specialized living environments for older people: a conceptual framework for evaluation

JOURNAL OF SOCIAL ISSUES VOLUME 36, NUMBER 2, 1980

Specialized Living Environments for Older People: A Conceptual Framework for

Evaluation

Rudolf H. Moos

Stanford University Veterans Administration Medical Center

Palo Alto

Some demographic and social factors that indicate the need to place high priority on the development of specialized living environments and of community settings that are responsive to the needs of older people are described. The article then focuses on one central aspect of this issue: the formulation of a conceptual framework to guide evaluations of the features and impacts of specialized living settings. The implementation of portions of the framework is illustrated by a description of a new environmental assessment procedure and by discussion of two aspects of congregate settings: person-environment selection and allocation; and the provision of opportunities for resident choice and control.

Older people in our society face many complex problems: bereavement and the loss of family members and friends, social isolation, the need to manage on essentially fixed incomes in a period of increasing inflation, impaired physical and intellectual functioning, and a gradual reduction of autonomy and self-esteem. In an era of growing recognition of these problems, citizens’ organizations and government agencies have increased the scope of their effort to address issues that affect the well being of older people. But with such pervasive and often intractable

The work was supported by NIMH Grant MH28177 and by Veterans Administration Health Services Research and Development Service Funds. I wish to thank Jane Clayton, Tom David and Sonne Lemke for their valuable comments on an earlier draft of the manuscript.

Correspondence regarding this article may be addressed to Rudolf H. Moos, Social Ecology Laboratory, Stanford University, Palo Alto, CA 94304.

75

76 RUDOLF H. MOOS

problems, and with society’s limited financial and social resources, what should our priorities be? Which of the many problems should we try to solve first?

I believe we should place high priority on the development of specialized living environments and community settings that are responsive to the needs of older people. It is difficult to obtain accurate figures, but it is estimated that two million of the 24 million Americans over the age of 65 reside in specialized living settings (Butler, 1975; Lawton, 1975; Manard, Kart & van Gils, 1975). Such settings include skilled nursing and residential care facilities, which house about 1.3 million older people, as well as board and care homes and foster family care settings, cluster-type congregate apartment housing, and single room occupancy (SRO) hotels. Some of these settings provide a full range of medical and nursing services (skilled nursing facilities), some provide a moderate level of supportive services (residential care settings), and others offer no services or only minimal or temporary personal care (most congregate apartment houses and SRO hotels).

Although cross-sectional data indicate that only about 8% of elderly people live in group settings at any one time, the percentage of people who spend some time in such settings is considerably higher. Data showing that 24% of deaths of people over 65 occurred in nursing homes or extended care facilities led Kastenbaum and Candy (1973) to conclude that “. . . more than eight times as many elders died in nursing homes than were assumed to be living there” (p. 18). In a study of the long-term care histories of 455 people who were followed for a ten year period, Vincente, Wiley and Carrington (1979) found that about 39% had stayed at least once in a nursing home or convalescent hospital before death and 15% had stayed in such a facility for six months or more. An extrapolation of these results suggests that over 3.5 million of the 24 million elderly Americans will live in specialized settings for extended periods, and up to 10 million may live in such settings for short intervals.

Furthermore, several demographic and social factors will probably accelerate the need and demand for group living among older people. The number of elderly people is expected to increase over the next 20 years, perhaps to over 30 million by the year 2000. The most rapid increase will be in the number of “old-old” (those 75 and over) who are least able to live independently. Trends toward the deinstitutionalization of mental hospital patients and the specialization of hospitals for acute medical crises

A CONCEPTUAL FRAMEWORK 77

will also continue to increase the need for residential care. Other relevant factors include the declining role of the extended family, greater population mobility, the trend toward smaller homes in which it may not be possible to accomodate another family member, the rise in the proportion of older people who live alone, and the increased labor force participation of women, who are the traditional providers of home-based care (Dunlop, 1979). These facts indicate that we face a national problem of considerable magnitude.

To address this problem, models of new types of residential settings such as mobile home parks, retirement villages, day treatment hospitals, domiciliary programs, and multilevel geriatric centers that provide a full range of housing and care are currently being developed. As the number and variety of residential programs for older people increases, the need for comprehensive evaluations of the effects of such programs becomes more acute. Although some evaluations of specialized living environments have been conducted (Brody, 1979; Carp, 1966, Linn, Gurel & Linn, 1977; Sherwood, Greer & Morris, 1979), such evaluations are rare, are usually carried out in only one type of facility, and do not stem from a common conceptual model. A necessary next step in this area is the articulation of a conceptual framework for organizing the different sets of variables involved in evaluating residential settings.

CREATING A CONCEPTUAL FRAMEWORK I turn now to a framework that addresses this need. The

framework depicts the major classes of personal and environmental factors, and mediating mechanisms that are involved in the environments of group living settings. This type of framework has been used to evaluate educational settings (Moos, 1979a) and to explore the effects of population density and crowding (Moos, 1979b). After a broad overview of the entire model, I provide a more detailed discussion of each domain of variables.

The model begins with the assumption that personal and environmental systems influence each other through selection and allocation factors (see Figure 1). In other words, most environments admit new members selectively and most people select the environments they wish to enter. The personal and environmental systems interact to produce cognitive appraisal and activation or arousal (motivation). Cognitive appraisal and activation are mediating variables involved in the process of person-environment

78 RUDOLF H. MOOS

- ENVIRONMENTAL

SYSTEM (physkal selting. policy B program factors. human

aggregate, social cllmate)

4

‘

FIGURE 1

Factors and Resident Stability and Change. A Model of the Relationship Between Environmental and Personal

w

transaction and they influence efforts to adapt (coping) and the results of such efforts (outcome). These mediating factors are affected both by personal characteristics (a functionally able resident is likely to appraise a residential care setting as lacking in stimulation; some residents are much more easily motivated than others) and environmental characteristics (stimulating settings tend to be appraised as involving and cohesive; some environments are more likely than others to motivate residents).

The next step in the model involves the resident’s efforts to adapt to the environment by using a preferred set of coping responses. These responses are determined in part by the personal system (people have different coping repertoires; for example, some are more inclined to participate in social-recreational activities than others) and the environmental system (some settings reward participation in social-recreational activities more than others). A resident’s use of a coping skill may also change both systems. A resident who participates in social activities may change his or her attitudes (a change in the personal system) and/or help to create a new social group (a change in the environmental system).

Efforts at adaptation ultimately affect such outcome indices

+ * COGNIT,VE ACTIVATION EFFORTS

APPRAISAL -b OR AT +

AROUSAL +Ays&y A A

RESIDENT STABILITY AND

CHANGE (morale. well being, healh. actlvlty level)

PERSONAL SYSTEM (soclodemographic variables, healh and 4 personality factors,


as the resident’s health, well-being, and level of functioning. These criteria are also affected directly by personal factors (residents with higher functional abilities on entrance to a setting usually function better six months later) and environmental factors (settings with more opportunities for choice and control tend to have residents with higher morale). In turn, changes in these criteria can influence both personal and environmental factors (an increase in functional ability may enhance a resident’s self-con- cept; residents who maintain higher levels of functioning may create a more cohesive setting). As noted in Figure 1, these personal and environmental processes may result in either stability or change. For instance, a residential setting oriented toward independence and self-exploration may help residents to maintain their level of functioning and to increase their self-understanding and personal awareness. To illustrate the model in more detail, I briefly discuss each set of variables shown in Figure 1.

The Environmental System Although there are an infinite number of environmental

variables, I have found it useful to consider them in terms of four major domains of resources: physical and architectural resources, policy and program resources, resident and staff resources, and social-environmental resources (Moos, 1976; Moos, 1979a). Each of these domains can influence resident functioning directly as well as indirectly through the other domains. For instance, the influence of physical and architectural features on resident functioning may be mediated through the social environment that such features help to create (Moos & Igra, 1980). A growing body of literature indicates that these four domains of environmental variables can be used to characterize group living settings and to explore their impacts.

Physical and Architectural Features Potentially salient architectural factors include the quality of

the physical milieu, the availability of facilities for social and recreational activities, and the provision of prosthetic, orientational, and safety features to enhance resident independence. Also important is the amount of public and private space available to residents, and the centrality of location of a setting and its “permeability” to the community (Lawton, 1975, Lawton, 1977). Positive physical qualities of the housing environment can influence an elderly person’s activity level, social contacts, well being, and general life style (Carp, 1976). The perceived physical attrac-

80 RUDOLF H. MOOS

tivenessof housing is related to tenant satisfaction (Sherman, 1972), and better physical facilities are associated with enhanced resident functioning (Linn, et al., 1977). The modification of specific physical features in a setting can exert an influence on resident and staff perception and behavior. For example, following in- stallation of a carpet, geriatric patients in two psychiatric units were more careful about spillage, neater in personal appearance, more willing to help other patients to the bathroom, and more eager to show visitors around the unit (Cheek, Maxwell & Weisman, 1971).

Policy and Program Factors Variations in facility programs and policies can have important

effects on elderly residents of community care settings. Some of the characteristics frequently observed among the elderly, such as feelings of depression and helplessness as well as accelerated physical decline, may be attributable in part to the policies in such settings, especially the relative lack of environmental choice and control. Residents are more alientated in community care settings that offer less freedom of choice, and there is less life satisfaction and developmental task accomplishment in high than in low constraint settings (Bennett & Eisdorfer, 1975; Schultz & Brenner, 1977). Furthermore, Lieberman (1974) found that the outcome of relocation of elderly people was more positive in “facilitative” environments, that is, those that fostered autonomy, placed the locus of control in the hands of the residents, and treated residents in an individualized and personal manner.

Resident and Staff Characteristics The use of average background and personal characteristics

as measures of environmental factors is based on the belief that most of the social and cultural environment is transmitted through other people and that the “character” of an environment depends in part on the typical characteristics of its members (the suprapersonal environment). Research in educational and occupational settings has shown that people who are congruent in background and interests with the other people in their environment tend to be more satisfied and secure and to function better in that environment (Holland, 1973). There is also evidence that a person’s behavior and values may change over time to conform to those of the majority of the other people in a setting (Moos, 1979a). The work in residential settings for older people has focused primarily on the relative degree of age homogeneity (Lawton,


1977; ROSOW, 1967). For instance, Sherman (1975a) found that elderly tenants in age-segregated congregate housing, in compari- son to those in age-integrated housing, had more new friends and visited more with neighbors and age-peer friends. However, they had fewer younger friends and interacted less with their children and other relatives (see also Teaff, Lawton, Nahemow & Carlson, 1978).

Social Climate The social climate perspective is based on descriptions of

environmental “press” obtained from an inferred continuity and consistency in otherwise discrete events. For example, if older people in a residential setting have a say in making the rules, if their suggestions are acted upon, if new and different ideas are often tried out, if staff members are flexible in interpreting rules and regulations, and so on, then it is likely that the program emphasizes resident influence and the development of assertive responses on the part of residents. It is these conditions which help to establish the climate or atmosphere of a setting.

Based on extensive work in a variety of social environments, I have conceptualized the underlying dimensions in this area in three domains. Relationship dimensions assess the extent to which people are involved in the environment, support one another, and express themselves freely and openly. Personal growth or goal orientation dimensions measure the basic directions in which personal development and self-enhancement tend to occur in the setting. System maintenance and change dimensions deal with the degree to which the environment is orderly, clear in its expectations, and responsive to change (Moos, 1974). Although variables drawn from these categories have been related to various outcome criteria in educational and psychiatric settings, there is little relevant work in residential settings for older people (but see Hochschild, 1973).

The Personal System With respect to the personal system, varied sets of individual

characteristics can help to explain the factors involved in how people select and respond to environmental contexts. Background and personal indices include age, gender, cognitive and functional ability, general health, ego strength, and self esteem. As shown in Figure 1, these factors help to determine what an environment means to an individual (cognitive appraisal) and the social and psychological resources available to adapt to the setting. Factors

82 RUDOLF H. MOOS

such as intelligence and the level of cognitive functioning influence a resident’s ability to seek or use information and to counteract uncertainty or a sense of powerlessness.

How people see the components of the environment, their adaptive responses, and the degree of stability or change they show in their mood and functioning, are partially defined by personal factors such as their assertiveness, sociability, and type of previous residential experience. For instance, Sherwood and her colleagues (Sherwood, Glassman, Sherwood & Morris, 1974) found that applicants well suited to a long-term care facility, as opposed to those less well suited, were lower in socioeconomic status, less likely to live alone, and more likely to be in poor functional health.

Mediating Factors: Appraisal and Activation Personal and environmental factors influence each other,

resulting in a process of cognitive appraisal. Cognitive appraisal is the individual’s perception of the environment as being either potentially harmful, beneficial, or irrelevant (primary appraisal) and his or her perception of the range of available coping alternatives (secondary appraisal). Although behavior can be affected directly by both the environmental system (residents in high rise buildings are likely to use elevators) and the personal system (a severely handicapped resident is unlikely to participate in strenuous activities), cognitive appraisal is an essential mediating factor in most issues related to resident functioning (Lazarus & Cohen, 1977). Activation or arousal usually occurs when the environment is appraised as requiring a response. This prompts efforts at adaptation or coping, which may change the environmental system (residents decide to use a lounge as a library or music room) or the personal system (residents seek and obtain information that changes their attitudes or expectations).

Coping and Adaptation As previously noted, personal and environmental factors can

affect the nature of cognitive appraisal and of the adaptive tasks faced by a resident, as well as the coping responses used to handle these tasks. Residents with a high need for control (personal factor) are more likely to confront the task of adapting to rules and regulations; the task of adapting to such rules and regulations is more likely to arise in a structured setting with little provision for resident freedom or independence (environmental factor). In terms of specific coping responses, there is evidence for the


positive value of action-oriented or mastery strategies, of impulse control, and of maintaining independence by an angry or de- manding adjustment to institutional life (Filsinger & Sauer, 1978; Gutman, 1978). It has also been noted that environmental factors can affect the use of independence-oriented and socially oriented coping responses, and that an environment that provides more supportive services does not necessarily elicit more passive or dependent coping (Sherman, 1975b). With respect to the model, it should be noted that the placement of variables in the coping or the outcome blocks is somewhat arbitrary, since some coping responses may mediate outcomes or be outcome criteria, depend- ing on the interest and conceptual framework of the investigator.

USING THE FRAMEWORK The conceptual framework provides a general model of the

process of person-environment interaction, only a portion of which has been operationalized. Since the development of better measures of environments is an initial step in implementing such a framework, I first describe a new procedure designed to assess the four domains of environmental resources. I then illustrate use of the procedure by focusing on two aspects of specialized living settings and their impacts. In the person-oriented approach used in most studies, investigators identify changes in individuals and then examine features of the environment that might be responsible for such changes. In contrast, my approach has been to develop concepts and methods to measure the environment and then to examine the “impact” of environmental dimensions on individual and group outcome (Moos, 1979a). This approach makes it possible to specify the environmental factors that are related to particular outcome criteria. It also enhances the likeli- hood of replicating results, or at least of understanding the contextual variations related to a failure to replicate.

Measuring the Environmental Domains My colleagues and I have constructed a Multiphasic Environ-

mental Assessment Procedure (MEAP) to assess group living settings for the elderly, using the four domains of environmental resources. The procedure was developed on a representative sample of 93 sheltered care settings in five counties of California. Further information on this sample, as well as on the psychometric and normative characteristics of the MEAP dimensions, is present- ed elsewhere (Moos & Lemke, Note 1).

84 RUDOLF H. MOOS

The dimensions themselves are conceptual; each is unified by a common functional implication for residents. The items represent opportunities or environmental “resources” for a given area of functioning. For example, the existence of a residents’ council offers residents a formal opportunity to participate in policy making and to experience a sense of efficacy, as do other items on the dimension of resident control. Such an institutional structure commonly arises out of a general philosophy about residents which also manifests itself in other ways.

The MEAP consists of five instruments that can be used either separately or in conjunction with one another, by a staff member or an outside evaluator, to obtain a comprehensive picture of a group living setting. In general the content of the instruments follows the conceptual organization of the four environmental domains previously described.

The Physical and Architectural Features Checklist (PAF) assesses nine dimensions of the physical and architectural resources of a facility. Information is obtained through direct observations (Moos & Lenike, 1980). Two dimensions focus on the presence of physical features that add convenience and special comfort and foster social and recreational activities (physical amenities, social-recreational aids). Three dimensions assess physical features that aid residents in activities of daily living and in negotiating the facility environment (prosthetic aids, orientational aids, safety features). Two dimensions assess the extent to which the physical setting provides residents with potential flexibility in their activities (architectural choice, space availability). The PAF also measures the presence of features that make the setting more pleasant for staff (staff facilities) and the degree of physical integration between the facility and the surrounding community (community accessibility).

The Policy and Program Information Form (POLIF) assesses ten dimensions of the policy and programmatic resources of a facility as reported by the administrator or other responsible staff members (Lemke &MOOS, 1980). The first three dimensions reflect how selective the facility is in admitting residents (selectivity) and the degree to which behavioral requirements are imposed on residents once they are in the facility (expectations for functioning, tolerance for deviance). The second set of dimensions taps the balance that exists between individual freedom and institutional order and continuity (policy clarity, policy choice, resident control, and provision for privacy), while the third set measures the provision of various services and activities in the facility (health services, daily living assistance, and social-recreational activities).


The Resident and Staff Information Form (RESIF) includes six dimensions that characterize the residents and staff in a facility. Information is obtained from records or from knowledgeable staff members (Lemke & Moos, Note 2). The dimensions measure the residents’ social resources (for example, their educational and occupational background) and their heterogeneity (in terms of such sociodemographic factors as age, ethnicity and religion). The RESIF also evaluates the functional ability and activity level of the residents and the degree to which they engage in activities in the community (such as attending religious services and eating in a restaurant). For staff resources, the RESIF considers staffing levels and includes a measure of staff richness that focuses on the heterogeneity of staff, staff training and turnover, and the contribution of volunteers.

The Sheltered Care Environment Scale (SCES), a question- naire to be completed by residents and staff members, assesses their perceptions of seven characteristics of a facility’s social environment (Moos, Gauvain, Lemke, Max & Mehren, 1979). The subscales cover the quality of interpersonal relationships (cohesion, conflict), the opportunities for personal growth, (independence, self exploration) and the mechanisms for system maintenance and change (organization, resident influence, physical comfort).

Environmental assessment procedures such as the MEAP help program planners, staff, residents, and evaluation researchers to obtain detailed information about the architectural, policy, suprapersonal, and social-environmental resources of a facility (see Moos & Lemke, Note 1, for a discussion of some practical applications). I use data derived from the MEAP to explore two aspects of the framework in more detail: person-environment selection and allocation, and the provision of opportunities for resident choice and control.

Person-Setting Selection and Allocation As previously noted, the first step in the model involves

processes of selection and allocation. Prospective residents and their family members may visit several facilities to select a “desirable” setting; administrators and staff often conduct interviews to select “desirable” residents from among the applicants to their facility. In addition, federal and state reimbursement procedures, and placement decisions by social workers and other para-medical personnel, can result in allocating poorer, less competent residents to less desirable settings.

What is the overall effect of these processes? To what extent

86 RUDOLF H. MOOS

do older people create homogeneous environments by selecting settings composed of residents with whom they share personal and social attributes? Furthermore, does selection and social allocation create a situation in which “privileged” people (that is, those with more personal and social resources) reside in settings with more positive environmental qualities?

To focus on these issues, the MEAP was used to describe the personal and social characteristics of residents in skilled nursing, residential care, and congregate apartment settings. We then related these factors to the architectural, policy, and social climate resources of these settings. As would be expected, selection into the three types of settings was related largely to residents’ functional abilities rather than to their sociodemographic characteristics. Residents’ functional capacities, activity levels, and participation in community activities are highest in apartments, interme- diate in residential care settings, and lowest in skilled nursing facilities.

Within each of the three kinds of settings, however, selection occurs on the basis of both social background and functional ability. Residents who are white, well-educated, married, and of higher socioeconomic status are likely to be in homogeneous settings with others of similar background. On the average, these residents are more active both in the facility and in the community. Their living groups provide more physical amenities, social- recreational aids, privacy, and space, and they enjoy greater flexibility in scheduling their daily activities. These settings are more selective, give residents greater input into decision making, and are seen as more physically comfortable. Residents also report more friendly interactions and better organization and believe they are able to influence facility policies (Lemke & Moos, Note 2).

Settings in which residents function more poorly have more prosthetic aids, but staffing levels and staff richness are no higher. If older people were rationally matched to settings, there should be a positive relationship between their need for services (as measured by their current health and functioning) and the services provided them, even beyond the gross differences between types of facilities. Contrary to this pattern, facilities that provide more health services and daily living assistance are those whose residents have higher functional abilities and are more active. Similarly, residents who initiate more activities on their own are also likely to have more activities provided by the facility.

These results indicate that there are relatively strong mechanisms of selection and social allocation that determine where a


person is likely to live. The population in a facility is not simply a random sample of the available group of older people in sheltered housing. In general, older people with more personal and social resources enjoy residential settings with more physical resources, less restrictive policies, and a group of homogeneous (presumably congenial) peers (see also Gottesman, 1974; Kart & Manard, 1976). The fact that these settings are also more expensive indicates that higher socioeconomic status individuals retain their privileged status in old age and highlights the need for social policies to help equalize the environmental resources available to older people in their declining years (e.g., vouchers to help people pay the monthly fees in residential settings of their choice).

O@@ortunities for Resident Choice and Control One of the pivotal problems in many residential settings for

older people is the relative lack of opportunity for residents to determine their daily routine (such as when to get up, eat meals, and go to bed) and to influence programs and policies (Austin & Kosberg, 1976; Smith, Discenza & Saxberg, 1978). We included measures of these factors in the MEAP to describe the variations in resident choice and control among settings and to explore their potential impacts in relation to resident characteristics. With respect to the conceptual framework, this work represents an attempt to describe environmental conditions and to relate suprapersonal and policy factors to resident morale and functioning.

The POLIF dimension of policy choice measures the extent to which the setting provides options from which residents can select individual patterns of daily living. The dimension of resident control assesses the influence residents have in decision-making and the extent of formal institutional structures that give residents a voice in running the facility (Lemke & Moos, 1980). The application of these measures to our sample of 93 settings high-lights the variability in the opportunities for choice and control available to their residents. Overall, the 93 settings scored positively on only 52% of the 20 policy choice items and 36% of the 29 resident control items. There were sharp differences between types of settings, with skilled nursing facilities (SNFs) obtaining average scores of 37% and 24% on the two dimensions, residential care settings (RCs) obtaining average scores of 53% and 42%, and congregate apartment houses (APTs) obtaining average scores of 78% and 5 1%.

More specifically, only 14% of SNFs and 29% of RCs gave

88 RUDOLF H. MOOS

residents a choice of time during which they could have dinner. (Similar percentages held for breakfast and lunch). Less than half the SNFs allowed residents to do laundry in the bathroom or rearrange furniture in their rooms, less than 10% permitted them to keep a fish or bird, and none allowed them to have a hot-plate or coffee maker. Most of the RCs and APTs allowed residents to do laundry and move furniture, but, surprisingly, only about 1/3 permitted them to keep a fish or bird (see Table 1). Other items (not shown) indicated that less than half the SNFs and RCs allowed residents to get up, take baths, and go to bed when they wished, but that almost all the APTs had this degree of flexibility. Almost 80% of the facilities allowed residents to have their own furniture, but only about 30% permitted them to drink alcoholic beverages in their rooms.

With respect to resident control, only about half of the APTs and 1/3 of the RCs included residents on committees and less than 10% of the SNFs did so. Residents in SNFs had very little input in planning social and recreational activities or in making decisions about facility policies. For instance, less than 20% of SNFs allowed residents to help plan entertainment activities, set meal times, make rules about the use of alcohol, or select new residents. Residents of RCs and APTs had more say in these areas, but their general level of influence was still relatively low. Other items (not shown) indicated that housemeetings and meet- ings of resident committees were infrequent (usually once a month or less), that only a small proportion of residents served on committees, and that residents rarely participated in decisions such as when a troublesome or sick resident should be asked to leave or in hiring or firing staff.

T o explore the potential effects of variations in choice and control, we attempted to predict the quality of the social environment (as measured by the SCES) and of resident functioning (as measured by the RESIF) from information about these two policy factors in combination with selected aggregate resident characteristics (social resources, functional ability, the proportion of women in the setting). As expected from the results on selection and allocation, residents with better social and functional resources, and women residents, were more likely to reside in settings high in choice and control. These personal and environmental factors combined to create more cohesive, organized, independence- oriented social environments with relatively little conflict (Moos, Note 3). These factors also enhanced resident activity levels and may have helped to reduce turnover rates by contributing to resident cohesion.


TABLE 1 . PERCENT OF FACILITIES RESPONDING I N THE SCORED DIRECTION ON SELECTED POLICY CHOICE

AND RESIDENT CONTROL I T E M S ~

Percent in Scored Direction

Skilled Residential Nursing Care Apartment Facilities Facilities Facilities

Item (N = 41) (N = 28) (N = 24) F-Value

Is there an hour’s range or more during which residents can choose to eat dinner? Are residents allowed a hotplate or coffee maker in their room? Are residents allowed to do some laundry in the bathroom? Are residents allowed to move furniture in the room? Are residents allowed to keep a fish or bird in their room? Are there committees which include residents as members? Do any of the residents perform chores or duties in the facility? Do residents plan entertainment activities? Do residents help to plan meals? Do residents help to set meal times? Do residents help make the rules about the use of alcohol. Do residents help select new residents?

14.0

0.0

43.9

39.0

9.8

7.3

19.5

7.3

39.5

12.2

19.5

2.4

28.6

25.0

67.9

75.0

35.7

32.1

67.9

32.1

64.3

28.6

35.7

21.4

87.5

70.8

83.3

95.8

33.3

54.2

54.2

70.8

50.0

50.0

45.8

25.0

29.31 ***

33.49 ***

5.82**

15.01 ***

4.17*

10.41 ***

10.44 ***

19.86 ***

2.1 1

6.08 **

2.70

4.39*

tAll items are scored in the “yes” direction. *p < .05 **p < .01 ***p < ,001

It should be noted that these sets of factors often mutually influence each other. For example, a cohesive resident population is more likely to be perceived as a social entity by administrators, and, as a social entity, it may be given a greater voice in running the facility. The turnover rate may be increased by resident

90 RUDOLF H. MOOS

dissatisfaction, but a higher turnover rate may also diminish the perceived need for resident input. Such reciprocal influences underscore the need to use comprehensive environmental assessment procedures in evaluating the “impact” of specific setting features.

A combination of high choice and control, in a setting with more women residents, and residents with greater functional resources, led to increased cohesion, organization, and observer- rated pleasantness beyond what would be expected from the relevant environmental and suprapersonal factors alone. This finding supports the idea that people with more personal resources are better able to take advantage of environmental opportunities (Carp, 1978-79; Lawton & Nahemow, 1973; Schulz & Hanusa, 1979). Surprisingly, the relative lack of such choices as when to get up, go to bed, bathe, and eat, and whether to do their own personal laundry, affected women more than men. This is probably because most of the elderly women living in group settings did not spend much of their lives working outside their homes and were used to organizing their own pattern of daily activities (Bennett & Eisdorfer, 1975). The results support the utility of the conceptual framework by suggesting that the impact of any one set of environmental resources needs to be studied in relation to the types of residents for which it is provided as well as the general context in which these residents function.

CONCLUSIONS I have noted the growing importance of specialized living

settings for older people and described a conceptual framework to help explore the environments and impacts of such settings. Use of portions of the framework has been illustrated by a brief description of an environmental assessment procedure and by an examination of person-setting selection and allocation and the provision of opportunities for resident choice and control. I believe that this work addresses issues of vital social concern, such as defining and regulating the quality of life in residential settings and exploring the impact of settings on their residents. The framework clarifies the need to develop better measures of specific constructs, most notably environmental factors and coping and adaptive responses. It can also help researchers to select relevant domains of variables to explore conceptual and theoretical issues, such as the hypotheses that environmental factors have especially strong influences on functionally-impaired people, that more


homogeneous settings may produce greater conformity, and that the effects of relocation depend primarily on the degree of difference between pre- and post-relocation environments.

The conceptual framework is potentially useful, but it is preliminary and should be used with caution. The model provides an overview of the major sets of factors involved in evaluating residential settings for older people, but the most promising variables in each domain remain to be identified. Furthermore, the model needs to be extended to encompass social factors external to a group living setting that can affect personal and environmental factors and thereby influence resident stability and change. For instance, changes in zoning regulations, certification or licensing requirements, provisions for public transportation, and the number and quality of alternative residential options all can influence the physical, policy, and suprapersonal environment of a setting. Personal characteristics can be affected by the occurrence of stressful life events (such as the death of a family member) and the degree of support available from relatives and friends.

A related issue is the need to specify the outcome criteria that are most sensitive to environmental factors. Lawton (1975, 1977) has pointed out that all human behaviors and feelings are not equally susceptible to environmental influences. Improved housing might lead to better environmental satisfaction, but perhaps not to fewer symptoms of anxiety. The removal of physical barriers might lead to more frequent trips outside a dwelling unit, but perhaps not to greater satisfaction with friends. In addition, any given environmental characteristic may affect different residents in different ways. Cohesion and support can help one resident over a personal crisis, engender conformity to subgroup norms that restricts another resident’s independence, and cause a third resident to feel isolated and lonely. High expectations for independent behavior can facilitate functioning for one resident but create debilitating anxiety for another.

Notwithstanding its limitations, a conceptual framework such as the one I have outlined here can help to sensitize gerontologists and other behavioral scientists to the environmental and personal factors, as well as to the mediating processes of cognitive appraisal and coping, that are involved in evaluating the impacts of specialized living settings on older people. Such a framework can enhance the conceptual adequacy and generality of research and advance our understanding of the complex ways in which personal, environmental, and behavioral factors operate as interlocking

92 RUDOLF H. MOOS

determinants of one another. Such an advance can be of practical benefit to older people if it helps us develop and apply an integrated body of knowledge about the environmental context for aging.

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