Integrating a Person-Environment Perspective
Nursing facilities have come a long way from the custodial environments that were dominant in many care settings some years ago. With recent regulations averring the need for nursing facilities to be more homelike environments, many nursing facilities today have invested in state of the art environments that are esthetically pleasing. Yet, esthetically pleasing environments that have been modernized and pleasant to the eye still fail to meet the needs of many residents.
Regardless of many of the modern facilities that shine in high gloss, giving the impression that tremendous advancements have been made in the nursing home industry, this might actually be specious. At best it provides a primacy effect that often allows many seeing the facility at first blush to be excited by the new, attractive and picturesque nature of the facility, leaving a handsome marketing impression upon consumers. However, how far have we come in tailoring a proper environment to meet the needs of the residents that we service? The question may not be one that many would like to hear. In reality, tailoring the environment to the needs of the residents still has not been successfully implemented in long-term care.
If at First You Don't Succeed, Regulate!
Many at CMS probably would look in agape at this comment. Many would say with all the rules and regulatory requirements that exist, we must be sufficiently meeting the environmental needs of the residents. Many of the quality of life requirements often dictate the need to meet these requirements. Furthermore, surveyors are mandated to look for, and enforce, these federal requirements. With all this said, how can it be said that most nursing care facilities still fail to have a sound person-centered environment?
With all the regulatory requirements that exist, individuals in long-term care regulatory offices often think that they have covered all areas, including the person-environmental fit, on a blanket level. Regulations in and of themselves do not always bring about sufficient change, however we have come to think that if we have enough regulations, we will eventually be able to cover everything. However, more regulations often bring about enforcement strategies that are often quite diffuse in nature.
Establishing a proper person-environment fit is based on more than just regulatory requirements, but knowledge of older adults, the environment that leads to their optimal level of functioning, and having a level of expertise in both resident care and environmental processes. Therefore, to establish a proper understanding of this area, it cannot be done just by regulatory requirements, but through sensitizing long-term professionals to understand and be vigilant in developing a "best-fit" environment. Inculcating this through establishing a mindset rather than adding a litany of regulatory requirements is the most fruitful way of establishing the "best-fit" environment.
So what is the "best fit" environment that needs to be considered for nursing care facilities? What continues to exist is a "one size fits all" view of nursing care environments. Regardless of regulatory requirements that assert a need to a more personalized environment to accommodate the needs or residents, nursing home environments have continued to maintain a level of homogeneity as it relates to establishing an environment of "best fit." The reason for this is difficult to understand since in the gerontology literature, consideration of the person-environment perspective has been researched for some time. Although most of the research has been directed toward non-institutional environments, a considerable level of applicability exists.
One theory well-known in the area of gerontology is the "environmental press" theory (Lawton & Nahemow, 1973). This theory looks at two things, a person's personal competence and the environmental press. Personal competence is rated from low to high and it deals with the level of personal ability the older adult has. It encompasses their social, physical, psychological, and intellectual abilities. It is evident that individuals differ considerably on these skill levels and residents within nursing home environments also differ quite dramatically in these areas as well. Environmental press on the other hand deals with the demands, levels of stimulation and challenges that the environment possesses. Environmental press is also rated on a scale from low to high levels. Here again, long-term care environments often maintain a level of homogeneity on the construct of environmental press.
The above model recognizes that individuals have different levels of competencies. This is not just found outside of the nursing home environment, but within the nursing home environment as well. To maintain an optimal level of challenge that continues to stimulate the older adult, the environment has to be adjusted to each individual's level of competency. This model assumes that there is an optimal level of adaptation that needs to exist to nurture the personal competencies of each individual. When an environment holds too view challenges for the individual that has higher levels of personal competencies, negative or maladaptive behaviors are the result. Conversely, on the other extreme, when an individual has too few competencies and exists in an environment that has too many challenges, the result also is negative or maladaptive behaviors. In essence, what is needed is a very close calibration of each resident's competencies and continuous attention being paid to matching each resident's competencies to the correct level of environment stimulation and challenges.
Organizationally here is the problem. It entails much work. Each individual has to be matched to the appropriate type of environmental challenges that will optimize their lives. This in particular would require major changes in the area of social services and recreational therapy, where the true individualizing of treatment plans would have to exist, not like the current titular process that exists, but a more thorough process that, to this point, has not be found in long-term care facilities. This would eliminate many individuals of varying levels of skills sitting through many forms of activities that for some, may provide proper stimulation, but for many others, provide too little or too many challenges for the individual.
All too frequently, as one wanders down the hallways of many nursing care facilities, one is able to witness the homogeneity of environmental press that exists, untailored and unvarying in its ability to properly sensitize the environment to the varying capabilities of the residents that the nursing home services. Although one of the paramount tenets of federal regulations to is prevent a regression in the skills and abilities of residents if possible, this cannot be fully brought to fruition unless the culture of nursing homes realize the need to continue to match the person to the environment. If this continues to not be addressed, many individuals will continue to desocialize, unnecessarily losing many of their skills and abilities due to failing to address the proper person-environment fit for each resident.
Currently, tailoring the environment to the resident is spoken about, addressed loosely, but really not carried out to any significant level. Because of this a continuation of many unnecessary losses in skills and abilities among nursing home residents will continue to exist. Will it change in the future?
One would hope but since the level of work to carry out such a program is great, and since the number of staff may actually have to increase, these become two formidable barriers that may preclude any changes in the near future. Nevertheless, one can still hope that as we eventually move to the next stage of nursing home change, this will be an important cultural focus. As mentioned earlier in the paper, it is questionable whether this could be achieved through continuous additions of more federal and state regulations. Stateways often cannot change folkways, and in this instance change in this area has to be recognized within the mindset of long-term care professionals and inculcated into the customs and habits of the long-term care culture.
Lawton, M. P., & Nahemow, L. (1973). Ecology and the aging process. In C. Eisdorfer and M. P. Lawton (Eds.), Psychology of Adult Development and Aging. Washington, D. C., American Psychological Association.