Original Manuscript

Older people’s experiences of their free will in nursing homes

Nursing Ethics 1–14 ª The Author(s) 2014 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733014557119 nej.sagepub.com

Leena Tuominen Hospital District of Helsinki and Uusimaa, Finland; University of Turku, Finland

Helena Leino-Kilpi University of Turku, Finland; Turku University Hospital, Finland

Riitta Suhonen University of Turku, Finland

Abstract Background: Older people in institutional care should be allowed to live a meaningful life in a home-like environment consistent with their own free will. Research on actualisation of older people’s own free will in nursing home context is scarce. Objectives: The purpose of this study was to describe older people’s experiences of free will, its actualisation, promoters and barriers in nursing homes to improve the ethical quality of care. Research design: Fifteen cognitively intact older people over 65 years in four nursing homes in Southern Finland were interviewed. Giorgi’s phenomenological method expanded by Perttula was used to analyse the data. Ethical considerations: Chief administrators of each nursing home gave permission to conduct the study. Informants’ written informed consent was gained. Findings: Older people described free will as action consistent with their own mind, opportunity to determine own personal matters and holding on to their rights. Own free will was actualised in having control of bedtime, dressing, privacy and social life with relatives. Own free will was not actualised in receiving help when needed, having an impact on meals, hygiene, free movement, meaningful action and social life. Promoters included older people’s attitudes, behaviour, health, physical functioning as well as nurses’ ethical conduct. Barriers were nurses’ unethical attitudes, institution rules, distracting behaviour of other residents, older people’s attitudes, physical frailty and dependency. Discussion: Promoting factors of the actualisation of own free will need to be encouraged. Barriers can be influenced by educating nursing staff in client-orientated approach and influencing attitudes of both nurses and older people. Conclusion: Results may benefit ethical education and promote the ethical quality of older people’s care practice and management. Keywords Experience, free will, nursing home, older people, phenomenological method

Corresponding author: Leena Tuominen, Helsinki University Central Hospital, Hospital District of Helsinki and Uusimaa, Turuntie 150, Espoo, PL 800, 00029 HUS, Finland. Email: [email protected]

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Background All older people do not age healthy preserving their functional capacity, but have to rely on institutional care. As the number of people over 80 years increases globally,1 attention needs to be paid to the ethical quality of older people’s care in long-term institutions. Admission to long-term care (LTC) may involve an ultimate change to older people’s existence.2 In LTC, everyday ethics often revolves around the basic activities of daily life, for example, washing, eating and toileting. Institutional rules, policies and practices can compromise older people’s autonomous choices. Institutional needs for order, safety and efficiency can also override their decisions. Sometimes caregivers can also override residents’ everyday choices,3 which are not minor decisions when they are taken away from us.4 In institutional care, it is necessary to have rules to secure the quality of care, but rules should not prevent older people from living their lives according to their own free will. It has been found that older people want to take apart in and are capable of making decisions concerning their own care.5,6 However, research has revealed that the level of freedom decreases after moving to a nursing home.6,7 Research on actualisation of older people’s free will in nursing home context is scarce. One of the basic components of free will is to feel free to choose among a variety of possibilities8 according to the values that reflect one’s personal life history.4 Actualisation of free will can be defined as freedom from obstacles to carry out one’s desires2 and also as a right to determine one’s interests, values and life free from unwarranted interference.9 Additionally, voluntariness is fundamental for free will, implying unrestrained thought or movement and unconstrained behaviour.10,11 According to Finnish law, people have the right to personal freedom12 and patient-centred care13 planned in agreement with them.14 LTC services should be implemented so that older people can feel meaningful and dignified. This means that when arriving in a nursing home older people maintain their social interaction and participate in activities which promote their well-being.15 Furthermore, the institution is considered the home of older people who live there,16 and the services are organised so that older people can have a good life in the society to which they belong.17 There are differences between countries in how nursing staff supports older people’s decision-making. In addition, compared to the older people’s own perception, nurses have a more positive view of how they support older people in these decisions.18 Older people have experienced that nurses do not always take into account their needs and hopes in nursing homes5,19–21 but make decisions on their behalf.7,22,23 Older people can usually make decisions about dressing24,25 but seldom about meals,26 toileting or when to go to shower,25,27 let alone about institutional procedures and principles.28 According to these findings, it can be concluded that older people’s free will is not actualised in institutional care. Barriers and promoters of actualisation of free will can be divided into two main categories: internal and external.2 The most common internal barrier to actualisation of older people’s free will is inability to move23,29–31 and dependency on others in everyday life.7,18,30 External barriers include staff routines,5,6,19,22,23,25,31,32 staff shortages6,19,22,32 and nurses’ rush.19,31 Furthermore, older people’s freedom of choice is prevented by institutional rules6,22,26 and power exercised by nurses.18,25,33 Internal promoters of own free will include factors such as health,6,29capacity to make decisions7,19 and strong zest of life.30 External promoters include social support from significant others6,30 or from nurses. In addition, conversational connection with nurses, knowing the resident, taking account of their wishes19 as well as nurse education, especially in ethical questions, are external factors promoting older people’s own free will.6,19 In older people’s care, attention is rarely given to non-dramatic events, everyday ethics that influence the quality of care.34 Internationally, there is a lack of evidence of how older people define their own free will and how it is actualised in their daily lives in nursing home context. The purpose of this study was to describe how

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Table 1. Interview guide. What does actualisation of own free will stand for you? – Define free will – If it is said that your own free will actualises, what does it mean to you? How does those things you mentioned actualise in this nursing home? – Can you choose when to go to bed or wake up in the morning? – Can you make wishes, for example, concerning food – Are they being taken into account? Is it possible to go to toilet when necessary? Is it possible to make decisions what to wear? Is it possible to go out as you wish? Is it possible to spend time alone/with others as you like? Is it possible to be engaged for a hobby or take apart in activities? What promotes own free will? – Nurse-related issues – Older people–related issues – Organisation-related issues What prevents own free will? – Nurse-related issues – Older people–related issues – Organisation-related issues

older people define free will and how they experience its actualisation, promoters and barriers in nursing homes. The knowledge provided by this study may be used for improvement of the ethical quality of LTC.

Methods Sample Data were collected with purposive sampling from April to June 2012 in four public nursing homes in Southern Finland. A purposive sample of 15 persons took part in the study (8 women and 7 men), who had lived in the facility from 4 months to 15 years (mean 2 years). Their ages were between 68 and 96 years (women’s mean age: 82 years and men’s mean age: 79 years). The nursing homes were one- or threestory buildings situated in medium-size municipalities with 10,000–50,000 inhabitants. Each ward had 14–23 residents with various general ageing-related problems including dementia. The nurses in charge were asked to select the participants using the following criteria: over 65 years, no diagnosis of dementing disease, healthy enough to take part in interviews and having lived in the facility for more than 3 months. The informants were visited for further information and to make reliable impression. Only one person refused to participate due to fatigue. Those who consented found it important to impact the ethical quality of the care of the nursing home residents.35,36

Interviews The descriptions of the phenomenon were elicited through open-ended unstructured interviews37 (Table 1). An interview guide based on previous studies was used,5,6,19–30 pre-tested in two pilot interviews, evaluated with the research group and used during the interviews. Small talk was used to establish a relaxed and confidential atmosphere.36 The emphasis was on facilitating the informants to talk about their everyday experiences about the topic. During the interviews, clarifying questions were asked to seek further exploration.38

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The interviews lasted 25–90 min (mean 68 min) and were conducted once in each informant’s private room with only a few interruptions by the nursing staff or relatives. Interviews were ended if the informant was tired or signalled that there was nothing more to say. Interviews were type recorded with permission of the informants and field notes were made after each interview39 to help the analysis.

Data analysis Descriptive phenomenological method was used to capture the essence of the researched phenomena in this qualitative study. Perttula’s modification of Giorgi’s phenomenological method was considered systematic and precise to analyse the essential meaning of the older people’s lived experience (Table 2). The aim of the analysis was to clarify the meaning of free will and how it appears to older people.43 The phenomenological reduction was used to experience the phenomenon with an open mind to understand it precisely without natural attitude. The preconceptions of the subject were written down and deliberately abstained from before the analysis. This is called bracketing. Free imaginative variation was employed during the analysis to determine which of the transformed meaning units were essential for the phenomenon under study40,43–45 and to justify the articulations of both the essential meanings and the general structure.37 The individual net of meaning was created at the first phase of the analysis. It is an explicit and systematic narration of how the phenomenon of free will appears in the life world of each informant. While creating the universal net of meaning, condensed meanings of each individual net of meaning were found and integrated into a consistent statement39,40 indicating the findings of the study.

Ethical considerations Chief administrators gave their permission to conduct the study. According to Finnish Advisory Board on Research Integrity,46 submitting the research plan for ethical review was not necessary. The informants were given both verbal and written information to explain the method and the aim of the study. The informants’ freely given written informed consents were gained. Voluntariness and withdrawal without explanation was emphasised, as was the fact that refusal had no effect on care. Privacy was respected by conducting the interviews in private rooms at a convenient time. The length of each interview was adapted to the informant’s capacity to concentrate. The data were handled confidentially and recordings were disposed of after having been transcribed verbatim. Confidentiality may cause tensions between the professional obligations as a nurse and being a nurse as researcher. According to the ethical code, nurse has to take appropriate action to safeguard individuals when their health is endangered by a co-worker or any other person.47 At the same time, researcher’s task does not include revealing information about individual subjects to authorities. It is unacceptable to reveal information on research data in such a way that it could influence the treatment of informants.48 However, nurse researchers have ethical obligations to safeguard the rights and interests of patients regardless of the role the nurse assumes. In this study, no such adverse events were found that would have called for immediate authority actions. The results of this study have been reported to the managers of each nursing home involved. It is the responsibility of the nurse leaders in each nursing home to intervene in unethical behaviour revealed in this study. The results have also been discussed in national conference of nursing science and research.

Findings The findings are presented according to the purpose of the study. They describe how older people define own free will and their experiences of its actualisation, promoters and barriers in nursing homes. In this

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Table 2. Phases and examples of the analysis.40–42 Phases

Data examples

I. Creating the individual net of meaning – 1. The interviews were transcribed verbatim. A phenomenological method was assumed by bracketing. The texts were read with an open mind several times to gain an overall impression of the text as a whole 2. The domains of content (1–4) were formed 1. Own free will as it is experienced by older people 2. Actualisation of own free will in nursing home 3. Promoters of own free will 4. Barriers to own free will 3 and 4. The meaning units were separated from data and ‘ . . . I groan immensely if I don’t have enough strength to transformed into scientific language do something or at least become passive, don’t take part or say nothing . . . then they realise that oh, well, now she has been insulted . . . ’ (2/31/I). ACTUALISATION OF FREE WILL IS PROMOTED BY GROANING ALOUD, BECOMING PASSIVE AND NOT TALKING (2/31/I) 5. Each meaning unit and its fraction were placed in one of 1. Own free will as it is experienced by older people the four domains of content ‘ . . . own will means that if I have a variety of needs that don’t belong to treatment, so that they would be listened, too . . . for example if I want to go shopping – because I can’t go unless someone comes with me – it means a great deal to me, that I can buy for example a chocolate bar . . . ’ ACTUALISATION OF HER OWN WILL MEANS THAT NEEDS SIGNIFICANT TO HER ARE LISTENED TO AND FULFILLED (9/1/I) 6. Fractions were located close to each other Own free will means to her that needs significant to her are listened to and fulfilled. It means that she is not treated as an object without taking account of her opinion (9/1/I) 7. The individual net of meaning was created ‘ . . . She can decide where and with whom to eat. She is satisfied with the food but hopes to have more often cosy food e.g. pancakes and potatoes. She believes her hopes wouldn’t come true even if she asked for it . . . ’ II. Creating the universal net of meaning 8. Individual nets of meaning were combined and domains Sometimes she has disagreed with nurses and would have liked to do things differently. TO DISAGREE WITH of content were formed. The text was condensed into NURSES (1/1/II) researcher’s language Sometimes she has to adjust to decisions the nurses have made. ADJUSTMENT TO THE DECISIONS NURSES HAVE MADE (1/1/II) Sometimes she has to wait for help. ONE HAS TO WAIT FOR HELP (2/1/II) 9. Data were read through thoroughly several times and 1. Experience of one’s own free will content areas were formed (1–5) 2. Experiences of satisfaction 3. Experiences of dissatisfaction 4. Meanings that strengthen one’s experiences of actualisation of free will 5. Meanings that weaken one’s experiences of actualisation of free will (continued)

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Table 2. (continued) Phases

Data examples

10. Each meaning unit was placed in one of the five domains of content

1. Experience of one’s own free will Own free will means that she can do what she has planned and action is consistent with her own mind. POSSIBILITY TO DO WHAT ONE HAS INTENDED TO DO, ACTIVITY CONSISTENT WITH ONE’S OWN MIND (1/1/II) Own free will is a possibility to do something according to her own mind. TO ACT ACCORDING TO ONE’S OWN MIND (3/1/II) 1. Experience of one’s free will a. Action consistent with one’s mind Own free will means action consistent with one’s own mind and possibility to do what one has intended to do (1/II) Own free will is possibility to act according to one’s own mind (3/II) Own free will means acting a way that is best for one’s own interest (4/II) I. I. Experience of one’s own free will Ia. Action consistent with one’s own mind Own free will means action consistent with one’s own mind and possibility to do as one has intended (1/ii) Own free will is possibility to act according to one’s own mind (3/II) Own free will means acting in a way that is best for one’s own interest (4/II) Own free will is freedom to move and do whatever one wants (6/II) Own free will is possibility to spend time in a cosy place (11/II) 1a. Own free will means action consistent with one’s mind, possibility to move and spend time in a cosy place Experience of one’s own free will Own free will means action consistent with one’s own mind, freedom to move and spend time in a cosy place. Own free will means possibility to influence one’s own affairs and make decisions. It means possibility to determine one’s personal matters. It is holding on to one’s rights . . . Deteriorating physical function and sickness are most commonly experienced barriers to actualisation of free will as well as dependency on nurse’s help in everyday life. Unwillingness to be a burden or having a fear endangering one’s own situation in nursing home as a result of complaining. As a barrier there is a common belief that wishes will not come true . . .

11. Each domain of content was divided into more specific content areas. The meaning units including condensed meaning were placed in these specific content areas

12. Each meaning unit including condensed meaning was placed close to each other based on their content. Specific universal net of meaning is created of each specific content area

13. The specific universal meaning units of each content area were connected with each other

14. The universal net of meaning was created

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Table 3. Actualisation of own free will in nursing homes. Own free will actualises

Own free will does not actualise

Social interaction with relatives Visits of relatives Regulating one’s privacy Having own room Visiting old home

Convenient recreation Convenient company Receiving help Receiving help on time Having bedpan, going to toilet or having incontinency pad changed when wished Shower day and arrangements Maintenance of own clothes Food, its texture, taste and portion size Mealtimes Time of getting up in the morning Free movement Outdoor exercise External services Seeing a doctor

Availability of help 24 h Wearing own clothes Having less food than offered Staying awake late in the evening in own room

study, the term ‘nurse’ refers to all persons with a professional healthcare training participating in the older people’s care. Older people experienced own free will as an action consistent with their own mind. This included the possibility to move freely both inside and outside the nursing home. It also included the possibility to spend time in a desired place, for example, own room, outdoors or old home. In addition, free will was perceived as a possibility to make decisions and influence their own affairs in nursing homes. Furthermore, own free will was experienced as holding on to one’s rights which meant that one should not be dominated or suppressed. Actualisation of own free will appear as older people’s satisfaction or possibility to influence personal matters in nursing homes (Table 3). Older people experienced that it was possible to influence bedtime because they were allowed to watch TV, listen to the radio or read in the bed late into the evening. They could regulate their privacy, for example, spending time in their own room or shared parlour. They felt satisfaction with the social life in the nursing home, including visits by relatives and opportunity to visit their old homes. They were satisfied with the availability of help 24 h a day and the possibility to wear their own clothes. Free will was also actualised when older people felt that they could have less food than was offered. Older people experienced that recreation and company in nursing homes were not consistent with their free will. Urinary and bowel functions were a common issue on which older people experienced they had no possibility to make decisions. Not getting help on time or being forced to wait was a common experience, for example, having to use a bedpan instead of toilet or wear wet incontinence pads for too long. In the older people’s experience, they had no say in when or how to take a shower as it was decided by the nurses. Older people had the possibility to wear their own clothes, but experienced difficulty having them safely handled in the laundry. They expressed having no opportunity to influence the frequency of meals or their texture, quality, taste or portion size. Furthermore, they experienced that they had little say about what time to get up in the morning. They experienced having no possibility to move freely both inside and outside the ward. Additionally, they experienced missing outdoor exercise and external services, for example, pedicure. They also experienced that opportunities to meet a doctor were scarce. Promoters of free will resulted from the older people themselves, nurses, external services and relatives (Table 4). Promoting factors associated with the older people themselves were the idea that they could promote their free will by getting along with nurses, for example, by conducting themselves humbly and

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Table 4. Promoters and barriers of own free will in nursing homes. Promoters

Barriers

Older people Older people Adaptation to institution’s procedure To get along with nurses Not want to be a trouble Resisting nurse’s orders Fear of worsen own situation as a result of complaining Persistence Belief that things are not going to change Asking bravely for help Deteriorated health and physical functioning Expressing own opinion Dependency on help Expressing the faults Restricted movement Holding on to own rights Health and functional capacity Nurse Nurse Unethical conduct Equal treatment Nurse’s attitude Flexibility Organisational perspective Positive attitude Lack of professional skills Willingness to help Respect of older people and their needs Understanding the importance of free will Professional skills of the permanent healthcare workers Own nurse External services Organisation Meaningful activities Resident’s placement on the ward Relatives Large number of residents Guardians of older people’s rights Lack of possibilities to meet the manager Restricted opportunity to influence organisational matters Savings focused at staff resources Savings focused at outdoor assistants Savings focused at gymnastic exercise Savings focused at incontinence pads Savings focused at food quality Physical environment Security orders and control

politely or being obedient. Another way to promote one’s will was to resist nurses’ orders by undertaking passive resistance, for example, refusing to talk or eat. Some made active resistance and protested against nurses’ orders by being persistent or complaining aloud. Also asking bravely for help, expressing one’s own opinion, needs or faults and holding on to one’s own rights were commonly used methods to enhance one’s free will. Older people experienced that one of the major promoters of free will was good physical functioning and health, which impacted the ability to demand rights. Promoters of free will associated with nurses included equal and flexible behaviour, positive attitude and willingness to help. In addition, older people experienced their own will to be actualised when nurses respected them and their needs as well as understood the importance of their own free will. A professionally skilled nurse or primary nurse was also experienced as significant promoters of older people’s free will. Promoters of free will associated with external factors included meaningful activities when they were arranged according to older people’s needs. External service providers were experienced as important promoters fulfilling older people’s needs.

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Relatives were experienced as promoting older people’s own free will and were considered as essential guardians of their rights. The relatives were usually mothers, daughters or sons. Barriers of free will were originated from the older people themselves, the nurses, other residents and the organisation (Table 4). Barriers of free will associated with the older people themselves were such as adaptation or settling to the institution’s procedures and not wanting to cause trouble. Some of them experienced fear of worsening their own situation as a result of complaining. The older people believed that things would not change even though they complained or made wishes. Deteriorating health and poorer physical functioning as well as dependency on help in everyday life were experienced as common barriers to free will in nursing homes. A barrier to free will originating from nurses was their unethical conduct. This included making decisions on behalf of older people. Nurses’ attitudes, including arbitrary, power-seeking or manipulative behaviour as well as a negative attitude towards requests of help, were also experienced as a barrier of actualisation of free will. Nurse’s way of viewing their work from the institution’s perspective was experienced as a barrier to the actualisation of own free will when certain routines and schedule set the pace of the day in nursing homes. Lack of professional skills on the part of the nurse was also one of the barriers experienced. This included, for example, laziness, lack of interest or inflexible behaviour. As a result, older people experienced the possibility of having their wishes realised as nurse-specific. Barriers to free will associated with other residents included residents’ placement on the ward. Older people were scared of the distracting behaviour and poor condition of other residents’, which is why they avoided shared parlour during mealtime, for example. Other residents’ different interests were also experienced as reasons to avoid interaction. Because of the large number of residents, older people did not always receive help when needed which was experienced as a barrier to their own free will. Barriers to free will associated with the organisation included having no possibilities to meet the manager to influence organisational matters. The older people experienced that the nursing homes suffered from economic cuts which focused on staff resources, outdoor assistants, exercise, incontinence pads and food quality. Factors in the physical environment such as door code numbers and difficulty to move through heavy doors limited free movement, which was experienced as a barrier of own free will. Regulations, supervision as well as security orders of the nursing home gave some of the older people the experience of being in prison.

Discussion The purpose of this study was to describe older people’s experiences of free will and its actualisation, promoters and barriers in nursing homes. Older people experienced their own free will related to their actions, rights and decision-making. According to the findings, older people experienced that their own free will is not actualised in nursing homes. According to patient rights, we must take into account the older people’s needs and encourage them to participate in decisions relating to their well-being.47 This basic right does not change when moving into institutional care. The informants were mainly representatives of the WWII generation and thus used to being content with little in life. In the future, the expectations may rise because people are accustomed to a certain level of service and make their own choices. Healthcare workers must learn to plan care together with older people based on their individual needs. Kukla49 refers conscientious autonomy which requires that healthcare professionals are responsibly and critically committed to the rightness of their own practices. When they act conscientiously, they act out of a commitment to uphold principles, practices and values that they take as their own normative standards. Healthcare professionals need to acknowledge and examine the authoritative role they play while delivering care. They need to find ways to use their role to enhance practices that express the integrity and dignity of their practitioners.

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Older people in nursing homes missed appropriate company, which may be difficult to arrange if cognitively impaired residents are placed together with cognitively intact older people. In addition, older people experienced they had to wait for help. Ethically difficult situations may arise when nurses are not able to offer older people care based on their needs. More consideration is therefore needed on how older people with different needs of care are placed on a ward. Older people’s ways to promote their free will by using active or passive resistance have not come forth in previous studies. When this kind of behaviour is not possible, the responsibility of promoting older people’s own free will falls entirely on the carer. Her ethical conduct is in a dominant role with flexible procedures, respect towards own free will and equal treatment being the key promoting factors. Older people experienced that nurses seemed to lack respect towards their own free will. This is in line with previous research indicating that older people perceive that their individual needs are not always met.6,19,21,30,31 There is a lack of conversation between older people and nursing staff to enable the individual needs of older people.6 Knowing the person has been perceived as essential for nurses when they solve ethical problems in nursing home.32 The previous life history of older people is worth knowing as it may help nurses to understand and respect the individual life lived. According to Agich,10 autonomy is socially situated and choice is always contextual. He points out that even when individuals are afforded plenty of choices, their autonomy may not be significantly enhanced because the choices available may not be meaningful for individuals involved. In addition, choice that enhances autonomy allows older people to express and develop their own individuality. Furthermore, the score sense of respecting autonomy involves treating individuals as unique individuals. Nurses’ organisational attitude, routines and schedules seem to run counter to older people’s will, in line with previous studies.5,19,22,23,31,32 Some nurses seem to consider their work from the organisation’s perspective when making decisions on care,6 for example, evening routines often set the pace of bedtime in nursing homes.25 This study articulated that older people have possibilities to make decisions at least when they are in line with the routines or do not cause extra work for the nurses. According to Kukla,49 the norms and standards of health practice present themselves as already authoritative and in place so they are largely found rather than chosen. She points out that informed, free choice would not be autonomous if one has not capacity to assess one’s own commitments, which requires that we have a fair amount of justifiable selftrust. This should be encouraged in older people’s care. Much of healthcare is made up of decisions and practices whose source is a complex combination of external, found authority and responsible commitment. In the evening, older people were helped in bed at a certain time, while in the morning they were not helped before breakfast. The same result has been found in previous studies,26,27 for example, older people were awakened according to breakfast or room order.25 Similarly, older people experienced that they had no opportunities to influence nutritional matters because ‘it is the institution’s kitchen’. Nurses have to recognise their role as agents in carrying the older people’s wishes forward. Further research is needed to identify more thoroughly the grounds for these organisational barriers to free will in older people’s care in order to prevent them. Older people experienced physical frailty and dependency on nurses’ help as a barrier to their own free will. This is in line with previous studies.7,22,23,29,30 Even if older people have a free will to make decisions, for example, having a bedpan, having incontinence pads changed or getting up from bed, they do not necessarily have autonomy to execute these decisions. We cannot talk about patient-centred care in this case. Also, environmental barriers6,22,23,26,31,32 such as heavy doors and door codes were experienced as barriers to own free will. Instead of decreasing older people’s ability to act, nurses must support older people’s resources to execute their own free will. This is an educational issue that needs more attention. It has been discovered internationally that educational requirements for LTC workers vary significantly, and their qualification requirements are few. Furthermore, less than a third of Organisation for Economic Co-operation and Development (OECD) countries collect systematically LTC quality measures, such user satisfaction,

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quality of life and service user’s rights. Public reporting on LTC quality has been shown to be effective in some countries encouraging care providers to improve their standards.50 Finnish nursing homes that are using international Resident Assessment Instrument (RAI) belong to Service Scale of National Institute for Health and Welfare. It gathers and publishes comparable information regarding older people’s LTC. This transparent and open information helps nursing homes to develop their care policies. RAI can be used, for example, to create individual care plan and measure quality of care and its efficacy.51 Main principle of the Quality recommendation for older person’s services by Finnish Ministry of Social Welfare and Health is to make older people’s voices heard in all decision-making that concerns them even when having lost some of their functional capacity.52 The responsibility to implement this recommendation rests mainly in the hands of manager of each nursing home.

Validity and limitations The credibility of the research was confirmed by avoiding interpretation and conceptualisation of the data and by maintaining the connection between original data and results during the analysis. Therefore, it can be assumed that the experiences of the informants correspond with the results. The study may be considered credible because of the bracketing during the analysis. However, the degree of objectivity in phenomenological research is questionable. It is difficult to assess the consistency of the results in qualitative research53,54 as each interview and interaction was different. The informants represented both genders and different ages, giving rich data on the subject. The rather small sample size proved to be sufficient to uncover core elements of the phenomenon. Based on previous description of the research design, it may be evaluated by the reader to which extent the findings can be transferred to other settings.54,55 It is a limitation of the study that bracketing was not done until after the interviews.53,54,56,57 Therefore, it was not possible to implement the interviews of older people as open and free as required by the phenomenological method. Many of the informants needed additional questions because of minor cognitive deficiency and the challenging topic. In addition, the nurse in charge selected the informants which may create a risk of selection bias.

Conclusion This study revealed that there is still much to be done to fulfil the spirit of the new Finnish law which supports the functional capacity of the older population and the social and health services for older people.15 The need for this legislation is clear since older people’s free will is not always actualised in nursing homes at the moment. There is a need to start thinking of nursing homes as older people’s homes instead of a place where older people are nursed. The actualisation of older peoples’ own free will would be promoted significantly by simply asking them what they want. Further research is needed on the means with which the actualisation of free will can be promoted in older people’s care. Everyday ethical discussion and reflection on ethically difficult situations in older people’s care is important to support nurses to take account of older people’s free will in nursing homes. Discussion of free will in work community may improve ethical consciousness. What is free will in nursing home context – how is it respected in everyday life particularly in this ward? It is useful to reflect one’s own nursing practice and compare it to organisation’s values and principles. It is essential to explore the interventions to enhance older people’s autonomy in LTC. The findings of this study provide an important message for education updating. Older people’s care management can also benefit from these findings while ensuring the ethical quality of care for older people.

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Older people's experiences of their free will in nursing homes.

Older people in institutional care should be allowed to live a meaningful life in a home-like environment consistent with their own free will. Researc...
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