ht.
J. Nurs.
Stud.
Vol. 14, pp. 69.76, Pergamon
Press,
1977. Printed
in Great
Britain
Choosing living arrangements for the elderly MARGARET R. GRIER, R.N., Ph.D. University
oflllinois
College of Nursing, at the Medical Center Chicago, Illinois U.S.A.
Many older people live in situations not in keeping with their needs. Daily living can be eased or worsened by the environment, Bratman (1974), and living arrangements which support older peoples’ decreasing physiological, psychological, and sociological capacities are essential, Beattie (1973). Studies suggest that for older people inappropriate living arrangements can result in hospital readmissions, serious impairment in functioning, and sometimes even death, Kelman and Muller (1967); Lieberman (1969). Knowledge is needed regarding what living situations are available to the aged, what is expected from those living situations, and what is desirable in the living situation, if living arrangements conducive to maintaining well-being during the aging process are to be chosen. Two descriptive studies concerning the choosing of living arrangements were conducted to gain understanding of how both nurses and elderly people select living situations for the elderly. The process of decision making was studied since this process focuses on variables pertinent’ to choosing living arrangements, and also provides a means for selecting living arrangements. Decision making
Decision making is the choosing of an action from among a set of alternatives. The process of decision making is the cognitive course of choosing an action from among a set of alternative actions. The process of choosing a living arrangement involves consideration of the following variables: alternative living arrangements, possible outcomes of the living situations, likelihood of those outcomes occurring, importance of the outcomes, and finally the choice of living arrangement itself, Kast and Rosenzweig (1974). Decision making can be classified as intuitive or quantitative. Intuitive decision making is the process of making choices without the conscious use of reasoning. A person can intuitively select a living arrangement without giving conscious consideration to alternative situations or without recognizing possible outcomes. With intuitive decisions the process for making a choice is neither objective nor systematic. Quantitive decision making is the process of making choices with the use of mathematics. Alternative living arrangements must be recognized and outcomes of the 69
70
MARGARET R. GRIER
situations must be determined in order to quantify decision making. The likelihood of each outcome occurring with each alternative is estimated, and a numerical value is assigned to each outcome according to its importance. The quantified choice is made by multiplying, for each alternative, the probability for the outcome times the value of the outcome [Z (P X u)]. The alternative with the highest number is the quantitive choice. The process of making a choice becomes systematic and objective when decision making is quantified, Kast and Rosenzweig (1974). Decision makers, or persons choosing a living situation for the aged, could be an older person, a family member, a significant other person, a health care worker, or any combination of these people. The value system, goals, personality, and environment of the person making the decision can influence the choice of action.
Methodology Subjects, or decision makers, in the study were all the registered nurses actively employed by a home visiting nurses association (VNA) in a large metropolitan area, registered nurses assigned to day duty on medical-surgical units of a general hospital located in the same area as the VNA, and elderly people from a geriatric center willing to participate in the study. The geriatric center was located in a different geographic area than the VNA and hospital. Data were analyzed and compared for 62 subjects, 21 visiting nurses, 25 medical-surgical nurses, and 16 elderly people. The elderly subjects ranged in age from 63 to 81 yr, and the age range of nurse subjects was 23-54 yr. Two elderly subjects and one nurse subject were male. No names or other identification were obtained for protection of the subjects. Data were collected from groups of 2-11 nurses in conference rooms of the VNA and hospital. Data were collected from each group of nurse subjects within 1 hr, between 9 and 12 in the morning. Data from all nurses were obtained over a 2 week period. Data were collected from elderly subjects 1 yr after collecting data from nurses. Data were collected from elderly subjects, either individually or in groups of two, in a quiet comer of the geriatric center. Data were collected from each elderly person within thirty minutes, between one and four in the afternoon. Data from all elderly subjects were obtained over a 4 week period. Less time was needed for collecting data from the elderly because only one decision process by elderly subjects was investigated while four decision processes by nurses were assessed, Grier (1976). The research instrument for the nurse subjects was composed of written descriptions of four patient situations. In developing the instrument, 100 patients’ records from the VNA were reviewed in order to identify recurring nursing decisions, and the two problems of mobility and future living arrangements for the elderly were used for decision making. Analysis of the data collected from nurse subjects revealed that visiting and hospital nurs& differed significantly in choosing living arrangements for one patient, a Mr. Thomas, Grier (1976). The Thomas situation, therefore, was subsequently used to investigate elderly peoples’ choosing of living arrangements. The instrument used for data collection with elderly subjects differed in the following ways from the instrument used for nurse subjects: 1. Only one decision making situation was included instead of four. 2. The decision making situation comprised more pages since larger type was used. 3. Different terms were used for some of the outcomes (food for diet, housekeeping
CHOOSING LIVING ARRANGEMENTS
FOR THE ELDERLY
71
for environment), although descriptions of the outcomes were the same. The tool used for data collection is presented in the appendix. The alternative living arrangements (actions) and needs to be met (outcomes) were based on VNA records and on findings in the literature. A face sheet containing descriptions of the outcomes was attached to the instrument. A paired comparison of the outcomes was also included in the instrument, in a counterbalanced manner, in order to obtain a measure of the importance of the outcomes without reference to a specific situation. Three experts, a geriatric nurse, a gerontologist, and a supervisor of visiting nurses, judged if the cues given for decision making were adequate for making the decisions and were typical of information usually available for selecting living arrangements. The instrument was pretested on 14 medical-surgical nurses from a general hospital and on 5 older people living in the community. Data were collected by having subjects make choices between three living arrangements for Mr. Thomas: his own apartment, his son’s home, or a nursing home. Subjects ranked the three living situations according to which was most suitable for Mr. Thomas. This decision was considered to be intuitive. After ranking the living situations, subjects indicated the probability (o-100) of each of the seven needs (activity, diet, environment, health care, medication, self care, and social) being met in each of the three living situations, and assigned a value to each need (o-100) according to its importance. The quantitative decision was computed by the investigator from the probabilities and values [ c (P x u)] for each alternative, and the living situation having the highest number was the quantitative choice. FhdhgS
The intuitive and quantitative choices of living arrangements for Mr. Thomas are presented in Tables 1 and 2 respectively. Almost half of the elderly intuitively chose Mr. Thomas’ own apartment and more than a third chose the nursing home. In comparison, most visiting nurses chose own apartment and most hospital nurses chose the nursing home as the best living arrangement for Mr. Thomas. None of the visiting nurses, and few hospital nurses, intuitively chose the son’s home, although 18% of the elderly made this choice. The three groups of subjects differ significantly in their intuitive choice of living arrangement, although no significant differences are present between the three groups in their quantitative choice of living arrangement. In using mathematics to choose a living situation (Table 2), all three groups of subjects most frequently choose the nursing home for Mr. Thomas. Table 1. Nurses’ and elderly people’s intuitive choice of living arrangements for Mr. Thomas
Choice
Own apartment Son’s home Nursing home 2 = 23.53;P
Visiting nurses (n=21)
Hospital muses (n=25)
Elderly people (n=16)
85.71% 0.00%
20.00% 8.00%
43.75%
14.28%
72.00%
J. Nurs.
Stud.
Vol. 14, pp. 69.76, Pergamon
Press,
1977. Printed
in Great
Britain
Choosing living arrangements for the elderly MARGARET R. GRIER, R.N., Ph.D. University
oflllinois
College of Nursing, at the Medical Center Chicago, Illinois U.S.A.
Many older people live in situations not in keeping with their needs. Daily living can be eased or worsened by the environment, Bratman (1974), and living arrangements which support older peoples’ decreasing physiological, psychological, and sociological capacities are essential, Beattie (1973). Studies suggest that for older people inappropriate living arrangements can result in hospital readmissions, serious impairment in functioning, and sometimes even death, Kelman and Muller (1967); Lieberman (1969). Knowledge is needed regarding what living situations are available to the aged, what is expected from those living situations, and what is desirable in the living situation, if living arrangements conducive to maintaining well-being during the aging process are to be chosen. Two descriptive studies concerning the choosing of living arrangements were conducted to gain understanding of how both nurses and elderly people select living situations for the elderly. The process of decision making was studied since this process focuses on variables pertinent’ to choosing living arrangements, and also provides a means for selecting living arrangements. Decision making
Decision making is the choosing of an action from among a set of alternatives. The process of decision making is the cognitive course of choosing an action from among a set of alternative actions. The process of choosing a living arrangement involves consideration of the following variables: alternative living arrangements, possible outcomes of the living situations, likelihood of those outcomes occurring, importance of the outcomes, and finally the choice of living arrangement itself, Kast and Rosenzweig (1974). Decision making can be classified as intuitive or quantitative. Intuitive decision making is the process of making choices without the conscious use of reasoning. A person can intuitively select a living arrangement without giving conscious consideration to alternative situations or without recognizing possible outcomes. With intuitive decisions the process for making a choice is neither objective nor systematic. Quantitive decision making is the process of making choices with the use of mathematics. Alternative living arrangements must be recognized and outcomes of the 69
70
MARGARET R. GRIER
situations must be determined in order to quantify decision making. The likelihood of each outcome occurring with each alternative is estimated, and a numerical value is assigned to each outcome according to its importance. The quantified choice is made by multiplying, for each alternative, the probability for the outcome times the value of the outcome [Z (P X u)]. The alternative with the highest number is the quantitive choice. The process of making a choice becomes systematic and objective when decision making is quantified, Kast and Rosenzweig (1974). Decision makers, or persons choosing a living situation for the aged, could be an older person, a family member, a significant other person, a health care worker, or any combination of these people. The value system, goals, personality, and environment of the person making the decision can influence the choice of action.
Methodology Subjects, or decision makers, in the study were all the registered nurses actively employed by a home visiting nurses association (VNA) in a large metropolitan area, registered nurses assigned to day duty on medical-surgical units of a general hospital located in the same area as the VNA, and elderly people from a geriatric center willing to participate in the study. The geriatric center was located in a different geographic area than the VNA and hospital. Data were analyzed and compared for 62 subjects, 21 visiting nurses, 25 medical-surgical nurses, and 16 elderly people. The elderly subjects ranged in age from 63 to 81 yr, and the age range of nurse subjects was 23-54 yr. Two elderly subjects and one nurse subject were male. No names or other identification were obtained for protection of the subjects. Data were collected from groups of 2-11 nurses in conference rooms of the VNA and hospital. Data were collected from each group of nurse subjects within 1 hr, between 9 and 12 in the morning. Data from all nurses were obtained over a 2 week period. Data were collected from elderly subjects 1 yr after collecting data from nurses. Data were collected from elderly subjects, either individually or in groups of two, in a quiet comer of the geriatric center. Data were collected from each elderly person within thirty minutes, between one and four in the afternoon. Data from all elderly subjects were obtained over a 4 week period. Less time was needed for collecting data from the elderly because only one decision process by elderly subjects was investigated while four decision processes by nurses were assessed, Grier (1976). The research instrument for the nurse subjects was composed of written descriptions of four patient situations. In developing the instrument, 100 patients’ records from the VNA were reviewed in order to identify recurring nursing decisions, and the two problems of mobility and future living arrangements for the elderly were used for decision making. Analysis of the data collected from nurse subjects revealed that visiting and hospital nurs& differed significantly in choosing living arrangements for one patient, a Mr. Thomas, Grier (1976). The Thomas situation, therefore, was subsequently used to investigate elderly peoples’ choosing of living arrangements. The instrument used for data collection with elderly subjects differed in the following ways from the instrument used for nurse subjects: 1. Only one decision making situation was included instead of four. 2. The decision making situation comprised more pages since larger type was used. 3. Different terms were used for some of the outcomes (food for diet, housekeeping
CHOOSING LIVING ARRANGEMENTS
FOR THE ELDERLY
71
for environment), although descriptions of the outcomes were the same. The tool used for data collection is presented in the appendix. The alternative living arrangements (actions) and needs to be met (outcomes) were based on VNA records and on findings in the literature. A face sheet containing descriptions of the outcomes was attached to the instrument. A paired comparison of the outcomes was also included in the instrument, in a counterbalanced manner, in order to obtain a measure of the importance of the outcomes without reference to a specific situation. Three experts, a geriatric nurse, a gerontologist, and a supervisor of visiting nurses, judged if the cues given for decision making were adequate for making the decisions and were typical of information usually available for selecting living arrangements. The instrument was pretested on 14 medical-surgical nurses from a general hospital and on 5 older people living in the community. Data were collected by having subjects make choices between three living arrangements for Mr. Thomas: his own apartment, his son’s home, or a nursing home. Subjects ranked the three living situations according to which was most suitable for Mr. Thomas. This decision was considered to be intuitive. After ranking the living situations, subjects indicated the probability (o-100) of each of the seven needs (activity, diet, environment, health care, medication, self care, and social) being met in each of the three living situations, and assigned a value to each need (o-100) according to its importance. The quantitative decision was computed by the investigator from the probabilities and values [ c (P x u)] for each alternative, and the living situation having the highest number was the quantitative choice. FhdhgS
The intuitive and quantitative choices of living arrangements for Mr. Thomas are presented in Tables 1 and 2 respectively. Almost half of the elderly intuitively chose Mr. Thomas’ own apartment and more than a third chose the nursing home. In comparison, most visiting nurses chose own apartment and most hospital nurses chose the nursing home as the best living arrangement for Mr. Thomas. None of the visiting nurses, and few hospital nurses, intuitively chose the son’s home, although 18% of the elderly made this choice. The three groups of subjects differ significantly in their intuitive choice of living arrangement, although no significant differences are present between the three groups in their quantitative choice of living arrangement. In using mathematics to choose a living situation (Table 2), all three groups of subjects most frequently choose the nursing home for Mr. Thomas. Table 1. Nurses’ and elderly people’s intuitive choice of living arrangements for Mr. Thomas
Choice
Own apartment Son’s home Nursing home 2 = 23.53;P
Visiting nurses (n=21)
Hospital muses (n=25)
Elderly people (n=16)
85.71% 0.00%
20.00% 8.00%
43.75%
14.28%
72.00%
