The influence of community context on the decision to enter a nursing home

THE INFLUENCE OF COMMUNITY CONTEXT ON THE DECISION TO ENTER A NURSING HOME

KATHLEEN M. FREUDENBERGER RAYMOND T. COWARD* NANCY E. SCHOENBERG R. PAUL DUNCAN University of Florida

JETT

JEFFREY W. DWYER Wayne State University ABSTRACT: The purpose of this research was to examine the association between community context (rural versus urban residence} and the reasons older adults (65+) decide to enter a nursing home. Personal interviews were conducted using open-ended questions with a sample of new admissions, or their proxies, in nine rural and nine urban nursing homes (N = 113). Responses were subjected to content analysis, which identified five categories of reasons that we labeled as: (1) Experiencing Sudden Events: some elders described a sudden unexpected event (such as a fall or serious illness) that caused them to be unable to continue to live in a community setting; (2) Changing Family Circumstances: some elders described family changes that reduced family members’ capacity to meet their needs; (3) Needing Skilled Care: some elders reported an increased need for skilled health care providers, like nurses and rehabilitative therapists; (4) Receiving Pressure from Others: some elders reported being “told to” enter a nursing home by a “significant other;” and (5) Living in Fear: some elders expressed apprehension about continuing to live in their community. Residential differences emerged in the frequency with which specific reasons were cited for nursing home admissions. These$ndings improve our understanding of the reasons for entering a nursing home described by older adults, highlighting the influence of residence.

*Direct all correspondence to: Raymond T. Cowurd, Center on Rural Health and Aging, P.O. Bar 100177, University of Florida, Health Science Center, Gainesville, FL 32610-0177. JOURNAL OF AGING STUDIES, Volume 10, Number 3, pages 237-254. Copyright 0 1996 by JAI Press Inc. All rights of reproduction in any form reserved. ISSN: 0890-4065.

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INTRODUCTION Despite the significant number of elders who reside in nursing homes and the substantial amount of public monies that are spent on nursing home care in the United States, our understanding of the factors and circumstances that surround an elder’s decision to enter a nursing home remains incomplete (Greene and Ondrich 1990). This investigation, based on personal interviews with older adults who were newly admitted into a nursing home, presents evidence that the type of community in which an older adult lives prior to entering a nursing home is an important contextual variable that is associated with the reasons behind the admission. The findings serve to remind social gerontologists that the community of residence of elders at the time immediately prior to their entering a nursing home shapes the choices they have about long-term care and, when taken into account, improves our understanding of the reasons that lead to admissions.

The Decision to Enter a Nursing Home Nursing homes remain a critical element in the long-term care of elders. On any given day, approximately 1.5 million American elders, or slightly less than 5 percent of all persons 65 years of age or older (Lazenby and Letsch 1990), reside in a nursing home (Business Publishers, Inc. 1993). Moreover, estimates suggest that approximately onethird of all persons over the age of 65 will reside in a nursing home at some point in their lifetime (Mmtaugh, Kemper, and Spillman 1990). National expenditures for nursing home care in 1989 were estimated to be $47.9 billion, or about 8 percent of all health care expenditures (Wolinsky, Callahan, Fitzgerald, and Johnson 1992), and are projected to nearly double to $98 billion by the year 2018 (Rivlin, Wiener, Hanley, and Spence 1988). Efforts to profile those elders who enter a nursing home have identified a large number of factors that are statistically associated with an increased likelihood of an admission (Hing 1989; Morris, Sherwood, and Gutkin 1988; Shapiro and Tate 1988). In addition, multivariate attempts to model patterns of institutionalization (Wolinsky et al. 1992) have identified personal, contextual, and health status characteristics that increase the risk of an admission. Research of this type, however, continues to be able to account for only a relatively modest amount of the variation in observed rates of admission. Indeed, it is by no means clear that the “decision” to enter a nursing home should be viewed as a fully autonomous choice in which the elder is the sole or preeminent participant. It may be that this decision is one that typically has several participants and that the elder’s role could be seen as varying along a continuum from being the principal decisionmaker to being a relatively passive recipient of decisions made by others. The current investigation is directed toward elders who have a substantial role in the decision-making process, but it is acknowledged that they are not fully independent of other people and structural circumstances. Some evidence suggests that the decision to enter a nursing home may be operationalized differently in rural and urban community contexts.’ First, elders living in nonmetropolitan counties are more likely to reside in a nursing home than their age counterparts who reside in metropolitan counties. In 1988, for example, the rate of nonmetropolitan elders living in nursing homes was 50.6 per 1,000 elders; whereas in metropolitan counties the rate was 34.6 persons per 1,000 elders-a 46.2 percent difference in the rate of occurrence (U.S.

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Bureau of the Census 1992). Second, Greene (1984) has argued, based on nursing home admissions data from Arizona, that rural elders are at-risk of “premature” institutionalization; i.e., more likely to enter nursing homes a younger ages and with less disability than their counterparts from more urban and suburban places2 He speculated that the smaller number and narrower range of in-home and community-based services in sparsely populated and remote rural places limited the alternatives to institutionalization that were available to rural elders and their families. Consistent with this line of argument, Coward, Duncan, and Freudenberger (1994) have reported, based on personal interviews with newly admitted residents in a sample of rural and urban nursing homes, that elders entering rural nursing homes were more likely to report that there were services that they had needed prior to their admission that had not been available in the rural communities where they lived. Indeed, even when they estimated a logistic regression model that included the age of the respondent and the difficulties they reported performing activities of daily living (ADLs) and instrumental activities of daily living (IADLS) (the three variables on which there had been statistical differences between the two residential groups), rural nursing home residents were still more than two and a half times as likely (2.68) to report that there were services that they had needed that were not available in their communities. Certainly there are both social and ecological differences in the community contexts in which rural and urban elders reside that may influence their decision to enter a nursing home. In the aggregate, for example, rural communities appear to have an abundance of intermediate care (ICF) nursing home beds. Shaughnessy (1994) has reported that on average nonmetropolitan communities have twice as many ICF-only beds per 1,000 elders as metropolitan areas. Nonmetropolitan and metropolitan locations are nearly identical, however, in terms of the number of skilled nursing home beds available; 29 and 28 per 1,000 elders, respectively. Other evidence indicates, nevertheless, that there is substantial variation in the availability of nursing home beds among nonmetropolitan communities and suggests that certain types of rural communities (e.g., nonmetropolitan persistent poverty counties and rural communities in the South) have substantially fewer beds available to their older residents than more urban and suburban places (Coward, Duncan, and Netzer 1993). Most of the nursing home beds that exist in a community are occupied. For example, using data from the 1991 National Health Care Provider Inventory of Nursing Homes and Board and Care Homes, Coward, Duncan, and Uttar0 (1996) have reported that the range of occupancy rates across nine county categories varies very little; from a low of 90.6 percent (in nonmetropolitan counties that were adjacent to a metropolitan county but that were completely rural or with an urban population of fewer than 2,500 persons) to a high of 92.9 percent (in metropolitan counties with populations between 250,000 and 999,999 residents). Indeed, the occupancy rates in none of the nine county categories that were examined varied more than 1.5 percent from the national average. Beyond the supply and use of nursing home beds, previous research has also demonstrated that older residents of small towns and rural communities have access to fewer community-based health care providers (Coward, McLaughlin, Duncan, and Bull 1994; Hicks 1990; Jones 1993). Although the shortage of physicians has received the most attention in this regard, the pattern of maldistribution is pervasive across a full spectrum of health care professions-from nurses, social workers, dentists, physical therapists and psychologists to lab technicians, X-ray technicians, and opticians (Coward 1992).

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Rural elders also tend to have access to a smaller number and narrower range of formal services to assist them when their health declines. Significant deficiencies in the health care systems available to rural elders have been identified with respect to in-home services (Nelson 1994), community-based services (Krout 1994), ambulatory services (Wallace and Colsher 1994) and mental health services (Buckwalter, Smith, and Caston 1994). Furthermore, Nelson (1983) has argued that the greatest discrepancies in service availability between rural and urban communities often occur in those programs specifically designed to assist the most disabled and frail elderly; i.e., those older adults most likely to be making decisions about their long-term care alternatives, including the possibility of entering a nursing home. As a consequence of these differences in the availability of community-based services, elders residing in sparsely populated and remote rural areas are less likely than their more urban and suburban counterparts to be receiving aid from a formal service provider (Blieszner, McAuley, Newhouse, and Mancini 1987) and are significantly more likely to be receiving assistance exclusively from informal helpers, primarily family members (Coward, Cutler, and Mullens 1990). Rural elders are also less apt than their urban counterparts to add a formal service provider to their network of helpers over time (Coward and Dwyer 1991). The greater reliance of rural elders on family care is frequently interpreted as a sign of stronger family relations among rural elders and their families (Longino and Smith 1994) though there is little empirical evidence for this popular image (Coward, Lee, and Dwyer 1993; Lee and Cassidy 1985). There is, however, substantial evidence that rural elders, particularly those engaged in farming, are more likely to have a marital partner and less likely to live alone (Coward, Cutler, and Schmidt 1989). Rural elders are not particularly advantaged, however, with regard to the proximity of their children (Lee, Dwyer, and Coward 1990). Thus, most analysts have concluded that the greater dependency of rural eiders on family care is more a reflection of the lack of formal services in sparsely populated and remote rural areas than it is an indication of stronger family relations among rural families (Coward and Dwyer 199 1; Coward, Lee, and Dwyer 1993). Thus, though we have enumerated a number of potential contributors to an elder’s decision to enter a nursing home, our knowledge about such decisions remains incomplete. There does appear, however, to be good reason to examine further the association between the community context in which an elder lives and their decision to enter a nursing home. This research was initiated, therefore, to examine the association between community context, specifically rural versus urban residence, and the reasons older adults decide to enter a nursing home. Qualitative techniques, particularly in-depth interviews, allowed us to explore more thoroughly the factors that potentially influence an elder’s decision to enter a nursing home, thereby avoiding preconceived, structured questionnaires that may have failed to capture all of the reasons behind the decision.

METHODS Sample This study was conducted with older persons who were newly admitted into a sample of skilled care facilities (N = 18) in rural and urban north Florida. The facilities represented a

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range of ownership and patient payer sources (i.e., church-based, private non-profit, corporate for-profit, Medicaid only, mixed payer, and predominantly Medicare) with the exception of those homes which were exclusively private pay. The sample of nursing homes that was selected for this investigation was stratified into two groups, rural and urban. Nine urban facilities were chosen from a pool of 29 skilled care centers located in a single large urban city, with a 1990 population of 635,230 persons (Shermyen 199 1). The urban facilities ranged in size from 60 to 232 beds with a mean of 140 beds and a mode of 180 beds. In addition, nine rural facilities were selected from a total of 12 nursing homes licensed to provide skilled care in seven nonmetropolitan counties in the same general region of the state as the large urban center. The nonmetropolitan counties had an average population of 29,071 and none contained a town of more than 10,000 persons (Shermyen 1991); indeed, there were only four towns in the entire seven county area that had populations of more than 2,500 persons. The rural facilities ranged in size from 60 to 180 beds with a mean of 112 and a mode of 120 beds. The average population of the towns in which the rural facilities were located was 5,332 people. Thus, although the communities selected for inclusion in this investigation do not represent the full range of community contexts present in the United States, they do reflect two distinct points along a residential continuum (see Note 1 for more details on the concept of residence as a continuum). Potential subjects for this study were at least 65 years of age, had resided in a rural area prior to admission to a rural facility or in an urban area prior to admission to a urban facility, had been admitted in the 30 days prior to data collection, and agreed to the interview or were competent enough to release the name of a proxy to speak on their behalf. During the 6-month study period (3 months in each community category), approximately 182 persons were admitted into the 18 nursing homes (accurate figures were not released by some of the facilities). Of these new admissions, approximately 80 percent met the eligibility criteria. Of the 146 eligible admissions, 113 (77%) agreed to participate. Ninety-five elders agreed to face-to-face interviews and 18 agreed to allow a proxy to be interviewed. All of the proxies who were contacted agreed to an interview. Table 1 contains residential comparisons of the demographic, personal and health characteristics of the sample. These data are presented to provide readers with an overview of the sample that was included in this investigation. Consistent with previous research that has identified residential differences in the composition of general populations of older adults (Coward, McLaughlin, Duncan, and Bull 1994) some significant differences in the composition of these two residential groups were observed. For example, rural-urban differences were observed in age, race, and difficulty performing activities of daily living (ADLs). The elders who were newly admitted to rural facilities were older than their urban counterparts (in contrast to the earlier finding of Greene 1984) and more apt to be white. Rural elders also reported difficulty performing a larger number of activities of daily living (again, in contrast to Greene 1984). There were no statistically significant differences between the rural and urban groups, however, on any of the other characteristics that were measured. The majority of both rural and urban new admissions were women who were not married. In addition, the modal categories in both samples were persons who had incomes of less than $5,000 per year, were not receiving special medical treatments prior to entering the nursing home, and received help from both formal and informal sources of support before they entered the nursing home. Although there was no statistically significant residential difference in the distribu-

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TABLE 1 of the Health and Sociodemographic Characteristics of Newly Admitted Patients in Rural (n = 59) and Urban (n = 54) Nursing Homes

Demographic

Rural

Characteristics

Urban

p-Value of

%

(N)

%

(N)

Statistic

82.0

(58)

79.0

(54)

9.05

Males

30.5

(18)

24.1

(13)

NS

Females

69.5

(41)

75.9

(41)

Married

33.9

(20)

24.1

(13)

Non-Married

66.1

(39)

75.9

(41)

White

94.9

(56)

72.2

(40)

Black

5.1

(4)

25.9

(14)

Lived Alone

20.3

(12)

35.9

(19)

Spouse Only

20.3

(12)

22.6

(12)

Live With Child (with or without spouse)

28.8

(17)

20.8

(11)

Live With Other Relatives (with or without spouse)

11.9

(7)

13.2

(7)

Live With Nonkin Only

18.6

(11)

7.6

(4)

$5,000 or Less

51.0

(25)

48.0

(24)

$5,001-$9,999

38.8

(19)

32.0

(16)

$10,000 or more

10.2

(5)

20.0

(10)

Age (Mean) Sex (%)

Marital Status (%) NS

Race (%)

Living Arrangement

>.Ol

Prior to

Nursing Home Admission

(%) NS

Annual Personal Income (%)

Self-Perceived

NS

Health (%)

Excellent

10.3

(6)

8.0

(4)

Good

51.7

(30)

38.0

(19)

Fair

20.1

(12)

32.0

(16)

Poor

17.2

(IO)

22.0

(11)

NS

Number of Activities of Daily Living (ADLs) Performed Difficulty

with

(Mean)

1.63

(59)

0.81

(54)

>O.Ol

NS

Recept of Special Medical Treatments (%) Yes

18.6

(11)

1.4

(4)

No

81.4

(48)

92.6

(50)

Composition of Caregiving Network Prior to Nursing Home Admission (%) No Help Informal Only

6.8

(4)

16.7

(9)

39.0

(23)

35.2

(19)

54.2

(32)

46.3

(25)

Mixed Network of Formal and Informal Help

NS

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Context

tion of persons in different types of living arrangements; among the urban sample, residents were most apt to have lived alone prior to admission, whereas in the rural sample the most frequently reported living arrangement prior to admission was residence with a child (with or without a spouse). The two samples had the same mean number of years of formal education (10.0 years).

Data Collection Data were collected primarily through face-to-face interviews, with a small number of proxy interviews (12) completed by telephone. Interviews averaged 30 minutes in length for elders and approximately one hour for proxies. The elders were interviewed at the nursing homes and the proxies were either met at the nursing homes (6) or called at their homes (12). A 25-item interview schedule, created by the authors, was administered to all subjects or proxies. The schedule included both open- and closed-ended questions about the elder’s health and functioning at the time of the interview and prior to admission, their use of formal and informal services prior to admission, and details about the factors and circumstances leading to the admission decision. The latter line of inquiry included the openended question: “Tell me about why you (the elder) decided to come here (to the nursing home) at this time.” Responses to this question were recorded verbatim and form the basis of this qualitative analysis.

Data Analysis The constant comparative method of Glaser and Strauss (1967) was used for content analysis. Responses were transferred to a computer text file and listed by subject identification number. Using the line-by-line analysis technique described by Strauss and Corbin (1990) and the coding system of Miles and Huberman (1984), response categories were developed. Color-codes by subject and subcategory facilitated the development of categories, the search for negative cases, and comparisons between rural and urban subjects. The identification of category exemplars was accomplished using color and letter coding, repeated sorting, resorting, searching, grouping, and regrouping. It is emphasized that the categories do not constitute a “variable” in the typical sense of that term; i.e., they are not mutually exclusive and may or may not exhaust all possible reasons for entering a nursing home.

RESULTS Five categories of reasons emerged from the content analysis that we completed of the descriptions offered by eiders about the factors and circumstances that had led to their decision to enter a nursing home. For purposes of this discussion, the categories are labeled as: (1) Experiencing Sudden Events: Twenty-nine percent (N = 33) of the elders in this sample described a sudden unexpected event (like a fall or an acute illness) that caused them to be unable to continue to live in a community setting; (2) Changing Family Circumstances: Twenty-seven percent (N = 3 1) of this study’s participants also described changes in family circumstances (sometimes sudden, in other cases a gradual eroding of physical, emotional, and/or financial resources) that reduced the capacity of family members to meet their needs

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TABLE 2 Comparisons of the Reasons for Entering a Nursing Home Described by Newly Admitted Patients in Rural (n = 59) and Urban (n = 54) Nursing Homes Rural Reason

%

Experiencing Sudden Events Changing Family Circumstances Needing Skilled Care Receiving Pressure from Others Living in Fear

31

Urban 04

%

04

(18)

2x

(15)

31

(18)

24

(13)

I3 I5

(8) (11)

30 I5

(16) (IO)

5

(3)

0

(0)

for personal care; (3) Needing Skilled Care: Twenty-one percent (N = 24) reported that their current health status required the intensive involvement of skilled health care providers, like nurses and rehabilitative therapists; (4) Receiving Pressure from Others: Nineteen percent (N = 21) of the elders reported being “told to” enter a nursing home by a “significant other” (i.e., a family member or an important health care provider); and (5) Living in Fear: a very small number of elders (3%, or N = 3) expressed apprehension about continuing to live in their community. Some elders reported only a single factor or circumstance that was so overwhelming that it alone served as the impetus for the admission. Others reported a combination of factors and circumstances which led to their decision. While all five of the categories of reasons that we created had some meaning for both rural and urban elders, comparisons by residence did reveal important differences between the two groups (see Table 2). Specifically, urban elders were much more likely than rural elders to indicate that their need for skilled care had precipitated their admission. In contrast, rural elders were more likely than urban elders to report that changing family circumstances had led to their decision to enter a nursing home. The experience of a sudden event that prompted the admission was almost equally cited by both rural and urban elders and, similarly, elders from both residence groups were equally likely to report receiving pressure from others. Although living in fear was reported by only a very small number of elders (N = 3), all of them lived in rural community contexts prior to entering the nursing home. In the sections that follow, the five categories of reasons that elders used to describe their decision to enter a nursing home are discussed and illustrated in more detail.

Experiencing

Sudden Events

Elders repeatedly described the occurrence of very specific events which precipitated their decision to enter a nursing homes. The events were sudden, unexpected, and in every case perceived as traumatic. They included both falls (with and without injury) and acute illnesses (including cerebral vascular accidents or strokes). In a substantial number of cases the sudden events included, but were not limited to, a hospitalization. We have no way of ascertaining the influence of hospital discharge planners on elders’ post-admission plans since the respondent indicated that the actual sudden event and not the discharge planner precipitated their nursing home admission.

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Falls are one type of sudden event that can precipitate a nursing home admission. Indeed, previous research has implicated falls as a contributing factor in approximately 40 percent of nursing home admissions (Tinetti, Speechley, and Ginter 1988). A fall was the single most frequent type of sudden event described by respondents in this investigation. For example, one resident reported, “I fell and now I have to learn to walk all over again so I can go back to my apartment. As soon as I can walk and get around by myself I’m going home.” A niece reported that her elderly, somewhat confused, aunt had been living with her equally impaired husband and that “. . . . between them they somehow managed.” However, after a fall while feeding her chickens, neither she nor her husband could be depended upon to follow medical instructions, hence she was admitted into a local nursing home. Rural elders were as likely as urban elders to report a fall as the reason for their admission decision. However, rural elders were slightly more likely than their urban counterparts to report an injury related to their fall, usually a fracture, and less likely to report a fall without injury. Rural elders were also much more likely than persons who formerly resided in more urban and suburban areas to express the “fear” of a fall as a factor that contributed to their decision to enter a nursing home. A second type of sudden event that precipitated admissions were illnesses, often requiring hospitalization. Both rural and urban elders reported strokes, heart attacks, exacerbations of diabetes, or other illnesses that had required hospitalization in the period immediately prior to their admission. Excluding stroke, the frequency of such reports was similar between rural and urban elders. There was, however, a dramatic residential difference in the percent of elders who reported a stroke as an antecedent to their nursing home admission. Of the urban elders who reported an acute illness, 37 percent had experienced a stroke, compared to only 15 percent of the rural elders who had suffered an acute illness. These self-reported differences were corroborated by the admission diagnosis that we observed when we reviewed the medical records of the respondents in our sample.

Changing Family Circumstances A second category of reasons that elders offered to explain their decision to enter a nursing home was a change in the family caregiving network. Sometimes the change was represented by a single event in the life of a family member on whom the elder was dependent; a spouse, child, or other family member returned to work, moved, became ill or died. In other cases, the change was a slow erosion of the capacity of the family to provide care for the older adult. These circumstances are akin to the “bum-out” phenomena that is widely discussed in the caregiving literature (Abel 1987). An example of a changing family circumstance that was precipitated by a single event is the rural elder who managed to maintain herself at home with the assistance of her brotherin-law and sister, despite a progressive and increasingly debilitating disease. However, after her brother-in-law’s death, she was no longer able to manage her home and personal affairs and sought admission into a nursing home. In another case, a man who was caring for his impaired older brother was forced to leave the area and move in with his daughter when his own health failed. The remaining brother, alone and without children, saw no alternative but to move to a nursing home so that someone could help him bathe and could

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prepare his meals. Another man said, I‘. my wife was taking care of me but she is in the hospital so I had to come here, I don’t have anyone else.” In addition to these single, isolated events in the lives of family members that altered their capacity to continue to give care, other circumstances were described to us that indicated a longer, more gradual, and slow-paced decline in the capacity of family members to provide care. Either the elder or their caregiving family member recognized this declining capacity. For example, one elder referring to the help she was receiving, said, “ . it had just gotten to be too much for my daughter.” Another reported, “My daughter’s back was never good and it got to be too hard on her, I need so much help and I didn’t want to make it any worse for her.” In another case, a rural daughter who had cared for her increasingly demented mother for two years said, “It just got to be too big a job - the mental and the physical.” Finally, a spouse who had provided a considerable amount of care, but no longer had the physical means to attend to her ailing husband, noted that “. it was the best thing to do . so someone could take proper care of him.” It is interesting to note that all of the proxies that were interviewed, regardless of what type of community context their family member had resided in prior to entering the nursing home, cited excessive demands for personal care or conflicts between the demands of personal care and other responsibilities in their lives as factors in the admission decision. All of the proxies indicated that they felt it was impossible for them to continue to provide an acceptable level of care at home.

Needing Skilled Care A portion of the elders with whom we spoke reported needing specialized rehabilitative services as the reason that they had entered a nursing home. Respondents mentioned needing services such as the supervision of medications, enteral and parenteral feedings, intravenous antibiotics, and specialized rehabilitative therapy. Elders in this category believed, or had been told, that the nursing home was the appropriate setting for the receipt of such services. Indeed, one urban woman refused to be interviewed for this study of nursing home admissions because she indicated she was “... not in a nursing home, I am in a rehabilitation center.” Urban elders were more likely than elders from rural places to report the need for skilled care as a factor that precipitated their admission. Specifically, urban elders were twice as likely as rural elders to state that they had been admitted to receive special therapy or treatments. Physical therapy was the type of specialized treatment most often reported as the reason for admission. Of those reporting the need for skilled care, 46 percent of the rural elders and 68 percent of the urban elders entered the nursing home for physical therapy. Those elders who reported the need for physical therapy as the reason for admission viewed their length of stay in the nursing home as limited. For example, an emaciated woman, dying of cancer, who had decided to come to the nursing home for physical therapy, planned to stay only “. until I can walk again.” Similarly, a robust 82-year-old, recovering from bilateral knee replacements, expected to remain only long enough to receive the intensive physical therapy that he needed to enable him to return to work. While long term care facilities are usually synonymous with the term nursing home or a place where one can receive nursing care, only a few elders, rural or urban, reported that they had moved to their present location in order to receive nursing care. When such care

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was needed it included nurse-supervised medications, artificial feedings, and observation. For example, a woman in an urban facility said that she I‘. . needs to be around nurses so they can watch my blood sugar.” In response to the inquiry “tell me about how you came to be here at this time,” another women looked up at the array of tubes hanging above her head and said, “So I can eat.” A man in an urban facility had been in and out of the hospital and emergency room a few times and finally was admitted to a nursing home so that “. . the nurses could watch my heart.” A man from a remote rural area, now in a rural facility, had been receiving in-home visits from home health nurses to administer intravenous antibiotics every four hours. Over time, however, it had become increasingly difficult for the home health agency to find enough nurses to provide such intensive intervention. As a consequence, he reported that he had moved into a nursing home where “. there’s always a nurse around.”

Receiving Pressure from Others When rural and urban elders or their proxies were asked to describe the admission decision, one in seven elders in each residential group responded that they had been “told to” enter a nursing home by some “significant other.” These respondents felt that they had not actively participated in the decision-making process, but merely acquiesced to the advice and instructions of others. About three-fourths of those who had advised a move into a nursing home were health care providers. For example, one new admission said, “I had been managing O.K. . . The doctor sent a home health nurse out to see me and she said that it wasn’t safe for me to live alone, so here I am.” Another women who had lived alone reported going to her doctor for a check-up and being told that she “. . should not go back home, but should be somewhere [the nursing home] where someone could take care of [her].” Physicians, according to many of the elders, directed them to enter nursing homes because of an observed or reported unmet need for care or because of the impact their needs for care would have on their caregivers. Thus, the physician’s recommendation to relocate to a nursing home was often perceived by elders as similar to a medication prescription. An unquestioned confidence in health care providers, or alternatively, intense pressure from practitioners, led one urban elder to enter a nursing home, stating “... the hospital staff arranged it I didn’t know there was a choice” and “. . the doctor said I couldn’t go home.” Another urban resident reported that it was “. understood that I would not be going home again when I left the hospital.” Close family members (e.g., spouses, children, grandchildren, and siblings) were also mentioned as persons who had advised the respondents to enter a nursing home. Family members who counseled elders to enter a nursing home similarly based their recommendations on the perceived health care needs of the elders, but often had the additional consideration of whether they felt able to adequately provide care for their older family member. For example, one elderly rural man with ambulatory disabilities and incontinence reported that, “My daughter decided I needed to go somewhere.” In another case, an urban man reported, “My daughter thought it would be better if I went away for awhile.”

Living in Fear A very small number of elders described living with fear and the desire for relief as a key element in their decision to enter a nursing home. They feared being alone all or part of the

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day while their caregivers worked, being alone at night when their adult children returned to their own family responsibilities, and, most often, a fear of falling while alone. One rural woman said, “My main trouble is I’m afraid of falling down”-despite the fact that she resided with a daughter who provided 24-hour care. Here again we found a striking difference by community context. Three rural elders described their fears of living in a community setting, some in great detail. In contrast, no urban elders reported this concern.

DISCUSSION The differences in the reasons for entering a nursing home that were described by rural and urban elders in this sample may reflect dissimilarities in the physical and social context in which each of these two groups operate and in which they attempt to cope with their declining health. For example, the admissions of urban elders were more likely to be in response to an injury from a fall or an acute illness. This pattern may indicate that urban elders. for the most part, are able to cope with the daily demands of their chronic illnesses and frailties through a combination of their own personal resources, the help of their families, and the aid and assistance of the formal service providers that are more likely to be available in their settings. Under these conditions, the decision to enter a nursing home may be more likely to be precipitated by an event that intensifies the need for increased formal or skilled care (even if temporary) and creates the demand for another level or kind of care. This latter interpretation (the need for a different kind of care) is consistent with the greater tendency we observed among urban elders to report the need for skilled care as a reason for their nursing home admission. In contrast, rural elders evidenced a different pattern of reasons for entering a nursing home that may, also. reflect the distinctive features of the social and physical environment in which they operate. The relative lack of formal helping resources in many rural regions in combination with the predominance of informal assistance frequently places rural elders in the position of greater reliance on their family for personal care. For example, Coward, Cutler and Mullens (I 990) have reported that severely impaired elders residing in nonmetropolitan communities are less likely than their metropolitan counterparts to be receiving aid from a formal care provider and are significantly more likely to be receiving assistance exclusively from informal helpers. Given these circumstances, it is not surprising that’rural elders were more likely than urban elders to report changing family circumstances as the reason they had entered a nursing home. In addition, the lesser availability of formal services in rural areas may have a negative effect on the long-term capacity of family members to provide care.3 Could it be that this tendency for rural elders to be dependent exclusively on informal sources of support wears away at the capacity of their family members to provide care over extended periods of time leading, eventually, to caregiver “burn-out”‘? Does the lesser availability and narrower range of formal services available in sparsely populated and remote areas erode the stability and endurance of rural informal helping networks? Or, could it be that rural elders have less access to family caregivers as their needs change? For example. although rural elders are more likely to have marital partners from whom they can receive help (Coward, Lee, and Dwyer 1993) the out-migration of young people from rural areas has left some elders without a nearby and easily accessible family support network (Clifford, Heaton, Voss, and

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Fuguitt 1985). Indeed, rural nonfarm elders (the largest category of elders in rural America) are the least likely of any residential category to have proximate adult children; i.e., children living within 30 minutes driving time (Lee, Dwyer, and Coward 1990). Other socioecological factors may play a part in the decisions of rural elders to enter a nursing home. For example, the new admissions to rural nursing homes in this investigation were also more likely than their urban counterparts to report a fall with injury, or the fear of falling, as a factor that precipitated their entrance into a nursing home. Falls are a major concern for many older persons (Tinetti, Speechley, and Ginter 1988; Tinetti and Speechley 1989) and are associated with an increased risk of institutionalization (Dunn, Furner, and Miles 1993). The physical isolation and remoteness of many rural dwellings, however, may exacerbate this concern among older rural adults. Without the physical proximity of neighbors that often accompanies urban and suburban living, rural elders may feel more vulnerable and at greater risk that a fall could go unnoticed and that they could be left injured and stranded. Even the specter of such an accident (e.g., the fear of such an incident) might cause some rural elders to reconsider their current living arrangements and to seek alternatives. Indeed, from the evidence presented in this study, this physical isolation factor appears to underlie the greater tendency of rural elders, in comparison to urban elders, to report apprehensions about living independently as a factor in their decision to enter a nursing home. Thus, it may be that the combination of physical isolation, the perceived absence of needed services, and, for some rural elders, a limited network of informal caregivers collectively creates a community context in which rural elders are more frequently uncertain about their continued well-being and safety in independent living arrangements. These interviews with new nursing home residents also revealed that a number of them perceived that they had been directed to enter a nursing home and had not chosen to do so of their own free will. Among urban elders, physicians were the most frequently mentioned individuals to have offered such advice. In contrast, among rural elders it was most often family members who were the purveyors of such advice. Both of these observations are consistent with earlier research findings about residential differences in the sources of assistance received by older adults. Such research indicates that urban elders are more likely to receive the assistance of formal service providers, while rural elders are less likely to receive aid from a formal service providers (Blieszner et al. 1987) and more likely to receive assistance exclusively from infomral providers, usually family members (Coward, Cutler, and Mullens 1990). Although previous research does not suggest that rural elders are emotionally closer to their family members than are urban elders (Coward, Lee, and Dwyer 1993), it may be simply a function of the greater prominence of family members in the caregiving networks of rural elders, combined with the relative absence of formal service provider, that leads to the greater frequency with which they are mentioned as the person advising the elder to enter a nursing home. In a similar manner, the more prominent role of physicians in the decision-making of urban elders may well reflect their greater abundance and accessibility in more urban and suburban settings and the greater frequency with which urban elders seek care from physicians. For example, Hicks (1990) has reported that metropolitan areas of the United States have approximately 79 percent more physicians per 100,000 population than nonmetropolitan places. Moreover, the recent growth in the number of physicians has not been evenly distributed between metropolitan and nonmetropolitan places and has, thus, exacerbated

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the problem of residential maldistributions. Between 1980 and 1986, the number of physicians in metropolitan areas increased 24 percent, while the number of physicians in nonmetropolitan places increased only 17 percent. Given this maldistribution, it is not surprising to learn that on average urban elders visit a physician more times in a year than do rural elders (Lassey and Lassey 1985) and that nonmetropolitan residents have somewhat longer intervals between visits to physicians offices than their counterparts residing in metropolitan areas (Adams and Hardy 1989). Some have argued that physicians may perceive nursing homes as the most appropriate setting to handle the medical care needs of their patients and may not be aware that many severe illnesses can now be cared for properly at home (Coward, Duncan, and Freudenberger 1994). Recent advances in medical and communications technology have significantly expanded the ability of nurses and family members to provide care for severely ill older adults in their own homes. Some of the advice that elders receive from physicians, however, may not reflect these advances and, therefore, may not adequately represent all of the care options that are truly available to the older person. Alternatively, physicians may be playing the “heavy” for family members who are reluctant to be seen by their parent or spouse as the person who caused them to enter a nursing home. In such circumstances, family members may request physicians to talk to their loved one and convince them that entering a nursing home is in their best interests. In other words, the fact that elders identify physicians as the person that “told’ them to enter a nursing home may underestimate the influence of family members because the elders may not be fully aware of the collusion between their family and their physician. The degree to which either of these scenarios reflects reality, however, needs to be determined by further research. Because of the interviewing techniques that were employed in this investigation, it is difficult, if not impossible, to discern fully either the links between the five categories described by the respondents as the reasons that they entered the nursing home or the logical continuum, if one exists, that underlies the categories that have been described. As a consequence, we are unable to determine if, or how, the five categories fit together to form a coherent taxonomy. It may be, for example, that the five categories really only reflect two or three distinctly different types of reasons and that underlying connections between the categories will emerge through further research, using more in-depth interviewing techniques that probe an elder’s history and perspectives and, perhaps, multiple contacts with each respondent. We can, certainly, envision connections between the five categories. For example, consider the fictional case of 78-year-old Mrs. Smith who experiences a fall that does not result in a fracture, but does leave her with limited mobility-perhaps a deep bruise or a strained ligament in her back that makes it difficult and painful for her to perform her normal activities. This injury may demand extra care from Mrs. Smith’s family. For example, she may have difficulty getting dressed in the morning, fixing meals, or she may be in so much pain that she forgets to take her normal medications. This need for extra care, either temporary or permanent, may erode the capacity of her family to cope with her needs for personal care and may propel the entire family into a crisis. Seeking the council of a trusted physician, the family and the doctor may conclude that it is time for Mrs. Smith to consider entering a nursing home. A conversation between the physician and Mrs. Smith may leave her with the impression that she has been “told to” enter a nursing home. Now, if our research team asks Mrs. Smith how she ended-up in a nursing home, what does Mrs.

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Smith tell us? Does she describe the whole sequence of events? Or, does she pick out the one event that she feels is most important and most salient? Does she see the “fall” as the incident that precipitated everything else that happened after that? Or, does she dwell on the fact that the physician told her that she needed to go into a nursing home and perceive everything as secondary to those instructions? Although this investigation has provided us with some insight into the variety of reasons that elders use to describe their entrance into a nursing home, and has also provided some preliminary data on the effect of community context on the reasons that are given by elders, it falls short of providing sufficient information from which to construct a “grounded theory” of the decision to enter a nursing home. In that sense, this investigation is just a small step in what may ultimately be a long journey. Much more research is needed, including more in-depth ethnographic interviews, before we will be in a position to offer a coherent theoretical framework that will describe the basic elements of the decision to enter a nursing home and, as importantly, the relationships between those elements. The findings of this investigation do provide, however, further evidence of the importance of observing the interaction of person and environment in interpreting human behaviors and actions. Most of the previous research that has attempted to illuminate the factors that influence an elder’s decision to enter a nursing home has failed to describe in any detail the community context-either micro or macro-in which the elder was living independently. This inquiry reminds gerontological researchers that the community of residence prior to entering a nursing home is an important contextual variable to take into account when attempting to improve our understanding of the circumstances surrounding the decision to enter a nursing home. To further extend our understanding of the interaction of person and place, future research should explicate in more detail (beyond a simple ruralurban dichotomy) the specific features of an elder’s community environment that shape their decisions regarding a nursing home admission. Support for this research was provided under a grant from the National Institute on Aging (AG09649). The opinions expressed here are those of the authors and do not, necessarily, reflect those of the funding agency. The authors wish to thank Laura Fox for her aid in conducting the interviews that are the basis of this investigation and to MrsAngela M. Hightower for her assistance in the preperation of the final manuscript. The authors also thank Drs. Julie K. Netzer and Chuck W. Peek for their comments on earlier drafts of this article. Finally, the authors are indebted ACKNOWLEDGMENTS:

to the administration

staff, and residents of the 18 nursing homes who cooperated in this research.

NOTES 1. Throughout the text, we use the terms rural and urban generically rather than only when they conform to the strict U.S. Census definitions for these terms (see Hewitt 1989, for a detailed discussion of the various definitions that are used to describe rural areas). In addition, we conceptualize residence as a continuum; see Coward and Cutler (1988) for a further discussion of this concept. At one end of the continuum are the very large cities, such as New York, Chicago, and Miami. At the other end of the continuum are very small and remote places. In between are a myriad of small towns, villages, and medium-sized cities. For the most part, when we refer to rural places in the United States, we have in mind settings that are both sparsely populated and physically removed from large urban settings. When we refer to find-

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ings from a specific study, however, we will use the residence categories employed by the original investigators. 2. There is conflicting info~ation currently emerging about residential differences in the rate of institutionalization. The one published report that has used longitudinal data to examine this issue (Dwyer, Barton, and Vogel 1994) reported that, over a two-year period of time, rural elders were the least likely residential group to enter a nursing home (7.6%) compared to elders living in large urban (8.8%) or small city (10.4%) environments. However, because of the inconsistency of that finding with data on residential differences in nursing home bed supply (Shaughnessy, 1994) and occupancy (Coward, Duncan, and Uttar0 I994), we have unde~aken a series of analyses to replicate that finding. We suspected that some of the unique attributes of the National Long-Term Care Survey (NLTCS), the data source used by Dwyer, Barton, and Vogel (1994), might account for the apparent discrepancy between their findings and data on bed supply and use. Using data from the Longitudinal Study on Aging (LSOA). we have been unable to replicate the findings of Dwyer, Barton, and Vogel ( 1994). Indeed, our analysis of LSOA data indicates higher rates of institutionalization over a six-year period among older adults residing in nonmetropolitan settings (particularly residents of lesser urbanized and thinly populated nonmetropolitan counties) in both the general population of persons over the age of 70 (Coward, Netzer, and Mullens) and in a subset of older adults experiencing problems with urinary incontinence (Coward, Horne, and Peek 1995). 3. The assertion that rural communities tend to have fewer formal services is not, necessarily, inconsistent with the lack of a residential difference in service utilization that is reported in Table 1. Etsewhere we have speculated (Coward, Duncan, and Freudenberger i 994) that elders who are at high risk of entering a nursing home (like the new admissions that we interviewed in this investigation) may be given priority in the receipt of scarce community-based services. That is, “even when there are significant residential differences in the health and human service infrastructure of places, it may be that those elders most in need ‘go to the front of the line’ and receive priority for the services that are available” (Coward, Duncan, and Freudenber~er 1994, p. 48).

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