Impact of environmental stimulation of functioning of nursing home patients

PDF

Download

Open document

Flip pages

Download a page range

Download transcript

Copy asset link

Request this asset

Transcript (if available)

Content IMPACT OF ENVIRONMENTAL STIMULATION ON FUNCTIONING OF NURSING HOME PATIENTS by Carol Lee Curlette A Thesis Presented to the FACULTY OF THE LEONARD DAVIS SCHOOL OF GERONTOLOGY UNIVERSITY OF SOUTHERN CALIFORNIA In Partial Fulfillment of the Requirements for the Degree MASTER OF SCIENCE IN GERONTOLOGY October 19 78 UMI Number: EP58868 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. Oiss^tation Pubi s h » n g UMI EP58868 Published by ProQuest LLC (2014). Copyright in the Dissertation held by the Author. Microform Edition © ProQuest LLC. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code ProQuest LLC. 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106- 1346 UHIVERSÎTV O F SOUTHERN CALIEORNIA LEONARD VAVLS SCHOOL Of GERONTOLOGY UNTVERSITV PARK LOS ANGELES, CALIFORNIA 90007 Ct C AON Ci 75 C,' T ( v c6 wnÂXtm by ___________Çâr.Q .l. Lee . G .ur].e±te andoA tkn d J j i o ^ c X o n . her CommÂXtto,, and appAoucd by alZ IXâ memb^/u, ho6 bzzn p A . z - 6dnt2 . d to and acczptud by the Vean The leonoAd Vaotà Sckoot o q GeAontotogy, tn poAttat. ^al^tttment ai the AequTAementô the degn.ee ai MASTER OF SCIENCE IN GERONTOLOGY /<?/rt> /fjS THESIS COmiTTEE C fldAJÜnCiirl ACKNOWLEDGMENT In Appreciation ....... Thanks to Dr. Robert Wiswell and Dr. Arthur Schwartz, whose help and encouragement made the completion of this study possible. 11 TABLE OF CONTENTS ACKNOWLEDGMENTS LIST OF TABLES Page 11 Chapter I. INTRODUCTION Variables Importance of the Study Definition of Key Concepts II. RELATIONSHIP TO OTHER RESEARCH . . III. SUBJECTS OF THE STUDY. ...... Data Collection Instruments The Procedures-*—Research Design Treatment of the Data IV. RESULTS V. SUMMARY, Findings Re commendati ons BIBLIOGRAPHY. ..... ........... APPENDIXES................... A. Patient Assessment-— Pretest. B. Patient Assessment— Posttest C. Descriptive Data . ........ D. Patient Interview— Pretest . E. Patient Interview— Posttest. F. Scoring Key for Patient Interview 12 28 39 59 70 76 77 83 88 90 96 101 111 Page G. Pretest Family Questionnaires ......... 104 H. Posttest Family Questionnaires. .... Ill I. Scoring Key for Family Questionnaires . 115 J. Staff Questionnaires— Pretest ......... 117 K. Staff Questionnaire— Posttest ......... 122 IV LIST OF TABLES Table Page 1. Descriptive Statistics of Subjects Participating in Pre/Post Tests of the Total Experiment and in the Patient Assessment and Interview. . . . 40 2. Summary of Patient Assessment Data in Pre and Posttests . ........ 42 3. Composite Scores of Functional Ability in Patient Assessment Pre and Posttests 43 4. Summary of Patient Interview Data in Pre and Posttests ................. 45 5. Composite Scores of Functional Ability in Patient Interview Pre and Posttests 47 6. T Scores of Patient Interview Questions Showing Greatest Differences in Pre/ Posttests................. 49 7. Summary of Family Questionnaire Data in Pre and Posttests ......... 51 8. Summary of Staff Questionnaire Data in Pre and Posttests . . . . . ...........55 9. T Scores of Staff Questionnaire Data Showing Greatest Differences in Pre/ Posttests ............ 56 10. Comparison of Responses on Family and Staff Questionnaire and Patient Interview ....... 58 V CHAPTER I INTRODUCTION Many older institutionalized individuals often ex hibit abnormal behavior which cause them to be labeled "mentally ill" or "senile." One reason for this label may be inherent of the person's medical condition. On the other hand, there is often no strong evidence to support that the mental or behavioral manifestations are related to the patient's diagnosis (Liederman, 1958; Lieberman, 1969). What is interpreted as being part of the person's disorder might be behavior stimulated by the environment. Ecological psychologists are currently studying the influential power which environment may have on man's be havior. In essence, from this perspective, man's activity is not seen as being independent of his surroundings but as being responsive continually in action or in reaction to certain sensory stimuli: how one receives and integrates the sensory input determines the response he will make (Schwartz, 1977). Environmental stimulation may be crucial in the determination of behavior of older people in nursing homes. An area to be investigated in this study is the effect of visual variation and stimulation in the mileu. Studies of sensory deprivation on healthy people have prevented or im paired vision or provided a monotonous visual field for subjects and have produced anxiety, hallucinations, irrita bility, and confusion, characteristics similar to many nursing home patients labeled "senile"(Pastalan, 1970). These symptoms might likewise be caused in qualities of the environment of the nursing home. Older people are prime candidates for sensory deprivation. Lack of mobility in nursing homes restricts patients to a limited area which is usually very monotonous. Additionally, vision problems common to the aging process diminish one's visual acuity, consequently reducing stimu lation received from the sensations (Buseck, 1976). Large percentages of nursing home residents suffer from brain syndromes which may be a product of sensory deprivation and/ or actual brain damage. Physical or mentally-based, this condition may also be influencing the person's perception of his environment (Snyder, 1976) . The need for obtrusive visual cues and stimulation to compensate for the decrements of older nursing home patients is now theorized by nursing home decorators (Burnside, 1976; Fitch, 196 7; Fowler, 1972; Lawton, 19 74; Snyder, 19 78). Bright colors, varying textures, and signs are among the techniques implemented to use the environment positively as a therapeutic treatment modality. In addi tion to providing sensory stimulation, the visual aids would help the patient to process information by helping him to know where he is in relation to other areas in the building. Patients may also benefit indirectly from a therapeutic nursing home environment through their con tacts with staff or visitors who are responding to the setting. As social contacts with the patients feel more comfortable in the nursing home milieu, the frequency and quality of their visits with the patients may increase, and this altered socialization may augment the stimulation the patient may additionally be receiving (Brody, 1976; Chaney, 1973; Downs, 1974). As of the present, however, actual proof is still needed that the therapeutic use of decoration will improve a patient's functioning, either directly through the patient's senses or indirectly by its influence on the patient's social contacts. This present study will ex amine aspects of a patient's life which might change as a result of an application of these nursing home decoration theories. Statement of the Problem The problem which this study will consider is the importance of a stimulating environment on nursing home residents. Recently, a local long-term care facility re quested the assistance of Arthur Schwartz, PhD., long term care expert at the Andrus Gerontology Center of the University of Southern California; and Victor Regnier, Preceptor, Environmental Studies Laboratory, Andrus Gerontology Center, University of Southern California, to make recommendations for refurbishing the interior of the building using the aforementioned assumptions of environ mental psychology. This study will measure the changes in the residents as a result of the redecoration. The research question to be addressed in the study is the following: Will increasing visual stimulation of patients in a nursing home, through environmental inter vention, improve levels of mental, emotional, physical, activity, or social functioning? In the event that the findings may also be produced by social contracts which have been altered by the changed environment, attitudes of the staff and relatives toward the home will also be ex amined . Statement of the Working Hypotheses Much research describes symptoms similar to "senile-like" behavior seen in many nursing home patients as being caused by conditions of sensory deprivation and as being reversed through sensory stimulation (Bower, 1967; Liederman, 1958; Pincus, 1968). If stimulation through the environment does have an effect on patients in nursing homes, then the following results can be expected follow ing refurbishing of a nursing home. Although these hypotheses are stated in a directional form, all statis tical tests for significance will be done using the null hypothesis as the test question. 1. In general, posttest scores indicating levels of the patients' mental, emotional, physical, activity, and social functioning are expected to change positively from pre test scores. 2, The patients will change in their perceptions of their environment : they will consider the facility a more pleasant place after redecoration, and they will spend more time in the public areas wbich. have been redecorated. Some theorists suggest that psychologically com fortable milieu may help to shape the social interaction taking place within it. Consequently, the environment will indirectly supplement the stimulation to the patient by its effect on his spcial contacts (Brody, 1976; Chaney, 1973; Downs, 1974; Pincus, 1968; Wood, 19771. If this is true, then the following general hypotheses can be ex pected to be supported by the findings of this study : 1. Pretest and posttest scores measuring the staff's attitude toward their job and toward the patients whom they serve will change in a positive direction. 2. The staff and the relatives of the patients will both report satisfaction with the en vironmental changes in the posttest. 3. The staff and the relatives will report observing an improvement in the patients or in their specific relative in the first six months following the redecoration. 4. The frequency of family visits to the nursing home will increase after the change in decor as indicated by the difference in the pre and posttest answers given by the family. 5. The families* impressions of nursing home patients in general will improve in the posttest scores. 6. The families' posttest scores will differ from those of the pretest, indicating an improvement in their attitude toward the nursing home and its care of the patients. Variables Independent Variable Environmental stimulation through painting the building using alternating bands of white and either vivid yellow or mustard in the corridors, painting figures of changing colors on the doors, and attaching plexiglass digits, identifying the room numbers on the wall outside the door. Dependent Variable Levels of mental, emotional, physical, activity, and social functioning of the patients, attitudes of the staff toward their job and the patients, and the relatives* frequency of visits, impression of nursing home patients in general, and their attitude toward the specific nursing home and its care of the patients. Op e ra t i o n a1i z a ti o n o f V a r i ab l e s Mental, emotional, physical, activity, and social levels will be measured by a self-administered question naire given to the nurses' aides, requesting information about their patients and by a directed interview given to designated patients by the experimenter. Additionally, information on mental status will be measured through an assessment given by the experimenter to the subjects at the time of the interview. Variables of staff attitudes toward their job and the patients will be measured using a questionnaire administered to the staff by the experimenter either in dividually or in groups. Each subject will complete the questionnaire individually. The families* frequency of visits, impression of nursing homes in general, and the families* specific attitude toward St. Theresa's and its care for the patients will be measured using a mailed, seIf-administered ques tionnaire . Importance of the Study Theoretical Importance Although this study cannot be generalized to a broader population of nursing home residents than those who live at St. Theresa's, results of the study can add some support for ideas which, at this point, are hunches which have yet to be studied. Methodological Importance A successful measurement used by this study would provide other researchers with adequate tools to repeat this experiment and to confirm the results. Practical Importance Disturbed patients in nursing homes are often medicated to manipulate mood or excitability and/or isolated from other patients when one creates a disturb- ance. This treatment may, in essence, be treating the problem with more of the same; What may be provoking the patient to malfunction initially might be the lack of en vironmental stimuli present, and the solution of increas ing further sensory deprivation through isolation or drugs may be increasing the problem. Additionally, patients who get lost and need attention demand much staff time. Significant results of this study will demonstrate environmental stimulation to be a natural means for help ing patients to be more self-reliant by providing cues to orient themselves and, consequently, for making the lives of the patients more meaningful, enjoyable, and worth while. Additionally, evidence will be provided for nursing home operators as to the value of environmental stimulation in improving efficiency of drug usage and staff time. Definition of Key Concepts Environmental stimulation : sensory excitement from objects or conditions in the surroundings. Sensory deprivation: absence or reduction of sensory stimulation or the presence of monotonous, meaning less stimulation. Mental functioning : ability to remember certain basic facts from the past and the present as measured by the Mental Status Questionnaire and by related questions asked of the nurses' aides. 9 Mental Status Questionnaire (MSQ); A research instrument which assesses one's mental functioning. Emotional functioning; ability with which the patient controls certain emotional feelings as determined through self-reports of the patients and ratings of the nurses' aides. Physical functioning; ability of a patient to attend to his physical needs independently as evaluated by self-reports of the patients and by the nurses* aides. Activity level ; the extent to which the patient engages in activities or keeps busy doing things as assessed by staff ratings and by self-reports of patients. Social level; ability to communicate and to make friends according to self-reports of patients and staff assessments. Good, fair, or poor vision; visual ability of the patient as assessed by the nurses* aides. Good mental ability ; ability of cognitive functioning indicated by scores from 0 to 3 wrong on the MSQ. Fair mental ability : ability of cognitive functioning indicated by scores from 4 to 7 wrong on the MSQ. Poor mental ability ; mental functioning indicated by scores of more than 7 wrong on the MSQ. 10 Racial background; race from which the person originated. H aw t home effect ; an interpretation of an en vironmental manipulation as being an expression of concern by the administration for the patient. 11 CHAPTER II RELATIONSHIP TO OTHER RESEARCH No empirical research has as yet focused directly in the area of this present study. However, theories addressing the importance of a nursing home environment to the patients base their arguments on strong parallels drawn between studies depriving subjects of certain levels of sensory stimulation and conditions which exist in nursing homes. Through conditions of sensory deprivation, psy chotic- like symptoms similar to those of many nursing home patients can be developed in normal, healthy subjects. Different types of sensory deprivation have been explored to test the response of healthy people to partially or absolutely reduced stimulation or monotony. Hebb, a pioneer in sensory deprivation research in 19 53, produced reduced stimulation in 22 college men placed in a semi- soundproof room. Each subject had movement restriction, translucent glasses allowing diffused light and prohibiting patterned vision, and gloves, and were subjected to a con tinual masking noise (Hebb, 1954). Lilly (1956), on the other hand, attempted to eliminate sensory stimulation completely by immersing his subjects in tepid water with a 12 breathing apparatus completely masking vision. A monoto nous environment was created by Leiderman (1958) using a respirator to limit sensory involvement, including a visual field, for his subject volunteers. All three stimulus conditions produced similar results. Subjects were found to be irritable and suffering from visual imagery, hallucinations, and a loss or impair ment of a sense for reality. Lilly's subjects were addi tionally observed to use methods of self-stimulating be havior such as muscle twitching or stroking of one finger with another. Effects of the experiments were found to last hours after the experience. Manifestations of sensory deprivation reported from other sources include a decrease of meaningful activity, boredom, inactivity, sleep, and psychosocial deterioration and disorientation (Jones, 1976). Many of these same symptoms are recognized as being symptoms of "institutional neurosis," senile dementia, and mental illness (Bower, 1967 ; Lieberman , 1969 ; Newcomer, 19 76). Although these symptoms in sensory deprivation ex periments were caused by limitations imposed on several senses, conditions of this present study necessitated re strictions of scope to the effects of stimulation through the visual sense. Possibly the simulated absolute or reduced sensory deprivation states produced in these experiments could also 13 be caused by normal physiological changes in the aging eye. Gradual loss of accommodation requires more time for the eye to refocus from looking at one object to another and causes difficulty in discriminating fine detail. As the pupil diameter decreases, the eye needs more light to see while simultaneously becoming more sensitive to glare. Additionally, the peripheral vision decreases, and a de cline in depth perception causes long hallways to appear endless (Snyder, 1978). The yellowing of the lens causes difficulty in discriminating colors, especially pastels and dark shades (Gilbert, 1957). In addition to these normal age changes, accompanying medical problems common in older people such as hypertension, diabetes, and cataracts obstruct normal vision (Buseck, 1976; Pastalan, 1973; Snyder, 19 78). Snyder C1976) speculates that what has been labeled "senility" may sometimes be the result of poor eyesight. Visual tests of 294 institutionalized aged were compared to corresponding scores on a Mental Status Questionnaire and showed that subjects with poor vision also had low scores on the Mental Status Questionnaire. Although results of Snyder's study could not conclude a causal relationship, further evidence would be most valuable for therapeutic interventions with institutionalized aged. Brain damage may also be a factor in how signals 14 from the visual organs are being received. If the brain is not interpreting visual messages properly, then full benefit from the sensory stimulation might not be utilized. Victims of cardiovascular accidents, for example, often have spatial-perceptual difficulties and cannot trust their interpretation of visual information (Fowler, 1972). Additionally, other forms of brain damage exhibit irrit ability, confusion, and hallucinations, symptoms similar to sensory deprivation. Besides visual or mental problems, another cause for sensory deprivation in nursing home patients is the monotonous milieu. The standard nursing home environment is typically sterile and barren. Pale walls, white nursing uniforms, and impersonal patient gowns provide little variation for stimulation (Burnside, 1976). Also, many people in nursing homes do not have the ability to move around and thus expose themselves to a variety of sights. Immobility has been implicated in producing effects similar to sensory deprivation (Schultz, 1965; Wood, 19 77). In addition to these stated factors, predisposing sensory deprivation in the nursing home population, characteristics of the aged make them more easily influ enced by their environment. According to Zuckerman (1969), changes in the nervous system cause older people to need increased stimulation and to react more extremely to a de- 15 prived environment than their younger counterparts. Addi tionally, this vulnerable position of the aged is referred to in Carp's (1976) "loss continum" and Lawton's (1974) "environmental docility hypothesis": physical decrements of aging cause the individual's behavior to be heavily in fluenced by the immediate environment according to these theories. Explanations for these responses to sensory depriva tion have been attempted from the neurophysiological and the psychological fields. Physiological studies have demonstrated that a complex, enriched environment produces high brain development in animals, whereas deprivation causes developmental deficiency (Walker, 1975). Walsh's (1971) rats habitated in a stimulating environment were found to have a cerebrum longer than that of the isolated group. Brain weights increased in response to stimulation in comparison to the deprived groups of rats in Riege (1971) and Cummins' (.1973) experiments. Additionally, the sub jects in the enriched colonies of the two studies proved to be faster in learning responses. Dru also discovered non specific stimulation after brain damage to be an important factor in his rats' ability to recover normal functioning (Walker, 19 75). In addition, age was not found to be a significant variable in the response of a rat's brain to stimulating 16 surroundings: old rat brains were found to be just as responsive to the environment as the young brains. Cummins' (197 3) rats approaching senescence showed a growth response of their brains to an enriched environment. Similarly, Dru's aged, brain-damaged rats exposed to stimulation responded as well as the younger rats in testing situations, but they needed more time for response (Walker, 1975). Walker states, "Age changes may not be due to aging alone, but also to the cumulative effects of the animal's isola tion in the relatively deprived environment" (p. 162), Other neurophysiological explanations for the symptoms of sensory deprivation state that the neuro muscular system is always searching for an optimum level of stimulation (Hebb, 1954). A condition of neither too great nor too little sensory stimulation permits the fullest exercise of the critical faculties upon that situation or any aspect of it (Fitch, 1967, p. 83). A certain range of deviation in stimulation is tolerable, but when too little or too much stimulation is present, the imbalance will cause stress (Fitch, 1967; Gregory, 1966; Lilly, 1956 ; White, 1967; Zuckerman, 1969). When the environment does stimulate the organism, the subject may force it through hallucinating, self-stimulating behavior, or other means (.Gregory, 1966). Fantasizing may cause anxiety, irritation, or amusement, for instance. Other symptoms cited as being 17 related to reduced stimulation include depression, decreased ability for sustained activity, confusion, and a preoccupa tion with physical ailments (.Zuckerman, 1969). When an extreme condition of sensory deprivation consistently prevails, then the individual may adjust, but such adaptation may have long-term effects (Wohlwi11, 1966). Walker (.1975) cites studies in which a stressful environ ment is related to pathological diseases in mice. Demands of stress on the body's system may cause changes in the endocrine function which accelerate arteriosclerosis, heart disease, kidney disease, and the aging process (Walker, 1975}. Whereas the physiologists emphasize the need for sensations or awareness of stimuli in the brain, psycholo gists stress the importance of the meaning or interpreta tion of the stimuli by the subject. If the person finds no meaning in the visual input, then he can also suffer from sensory deprivation in this sense (Wohlwi11, 1966). Burn side (1976) labels these two distinct differences between the perspectives of the physiologists and psychologists as an emphasis on "sensory process" versus on "perception," respectively. Corso (1967) further defines perception deprivation ; "It is this restriction of meaning and not the specific physical limitation of the stimuli per se that produces the effects of sensory deprivation" (p. 5 87). 18 Psychologists believe that meaningful stimulation is necessary for the ego to react to the surroundings and to maintain its structure (Lilly, 1956). Such interactions form a reality testing in which the individual is continu ally forced to affirm who he is in relation to his environ ment. Not only have studies shown how necessary stimula tion is for normal functioning, but they are also now be ginning to consider its therapeutic value (Carp, 1976; Lawton, 19 74; Lieberman, 1969; Pastalan, 19 70). Pincus (1968) summarizes this position by stating, "When the en vironment is made more stimulating, residents who were pre viously assumed to be physically or mentally incapacitated and apathetic often become much more active and involved in the world around them" (p. 2). For illustration, Liederman (1958) demonstrated that the symptoms of sensory deprivation in mentally healthy subjects can be caused by a hospital situation and can be reversed with stimulation. In Liederman's study, a group of patients with medical diagnoses unrelated to the psychotic-like symptoms they began exhibiting after hospital admission were enlisted in a program of sensory stimulation. Symptoms of anxiety, delusions, and visual and auditory hallucinations were relieved as a result of the intervention, and the symptoms reportedly did not recur. 19 Additionally, sensory stimulation may be useful in reversing or delaying progressive decline of individuals with senile dementia. Bower (1967) divided 50 patients suffering from senile dementia (half male and half female) into an experimental and a control group. The experimental group received stimulation for six months, five days a week, and the control group received no treatment. Bower con cluded, ". . .senile dementia is a disease process which is only partially based on pathologic changes in the brain; its symptomatology is influenced to a not inconsiderable extent by the sensory deprivation which accompanies the disease. Intensive stimulation therapy may reverse, or at least slow down, the dementing process" (p. 1119). On the other hand, sensory restriction has likewise been used therapeutically in treatment of some psychiatric patients (Schultz, 1965). "Among these reported effects have been reduction in hallucination intensity, increased ego strength, a less rigid utilization of defenses, and an increased desire for social contacts" (p. 108). Explanation of these results may be that lower stimulation causes cer tain individuals to reassess their prior behavior and to be malleable to the advice and suggestion of others. As of yet, however, many questions on this issue remain un answered . Another condition present in sensory restriction. 20 but not frequently isolated as being a factor contributing to its symptoms, is an alteration in social environment. As in subjects of experiments limiting sensory stimulation, patients in nursing homes also undergo a changed relation ship with their social world. "Human contact is vital to the person who is on bed rest even for a few hours" (Downs, 1974, p. 438). Wood (1977) includes social isolation in her definition of sensory deprivation and examines it as an intervening variable in her study of sensory stimulation of 77 patients assigned to one or two-bed rooms. Although the amount of time spent with visitors is hypothesized as being a variable of sensory disturbance, the interaction of this variable did not show significant results in this study. In addition to social isolation, the quality of interaction with others may be a contributing factor to this facet of sensory deprivation. Self-concepts are often formed by internalizing what others think about ourselves (Mead, 19 34). People in isolation have been shown to be especially vulnerable to external influence in changing their attitudes [Schultz, 1965). Consequently, patients in nursing homes may fall into a high risk group for falling prey to a self-fulfilling prophesy: "When the staff hold low expectations of the residents* abilities. , .the resi dents in turn begin to live up to these expectations" (Pincus, 1968, p. 2). Inversely, when the staff treat the 21 patients with dignity and respect, the patients may respond at their highest potential. Although this form of sensory deprivation is con tingent on other people rather than visual stimulation, how visitors or staff respond to patients may be influenced by the physical environment. "Excess environmental stress on nurses may contribute to some withdrawal from patients" (Downs, 1974, p. 438). And, conversely, a pleasant, com fortable environment may facilitate a healthy interaction between patients and staff. Likewise, visitors' emotions may be partially created by the surroundings and may be communicated to the patients; an inviting environment may help to produce a satisfying social contact CGhaney, 1973). Additionally, frequency of visits by outsiders may increase. In support, Brody (19 76) observed the number of visits to residents of the Weiss Institute to increase after being relocated to a new, well decorated facility from an older, less appealing building, previously housing the geriatric center. Believing these studies regarding the value of environment to be true for patients as well as for their visitors and staff, hospital and nursing home decorators are now showing interest in assembling a decor which would provide a healthy degree of stimulation. Fitch (2196 7) describes this shift of interest from regarding the 22 hospital as a "container for men" to an "actual instrument of therapy." Burnside (1976) suggests, "Signs, textures, posters, arrows, right color-coding, written messages are but a few of the possibilities. . ." (p. 384) for making the nursing home environment more therapeutic. Clear, simple, bold visual cues have been hypothe sized to be an essential element of the decor (Burnside, 1976). Such visual aids could be seen by patients with some sight impairment. Brain-damaged people--as well as normal people in a void setting--have difficulty orienting themselves and need this simple type of environmental due to help their memories (Fowler, 1972; Lawton, 1974). Such signs could also function as landmarks in establishing territories or as social "boosters" in providing points of interest for conversation (Snyder, 19 78). Color psychologists have found that certain emo tional reactions can be induced by specific colors. Chaney (.1973) claims that warm colors raise blood pressure and pulse rate, whereas blues and greens have an opposite effect. Hayward (1974) attributes these responses to emotions associated with the following colors: Red; exciting, stimulating, defiant, contrary, hostile, hot, passionate, active, fierce, intense, happy, sometimes irritating. Blue : calm, peaceful, soothing, tender, secure, comfortable, melancholy, contemplative, subduing, sad, dignified, restful. (p. 124) 23 Knowing typical color effects might increase pre dictability of responses to a decor. When designing an environment, it is this therapeutic value of a color rather than color preference of the individual with which the decorator must be concerned (Hayward, 19 74) . In addition to color effects on the individual, the activity taking place in a specific area should be considered (Chaney, 1973; Hayward, 1974). Areas of greatest activity should be decorated with bright colors to stimulate the desired kind of activity. Chaney (1973) recommends that passageways for transit, where actual activity is not taking place, should be decorated in neutral tones with variations in patterns and orientation points, for example. Although environmental psychologists tend to pre dict environmental reactions based on certain design characteristics. Moos, Harris and Schonborn (1969) postu lated that the decorator must consider the specific group of people for whom he is designing. These theorists sup port this idea in their study of 64 psychiatric patients and 36 staff members who were given questionnaires measur ing their reactions to six different rooms (Moos, et al., 1969). Results showed that the reactions of the patients tended to be different from those of the staff on the whole Additionally, subjects reacted consistently to their en vironment, regardless of which room they were rating. The 24 experimenters conclude, . . .one can predict a subject's reaction to a room better by knowing who the subject is than by knowing which room he is rating. . . it was possible to predict only a very small proportion of the reaction of a subject to a room by knowing about the physical dimensions, color, lighting, and other characteristics of the room. (Moos et al., 1969, p. 324) Culture, for example, may be a determinant of the emotional reaction of a specific group of people to decor. Different cultures seem to name and break down the color spectrum differently, but it is not certain whether this is due to difference in perception. "Different people organ ize the world differently, in accord with cultural forces rather than in a manner dictated by its intrinsic structure" (Segal1, 1966, p. 48). If color perception is enculturated, then perhaps responses for colors would be different across cultures (Burnside, 1976). Additionally, what is meaningful for one culture may not necessarily be so for another. Each culture has items which are uniquely familiar to its past. Older people— especially the brain-damaged— remember the old more easily than the current, and use of symbols from the past may be useful in providing a bridge to the present and alleviating stress in a foreign environment (Burnside, 1976; Fowler, 1972). If the environmental decor does not appeal to the culture of the group for which it is designed, then perhaps a lack of meaning is not using the environmental potential for stimulation. ______________ 25_ Illustrating the importance of culture in an en vironmental response, Segall (1966) reports about a study done by Bagby in 195 7 in which matched pairs of Mexicans and Americans were shown pairs of photographs in a stereo scopic viewing device. One of the pictures was Mexican- oriented, and the other was American-oriented. Because each eye was shown a different picture, the mind could only focus on one image at a time. After seeing 10 pairs, Americans showed dominance to American-oriented pictures half the time, whereas the Mexicans always showed Mexican dominance. It was concluded that ". . .differences in ways of perceiving are a consequence of differences in past ex perience, in this instance the experimental differences being cultural" (Segall, 1966, p. 51). In measuring people's responses to their environ ment, self-reports of subjects relating to their preferences in environment may not be an accurate representation of their actual desires. Canter (1975) suggests that people tend to rate their environment by what they have already experienced. Behavior is often adapted for particular situations rather than the situation changed to be a more ideal environment (Canter, 1975). The aged especially adjust to pain and discomfort as being normal for their stage of life (Burnside, 1976; Buseck, 1966). "The result of this attitude may be an elderly person who seeks pallia- 26 tive rather than corrective or preventive treatment" (Buseck, 1976, p. 35). The study currently being described is intended to measure the success of environmental psychologists in applying their hunches about the need for stimulation to nursing home decoration. Studies already mentioned have considered the therapeutic use of sensory stimulation, but they have never implemented it through interior design. Results of this study should consequently extend knowledge of the effect of the environment on the well-being of the patient. 27 CHAPTER III SUBJECTS OF THE STUDY The subjects used for this study are patients living at St. Theresa's, both, before and after the environmental change, their significant others Crelative or friendl, and the staff working at the nursing home. No sampling pro cedure was used, and all possible data was collected from the population. Out of a total of 99 patients, some form of information was collected on 79 patients in the initial testing. The following chart indicates the total possible and the number of subjects on which data was actually supplied in the pretests and the posttests. Patient Interview Total Possible Actual Total Family Questionnaire Total Possible Actual Total Staff Assessment Total Possible Actual Total Staff Questionnaire Total Possible Actual Total Pretest 30 27 Posttest 18 15 74 45 99 67 ? 32 29 21 47 16 19 9 28 The number of possible subjects for each pretest was determined by all the patients present for the staff assessment, by all the responsible parties listed in each patient's records for the family questionnaire, by all the patients identified by the director of nursing or the assistant administrator as being coherent for the patient interview, and by all the administrative and nursing staff contacted for the staff questionnaire. The total possible number of subjects for the posttest was determined by the number of subjects who had been represented in the pretest and who still maintained their relationship with St. Theresa's after the redecoration. All participation in this experiment was voluntary, and all answers were assured strict confidentiality. Of the patient subjects in the pretest, approxi mately 25 percent were male. A broad range of ethnic groups was represented: 33 percent of the patients were of Spanish descent, 1 percent were Black, 1 percent were of other origins, and the remaining number were Caucasian. Of that number, 36 percent of the subjects had lived at St. Theresa's 3 months or less, 31 percent from 3 months to 1 year, 6 percent from 1 year to 2, 10 percent from 2 to 3 years, 2 percent from 3 years to 4, 5 percent from 4 to 5 years, 2 percent from 5 years to six, and 8 percent longer than 6 years. 29 Out of the total 79 patients on which some form of data was collected, 26 (33 percent) no longer remained at St. Theresa's during the posttest. Of the dropouts, 19 (24 percent) died, and 7 (8 percent) were relocated either to another facility or to home. Of the staff dropouts in the posttest, 40 percent were no longer employed at St. Theresa's at that time, and the remainder not included in the posttest were unavailable for testing. All pretest scores of subjects dropping out before the posttest are discarded, and the statistical conclusions of this study will be based exclusively on the actual number of posttest scores with corresponding pretests. Results from the study will be representative of the residents of St. Theresa's Convalescent Home. General izations to the entire nursing home population from this study cannot be drawn because of the small sample size, the unique racial makeup of the sample, and other important variables like nursing home administration, size of the facility, and staff turnover, for example, which could not be controlled through this study. Data Collection Instruments A functional assessment tool developed by Plutchik, Conte, Lieberman, Bakur, Grossman, and Lehrman (1970) and modified by the experimenter was used for the questionnaire to be completed by the staff concerning each individual 30 patient. Few other questionnaires have been designed for assessment of functional ability. This questionnaire is selected because it has many items and consequently may be sensitive to a change in the patient. The experimenter will also use the Mental Status Questionnaire designed by Kahn (1960). This tool is selected for its simplicity of administration and for the quantifiable method of evaluating mental ability. Questions comprising the interview format given by the experimenter to the subjects have been selected from a questionnaire designed by Neugarten, Havinghurst, and Tobin (1961), and combined with a number of other questions formed by the experimenter. Neugarten's et al. scale was chosen for its special adaptation for use in determining life satisfaction in older people. Through questions in the patient interview covering the patient's self-perceived physical, emotional, activity, mental, and social function ing, it is hoped that the validity of the staff assessment of the patient can be checked by use of this patient inter view instrument. The questionnaires given to both the staff and the relatives or friends of the patients have been designed pre dominantly by the experimenter with augmentation from a test by Schwartz and Tiberi for the original purpose of measuring nursing home staff views of their facility. 31 Because several of the staff and relatives were thought to be Spanish-speaking, these questionnaires were translated into Spanish. Questions in the pretest which the experimenter has felt redundant, misunderstood, or unclear have been omitted in the posttest. Also, certain questions relating more specifically to the environmental change have been added in the concluding questions of the posttest to insure that the results indicate the respondents* direct responses to the independent variable. Unfortunately, these tests do not measure all the variables which might be involved in this experiment. Variables which still remain beyond control in this experi ment might be staff turnover rates or an inconvenience in remodeling, for instance. In addition, no control for per sonality of the patient is present, and this might affect the person's adjustment to the change. Lastly, no means are available for measuring hallucinations, and this phenomena is expected to change. The Procedures— Research Design This study is a field experiment using a pretest and a posttest design. Each testing period spanned approx imately one month in length on varying days in the week with, more than six months dividing the two testing period. After the experimenter received permission from the 32 administrators of St. Theresa's to perform the study, the questionnaires were developed by the experimenter and critiqued and approved by the nursing home. The first set of questionnaires were administered to the staff in a meeting with the nurses' aides. In this meeting, the experimenter was introduced as a student learning about nursing homes, who would be spending some time at St. Theresa's asking people some questions. Staff cooperation was requested in completing the forms measuring staff attitudes. Staff members not in attendance were administered questionnaires individually and were asked to complete them as soon as possible, preferably at that time. Those staff members speaking only Spanish were given questionnaires in their language. Respondents were asked to at least initial the questionnaire, and strict con fidentiality of answers was promised. Patient assessments to be completed by the staff were given to the assistant administrator who, in turn, asked each head nurse's aide to distribute the forms among the aides. Each aide working a day shift filled out a questionnaire on each patient for whom she was caring that day. Some patients were assessed by two different people to demonstrate reliability of the aides' evaluations. The staff were given one week to complete the questionnaires. Answers given by each nurses* aide were checked by the 33 assistant administrator for accuracy of information. Patients who could coherently answer interview questions were identified by the assistant administrator or the director of nurses. The experimenter introduced herself to those identified patients and explained that she was a student learning about nursing homes. Patients who consented to participate in the experimenter's study were given the interview, which averaged about 45 minutes in length. Questions from the Mental Status Questionnaire were interjected periodically throughout the interview to casually test the patient's mental functioning in a non- threatening manner. Questionnaires measuring the families* attitudes were mailed during the first week of the pretest with a letter of introduction from the experimenter and the owner/ administrator of the nursing home. The families were asked to complete the form and to mail it in the enclosed, self- addressed , stamped envelope. Those families identified as being Spanish-speaking by the assistant administrator were mailed a form in their own language. Basic information regarding the patients' histories was supplemented by information recorded in the patients' medical charts. Following the month of pretesting, the interior dec oration began. Hallway walls were painted in alternating 34 bands of white and a color; in the section housing the alert patients , the color introduced was a vivid yellow ; in the section in which the mentally-confused patients reside, the alternating color used was mustard. Each door was painted in a primary or a secondary color with a shape resembling a segmented ball placed half on the door and half on the adjacent wall. The colors of the balls moving down the hallway varied, following the pattern of colors on a color wheel. Adjacent to the door on a section of the ball was attached a plexiglass digit one-quarter of an inch thick which designated the room number. About three months after the majority of the work was completed, the posttest was begun. This time period was selected because the administrator of St. Theresa's was considering following the advice of another decorator in completing the project, and the experimenter did not want to confound her results with the theories of two different decorators. In beginning the posttest, the experimenter first determined which patients and staff were remaining after the interval period. Questionnaires measuring staff attitude were administered individually to the staff by the experimenter in the same procedure as they had been in the past. Similarly, the interviews of the experimenter with the patients and the completion of the family questionnaires 35 followed the same pretest procedure. However, no Spanish questionnaires were used in the posttest design because their use in the pretest was almost null. One Spanish- speaking nurse's aide used another aide as a translator in completing her questionnaire. In the staff assessments, questionnaires on the patients remaining in the facility were organized so that the evaluation was to be completed by the same staff member who made the initial assessment. When the staff person was no longer employed at St. Theresa's, the assistant adminis trator was asked to appoint an aide who would be knowledge able in completing the form. This procedure was to minimize the individual interpretations of each staff member for the questions. The forms to be filled out were distributed by the assistant administrator, as they had in the pretest. Staff members were asked to have their evaluations completed in one week, but this period was extended to two. Treatment of the Data Open-ended questions in the testing instruments were scored according to the criteria established, as noted in the Appendixes, The first step in the statistical analysis was to calculate a frequencies distribution on pretest and posttest questions in the patient assessment, patient interview. 36 family questionnaire, and staff questionnaire. This pro cedure was repeated for the family and staff questionnaires for those subjects which were represented in both tests. Subjects without posttest data were omitted from calcula tions so that the change made within a specific group of people would be more easily observable. Next, questions in the patient assessment, and in the patient interview, were categorized into the following groups of functional ability: physical, mental, activity, social, and emotion (See Appendixes for distribution). Scores from each subject in each of the groupings were added together to form a composite score for each of the categories. A general frequencies distribution was then performed for all the composite scores, both pre and post test, and compared for differences. Because many of the subjects in the pretest were not represented in the posttest, a missing value was assigned to pretest/posttest couples not having a post test. A general frequencies distribution was then repeated on the data. This procedure was intended to give more sensitive information as to changes taking place within a certain group of subjects as a result of the independent variable, whereas the treatment described in the preceeding paragraph provided data on the general pre/posttest groups as a whole. 37 In order to provide descriptive information on subjects, a frequencies distribution was then executed on scores of age, race, sex, length of stay, and vision on pre and posttest data. These scores were then compared to like scores of subjects completing both pre and posttests of the interview and assessment. This information in dicated how the subjects remaining in the experiment through the posttest varied from the total pretest pool. All data thus far compiled was then analyzed for obvious differences between the pre and posttest groups of subjects being represented in both tests. A T test was then performed on these scores to test for significant differences, and a level of confidence at .05 was estab lished. 38 CHAPTER IV RESULTS This chapter will present the results of this re search as each, test instrument is analyzed, A description of the group of subjects participating in each testing, a summary of the data collected with each instrument, and inferential statistics describing differences between groups of scores will be presented. All direct relation ships of the results to the initial hypotheses will be drawn in the following chapter in which conclusions are made. Descriptive statistics of patient subjects partici pating in the study are presented in Table 1. As the data summary reveals, the subjects in the total group pretested averaged 77.74 years of age. Additionally, subjects were predominantly female Caucasians with slight visual impair ment who had lived at the facility from one to two years. No significant changes occurred from the total pretest to the total posttest group. Likewise, descriptive data remains not significantly changed from the pre to posttest groups in the patient assessment. As presented in Table 1, the mean age of z LO CO CO eo co CO CM r— c CM co o CO O o , Q co co CO t / l > CM œ CO co OO CM LO LO LO LO h- co )x CM CM CM CM CM CM CD CO eo co r^ « = J - z CO co CM 1 —' o co LO O 00 CM 4- Q O e / l CM CM CM * — CM CM -C >1 +j ai CJl+J r > . 00 CO co CO c c e / l co LO ' = d " 00 e u !x c r > c +J "O LO co CM LO h- (O c z co co CM Q. r o 5 • 1 — d ) O + - > « r “ 1— C > e r > CM LO CD « = 1 - + - > e u S - 0 1 en o o CD 00 en s - E e u o Q < 0 *r- - » - > f O t / l a. S - C e u » —» ( / ) Q. 4 - > X -O 1^ r > - i> U LU c co co LO e u ( O |x • ■ • r - > i — r — -Û r t J -M = 5 4 - > C C L ) co o e u i — E « = t - co h- 4- t / l Z CO CO CM f O O e u l / l I — j c z e u ( /!+- ) ( / ) eu, t / l X LO 00 en • r - 4— e u Q K j " « c f CD « j - +J O e / l C / ) t / l +J • 1 — t / l C 4 - > 4 - > ( U t r S t / J " r — LO 00 lO eo en 4 - > e u CM CM CM to eo CM e / l H- ( O |X a. e u 4 - 1 > tn e u - r - o _C ■M CL. 4-> CO LO CM co co to z CO CO CM 1 — • r — e u S - s - o a. t / l O co CO CO co to e u Q o CO O eo co e u en ai < ro CO 00 et |x co OO CM 00 LO X to t n e u 4-1 e u to 4-1 4-1 O t / l w 4-1 C o I — I — 1 « = C 1 c t —1 1 —1 1 4-> 1 -O 1 4-1 1 4-1 t / l e u t / l e u t / l e u t / > e u s - O s - O s - O 1 — o_ Cl. CL. CL. o_ Ou 40 subjects appears to be the statistic of greatest change. A T test of this statistic of the pre and posttest patient assessment groups reveals a score of 1.23 which is not significant at the .05 level. Data collected through the staff's assessment of the patients is presented in Tables 2 and 3. This informa tion describes a group of patients who are generally fairly dependent in dressing, bathing, and tooth brushing needs, but who are somewhat independent in elimination control and in eating. Their memories tend to be poor, but they are mostly aware of who and where they are. The profile of these patients is fairly inactive in that they nap quite often, infrequently participate in group activities, and need some encouragement to leave their rooms. These patients receive visits from family or friends on the average between once a week to once a month, and they do not very often begin conversations with others in the facility. They are generally able to communicate a message, although they often ramble or respond with moderate sense to questions. Additionally, this data describes the group to be agitated at times, but almost never tearful or complaining. A comparison of the individual responses in the pre and posttests and of their composite scores indicating general levels of functional ability reveals little change 41 C M e u JO f O < / » +J c n 4J S Q . -o c < o Q . f O 4 - > 0 3 O +-> c I / ) CO c u to +) c c u +-> 03 CL. 03 OO 0 3 c n| c 03 JZ o |x 0 3 II 4J +J 03 f~ O C31 r- 03 C 03 S- 03 05 - t ~ ~ SZ cyco o I +J +J • to to C D o c u • a. I — c / 3 | X I + ■ > • 03 to CD S- c u • CL. I — OO \X c o +-> to 03 3 CDI r^«d- to CO ,— CMOCT><^VOi— 00 CM 00 C T 3 ro I— CM I— 0 0 0 < — I— C M O O C M O O O l — CM • • • * • • • • • • • • • • • • • I I I I 4- I 4- I i4-4*4-l « 4- I I tovototO'^'si’toc'OLnrooo lo lo touOLOuntovotoco oooorororococOLOCMOCMro'so-corotD'ïJ'Oor^LO Lor^cT»r^CMr».Lor^tocT»i— tor^r—cOLOtOLO«^oo«;0- L o o t n o ' s J ' r ^ L O i — c o L o c M o r ^ ' ^ J 'r ^ o r o c o i — o u o CMLOCMtni— LOr^COOOr“ tOtOCOC3^C!OCMLOCOOOOCM CM CM CM CM CM CM CM CM CM CM CM LO LO to to ro cf uD I — cOo^CM*d-CM'!d"cr>CM LOVOtOtOLOlOtOtOtOLOLOtOtOtOVOLOtO tOUO CM CXDCM r^CM O Oi— toooootoror».r>N.ooi^r». cr> CO CO CM 00 to r— lo CM'ïJ'i— COCOC7>LOOCOCyii— CMC7>CM00'vflO •^•^•^J-LOr-rLOtOLOLDOLOCOCOOI^OOr^ CM CM CM 1 — CM CM CM CM CM CM § 4-> to O Q. cn c to . to ■ E f o I to to 4 -> +-> 0 3 s- a s to +-> o to to o to • 0 3 -M 4-S CU s- Ou O "O to cn 0 3 Ou .—. c c c c > to 0 3 > — >4-> o o o o **— to C to to C _ 3 Q. +-> > to o to to c o 4 -> 4 -> to o 0 3 o -a c 0 3 O Q_ 1 — <o 0 3 cu <c to 0 3 z: to 0 3 • 1 — c *T~ ''— ^ 0 3 c cn > v4 -> oc -o to s- 4 -> fC +J 4 -> L3 f — c s- c CL 0 3 "r- to c 0 3 0 3 to s- C to *r— E o 0 3 to 3 > to 0 3 S 4 - > 0 3 CL 0 3 0 3 "O to +J E CL p R34 - > > cn to E + j +J o « 3 0 3 S- « 3 n3 S- S- 3 0 3 C cn L o 4 -> O JC LU u j s : o Z C D I — O CDCÛ'=C«=CCO O «=C«=C2 :CL. 42 0 ) L O o cni ro C M 1 X sz r O + + + . c o to o cn to I z 4 -> r-. o to to ro 00 o o o 1 to D_ t> 0 C M C M s- *r- ro C L o L O o L O C M o C M -a | x 1 0 3 r~- to C O to s z u +J to z ; z C O o cn to I 0 3 L O o to L. Q to to C O ro D_ O O I C M r — C M cn to ro o o O •f~ 1 »r- 4 - > to C O to JO to <c o o_ 0 3 C O ro *0 X sz C O 00 r^. to <n c sr to C M o C O O to J= o 1 1 1 + ) 4 - > 0 > O S - ro sr o_ 3 z to C M cn to c JO 4- 0 ) ro O B I— to 4 - 3 o to o to to to ro C 3 0 o to (U 0 3 O Q • s- to D_ t/) C M C M r— o to ro +> O O O +J 1 — o to o 0 3 C i x L O C M o C M L O 4 -> 0 3 to 00 to «i- to 4 -> o to Q.D_ E o c z C M ■ s i ’ o L O O 1 - L O •s j- to L O o O O cn cn C O 0 3 L O C O cn o L O i- Q C L . O O C M ' to O O r>. C M to | X cn C M cn to C O to c >> ro o ro 4 -3 c *r- U o 4-) ro > ro < J to 4 - 3 4 -3 C >» c 4 -3 O o 3 0 3 U O E U_ Û- z : < 0 0 L U 4 3 as a result of the intervention. Although changes are minimal, individual scores indicate more decline than im provement in the areas of question. A T test was performed on the score showing greatest change, the patient's ability to give messages. A 1.05 T test was calculated, which was not significant, at the .05 level. Concluding questions answered by the staff in the posttest evaluated the patients on the whole to have declined slightly in mental altertness, physical health, and independence in the time following the pretest, but rated patients' moods to have remained the same. As in the patient assessment, subjects tested in the patient interview appear to be not significantly changed from the total group as a whole, and from the subjects participating in the pre/post patient interview. Table 1 presents the data with the average age declining slightly and other categories remaining relatively unchanged. Statistics of the responses of the patients in their interview are listed in Tables 4 and 5. According to this data, patients perceive their physical health to be better than average on the whole. In activity, patients report to be fairly satisfied with tlieir days, although they are spent predominantly in solitary activity, activities of daily living, or in body functions. Patients report social contacts to be low in frequency both from people at 44 <v as (A 4-> CO 0) to o a. -a c »o OL. <o 4-> to Q I *> s- C O J tx 3 oo O) D T ! |x « o 4-> ^ c / » Q o tn Q. z: E ! Q 0_ CO c 0 +J CO O) 3 01 r— o f — o CO I — CO I I I + LO L f 5 < ï - CO CM ^ LO 00 CO to to CT» C». to to to <j - to CM CM CM CM I — O o to CO CO I — to 1^ to CMO'«53"Oi— O r O r — O C M r o r > . O O C ^ r— CO I — " ( z f to r— I — I — CO CM CD lO r — CD • • • • • • • • • • • • • • + I I I I I r p I ++IIII CO^OOOCT»!— LDLOLnLOlOLOLOLOCOLOLOKj-LOtfLO O O O O O O C O ^ C 5 > I — CO CO Lf) I — cr* (O CO to I — I — to COI^CTiOi— COi— LOOCOtOCOOtor^ r— r— CM r— i— O O O O O O 0 0 O 0 0 O 0 0 O O O 0 0 O O t 0 O C T > O o O O O O O LO^I— 00 I — 'îJ-CM*îfCM*=d-^OOCMCMO CM CM CM CM CM CM CM CM c7>to«=i"ir)CT>»— r^r^tOLor^toi^r^totocor^rv-toi^ I — CMCMCMCMCMCMCMCMCMCMCMCMCMCMCM 0 0 0 0 0 0 ^ 1 — CM CD I — to I — r^tooooor^ioco tocy>cr»ocMOOtotoi— ooor^tor^i^ o o o o o o » - - o i ^ o ^ o r ^ > — CO 00 r-' CO CD cr> OCDOOOO'^r^CMCMr^iOOl-OCMO*— C7>r^COO CM CM CM CM CM CM CM CM c u fO »r— r- C O tn c • o <D r — E 4J C to -a c § s- <o 4-> O) <o d) -C g < 0 CD OC 3: i _ E 4J CL I to C ' - * * T “ • f * " QJ 4— 0.-C 4-» 00 < l ) » — E cn o I — o > o 3 "O CL to ( / ) CO ( / ) u C D ....... C (U c: c u C L .................. 4 - 3 t / ï ns ^ 5 3 O 0Û =c cu T- ( _ ) 4 -3 fS o _ * ( 5 4J • r — - r — O: C ' - * O r— 4-3 C L ) O O O ^ O* O to to ro a. E 3 4-3 O L * c^ to o) S- CD T- 4-^ I — • f — (/) to • Î — <0 > c cu 03 -o 4-3 M- 4- (O O 4-3 O -S o 4-3 to to C ^ « CU XJ b: 03 -r— jC 4- I — CO to to 2 CU 4-3 to CO CU 4-3 4-3 to to l | CU &- 5- 4- 4- O > * 4-3 4-3 to _ _ _ COtOtDZCQlJ-CQtOOO—J 4-3 tC E to s- Q. cu 03 E 03 C O x: O CM CO LO tor^COCTtCDi— CM CO 'd- LD to 00 CD CD 45 ( U c r i IX ^ XT c _ > t o o O CO Cl. X CD CL. CO TD g C 8 < _ > < d - O J X ) r O C o 4 - > to O ) ë «O' L O L O C \J t o O I — O O I I f I + <D O O O O O < j- CD CD O LO I I— C M I— I r + + lO LO LO LO LO CO <d" C 3 C 3 I— CD "<f- r - CD CD CD CD CD « — I CO r - t o CM CM CDCDaOOOOO CD CD C D CD CD CD CD CD CD CD I LO LO CM t o t o LO «0- C D r ^ r ^ c ^ r ^ (D CD CD CD CD CD CD t o CD CD CD CD CD CD CD CD CD CD tO t o «j- CD CO "d- O O O O O O O C O CD CD CD CD CD CD I CM I— r— r— r~ r— r— r— ' r— r— r— r— r—" CVI r-^ r~ r— r— î— r^LOi^tor^ ootocMcococM«5j-to c m o o c m o ■ — co cM cm cD to i C M C M C M C M C M C M C M L O r v .i— LO CD O O O O O O O I ^ CD CD CD r - CD CD CD CD CD CD CD r-. L O L O C O rv. f C M C M L O C D O O O O O O t O CD CD CD CD CD CD O (D CD CD 1^ LO CM CO C D C D C D C D C D C D C D C O L O CD CD CD CD i C M g C U % B to o 4J 4 - 3 o 4 - 3 c C. c o to 4 - 3 C U 4 - 3 0 3 s- C U c to c m c u c to E C 7 > B c 0 3 c u c cn1 c C 0 3 0 3 c c m to C U C 0-. cn to S L . o c B p c to c B o c 0 3 > c u c X C U O "O o O 4 - 3 & _ •r“ C D 4 - 5 S — -r- c m > B t — X S r — to *r- C s- to t O C L*r— X Ü u to to C L *i- X: c C U ‘1 — c X S I— & _ 4 - 3 3 T3 c u & _ C U C L > 4 - 3 & _ c u C L > 4 -3 to O C - » 4 - 3 o to D to to (U O) C U s- D c O ■a C U & _ 3 c o x ; C - » & _ ra C U o _ i m S C Û. _J C O c C L 1 — C O L U Z C L I— C O LU Z o to c u C c *o to 3 0 3 X : a . o C X: O c y C 3 4 -3 C U o 5 C p 4 -3 >-,4-3 ro O- •f— to & _ C (O cr to XJ 4 -3 X : i~ s f C S C U (U C C J c u C D to xs c u o c - C U -o & _ O-XJ f O & _ •r— ' 4 - 3 f — 0 3 c u c c u < = c u 4 - 3 to 4 -3 3 XT O f - f O X: o x : to Q 3 z : u_ C L C D 3 Q _ _u , * * . , « . « . C M C O ' = d - L O to CO C 3 S C D C M C M C M C M C M C M C M C M C M C O C O A6J L O C Ü jD f O ^45 • I — t / > r— CD • r — +J ■ = C t / i o I— Q. 0 3 B Y 1— f O 4 - ) U O J E t Ll. 4- m O M- > 00 S “ O ) O ) 5- 4-> O C U w S E « / ) +J o m S ^ o c O * 1 — o cr X «3 CO CO < N J Lf) 4-> O O CL. OO CO CO CO o IX Q_ ■o CO CO <M z: +-> C M C M LO CM S- o O- CO CO C M 00 S X CO L O CD o L O o X fO o CO C M LO 4-> O O o. OO o L O LO CO CO CO (a 4-> o C M C M L O LO i- ^ CL CO CO C M C M 00 o CM Ix LO LO f O +-> +-> ÜJ 47 St. Theresa's and from visitors from the outside. However, patients say that they are satisfied in respect to the possible contacts at the facility, but that they wish socialization would increase from outside visitors. Emo tionally , patients express moderate satisfaction with their lives, although they are sometimes lonely and they occasion ally feel that there is no point in living. Additionally, they say that getting older is worse than they thought it would be and that earlier periods of their lives were much happier. Scores in the Mental Status Questionnaire re flected the tested group to have fair mental ability. In assessing their environment, patients indicate very little difficulty in finding their way around the building, and they consider the facility a somewhat pleasant place in which they can be alone on occasion. The dining room and lobby are reported to be areas most commonly fre quented, although the hall, nursing station, patiov laundry and bedroom are also mentioned. Posttest results of the patient interview show little difference from their pretest companion questions. Scores with the greatest noticeable differences were given a T test, as presented in Table 6, and indicate no sig nificance at the established .05 level. Although scores in the interview are not significant, differences in the pre test and posttest answers are mostly in a direction 48 CO CO CO CO CO c n CO 4 - > o o CO cn CO +J cn CO < L > C 4-> O +J •r— c/) 4-5 O CO Q- Cr Q- |X CO o CsJ o CsJ 4-> cn to Csl CsJ CsJ a. 00 r^ Q O If) CO o Q_ 4-5 CO M- < D CsJ Csl ÛL. 4 - 5 cn C£3 cn CO ( / > CO 4-5 CO O) CO •o 4-5 cn C l cn 4-5 4-5 g 4-5 CO O o cn Of CO CsJ un 49 indicating slightly positive qualitative movement. When asked directly about the environmental change in the posttest, 9 out of 14 patient respondents indicated an awareness of a change although only 7 could pinpoint it to the environment. Six out of 8 expressed a positive opinion about the intervention. Although the dining room, lobby, and bedroom were listed by patients in the posttest as places where they most liked to spend their time, the hall, nurses* station, and laundry were not mentioned as they had been in the pretest. While 9 in the pretest mentioned items in the environment which they would like to change, no mention was made of such areas in the posttest. Family questionnaires, as detailed in Table 7, reveal a group of subjects who visit their relative at least once a week and are fairly satisfied with this fre quency. Additionally, the surveyed relatives consider St. Theresa*s a somewhat pleasant place, where the facility is trying fairly hard to give good patient care. In express ing their views in general on nursing homes and their patients, the families disagree that nursing homes should be run more like a hospital, and they also disagree that people who live in nursing homes are too confused to under stand what is going on around them. Families describe theii impressions of St. Theresa's to be positive, on the whole. However, relatives responding in both pre and posttests 50 r ~ . < u -O f O h- CU If) o O o LO O o Ol o CsJ O LO 1 t 1 1 1 1 , C |x t o 1 + + 1 + X: (_) CD o O o o CD o 1 1 1 1 1 1 CM CM CM CM CM z 00 Co CO Ms 00 4-5 If) to LO lo 00 CO 1 1 1 1 1 1 to to O Q S- o_ (/) (O Cl O O LO o O St LO o LO LO CO CM CO to •O Ix 1 1 1 1 1 1 0) CsJ CO CM x: o 4-5 CO 03 z CD o o O O CD o 1 1 1 1 1 1 4-5 s: CsJ CM CM CM CM (O O) 4-5 4-5 ^N. CO h - s . to (U sd- LO -d* CO CO CO 1 1 1 1 1 1 o s - o CL CL c/3 -o C If) O LO o to to ta o CO LO CM CM 00 |X 1 1 1 1 1 1 a> Cvl CO CM < — S- O- 0> c 03 LO CO LO M- o O o o o o o , C o CM o O O CO X to fO XT + + + + + + + 4-5 (_) (O O z CD o o o o CD o Ms CM CM LO o Ef CsJ CM CM CM CM CM ta c 4-5 00 r~- Ms CO Ms 00 O O o O o •d- c CO Lf) LO to LO CO M. 00 to o C 3 o t o Cl CO 4-5 4-5 CO O c u K- o o LO O o St LO O O o O o o 3 o If) to CO CM 00 LO O o o o o O' | x CsJ CO CM CM >) a z LO LO LO If) CO CO CO CO LO CO CO CD 1 ta *0- «d- •d* >d- 'd- «d- Ll. M- o c u LO CD CM CM CO LO O o o o I >> S - Q LO «d- LO 00 M- LO Lf) s- CL C/5 «3 a a 3 (/) |X to CD O CM LO M. LO LO O o o o CD CM to CM O M. CO O o o o 1 r— 1 — CO CM p — r— 1 — to • c u c CD 4-5 -C3 C -p- o c C 4-5 C U to o 4-5 S - . t o CD O to to 0) to ta CL XT 4-5 C to C < 3 c u CD s - c u CL > 4J 4-5 c •r— C U t o 1 — tj- S- C (U s- 3 c o S - o to 4-5 c u > i to C Q. ta C L 1 — tyO w z O CL I— z o o < to (U 3 CM CO •d- LO to Ms C O CD czr 51 ■o a > 4 - > c 5 e u JD C C S 4 - > O O CL. co i n « 3 CL X < T 3 X a i c o o o IX o o o o co tn r o m ro CM 00 00 o CD LD LO O O Q 0_ CO O LO +-> CO ro O O CO CO O O co co o o CM o CM LO CM CM CL. CO e n cn t/) + - > ■o û. T- t s OO LU en 4_> o -, ■ a Q_ o c + - > co co < 3 - C D 3 CD O 52 report their initial impressions to be slightly higher than their posttest views of the facility. Areas needing change, according to the families, are personnel and management (doctor availability, more staff, higher salaries, new administration, professional staff, better training, and increased communication), treatment (handling of personal clothes, etc.), supplies (food, bedding, and linens), and environment (patient division into coherent and incoherent, redecoration, cleanliness, and activity room area placement). As listed in Table 7, personnel, treatment, and supplies are highest in concern. More frequently mentioned than painting and redecoration under environment is cleanliness. Posttest responses in the family questionnaire are not visibly different from those in the pretest. A T test was used on the item with greatest change, the relatives* impressions of the facility. For all subjects in the groups tested, the T score was 1.04. Scores of respondents being represented in both tests had a higher T score of 1.73, but neither score is significant at the .05 level. Of the 21 subjects in the family posttest, 14 in dicate that they are aware of a change which has taken place, although some are not able to identify the specific redecoration which has occurred. These subjects describe the changes in more general terms as being cleaner, more 53 cheerful and pleasant, and in better repair. Approval of the change is rated from 16 family subjects, with the re maining noting no opinion. Families also report no change in their relative's moods or alertness within the six months of redecoration and say they have noticed no apparent response of the patient to the environmental intervention. Additionally, subjects show slight support for the opinion that the redecoration does not facilitate the patient find ing his way around the building. Staff questionnaire scores are presented in Table 8. Generally, the staff express that they consider their job to be interesting, challenging, worthwhile, and of educa tional value. Pretest scores show agreement, whereas the posttest results indicate disagreement on the opinion that after one has worked at St. Theresa's one pretty much knows what there is to know about old people. The staff, for the most part, disagree in both questionnaires, however, about the patients being too confused to understand what is going on around them and that the nursing home should be run more like a hospital with fewer parties and activities. As can be seen in Table 8, five questions have a somewhat larger numerical difference in the pretest and posttest scores. A T test was performed with this data, and results are presented in Table 9. NO T scores are sig nificant at the .05 level. 54 CM CM 00 UD CM CM LO VO o ^ CO O « = ! • c n |x « J= ( _ ) c r » c r » C T » C T > C T » c r » C T > c r > < y » r— cocor>- o*=i-oco 0»-CT»CT» V 0 O " 5 J ’ L0ir) +J o d Ol. CO t x . 00 o c r» 0 » . O CO CO o 00 CO VO r» - o r^ C O L O CO CM CM CO CO CO c r» CT» CT» CT» CT» c r» CT» CT» CT» I — CO ro CO CM r - * - CO r » - 00 o I— o LO S - Q C L . CO « 5 J - O CO CM VO 00 LO r » - r » - <rOCOCMLO r^CMVDLD o_ X XJ CM CO CM CM CO CM r— r — LO 00 r— O CM CM CO LO CD LO O O O c r» V O L O CO CT* 00 o_ o cr»cr»cr»cT»cr»cr»cr»cT»cT»cor^LO o CO r— cocor^o«=i-ocoo r^cr»cr»voo^LOLO o Q Cl. CO VO LO r> LO JO «3 coococovoocr» o r^or^coLOOCMvo C T » o cr» r^ o 00 |X CO CO CO CO CM CM =3 CO" 4- ocoooococj^oocr» COCMCOCOCOCMCMCMCM •P CO 4- 00 r^ VO C T » r^ VO o c r » 00 r » - VO CM CO CM O VO S - Q 0_ CO O > « ! } • CO « = * - o o o r^ L O o C M I — T — LO r^ C T * 00 ^ O O X CM CO CM CM CM CM o > ■ a CO "O C L Cl - a O -P Q D_ C M c o ^ L O v o r ^ o o c r > o CM 55 cr» c .c CO CO 4-> ra to CD r t j Q +J to CU O &_ O l. X. m c & _ E Q. O CT» E CU to 4- CO 4- 4- Q O 4-> to to e Si O fO o cu CO s_ CD 1 — OS CO 4 - ) to CU CM LO fO CO 1 — rv LO o CM 1 — ' — 4-» to O a. a. o CO CM CO CO z . z z CO 00 o o CT> 00 00 CO CO CO CM CO CO CO m CO CM to CM CO CO CM CU X3 0> CL to o 3 cu 4- to CL E -P O -a O a. to JD o o o O o x: + - > -p 3 tu 3 c O to J a C ■ o o J3 4-Î ro E to E CU •r- E E 2 O ro O +4 JO (U E fO O O ■P _ _ l X Û- DC X) to cu 3 CO- 1 — CM ro 'O ' LO 56 In the posttest of the staff questionnaire, ques tions directed toward assessment of the environmental change and its impact reveal approval of all eight respond ents for the redecoration. Six of the eight evaluate the patients* responses as positive, with one staff person re porting no apparent response and one with no opinion. Three out of five opinions expressed indicate that the subjects do not feel that the changes make it easier for the patients to find their way around the building. Table 10 compares the responses of similar ques tions asked the patients, staff, and family. All three groups generally report liking the changes, although the patients* mean scores indicate a weaker agreement. Six each of family and staff subjects report that patients have appeared to respond positively to the intervention. Nine family subjects record no apparent response in this same item, as does one staff member. Additionally, both family and staff subjects indicate that they do not necessarily feel the redecoration to be of importance in helping the patients to find their way around the building. 57 z 00 l I -M Q co C co 1 1 ( U 4 - > f O OL. LO |X CM 1 1 4- 4- <o +J z CO LO CO 2 XJ 4- o co LO E < 0 Q LO >, e u 4 - 3 CO r— 4 - 3 CO T- C E H - , f Ü Uu 4 - 3 o c r i o C |X o CM co o c ( U r — O « T — 4 - 3 O) < / ) < t S r — Q J C L . JD CO f l O C XJ t — OC z co LO co Q. < 0 CO ( U ( U ÛC E " 1 — 4 - f l O >, o « — 1— O C r — Q o LO C CO c o E o * 1— as co 4 - 3 Ü L . • 1— t o E 0 ) fO 3 o o CM CLcy c o CM CO E \X o 1 — CM 1 — o o- ( U C J 3 ( U c c o ra e z J C . o a a. P ( U s - f— co ^ r— — fO 4-3 2 3 C c O eu XJ o >0 T - c 4 - 3 - 1 — 4 - 3 o ns tx . CO Q O - ( U 3 c r t— CM co 58 CHAPTER V SUMMARY The purpose of this study was to examine the changes occurring as a result of redecoration of a skilled nursing facility. Of specific concern was the nursing home patient's mental, emotional, physical, activity, and social levels of functioning. The researcher suspected any changes of the patients observed after the environmental change to be due directly to the milieu or indirectly to the response of families or staff in reaction to the altered surround ings. Consequently, the impressions of the family and staff toward the nursing home, its patients, and the redecoration were also studied. other researchers have previously demonstrated the importance of the environment to the functioning of its inhabitants. An optimum level of stimulation from the en vironment has been found to be essential in normal brain development, regardless of the age of the individual. Too much or too little stimulation, according to this premise, may have serious effects. Experiments in sensory deprivation, for example, have caused symptoms similar to characteristics of senility 59 in healthy subjects by exposing them to sterile, unstimu- lating surroundings. Poor vision and lack of mobility com mon to nursing home patients compounded with bland, monoto nous surroundings typical of most nursing home appearances may be replicating these experimental conditions causing patients to be a high risk group for sensory deprivation. Limited studies have experimented with the thera peutic use of sensory stimulation in the environment to treat people with psychotic-like syitptoms. Environmental psychologists theorize the importance of a stimulating milieu to nursing home patients, but at present no scien tific work has; yet proven the value of such a surrounding nor have essential decor components been identified which should be included in nursing home decorations. The independent variable for this study was en vironmental stimulation produced through redecoration of a nursing home according to environmental psychologists theories. The dependent variables expected to change were levels of the patients * functioning, the attitude of the staff toward the nursing home and their job, and the relatives' frequency of visits and attitude toward nursing home patients and, specifically, to St. Theresa's. The subjects chosen for this experiment were all patients, family, and staff of St. Theresa's who were available for pretesting and all those who remained from 60 the group pretested for posttesting. Of the 67 patients assessed by the staff in the pretest, 16 completed the post- test . Likewise, patients identified by the administration as being able to answer interview questions declined in number in the posttest: Of 27 patients being interviewed in the pretest, 15 actually completed the two tests. Similarly, 21 of 45 families who were pretested and 9 of 32 staff pretested actually completed the posttest. Instruments used for testing the patients were an interview given by the experimenter to the patient and a written assessment of the patient administered to the nursing staff. Family attitudes were examined using a mailed questionnaire for pre and posttests. Additionally, a questionnaire given to the staff was. used to measure staff opinions under observation. The first hypothesis proposed for examination by this Study was that there would be a significant change in the patients* level of mental, emotional, physical, activity, and social functioning as measured in the patient interview and the staff assessment. Although the score indicating the patients * ability to give messages went up numerically in the posttest, none of the items showed a significant statistical difference in the pretest and the posttest of the patient assessment. Additionally, staff 61 assessed the patients* alertness, physical health, inde pendence, and moods to have remained about the same in the posttest as prior to the intervention. Similarly, no scores were satistically significant in noting changes taking place in pre and posttests of the patient inter view. Scores, however, revealed slight positive change in posttests, and the patients' health coirç>arison, number of visitors from within the facility, close friends at St. Theresa's, and the patients' comparison of life to earlier times indicated a considerable improvement, although not significant. On this basis, the research hypothesis was rejected; No change in the patients* functional ability was observed from the pre to the posttesting. The next hypothesis proposed that the patient would find the nursing home a more pleasant place and would fre quent the redecorated areas more often after the interven tion. Scores in the patient interview measuring this hypothesis showed no difference in the pretest and post- test responses. The dining room and front lobby still re mained popular places, although the hall, nurses* station, and laundry were no longer mentioned. In summary, the null hypothesis was accepted that the redecoration made no dif ference in the patients' perception of the facility as a pleasant place, nor in the use of its space, although the patients said, for the most part, that they liked the change j5 l2 The staff's attitude toward their job and toward the patients they serve was expected to change in the third hypothesis. Five questions appeared to be different in pre and posttests in this area : staff rated patients as being more confused and the amount that they could learn on their job as reportedly declined in the posttests, whereas staff indicated that they were less likely to be lieve that they know what there is to know about old people, the home should be run like a hospital, and the nursing home job is dull. None of the T tests were sig nificant, however, so the research hypothesis was rejected that the decoration changed the staff's attitude toward their job and the patients. The fourth hypothesis involved both the staff and the relatives: it was predicted that both groups would report satisfaction with the environmental changes in the posttest. Of 16 family members and 8 staff reporting, all stated approval of the intervention. Consequently, this research hypothesis was accepted that the families and staff did like the changes. The next hypothesis stated that both families and staff would report observing improvements in the patients in the period following the intervention. In assessing alertness and moods, both groups rated the patients to have remained about the same* The score evaluating the overall 63 response of the patient, however, was given a positive vote by the staff, although families on the average rated this area as remaining about the same. When compiling these results into summary findings, the hypothesis was rejected that the patients were reported to have improved following the intervention. In spite of this rejection, the data indicates that there may still have been some change which has not been included in the final conclu sions . The sixth hypothesis predicted that the frequency of family visits would increase following the redecoration. No change was evident in either the patients' or the families' reports of how often the families visit, so the null hypothesis was accepted that there was no change in frequency of family visits. The families' impressions of nursing home patients in general were expected to improve in the seventh hypothesis. In actuality, there was almost no change in questions measuring this speculation, so the null hypothesis was accepted that the families maintained the visiting pattern with nursing home patients throughout the pre and posttests, regardless of the intervention. The last hypothesis stated that the families' post test scores would indicate an improvement in their attitudes of St. Theresa's and its care of their relative. 64 No change was found in scores assessing this hypothesis, so the prediction was rejected that the relative's im pressions would change after the redecoration. Conclusions Relative to the objectives of this study, the analysis of data, in sum, indicated no significant changes from the pre to posttests following the environmental intervention. Although not significant, some questions in the patient interview and the staff questionnaire showed the greatest inclination to change. Even though no effects of the redecoration as measured were found, many of the patients, staff, and family stated that they liked the changes. In the opinion of the researcher, this data in dicated that the decoration of a nursing home using stimulating environmental cues was not instrumental in achieving therapeutic effects on the patients, staff, or family. The intervention's function was merely of cosmetic value in making the facility appear to be in better repair. Recommendations Perhaps data obtained through this study was affected by the problems encountered in implementation. Because the time required to complete the redecoration was unexpectedly lengthy, with many false starts and stops. 65 there was a high mortality rate of subjects. The small sample made statistical significance difficult. This problem may be resolved in future studies by using inter ventions which are carefully defined and which are capable of being executed in a minimal length of time. Problems with the testing instruments in this study emphasized the difficulty of operationalizing en vironmental changes. In the opinion of the researcher, test questions used in the patient interview often did not elicit the response for which the question was designed. Many of the replies given by patients were given with ex ceptions or with prefaces indicating an effort to adjust to an unpleasant situation. One suggestion for further research is to develop an environmental impact testing instrument for older people which has validity. Rather than the direct method used in this study, a projective test should be considered for its use in getting behind different pretests through which questions are answered. Additionally, behavior mapping or other observational techniques could provide more objective measures. A related problem of the testing situation was that many of the subjects lacked confidence in the experi menter in spite of the confidentiality which was assured. Many of the patients completed their interviews with, "I did not say anything wrong, did I?” Similarly, some of 66 the family members admitted not participating in the ex periment fearing that information would get back to the administration and that retaliation would be vented on their relative. This hypothesized lack of confidence of the sub jects could also be evidence of a concern with social desirability. Fearing that answers may not be as the ex perimenter desired, or as the other subjects responded, subjects may have been hesitant to respond and to provide valid information. The answers of both patients and families saying that they noticed a change, but not being able to identify it specifically, may also be an indica tion of social desirability concern. Subjects may have thought that because the experimenter asked them if they noticed a change, they were expected to and they, conse quently, responded positively without actually having noticed the change. In the patient assessment, questions asked the staff were lengthy and appeared to be demanding of time, especially for staff members of little education. Addi tionally, respondents were hesitant to venture an opinion when the administration was not backing the research with firm encouragement for the questionnaires to be completed. More brief, simplified questionnaires should be used in future studies of this kind. 67 Another problem encountered was in working around language barriers. Sending Spanish questionnaires to family members designated by the administration as Spanish speaking caused resentment of the subjects. Some families informed the researcher that they spoke English, and they intimated that they considered it an insult for a Spanish questionnaire to be given to them. On the other hand, many patients were Spanish and could not be interviewed by the researcher because they could not understand English Before performing such an experiment, it is advisable that the group of subjects be accessible with some language with which the experimenter is familiar. Additionally, the testing in this study involved measurement over several environmental changes and pro vided a general indication of the patients* responses to the environment as a whole. Perhaps if changes were made, one at a time, and if patients* responses to specific changes, such as color or visual cues, were operationalized independently, a more accurate assessment of the environ mental impact could be made, and the changes creating the desired response could be identified. Lastly, the groups of subjects had no control group with which to compare the experimental group. Similar subjects, under constant conditions, may naturally decline in functional ability over time, for instance, and the lack 68 of this experiment to produce significant change results may actually demonstrate an improvement in the subjects following the environmental intervention. Replication of this study, using matching subjects experiencing no environ:- mental change would provide information on the change which would normally be expected in this type of people over time. Such a study would serve as a control and provide data with which this study could then be compared. Although no significant results were found through this study, more research in this area could unveil dra matic evidence of the therapeutic value of environment on nursing home patients. Limited results gained through this study, however, would tend to support the opposite; that the milieu plays a more passive role in its inter action with nursing home patients. If a stimulating en vironment is important to people who live in it, then this discovery would revolutionize the nursing home industry and other fields as well. At the present, however, more work needs to be done in this field. 69 BIBLIOGRAPHY Bower, H. M. Sensory stimulation and the treatment of senile dementia. The Medical Journal of Australia. June 3, 1967, 1113-1119. Brody, E. M. The human treatment system of the Weiss Institute. Paper prepared for the Symposium on the Weiss Institute and presented at the Annual Scientific Meeting of the Gerontological Society, New York, October 19 76. Brown, J. Stimulation— A corollary to physical care. American Journal of Nursing, April 1976, 578-581. Burnside, I. The special senses and sensory deprivation. Irene Burnside (Ed.), Nursing and the aged. New York; McGraw-Hill Co., 1976, 380-395. Buseck, S. A. Visual status of the elderly. Journal of Gerontological Nursing, September-October 1976, 2, 34-39. Canter, D. & Stringer, Peter. Environmental interaction. New York ; International Universities Press, Inc., 1975. Carp, F. M. Housing and living environments of older people. Robert Binstock and Ethel Shanas (Eds.), Handbook of aging and the social sciences. New York; Van Nostrand Reinhold Co., 1976, 244-271. Chaney, P. Decor reflects environmental psychology. Hospitals, June 1, 1973, £7, 61-66. Corso, J. F. The experimental psychology of sensory be havior . New York: Holt, Rinehart, and Winston, 196 7. Cummins, R. A., Walsh, R. N., Budtz-Olsen, Otto, Konstantinos, T., & Korsfall, C. R. Environmentally- induced changes in the brains of elderly rats. Nature, June 29, 1973, 243, 516-518. 71 Downs, F. Bed rest and sensory disturbances. American Journal of Nursing, March 1974, 7£, 434-438. Fitch, J. M. Experimental bases for aesthetic decision. Harold Proshansky, William Ittelson, & Leanne Rivlin (Eds.), Environmental psychology. New York: Holt, Rinehart, and Winston, Inc., 1967, 76-84. Fowler, Roy, & Fordyce, W. Adapting care for the brain damaged patient. American Journal of Nursing, November 1972, 2056-2059. Gilbert, J. G. Age changes in color matching. Journal of Gerontology, 1957, 12, 210-215. Hayward, G. Psychological factors in the use of light and lighting in buildings, Jon Lang, Charles Burnette, Walter Moleski, & David Vachon fEds.), Designing for human behavior . Pennsylvania : Dowden Hutchingon and Ross, Inc., 1974, 120-129. Hebb, H. Discussion : Sensory deprivation; Facts in search of a theory. Journal of Nervous Mental Dis orders , 1954, 132, 40. Howell, S. C. Familiarity and complexity in perceptual recognition. Journal of Gerontology, 1972, 27(31, 36 4- 371. Jones, J. Deprivation and existence or stimulation and life; Our choices for the elderly. Journal of Gérontologieal Nursing, March/April 1976, £(2), 17-20. Kahn, R. L. Brief objective measures for the determination of mental status in the aged. American Journal of Psychiatry, 1960, 117, 326-328. Kleban, M. H., & Agger, Samuel. Staff and relative evalua tions of traditional and prosthetic settings. Paper presented at the Gerontological Society, New York, October 1976. Lawton, M. P. The human being and the institutional building. Jon Lang, Charles Burnette, Walter Moleski, David Vachon (Eds.), Designing for human behavior. Pennsylvania: Dowden, Hu tchin g ton and Ros s, Inc., 19 74, 60-71. 72 Lieberman, M. Institutionalization of the aged: Effects on behavior. Journal of Gerontology, July 1969, 24 (3) , 330-338. Liderman, H., Mendelson, J., Wexler, D., & Solomon, P. Sensory deprivation. Archives of Internal Medicine. February 1958, 101, Lilly, M. Mental effects of reduction of ordinary levels of physical stimuli on intact, healthy persons. Psychiatric Research Reports, June 1956, Maslow, A. H., & Mintz, N. L. Effects of esthetic surroundings; Initial effects of three esthetic con ditions upon perceiving "energy" and "well-being" in faces. The Journal of Psychology, 1956, ££, 247-254. Mead, G. H. Mind, self, and society. Chicago; University of Chicago Press, 1934. Moos, R. H., Harris, R. , & Schonborn, K. Psychiatric patients and staff reaction to their physical environ ment. Journal of Clinical Psychology, 1969, 25, 322- 324. Neugarten, B., Havinghurst, R., & Tobin, S. The measure ments of life satisfaction. Journal of Gerontology, 1961, 16, 134-143. Necomer, R., & Caggiano, M. Environment and the aged person. Irene Burnside (Ed.), Nursing and the aged. New York; McGraw-Hill Book Co., 1976, 559-572. Pastalan, L. Privacy as an expression of human territori ality. L. Pastalan,and D, Carson (Eds.), Spatial behavior of older people. Ann Arbor, Michigan ; University of Michigan Press, 1970. Pastalan, L. How the elderly negotiate their environment. T. Byerts (Ed.), Housing and environment for the elderly. Washington, D.Ç.; The Gerontological Society, 1973. Pincus, A. The definition and measurement of the institu tional environment in homes for the aged. Paper pre sented at the 20th Annual Meeting of the Gerontological Society, St. Petersburg, Florida, November 9, 1967. Printed in The Gerontologist, 1968, 8(3), 207-210. 73 Plutchik, R. , Conte, H., Lieberman, M., Bakur, M., Gross man, J., & Lehrman, N. Reliability and validity of a scale for assessing the functioning of geriatric patients. Journal of American Geriatrics Society, June 1970, 1£(6), 491-499. Riege, W. Environmental influences on brain and behavior of year-old rats. Developmental Psychobiology, 1971, 4 (2) , 157-167. Schooler, K. K. The relationship between social inter action and morale of the elderly as a function of environmental characteristics. The Gerontologist, 1969, 9, 25-29. Schultz, D. Sensory restriction: Effects on behavior. New York : Academic Press, 1965. Schwartz, A. S. A transactional view of the aging process. Arthur S. Schwartz,’ and Ivan Mensch (Eds.) , Professional oblieations and approaches to the aged. Springfield, Illinois : Charles C. Thomas , 1974, 5-29 . Segall, M., Campbell, D., and Herskovits, M. The in fluence of culture on visual perception. Indianapolis : Bobbs-Merrill Company, Inc., 1966. Snyder, L. H. The environmental challenge and the aging individual. Council of Planning Librarians, Exchange Bibliography #254, Snyder, L. H. Environmental changes for socialization. Journal of Nursing Administration, January 1978, 44-50. Snyder, L. H., Pyrek, J., & Smith, K. C. Vision and mental function of the elderly. The Gerontologist, 19 76, 16(6) 491-495. Solomon, P., Liederman, P., Mendelson, J., & Wexler, D. Sensory deprivation. American Journal of Psychiatry, October 1957, 114, 357-363. Sommer, R. Personal space. New York : Prentice-Hall, 1969. Walker, J;, &Hertzog, C. Aging, brain function, and be havior. Diana Woodruff and James Birren (Eds.), Aging, New York: D. Van Nostrand Co., 19 75, 152-178. 74 Wapner, S., Cohen, S., & Kaplan, B, Experiehcing the environment. New York : Plenum Press , 19 76 . White, R. Excerpts from motivation reconsidered: The concept of competence. Harold Proshansky, William Ittelson, and Leanne Rivlin (Eds.), Environmental Psychology.V New York ; Holt, Rinehart, and Winston, Inc., 1967, 125-134. Wohlwill, J. The physical environment: A problem for a psychology of stimulation. Journal of Social Issues, 1966, 22 (4) , 29-37. Wood, M. Clinical sensory deprivation: A comparative study of patients in single care and two-bed rooms. Journal of Nursing Administration, December 1977, 28-32, Zubek, J. P. (Ed.) Sensory deprivation : Fifteen years of research. New York: Appleton-Century Crofts, 1969. Zuckerman, M. Theoretical formulations : I. J. P. Zubeck (Ed.), Sensory deprivation: Fifteen years of research. New York; Appleton-Century Crofts, 1969, 407—432. 75 APPENDIXES 76 APPENDIX A PATIENT ASSESSMENT— PRETEST 77 APPENDIX A PATIENT ASSESSMENT--PRETEST Directions: Please circle the appropriate number at the right that best describes the patient. Circle ONLY ONE number per question and leave NO question blank. Some questions may not concern the patient or you may not know the answer. In either case, circle number 8 on the answer sheet. This form looks long, but it will only take a few minutes to answer. Thanks. 1. Bathing/dressing: Dependent-patient needs help with everything. . . . . . . . 1 Needs a little help ................ 2 Independent-patient does everything for himself ........ 3 Does not apply, don't know . . . . . . . . . . ......... 8 2. Brushing teeth : Dependent-patient needs complete h e l p . . . 1 Needs a little help ........ 2 Independent-patient does for himself . . . . . . . . . . . 3 Does not apply, don't know . ......... 8 3. Unassisted grooming: Almost always s l o p p y .................. 1 Sometimes s l o p p y ......... 2 Usually neat, appropriate . . . . . . . . . ........... 3 Does not apply, don't know .............. 8 4. Elimination: Incontinent of urine/feces . ............. . . . . . 1 Continent if reminded or taken to bathroom . . . . . . . . 2 Continent . ........ 3 Don't know ........... 8 5. Eating: Spoon fed or tube fed .................. 1 Needs some assistance or supervision . . . . . . . . . . . 2 Independent-1akes care of himself ........ 3 Don't know ..................... 8 78 APPENDIX A (C onf d .) 6. Transfer ability: Bedfast-needs help in turning, etc. .............. 1 Needs help getting into a chair ............. . 2 Able to get in and out of bed without h e l p ........... 3 Don’t know . . ............. 8 7. Patient keeps his own room and belongings in excellent order: Hardly ever--in spite of help, room is usually a mess . . . 1 Sometimes— room is occasionally sloppy, needs help . . . . 2 Almost always--keeps room in excellent order .......... 3 Does not apply, don't know ........... . 8 8. Vision at best, including glasses, if needed: Extremely poor or blind . . . . .................. 1 Somewhat impaired, even with glasses ............. 2 Apparently normal ........ 3 Don't know ........ 8 9. Hearing at best, including aid, if needed: Extremely poor or deaf ...... . . . . . . . . . . . . . 1 Somewhat impaired, even with an a i d ............... 2 Apparently normal ............................. 3 Don't know ............. 8 10. Patient remembers: Both recent as well as long ago e v e n t s .............. . 1 Recent events, but not long ago . . . . . . ........... 2 Long ago events, but not recent ........ 3 Neither recent nor long ago events ......... 4 Does not apply, don't k n o w ....................... . . 8 11. Patient knows where he is : Always--is hardly ever lost in a familiar a r e a ........ 1 Some times— occasionally needs help .................. 2 Hardly ever— is frequently lost, a wanderer . ......... 3 Does not apply, don't k n o w ............. 8 12. Responds to own name: Almost never responds . ........ 1 Sometimes responds . . . . . . ................ 2 Almost always responds . ................ 3 Don't know ................... 8 13l APPENDIX A (C ont'd.) 13. Knows the names of: None of the s t a f f .................................. 1 Only one staff members .................. . . . . . 2 Several staff members ........ 3 Does not apply, don't know . . . . . ................. 8 14. During the day, the patient Naps most of the day ............. 1 Often naps ...... 2 Sometimes n a p s ............. 3 Don't know . . . . . . . . . . . . . . . . . . ........ 8 15. Joins in group social activities: Almost never . . . . . . . ...... . ........ 1 Sometimes...... ........................... . . . 2 Often ....................... . . 3 Does not apply, don't know ........... 8 16. Has hobbies, engages in them: Almost never ............. 1 Sometimes ..................... . . . . . . 2 Often . . . . . . . . . . . . . . .. ............. 3 Does not apply, don't know .............. 8 17. Patient reads newspapers, books, etc.: Almost never . . . . . . . . . . . . . . ... ......... 1 Sometimes ........... 2 Often . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Does not apply, don't k n o w ................ 8 18. Resident travels around the nursing home; Not at all— insists on remaining in his room . ......... 1 With some help and encouragement..................... 2 Frequently on his own .......... 3 Does not apply, don't k n o w ........ ................ 8 19. Receives visits from friends/re1atives: Daily .................. 1 At least once a w e e k ............ 2 At least once a m o n t h ........... 3 Less often ................................ 4 Don't k n o w .......... 8 20. Leaves institution for visits with family/friends : Almost never . ............. 1 Occasionally . ............................. . 2 Often ...... . . . . . . . . . . . . . . . . . . . . . . 3 Don't know ......... 8 80 APPENDIX A (C ont'd.) 21. Resident is willing to do things asked of him: Almost n e v e r ........................ 1 Sometimes . . . . . . ............................ 2 Often ......... 3 Does not apply, don't k n o w ......... 8 22. Voluntarily helps other residents: Almost never ........ 1 Sometimes ....... 2 Often ........ 3 Does not apply, don't know . ............. 8 23. Ability to give a message (speaking, writing, gesturing, etc.): Almost never understood . ........ 1 Sometimes understood ............. 2 Almost always understood . . . . . ............ . . . . 3 Does not apply, don't know ..................... 8 24. Begins conversation with others: Almost never ........ 1 Sometimes . . . . . .............................. 2 O f t e n ......... 3 Does not apply, don't know . . . . . . . 8 25. Answers a question or instruction sensibly: Almost always ........ 1 Often, but rambles or doesn't stick to the point ....... 2 Sometimes— ^needs simple instructions . . . . . . . . . . . 3 Hardly ever— cannot respond sensibly, does not respond, or responds with nonsense . . . . . . . . . . 4 26. Has made friends on the floor: . . . . . . Has not friends . . . . . . .......... . . . . . . . .1 Has just one friend ........ 2 Has several friends . . . . . . . . . . ........ 3 Does not apply, don't know . ........... 8 27. The patient becomes agitated : Almost never . ......... .1 Sometimes .......................... ^ 2 O f t e n ........... 3 Don't know ......... 8 81 APPENDIX A (C ont'd.) 28. The patient cries: Almost never ............................ . 1 S o m e t i m e s .......... 2 Often ........ . 3 Don ' t know ..................... 8 29. The patient complains: Almost never ......... 1 Sometimes . ........ 2 O f t e n ........ 3 Don't know, does not a p p l y........ 8 82 APPENDIX B PATIENT ASSESSMENT— POSTTEST 83 APPENDIX B PATIENT ASSESSMENT-POSTTEST Directions: Please circle the appropriate number at the right that best describes the patient. Circle ONLY ONE number per question and leave NO questions blank. Thank you. 1. Bathing/dressing: Dependent— patient needs help with everything...... . . 1 Needs a little h e l p ...... . ................... . . 2 Independent— patient does everything for himself ...... 3 Does not apply, don't k n o w ........ 8 2. Brushing teeth: Dependent— patient needs complete h e l p ................ 1 Needs a little help . . . . ............. 2 Independent— patient does for himself . ......... 3 Does not apply, don't know ......... 8 3. Elimination: Incontinent of urine/feces ........ 1 Continent if reminded or taken to the bathroom ........ 2 Continent . . . . . . . . . ............. 3 Don't know ........ 8 4. Eating: Spoon fed or tube f e d ............. 1 Needs some assistance or supervision . . . . . ........ 2 Independent— takes care of himself .................. 3 Don't know . . . . . . . . . . . . . . . . ........... 8 5. Vision at best, including glasses, if needed: Extremely poor or blind ............................ 1 Somewhat impaired, even with glasses . .............. 2 Apparently n ormal......... 3 Don't know ...................................... 8 6. Patient remembers: Both recent as well as long ago events ........... 1 Recent events, but not long a g o ....................... 2 Long ago events, but not recent....................... 3 Neither recent nor long ago e v e n t s ................... 4 Does not apply, don't know ..................... 8 84 APPENDIX B (C o n fd .) 7. Patient knows where he is: Always— is hardly ever lost in a familiar a r e a .......... 1 Sometimes— occasionally needs h e l p ........ 2 Hardly ever— is frequently lost, a wanderer ........... 3 Does not apply, don't know . ......... 8 8. Responds to own name: Almost never responds. . . . . . 1 Sometimes responds . . . . . ........................ 2 Almost always responds . . ..................... . 3 Don't know ............................ 8 9. During the day, the patient: Naps most of the day . ............................ 1 Often n a p s ........ 2 Sometimes naps . ................................. 3 Don't know ............. 8 10. Joins in group social activities: Almost never . . . . . . . ......................... 1 S o m e t i m e s ................ 2 Often ........... . 3 Does not apply, don't know .......... 8 11. Patient travels around the nursing home: Not at all--insists on remaining in his r o o m ............ 1 With some help and encouragement . ......... 2 Frequently on his own ........ 3 Does not apply, don't know ............. 8 12. Recei ves vis1ts from friends/relati ves: Daily ....................... 1 At least once a w e e k ........ 2 At least once a month .............. 3 Less often . . . . . . ............... 4 Don't know ............................... 8 13. Ability to give a message (speaking,writing, gesturing, etc.); Almost never understood . . . . . . . . . . . . . . . . . 1 Sometimes understood . . . . . . ................... 2 Almost always understood ....... 3 Does not apply, don't know ........ 8 85 APPENDIX B (C ont'd.) 14. Begins conversation with others: Almost never ................ . 1 Sometimes ........................ 2 Often . . . . . . . . . .......................... 3 Does not apply, don't k n o w ........ . .............. 8 15. Answers a question or instruction sensibly: Almost always . . . . . . . . . . . . . . . .......... 1 Often, but rambles or doesn't stick to the point ......... 2 Sometimes--needs simple instructions. ................ 3 Hardly ever— cannot respond sensibly, does not respond, or responds with nonsense . .......... 4 16. The patient becomes agitated: Almost never . ........ 1 Sometimes .......................... 2 O f t e n ........... 3 Don't know ...................................... 8 17. The patient cries : Almost never ........ 1 Sometimes ...... 2 Often .............. . 3 Don't know ......... 8 18. The patient complains : . . . , Almost never ................ 1 S o m e t i m e s ........... 2 O f t e n .................... .................... 3 Don't know, does not apply ............. 8 19. Within the last six months, has the patient become more alert and aware of things going on around him? Yes, he appears more alert ........ 1 He is just as alert as he was six months ago . . . . . . . 2 No, he appears less alert . ........ ........ . . 3 Don't k n o w ....................... . .......... . 8 20. Has this patient changed in the amount of attention he requires from you within the last six months? Requires more attention . ........ 1 Requires about the same as he did six months ago . . . . . 2 Requires less attention . . . . ... .................. 3 Don't k n o w ............................. 8 86 APPENDIX B (C ont'd.) 21. Within the last six months, has there been a change in the patient's moods on the whole? He has become more cheerful........................ 1 His moods are about the same ........... 2 He has become more depressed .............. . 3 Don't know ............. 8 22. Has there been a change in the patient's physical condition within the last six months? He is better .................. 1 He is about the same .................. 2 He is w o r s e ....... 3 Don't know ......... 8 23. Please comment on any specific responses of this patient to the redecorati on : DESCRIPTIVE DATA APPENDIX C DESCRIPTIVE DATA Name: Age: _____________ Sex:___________ Race :____ _____ Length of Stay_____________________ MENTAL STATUS QUESTIONNAIRE: NUMBER OF QUESTIONS CORRECT: Where are you now? (name?...kind of place?) .......... + Where is it located? - . .............. + What is the date today? Day? . .......... + Month?. ..................... + Year? . ............. + How old are you? . . . . . . . . .......... . . . . . + When were you born? Month? .................. + Year of birth? .......... + Who is the president of the United States? . ........ + Who was the president before him? ........... . . . . . + Scoring Key for Descriptive Data Sex: 0) Female (2) Male Race: 0 ) Caucasian (2) Negro C3) Spanish/Mexican (4) Other Length of s t a y : (0) Under three months 0 ) Three months to one year (2) One to two years (3) Two to three years (4 Three to four years -5 Four to five years 16) Five to six years (7) More 89 APPENDIX D PATIENT INTERVIEW— PRETEST 90 APPENDIX D PATIENT INTERVIEW— PRETEST 1. How well do you get around? Without any help ........ 1 With some help, or . . . . . . ..................... 2 With great help . ........... 3 NO RESPONSE, NO O P I N I O N ........ 8 2. How would you rate your health? Good .......................... 1 Fair, o r ........... 2 P o o r ........ 3 NO RESPONSE, NO O P I N I O N ............. 8 3. Compared to other persons your age, would you judge your health to be: Same as others . ....................... 1 Better than others, or . . . . . ................... 2 Worse than others . . . . . . ..................... 3 NO RESPONSE, NO OPINION . ........................ 8 4. During the average day, are you usually: About busy enough . . . . . . .......... 1 Too busy, o r ........ 2 Not busy enough to keep you occupied ................ 3 NO RESPONSE, NO O P I N I O N ............... 8 5. How do you usually spend your day? 6. Do you like what you do? Yes . . ......... 1 S o - S o ............... 2 N o ............................... 3 NO RESPONSE, NO O P I N I O N ........... 8 7. Does time pass quickly? Yes ......... 1 S o - S o .......... ............................... 2 N o ......................... 3 NO RESPONSE, NO OPINION .......................... 8 91 APPENDIX D (C ont'd.) 8. How often do you have outside visitors? Daily . ................ ..................... 1 At least once a week . ................ 2 At least once a month, o r ................. ........ 3 Less o f t e n ...... . .................. ......... 4 NO RESPONSE, NO OPINION ...................... 8 9. In general, do you see these visitors as often as you would like? As often as I would like ....................... 1 Some as often, others not as o f t e n ......... ........ 2 Not as o f t e n ...... . .......................... 3 More o f t e n ......................... ........... 4 NO RESPONSE, NO OPINION ...................... 8 We were just talking about outside visitors. Now I'd like to ask you some questions about people here at St. Theresa's. 10. How often do you visit with other people at St. Theresa's? Would you say that you visit with them: Several times a day ............................ 1 Once or twice a day ........... ............. 2 Once every few days, or . ...... .. ............ 3 Less o f t e n ............ .. ..................... 4 NO RESPONSE, NO OPINION . . . . . . . . ............. 8 11. Overall, are you satisfied with how often you visit with other people here at St. Theresa's? Are you : Very satisfied ............................ 1 Somewhat satisfied, or ............... 2 Not so satisfied . ............................ 3 NO RESPONSE, NO OPINION .......................... 8 12. Do you have as many friends as you would like at St. Theresa's? Y e s ...................... .... ......... . 1 So-So................. . ....................... 2 N o ........................................... 3 NO RESPONSE, NO OPINION ......................... 8 13. About how many close friends would you say you have here? 14. Can you tell me what the first names of your roommates are? 92 APPENDIX D CCont'd.) Now I would like to ask you for your opinion on some other questions 15. What are the best tKings about being your age? 16. What plans do you have for the future? [What is the most important thing in your life right now?) 17. Will they/this most like happen : Today . . 1 Tomorrow .................. 2 Next week ............. 3 Next month, or . . 4 Later? ........ . . . . . . . . . ........ 5 NO RESPONSE, NO OPINION . . . . . . . . ... . . . . . . 8 18. As you get older, would you say things seem to be better or worse than you thought they would be? Better . . . . . . . . . . . . . . . . . . . 1 About the same . . . . . . . 2 W o r s e ............. 3 NO RESPONSE, NO OPINION . . . . . . . . . . . . 8 19. How satisfied would you say you are with your life right now? Very satisfied . . . . . . . . . . . . . . . . . . . . . 1 Fairly satisfied, or . . . . . . . . . . . . 2 Not very satisfied ......... . . . . . . . . . . ... 3 NO RESPONSE, NO OPINION . . . . . . . . . . . . . . . . . 8 20. How does this compare with the earlier periods in your life? Would you say that: This is the happiest time [all have been happy or it's hard to make a choice} . . . . . . . . . . . . 1 There has been some decline in recent years, or . . . . . 2 Earlier periods were much happier? . . . . . . . . . . . 3 NO RESPONSE, NO OPINION . . . . . . . . . . . . . , ... 8 21. What do people expect of you at St. Theresa's? APPENDIX D (C ont'd.) 22. Do you ever worry about nieeting these expectations? N o .................. 1 Qualified y e s / n o......... 2 Y e s ........... .......................... . 3 NO RESPONSE, NO O P I N I O N .......... 8 23. Are you generally a cheerful or a blue person? Cheerful ............ . . . . . . . ............... 1 Depends ............. 2 Blue ................ . 3 NO RESPONSE, NO OPINION . . . . . . ................ 8 24. How often do you find yourself feeling lonely? N e v e r .......... ... ............................ 1 Sometimes, or ................ 2 Fairly o f t e n.......................... 3 NO RESPONSE, NO OPINION .................. 8 25. If you could live anywhere you pleased, where would you most like to live? 26. Do you ever feel there is no point in living? Would you say you feel that: Hardly ever ............................. 1 Sometimes, or ................ 2 Quite often? ............. 3 NO RESPONSE, NO OPINION . . . ..................... 8 Now I'd like to ask you some questions about the surroundings here at St. Theresa's. + - X 27. Is it easy for you to find your way around St. Theresa's? 1 2 3 8 28. Do you go outside your room as much as you would like?l 2 3 8 29. Do you go outside the building as much as you would like? 1 2 3 8 30. Is St. Theresa's as pleasant a place as you would l i k e ? ............. 1 2 3 8 31. Could you be alone here if you wanted t o ? ...... 1 2 3 8 94 APPENDIX D (C ont'd.) 32. Outside of your bedroom, where in St. Theresa's do you most like to spend your time? 33. Have you noticed anything different here lately? Yes ........ 1 N o ...... (Skip to Question 34) . ............ . 2 NO RESPONSE, NO OPINION . . . . . (Skip to Question 34) 8 What? 34. Would you like to see some things different than are here now? Yes . . . ... 1 No . . ......... 2 NO RESPONSE, NO OPINION ....... . 8 35. If you could change anything here, what would you change? 9) 5: APPENDIX E PATIENT INTERVIEW— POSTTEST 96 APPENDIX E PATIENT INTERVIEW— POSTTEST 1. How well do you get around? Without any h e l p ....................... 1 With some help, or . ........ 2 With great help ....................... 3 NO RESPONSE, NO OPINION ............. 8 2. How would you rate your health? G o o d ......... 1 Fair, o r ............................ 2 P o o r ...................... .. .................. 3 NO RESPONSE. NO O P I N I O N ................... 8 3. Compared to other persons your age, would you judge your health to be: Same as others .............. 1 Better than others, o r ....... ......... ........... 2 Worse than others? . ........ 3 NO RESPONSE, NO OPINION ............. 8 4. During the average day, are you usually: About busy enough . . . . . . . . . . . ........... .1 Too busy, or .............. 2 Not busy enough to keep you occupied? . . . . . . . . . . 3 NO RESPONSE, NO OPINION . . . . . . . . ........ . . . . 8 5. How do you usually spend your day? 6. Do you like what you do? Yes ........ 1 S o - S o .......... .................... . ......... 2 N o ......... ................................... 3 NO RESPONSE, NO O P I N I O N ................ 8 7. Does time pass quickly? Yes ......... 1 S o - S o .................................. 2 No . . . . . . .................. 3 NO RESPONSE, NO OPINION ........................... 8 APPENDIX E (C ont'd.) 8. How often do you have outside visitors? D a i l y......................................... 1 At least once a w e e k ............................ 2 At least once a month, or . ...... 3 Less o f t e n ................ ................... 4 NO RESPONSE, NO OPINION ......................... 8 9. In general, do you see these visitors as often as you would like? As often as I would like ................... 1 Some as often, other not as often . ............... 2 Not as often ............. 3 NO RESPONSE, NO OPINION . ....................... 8 We were just talking about outside visitors. Now I'd like to ask you some questions about people here at St. Theresa's. 10. How often do you visit with other people at St. Theresa's? Would you say that you visit with them: Several times a day ......... 1 Once or twice a day .............. . 2 Once every few days, or . . . . . . .............. 3 Less often? . . . . . .............. 4 NO RESPONSE, NO OPINION . . ........... 8 11. Overall, are you satisfied with how often you visit with other people here at St. Theresa's? Are you: Very satisfied . . . . . . ..... 1 Somewhat satisfied, or ........... 2 Not so satisfied? . ........ 3 NO RESPONSE, NO OPINION . .......... 8 12. About how many cl ose friends would you say you have here? 13. Can you tell me what the first names of your roommates are? Now I would like to ask you for your opinion on some other questions 14. What are the best things about being your age? 15. What plans do you have for the future? 98 APPENDIX E (C ont'd.) 16. As you get older, would you say things seem to be better or worse than you thought they would be? Better . . 1 About the same . ............. 2 Worse . . . . . . . . . 3 NO RESPONSE, NO OPINION ....... . . . . . . . . . . . 8 17. How satisfied would you say you are with your life right now? Very satisfied ........ 1 Fairly satisfied, o r .......... . 2 Not very sati s f i e d ?........ ...... ............. . 3 NO RESPONSE, NO OPINION . . . . . . . . . . . . . . . . 8 18. How does this compare with the earlier periods in your life? Would you say that: This is the happiest time (all have been happy, it's hard to make a choice) . . . . . . . . . . . . . 1 There has been some decline in recent years, or . . . . 2 Earlier periods were much happier? . .. . . . . . . . . 3 NO RESPONSE, NO OPINION . . . . . . ... . . . . . . . 8 19. Are you generally a cheerful or a blue person? Cheerful . ........... 1 Depends . . . . . ........ 2 B l u e ....................... ...... . . . . . . . . 3 NO RESPONSE, NO OPINION . . . . . . . . . . . . . . . . 8 20. How often do you find yourself feeling lonely? Never . . . . . . . . . . . . . . . . . . . . . . . . . 1 Sometimes, or . . . . . . . . . . 2 Fairly often? . . . . . . . . . . . . . . . 3 NO RESPONSE, NO OPINION . . . . . . . . . . . . . . . . 8 21. If you could live anywhere you pleased, where would you most like to live? 22. Do you ever feel there is no point in living? Would you say you feel that: Hardly ever ........ 1 Sometimes, or . . . . Quite often? . . . . . NO RESPONSE, NO OPINION Now I'd like to ask you some questions about the surroundings here at St. Theresa's, 99 APPENDIX E CCont'd.) + - + X 23. Is it easy for you to find your way around St. Theresa's? 1 2 3 4 24. Is St. Theresa's as pleasant a place as you would l i k e ?.................. 1 2 3 4 25. Could you be alone here if you wanted to? . . . . 1 2 3 4 26. Outside of your bedroom, where in St. Theresa's do you most like to spend your time? 27. Have you noticed any changes at St. Theresa's within the last six months? Y e s ......................................... 1 N o ................................. 2 NO RESPONSE, NO OPINION ........ 8 28. What?_____________________________ - ■ • - ^ ■ 29. Do you like the changes? Yes ........................... 1 N o .................................... 2 NO RESPONSE, NO OPINION ............... 8 30. If you could change anything here, what would you change? 100' APPENDIX F SCORING KEY FOR PATIENT INTERVIEW 101 APPENDIX F SCORING KEY FOR PATIENT INTERVIEW 5. How do you usually spend your day? (1) Position (sit, lie, walk, etc.) (2) Sleep (3) Self-maintenance (toilet, eat, groom, etc.) (4) Social activities (activities, help others, visit, etc.) (5) Solitary activities (television, radio, read, watch) (6) Nothing 13. About how many close friends would you say you have here? (0-4) The exact number which the subject reports (5) All of the people here are friends, many (8) No response, no opinion 14. Can you tell me what the first nams of your roommates are? (1) Mentions at least one name (2) Know no name, "I'd know them if I saw them" (8) No response, no opinion 15. What are the best things about being your age? (1) A positive answer (2) Things are about the same as they have always been (3) A negative answer (4) An evasive answer avoiding the question (8) No response, no opinion 16. What plans do you have for the future? (1) Pleasant interpretation (2) Maintaining status quo (3) Nothing now, reference to the past (4) Negative interpretation (8) No response, no opinion 25. If you could live anywhere you pleased, where would you most like to live? (1) Here (2) Any other location (8) No response, no opinion 102 APPENDIX F (C ont'd.) 32. Outside of your bedroom, where in St. Theresa's do you most like to spend your time? (1) Dining room (2) Lobby (3) Hall (4) Near nurses station (5) Patio--outside (6) No place outside of bedroom 33. Have you noticed anything different here lately? What?* Cl) Personnel (2) Treatment (3) Supplies (4) Environment (5) Nothing * Each type of response was scored independently with a "1" for a positive response and a "2" for a negative one. 35. If you could change anything here, what would you change?** (1) Personnel (2) Treatment (3) Supplies (4) Environment (5) Nothing ** Each type of response was scored independently with a for the kind of response made. 103 APPENDIX G PRETEST FAMILY QUESTIONNAIRES 104 APPENDIX G PRETEST FAMILY QUESTIONNAIRES Letter Accompanying Pretest Family Questionnaire April 30, 1977 Dear I am a student at the University of Southern California doing a project at St. Theresa's Convalescent Hospital on nursing home care. One important aspect in delivering good care to patients is the response of their families, and that's where you fit in. Please answer the enclosed questionnaire as it applies to you and your relative at St. Theresa's. The few minutes it takes to fill it out will help me with my study and will supply St. Theresa's with general information necessary to improve their service to your rela tive. Your name will be kept strictly confidential. If you are either too busy or not interested in filling out these forms, please return the blank form to me anyway in the enclosed, self- addressed, stamped envelope. Thank you for your help. Sincerely, Carol Curlette Dear Friend: I ask for your cooperation with the above request of Carol Curlette. Carol has her bachelor's degree and is studying for her master's degree in gerontology. We at Saint Theresa Convalescent Hospital are embarking on a plan to refurbish the convalescent hospital under the direction of Dr. Schwartz, Gerontology Center at U.S.C. To make our refurbishing pro gram meaningful to the patient, it is most essential that we have the thoughts and ideas of the patient's relatives. Thank you for your cooperation. We will keep you advised as we progress in this plan of refurbishing. Sincerely, Neil Archibald, Administrator Saint Theresa Convalescent Hospi tal 105 APPENDIX G (Cont'd) FAMILY QUESTIONNAIRE Please circle the number at the right which indicates your response. 1. How often do you visit your relative at St. Theresa's? Daily .............. 1 At least once a week . . . . . . . . . . . . . ...... 2 At least once a month ......... 3 Less often . . . . . . ......... 4 2. Do you see your relative as often as you would like? Yes, as often as would like to ......... 1 Not as often, would like to see him more . . . . . . . . 2 T 00 o f t e n............. . ............ . ........ 3 3. Do you find visiting at St. Theresa's enjoyable, convenient? Y e s .......... .1 Sometimes, depends ............... 2 No ............................. . 3 4. Do you think it easy to find your way around St. Theresa's? Y e s ................ 1 No ......... 2 5. Is St. Theresa's as pleasant a place as you would like? Yes ................ 1 Sometimes, depends .............................. 2 No . . . . . . . . . . . . . . . . . ............... 3 6. Do you feel that St. Theresa's is trying its best to give good patient care? Yes ........ . 1 Sometimes .................................... . 2 No ............. 3 7. This nursing home should be run more like a hospital: for instance, parties and activities interfere with good patient care. Do you: Agree strongly ........ 1 Agree . . . . .............. 2 Disagree . . . . . . . . . . . . . . . . ............ 3 Disagree strongly . . . . . . . . . . . . . ...........4 106 APPENDIX G (C ont'd.) 8. Most of the people who live in nursing homes are just too con fused to understand or appreciate what is going on around them. Do you: Agree strongly........................ 1 Agree .................. 2 Di sagree ...................... 3 Disagree strongly................... . 4 9. Would you like to see different or additional activities than are now at St. Theresa's? Yes ............................ 1 No .............. 2 10. If so, what activities would you like to see? 11. When you first admitted your relative, what was your first impression of St. Theresa's? 12. If you could change anything?; what would you change? 107 APPENDIX G (Cont'd.) SPANISH VERSION OF LETTER Queri do : Estudio en las Uni vers1 dad del Sur de California y estoy haclendo un proyecto en el Hospital de Santa Teresa sobre el cuidado de los h a d entes convalecientes. Un aspecto importante en pro- pocionarle buen quidado al paciente es de tener en cuenta las opiniones de los fami 11 ares buen esto me podria Usted ayundar. Por favor responda a l^as preguntas que le he envi ado. Los pocos minutos que le tomara en responded as me ayudara en el proyecto e informera al Hospital de Santa Teresa como mejorar los présente servi ci os. Su nombre sera mantenido en estrica confidencia, Si no esta interesado en participer, haga el favor de envi arme el questionario en blanco en el sobre que le he proporcionado. Muchas gracias por su cooperacion. Sinceramente, Carol Curlette 108 APPENDIX G (Cont'd.) PREGUNTAS SOBRE LA FAMILIA— PRETEST Responda a las siguientes preguntas marcando a la derecha el numéro que mejor indica su respuesta. 1. Con que frecuencia visita listed a su familiar en el hospital de Santa Teresa? Di ari amente ......... 1 Por los men os una vez a la semana ............. 2 Por lo menos una vez al mes . . . . .......... . 3 Con menos frequencia . . . . . . . . . . . . . . . . . . 4 2. Ye a^su familiar con la frequencia que le gustariéT hacerlo? Si, las veces que quiero ........ 1 No tan amenudo, me gustaria verlo mas amenudo . .... 2 Demasiadas veces .............. 3 3. Encuentra su visita a Santa Teresa agradable, conveniente? S i ....................... 1 Algunas veces, depende . . . . . . . . . 2 No . . . . . . . . . . . . . . . . ............. . . 3 4. Encuentra Ud. facil encontrar el camino por dentro de este hospital? Si ........................................... 1 N o ........................................... 2 5. Encuentra Ud. el hospital de Sta. Teresa tan piacentero como le gustajri'a? S i .................. 1 Algunas veces, depende .......................... 2 No ........................ 3 6. Piensa Ud. que en este hospital tratan de darle al paciente el mejoi; cuidado possible? Si 1 Algunas veces .............. 2 N o ........................................... 3 7. Este hospital de convaleciente debe ser mas como un hospital: por ejemplo, flests y actividades interfieren con el buen cuidado del paciente. Estoy acuerdo . ................... 1 No esta de acuerdo .............................. 2 109 APPENDIX G (C ont'd.) 8. La mayori"a de los oacientes en este hospital de convalecientes estan demasiado confusos qara com- prender o apreciar lo que ocurre a su alrededor. Ud.: Esta de acuerdo . . . . . . . . . . . ............. 1 No esta de acuerdo ..................... 2 9. Le gustaria ver actividades diferentes o adicionales de las que hay ahora en este hospital? Si. . . . . . . . . . . . . . .................. 1 No. . ................ 2 ' 10. Si respgndido que si, que tipo de actividades le gustaria ver? 11. Cuando ^u familiar fu^ admitido por primera vez, que impresion le dio esta institucioTi? 12. Si podria cam^iar algo en esta institucion, que cosa cambiaria? 13. Ud. piensa que su visita hace a fami 1ia ustoso? Si, mira a del ante de mi visitas . ............. 1 Si, cuando you es to aqui, pero me olvida cuando yo me voy ............. 2 Yo no se si mi paciente se da cuenta de mis visitas . . 3 No, mis visitas disgustan a mis pari entes . . . . . . . 4 14. Que capacitado creer que tu paciente esta para hacer COSas para el mismo. Puede hacer por si m i s m o .......... ............ 1 Necesi ta ayuda la major parte .............2 Necesita una poca de ayuda . . . ........ 3 110 APPENDIX H POSTTEST FAMILY QUESTIONNAIRES 111 APPENDIX H POSTTEST FAMILY QUESTIONNAIRE Letter Accompanying Posttest Family Questionnaire February 9, 1978 Dear Friend: I am a student at the University of Southern California doing a project at St. Theresa's Convalescent Hospital. About six months ago you kindly helped me with my project by filling out a questionnaire. This information which you provided me at that time will not be complete unless you now fill out this second questionnaire. Please help me with this project and St. Theresa's with their service to your relative or friend by sending me the requested information in the enclosed, self-addressed, stamped envelope. All comments will be kept strictly confidential. St. Theresa's knows of this project and has permitted me to do it. General conclusions from this study will be given to St. Theresa's, and a copy of the completed report will be available at St. Theresa's for your examination in about two months. Many thanks for your help in this work. Sincerely, Carol Curlette P.S. Your quick response would be greatly appreciated! 112, APPENDIX H (C ont'd.) POSTTEST FAMILY QUESTIONNAIRE Please circle the number at the right which indicates your response 1. How often do you visit your relative at St. Theresa's? D ai l y ......................................... 1 At least once a week . . . . . . . . . . ........... 2 At least once a m o n t h ....................... 3 Less often . . . . . . . . . ................... 4 2. Do you see your relative as often as you would like? Yes, as often as would like to ........ 1 Not as often, would like to see him m o r e ........... 2 Too often ................ . . . . . . . . . . . . 3 3. Is St. Theresa's as pleasant a place as you would like? Y e s .......................... ............... 1 Sometimes, depends . . . . . . ................... 2 N o ...........................................3 4. Do you feel that St. Theresa's is trying its best to give good patient care? Yes . . . . . . . . . . . . . . 1 Sometimes......................... 2 No . . . . . . . . . . . . . . . . . .............. 3 5. This nursing home should be run more like a hospital: for instance, parties and activities interfere with good patient care. Do you: Agree strongly . ............................. 1 Agree . ............................ 2 Disagree . . . . . . . . . . . . . . . ............ 3 Disagree strongly . . . .................. 4 6. Most of the people who live in nursing homes are just too confused to understand or appreciate what is going on around them. Do you : Agree strongly ...... . . . . . . .............. 1 A g r e e ............................. 2 D i s a g r e e ..................... ............... 3 Disagree strongly . ........................... 4 7. Within the last six months, has your relative become more alert and aware of things going on around him? . . Yes , he appears more alert . , . . ........... 1 He is just as alert as he was six months a g o ........ 2 No, he appears less alert .................. 3 113 APPENDIX H CCont'd.) 8. Within the last six months, has there been a change in your relative's moods on the whole? He has become more cheerful..................... 1 His moods are about the same ........ 2 He has become more d e p r e s s e d................... 3 9. What is your impression of St. Theresa's now? 10. Have you noticed any changes at St. Theresa's within the last six months? Y e s ........... 1 No .................. 2 If you have noticed some changes, please answer 11-14: 11. What changes have you noticed? 12. Do you like the changes? Yes ................ 1 No ....................... . 2 13. How do you think your relative has responded to the changes? Positively ................ 1 Negatively ............. 2 No apparent response , ........... 3 14. Have the changes made it easier for your relative to find his way around the building? Yes . . ......... 1 No ............................... 2 15. If you could make additional changes at St. Theresa's, what would you change? 114 APPENDIX I SCORING KEY FOR FAMILY QUESTIONNAIRES 119 APPENDIX I SCORING KEY FOR FAMILY QUESTIONNAIRES 9. What is your impression of St. Theresa's initially/now? (1) Any positive opini on (2) Any negative opinion (3) The same, O.K., neutral IT. What changes have you noticed?* (post test only) (1) Personnel (more staff, new personnel) (2) Treatment (more activities, etc.) (3) Supplies (_4) Environment (redecoration, cleaner, cheerful, pleasant, better repair) (5) Nothing * Each type of response was scored independently with a "1" for a positive response and a "2" for a negative one. 12. & 15. If you could make additional changes at St. Theresa's, what would you change? ** (1) Personnel (doctor availability, more staff, higher salaries, new administration, more professional staff, increased communication) (2) Treatment (better treatment, better handling of personal clothing) (3) Supplies (food, better mattresses, pillows, blankets, wash cloths, and towels) (4) Environment (division of patients into coherent and incoherent sections, redecoration, more cleanliness) ** Each type of response was scored independently with a "1" for each kind of response made. 116 APPENDIX J STAFF QUESTIONNAIRES— PRETEST 117 APPENDIX J STAFF QUESTIONNAIRES— PRETEST 1. 3. 4. 5. 6. 7. 8. 9. Strongly Dis- Strongly Agree Agree agree DIsagree I can learn a great deal on my job here. Once you have worked here, even a short while, you pretty much know what there is to know about old people. Most of our nursing care patients are just too confused to understand or appreciate what goes on around them. Occasionally a patient has said or done something to make me sad or depressed. I am doing something really worthwhile on my job. My job is not very interesting or challenging. This nursing home should be run more like a hospital: for in stance, parties and activities interfere with good patient care My job is frequently dull monotonous. and Sometimes a patient has said or done something to really make my day happy. 118 APPENDIX J CCont'd.) Please circle the number which indicates your feelings. On the whole, residents of St. Theresa's are. . . . not adaptable inflexible 1 somewhat adaptable 2 adaptable flexible 3 active 1 somewhat active 2 not active 3 not pleasant 1 somewhat pleasant 2 pleasant - 3 sensible 1 somewhat sensible 2 not sensible 3 119: APPENDIX J (C ont'd.) QUESTlONARIO PARA LOS MIEMBROS DE LA FACULTAD— PRETEST Eficiente Eficiente Acuerdo Acuerdo Desacuerdo Desacuerdo Yo puedo aprender mucho aqui, en mi trabayo. Cuando Ud. haya tra- bajado aqui^ aun poco ti empo 5 jfni entras, aprendio a conocer mucho, de To que hay para conocer acerca de la personas may ore r. Deben nuestras enferm eras al cuidar los pacientes estar justa- mente confudidas para entender o appreciar lo que est? alrededor de ellos. 1 4. Ocasionalmente un paciente tieme ha dicho 0 heeho algo para que yo este triste o deprimida? 1 5. Yo estoy haciendo algo real mente un el tiempo que estoy trabajando. 1 6. Mi trabajo no es muy interesante para tomar una formal decision. 1 7. Esta enfera^en casa esta corriendo mas, parecido al hospital: por ejemplo, interviene en reuntones familiares y actividades que inter- fierem con el buen cuidado del paciente. 1 120 APPENDIX J (Cont'd.) Eficiente Acuerdo Eficiente Acuerdo Desacuerdo Desacuerdo 8. Mi trabajo es frecuent- mente estupido y monC& tono.. 9. Algunas veces un paciente tiene dicho o heedo algo que me hace el dia feliz. 1 Por favor circule el numéro que indique sus sentimientos. 0 todos los residentes de Santa Teresa, estan . . . Inflexible 1 Algunas veces Adaptable 2 Adaptabe Flexible 3 Acti vo 1 Algunas veces Activo 2 No Activo 3 No Placentero 1 Algunas veces Placentero 2 Placentero 3 Sensible 1 Algunas veces Sensible 2 Insensible 3 1211 APPENDIX K STAFF QUESTIONNAIRE— POSTTEST 122 APPENDIX K STAFF QUESTIONNAIRE— POSTTEST Strongly Strongly Agree Agree Disagree Disagree 1. I can learn a great deal on my job here. 2. Once you have worked here, even a short while, you pretty much know what there is to know about old people 3. Most of our nursing care patients are just too con fused to understand or appreciate what goes on around them. 4. Occasionally a patient has said or done something to make me sad^ or depressed. 5. I am doing something really worthwhile on my job. 6. My job Is not very interest ing or challenging. 7. This nursing home should be run more like a hospital : for Instance; parties and activities interfere with good patient care. 8. My job is frequently dull and monotonous. 9. Sometimes a patient has said or done something to really make my day happy. 123 APPENDIX K CCont!d.) 10. Do you like the changes in redecoration within the last six months? Y e s ........ 1 No ............................... . . 2 11. How do you think the patients have responded to the changes in redecoration? Positively.................................. 1 Negatively ........... 2 No apparent response . . . . . ................ 3 12. Have the changes made it easier for the patients to find their way around the building? Yes . ............. 1 N o ................... . . . . . 2 124

Asset Metadata

Creator Curlette, Carol Lee (author)

Core Title Impact of environmental stimulation of functioning of nursing home patients

Contributor Digitized by ProQuest (provenance)

Degree Master of Science

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Health and Environmental Sciences,OAI-PMH Harvest,Social Sciences

Format application/pdf (imt)

Language English

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c37-403214

Unique identifier UC11657831

Identifier EP58868.pdf (filename),usctheses-c37-403214 (legacy record id)

Legacy Identifier EP58868.pdf

Dmrecord 403214

Document Type Thesis

Format application/pdf (imt)

Rights Curlette, Carol Lee

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA

Linked assets

University of Southern California Dissertations and Theses