Autonomy as resident-facility fit (article 1)

The residents’ autonomy seemed to be highly relational, insomuch that I approached it through the concept of facility fit (e.g. Ball et al. 2004). I used resident-facility fit as a philosophical value judgment where the fit was good when residents felt that they had control over the environment, i.e. a good resident-facility fit entailed that the environment offered positive opportunities for autonomous living.

Whereas previous research had seen the fit as a goal for a process aiming to avoid resident transfers from one facility to another due to diminishing health and functional abilities (Ball et al. 2004; Roth & Eckert 2011; Zimmerman et al. 2003), I comprehended the fit more as a result of a process that aimed for residents to have control over their lives. Thus, the resident-facility fit was neither an objectively measurable phenomenon nor a subjective feeling, but rather a combination of the two; the resident-facility fit was the residents’ perception of their ability to manage in their new surroundings with their current capability. Therefore, I changed the concept of resident-facility fit to perceived resident-facility fit in the original article.

The residents’ autonomy when perceived as resident-facility fit was mainly based on three factors: i) the social, functional, and physical features of the facility, ii) the residents’ individual traits, and iii) the residents’ potential to act.

6.1.1 Surroundings

Although the residents’ everyday social world consisted mostly of the staff and other residents, people outside the facility seemed to be very important with regard to the residents’ control over their lives. The role of the staff and peers was emphasized more with regard to the residents’ social fit with their surroundings. I will study this issue in more detail in subsection 6.4 concerning affiliation. The residents often seemed to base their autonomy feelings on relatives and friends, who took them out to run errands and brought them the goods they needed. In the first excerpt, Paul gave the words for the importance of “outsiders.”

Jari: Can you easily get stuff here that the house won’t provide, the bottle of cognac for instance or…

Paul: I only need to give my nephew a ring, say that we’ll make a trip to the market and it’s settled.

Jari: Right. So, whatever you’ll need, you’ll just go over and …

Paul: Yeah. Likewise all this equipment. I can’t even bring that stuff myself or go and get it anywhere, so …

Jari: Yeah, you mean the TVs and…

Paul: Yeah, my son-in-law will bring them to me with my daughter. (Excerpt 1, male resident, 82, moved independently with walker)

Visitors and phone calls from the outside were emphasized by the residents’ own initiative during the interviews, which is a sign of their importance. In addition to taking residents outside and bringing desired goods, friends and relatives served as psychosocial resources, which reduced the residents’ dependence on official care, in line with previous research (Lloyd et al. 2014). Highlighting visitors may also indicate their importance with regard to the residents’ social status among peers and the staff and it certainly boosted the residents’ self-esteem. Anita seemed proud to share in the interview that even her son’s parents-in-law visited her regularly, which meant

that she still was a significant family member, even after she had transferred into the facility.

In addition to social factors, the environment encompassed functional and physical features that affected the residents’ autonomy. The functional features were practices and procedures necessary for the care organization to fulfill its purpose and I will open them up in more detail when scrutinizing residents’ recognition in subsection 6.3. Here it is sufficient to conclude that daily routines had both positive and negative effects on autonomy feelings, depending on whether they matched the residents’ own preferences or not. Being woken up by the staff in the mornings was not necessarily desirable but mealtimes regular as clockwork were appreciated.

An obvious autonomy-influencing feature of the physical environment was that the front doors of group homes were always locked and opened with a five-number code, which restricted residents’ freedom of movement. An excerpt from the observational notes is clear about this.

When I arrived at the group home, some people were sitting at the table in the dining room. I sat down at one of the tables with three female residents. One of them asked me what ailment was preventing me from opening the door out. She said she can’t go out and it feels like being in prison here. I told her that people probably get to go out only with an escort. The lady kept on talking to herself for a while still, about being a prisoner, but I couldn’t quite make out what she said.

(Excerpt 2, observation notes)

Feeling imprisoned could be the worst situation when considering the perceived resident-facility fit. Keeping the doors locked was a procedure to keep people with dementia illnesses safe, but it was just these people who did not understand why the doors were locked. Some of the cognitively capable residents knew the code and moved in and out freely. In addition to locked doors, some residents were tied to their wheelchairs with a lap belt to prevent them from falling and hurting themselves, although prior research has found that physical restraint use agitates older people in care facilities (Werner et al. 1989) and there is no strong evidence of the efficacy of restraints for safeguarding residents (Evans & Strumpf 1989). Physical restrictions in elderly care have raised vivid public discussion for a reason. People with dementia need to be protected, but interfering with basic rights, such as freedom of movement, is an extremely delicate matter. I will return to the issue of self-determination in subsection 6.5 on dementia-related issues.

6.1.2 Individual traits

All of the residents lived in a sheltered home due to diminishing functional abilities, which inevitably affected their chances to lead an autonomous life. However, residents had their ways of feeling autonomous regardless of this, especially by lowering standards of autonomy, highlighting their remaining abilities, adjusting their activities to their functional level, and comparing their situation with co-residents with a lower level of functional abilities. Sarah expressed how standards of autonomy were lowered in practice. She suffered from a somatic illness that had taken away her ability to walk, and was asked whether she could move around independently in the home with her wheelchair.

Sarah: Yes I can. I can wheel myself around a bit. They usually take me to the dining room for lunch, for example, but then I sometimes end up waiting at my door for someone to let me in, because I always keep my door locked because of that person (a resident who wandered around). So if I want to get away from the dining room, I’ll wait there for someone to open the door.

(Excerpt 3, female resident, 86, could move only aided)

Sarah answered the question about whether she was able to move around independently with a straightforward “yes I can”, but her account reveals the phenomenon that Street et al. (2007) called miniaturization of autonomy. Sarah was not able to pass through the door on her own, but she considered herself autonomous since she could roll herself to the door. At the same time, she highlighted her remaining abilities, which may be interpreted as a coping strategy.

Coping strategies (SOC) (selection, optimization, compensation) are used to compensate functional losses in old age (see. e.g. Freund & Baltes 1998). Another coping strategy was to adjust one’s doings to one’s diminishing abilities. Sarah had switched knitting to cryptic crosswords due to her aching wrists, whereas Harry sat on a bench outside instead of walking due to shortness of breath.

Previously I introduced the concept ability others, which we found earlier to describe how community-dwelling nonagenarians highlighted their autonomy by checking it against the situation of those peers who had transferred into a care facility (Pirhonen et al. 2016). Institutionalized people were seen as ability others since they had lost their independence due to diminishing abilities that forced them to transfer into a facility. According to this study, the phenomenon still prevails in assisted

living. Joanna said it herself when she was asked whether the help from the staff was sufficient.

Joanna: The help’s been enough for me, but I don’t know if you’ll get the necessary care if you’re in worse shape than I am. (Excerpt 4, female resident, 85, moved independently with walker)

Like Joanna did here, residents boosted their own autonomy feelings by comparing their situation to co-residents with a lower level of functional abilities.

6.1.3 Potential to act

One significant finding was that having the potential to do something seemed sometimes to be even more important than actualizing the potential. The next two excerpts highlight how having potential to act may affirm the perceived resident-facility fit by enabling the feeling of control over one’s life. In the first excerpt, Paul was asked whether he felt connected to people outside the home. In the latter, Sarah differentiates between life in a sheltered home and a geriatric hospital.

Paul: I do. I can get a ride in a car. My daughters or buddies will pick me up and take me places if I want to go somewhere.

Jari: Okay.

Paul: So I don’t have any problems with that. The other thing is that I can go for a walk any time, or catch a bus and go to the city center, but I don’t like to do that, go there on my own. (Excerpt 5, male resident, 82, moved independently with walker)

Sarah: It’s a good thing this is different, but better in the sense that, of course, I prefer to be alone in my own home and be free to go where I want.

I could take a wheelchair-accessible taxi to go visit my friends, but I haven’t gotten around to it yet... (Excerpt 6, female resident, 86, could move only aided)

Similarly to these excerpts, residents talked about things they could do if they wanted. They could go to recreational area nearby, could pick a phone and call their relatives, or get some fresh air in a balcony although they never had done those

things. Apart from enabling a feeling of control over one’s life, potential to act provided people with positive expectations of the future. Saving enjoyable activities for later expressed positive prospects regarding the residents’ remaining functional abilities still available in the future. Potential to act is also important for hope, which has been found a key factor in residents’ ability to maintain their feeling of autonomy in assisted living settings (Perkins et al. 2012).