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Beliefs about Self-Care among Nursing Home Staff and Residents in Taiwan
FEATURE ARTICLE Beliefs about Self-Care among Nursing Home Staff and Residents in Taiwan Su-Hsien Chang, PhD, MSN, RN
The purpose of this qualitative study was to investigate the beliefs about self-care among nursing home staff and residents. Subjects included 10 nursing home staff members and 10 residents. Results indicated 3 major themes: 1) the importance of performing self-care, 2) barriers to regaining self-care abilities, and 3) facilitators to regaining selfcare ability. The importance of performing self-care was related to subjects’ beliefs about being independent, to high-quality nursing care, and to negative feelings about asking for assistance. Barriers for elders to regaining self-care abilities were physical limitations, fear of falling, depressed mood, and stafffostered dependency. However, facilitators for elders to regain self-care were increasing self-esteem, wishing to return home, and receiving support from staff and family members. The findings from this study will be useful for planning interventions to improve health and wellness among nursing home elders in Taiwan. (Geriatr Nurs 2009;30:90-98) hinese elderly in Taiwan normally wish to take care of themselves because it is an important way to gain respect from others, especially their adult children.1 Although Chinese elders in Taiwan often want to be independent in performing self-care, they may not be able to do so because of physical illness, depression, and the effects of medications.2-4 Physical and mental conditions may limit Chinese elders’ ability to perform basic activities of daily living (ADLs) such as feeding, bathing, dressing, grooming, toileting; inhibit their mobility including transferring, ambulating, and stair climbing; or affect their performance of instrumental ADLs, such as preparing their own meals, using the telephone, shopping for groceries, getting to places beyond walking distance, doing housework, doing handyman work, doing laundry, managing money, and taking medications. When elders have 1 or more functional limitations, their selfcare ability is weakened and they may need to be admitted to a long-term care institution. According to Taiwan’s Ministry of the Interior,
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Department of Social Affairs,5 the number of registered long-term care facilities increased from 70 in 1997 to 960 in 2006. The number of nursing homes has been increasing because of the rapidly aging population and the changing family structure. In 1993, the total number of those aged 65 and older was 1,490,801. The number increased to 2,287,527 in 2006, or to 10% of the total population in Taiwan.5 Traditionally, Chinese elders in Taiwan have believed that the ideal living arrangement for elders is living with children. However, after World War II, family resources for taking care of elders decreased because more women were pursuing careers outside the home and because of an increase in nuclear families and young urban dwellers.6,7 Therefore, placing elderly parents into a long-term care facility such as a nursing home has become a new caregiver alternative. Because long-term care services were established in a short period in Taiwan, the most urgent and severe problem has been the lack of well-educated, long-term care providers.6-8 Because of the lack of knowledge in gerontological nursing among long-term care providers, nursing home staff members may foster residents’ dependent behaviors. As a result, elders’ basic ADL selfcare abilities may continue to decline and their disabilities worsen after their admission to a nursing home.9,10 Little is known about the beliefs of self-care among nursing home staff and elders in Taiwan.11 Quantitative research on nursing interventions in the current literature lacks meaningful descriptions of self-care ability among Taiwanese nursing homes elders.11 Therefore, the purpose of this study was to investigate the beliefs about self-care among staff and elders in nursing homes in Taiwan.
Background Self-care is important for older adults to maintain and create meaning and purpose in life.1 Elders’ perceptions of meaning and purpose in life are ultimately linked to their perception of health.12 Miller and colleagues13 indicated that
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by strengthening self-concept, people were motivated to engage in self-care behaviors, which might positively affect well-being. Similarly, Smits and Kee14 studied 48 elders aged 65 or older and living independently in the community to understand the relationship between self-concept and self-care. They found a positive correlation between self-care and self-concept. They concluded that elders who had a higher score of self-concept and engaged in self-care activities had enhanced physical and psychological wellbeing. In brief, a decline in self-care ability can result in elders’ decreased physical and psychological well-being.1,13,14 The term self-care refers to any self-initiated or self-directed action of engaging in activities of daily living and other activities to preserve bio-psycho-social well-being. Orem15 indicated that self-care is the practice of activities which people initiate and perform on their own behalf in maintaining life, health and well-being. Lin and Hwu16 also stated that self-care is the practice of activities that a person performs to maintain life, health, and wellness. Traditionally, selfcare has been defined as activities associated with health promotion. It represents behaviors that individuals undertake to promote or maintain their physical, psychological, and social wellness.17 To understand self-care behaviors, it is necessary to understand the interaction among the components of self-care and sociocultural influences. For the Chinese, traditional philosophies of Confucianism, Taoism, and Buddhism have influenced both the behaviors and rules of social interaction. They have also provided a perspective on life, health, and illness.1,18 These philosophies share an approach to self-care for the Chinese. Their view is that taking care of self is valued because it is a way to gain self-respect and respect from others, and, therefore, is a way to improve health and wellness.1 Although self-care is important for a Chinese person to achieve health and wellness, not everyone can take care of oneself. This may be because self-care means different things to different people; nursing home staff members and residents, for example, may have different ideas about what self-care is. Staff caregivers usually are taught to encourage residents to perform self-care in nursing schools,10,18 but nursing administrators and experienced nurses in clinical settings may discourage them from doing so.19
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Their intentions may be good. Nursing administrators and experienced nurses often encourage novice nurses or nursing students to do everything for elders because they believe that is the way to show caring and respect.19 However, despite their good intentions, elderly adults may learn it is acceptable to receive assistance from others. Elders learn to ask for help instead of doing for themselves. Elders are induced to a dependent role, and they may begin to behave in this expected role. Ultimately, they may begin to practice dependent behaviors. The meanings that staff attribute to self-care influence their behaviors in assisting elders to promote selfcare.9 Therefore, to foster self-care behaviors among Chinese elders in nursing homes, it is important to study the meanings of self-care for both nursing home staff and residents because nursing home staff are the primary caregivers for elders.
Methodology Research Design This study used a qualitative approach to gain a deeper understanding of nursing home staff members’ and residents’ beliefs about self-care. The data were collected through face-to-face interviews with nursing home staff and residents. Study Participants A convenience sampling method was used. Ten subjects were nursing home staff including nurses and nursing assistants. Eligibility for the staff group included having worked at the nursing home for 6 months and being a direct-care provider. Ten nursing home residents were recruited to participate in this study. Eligibility for the residents group included 1) living in the nursing home for 3 months or more, 2) aged 65 and over, 3) ability to walk or sit in a wheelchair, 4) no dementia as determined by a score of 23 or greater (of 30 points) on the Mini-Mental State Examination, and 5) not bedridden. To recruit subjects, the primary investigator (SHC) first presented the purpose, rationale, and background of the study to staff at a staff meeting and to individual residents who met the subject selection criteria. Subjects were encouraged to ask questions and to participate in the study. If the subjects agreed to participate, they signed a consent
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form. Because some residents were not able to read or write, they used their finger print as a signature, and a staff member acted as a witness. Finally, a copy of the signed consent form was given to the subjects that included statements about their rights as subjects, the protection of confidentiality and anonymity, and the benefits and risks of the study. The data collection and analysis procedures were approved by the Human Subjects Protection Program at The University of Arizona. Data Collection and Analysis Subjects were interviewed using an interview guideline (Table 1) to standardize content. The principal investigator (SHC) conducted all the interviews. Methods for facilitating unconstrained subjects’ responses such as facial expressions, body posture, and silence were applied during the interviews. Subjects were asked about their beliefs about the importance of self-care. They also were asked to describe the facilitators and barriers to performing self-care. Detailed field notes and memos were recorded immediately after each interview and used in the analysis. All subjects were interviewed in a private and quiet room in the nursing home or in a place convenient to each subject. All interviews were conducted by the investigator in Mandarin or Taiwanese and were audio tape-recorded. Interviews ranged from 30 to 90 min. Tapes were transcribed, and all subjects’ identifying information was removed from the transcription and the data. Translations of the transcribed interviews in the original language were analyzed using content analysis.20,21 The principal investigator individually summarized segments of the data from interviews into categories, then discussed them with a research partner (Miao-Chun Fang), who was experienced in qualitative research and familiar with the coding scheme. After agreeing on the general categories, the principal investigator coded each interview. All disagreements were discussed until a consensus was reached. After most of the data had been analyzed and the categories were clearly exhausted, pattern coding was used to group the categories into a smaller number of themes. The coding was performed in the original language, then translated by the principal investigator into English. A back-translation was not done.
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Results Participants’ Demographic Data Of the staff group, 70% of the participants were nursing assistants. All were female. Their total number of years of work experience in the nursing field ranged from 6 months to 18.5 years. Their work experience in nursing homes ranged 1 year to 8.5 years. Of the resident group, 70% were female. The oldest participant was aged 90 years. The maximum number of months living in the nursing home was 51. A summary of the demographic data is presented in Table 2. Findings Fifteen codes were identified, and from these codes 3 themes were established. Themes in the qualitative data reflected nursing home staff’s and residents’ beliefs about 1) the importance of performing self-care, 2) barriers to regaining selfcare ability, 3) and facilitators to regaining selfcare ability. These themes are now presented. Table 3 summarizes the nursing home staff members’ and residents’ beliefs about self-care. The importance of performing self-care. Staff members and residents believed that the importance of self-care related to 1) being independent, 2) high-quality nursing care, and 3) negative feelings of asking for assistance. Being independent. Residents and staff members believed that performing self-care was a way to achieve independence. Staff indicated that the outcomes associated with being independent were to 1) increase self-esteem, 2) increase self-confidence, and 3) maintain physical function. One staff member reported, ‘‘If people cannot take good care of themselves, they may lose self-confidence and self-worth.’’ Residents pointed out that being independent in performing self-care increased their happiness. Another resident said, ‘‘If I can take care of myself, I feel happy. However, if I need to ask other people to assist me in performing self-care, I feel distress.’’ High-quality nursing care. The meaning of high-quality nursing care for staff and residents was allowing elders to perform self-care. To increase residents’ self-care abilities, staff members indicated it was important that they 1) take more time to be with elders, 2) allow elders to do what they could do, 3) assist elders to regain or maintain their self-care abilities, 4) provide
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Table 1. Guidelines for interviews conducted with nursing home residents and staff Definition of self-care is ‘‘the practice of activities that individuals initiate and perform on their own behalf in maintaining life, health, and well-being’’ (Orem, 1995, p. 104). These include bathing self, feeding self, going to toilet self, transferring self, dressing self, and maintaining continence.
Interview guideline for nursing home resident group General questions important to exercise self-care: How do you feel about self-care? How do you feel you are cared for by others? How do you feel if nursing home staff ‘‘doing everything for you’’? Do you think it is important for everyone to take care themselves? If yes, why? If no, why? Do you think it is important for you to take care of yourself? If yes, why? If no, why? General questions about abilities to perform self-care: What are facilitators and barriers for you to perform self-care? Tell me when you moved here? What was happening with your health? And what was happening with your self-care? How well do you think that you are able to take care of yourself? How comfortable are you asking for help? Do you think that you will have more ability to take care of yourself one day? If yes, what would you do to help yourself gain ability? What do you want nurses or nursing assistants to do to help you gain ability? If no, what prevents you from enhancing your self-care abilities? Interview guideline for nursing home staff group General questions important for performing self-care: How important for elders to perform self-care? Do you think it is important for everyone to perform self-care? If yes, why? If no, why? Do you think it is important for the elderly to perform self-care? If yes, why? What do you do to help elders enhance their self-care abilities? If no, why not? General questions about residents’ abilities to perform self-care: What are facilitators and barriers for elders to exercise of self-care? Tell me how well nursing home elders are able to take care of themselves? When do elders ask for help? And when do they do things for themselves? How comfortable are elders asking for help? Do you think that your elder patients have abilities to perform their self-care? If yes, why do you think they have abilities to perform self-care? What do you do to help them? If no, why don’t you think they have abilities to perform self-care?
heartfelt care, and 6) were able to identify elders’ current needs. Similarly, residents believed that to increase their self-care ability, staff should 1) spend more time with them, 2) allow them to per-
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form self-care independently, and 3) assist them to regain their self-care abilities. For example, one staff member stated, ‘‘if it is possible, I would like to spend more time with my clients
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Table 2. Participants’ characteristics Characteristics Staff group (n 5 10) Age Length of working experiences in nursing field Length of working experiences in nursing homes Education level College 2-years’ Junior college Vocational school 7 Grades Occupations Nurses Nursing assistants Resident Group (n 5 10) Age Length of time living in the nursing home Gender Male Female
Mean (±S.D.), Median (Range) Mean 30.9 11.53 years, Median 28 (19-53) years Mean 4 5.53 years, Median 1 (0.5-18.5) years Mean 2.35 2.40 years, Median 1 (0.5-8) years
1 (10) 1 (10) 7 (70) 2 (20) 3 (30) 7 (70) Mean 81.1 5.76 years, Median 79.5 (70-90) years Mean 0.95 1.20 years, Median 0.58 (0.17-4.25) years
[residents] to promote self-care.’’ Another staff member said, ‘‘[An example of] high quality of nursing care is to help a client to regain his/ her self-care abilities.’’ A resident reported, ‘‘Helping me is to guide me how to get up from my bed ., they only need to give me some tips, instruct me several times, demonstrate several times, and allow me to practice several times; that is enough.’’ Negative feeling of asking for assistance. Both staff members and residents indicated that asking for assistance resulted in negative feelings. Staff indicated that when elders asked for assistance, they tended to feel embarrassed and shameful. Residents also stated that when they asked for assistance, they felt embarrassed, distressed, upset, depressed, hopeless, and troublesome to others. Both a staff and a resident indicated that ‘‘They (elders) feel embarrassed to ask for help’’ and ‘‘If a person lost self-care ability, he/she will feel upset, hopeless.’’ Barriers to regain self-care ability. Common challenges for elders to regain self-care ability included physical limitations, fear of falling, depressed mood, and staff-fostered dependency.
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Number (%)
3 (30) 7 (70)
Physical limitations. Lack of physical strength and health problems such as stroke, asthma, heart problems, and fractures prevented elders from regaining self-care ability. One staff member stated, ‘‘Some elders may have had a stroke and may be paralyzed on one side of their body. They lack physical strength to perform self-care because they have weak muscle power.’’ A resident pointed out that ‘‘If my heart problem did not occur, I could walk and do things for myself (perform self-care independently). However, if it occurred (having symptoms of heart disease), I could not even lie down (on my bed), and would need staff assistance (to perform self-care).’’ Fear of falling. Fear of falling inhibited elders’ motivation to perform self-care independently in this study. A staff member stated, ‘‘some elders were afraid to learn to walk because they were afraid to fall again,’’ and ‘‘we [staff] tried to assist a grandma who had experienced a fall to learn self-bathing. She refused because she was afraid to fall again.’’ A resident stated, ‘‘I am afraid of falling because I am overweight, and lack strength. It is difficult for me to regain self-care.’’ Depressed mood. Staff and residents indicated that depression was the major force that
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Table 3. Nursing home staff and residents beliefs about self-care Theme The importance of performing self-care
Pattern
Categories
Being independent
Staff belief: Increase one’s self-esteem; Increase one’s self-confidence; Maintain one’s physical functions Residents belief: Increased one’s happiness
Barriers to regain self-care ability
Facilitators to regain self-care ability
A high quality of nursing care
Staff beliefs: Took more time to be with elders; Allowed elders to do what they could do; Assisted elders to regain or maintain their self-care abilities; Provide heartfelt care; Be able to identify elders’ current needs Residents beliefs: Spend more time with them; Allow them to perform self-care independently; Assist them to regain their self-care abilities
Negative feeling of asking for assistance
Staff beliefs: Feeling embarrassed; Feeling shameful Residents beliefs: Feeling embarrassed; Feeling distressed Feeling upset; Feeling depressed; Feeling hopeless; Feeling troublesome to other
Physical limitations Fear of falling Depressed emotions
Staff and residents beliefs: Lack of physical strength; Health problems
Staff fostered dependency
Staff beliefs: A staff shortage Family members supporting dependency
Increasing self-esteem Wishing to return home Receiving support from staff members Receiving support from family members
Staff and elders beliefs: Allowing elders to perform self-care Encouraging elders to perform self-care
prevented elders from performing self-care and requiring assistance. A staff member said, ‘‘I think that the major barrier (interferes with elders to regain self-care) is depression,’’ and ‘‘after she experienced falls, she became very depressed. She didn’t practice walking, and learn to promote self-care ability.’’
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Giving praise
Staff-fostered dependency. Many elders described that staff did not encourage them to perform self-care activities such as self-bathing: ‘‘Yes, I do [want to bathe myself]. However, they [staff members] don’t allow me to,’’ and ‘‘Yes. I can walk without anyone’s assistance. I think I can do self-bathing, too. However, we are
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not allowed to [self-bathe]. They [staff members] assist us with bathing because that is a rule [assisting residents to bathe] here [at the nursing home].’’ Although staff members believed that it was important for elders to perform self-care independently, most reported that they discouraged elders from performing self-care because of a staff shortage and family members supporting dependency. Staff indicated that ‘‘We have a staff shortage problem. . We are very busy. We don’t have too much time to wait for them to do every thing [performing ADLs] for themselves because they are very slow [their movements are very slow].’’ Moreover, because family members preferred that staff assist elders in performing self-care, they encouraged staff-fostered dependency. A staff member stated, ‘‘they [residents’ family members] think they are the bosses because they pay lots of money for their elders to live here [at the nursing home]. . Family members perceive that staff should assist elders to perform activities of daily living. They even tell elders if they (elders) need anything, just ask for help [from staff].’’ Facilitators for elders to perform self-care. Both staff and residents indicated that facilitators that enabled elders to regain self-care included 1) increasing self-esteem, 2) wishing to return home, 3) receiving support from staff members, and 4) receiving support from family members. Increasing self-esteem. Staff members indicated that nursing home elders gained respect and selfesteem from others by performing self-care independently: ‘‘Actually, every elder would like to do things to cultivate a high self-esteem. If they can do it [perform self-care] by themselves, they wish to do it for themselves because that is one way to increase self-worth.’’ Elders also made statements to support this belief: ‘‘performing self-care independently not only can increase elder’s self-worth, but it also increases their happiness.’’ Another elder stated, ‘‘Yes, it is very important [to take care of self such as walking]. . If one is moveable, he or she is useful in the world. But if one cannot walk, his or her life is meaningless. . Now, I only have one wish, which is to walk again. If I can walk, I will be very happy.’’ Wishing to return home. ‘‘Wishing to go back home’’ was an important motivator for an elder to regain self-care ability. Staff members gave examples: ‘‘they work very hard to learn [self-care]
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because they want to go back home.’’ One elder reported, ‘‘I wish I could go home as soon as possible. . I will be happier if I go back home,’’ and ‘‘I do simple exercises every morning. I can get up and off the bed, and go to the restroom by using a cane and walking slowly. I also do selffeeding. . I wish I could go back home.’’ A strong expectation to go home motivated elders to regain self-care ability. Receiving support from staff members. To regain or maintain self-care ability, elders needed to receive support from staff members. Strategies that staff usually used included allowing elders to perform self-care, encouraging elders to perform self-care, and giving praise. Examples staff provided were the following: ‘‘if an elder asks you to assist to perform an activity of daily living that she is able to do by herself, you need to assist her. At the same time, you [staff members] also need to tell her that you should try to perform self-care; and you cannot depend on others to assist you all the time. Just let her try to do things by herself. If they have difficulty to perform one specific task of daily living, we still need to help them’’; ‘‘they (elders) need encouragement. . For example, we encouraged him [an elder] to feed himself. We allowed him to take time during the mealtime. Now, he can feed himself without any assistance.’’ Receiving support from family members. Receiving support from family members increased elders’ motivation to regain self-care ability or perform self-care. Staff members gave examples: ‘‘To regain or maintain elders’ self-care ability, they need to receive support from their family members. If they receive more support from their family members, they will try harder to learn how to improve their self-care abilities.’’ ‘‘Even if the family member only talks to him/ her a little, his or her mood turns good. . Then they [elders] will work harder [to learn self-care].’’ In addition, an elder gave this example: ‘‘It is important to take care of self [and perform activities of daily living independently]. My sons always encourages me [to practice walking and self-care].’’
Discussion This study explored the influence of Chinese culture and philosophy on the beliefs of nursing home staff and residents about self-care. Two
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key philosophical components of traditional Chinese culture are Confucianism and Taoism. Both Confucianism and Taoism emphasize that human beings should not be self-centered and should be in harmony with other people and nature. Influenced by Confucianism and Taoism, most Chinese elderly believe that being respected by others is essential, which also brings them happiness and health.1,22,23 To gain respect from others, it is important to perform self-care. Elders in nursing homes performing self-care independently not only increases their self-esteem, selfconfidence, and happiness, it also enhances their physical health. Further, it helps them to return home earlier. Therefore, results of this study support the concept that allowing and encouraging nursing home elders to perform self-care indicates a high quality of nursing care among nursing home staff. Conversely, doing for elders or assisting elders to perform self-care likely results in elders feeling shameful, distressed, and upset, which is undesirable and detrimental.1,18,23 Although it is important for nursing home elders in Taiwan to promote or practice self-care, they might not be able to do so because of physical limitations, fear of falls, depressed mood, and stafffostered dependency. This result was consistent with previous studies from Western countries.24,25 For example, Espiritu and colleagues25 investigated whether self-reported depression is related to functional ability among 121 dementia elders. Their results indicated that depression in dementia is significantly related to functional ability. Baltes and colleagues26 examined whether ‘‘dependency-support’’ and ‘‘independence-ignore’’ scripts could be modified through a staff training program. The program focused on communication skills, knowledge of aging, and basic behavior principles. Fourteen staff members attended the training program (experimental group), and 13 did not (control group). Data were collected through observation of interactions between staff members and residents in the context of self-care. Results indicated that there were significant changes for the experimental group. Increases in staff independence-support behavior, in independent behavior of residents, and independence-related interaction patterns were demonstrated. In addition, evidence indicated that falls were the most common causes of injury and hospital admissions among elders.27,28 Approximately 87% of fractures resulted from falls.29 Because of fear of falls and the consequences of falls such as fractures, nursing home el-
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ders were not motivated to pursue or practice selfcare. In addition, Taiwanese nursing home elders might not be given opportunities to perform self-care independently because nursing home staff do not allow them to do so.19 Although staff caregivers may be taught to encourage residents to perform self-care in nursing schools,10 they might not able to do so because of staff shortages and attitudes among elders’ family members that support dependency. Current staffing standards in nursing homes in Taiwan require at least 1 full-time registered nurse for every 15 residents and at least 1 nursing assistant for every 5 residents. However, it is unlikely that nursing homes fulfill these requirements. When 1 nurse needs to take care of 30 to 40 elders and 1 nursing assistant is responsible for 12 to 20 elders during a shift, many elders may not be given opportunities to do self-care. Because of physical limitations, it takes longer for an elder to complete a basic ADL task such as bathing. Nursing home staff can complete a task faster than elders do. Staff members also worry that all required tasks may not be completed if they allow elders to perform self-care.30 Therefore, although residents are able to perform essential ADLs independently, nursing home staff members do not allow elders to do so; instead, they perform the tasks for them. Moreover, nursing home elders’ family members often strongly encourage elders to ask nursing staff to do everything for them.9,19, 30 Reasons for this include 1) doing things for elders is one way to show respect and caring for their elderly parents and 2) the belief that high-quality nursing care means staff members do everything for elders to satisfy their needs.19
Conclusion Results of this study found that both staff members and residents had similar beliefs within 3 major themes: the importance of performing self-care, barriers to regaining self-care abilities, and facilitators to regaining self-care ability. Although nursing home staff believe it is important for nursing home elders to perform self-care, nursing home residents may have difficulty reaching this goal because of several barriers. Encouraging residents to do things for themselves is not enough to overcome the barriers that affect nursing home residents’ ability to perform
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self-care. It is important for staff members to enhance residents’ self-care abilities by facilitating elders’ self-care.
References 1. Chen YLD. Conformity with nature: a theory of Chinese American elder’s health promotion and illness processes. Adv Nurs Sci 1996;19:7-26. 2. Shyu YIL, Lee HC. Predictors of nursing home placement and home nursing services utilization by elderly patients after hospital discharge in Taiwan. J Adv Nurs 2002;38: 398-406. 3. Chiu L, Shyu WC, Liu YH, et al. Factors determining the attitudes of family caregivers of dementia patients toward nursing home placement in Taiwan: comparisons between urban and semiurban areas. Pub Health Nurs 2001;18:281-91. 4. Wu SC, Li CY, Chang AL. The influence of intergenerational exchange on nursing home admission in Taiwan. J Cross-Culture Gerontol 1997;13:163-74. 5. Ministry of the Interior, Department of Social Affairs. Statistics. Available at http://sowf.moi.gov.tw/04/07/07. htm. Cited April 7, 2006. 6. Kao HF, Stifbergen AK. Family experiences related to the decision to institutionalize an elderly member in Taiwan: an exploratory study. Soc Sci Med 1999;49: 1115-23. 7. Chiu HC. Organization and delivery of long-term care in Taiwan. J Aging Soc Policy 2001;13:217-32. 8. Wu SC. Assessment of the policy for long-term care. J Long-Term Care (Taiwan) 1998;12:7-13. 9. Jensen B, Cohen-Mansfield J. How do self-care routines of nursing home residents compare with past self-care practices? Geri Nurs 2006;27:244-51. 10. Yeh HY, Lin LW, Wang SY, et al. Continuing education needs and knowledge of gerontological nursing among nurses in nursing homes [in Chinese]. J Nurs Res 2001;9: L300-10. 11. Chang CC, Wykle ML, Madigan EA. The effect of a feeding skills training program for nursing assistants who feed dementia patients in Taiwanese nursing homes. Geriatr Nurs 2006;27:229-37. 12. Liu SJ. Health conception and health behavior for community elderly in Taiwan. J Nurs (China) 1998;4:22-8. 13. Miller ME, Rejeski WJ, Reboussin BA, et al. Physical activity, functional limitations, and disability in older adults. J Am Geriatr Soc 2000;48:1264-72. 14. Smits MW, Kee CC. Correlates of self-care among the independent elderly: Self-concept affects well-being. J Gerontolog Nurs 1992;18:13-8. 15. Orem D. Nursing: concepts of practice. 6th ed. St. Louis: Mosby; 2001.
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16. Lin PJ, Hwu SF. Changes in physical-psychological responses, self-care behaviors, and related factors among patients receiving artificial valve replacement. J Nurs (China) 1993;40:3746. 17. Backman K, Hentinen M. Model for the self-care of homedwelling elderly. J Adv Nurs 1999;30:564-72. 18. Chen YC. Chinese values, health and nursing. J Adv Nurs 2001;36:270-3. 19. Yang CL. Indicators of quality of care in nursing home: from nursing home family members’ perspective. J LongTerm Care (China) 2000;4:33-41. 20. Denzin NK, Lincoln YS. Narrative, content, and semiotic analysis. In: Handbook of qualitative research. Thousand Oaks, CA: Sage; 1994. p. 463-77. 21. Munhall PL. Nursing research: a qualitative perspective. 3rd ed. Boston: Jones and Bartlett; 2001. 22. Graham AC. Studies in Chinese philosophy and philosophical literature. Albany: State University of New York Press; 1990. 23. Chen YC. Chinese values, health and nursing. J Adv Nur 2001;36:270-3. 24. Thomas VS. Excess functionally disability among demented subjects? Demen Geriatr Cogn Dis 2001;12: 206-10. 25. Espiritu DA, Rashid H, Mast BT, et al. Depression, cognitive impairment and function in Alzheimer’s disease. Int J Geri Psy 2001;16:1098-103. 26. Baltes M, Neumann EM, Zank S. Maintenance and rehabilitation of independence in old age: an intervention program for staff. Psychol Aging 1994;9:179-88. 27. Reynolds J, Kelly J. Falls prevention, or ‘‘I think I can’’: an ensemble approach to falls management. Home Healthcare Nurs 2006;24:103-11. 28. Chow SKY, Lai CKY, Suen LKP, et al. Evaluation of the Morse Fall Scale: applicability in Chinese hospital populations. Int J Nurs Stud 2007;44:556-65. 29. John-Tung Foundation. Introduction to depression. Available at http://psyche.jtf.org.tw/melancholia/aged. asp. Cited Oct. 1, 2007. 30. Shun HG, Chang SM. Investigation nursing home aides remain reasons in one eastern Taiwan. J Long-Term Care (China) 2000;4:42-55. SU-HSIEN CHANG, PhD, MSN, RN, is an Assistant Professor at Chung Hua University of Medical Technology, Department of Nursing, Taiwan, ROC. ACKNOWLEDGMENTS The author acknowledges the assistance of the faculty, Dr Sandra L. Cromwell and Miao-Chun Fang, who helped her with data analysis. The author thanks the subjects who graciously agreed to participate in this study. 0197-4572/08/$ - see front matter Ó 2009 Mosby, Inc. All rights reserved. doi: 10.1016/j.gerinurse.2008.04.011
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The purpose of this qualitative study was to investigate the beliefs about self-care among nursing home staff and residents. Subjects included 10 nursing home staff members and 10 residents. Results indicated 3 major themes: 1) the importance of performing self-care, 2) barriers to regaining self-care abilities, and 3) facilitators to regaining selfcare ability. The importance of performing self-care was related to subjects’ beliefs about being independent, to high-quality nursing care, and to negative feelings about asking for assistance. Barriers for elders to regaining self-care abilities were physical limitations, fear of falling, depressed mood, and stafffostered dependency. However, facilitators for elders to regain self-care were increasing self-esteem, wishing to return home, and receiving support from staff and family members. The findings from this study will be useful for planning interventions to improve health and wellness among nursing home elders in Taiwan. (Geriatr Nurs 2009;30:90-98) hinese elderly in Taiwan normally wish to take care of themselves because it is an important way to gain respect from others, especially their adult children.1 Although Chinese elders in Taiwan often want to be independent in performing self-care, they may not be able to do so because of physical illness, depression, and the effects of medications.2-4 Physical and mental conditions may limit Chinese elders’ ability to perform basic activities of daily living (ADLs) such as feeding, bathing, dressing, grooming, toileting; inhibit their mobility including transferring, ambulating, and stair climbing; or affect their performance of instrumental ADLs, such as preparing their own meals, using the telephone, shopping for groceries, getting to places beyond walking distance, doing housework, doing handyman work, doing laundry, managing money, and taking medications. When elders have 1 or more functional limitations, their selfcare ability is weakened and they may need to be admitted to a long-term care institution. According to Taiwan’s Ministry of the Interior,
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Department of Social Affairs,5 the number of registered long-term care facilities increased from 70 in 1997 to 960 in 2006. The number of nursing homes has been increasing because of the rapidly aging population and the changing family structure. In 1993, the total number of those aged 65 and older was 1,490,801. The number increased to 2,287,527 in 2006, or to 10% of the total population in Taiwan.5 Traditionally, Chinese elders in Taiwan have believed that the ideal living arrangement for elders is living with children. However, after World War II, family resources for taking care of elders decreased because more women were pursuing careers outside the home and because of an increase in nuclear families and young urban dwellers.6,7 Therefore, placing elderly parents into a long-term care facility such as a nursing home has become a new caregiver alternative. Because long-term care services were established in a short period in Taiwan, the most urgent and severe problem has been the lack of well-educated, long-term care providers.6-8 Because of the lack of knowledge in gerontological nursing among long-term care providers, nursing home staff members may foster residents’ dependent behaviors. As a result, elders’ basic ADL selfcare abilities may continue to decline and their disabilities worsen after their admission to a nursing home.9,10 Little is known about the beliefs of self-care among nursing home staff and elders in Taiwan.11 Quantitative research on nursing interventions in the current literature lacks meaningful descriptions of self-care ability among Taiwanese nursing homes elders.11 Therefore, the purpose of this study was to investigate the beliefs about self-care among staff and elders in nursing homes in Taiwan.
Background Self-care is important for older adults to maintain and create meaning and purpose in life.1 Elders’ perceptions of meaning and purpose in life are ultimately linked to their perception of health.12 Miller and colleagues13 indicated that
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by strengthening self-concept, people were motivated to engage in self-care behaviors, which might positively affect well-being. Similarly, Smits and Kee14 studied 48 elders aged 65 or older and living independently in the community to understand the relationship between self-concept and self-care. They found a positive correlation between self-care and self-concept. They concluded that elders who had a higher score of self-concept and engaged in self-care activities had enhanced physical and psychological wellbeing. In brief, a decline in self-care ability can result in elders’ decreased physical and psychological well-being.1,13,14 The term self-care refers to any self-initiated or self-directed action of engaging in activities of daily living and other activities to preserve bio-psycho-social well-being. Orem15 indicated that self-care is the practice of activities which people initiate and perform on their own behalf in maintaining life, health and well-being. Lin and Hwu16 also stated that self-care is the practice of activities that a person performs to maintain life, health, and wellness. Traditionally, selfcare has been defined as activities associated with health promotion. It represents behaviors that individuals undertake to promote or maintain their physical, psychological, and social wellness.17 To understand self-care behaviors, it is necessary to understand the interaction among the components of self-care and sociocultural influences. For the Chinese, traditional philosophies of Confucianism, Taoism, and Buddhism have influenced both the behaviors and rules of social interaction. They have also provided a perspective on life, health, and illness.1,18 These philosophies share an approach to self-care for the Chinese. Their view is that taking care of self is valued because it is a way to gain self-respect and respect from others, and, therefore, is a way to improve health and wellness.1 Although self-care is important for a Chinese person to achieve health and wellness, not everyone can take care of oneself. This may be because self-care means different things to different people; nursing home staff members and residents, for example, may have different ideas about what self-care is. Staff caregivers usually are taught to encourage residents to perform self-care in nursing schools,10,18 but nursing administrators and experienced nurses in clinical settings may discourage them from doing so.19
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Their intentions may be good. Nursing administrators and experienced nurses often encourage novice nurses or nursing students to do everything for elders because they believe that is the way to show caring and respect.19 However, despite their good intentions, elderly adults may learn it is acceptable to receive assistance from others. Elders learn to ask for help instead of doing for themselves. Elders are induced to a dependent role, and they may begin to behave in this expected role. Ultimately, they may begin to practice dependent behaviors. The meanings that staff attribute to self-care influence their behaviors in assisting elders to promote selfcare.9 Therefore, to foster self-care behaviors among Chinese elders in nursing homes, it is important to study the meanings of self-care for both nursing home staff and residents because nursing home staff are the primary caregivers for elders.
Methodology Research Design This study used a qualitative approach to gain a deeper understanding of nursing home staff members’ and residents’ beliefs about self-care. The data were collected through face-to-face interviews with nursing home staff and residents. Study Participants A convenience sampling method was used. Ten subjects were nursing home staff including nurses and nursing assistants. Eligibility for the staff group included having worked at the nursing home for 6 months and being a direct-care provider. Ten nursing home residents were recruited to participate in this study. Eligibility for the residents group included 1) living in the nursing home for 3 months or more, 2) aged 65 and over, 3) ability to walk or sit in a wheelchair, 4) no dementia as determined by a score of 23 or greater (of 30 points) on the Mini-Mental State Examination, and 5) not bedridden. To recruit subjects, the primary investigator (SHC) first presented the purpose, rationale, and background of the study to staff at a staff meeting and to individual residents who met the subject selection criteria. Subjects were encouraged to ask questions and to participate in the study. If the subjects agreed to participate, they signed a consent
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form. Because some residents were not able to read or write, they used their finger print as a signature, and a staff member acted as a witness. Finally, a copy of the signed consent form was given to the subjects that included statements about their rights as subjects, the protection of confidentiality and anonymity, and the benefits and risks of the study. The data collection and analysis procedures were approved by the Human Subjects Protection Program at The University of Arizona. Data Collection and Analysis Subjects were interviewed using an interview guideline (Table 1) to standardize content. The principal investigator (SHC) conducted all the interviews. Methods for facilitating unconstrained subjects’ responses such as facial expressions, body posture, and silence were applied during the interviews. Subjects were asked about their beliefs about the importance of self-care. They also were asked to describe the facilitators and barriers to performing self-care. Detailed field notes and memos were recorded immediately after each interview and used in the analysis. All subjects were interviewed in a private and quiet room in the nursing home or in a place convenient to each subject. All interviews were conducted by the investigator in Mandarin or Taiwanese and were audio tape-recorded. Interviews ranged from 30 to 90 min. Tapes were transcribed, and all subjects’ identifying information was removed from the transcription and the data. Translations of the transcribed interviews in the original language were analyzed using content analysis.20,21 The principal investigator individually summarized segments of the data from interviews into categories, then discussed them with a research partner (Miao-Chun Fang), who was experienced in qualitative research and familiar with the coding scheme. After agreeing on the general categories, the principal investigator coded each interview. All disagreements were discussed until a consensus was reached. After most of the data had been analyzed and the categories were clearly exhausted, pattern coding was used to group the categories into a smaller number of themes. The coding was performed in the original language, then translated by the principal investigator into English. A back-translation was not done.
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Results Participants’ Demographic Data Of the staff group, 70% of the participants were nursing assistants. All were female. Their total number of years of work experience in the nursing field ranged from 6 months to 18.5 years. Their work experience in nursing homes ranged 1 year to 8.5 years. Of the resident group, 70% were female. The oldest participant was aged 90 years. The maximum number of months living in the nursing home was 51. A summary of the demographic data is presented in Table 2. Findings Fifteen codes were identified, and from these codes 3 themes were established. Themes in the qualitative data reflected nursing home staff’s and residents’ beliefs about 1) the importance of performing self-care, 2) barriers to regaining selfcare ability, 3) and facilitators to regaining selfcare ability. These themes are now presented. Table 3 summarizes the nursing home staff members’ and residents’ beliefs about self-care. The importance of performing self-care. Staff members and residents believed that the importance of self-care related to 1) being independent, 2) high-quality nursing care, and 3) negative feelings of asking for assistance. Being independent. Residents and staff members believed that performing self-care was a way to achieve independence. Staff indicated that the outcomes associated with being independent were to 1) increase self-esteem, 2) increase self-confidence, and 3) maintain physical function. One staff member reported, ‘‘If people cannot take good care of themselves, they may lose self-confidence and self-worth.’’ Residents pointed out that being independent in performing self-care increased their happiness. Another resident said, ‘‘If I can take care of myself, I feel happy. However, if I need to ask other people to assist me in performing self-care, I feel distress.’’ High-quality nursing care. The meaning of high-quality nursing care for staff and residents was allowing elders to perform self-care. To increase residents’ self-care abilities, staff members indicated it was important that they 1) take more time to be with elders, 2) allow elders to do what they could do, 3) assist elders to regain or maintain their self-care abilities, 4) provide
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Table 1. Guidelines for interviews conducted with nursing home residents and staff Definition of self-care is ‘‘the practice of activities that individuals initiate and perform on their own behalf in maintaining life, health, and well-being’’ (Orem, 1995, p. 104). These include bathing self, feeding self, going to toilet self, transferring self, dressing self, and maintaining continence.
Interview guideline for nursing home resident group General questions important to exercise self-care: How do you feel about self-care? How do you feel you are cared for by others? How do you feel if nursing home staff ‘‘doing everything for you’’? Do you think it is important for everyone to take care themselves? If yes, why? If no, why? Do you think it is important for you to take care of yourself? If yes, why? If no, why? General questions about abilities to perform self-care: What are facilitators and barriers for you to perform self-care? Tell me when you moved here? What was happening with your health? And what was happening with your self-care? How well do you think that you are able to take care of yourself? How comfortable are you asking for help? Do you think that you will have more ability to take care of yourself one day? If yes, what would you do to help yourself gain ability? What do you want nurses or nursing assistants to do to help you gain ability? If no, what prevents you from enhancing your self-care abilities? Interview guideline for nursing home staff group General questions important for performing self-care: How important for elders to perform self-care? Do you think it is important for everyone to perform self-care? If yes, why? If no, why? Do you think it is important for the elderly to perform self-care? If yes, why? What do you do to help elders enhance their self-care abilities? If no, why not? General questions about residents’ abilities to perform self-care: What are facilitators and barriers for elders to exercise of self-care? Tell me how well nursing home elders are able to take care of themselves? When do elders ask for help? And when do they do things for themselves? How comfortable are elders asking for help? Do you think that your elder patients have abilities to perform their self-care? If yes, why do you think they have abilities to perform self-care? What do you do to help them? If no, why don’t you think they have abilities to perform self-care?
heartfelt care, and 6) were able to identify elders’ current needs. Similarly, residents believed that to increase their self-care ability, staff should 1) spend more time with them, 2) allow them to per-
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form self-care independently, and 3) assist them to regain their self-care abilities. For example, one staff member stated, ‘‘if it is possible, I would like to spend more time with my clients
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Table 2. Participants’ characteristics Characteristics Staff group (n 5 10) Age Length of working experiences in nursing field Length of working experiences in nursing homes Education level College 2-years’ Junior college Vocational school 7 Grades Occupations Nurses Nursing assistants Resident Group (n 5 10) Age Length of time living in the nursing home Gender Male Female
Mean (±S.D.), Median (Range) Mean 30.9 11.53 years, Median 28 (19-53) years Mean 4 5.53 years, Median 1 (0.5-18.5) years Mean 2.35 2.40 years, Median 1 (0.5-8) years
1 (10) 1 (10) 7 (70) 2 (20) 3 (30) 7 (70) Mean 81.1 5.76 years, Median 79.5 (70-90) years Mean 0.95 1.20 years, Median 0.58 (0.17-4.25) years
[residents] to promote self-care.’’ Another staff member said, ‘‘[An example of] high quality of nursing care is to help a client to regain his/ her self-care abilities.’’ A resident reported, ‘‘Helping me is to guide me how to get up from my bed ., they only need to give me some tips, instruct me several times, demonstrate several times, and allow me to practice several times; that is enough.’’ Negative feeling of asking for assistance. Both staff members and residents indicated that asking for assistance resulted in negative feelings. Staff indicated that when elders asked for assistance, they tended to feel embarrassed and shameful. Residents also stated that when they asked for assistance, they felt embarrassed, distressed, upset, depressed, hopeless, and troublesome to others. Both a staff and a resident indicated that ‘‘They (elders) feel embarrassed to ask for help’’ and ‘‘If a person lost self-care ability, he/she will feel upset, hopeless.’’ Barriers to regain self-care ability. Common challenges for elders to regain self-care ability included physical limitations, fear of falling, depressed mood, and staff-fostered dependency.
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Number (%)
3 (30) 7 (70)
Physical limitations. Lack of physical strength and health problems such as stroke, asthma, heart problems, and fractures prevented elders from regaining self-care ability. One staff member stated, ‘‘Some elders may have had a stroke and may be paralyzed on one side of their body. They lack physical strength to perform self-care because they have weak muscle power.’’ A resident pointed out that ‘‘If my heart problem did not occur, I could walk and do things for myself (perform self-care independently). However, if it occurred (having symptoms of heart disease), I could not even lie down (on my bed), and would need staff assistance (to perform self-care).’’ Fear of falling. Fear of falling inhibited elders’ motivation to perform self-care independently in this study. A staff member stated, ‘‘some elders were afraid to learn to walk because they were afraid to fall again,’’ and ‘‘we [staff] tried to assist a grandma who had experienced a fall to learn self-bathing. She refused because she was afraid to fall again.’’ A resident stated, ‘‘I am afraid of falling because I am overweight, and lack strength. It is difficult for me to regain self-care.’’ Depressed mood. Staff and residents indicated that depression was the major force that
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Table 3. Nursing home staff and residents beliefs about self-care Theme The importance of performing self-care
Pattern
Categories
Being independent
Staff belief: Increase one’s self-esteem; Increase one’s self-confidence; Maintain one’s physical functions Residents belief: Increased one’s happiness
Barriers to regain self-care ability
Facilitators to regain self-care ability
A high quality of nursing care
Staff beliefs: Took more time to be with elders; Allowed elders to do what they could do; Assisted elders to regain or maintain their self-care abilities; Provide heartfelt care; Be able to identify elders’ current needs Residents beliefs: Spend more time with them; Allow them to perform self-care independently; Assist them to regain their self-care abilities
Negative feeling of asking for assistance
Staff beliefs: Feeling embarrassed; Feeling shameful Residents beliefs: Feeling embarrassed; Feeling distressed Feeling upset; Feeling depressed; Feeling hopeless; Feeling troublesome to other
Physical limitations Fear of falling Depressed emotions
Staff and residents beliefs: Lack of physical strength; Health problems
Staff fostered dependency
Staff beliefs: A staff shortage Family members supporting dependency
Increasing self-esteem Wishing to return home Receiving support from staff members Receiving support from family members
Staff and elders beliefs: Allowing elders to perform self-care Encouraging elders to perform self-care
prevented elders from performing self-care and requiring assistance. A staff member said, ‘‘I think that the major barrier (interferes with elders to regain self-care) is depression,’’ and ‘‘after she experienced falls, she became very depressed. She didn’t practice walking, and learn to promote self-care ability.’’
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Giving praise
Staff-fostered dependency. Many elders described that staff did not encourage them to perform self-care activities such as self-bathing: ‘‘Yes, I do [want to bathe myself]. However, they [staff members] don’t allow me to,’’ and ‘‘Yes. I can walk without anyone’s assistance. I think I can do self-bathing, too. However, we are
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not allowed to [self-bathe]. They [staff members] assist us with bathing because that is a rule [assisting residents to bathe] here [at the nursing home].’’ Although staff members believed that it was important for elders to perform self-care independently, most reported that they discouraged elders from performing self-care because of a staff shortage and family members supporting dependency. Staff indicated that ‘‘We have a staff shortage problem. . We are very busy. We don’t have too much time to wait for them to do every thing [performing ADLs] for themselves because they are very slow [their movements are very slow].’’ Moreover, because family members preferred that staff assist elders in performing self-care, they encouraged staff-fostered dependency. A staff member stated, ‘‘they [residents’ family members] think they are the bosses because they pay lots of money for their elders to live here [at the nursing home]. . Family members perceive that staff should assist elders to perform activities of daily living. They even tell elders if they (elders) need anything, just ask for help [from staff].’’ Facilitators for elders to perform self-care. Both staff and residents indicated that facilitators that enabled elders to regain self-care included 1) increasing self-esteem, 2) wishing to return home, 3) receiving support from staff members, and 4) receiving support from family members. Increasing self-esteem. Staff members indicated that nursing home elders gained respect and selfesteem from others by performing self-care independently: ‘‘Actually, every elder would like to do things to cultivate a high self-esteem. If they can do it [perform self-care] by themselves, they wish to do it for themselves because that is one way to increase self-worth.’’ Elders also made statements to support this belief: ‘‘performing self-care independently not only can increase elder’s self-worth, but it also increases their happiness.’’ Another elder stated, ‘‘Yes, it is very important [to take care of self such as walking]. . If one is moveable, he or she is useful in the world. But if one cannot walk, his or her life is meaningless. . Now, I only have one wish, which is to walk again. If I can walk, I will be very happy.’’ Wishing to return home. ‘‘Wishing to go back home’’ was an important motivator for an elder to regain self-care ability. Staff members gave examples: ‘‘they work very hard to learn [self-care]
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because they want to go back home.’’ One elder reported, ‘‘I wish I could go home as soon as possible. . I will be happier if I go back home,’’ and ‘‘I do simple exercises every morning. I can get up and off the bed, and go to the restroom by using a cane and walking slowly. I also do selffeeding. . I wish I could go back home.’’ A strong expectation to go home motivated elders to regain self-care ability. Receiving support from staff members. To regain or maintain self-care ability, elders needed to receive support from staff members. Strategies that staff usually used included allowing elders to perform self-care, encouraging elders to perform self-care, and giving praise. Examples staff provided were the following: ‘‘if an elder asks you to assist to perform an activity of daily living that she is able to do by herself, you need to assist her. At the same time, you [staff members] also need to tell her that you should try to perform self-care; and you cannot depend on others to assist you all the time. Just let her try to do things by herself. If they have difficulty to perform one specific task of daily living, we still need to help them’’; ‘‘they (elders) need encouragement. . For example, we encouraged him [an elder] to feed himself. We allowed him to take time during the mealtime. Now, he can feed himself without any assistance.’’ Receiving support from family members. Receiving support from family members increased elders’ motivation to regain self-care ability or perform self-care. Staff members gave examples: ‘‘To regain or maintain elders’ self-care ability, they need to receive support from their family members. If they receive more support from their family members, they will try harder to learn how to improve their self-care abilities.’’ ‘‘Even if the family member only talks to him/ her a little, his or her mood turns good. . Then they [elders] will work harder [to learn self-care].’’ In addition, an elder gave this example: ‘‘It is important to take care of self [and perform activities of daily living independently]. My sons always encourages me [to practice walking and self-care].’’
Discussion This study explored the influence of Chinese culture and philosophy on the beliefs of nursing home staff and residents about self-care. Two
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key philosophical components of traditional Chinese culture are Confucianism and Taoism. Both Confucianism and Taoism emphasize that human beings should not be self-centered and should be in harmony with other people and nature. Influenced by Confucianism and Taoism, most Chinese elderly believe that being respected by others is essential, which also brings them happiness and health.1,22,23 To gain respect from others, it is important to perform self-care. Elders in nursing homes performing self-care independently not only increases their self-esteem, selfconfidence, and happiness, it also enhances their physical health. Further, it helps them to return home earlier. Therefore, results of this study support the concept that allowing and encouraging nursing home elders to perform self-care indicates a high quality of nursing care among nursing home staff. Conversely, doing for elders or assisting elders to perform self-care likely results in elders feeling shameful, distressed, and upset, which is undesirable and detrimental.1,18,23 Although it is important for nursing home elders in Taiwan to promote or practice self-care, they might not be able to do so because of physical limitations, fear of falls, depressed mood, and stafffostered dependency. This result was consistent with previous studies from Western countries.24,25 For example, Espiritu and colleagues25 investigated whether self-reported depression is related to functional ability among 121 dementia elders. Their results indicated that depression in dementia is significantly related to functional ability. Baltes and colleagues26 examined whether ‘‘dependency-support’’ and ‘‘independence-ignore’’ scripts could be modified through a staff training program. The program focused on communication skills, knowledge of aging, and basic behavior principles. Fourteen staff members attended the training program (experimental group), and 13 did not (control group). Data were collected through observation of interactions between staff members and residents in the context of self-care. Results indicated that there were significant changes for the experimental group. Increases in staff independence-support behavior, in independent behavior of residents, and independence-related interaction patterns were demonstrated. In addition, evidence indicated that falls were the most common causes of injury and hospital admissions among elders.27,28 Approximately 87% of fractures resulted from falls.29 Because of fear of falls and the consequences of falls such as fractures, nursing home el-
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ders were not motivated to pursue or practice selfcare. In addition, Taiwanese nursing home elders might not be given opportunities to perform self-care independently because nursing home staff do not allow them to do so.19 Although staff caregivers may be taught to encourage residents to perform self-care in nursing schools,10 they might not able to do so because of staff shortages and attitudes among elders’ family members that support dependency. Current staffing standards in nursing homes in Taiwan require at least 1 full-time registered nurse for every 15 residents and at least 1 nursing assistant for every 5 residents. However, it is unlikely that nursing homes fulfill these requirements. When 1 nurse needs to take care of 30 to 40 elders and 1 nursing assistant is responsible for 12 to 20 elders during a shift, many elders may not be given opportunities to do self-care. Because of physical limitations, it takes longer for an elder to complete a basic ADL task such as bathing. Nursing home staff can complete a task faster than elders do. Staff members also worry that all required tasks may not be completed if they allow elders to perform self-care.30 Therefore, although residents are able to perform essential ADLs independently, nursing home staff members do not allow elders to do so; instead, they perform the tasks for them. Moreover, nursing home elders’ family members often strongly encourage elders to ask nursing staff to do everything for them.9,19, 30 Reasons for this include 1) doing things for elders is one way to show respect and caring for their elderly parents and 2) the belief that high-quality nursing care means staff members do everything for elders to satisfy their needs.19
Conclusion Results of this study found that both staff members and residents had similar beliefs within 3 major themes: the importance of performing self-care, barriers to regaining self-care abilities, and facilitators to regaining self-care ability. Although nursing home staff believe it is important for nursing home elders to perform self-care, nursing home residents may have difficulty reaching this goal because of several barriers. Encouraging residents to do things for themselves is not enough to overcome the barriers that affect nursing home residents’ ability to perform
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self-care. It is important for staff members to enhance residents’ self-care abilities by facilitating elders’ self-care.
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Geriatric Nursing, Volume 30, Number 2