An Examination of Nursing Home Personnel's Perceptions of Residents' Autonomy.

Autonomy, especially of nursing home residents, concerns the essence of values such as personal freedom and independence. This study examines Collopy's six polar dimensions of autonomy from the perspective of 202 nursing home personnel from a sample of 15 nursing homes in West Central Florida. Using regression analysis, autonomy was examined with respect to four categories of variables: (a) nursing lupine staff background factors, for example, education; (b) nursing home staff attitudinal issues, for example, job satisfaction; (c) staffing issues, for example, turnover rates of nurses; and (d) formal facility and resident characteristics, for example, percentage of residents physically restrained. The results confirm that autonomy is a complex construct with considerable subtlety. The most predictive set of variables overall include race, educational attainment, and employee type (i.e., certified nursing assistants vs. others). The results are discussed with respect to their implications for care.

The nursing home, where it is estimated that 43% of persons aged 65 and older will spend some time before they die (Kemper & Mutaugh, 1991), is an environment in which frail older persons are dependent on care providers for medical attention and assistance with daily activities. In such settings, beneficent care can easily begin to slide toward control. Intrusions on personal freedom and self-regulation can become commonplace--not necessarily out of ill-will but in response to a perceived notion of "what is best for the resident" or an assumption of the need for substitute judgment. The amount of control allowed the individual, then, depends in some part on the willingness of the caregiver to allow it (Kane, 1991).

There is the danger that abuses of residents' rights to autonomy may occur as a result of an overworked nursing staff who may be acting out of a sense of efficiency, that is, "getting the job done." Many factors, for example, institutional regulations, dependence on others for physical care and economic support, increased frailty, cognitive impairment, and attitudes among some elderly residents that compliance and nonparticipation are appropriate responses to their situation, can contribute to lessened autonomy (Wetle, 1991).

This study examines nursing home resident autonomy from the perspective of the nursing home personnel. Using the. conceptual framework provided by Collopy (1988, 1990), that is, his explication of six polarities of autonomy within the context of nursing home care, two issues are examined: (a) the staffs' perceptions of the facility practice with regard to each autonomy dimension and (b) how these perceptions are influenced by selected categories of variables, that is, structural characteristics related to the staff, characteristics of facilities and the residents, sociodemographic characteristics of the staff members, and attitudes of the nursing home personnel.

The Concept of Autonomy

Definitions of autonomy have undergone considerable revision due to the complexity and evolving contextual nature of the concept. Cicirelli (1992) points out that autonomy has been examined from at least three differing perspectives, for example, moral, political, or individual autonomy. It has been described by different terms, such as self-determination, self-rule, self-governance, personal control, liberty, and independence (Collopy, 1988). It connotes having direction over one's life (Lidz, Fischer, & Arnold, 1992; Wetle, 1991).

Often, autonomy is defined in terms of personal independence (Kane, 1991; Lidz et al., 1992; Wetle, 1991). Kane (1991) warns, however, that care should be taken not to equate physical independence with autonomy. Just because a person has lost the capacity to execute autonomy does not mean that the ability to make decisions has been lost. Even in the face of severe physical disability, persons can still retain their decisional capacity. Kane and Caplan (1992) stress that autonomy must be respected and given priority over other values and morals. Autonomy means being allowed to make choices and to exercise control over one's life. It does not give one person authority over another's rights (Kane, 1991). Collopy (1990) makes the observation that the dilemma of autonomy often requires "choosing right from right" or "one value over another"--most decisions are not clear cut.

Crabtree and Caron-Parker (1991) feel that the modern notion of autonomy in medical care has been crafted around the acute care setting. They point to the differences between acute and chronic illness that necessitates a revision of the concept, especially where long-term care is involved. Chronic illnesses in contrast to acute conditions may last for many years, family involvement in decision making tends to be greater, the loss of mental function is more likely, and medical care typically requires more participation from the older person.

Moody (1988) stresses a situation of "negotiated consent," that is, a cooperative effort between paternalism and autonomy. It is argued that there are situations in which paternalistic intervention would serve to heighten autonomy; for example, requiring greater physical movement can lead to greater well-being, thus facilitating autonomy. Negotiation by all parties involved also may work well when the decisions made by the resident may not be in line with the reality of the situation.

In an essay by Collopy (1988), the subject of autonomy in long-term care is recognized as a complex ethical issue involving conflict between the self-determination of older persons and the standards of caregivers that form the basis of their decisions. Although autonomy translates to freedom of choice and action, its definition does not permit the individual to be in control of everything, without influence from outside circumstances and restrictions. To better address the complexity of autonomy of dependent older persons in long-term care settings, Collopy identifies and examines six polarities of autonomy: decisional versus executional autonomy, direct versus delegated autonomy, competent versus incapacitated autonomy, authentic versus inauthentic autonomy, immediate versus long-range autonomy, and negative versus positive autonomy.

Decisional versus executional autonomy. Decisional autonomy involves the ability and freedom to make one's own decisions. Executional autonomy is the ability one has to implement those decisions. In a perfect world, autonomy would be both decisional and executional. In a long-term care setting, however, this is very often not the case. Executional autonomy may erode with increased disability and should not be confused with loss of decisional autonomy. Care should be taken by caregivers to continue to respect the decisional capacity of those frail individuals who have become dependent on their care for daily activities. Doing things for the older person is not equated, then, with deciding for him or her (Collopy, 1990).

Direct versus delegated autonomy. Direct autonomy is the ability to act as an independent agent, whereas in delegated autonomy, that authority is given to someone else. In the legal system, delegation of authority is sometimes mandated through the use of power of attorney. In long-term care facilities, designated agents may be identified at the time of admission (Wetle, 1991). Delegated autonomy can be damaging to the older person when the agent is not acting in the resident's best interest. The person responsible for caregiving may not have the same perception as the older person on what has, or has not, been delegated. When a frail older person has the option of delegating certain tasks and decisions to trusted others, it can serve to enhance autonomy.

Competent versus incapacitated autonomy. Competent autonomy infers judgmentally coherent choice. Incapacitated autonomy is that which reflects incoherence in judgment. Competency is in fact a legal issue; thus, it is very important that proper assessment be conducted whenever competency is in question. Competency of resident judgment, however, is often routinely, but informally, assessed by nursing home personnel. Incompetence should not be judged based on unpopular decisions by the resident that do not conform to popular opinion or on cogent resident decisions that do not conform to the advice of health care professionals. Rather, incompetence should be judged based on an objective examination of the individual within the …