be unaffected, regardless of the l e v e l of choice available, i f the residents do not perceive the a c t i v i t y to be important. In the present study, the items, "what time to eat meals" and "when and where to see v i s i t o r s and friends", each represented such an a c t i v i t y . The findings regarding these two items suggest residents' indifference to any opportunity for acting on any choices available. Examining the residents'perceptions within the context of the study's conceptual framework gave the researcher a basis for assessing t h e i r needs for achievement and self-esteem. Although these two basic human needs were not examined i n t h i s study per se, the extent to which they were met by residents could be assessed based upon the residents' l a t i t u d e of choice and freedom of choice. The s t a f f ' s perceptions of residents' l a t i t u d e of choice broadened the perspective i n which the researcher could examine the residents' perceived la t i t u d e of choice and freedom of choice. It was useful, therefore, to examine the two concepts with regard to the s t a f f ' s perceptions. This examination provided a means for determining the eff e c t s of a major force (i. e . the staff) on residents' l a t i t u d e of choice and freedom of choice. The conceptual framework, s p e c i f i c a l l y i t s importance and choice components, provide a basis for examining residents' and s t a f f ' s perceptions regarding the residents' l a t i t u d e of choice. In the present study, both the residents and s t a f f perceived the items, "what clothes to wear", "when to go out (leave l i v i n g quarters for a few hours)" and "whether to par t i c i p a t e i n organized group a c t i v i t i e s " , as being important to the residents. Both groups also associated these a c t i v i t i e s with "free choice". Within the context of the conceptual framework, the inference can be made that, with regard to the above a c t i v i t i e s , the s t a f f may have provided the residents with the opportunity to make choices. Further, the s t a f f may have assisted the residents i n developing coping behaviors to act on t h e i r choices. As noted i n the "conceptual framework", when the nurse promotes suitable coping behaviors and allows l a t i t u d e of choice, he/she i s creating "opportunities for residents to make choices and to take actions that w i l l enhance t h e i r sense of mastery" both over the environment and the events that e f f e c t him/her (Gerontological Nursing Association, 1987, p. 9). B r i e f l y stated, by allowing the residents to act on choices that 75 are important to them, s t a f f members ultimately are promoting residents' feelings of achievement. The study findings regarding the above three items can be further interpreted within the context of the conceptual framework. When the residents are afforded the opportunity for choice on any given a c t i v i t y that i s meaningful to them, residents are i n fact r e a l i z i n g freedom of choice with t h i s a c t i v i t y . When the residents experience freedom of choice, the inference can be made that the s t a f f are respecting the residents' right to make choices regarding an a c t i v i t y that i s meaningful to them. Further, as stated i n the conceptual framework, i f the el d e r l y resident perceives freedom of choice over an a c t i v i t y of importance, his/her feelings of respect for s e l f w i l l be enhanced. The residents' r e a l i z a t i o n of freedom of choice over a given a c t i v i t y they, deem to be important i s therefore also a r e a l i z a t i o n of a higher l e v e l of self-esteem. When residents believe they are not given the opportunity to exercise choices that are important to them, t h e i r feelings of achievement are l i k e l y to be undermined. In the present study, the residents and s t a f f perceived the item "who to l i v e with" as being important to residents, and the s t a f f associated the a c t i v i t y with free choice whereas the residents associate i t with no choice. With t h i s item, the following inference can be made: the s t a f f may not have recognized residents' perceived need for opportunities of making choices regarding p a r t i c u l a r a c t i v i t i e s . Further, the s t a f f may not have perceived the 76 r e s i d e n t s ' d e s i r e t o develop coping behaviors t o act on t h e i r c h o i c e s r e g a r d i n g p a r t i c u l a r a c t i v i t i e s . Given t h a t the above s i t u a t i o n s p r e v a i l , the s t a f f u n w i t t i n g l y may r e s t r i c t the r e s i d e n t s ' f e e l i n g s of achievement. A r e s t r i c t i o n of r e s i d e n t s ' l a t i t u d e of choice t h a t excludes any p a r t i c u l a r a c t i v i t i e s of importance s i g n i f i e s the nonexistence of r e s i d e n t s ' p e r c e i v e d freedom of ch o i c e over these a c t i v i t i e s . The i n f e r e n c e can be made then t h a t a r e s i d e n t ' s s e l f - e s t e e m i s not as complete as i t c o u l d be, f o r the r e s i d e n t i s not e n j o y i n g freedom of ch o i c e over a l l the a c t i v i t i e s he/she deems to be important. T h i s s e c t i o n ' s d i s c u s s i o n r e g a r d i n g the study's conceptual framework i n d i c a t e s the d i r e c t a p p l i c a b i l i t y of the conceptual framework f o r determining both the r e s i d e n t s ' and s t a f f ' s p e r c e p t i o n s r e g a r d i n g the r e s i d e n t s ' l a t i t u d e of c h o i c e . Although the conceptual framework's a p p l i c a b i l i t y r e g a r d i n g the assessment of the r e s i d e n t s ' needs f o r achievement and s e l f - e s t e e m was not d i r e c t l y determined i n t h i s study, the r e s e a r c h e r ' s i n c o r p o r a t i o n of the study r e s u l t s ( within the context of the conceptual framework) suggests t h a t the conceptual framework can be u s e f u l i n a s s e s s i n g the above b a s i c human needs of r e s i d e n t s . Summary In t h i s chapter, the r e s e a r c h e r has analyzed and d i s c u s s e d the study f i n d i n g s . The r e s i d e n t s ' m a j o r i t y o p i n i o n r a t i n g s f o r 77 item importance s i g n i f y t h a t the r e s i d e n t s p e r c e i v e d 16 items concerning: (a) the s e l e c t i o n and t i m i n g of d a i l y l i v i n g a c t i v i t i e s (b) the s e l e c t i o n of a s s o c i a t e s , and (c) s e l e c t i o n of surrounding as being of p a r t i c u l a r s i g n i f i c a n c e t o them. That i s , the r e s i d e n t s ' p e r c e i v e d 80% of the study q u e s t i o n n a i r e items as b e i n g p a r t i c u l a r l y s i g n i f i c a n t t o them. In c o n t r a s t t o the r e s i d e n t s ' r a t i n g s of items, the s t a f f p e r c e i v e d 11 of the q u e s t i o n n a i r e items as b e i n g "very important" t o the r e s i d e n t s . T h e ' s t a f f may have chosen only these 11 items because they r e p r e s e n t e i t h e r a c t i v i t i e s common to every person i n h i s / h e r d a i l y e x i s t e n c e ( f o r example, who t o have f o r f r i e n d s ) , or the items r e p r e s e n t r e s i d e n t s ' d a i l y l i v i n g a c t i v i t i e s i n which the s t a f f , due to t h e i r work r o l e s , have d i r e c t involvement with the r e s i d e n t s . The r e s i d e n t s ' and s t a f f ' s concurrence on the l e v e l of c h o i c e a s s o c i a t e d with ten of the study items l e n d support t o Morganti et a l . ' s (1980) c o n c l u s i o n : r e s i d e n t s ' and s t a f f ' s concurrence concerning the l e v e l of c h o i c e a v a i l a b l e t o r e s i d e n t s suggests t h a t both groups are aware of the r e g u l a t i o n s and p o l i c i e s governing a long term care f a c i l i t y . The two f a c t o r s t h a t may have c o n t r i b u t e d to t h i s study's s i g n i f i c a n t c h i - s q u a r e analyses i n c l u d e the f o l l o w i n g : the s t a f f ' s p e r c e p t i o n was based upon what they p e r c e i v e d as the " t y p i c a l " i n t e r m e d i a t e care l e v e l 1 r e s i d e n t , whereas the r e s i d e n t s ' p e r c e p t i o n s were based on t h e i r own experiences i n the f a c i l i t y . 78 The d i s c r e p a n t p e r c e p t i o n s i n d i c a t e d by approximate p a r t i t i o n i n g suggest t h a t (a) the r e s i d e n t s ' l a t i t u d e of ch o i c e may be u n a f f e c t e d i f an a c t i v i t y i s unimportant t o them, or (b) the r e s i d e n t s ' l a t i t u d e of choice may be l e s s e n e d i f e i t h e r the s t a f f do not p e r c e i v e the same degree of importance t h a t the r e s i d e n t s a t t a c h t o a p a r t i c u l a r a c t i v i t y ( i e s ) , or the s t a f f may not p e r c e i v e t h a t the r e s i d e n t s a s s o c i a t e "some" or "no c h o i c e " with a p a r t i c u l a r a c t i v i t y t h a t i s important t o them. The conceptual framework, s p e c i f i c a l l y the importance and cho i c e components of the framework, p r o v i d e a u s e f u l measure f o r determining not only the r e s i d e n t s ' p e r c e i v e d freedom of ch o i c e , but a l s o the r e s i d e n t s ' and s t a f f ' s p e r c e p t i o n s r e g a r d i n g the r e s i d e n t s ' l a t i t u d e of c h o i c e . By determining the r e s i d e n t s ' p e r c e p t i o n s of l a t i t u d e of choice, the r e s e a r c h e r has a b a s i s f o r a s s e s s i n g the r e s i d e n t s ' need f o r achievement. Correspondingly, by determining the r e s i d e n t s ' freedom of choi c e , the r e s e a r c h e r has a b a s i s upon which t o assess the r e s i d e n t s ' need f o r s e l f - e s t e e m . Chapter Six Summary, Conclusions, Implications and Recommendations In t h i s chapter, a summary of the study, c o n c l u s i o n s based upon the study f i n d i n g s , i m p l i c a t i o n s f o r n u r s i n g p r a c t i c e and education, and recommendations f o r f u r t h e r r e s e a r c h are presented. Summary The establishment of i n t e r m e d i a t e care f a c i l i t i e s i n B r i t i s h Columbia, as w e l l as the establishment of s i m i l a r f a c i l i t i e s throughout the r e s t of Canada, was and s t i l l i s a w e l l - i n t e n t i o n e d approach to meet the long term care needs of the e l d e r l y . The p r a c t i c e s and procedures adopted by long term care f a c i l i t i e s , however, tend to i n h i b i t the p e r s o n a l autonomy of r e s i d e n t s (Thomasma, 1985). S p e c i f i c a l l y , a f a c i l i t y ' s p r a c t i c e s and procedures tend to i n h i b i t r e s i d e n t s ' l a t i t u d e of c h o i c e r e g a r d i n g d a i l y l i v i n g a c t i v i t i e s . R e s i d e n t s ' l a t i t u d e of c h o i c e may a l s o be l e s s e n e d when nurses implement w e l l - i n t e n t i o n e d h e l p i n g i n t e r v e n t i o n s based on t h e i r own m o t i v a t i o n s and goals, r a t h e r than those of e l d e r l y r e s i d e n t s . D i s c r e p a n t p e r c e p t i o n s between r e s i d e n t s and s t a f f may pose a p o t e n t i a l danger t o the long term care environment, i n s o f a r as one group's p e r c e p t i o n (e.g. the s t a f f ' s ) may overshadow t h a t of the other. Consequently, the s t a f f ' s a c t i o n s , no matter how w e l l - i n t e n t i o n e d , may or may not be based upon an awareness of 80 the f o l l o w i n g r e s i d e n t p e r c e p t i o n s : (a) the importance r e s i d e n t s a t t a c h t o a c t i v i t i e s of d a i l y l i v i n g and (b) the importance r e s i d e n t s a t t a c h t o the r i g h t t o make ch o i c e s r e g a r d i n g s p e c i f i c a c t i v i t i e s . At present, t h e r e i s l i m i t e d r e s e a r c h a d d r e s s i n g both r e s i d e n t and s t a f f p e r c e p t i o n s r e g a r d i n g the autonomy (freedom of choice) of r e s i d e n t s , p a r t i c u l a r l y i n r e l a t i o n t o t h e i r d a i l y a c t i v i t i e s . A c c o r d i n g l y , t h i s study's purpose was to determine the i n s t i t u t i o n a l i z e d e l d e r l y r e s i d e n t s ' and t h e i r c a r e g i v e r s ' p e r c e p t i o n s of r e s i d e n t s ' l a t i t u d e of ch o i c e r e g a r d i n g a c t i v i t i e s of d a i l y l i v i n g . From determining these s p e c i f i c s t a f f and r e s i d e n t p e r c e p t i o n s , s i g n i f i c a n t d i f f e r e n c e s were i s o l a t e d . T h i s study was conducted i n two i n t e r m e d i a t e care f a c i l i t i e s l o c a t e d i n a l a r g e c i t y w i t h i n the p r o v i n c e of B.C. The data c o l l e c t i o n instruments i n t h i s study i n c l u d e d s e l e c t e d q u e s t i o n s from H u l i c k a et a l . ' s (1975) r e v i s e d Importance, Locus and Range of A c t i v i t i e s C h e c k l i s t , as w e l l as a demographic data sheet developed by the r e s e a r c h e r . F o r t y - f i v e i n t e r m e d i a t e care 1 r e s i d e n t s and f o r t y - f i v e nurses ( R e g i s t e r e d Nurses, L i c e n s e d P r a c t i c a l Nurses and Nurses' Aides) completed the study q u e s t i o n n a i r e and the demographic data sheet. The r e s i d e n t sample c o n s i s t e d of 7 men (15.6%) and 38 women (84.4%). The r e s i d e n t s ' ages ranged from 65 years t o 98 years w i t h a mean age of 81.18 years. The m a r i t a l s t a t u s of the r e s i d e n t s i n c l u d e d 7 (15.6%) who were s i n g l e , 1 (2.2%) who was 81 married, 4 (8.9%) who were divorced and 33 (73.3%) who were widowed. Prior to residing i n the intermediate care f a c i l i t y , 16 residents (35.6%) had l i v e d alone i n t h e i r own house, 22 (48.9%) had l i v e d alone i n an apartment and 5 (11.1%) had l i v e d i n a house or apartment with a spouse or other family member. Only one resident had been ho s p i t a l i z e d p r i o r to residing i n the intermediate care f a c i l i t y . Residents' length of stay i n the f a c i l i t y ranged from 6 months to 11 years. The residents' mean length of stay was 2.8 years with a standard deviation of 2.4 years and a median of 2.0 years. Of the nursing s t a f f who pa r t i c i p a t e d i n t h i s study, 15 (33.3%) were Registered Nurses, 6 (13.3%) were Licensed P r a c t i c a l Nurses and 24 (53.3%) were Nurses' Aides. Staff members' respective years of practice i n nursing ranged from 2 years to 45 years employment i n nursing, with a mean of 17.78 years, a median of 17 years and a mode of 17.5 years. These study part i c i p a n t s ' years of practice i n long term care settings ranged from 2 years to 30 years with a mean of 11.62 years, a median of 11 years and a mode of 15 years. The participants' average length of employment i n the study setting was 9.33 years, ranging from 1 year to 16 years with a median of 10 years and a mode of 14.5 years. The researcher studied the residents' and s t a f f ' s responses to the Importance, Locus and Range of A c t i v i t i e s Checklist by using non-parametric techniques for s t a t i s t i c a l analysis. The researcher used these techniques to determine the existence and 82 location of differences i n perceptions among the residents and s t a f f . The researcher f i r s t used "majority opinion" c r i t e r i a , whereby the study questionnaire item should have a minimum of 50% response by either residents or s t a f f . If the item met t h i s c r i t e r i a , i t was rated as being "very important" or "unimportant" and/or as having "free choice" or "no choice". Having determined the ratings, the researcher obtained a general in d i c a t i o n of a c t i v i t i e s considered by residents and s t a f f to "very important" or "unimportant" and a c t i v i t i e s associated with "free choice" or "no choice". Analysis of the "majority opinion" c r i t e r i a responses revealed differences among the residents and s t a f f i n t h e i r perceptions of the importance of d a i l y l i v i n g a c t i v i t i e s to the residents. The residents perceived 16 of the 20 study questionnaire items (daily l i v i n g a c t i v i t i e s ) as being "very important", whereas the s t a f f perceived 11 questionnaire items as being "very important" to residents. There was concurrence in s t a f f and resident responses of "very important" for nine items. Although majority opinion ratings provide only a general in d i c a t i o n of item importance, they do s i g n i f y that residents perceived items concerning the selection and timing of d a i l y l i v i n g a c t i v i t i e s , the selection of associates, and the selection of surroundings as being of p a r t i c u l a r importance to them. The residents may have rated a higher number of items as being important (as compared to the staff) because the residents 83 are the best judge of t h e i r p e r c e p t i o n s , and t h e r e f o r e are i n a b e t t e r p o s i t i o n than the s t a f f t o determine what i s important t o themselves as r e s i d e n t s . The s t a f f ' s " m a j o r i t y o p i n i o n " r a t i n g s of item importance suggest t h a t they chose items t h a t r e p r e s e n t e i t h e r a c t i v i t i e s common t o every person i n h i s / h e r d a i l y e x i s t e n c e ( f o r example, who t o have f o r f r i e n d s ) , or d a i l y l i v i n g a c t i v i t i e s i n which the s t a f f have d i r e c t involvement with the r e s i d e n t s ( f o r example, a s s i s t i n g r e s i d e n t s at meal t i m e s ) . The concurrence i n s t a f f and r e s i d e n t responses suggests some " g e n e r a l " evidence t h a t s t a f f p e r c e p t i o n s are s i m i l a r t o r e s i d e n t p e r c e p t i o n s with r e g a r d t o p a r t i c u l a r l i v i n g a c t i v i t i e s , t h a t i s , a c t i v i t i e s i n which the s t a f f , as mentioned p r e v i o u s l y , e i t h e r have d i r e c t involvement or b e l i e v e t o be common t o human e x i s t e n c e . In examining the r e s i d e n t and s t a f f " m a j o r i t y o p i n i o n " r a t i n g s of item c h o i c e , the r e s e a r c h e r noted t h a t t h e r e were d i s c r e p a n c i e s between the r e s i d e n t s ' and s t a f f ' s p e r c e p t i o n s r e g a r d i n g the l e v e l of ch o i c e a s s o c i a t e d with t e n (50%) of the q u e s t i o n n a i r e items. D e s p i t e these d i s c r e p a n c i e s , t h e r e was concurrence i n the r e s i d e n t s ' and s t a f f ' s m a j o r i t y o p i n i o n r e g a r d i n g the l e v e l of ch o i c e with the remaining t en q u e s t i o n n a i r e items. The c o n c l u s i o n drawn (by the researcher) from these study f i n d i n g s c o i n c i d e s with the i n c l u s i o n reached by Morganti et a l . (1980): r e s i d e n t s ' and s t a f f ' s concurrence concerning the l e v e l of ch o i c e a v a i l a b l e t o r e s i d e n t s suggests 84 t h a t both groups are aware of the r e g u l a t i o n s and p o l i c i e s governing a long term care f a c i l i t y . The study data were a l s o analyzed t o determine any s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e s i n r e s i d e n t and s t a f f r a t i n g s , t h a t i s , d i f f e r e n c e s r e g a r d i n g the p e r c e i v e d importance and choice each group a s s o c i a t e d with i n d i v i d u a l q u e s t i o n n a i r e items. The chi - s q u a r e analyses r e v e a l e d 14 of the 20 q u e s t i o n n a i r e items as having s i g n i f i c a n t d i f f e r e n c e s . Two f a c t o r s may have c o n t r i b u t e d t o the d i s c r e p a n t p e r c e p t i o n s . F i r s t , t h i s study focussed on s p e c i f i c e l d e r l y r e s i d e n t s ' p e r c e p t i o n s , whereas the s t a f f ' s p e r c e p t i o n s were based upon what i t s members c o n s i d e r e d t o be " t y p i c a l " of i n t e r m e d i a t e care 1 r e s i d e n t s . Second, d e s p i t e any e f f o r t s on the s t a f f ' s p a r t t o be as o b j e c t i v e as p o s s i b l e when choosing t h e i r responses, the s t a f f ' s p e r s o n a l b i a s e s may have a f f e c t e d t h e i r c h o i c e of responses. Approximate p a r t i t i o n i n g was a l s o used t o determine any s i g n i f i c a n t d i f f e r e n c e s between r e s i d e n t s ' and s t a f f ' s response p a t t e r n s r e g a r d i n g the 14 q u e s t i o n n a i r e items having s i g n i f i c a n t c h i - s q u a r e t e s t s . The above form of a n a l y s i s r e v e a l e d s i g n i f i c a n t d i f f e r e n c e s between r e s i d e n t s ' and s t a f f ' s response p a t t e r n s r e g a r d i n g a) the importance of p a r t i c u l a r d a i l y l i v i n g a c t i v i t i e s t o r e s i d e n t s and b) the degree of choice r e s i d e n t s a s s o c i a t e with the a c t i v i t i e s . The d i s c r e p a n t p e r c e p t i o n s i n d i c a t e d by approximate p a r t i t i o n i n g suggest two p o s s i b l e outcomes: (1) the r e s i d e n t s ' 85 l a t i t u d e of choice may be unaffected i f an a c t i v i t y i s unimportant to them, (2) the residents' la t i t u d e of choice may be lessened i f the s t a f f do not perceive the same degree of importance that the residents attach to a p a r t i c u l a r a c t i v i t y (ies), or the s t a f f may not perceive that the residents' associate "some" or "no choice" with a p a r t i c u l a r a c t i v i t y that i s important to them. Conclusions Based on the findings of t h i s study, the following conclusions can be drawn. Eld e r l y residents selected for t h i s study perceive the selection and timing of a c t i v i t i e s , the selection of associates and the selection of surroundings as being of p a r t i c u l a r significance to them. The majority of residents and s t a f f have considerable agreement regarding the l e v e l of choice available to residents over various d a i l y l i v i n g a c t i v i t i e s . This concurrence i n perceptions suggests that the residents and s t a f f are aware of the rules and regulations governing a long term care f a c i l i t y . The majority of residents associated "no choice" with the items "what time to eat meals," "when to take a bath" and "who to l i v e with", perhaps because these items are invariably scheduled or arranged according to the f a c i l i t y ' s established procedures and/or p o l i c i e s . 86 S i g n i f i c a n t d i f f e r e n c e s e x i s t i n r e s i d e n t s ' and s t a f f ' s p e r c e p t i o n s when each group's importance r a t i n g s a re combined w i t h c h o i c e r a t i n g s . I s o l a t i o n o f t h e above importance and c h o i c e components f o r i n d i v i d u a l a n a l y s e s i n d i c a t e t h a t t h e r e s i d e n t s and s t a f f had s i g n i f i c a n t l y d i f f e r e n t response p a t t e r n s r e g a r d i n g a) t h e importance r e s i d e n t s a t t a c h t o d a i l y l i v i n g a c t i v i t i e s and b) t h e degree o f c h o i c e r e s i d e n t s a s s o c i a t e w i t h d a i l y l i v i n g a c t i v i t i e s . The above f i n d i n g s i n d i c a t e d t h a t r e s i d e n t s ' l a t i t u d e o f c h o i c e may not be r e a l i z e d t o a g r e a t e r e x t e n t i f t h e s t a f f do not a t t a c h a degree o f importance t o a p a r t i c u l a r a c t i v i t y ( i e s ) s i m i l a r t o t h a t a t t a c h e d by t h e r e s i d e n t s . R e s i d e n t s ' l a t i t u d e o f c h o i c e may not be r e c o g n i z e d t o a g r e a t e r e x t e n t i f s t a f f do not p e r c e i v e t h a t r e s i d e n t s a s s o c i a t e "some" o r "no c h o i c e " w i t h an a c t i v i t y o f p a r t i c u l a r i m p o r t a n c e t o them. I m p l i c a t i o n s f o r N u r s i n g P r a c t i c e and E d u c a t i o n The f i n d i n g s o f t h i s s t u d y have i m p l i c a t i o n s f o r n u r s i n g i n l o n g t e rm c a r e f a c i l i t i e s and n u r s i n g e d u c a t i o n . I n such f a c i l i t i e s , i t behooves n u r s e s t o det e r m i n e whether any d i f f e r e n c e s e x i s t between r e s i d e n t s ' and s t a f f ' s p e r c e p t i o n s , p a r t i c u l a r l y t h o s e r e g a r d i n g t h e importance and c h o i c e r e s i d e n t s a s s o c i a t e w i t h d a i l y l i v i n g a c t i v i t i e s . As t h e p r i m a r y p r o v i d e r s o f c a r e i n l o n g term c a r e f a c i l i t i e s , n u r s e s have t h e o p p o r t u n i t y t o i n f l u e n c e b o t h t h e o b j e c t i v e e x t e n t o f a 87 resident's l a t i t u d e of choice and his/her subjective sense of freedom of choice regarding d a i l y l i v i n g a c t i v i t i e s . Nurses need to r e a l i z e that t h e i r perceptions and residents' perceptions may d i f f e r s i g n i f i c a n t l y with regard to the importance and choice that residents associate with d a i l y l i v i n g a c t i v i t i e s . The d a i l y l i v i n g a c t i v i t i e s that s t a f f perceive as being important to e l d e r l y residents often, are a c t i v i t i e s which are common to every person i n t h e i r d a i l y existence, or they are a c t i v i t i e s i n which the s t a f f have di r e c t involvement with the residents. Consequently, s t a f f ' s perceptions frequently eclipse residents' perceptions regarding a c t i v i t i e s of importance to the residents. Staff's perceptions of the degree of choice available to residents also may be based mainly upon a c t i v i t i e s i n which s t a f f have d i r e c t involvement with residents. If they are to overcome d i s p a r i t i e s i n staf f - r e s i d e n t perceptions, nurses f i r s t should s t r i v e to be cognizant of the long term care setting's impact on residents, p a r t i c u l a r l y with regard to t h e i r l a t i t u d e of choice and freedom of choice. Nurses also should assess residents' perceptions of importance and choice regarding a c t i v i t i e s i n which the s t a f f are not d i r e c t l y involved. By having t h e i r perceptions then validated by residents, nurses are better able to avoid implementing inappropriate nursing interventions that would otherwise result from the s t a f f ' s misperceptions of residents' la t i t u d e of choice. F i n a l l y , i n making in d i v i d u a l assessments of residents' 88 l a t i t u d e of choice, nurses should r e c o g n i z e e l d e r l y r e s i d e n t s as a group whose members are heterogeneous with r e s p e c t to each other; each r e s i d e n t has a " w e l l d i f f e r e n t i a t e d s e l f - c o n c e p t u a l i z a t i o n " based on past and present r o l e s (Kahana and Coe, 1969). Long term care f a c i l i t i e s ' nurse a d m i n i s t r a t o r s should a l s o s t r i v e t o be cognizant of r e s i d e n t s ' p e r c e p t i o n s of importance and choice r e g a r d i n g d a i l y l i v i n g a c t i v i t i e s . With an awareness of r e s i d e n t s ' p e r c e p t i o n s , nurse a d m i n i s t r a t o r s can i n i t i a t e changes i n t h e i r f a c i l i t i e s ' procedures and/or programs t h a t extend r e s i d e n t s ' l a t i t u d e of c h o i c e . Such awareness among n u r s i n g s t a f f can be promoted . by nurse a d m i n i s t r a t o r s i n c o r p o r a t i n g the concept of l a t i t u d e of c h o i c e i n t o the f a c i l i t y ' s p h i l o s o p h y of n u r s i n g care. T h i s p h i l o s o p h y can be r e i n f o r c e d by a d m i n i s t r a t o r s i n i t i a t i n g inservices/workshops f o r t h e i r s t a f f r e g a r d i n g not only the importance of p r o v i d i n g a range of c h o i c e f o r e l d e r l y r e s i d e n t s , but a l s o the importance of e f f e c t i v e communication between s t a f f and r e s i d e n t s . Among other p r a c t i c a l c o n s i d e r a t i o n s , a primary c o n s i d e r a t i o n f o r nurse a d m i n i s t r a t o r s should be f a c i l i t a t i n g s t a f f attendance to such workshops by s c h e d u l i n g them d u r i n g work hours. I d e a l l y , a l l nurses i n v o l v e d i n g e r o n t o l o g i c a l n u r s i n g should have more educa t i o n r e g a r d i n g care of the e l d e r l y than i s c u r r e n t l y p r o v i d e d i n most n u r s i n g c u r r i c u l u m s . Indeed, Feeney, W i l l i a m s and Doyle (1986) note t h a t "although a l a r g e m a j o r i t y of the b a s i c p r e p a r a t i o n a l courses ( i n nursing) have aspects of 89 gerontological nursing integrated into the curriculum, most programs do not of f e r s p e c i a l i z e d courses on the care of the el d e r l y " (p. 35). Mion, Frengly and Adams (1986) and Strumpf (1987) concur with t h i s view. With greater preparation i n gerontological nursing, nurses can extend t h e i r a b i l i t i e s to meet the p a r t i c u l a r care needs of the eld e r l y . It i s espe c i a l l y c r i t i c a l for Registered Nurses employed i n long term care f a c i l i t i e s to have knowledge of gerontological nursing, because often they are the "caregiver" role model for non-professional s t a f f (Licensed P r a c t i c a l Nurses, Nurses' Aides) i n these f a c i l i t i e s . For a l l nurses, both non-professionals and professionals, who provide care to el d e r l y residents, i t i s p a r t i c u l a r l y imperative to pursue continuing education or post-basic specialty courses i n gerontological nursing. Examples of such course topics include the el d e r l y and the nursing process, health and i l l n e s s , communication, and confusion. Latitude of choice and freedom of choice are central to the residents' feelings of accomplishment and self-esteem. The nurse i s , i n eff e c t , a s s i s t i n g residents to act on t h e i r choices when he/she helps residents to develop and use suitable coping behaviors toward meeting his/her need for achievement. When the nurse promotes suitable coping behaviors and allows l a t i t u d e of choice, he/she i s creating "opportunities for residents to make choices and to take actions that w i l l enhance t h e i r sense of mastery "both over the environment- and the events that af f e c t him/her (Gerontological Nursing Association, 1987, p. 9 ) . 90 By helping the resident to extend his/her la t i t u d e of choice towards r e a l i z i n g freedom of choice over a c t i v i t i e s of importance to him/her, the nurse i s a s s i s t i n g the resident i n meeting not only the need for achievement but also the need for self-esteem. An e l d e r l y resident's perceived freedom of choice i s largely contingent upon the respect he/she receives from others (for example, nurses), p a r t i c u l a r l y i n regard to the resident's opportunities for choices over a c t i v i t i e s df da i l y l i v i n g . Further, the el d e r l y resident's perceived freedom of choice enhances his/her feelings of respect of s e l f . When the nurse provides a resident with opportunities to augment his/her l a t i t u d e of choice toward experiencing freedom of choice over a c t i v i t i e s of importance to him/her, the nurse i s i n fact staving o f f the otherwise inexorable decline of the resident's self-esteem as contributed from aging. Perceiving freedom of choice i s c r i t i c a l to the el d e r l y resident who i s experiencing a gradual loss of self-esteem with "the r e a l i z a t i o n of his diminishing control of the environment, lessened effectiveness and lessened impact" (Schwartz and Mersh, 1974, p. 12). Recommendations for Further Research Intermediate care residents and extended care residents should be included i n a study s i m i l a r to t h i s present one i n order to investigate any differences between extended care and intermediate care residents' l a t i t u d e of choice. This present 91 s t u d y f o c u s s e d e x c l u s i v e l y on i n t e r m e d i a t e c a r e 1 r e s i d e n t s . These r e s i d e n t s a r e ( g e n e r a l l y ) i n d e p e n d e n t l y m o b i l e w i t h o r w i t h o u t m e c h a n i c a l a i d s but r e q u i r e some h e a l t h s u p e r v i s i o n and a s s i s t a n c e w i t h a c t i v i t i e s o f d a i l y l i v i n g . A d d i t i o n a l l y , such i n d i v i d u a l s need a p r o t e c t i v e h o u s i n g environment as w e l l as s o c i a l / r e c r e a t i o n a l p r o g r a m ( s ) . Extended c a r e r e s i d e n t s , i n c o n t r a s t , r e q u i r e " a v a i l a b i l i t y o f p e r s o n a l c a r e on a c o n t i n u i n g 24-hour b a s i s w i t h m e d i c a l and p r o f e s s i o n a l n u r s i n g s u p e r v i s i o n and p r o v i s i o n f o r m e e t i n g p s y c h o s o c i a l needs" (Forbes, J a c k s o n and K raus, 1987, p. 19). G i v e n t h e d i f f e r e n c e s between i n t e r m e d i a t e c a r e 1 and e xtended c a r e r e s i d e n t s ' f u n c t i o n a l a b i l i t i e s and t h e i r needs f o r p e r s o n a l c a r e , i t would be w o r t h w h i l e f o r n u r s e s t o d e t e r m i n e any c o r r e s p o n d i n g d i f f e r e n c e s i n r e s i d e n t s ' p e r c e i v e d l a t i t u d e o f c h o i c e . I d e n t i f i c a t i o n o f any d i f f e r e n c e s would a s s i s t n u r s e s toward u n d e r s t a n d i n g e x t e n d e d c a r e and i n t e r m e d i a t e c a r e r e s i d e n t s ' l a t i t u d e o f c h o i c e i n r e l a t i o n t o t h e i r f u n c t i o n a l a b i l i t i e s . Nurses s h o u l d a l s o conduct l o n g i t u d i n a l s t u d i e s t oward i n v e s t i g a t i n g any change(s) i n i n s t i t u t i o n a l i z e d e l d e r l y r e s i d e n t s ' l a t i t u d e o f c h o i c e over t i m e . The n a t u r e of t h e change (s) and i t s / t h e i r d e t e r m i n a n t f a c t o r s a l s o s h o u l d be s t u d i e d . R e s u l t s o f such a s t u d y would a s s i s t n u r s e s (indeed, a l l h e a l t h c a r e p r o f e s s i o n a l s ) t o w a r d u n d e r s t a n d i n g t h e l o s s i n b e h a v i o u r a l c h o i c e s t h a t o c c u r w i t h r e s i d e n t s ' o v er t i m e . 92 The p o t e n t i a l r e l a t i o n s h i p between l a t i t u d e of choice and the need f o r achievement and between freedom of c h o i c e and the need f o r s e l f - e s t e e m should be i d e n t i f i e d and s t u d i e d . I f a p o s i t i v e c o r r e l a t i o n can be seen to e x i s t between l a t i t u d e of c h o i c e and the need f o r achievement and between freedom of ch o i c e and the need f o r self - e s t e e m , nurses can l e a r n t o re c o g n i z e l a t i t u d e of c h o i c e and freedom of c h o i c e as being t a n g i b l e i n d i c a t o r s of two b a s i c human needs. 93 References Avorn, J.B. & Langer, E. (1982). 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J o u r n a l of Gerontology, 31 89-98. 97 Appendix A Importance, Locus and Range of A c t i v i t i e s Checklist (Resident form) 98 Importance, Locus and Range of A c t i v i t i e s Checklist Please sta r t by reading the statement under a c t i v i t i e s . The f i r s t statement i s "What i s served at mealtime". If i t matters a l o t to you what i s served at mealtime, put a check mark ( ) under the "very important" column; i f i t matters some, but not a great deal, put a check mark under the "somewhat important" column; i f i t doesn't matter at a l l , put a check mark in the "not important" column. Then i f you f e e l you have free choice about what i s served at mealtime, put a check mark under the "free choice" column; i f you have some, but not free choice, put the check mark under the "some choice" column; i f you have no choice, put the check mark under the "no choice" column. Please do the same for a l l the other a c t i v i t i e s l i s t e d . A C T I V I T I E S HOW IMPORTANT I S THI S TO YOU? HOW MUCH CHOICE DO YOU HAVE? VERY IMPORTANT SOME-WHAT IMPORTANT NOT IMPORTANT F R E E CHOICE SOME CHOICE NO CHOICE WHAT I S SERVED A T M E A L T I M E WHAT T I M E TO E A T MEALS WHAT T I M E TO G E T UP AND TO GO TO BED WHEN TO TAKE A B A T H WHEN AND WHERE TO S E E V I S I T O R S AND F R I E N D S WHAT TV PROGRAMS TO WATCH HOW TO SPEND L E I S U R E T I M E WITH WHOM TO SP E N D L E I S U R E T I M E WHO TO HAVE FOR F R I E N D S WHAT CLOTHS TO WEAR A C T I V I T I E S HOW IMPORTANT I S T H I S TO YOU? VERY IMPORTANT SOME-WHAT IMPORTANT NOT IMPORTANT HOW MUCH CHOICE DO YOU HAVE? FREE CHOICE SOME CHOICE NO CHOICE PURSUING HOBBIES OR ACTIVITIES HOW TO SPEND YOUR MONEY WHETHER TO OFFER SUGGESTIONS ABOUT HOW THINGS SHOULD BE DONE HAVING SOMEONE TO CONFIDE IN HOW MUCH PERSONAL PRIVACY IS AVAILABLE WHAT PERSONAL POSSESSIONS TO HAVE WHO TO LIVE WITH COLOR OR WALLS, PICTURES, ETC., IN LIVING QUARTERS WHEN TO GO OUT (LEAVE LIVING QUARTERS FOR A FEW HOURS) WHETHER TO PARTICIPATE IN ORGANIZED GROUP ACTIVITIES (GAMES, SPORTS, EDUCATIONAL MEETINGS, ETC.) Appendix B Importance, Locus and Range of A c t i v i t i e s C h e c k l i s t ( S t a f f form) 102 Importance, Locus and Range of A c t i v i t i e s Checklist For each of the a c t i v i t i e s l i s t e d i n the l e f t column, w i l l you please consider how important the a c t i v i t y i s to residents, and how much choice the resident has with respect to the a c t i v i t y . For example, the f i r s t item i s "What i s served at mealtime." If you think what i s served at mealtime matters very much to residents, please check ( ) the "very important" column; i f you believe i t to be only somewhat important, check the "somewhat important" column, or i f unimportant to the resident, check the "not important" column. Likewise, i f residents have free choice regarding what i s served at mealtime, check the "free choice" column; i f they have some choice, check the "some choice" column, and i f they have no choice, check the "no choice" column. Please do exactly the same for each of the other a c t i v i t i e s l i s t e d i n the questionnaire. ro o HOW IMPORTANT I S THI S TO YOU? HOW MUCH CHOICE DO YOU HAVE? A C T I V I T I E b VERY IMPORTANT SOME-WHAT IMPORTANT NOT IMPORTANT F R E E CHOICE SOME CHOICE NO CHOICE WHAT I S SERVED A T ME A L T I M E WHAT T I M E TO E A T MEALS WHAT T I M E TO GET UP AND TO GO TO BED WHEN TO T A K E A B A T H WHEN AND WHERE TO S E E V I S I T O R S AND F R I E N D S WHAT TV PROGRAMS TO WATCH HOW TO SPEND L E I S U R E T I M E WITH WHOM TO SP E N D L E I S U R E T I M E -WHO TO HAVE FOR F R I E N D S > WHAT CLOTHS TO WEAR HOW IMPORTANT I S T H I S TO YOU? HOW MUCH CHOICE DO Y( DU HAVE? A C T I V I T I E S VERY IMPORTANT SOME-WHAT IMPORTANT NOT IMPORTANT FREE CHOICE SOME CHOICE NO CHOICE PURSUING HOBBIES OR A C T I V I T I E S HOW TO SPEND YOUR MONEY WHETHER TO OFFER SUGGESTIONS ABOUT HOW THINGS SHOULD BE DONE HAVING SOMEONE TO CONFIDE IN HOW MUCH PERSONAL PRIVACY IS AVAILABLE WHAT PERSONAL POSSESSIONS TO HAVE WHO TO L I V E WITH COLOR OR WALLS, PICTURES, ETC., IN L I V I N G QUARTERS WHEN TO GO OUT (LEAVE L I V I N G QUARTERS FOR A FEW HOURS) WHETHER TO P A R T I C I P A T E IN ORGANIZED GROUP A C T I V I T I E S (GAMES, SPORTS, EDUCATIONAL • MEETINGS, ETC.) 105 Appendix C Demographic Data Sheet (Residents) 106 Demographic Data Sheet Please complete the following: 1. Age 2. Sex 3. Marital Status 4. Where did you l i v e p r i o r to residing here? 5. 6. What was your previous occupation? Approximately what length of time have you l i v e d here? Appendix D Demographic Data ( S t a f f ) Demographic Data Sheet 108 Please complete the f o l l o w i n g q u e s t i o n s : 1. Are you a a) L i c e n s e d P r a c t i c a l Nurse b) Nurse's Aide c) R e g i s t e r e d Nurse d) other? 2. How long have you worked i n nursing? 3. How long have you worked i n long term care s e t t i n g s such as extended care u n i t s , i n t e r m e d i a t e care f a c i l i t i e s , e t c . ? 4. How long have you worked i n t h i s p a r t i c u l a r f a c i l i t y ? 109 Appendix E Resident Information L e t t e r I l l Appendix F S t a f f Information L e t t e r Appendix G Pe r m i s s i o n t o Use the Research Tool 

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