PRACTICE DEVELOPMENT – AUTONOMY FOR OLDER PEOPLE IN RESIDENTIAL CARE

Enhancing autonomy for older people in residential care: what factors

affect it?

Vivien Rodgers RN, BA, BN, GDGN, MN

Lecturer, School of Health & Social Services, Massey University, Palmerston North, New Zealand

Claire Welford MSc

Lecturer, Department of Nursing, National University of Ireland Galway, Galway, Ireland

Kathy Murphy BA, MSc, PhD, RNT, RGN

Professor, Nursing and Midwifery Studies, National University of Ireland Galway, Galway, Ireland

Theresia Frauenlob RN, M.Phil

Researcher, Faculty of Health, University of Witten/Herdecke, Witten, Germany

Submitted for publication: 16 September 2011

Accepted for publication: 20 December 2011

Correspondence:

Vivien Rodgers

School of Health & Social Services

Massey University

Tennant Rd

Palmerston North 4442

New Zealand

Telephone: 0064 6356 9099 ext. 7718

E-mail: v.k.rodgers@massey.ac.nz

RODGERS V. , WELFORD C., MURPHY K. & FRAUENLOB T. (2012)RODGERS V. , WELFORD C., MURPHY K. & FRAUENLOB T. (2012) Enhancing

autonomy for older people in residential care: what factors affect it? International

Journal of Older People Nursing 7, 70–74

doi: 10.1111/j.1748-3743.2012.00310.x

As the population ages, the expectations of consumers rise and future care provision

for older people will demand that autonomy is operationalised in residential care

facilities. This paper looks at international publications related to identifying the

factors which facilitate or hinder residents autonomy and directs the reader to reflect

on their own custom and practice. There are many factors which both facilitate and

hinder the level of autonomy which older people experience in residential care. This

paper will discuss the three most pertinent factors that are discussed repeatedly in

the literature, and they are as follows: the organisations approach to care, person-

centred care and life planning.

Key words: autonomy, older people, residential care

Introduction

Globally, there is a rise in the ageing population. In the USA,

it is estimated that by the year 2020, 7 million people will be

over 85 years and 35 million will be over 65 years. New

Zealanders aged 65+ are expected to account for 17.2% of

the population by 2021. The Swedish population of over 65s

in 2000 was 23%, and this is expected to increase to 31% by

2050. The German Federal Statistical Office calculates a 48%

increase in the over 80s German population by the year 2020.

Similarly, in Ireland, 13.14% of its population are currently

over 65 years of age. This is estimated to increase to 23.4%

by 2036. As the ageing population increases, so too does the

population in aged residential care. The quality of life

experienced by this population group is both of interest and

importance to nurses and nursing.

Paper one reviewed the theoretical literature which dis-

cusses and debates the meaning of autonomy. This paper

considers the findings from research undertaken in residential

care and delineates what factors may facilitate autonomy and

70 � 2012 Blackwell Publishing Ltd

what factors may hinder it. One must be cognizant that many

of these research studies were undertaken without a consen-

sus in the literature of what autonomy means for older people

in residential care. However, the findings can shed some light

on how residential care provision and practice can impact

upon autonomy and hence pave the way for further research

and practice development. The findings from the literature

support the belief that autonomy for older people is impor-

tant and contributes to an enhanced quality of life.

Residential care research

The literature revealed that many studies have been con-

ducted in residential care units for older people. This helps in

our understanding of the context of autonomy for older

people in residential care. Some of these studies examined the

organisations approach to care including the institutional

philosophy, the leadership and the impact of task-based

approaches to care (Forbes-Thompson & Gessert, 2005;

Swagerty et al., 2005). Some explored perceptions of care

including staff perceptions (Ryan & Scullion, 2000; Redfern

et al., 2002; Murphy, 2006), resident perceptions (Boyle,

2004; Cooney et al., 2009) and families perceptions (Ryan &

Scullion, 2000). One study examined the role of nurse

specialism in gerontological care (Hunter & Levett-Jones,

2010), and several researchers connected health care profes-

sionals level of knowledge about ageing with positive

attitudes towards older people (Wade, 1999; Wells et al.,

2004; Mandy et al., 2007). A number of studies investigated

quality of life and quality of care in residential care for older

people (Pearson et al., 1993; Murphy, 2006; Dwyer et al.,

2008). Several papers discussed the benefits of delivering

person-centred care in residential care for older people

(McCormack, 2001a,b; Manley & McCormack, 2008) and

provided frameworks for operationalising it (Ford &

McCormack, 2000; McCormack, 2001; McCormack &

McCance, 2006; Manley & McCormack, 2008).

For this paper, three main factors are analysed. Firstly, the

organisations approach to care, which is multi-faceted but is

suggested to impact upon the level of autonomy a resident

experiences. Secondly, person-centred care because resident

autonomy was identified in the literature as being an integral

ingredient in person-centred care and ultimately in achieving

quality of life. Thirdly, a common suggestion across the

decades and throughout the literature is that life plans are

essential for knowing the person in person-centred care

provision and for the realisation of autonomy for older

people in residential care (Meyers, 1989; Agich, 1990; Lidz

et al., 1992; Tutton, 2005); hence, the literature pertaining to

this will also be considered.

Organisations approach to care

One factor which may facilitate or hinder autonomy for

residents is the organisations approach to residential care,

and this has been discussed in the literature for many years

with some of the first discussions appearing in the early 1990s

(Smith, 1992; Erlander et al., 1993; Hofland, 1994; Quill &

Brody, 1996). An organisation which values leadership was

deemed to be most beneficial to resident autonomy. Many

researchers have found that leadership permeates all aspects

of care and creates an organisation which values an approach

to care that sustains expert practice (McCormack & Ford,

2000; Forbes-Thompson & Gessert, 2005; Swagerty et al.,

2005) and that lack of leadership results in fragmented, task-

based approaches to care (Swagerty et al., 2005).

Forbes-Thompson and Gessert (2005) in a qualitative case

study found that two nursing homes (NH1 and NH2) adopted

different approaches to care. NH1 operated on a philosophy of

only providing physical care and paying higher wages to a core

group of staff rather than lower wages and employing more staff

while NH2 operated on a philosophy of providing the best

possible nursing home services to residents who had limited

assets. Resident admissions to NH2 were in line with staffing

levels and were reduced during times of staff shortages. NH1

was described as noisy, lacking privacy and with unpleasant

odours, while NH2 was described as bright with a homelike

feeling, pets and gardens added to the initial impression. NH1

focused on task orientation, while NH2 facilitated residents

requests to stay in bed, eat outside meal times and demonstrated

affectionate relationships with the residents. The researchers

discussed the powerful connections between structure, process

and outcomes in an organisations approach to care. At the

structural level, the two homes had contrasting institutional

philosophies which were reflected in staffing and the environ-

ment. The two homes contrasted in their processes of care by

having different patterns of planning, communicating and

making decisions. Thus the outcomes were substantively differ-

ent, and the relationship between the organisations approach to

care and positive resident outcomes particularly in relation to

autonomy was highlighted. Routine and task-based care was

revealed to impact negatively on residents autonomy. Manley

and McCormack (2008) have suggested that residents can

identify better with an approach to care whereby staff listen to

them and plan care around their individual needs thus enabling

them to participate in their own care as opposed to an approach

to care where older people feel that care is ‘done to’ them.

Person-centred care

Possibly, the most discussed factor in the literature which

affects autonomy is that of person-centred care. The philos-

Enhancing autonomy

� 2012 Blackwell Publishing Ltd 71

ophy of person-centred care is professed by nurses and most

of the health disciplines. While no one definition exists, it is

influenced by a holistic view of the whole person. The

concept of personhood relates to our being human, and

personal autonomy provides the basis for the respect that

each person commands. The theory of person-centred care

seems to have evolved from a desire to create an approach to

care which is non-paternalistic and non-task orientated.

There has been an extensive amount of debate and discussion

in the literature advocating for organisations to adopt a

person-centred approach to care in residential homes for

older people (McCormack, 2001a,b; Manley & McCormack,

2008). Most importantly, policy documents (The Irish Health

Service Executive Transformation Programme 2007–2010,

The UK Darzi report 2009, The Department of Health,

2001, Health and Wellbeing Strategy for Older People 2001–

2006) have recognised that autonomy is a central ingredient

in realising person-centred care and subsequently quality of

life for older people in residential care. Hence, a person-

centred approach to care may enhance a residents autonomy,

and while Hunter and Levett-Jones (2010) found that

delivering person-centred care remains a challenge for nurses

working in residential care in Australia, perhaps it can be

suggested that operationalising and understanding one of its

key ingredients, that is, autonomy may help to eradicate part

of the challenge.

The literature relating to person-centred care identified

knowing the person and being respectful of and responsive to

individual patients’ preferences, needs and values as key to its

success. Thus, the therapeutic relationships between staff and

residents in a person-centred care environment can enable

resident life planning with the resident.

Life plans

Many researchers have stated that life plans are essential for

realisation of autonomy for older people in residential care

(Meyers, 1989; Agich, 1990; Lidz et al., 1992; Tutton,

2005). Meyers (1989) stated that to live a harmonious

existence and acquire autonomy, one must possess a life plan,

and to do this, one must possess certain skills to make

decisions and thus realise that life plan.

Agich (1990) also recognised the importance of life plans if

older people with reduced capacity wished to remain auton-

omous. Focusing his work on older people in residential care,

he called for a refurbished, concrete concept of autonomy

that systematically attends to the history and development of

persons and takes account of experiences of daily living.

Agich (1990) stated that while action, speech and thought are

important elements of autonomy, it must be remembered that

these associations with autonomy date back to seventeenth-

century political and legal debates, and hence, the

understanding of the concept of autonomy needs newer

associations. He further stated that definitions of autonomy

which focus only on action and choice are idealistic defini-

tions and that a concrete definition of autonomy should

include a daily living account of the person who engages with

meaningful options (meaningful to the older person). Agich

(1990) rationalised that autonomy is socially conditioned and

contextually situated, and thus, expressions of autonomy are

unique to each individual. He also recognised that the

‘individual’ is always in a state of change and development

across the life cycle:

thus, to speak of individuals as autonomous requires that we pay

attention to the kinds of things with which they properly identify in

their lives….we need to learn how to acknowledge their habits and

identifications (Agich, 1990, Hastings Center Report, p. 12)

Agich (1990) added that to be dependent on something is not a

loss of autonomy if one truly identifies with what one is

dependent on. He reflected on the concept of autonomy as it

relates to residential care and questioned whether the choices

actually afforded to residents were indeed meaningful or

worth making and stated that being able to identify with one’s

own choices is a prerequisite for true autonomy. In other

words, whether or not a resident has a shower at 6 am or 12

noon may be irrelevant to them but what they may wish to be

autonomous about is their love for documentaries about

animals and being enabled to watch them on TV.

Tutton (2005) stated that understanding patients’ personal

histories creates opportunities for knowing what is important

to them. It also provides an insight into how they are

experiencing their present situations. Tutton (2005) reported

that knowing the (authentic) person and how they would like

to live their daily life provided the basis for participation in

daily care. Thus, compilation of life plans may impact upon

whether or not an older person in residential care experiences

autonomy.

Discussion

Knowledge of who each resident is, is a key factor in

promoting their personal autonomy and underpins the

approach taken in establishing the environment. McCormack

and Ford (2000) stated that Registered Nurses possessing

expertise in their individual practice are not enough to sustain

effectiveness in gerontological care and that nurses require

expertise in leadership to create an organisation which values

an approach to care that sustains expert practice. The

Registered Nurse as leader of the care team must be able to

V. Rodgers et al.

72 � 2012 Blackwell Publishing Ltd

see opportunities for residents to be provided with relevant

options rather than simply told what will happen to them, and

then be able to respond appropriately to the choices made.

‘Jo’ was an 80-year-old man who had been in residential

care for 6 months when his wife of 56 years died. ‘Mary’ had

been Jo’s constant companion and they spent many hours

together in the facility and at community events; both were

gregarious and friendly people. Jo’s children lived overseas

and were unable to travel immediately to be with him in his

grief. The senior staff at the facility consulted Jo’s care and

lifestyle plan and determined from it that Jo needed constant

activity and people-contact to get him through the first

difficult weeks. A week after Mary’s funeral, a RN who had

been on leave returned to the facility to find Jo depressed and

exhausted and took him quietly aside to talk. Jo finally

revealed that all he had wanted to do in the days after Mary’s

death was to quietly visit their ‘special’ places and to reflect

on all the wonderful days they had spent together; he just

needed some space and time to himself. When prompted to

think why this had not happened, Jo revealingly stated ‘No-

one asked me what I wanted’.

Staff here had utilised a holistic care plan that represented a

key tool of person-centred care but somehow the experience of

personal autonomy at the core of the person had been

misplaced, with the result that quality of life was compromised.

Conclusion and recommendations

Aged residential care settings are often institutionalised

nursing centres run on tight budgets controlled by owner/

operators who answer to shareholders for a return on

investment. Despite their best intentions to honour the

unique personhood of each resident, many nurses find

themselves constrained to prioritise physical needs ahead of

what might be more important to the resident’s experience of

autonomy or quality of living. With the rapid increase in the

ageing population, it is essential that nurses take time now to

rethink the organisations for whom they work and their

approach to aged residential care delivery. Older people in

the future are unlikely to accept the limitations to their

experience of autonomy in the same way as today’s elders do.

Care models that start with the resident and continue

interdependently with the resident will respect, acknowledge

and operationalise care that enhances the experience of

autonomy for the older people in residential care.

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