Improving Residents' Life Satisfaction.

Long-term care facilities are concerned with their residents' psychological well-being in addition to their physical needs. However, strategies to maintain or improve residents' psychological health are not always obvious. We conducted a [study.sup.*] in which 131 cognitively alert older adults, residing in long-term care facilities, were individually interviewed concerning their general satisfaction with life in the facility, those aspects they liked the most and those they would like changed. Each resident was approached and asked if he/she wished to participate. Participation was voluntary, and no resident was coerced into participating. The residents were then interviewed by students enrolled in a Psychology of Aging class. Each student was assigned a resident and provided with a set of questions to ask. The student was instructed to record the responses as they were made. The study uncovered several factors related to life satisfaction and offered suggestions for improving it.

Social Support

Many associate life satisfaction with social support.[1-3] Older adults are perceived as being unsatisfied with their lives because of a sense of isolation. This contention might be especially true for older adults residing in long-term care facilities when considering the significant decrease in the quantity and, often, quality of a resident's contact with others. It is often believed that frequent visits, particularly from family members, are crucial in maintaining happiness in older adults. [4-5] This perception is so strong that many staff members worry about residents who do not have frequent family visitors. Our experience has been that this concern even turns into anger toward the family for neglecting the resident.

Results of our study indicate that residents did not associate frequent visits, as well as family contact, with life satisfaction. Interestingly, what really mattered to them was having visits from friends. While this might seem counterintuitive at first (family members are often thought of as the most important members of a social support network), there is a possible explanation: Relationships with friends do not carry the sense of obligation that relationships with family members do. There might be situations in which family members feel obligated to visit a relative, and this sense of duty might be conveyed to the resident. Another possible explanation is that family visits are expected and, to some extent, are taken for granted. It is also possible that residents who do not receive family visits found other aspects of life in long-term care to foster life satisfaction.

A common theme in our findings was the importance of social life. Positive relationships with the other residents can ease adjustment to the facility. In fact, when older adults were asked what they liked most about the facility, the most common response was "the other residents."

The other component of social life within a long-term care facility--namely relationships with the staff--is also very important. Like the relationship with the other residents, a positive relationship with staff members can ease adjustment to the facility. This relationship was the second most common response when residents were asked what aspect of the facility they liked the most.

It makes sense that the quality of the relationships within the facility is more associated with life satisfaction than having visitors; interactions with other residents and staff members occur on a daily basis, whereas interactions with visitors occur more sporadically. Our personal experience has been that often when family members visit, the residents talk about what is transpiring in the lives of the staff and/or other residents.

One recommendation we offer is to encourage more opportunities for resident-resident and resident-staff interaction. Long-term care facilities often plan very large events and activities that involve a large number of residents and staff. The size of such events would seem to stifle the ability to create intimate, meaningful interactions. Greater emphasis should be placed on smaller activities that encourage greater rapport among residents, as well as between residents and staff members. Also, the concept of primary care attendants (having a staff person care for the same residents on a daily basis), which was popular years ago, should be instituted in those facilities that frequently rotate their staff among residents. Many administrators discourage staff from sharing personal information. While staff should not burden residents with their personal problems, discussing some aspects of their personal lives can foster greater intimacy and increase a resident's sense of connection to the facility.

A Sense of Control

Moving to a long-term care facility can provide a special challenge to a resident's sense of independence. It is difficult for incoming residents to adjust to having others perform tasks that they previously handled.

Our findings indicated that residents who believed that they were living in the facility because of its benefits had high life satisfaction. When residents felt that they were forced to live there, they were less satisfied with their lives. It is important to distinguish those residents who perceive that they were coerced by family or placed involuntarily by the social service system and forced to live in the facility, from those who actually were not involved in the decision to relocate. we found no difference in life satisfaction between those who were involved in the decision and those who were not. Perhaps involvement in the placement decision is not related to life satisfaction, because many of the residents, although not actively involved in the decision making process, perceived the decision to be in their best interests. For many in this situation, a sense of control was not compromised.

An important note is the issue of medical limitations. The majority of residents in our study reported medical problems as the reason for living in the facility. Numerous researchers have reported an inverse association between life satisfaction and poor health [3,6-8] Having age-associated medical problems can lead to less independence and, consequently, less life satisfaction. [9] We found that this is not necessarily the case, however, for residents receiving long-term care. Medical limitations, reported as the reason for living in the facility, were not associated with life satisfaction; having medical difficulties is a situation that often accompanies the need for residential care. However, those who reported liking the medical care that the facility provides more than any other aspect of facility life were less satisfied. The difference is this: One can attribute living in the facility to medical problems because that is indeed the case; medical problems, though, are not the primary focus of their live s. Life satisfaction is endangered when one's medical limitations are considered to be the most acknowledged aspect of life. This might be caused by severe health problems or a stronger-than-average focus on one's medical difficulties.

Since the subjective assessment of health has been found to be more critical than the actual extent of the physical condition, [7] our findings suggest that social workers in long-term care facilities should help residents minimize the focus on their medical limitations. Interventions, such as cognitive refraining, can help residents perceive their daily lives in a more positive, self-directed manner. Also, residents should be consulted on planning interventions, activities and basic elements, such as room arrangements and roommate selection. These activities can help redirect the resident's attention away from preoccupation with health and toward constructive and potentially life-satisfying activities.

Adjustment

The ability to adjust to changing circumstances and high life satisfaction often coexist. In fact, the quality of the initial adjustment experience can often predict later satisfaction with life in the residence. This is probably because the ability to adjust often corresponds to the ability to perceive situations more positively. The challenge of adjusting to relocation at a long-term care facility, however, is complicated by the presence of concurrent losses. Many older adults relocate to a long-term care facility after a serious medical injury or the loss of an important figure in their support network (usually, a spouse). This can magnify the already high level of difficulty in transitioning to a long-term care facility. It is important that long-term care staff, especially social workers, provide interventions to help the older adult perceive this often troubling situation in a more positive, yet realistic, manner. Perception of the facility and one's circumstances during adjustment can have profound ef fects on perceptions and life satisfaction, even after the initial adjustment period is over.

As previously mentioned, liking the other residents and the staff are two of the most common factors that ease adjustment to the facility. In addition, liking the facility in general can ease adjustment. Some of the most common difficulties in adapting to life in a long-term care facility are a decrease in independence, being uncomfortable with other residents, missing their previous home and being uncomfortable with the new environment. It is important that long-term care staff ease the transition by promoting friendships with other residents, developing a positive rapport with the newly admitted resident and cultivating a comforting and welcoming atmosphere. When circumstances allow, a gradual transition into facility life, perhaps starting with short visits, could be effective in easing the adjustment experience. A welcoming committee made up of residents could help the new resident feel welcomed and also provide opportunities for the development of friendships.

Aspects Liked and Desired Changes in the Facility

It can be useful to know what aspects of long-term care facilities are most liked by their residents. As previously mentioned, the other residents and the staff were the most frequently liked aspects of the facility. In addition, the general comfort or atmosphere of the facility and its activities were frequently cited. Improving or emphasizing these areas could increase satisfaction of the facility.

The most commonly desired changes in the facility were having more suitable surroundings (e.g., increased access to the bathroom, more comfortable chairs, cable television installed, a private room), more family visitors, more privacy and better food. It is very important that the facility's surroundings match the preferences of the residents. This can be done by promoting a sense of warmth and control within the facility. There are limitations, however, to what a facility can do to make its surroundings favorable to its residents. When circumstances permit, prospective residents should visit several facilities to find the one with the best fit for them.

While many residents desire more visits by family, their life satisfaction doesn't suffer when there is a lack of them. Family visits, then, are something desired but not essential. Direct care staff are advised to work on their relationships with the residents and not worry about the lack of visitors.

Efforts to provide the residents with more privacy should be made carefully. Many of the residents who reported this desire for change had lower life satisfaction. Their desire for privacy could very well result from dissatisfaction with other aspects of life within the facility. While it is important that residents have time and space to themselves, efforts should be made to avoid their social isolation. We suggest that residents who express a desire for more privacy be questioned as to what they specifically desire. It is likely that the complaint is a legitimate one, e.g., an intrusive roommate or neighbor who enters the room at will or staff who enter a bathroom before knocking and pausing before entering. However, the desire for increased privacy could be an indicator of depression. Many depressed residents tend to be withdrawn and social isolates. [10]

Conclusions

In sum, our study suggests that interventions that are aimed at increasing the quality of social life in long-term care facilities and that encourage a positive perception of life during and after adjustment to the facility might be successful in improving residents' life satisfaction. Greater emphasis should be placed on developing measures of social compatibility and promoting small group activities that encourage intimacy and friendship. The importance placed on staff as an aspect appreciated about the facility indicates that residents who are dissatisfied with life in the facility might benefit from strategies to increase rapport with staff members. Long-term care facilities also need to continue their efforts to promote the residents' sense of control over their environment. Facilities must explore every opportunity for the residents to make decisions about their lives.

Pearl M. Masher-Ashley, PhD, is a professor of psychology at Worcester State College, 486 Chandler St., Worcester, MA, 01602-2597, and Edward P. Lemay, BS, is a doctoral candidate in social psychology at Rutgers University.

(*.) This article is based on a study presented at The Gerontological Society of America in San Diego, Calif., in November1999.

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