5 HUS 133 Where People Live

Chapter fiveChapter fiveWhere People Live:

Person-Environment Interactions

Adulthood and Aging, 6eJohn C. CavanaughFredda Blanchard-Fields

Describing Person—Environment Interactions

Learning Objectives• What is the competence and environmental press

model?• What is the congruence model?• What are the major aspects of stress and coping

theory relating to person—environment interactions?

• What are the common themes in the theories of person—environment interactions?

Person—Environment interactions conceptualized (Kurt Lewin, 1936)

B = f(P, E)Where:B = BehaviorP = PersonE = Environment


Competence and Environmental Press• Competence is the theoretical upper limit of

a person’s capacity to function.• Environments can be classified on the basis

of the varying demands they place on the person, a notion called environmental press.– Adaption Level: Where behavior and affect are

normal, slight increases in press improve performance, slight decreases create a Zone of Maximum Comfort.


The Congruence Model• According to Kahana’s (1982) congruence

model, people with particular needs search for the environments that meet them best.

• Can you offer examples?

1. A person without personal transportation seeks a house near a bus route.

2. A handicapped person needs a home adapted to a wheelchair (no steps).

3. An elderly person may need to relocate to an assisted-living facility.


Stress and Coping Framework• Interaction with the environment can produce

stress (Lazarus, 1984).• Evaluating one’s situation and surroundings

for potential threat value– Harmful– Beneficial– Irrelevant

• If harmful, what is the coping mechanism and response? Outcome positive or negative?


Common Theoretical Themes and Everyday Competence

• Everyday competence is a person’s potential ability to perform a wide range of activities considered essential for independent living.– Broader than just ADL or IADL– Necessary determinate for whether an

elderly person can take care of themselves


The Ecology of Aging

Learning Objectives• What is aging in place?• How do people decide the best option?• How can a home be modified to provide a

supportive environment?• What options and services are provided in adult day

care?• What is congregate housing?• What are the characteristics of assisted living?

• Aging in Place– Balancing environment press and competence

through selection and compensation.– How a place becomes a home.– Cluster housing.


• Deciding on the Best Option– Does the individual have significant cognitive or

physical impairment requiring intervention?• What is the severity?

– The individual needs to be an integral part of the decision making.

– Get a physician’s diagnostic evaluation (required in many states).


• Home Modification– Helping people deal with tasks of daily living by

modifying the environment• Hook for car keys near the door• Hand rails in bathrooms• Door handles that are easier to grasp• Widening doorways• Lowering countertops• Wheelchair ramps


• Adult Day Care– Designed to provide support, companionship, and

certain services during the day– Goal is to delay placement in more formal care

setting.– Three types of adult day care

1. Social services, meals, recreation, and minor health care

2. More intensive health care, therapy, for serious medical problems

3. Specialize care for dementia or developmental disabilities.

Profit (22%) or non-profit (78%)


• Congregate Housing– Apartment complex for older adults

• Shared meals• Affordable

– Differs from assisted living in level of services– Residents must be capable of independent living

and:• Not require continual medical care• Know where they are and oriented to time• No evidence of disruptive behavior• Able to make independent decisions• Be able to follow specific service plans


• Assisted Living– Provides a supportive living arrangement for

people who need assistance with personal care (bathing, taking medication) but are not physically or mentally impaired to require 24-hour care.

• Has three essential attributes1. As much like a single family house as possible2. Emphasizes personal control, choice, dignity, and autonomy3. Should meet routine services and special needs


• Assisted Living (continued)

– Utilize check list to ensure the selected facility meets specific requirements of the individual

– Costs average about $35,000 per year.– Not offset by Medicare

• Specialty Care Assisted Living


Living in Nursing Homes

Learning Objectives• What are the major types of nursing homes?• Who is most likely to live in nursing homes?• What are the key characteristics of nursing homes?• What are special care units?• How can a nursing home be a home?• How should people communicate with nursing home

residents?• How is decision-making capacity assessed?• What are some new directions for nursing homes?

Types of Nursing Homes• Two levels of care are defined in

federal regulations.1. Skilled nursing care consisting of 24-hour care,

including medical and other health services

2. Intermediate care also 24-hour but at a less intensity


Who is Likely to Live in Nursing Homes?• Characteristics of People Most Likely to Be

Placed in a Nursing Home– Over age 85– Female– Recently admitted to a hospital– Lives in retirement housing rather than being a

homeowner– Widowed or divorced – Has no children or siblings nearby– Has some cognitive impairment– Has one or more problems with IADL


Who is Likely to Live in Nursing Homes?• Health issues and functional impairment

– Average resident has significant mental and physical problems

– Main reason for placement (80%)– One third of residents have mobility, eating or

incontinence problems.– 30 to 40% show signs of clinical depression.


Characteristics of Nursing Homes• The competence-environmental press model

– Goal is to find the optimal level of environmental support for people of low levels of competence

– In selecting a nursing home relatives should keep the following in mind:

• Level of skilled nursing care• Be mindful if facility is primarily Medicare or Medicaid • Is the director and upper staff fully licensed?• Is the care plan put in place by professionals?• Ask questions about staff educational levels and staff

turnover.


Special Care Units– Does the facility have well-designed special

care units for people with dementia?– Special care units must have the right level of

environmental support to provide additional care when the person’s competence level continues to decline.

– Memory aids should be built into the unit.– Special care for severely cognitive impairment

residents


Can a Nursing Home Be a “Home?”• What can be done to foster the sense of “home?”

– Being included in the decision and selection of a specific nursing home

– Having prior knowledge of, and positive experience of a specific facility

– Defining the home in terms of family and social relationships rather than place, objects, or total autonomy

– Establish a continuity between home and nursing home– Reminiscing about home may facilitate adjustment


Can a Nursing Home Be a “Home?”

How Not to Communicate with Residents• Patronizing speech• Infantilization or baby “talk”• Inappropriate use of first names• Terms of endearment—“Honey,” “Sweetie”• Assumption of greater impairment than may

be the case• Cajoling to demand compliance

to persuade with flattery or gentle urging especially in the face of reluctance


Decision-Making Capacity and IndividualChoices• How well can a nursing home resident

make decisions regarding their care?– Cognitive impairment– Patient Self-Determination Act (PSDA)– Provide written information at time of admission

concerning their right to make treatment decisions– Living will– Patients normally give the decision to family

members.


New Directions for Nursing Homes• The Eden Alternative

– The ten principles of the Eden Alternative.– Use of pets and other approaches seem to make

stronger associations between current and former living situations.• Research (Coleman et al. 2002) does not

support this view.• Quality of Life difficult to assess using

traditional methods.• Further research needed in this area.


New Directions for Nursing Homes• Green House Project

– Radical departure from the idea of large residential facilities

– Encourages residents to participate in their care through helping with daily tasks

– Personal dignity is maintained and quality of life is improved.


5 HUS 133 Where People Live

Health & Medicine

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