**3. Patterns of decision-making and influences on residents**

Based on the case analyses of the three homes, distinct patterns of decision-making and the influences on the residents' approach to decision-making could be delineated. The processes by which residents were facilitated or hindered from decision-making were strongly influenced by the pattern of decision-making that predominated in the homes. **Table 2** summarizes the three processes and six elements that were identified to capture the subtleties of the process of decision-making for residents that unfolded from entry into the homes to how they continued to make decisions to adjust to the living environment.

Residents proceeded through a fairly logical approach and had varying degrees of involvement in decision-making. These processes demonstrated how residents settled into the home by becoming familiar with it and then becoming more involved in the decisions that influenced their lives. As residents moved through these decision-making processes that were practiced in the homes, the degree of negotiation that was possible determined the extent to which they were able to negotiate successful, less successful and unsuccessful decisions. As residents engaged in these processes the extent to which the family and staff ensured that decisions were successfully negotiated to meet needs or needs were not met were also highlighted. In comparing the similarities and differences in these processes across the three homes, three decision-making patterns were identified as negotiated, partially-flexible and constrained patterns of decision-making. Through the interactions between the participant groups, negotiations and/or compromises occurred that either facilitated or hindered residents' involvement


The process of being told and observing the daily routines enabled residents and families to learn the roles of staff and their expectations. Some residents quickly settled into a pattern of

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*They are good to me. I do not have to do anything. I am over 90. Staff help to prepare everything for me.* 

The importance of families in maintaining relationships with the residents was emphasized by the staff from the outset. Families played a central role during this transitional period by providing supplementary baseline information to the staff about their relative's condition and usual habits that shaped the level of supervision needed and improved understanding of the resident. Indeed, the superintendents and staff, especially in home one, initiated contact with the families each time they visited. The family's contribution in this process was to make regular visits to observe and get to know the home, and what was happening in the resident's daily life, and what was acceptable to do. Families were keen to lend a helping hand and to reassure the residents that they had not been abandoned. Families also learned from staff and

The processes of 'trial and error testing' and 'asking and questioning' marked the beginning of negotiation in the decision-making experiences of residents. These processes were largely triggered by the discrepancies arising from what was being told and observed about the home's operation and from the people around them. They wanted to 'trial and error test' and

In homes one and two, the process of trial and error testing was usually observed in physical care decisions, although the processes differed slightly. These decisions were examples of major initial concerns, such as who performed the hygiene care, or decisions about meal choices were requested by the residents or families. Of concern to residents were asking to change the order of taking baths and who performed it. Bathing routines tended to prioritize those whom staff felt were most pressing (e.g. wound dressing or medical appointments). On the spot requests like 'I want to be first today' without a 'good' reason were not entertained. In home one, an upfront request to bath alone was made by the residents to the superintendents and, if staff agreed, the level of supervision needed was assessed. In reality staff felt constrained by the need to rush through baths and safeguard those who bathed alone. Residents

*They do not really need to take care of me. If they do not call me (to help me), I bath myself. It's safe and simple. No need to ask others to help with things I can do. If I ask for too much help, I feel embarrassed* 

The main reason for wanting to regain independence and control over bathing was the dissatisfaction directed at staff for being too busy and rushing through the procedure. Instead of

*They bathed me and did not completely wash away the soap. I kept it a secret, or the seniors will condemn them. I told them I could bath myself, and thanked them for helping me. They said to* 

letting staff do things for them:

*3.1.2. Finding out what I can do and want*

spoke of the embarrassment of asking for help:

moaning, they proactively dealt with the problem:

*call them if I could not handle it.* (SH, elder, E4B).

*and useless* (POAH, elder, E8B)*.*

*They do not need me to do anything.* (POAH, elder, E6A)*.*

observed them to see whether their requests were followed up.

'ask and question' about the possibility of doing things by themselves.

**Table 2.** Decision-making processes matched against its elements.

in decision-making. Participants' decision-making patterns and how they shaped the three processes of adjustment to decision-making will be discussed below.

#### **3.1. Negotiated patterns of decision-making**

Residents from home one undertook most negotiation in decision-making. Some residents from home two were also allowed to practice this approach provided that decisions did not disrupt the smooth running of the home. This approach was less evident in home three and, when it did occur, it caused conflict resulting in the resident terminating their stay.

#### *3.1.1. Making the unknown familiar*

During the settling-in period, residents' abilities and desires were revealed through the processes of 'being accompanied and supervised', and 'being told and observing'. Staff were predominately identified as key people in the process of getting to know the resident's concerns, health condition, personality and personal preferences on which to base decisionmaking later on. As the weeks passed, the exchanges with accompanying and supervising staff allowed residents to gradually understand the operation of daily practices affecting their lives. Of concern to residents at this time was the ways in which baths were planned:

*Staff arrange baths for me. I do not bath on my own. I know the time to bath. If I bath today, I bath the day after tomorrow so I can prepare myself. But there's nothing for me to get ready 'cause they do it all for me.* (POAH, elder, E5A)*.*

This process also enabled most staff to claim that they knew about 70–80% of the resident's personal habits and preferences. The remaining 20–30% was attributed to the limited knowledge about family composition and support to give to them. This information was important in making a judgment about resident's abilities to make decisions. Information about the resident's mobility, level of independence and self-care abilities, capabilities, mental state, motivation to do own things, beliefs in one's ability to do it, and ability to make sensible suggestions were helpful. When they were perceived to be unable to mobilize safely, negotiating to do tasks independently were often rejected by staff. This was frustrating for some:

*You need a clear mental state, or else how can you do the task? I can make decision whenever I need to. You cannot deceive me on anything. You cannot ignore what I am saying. The only thing is that I cannot walk on my own and this is killing me* (POAH, elder, E5A)*.*

The process of being told and observing the daily routines enabled residents and families to learn the roles of staff and their expectations. Some residents quickly settled into a pattern of letting staff do things for them:

*They are good to me. I do not have to do anything. I am over 90. Staff help to prepare everything for me. They do not need me to do anything.* (POAH, elder, E6A)*.*

The importance of families in maintaining relationships with the residents was emphasized by the staff from the outset. Families played a central role during this transitional period by providing supplementary baseline information to the staff about their relative's condition and usual habits that shaped the level of supervision needed and improved understanding of the resident. Indeed, the superintendents and staff, especially in home one, initiated contact with the families each time they visited. The family's contribution in this process was to make regular visits to observe and get to know the home, and what was happening in the resident's daily life, and what was acceptable to do. Families were keen to lend a helping hand and to reassure the residents that they had not been abandoned. Families also learned from staff and observed them to see whether their requests were followed up.

#### *3.1.2. Finding out what I can do and want*

in decision-making. Participants' decision-making patterns and how they shaped the three

• Being told and observing

• Asking and questioning

• Compromising

Residents from home one undertook most negotiation in decision-making. Some residents from home two were also allowed to practice this approach provided that decisions did not disrupt the smooth running of the home. This approach was less evident in home three and,

During the settling-in period, residents' abilities and desires were revealed through the processes of 'being accompanied and supervised', and 'being told and observing'. Staff were predominately identified as key people in the process of getting to know the resident's concerns, health condition, personality and personal preferences on which to base decisionmaking later on. As the weeks passed, the exchanges with accompanying and supervising staff allowed residents to gradually understand the operation of daily practices affecting their

*Staff arrange baths for me. I do not bath on my own. I know the time to bath. If I bath today, I bath the day after tomorrow so I can prepare myself. But there's nothing for me to get ready 'cause they do it all* 

This process also enabled most staff to claim that they knew about 70–80% of the resident's personal habits and preferences. The remaining 20–30% was attributed to the limited knowledge about family composition and support to give to them. This information was important in making a judgment about resident's abilities to make decisions. Information about the resident's mobility, level of independence and self-care abilities, capabilities, mental state, motivation to do own things, beliefs in one's ability to do it, and ability to make sensible suggestions were helpful. When they were perceived to be unable to mobilize safely, negotiating

when it did occur, it caused conflict resulting in the resident terminating their stay.

lives. Of concern to residents at this time was the ways in which baths were planned:

to do tasks independently were often rejected by staff. This was frustrating for some:

*cannot walk on my own and this is killing me* (POAH, elder, E5A)*.*

*You need a clear mental state, or else how can you do the task? I can make decision whenever I need to. You cannot deceive me on anything. You cannot ignore what I am saying. The only thing is that I* 

processes of adjustment to decision-making will be discussed below.

Finding out what I can do and want • Trial and error testing

Negotiating-compromising the past to fit the present • Suggesting and negotiating

Making the unknown familiar • Being accompanied and supervised

**Processes Elements**

228 Gerontology

**3.1. Negotiated patterns of decision-making**

**Table 2.** Decision-making processes matched against its elements.

*3.1.1. Making the unknown familiar*

*for me.* (POAH, elder, E5A)*.*

The processes of 'trial and error testing' and 'asking and questioning' marked the beginning of negotiation in the decision-making experiences of residents. These processes were largely triggered by the discrepancies arising from what was being told and observed about the home's operation and from the people around them. They wanted to 'trial and error test' and 'ask and question' about the possibility of doing things by themselves.

In homes one and two, the process of trial and error testing was usually observed in physical care decisions, although the processes differed slightly. These decisions were examples of major initial concerns, such as who performed the hygiene care, or decisions about meal choices were requested by the residents or families. Of concern to residents were asking to change the order of taking baths and who performed it. Bathing routines tended to prioritize those whom staff felt were most pressing (e.g. wound dressing or medical appointments). On the spot requests like 'I want to be first today' without a 'good' reason were not entertained. In home one, an upfront request to bath alone was made by the residents to the superintendents and, if staff agreed, the level of supervision needed was assessed. In reality staff felt constrained by the need to rush through baths and safeguard those who bathed alone. Residents spoke of the embarrassment of asking for help:

*They do not really need to take care of me. If they do not call me (to help me), I bath myself. It's safe and simple. No need to ask others to help with things I can do. If I ask for too much help, I feel embarrassed and useless* (POAH, elder, E8B)*.*

The main reason for wanting to regain independence and control over bathing was the dissatisfaction directed at staff for being too busy and rushing through the procedure. Instead of moaning, they proactively dealt with the problem:

*They bathed me and did not completely wash away the soap. I kept it a secret, or the seniors will condemn them. I told them I could bath myself, and thanked them for helping me. They said to call them if I could not handle it.* (SH, elder, E4B).

Some residents (influenced by roommates) initiated plans to bath alone, without telling the staff. Experimenting cleansing in secret led them to become confident to persuade staff to let them do it under supervision:

As most families were in full-time work and visited during the weekends, they got to know about the residents' decision-making capabilities through the staff who took initiative to tell them about the daily happenings. They were delighted to know that residents were taking care of themselves and finding things to occupy their time. Negotiating about care that went beyond the usual home practice (e.g. preparing packets of drinks or snacks families have brought), and exploring items to purchase for bed unit) were some topics that were success-

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This approach was most apparent in home two, and sometimes evident in home one due to the constraints of staff and facilities. Few residents from home three wanted to let staff know

Compared with home one, the processes of accompanying and supervising elders was not as closely monitored by staff in home two, while the processes of telling and observing was given greater emphasis. The processes of accompanying and supervising involved staff helping residents to become familiar with the routine and physical care, particularly how they fitted in with the baths, meals and sleeping arrangements. Being a larger home, these processes identified issues that could potentially cause unharmonious relationships such as room- and

*The idea of decision-making depends on reciprocal relationship of elders to respect each other. It's communal living. You are not in a single room. Issues like over-using or not letting others use the airconditioning and fans in the bedrooms, or asking to live on a specific floor.* (SH, social worker, S8)*.* Residents and families were not fully told about the roles of staff (due to many staff) and the pattern of work. Instead families were told of an appointed social care staff and to approach the care staff on each floor for enquiries. They only needed to be observant, oblige and accept what they had been told. Indeed, residents learnt more by observing other resident's behaviour and attitudes of staff towards them, particularly towards room-sharing and how they formed friendships. Unlike home one where residents had single rooms, a major issue in home two was the resident's uncertainties about forming relationships in a

Here families' visits to the residents were confined mostly to the weekends, and there were less daytime/evening visits to lend a helping hand, because of work and family commitments. Families found out about the home's routines largely through talking to the resident, the majority in this home being cognitively intact. The opportunity to move freely around and outside the home, without the operation of a rigid documentation procedure, was viewed

*The rules for taking residents out are a bit loose. I thought it was strange when no one asked me questions (visited biweekly). The home likes to give freedom and convenience to resident and families, and* 

their needs because they were reluctant to confront the rigid culture of the home.

table-sharing, and being prepared to minimize conflicts should they arise:

with initial surprise by families, although they liked the freedom it gave:

*prevents a feeling of imprisonment.* (SH, daughter, R8)*.*

fully discussed by the family on behalf of the residents.

**3.2. Partially flexible patterns of decision-making**

*3.2.1. Making the unknown familiar*

large home.

*They bathed me the first 2 weeks. How can you bath without them knowing? I saw a resident bathing alone so I bathed secretly a few times. I could do it. I did not know that before. They found out, scolded, observed me. Now I do it myself.* (SH, elder, E11A)*.*

Families' views of residents' abilities to make physical care decisions were welcomed. There was a general agreement to allow them to partake in 'basic' daily life decision-making when they were capable and they were not too disruptive to staff or families. Indeed, while some families promoted such decision-making, they also believed that residents should only make decisions on things that were within their capability, even if they could do this slowly.

#### *3.1.3. Negotiating-compromising the past to fit the present*

The processes of 'suggesting and negotiating' and 'compromising' with staff and families about creating a way of life that was reasonably familiar and comfortable for residents marked the continuation of the negotiated decision-making process. The process of suggesting-negotiating arose after residents, who were successful in making some changes, continued to ask and question, and were more likely to discuss and further explore their needs: Everyday it's I see what I can do. I depend on myself all the time. (POAH, elder, E2A).

In both homes one and two, an activity enjoyed by residents was the ability to go out alone, and not to be supervised by anyone. Undoubtedly, the ability to go outdoors independently was a rule determined by the home's management and was made known to residents and families on admission. Although residents were able to maneuver freely around the grounds of the home, granting them the freedom to leave the home grounds as they pleased depended on their physical capability, mental alertness and independence. Such requests were carefully negotiated with the family who had to sign a consent form to accept responsibility. The freedom and independence to go outdoors was highly valued, although the outskirts of home one was an industrial area and it was potentially dangerous for elders to be out alone. They therefore spent time walking along the streets, in front of the home. Whilst this created administrative work homes one and two believed that residents should be given freedom to connect with the community, and encouraged to go out freely, providing it had been approved beforehand.

Another example of the process of negotiating-compromising pertained to food choices. This was a longstanding and difficult problem that was not easy to solve. Over time, the food served and timing of meals were not entirely suitable. Some residents questioned the food textures and tastes, and made requests for a change. As there were no resident meetings in home one, the matter was discussed with the residents on an individual level. Avoiding foods the majority disliked was the preferred practice in communal living, as opposed to boosting food tastes for the few who raised it as a concern. With the help of families and approval of staff in both homes, this was resolved by allowing residents to purchase small bottles of soy sauce, pickle onions or shredded pickle to enhance the tastes of foods. Other food issues were not always easily resolved.

As most families were in full-time work and visited during the weekends, they got to know about the residents' decision-making capabilities through the staff who took initiative to tell them about the daily happenings. They were delighted to know that residents were taking care of themselves and finding things to occupy their time. Negotiating about care that went beyond the usual home practice (e.g. preparing packets of drinks or snacks families have brought), and exploring items to purchase for bed unit) were some topics that were successfully discussed by the family on behalf of the residents.

#### **3.2. Partially flexible patterns of decision-making**

This approach was most apparent in home two, and sometimes evident in home one due to the constraints of staff and facilities. Few residents from home three wanted to let staff know their needs because they were reluctant to confront the rigid culture of the home.

#### *3.2.1. Making the unknown familiar*

Some residents (influenced by roommates) initiated plans to bath alone, without telling the staff. Experimenting cleansing in secret led them to become confident to persuade staff to let

*They bathed me the first 2 weeks. How can you bath without them knowing? I saw a resident bathing alone so I bathed secretly a few times. I could do it. I did not know that before. They found out, scolded,* 

Families' views of residents' abilities to make physical care decisions were welcomed. There was a general agreement to allow them to partake in 'basic' daily life decision-making when they were capable and they were not too disruptive to staff or families. Indeed, while some families promoted such decision-making, they also believed that residents should only make decisions on things that were within their capability, even if they could do this slowly.

The processes of 'suggesting and negotiating' and 'compromising' with staff and families about creating a way of life that was reasonably familiar and comfortable for residents marked the continuation of the negotiated decision-making process. The process of suggesting-negotiating arose after residents, who were successful in making some changes, continued to ask and question, and were more likely to discuss and further explore their needs: Everyday it's I

In both homes one and two, an activity enjoyed by residents was the ability to go out alone, and not to be supervised by anyone. Undoubtedly, the ability to go outdoors independently was a rule determined by the home's management and was made known to residents and families on admission. Although residents were able to maneuver freely around the grounds of the home, granting them the freedom to leave the home grounds as they pleased depended on their physical capability, mental alertness and independence. Such requests were carefully negotiated with the family who had to sign a consent form to accept responsibility. The freedom and independence to go outdoors was highly valued, although the outskirts of home one was an industrial area and it was potentially dangerous for elders to be out alone. They therefore spent time walking along the streets, in front of the home. Whilst this created administrative work homes one and two believed that residents should be given freedom to connect with the community, and encouraged to go out freely, providing it had been approved beforehand.

Another example of the process of negotiating-compromising pertained to food choices. This was a longstanding and difficult problem that was not easy to solve. Over time, the food served and timing of meals were not entirely suitable. Some residents questioned the food textures and tastes, and made requests for a change. As there were no resident meetings in home one, the matter was discussed with the residents on an individual level. Avoiding foods the majority disliked was the preferred practice in communal living, as opposed to boosting food tastes for the few who raised it as a concern. With the help of families and approval of staff in both homes, this was resolved by allowing residents to purchase small bottles of soy sauce, pickle onions or shredded pickle to enhance the tastes of foods. Other food issues were

them do it under supervision:

230 Gerontology

not always easily resolved.

*observed me. Now I do it myself.* (SH, elder, E11A)*.*

*3.1.3. Negotiating-compromising the past to fit the present*

see what I can do. I depend on myself all the time. (POAH, elder, E2A).

Compared with home one, the processes of accompanying and supervising elders was not as closely monitored by staff in home two, while the processes of telling and observing was given greater emphasis. The processes of accompanying and supervising involved staff helping residents to become familiar with the routine and physical care, particularly how they fitted in with the baths, meals and sleeping arrangements. Being a larger home, these processes identified issues that could potentially cause unharmonious relationships such as room- and table-sharing, and being prepared to minimize conflicts should they arise:

*The idea of decision-making depends on reciprocal relationship of elders to respect each other. It's communal living. You are not in a single room. Issues like over-using or not letting others use the airconditioning and fans in the bedrooms, or asking to live on a specific floor.* (SH, social worker, S8)*.*

Residents and families were not fully told about the roles of staff (due to many staff) and the pattern of work. Instead families were told of an appointed social care staff and to approach the care staff on each floor for enquiries. They only needed to be observant, oblige and accept what they had been told. Indeed, residents learnt more by observing other resident's behaviour and attitudes of staff towards them, particularly towards room-sharing and how they formed friendships. Unlike home one where residents had single rooms, a major issue in home two was the resident's uncertainties about forming relationships in a large home.

Here families' visits to the residents were confined mostly to the weekends, and there were less daytime/evening visits to lend a helping hand, because of work and family commitments. Families found out about the home's routines largely through talking to the resident, the majority in this home being cognitively intact. The opportunity to move freely around and outside the home, without the operation of a rigid documentation procedure, was viewed with initial surprise by families, although they liked the freedom it gave:

*The rules for taking residents out are a bit loose. I thought it was strange when no one asked me questions (visited biweekly). The home likes to give freedom and convenience to resident and families, and prevents a feeling of imprisonment.* (SH, daughter, R8)*.*

#### *3.2.2. Finding out what I can do and want*

A policy that became more flexible in home two was a result of female residents' determined efforts to launder their own clothes (not an established home policy) by not approaching the staff first to ask for permission. There was considerable dissatisfaction with the laundry service that often produced creased clothes that were impossible to wear. Instead of openly expressing their dissatisfaction, residents chose to launder light clothing and balanced this by complying with the rules to let the home launder larger garments. Once it was clear that this did not cause major disruption, staff turned a blind eye and provided floor mats, fans and mops to ensure safety:

home one, residents with prior successes in negotiation continued to make requests, however they were persuaded to take advice from staff, which was considered to be in their best interest, and thereby sometimes had to compromise their own expectations. For example, residents were highly influenced by the advice of their family members. Some residents were happy not to go outdoors unless accompanied by relatives. In such situation, they would not bargain with the staff. They would choose to wander in the home's premises and remain in the garden, which

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*I will not go outdoors by myself. There're rules. I cannot go out whenever I want without telling them. I say, "I'm going to the garden. If someone wants me I'll be there." That's already good enough for me.* 

Some alert residents with physical limitations compromised by sacrificing outdoor activities they had previously enjoyed due the burden they felt would be placed on others to help them.

*I have not joined the trips. I cannot walk. I need others to push me (on wheelchair), and it's hot outside. I join activities that do not need others' help. They said if my family can push me, I can go. I do not want* 

Indeed, a resident's state of health seemed to be the determining criterion for having wishes granted. Staff were rather flexible and allowed negotiations when managing residents who insisted, for example, to go against relatives who forbid them from going outdoors. As this home had easy access to the shops, when such circumstances occurred, it was managed individually and flexibly by re-assessing the situation with the resident and family and coming to

In principle home two was in agreement that residents should be accorded the freedom to do things for themselves, however there were contradictory policies that restricted their freedom. Continuing with the example of going outdoors, residents who wanted to go for a walk after dinner would be limited by the regulation to return by a certain time, and therefore limiting true freedom. Although it was difficult to check on the flow of people moving around the home, this issue was not addressed by confining residents to remain indoors to ensure their safety. Instead, strategies were developed to react positively to the resident's situations and still continue to keep the main entrance open to avoid feelings of being in jail or locked up. In home one, while staff tried to maintain the resident's prior lifestyle of allowing them to keep hold of money and make decisions about small purchases, staff in home two did not fully facilitate this practice, although they welcomed appropriate purchases by the family provided there was minimal interference to the running of the home. Although some residents could keep a little money they had to negotiate help from families if they wished to purchase anything, and staff did not help to make any purchases. For residents with no relatives, money matters were handled by the resident until their health deteriorated and a guardian

The data highlighted that the type of decisions families made were guided by the expressed needs of the resident. Families would react in the best interest of these residents, who were less able to express personal preferences and tended to fit in with the majority. Families were also found to support residents to cooperate with the home's decisions and arrangements.

The choice of outdoor activities was limited to those that required no companion:

a new consensus that provided instructions for staff on the provision of care.

*to bother my family so I do not join.* (SH, elder, E8B)*.*

were acceptable alternatives:

(SH, elder, E6A).

would be appointed.

*I wash my clothes and hang them in the bathroom. I do not disturb the others. All elders in my room do their washing. Staff know it. It's no secret. We look after each other and consider safety. Dry the floor and turn on the fan if the bathroom is wet.* (SH, elder, 6B)*.*

Home two had the most choice of social activities (e.g. small groups of elders with dementia playing mahjong, or in large group of 100 to 130 residents). Such activities required staff to make decisions about scheduled indoor activities, including group size, target groups, purpose, and venues. Residents learned about these activities when staff informed them in person, or roommates discussed these activities among themselves. Through these activities, some residents realized their abilities and developed new interests and friends. They preferred activities that taught them to learn new skills such as singing, writing Chinese characters, and the physiotherapy sessions. Activities that required them to communicate had low enrolment. Indeed, it was those residents who were cooperative and obeyed the rules that seemed to be allowed more personal requests. For example, residents who had befriended other residents would group together to ask staff's permission first before engaging in mahjong gatherings. Some residents with difficulties in mobilization aspired for more outdoor activities, or to be trained to walk or use the wheelchair, and were finding ways to make this happen without being seen as troublesome:

*I seldom go outside. It's what you can do when you go outside. I do not know how to use the wheelchair. They do not have activities to allow people in wheelchair to go out and sit under the sun. All the activities are indoors.* (SH, elder, 3A)*.*

To increase resident's participation, special arrangements were facilitated by staff to maximize frail and less able residents to participate in different activities:

*We choose suitable time and venue for the residents. We know some residents come out and have their tea so activities are arranged at those times* (SH, welfare worker, S5)*.*

Despite visiting less often than in home one, families still provided close support and encouragement in the course of decision-making. While families became concerned about safety, they supported resident's decisions to launder own clothes by offering to take larger-sized clothes home to wash, but thought it was unnecessary to intervene with the home's practices when the solution to deal with the issue was not entirely inconvenient.

#### *3.2.3. Negotiating-compromising the past to fit the present*

The processes of 'suggesting and negotiating' and 'compromising' with staff and families occurred in such a way that allowed requests to be considered before coming to a final decision. Like home one, residents with prior successes in negotiation continued to make requests, however they were persuaded to take advice from staff, which was considered to be in their best interest, and thereby sometimes had to compromise their own expectations. For example, residents were highly influenced by the advice of their family members. Some residents were happy not to go outdoors unless accompanied by relatives. In such situation, they would not bargain with the staff. They would choose to wander in the home's premises and remain in the garden, which were acceptable alternatives:

*3.2.2. Finding out what I can do and want*

232 Gerontology

*and turn on the fan if the bathroom is wet.* (SH, elder, 6B)*.*

happen without being seen as troublesome:

*ties are indoors.* (SH, elder, 3A)*.*

A policy that became more flexible in home two was a result of female residents' determined efforts to launder their own clothes (not an established home policy) by not approaching the staff first to ask for permission. There was considerable dissatisfaction with the laundry service that often produced creased clothes that were impossible to wear. Instead of openly expressing their dissatisfaction, residents chose to launder light clothing and balanced this by complying with the rules to let the home launder larger garments. Once it was clear that this did not cause major disruption, staff turned a blind eye and provided floor mats, fans and mops to ensure safety:

*I wash my clothes and hang them in the bathroom. I do not disturb the others. All elders in my room do their washing. Staff know it. It's no secret. We look after each other and consider safety. Dry the floor* 

Home two had the most choice of social activities (e.g. small groups of elders with dementia playing mahjong, or in large group of 100 to 130 residents). Such activities required staff to make decisions about scheduled indoor activities, including group size, target groups, purpose, and venues. Residents learned about these activities when staff informed them in person, or roommates discussed these activities among themselves. Through these activities, some residents realized their abilities and developed new interests and friends. They preferred activities that taught them to learn new skills such as singing, writing Chinese characters, and the physiotherapy sessions. Activities that required them to communicate had low enrolment. Indeed, it was those residents who were cooperative and obeyed the rules that seemed to be allowed more personal requests. For example, residents who had befriended other residents would group together to ask staff's permission first before engaging in mahjong gatherings. Some residents with difficulties in mobilization aspired for more outdoor activities, or to be trained to walk or use the wheelchair, and were finding ways to make this

*I seldom go outside. It's what you can do when you go outside. I do not know how to use the wheelchair. They do not have activities to allow people in wheelchair to go out and sit under the sun. All the activi-*

To increase resident's participation, special arrangements were facilitated by staff to maxi-

*We choose suitable time and venue for the residents. We know some residents come out and have their* 

Despite visiting less often than in home one, families still provided close support and encouragement in the course of decision-making. While families became concerned about safety, they supported resident's decisions to launder own clothes by offering to take larger-sized clothes home to wash, but thought it was unnecessary to intervene with the home's practices

The processes of 'suggesting and negotiating' and 'compromising' with staff and families occurred in such a way that allowed requests to be considered before coming to a final decision. Like

mize frail and less able residents to participate in different activities:

*tea so activities are arranged at those times* (SH, welfare worker, S5)*.*

when the solution to deal with the issue was not entirely inconvenient.

*3.2.3. Negotiating-compromising the past to fit the present*

*I will not go outdoors by myself. There're rules. I cannot go out whenever I want without telling them. I say, "I'm going to the garden. If someone wants me I'll be there." That's already good enough for me.*  (SH, elder, E6A).

Some alert residents with physical limitations compromised by sacrificing outdoor activities they had previously enjoyed due the burden they felt would be placed on others to help them. The choice of outdoor activities was limited to those that required no companion:

*I have not joined the trips. I cannot walk. I need others to push me (on wheelchair), and it's hot outside. I join activities that do not need others' help. They said if my family can push me, I can go. I do not want to bother my family so I do not join.* (SH, elder, E8B)*.*

Indeed, a resident's state of health seemed to be the determining criterion for having wishes granted. Staff were rather flexible and allowed negotiations when managing residents who insisted, for example, to go against relatives who forbid them from going outdoors. As this home had easy access to the shops, when such circumstances occurred, it was managed individually and flexibly by re-assessing the situation with the resident and family and coming to a new consensus that provided instructions for staff on the provision of care.

In principle home two was in agreement that residents should be accorded the freedom to do things for themselves, however there were contradictory policies that restricted their freedom. Continuing with the example of going outdoors, residents who wanted to go for a walk after dinner would be limited by the regulation to return by a certain time, and therefore limiting true freedom. Although it was difficult to check on the flow of people moving around the home, this issue was not addressed by confining residents to remain indoors to ensure their safety. Instead, strategies were developed to react positively to the resident's situations and still continue to keep the main entrance open to avoid feelings of being in jail or locked up.

In home one, while staff tried to maintain the resident's prior lifestyle of allowing them to keep hold of money and make decisions about small purchases, staff in home two did not fully facilitate this practice, although they welcomed appropriate purchases by the family provided there was minimal interference to the running of the home. Although some residents could keep a little money they had to negotiate help from families if they wished to purchase anything, and staff did not help to make any purchases. For residents with no relatives, money matters were handled by the resident until their health deteriorated and a guardian would be appointed.

The data highlighted that the type of decisions families made were guided by the expressed needs of the resident. Families would react in the best interest of these residents, who were less able to express personal preferences and tended to fit in with the majority. Families were also found to support residents to cooperate with the home's decisions and arrangements. Some found themselves trying to reduce residents' dissatisfaction when they were prohibited from doing things. In the course of incorporating residents' preferences and exploring the best option to address their needs, the data revealed that families and staff had to first agree and, if necessary, compromise their own expectations before deciding on the best action to take to meet the residents' interests. For example dealing with residents' concerns such as returning home for a few days and purchasing accessories highlighted that an agreement between families-staff could be negotiated based on the resident's capabilities and provided that it did not unduly disrupt the home's routines. Indeed, only a minority got to go home to stay during the weekends, with the majority perhaps going home for a few hours. For others, going home to stay a few days was never discussed for fear that the elder would refuse to come back.

Although the efforts of staff to get to know and listen to new residents were noted, generally

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235

*Care staff walk around to see if we are eating safely, and collect feedback about the meals. As the social care staff is responsible for the kitchen, she'll keep walking around the tables to see residents' eating condition – how much is eaten and tastes of foods. When they complain about the dry and tasteless meat, we explain that meals are healthier and low salt, of course, it's tasteless (laughs).* (NSH, RN, S1)*.* However, very little effort was made to get to know the residents as individuals and commu-

*I rarely speak to the staff. I seldom have any problems. When I come, I greet them. They do not tell me about his condition. They are not fussy. I do not expect them to tell me. I have nothing to say. What else* 

Consequently, the process of settling-in at home three involved far less open exchange of information and was an instrumental process based on informing residents-families about

Unlike the other homes, the residents rarely undertook their own physical care as bathing alone was totally discouraged, even if they were capable. Only three residents engaged in

*I bath myself. I can do it myself. I do not need to ask for help with bathing if I can do it. If I cannot do it, there's nothing I can do except to ask for help. If I can manage for myself, I do it on my own. I am* 

Another resident made a strong request to bath alone but this was not granted because she believed that her independent nature was a threat to staff authority. This elder stayed less than 2 months and left because she could not fit in with the home's expectations. The above excerpt highlights the resident's generally obliging attitude towards fitting in with the constraints of communal living and following the schedule. It seemed that only personal requests

*They cannot completely make their own decisions. If it's dinner time and they want to bath, this cannot happen. They need to follow our arrangements. What I can do is to meet their personal requests, if it's not over-exaggerated and is sensible, we let them have their way, like exercising and going to church.* 

Another attempt made by residents to find out their own capabilities was in relation to developing relationships with residents and learning how to pass the day. Unlike home two which had many social activities to draw residents together, in-house group social activities in home three (e.g. bingo and beach ball games) were not particularly enjoyable. Whilst these activities helped to 'pass the time' they did not help to form any meaningful relationships. As opportunities to develop meaningful relationships were limited, residents valued any opportunities to engage in activities that would help them to pass the time and the more able residents did much to try and encourage more options. Other activities were more therapeutic and enabled

residents soon learned to accept and conform to the norm:

nication with families was limited and often superficial:

what was expected of them, as opposed to exploring their needs.

some negotiations about baths after declaring a clear need:

that had no impact on the home were considered:

*is there to talk about?* (NSH, wife, R1)*.*

*3.3.2. Finding out what I can do and want*

*safe.* (NSH, elder, E7B)*.*

(NSH, health worker, S9)*.*

#### **3.3. Constrained patterns of decision-making**

This decision-making pattern was found across all the homes to varying degrees, but largely dominated life in home three.

#### *3.3.1. Making the unknown familiar*

Like the other two homes, home three shared similar practices in the way that information was provided to the residents and families during the early days of admission. Some staff believed that residents should be fully involved in decision-making. In reality, they tended to closely supervise elders and not allow them to take risks:

*When residents have health problems, will their decisions bring maximum benefit? It'll be difficult to ask them to make a correct decision. I'll consider the requests of those in good physical and psychological health. Why 'consider'? They might have done it in a certain way for many years, does it mean it's free of risk? Yes, we should respect them, but we should provide adequate supervision.* (NSH, RN, S10).

As in home two, a key message disseminated to residents and families was the need to comply with the routines that dominated communal living. The processes of 'being accompanied and supervised' rather than 'being told and observing' was more evident in this home. Although the other two homes used these processes to enable newly-admitted residents to know how to 'behave' in the new home, and to acquire knowledge about the routines, home three continued to use these processes from admission and thereafter to strictly supervise residents, allowing far less involvement in the decision-making processes.

Close surveillance was welcomed by residents whose reason for admission was to have staff around to call them for help. However, for many, the level of supervision went too far. For instance, getting up from a chair to fetch a cane to try walking to the toilet was immediately supervised by a staff, who sat them on the toilet, only to return to help as soon as they had finished. Indeed, residents generally understood that close surveillance by staff was part of their training and way of doing things:

*It's their responsibility. They are taught not to allow residents to walk alone. They hold my arms, hold my clothes and go into the toilet with me.* (NSH, elder, E5A).

Although the efforts of staff to get to know and listen to new residents were noted, generally residents soon learned to accept and conform to the norm:

*Care staff walk around to see if we are eating safely, and collect feedback about the meals. As the social care staff is responsible for the kitchen, she'll keep walking around the tables to see residents' eating condition – how much is eaten and tastes of foods. When they complain about the dry and tasteless meat, we explain that meals are healthier and low salt, of course, it's tasteless (laughs).* (NSH, RN, S1)*.*

However, very little effort was made to get to know the residents as individuals and communication with families was limited and often superficial:

*I rarely speak to the staff. I seldom have any problems. When I come, I greet them. They do not tell me about his condition. They are not fussy. I do not expect them to tell me. I have nothing to say. What else is there to talk about?* (NSH, wife, R1)*.*

Consequently, the process of settling-in at home three involved far less open exchange of information and was an instrumental process based on informing residents-families about what was expected of them, as opposed to exploring their needs.

#### *3.3.2. Finding out what I can do and want*

Some found themselves trying to reduce residents' dissatisfaction when they were prohibited from doing things. In the course of incorporating residents' preferences and exploring the best option to address their needs, the data revealed that families and staff had to first agree and, if necessary, compromise their own expectations before deciding on the best action to take to meet the residents' interests. For example dealing with residents' concerns such as returning home for a few days and purchasing accessories highlighted that an agreement between families-staff could be negotiated based on the resident's capabilities and provided that it did not unduly disrupt the home's routines. Indeed, only a minority got to go home to stay during the weekends, with the majority perhaps going home for a few hours. For others, going home to stay a few days was never discussed for fear that the elder would refuse to

This decision-making pattern was found across all the homes to varying degrees, but largely

Like the other two homes, home three shared similar practices in the way that information was provided to the residents and families during the early days of admission. Some staff believed that residents should be fully involved in decision-making. In reality, they tended to

*When residents have health problems, will their decisions bring maximum benefit? It'll be difficult to ask them to make a correct decision. I'll consider the requests of those in good physical and psychological health. Why 'consider'? They might have done it in a certain way for many years, does it mean it's free of risk? Yes, we should respect them, but we should provide adequate supervision.* (NSH, RN, S10).

As in home two, a key message disseminated to residents and families was the need to comply with the routines that dominated communal living. The processes of 'being accompanied and supervised' rather than 'being told and observing' was more evident in this home. Although the other two homes used these processes to enable newly-admitted residents to know how to 'behave' in the new home, and to acquire knowledge about the routines, home three continued to use these processes from admission and thereafter to strictly supervise

Close surveillance was welcomed by residents whose reason for admission was to have staff around to call them for help. However, for many, the level of supervision went too far. For instance, getting up from a chair to fetch a cane to try walking to the toilet was immediately supervised by a staff, who sat them on the toilet, only to return to help as soon as they had finished. Indeed, residents generally understood that close surveillance by staff was part of

*It's their responsibility. They are taught not to allow residents to walk alone. They hold my arms, hold* 

residents, allowing far less involvement in the decision-making processes.

come back.

234 Gerontology

**3.3. Constrained patterns of decision-making**

closely supervise elders and not allow them to take risks:

dominated life in home three.

*3.3.1. Making the unknown familiar*

their training and way of doing things:

*my clothes and go into the toilet with me.* (NSH, elder, E5A).

Unlike the other homes, the residents rarely undertook their own physical care as bathing alone was totally discouraged, even if they were capable. Only three residents engaged in some negotiations about baths after declaring a clear need:

*I bath myself. I can do it myself. I do not need to ask for help with bathing if I can do it. If I cannot do it, there's nothing I can do except to ask for help. If I can manage for myself, I do it on my own. I am safe.* (NSH, elder, E7B)*.*

Another resident made a strong request to bath alone but this was not granted because she believed that her independent nature was a threat to staff authority. This elder stayed less than 2 months and left because she could not fit in with the home's expectations. The above excerpt highlights the resident's generally obliging attitude towards fitting in with the constraints of communal living and following the schedule. It seemed that only personal requests that had no impact on the home were considered:

*They cannot completely make their own decisions. If it's dinner time and they want to bath, this cannot happen. They need to follow our arrangements. What I can do is to meet their personal requests, if it's not over-exaggerated and is sensible, we let them have their way, like exercising and going to church.*  (NSH, health worker, S9)*.*

Another attempt made by residents to find out their own capabilities was in relation to developing relationships with residents and learning how to pass the day. Unlike home two which had many social activities to draw residents together, in-house group social activities in home three (e.g. bingo and beach ball games) were not particularly enjoyable. Whilst these activities helped to 'pass the time' they did not help to form any meaningful relationships. As opportunities to develop meaningful relationships were limited, residents valued any opportunities to engage in activities that would help them to pass the time and the more able residents did much to try and encourage more options. Other activities were more therapeutic and enabled residents to either make the effort to keep in good health or to choose to maintain contacts with the outside community. There was a high enrolment in the few in-house exercise sessions available and many of the residents made a conscious decision to include physical therapy sessions into their week to stay in good health.

The monthly resident meeting (with low attendance) was a regular activity bringing together superintendent, social worker, nurses and families. But these were largely symbolic rather than actively managed to ensure optimal attendance and a contribution from all. Over time, families learned to recognize and approach individual staff with whom residents had forged relationships on a one-to-one level to get updates about the resident's daily care. While staff believed that families must be told of the resident's current lifestyle and condition, there was a perception among staff that building relationships with families was difficult because they were very busy people with little time to spend wanting to know about the home. In fact, to the contrary, some families were highly interested in what went on at the home, and took the

Decision-Making Experiences and Patterns in Residential Care Homes for Older Residents…

http://dx.doi.org/10.5772/intechopen.74267

237

*I want to know what's happening here and its development, whether it'll build 10 more floors or cut the* 

Generally families were in agreement that residents should make their own decisions with the

*You must rely on yourself and make your own decision. The decisions are still made by the elders. Apart from meal times, things like resting, getting up, brushing teeth and washing face can be decided by him.* 

Overall, and despite the obvious limitations, especially in home three it was felt that the resi-

*He can make many decisions and do things for himself. It's just the physical functioning of his upper and lower limbs are degenerating. There's no problem with his ability to be reason and think logically. When you give him choices, he can still make a decision on what choice he wants.* (NSH, son, R2). In reality, there were few opportunities for discretionary choice in home three and despite the constrained-rigid leadership style that enforced staff to regularly report the resident's progress to families blunders did occur that affected family-staff relationships and impacted the families' level of confidence in staffs' decision-making. Unlike the other two homes which were praised for providing families with reassurance, unsatisfactory blunders in handling the residents' health and medical concerns, including mismanagement of follow-up appointments and communication breakdown among staff, were beginning to surface at home three and resulted in families becoming dissatisfied. Misunderstanding often arose when messages about the resident's care were not always correctly conveyed. Moreover, as families were not formally informed about different staff members' roles, they formed their own perceptions of staff's job responsibilities that were not always correct. This could result in further confusion

**4. Discussion: decision-making processes and patterns of residents**

The findings generated served to provide an in-depth understanding of the decision-making experiences of older people residing in residential care homes in HK, and the roles and level of involvement family members and care providers in supporting them, or not, to meet their wishes and preferences. Based on the vivid accounts of experiences that were described by the participants, the patterns of decision-making in the homes were shaped by three processes

limited opportunities to interact with the staff:

dent should still be given choice to make decisions:

(NSH, wife, R1).

and misunderstanding.

*manpower. There's no channel to converse with them.* (NSH, son, R2).

families' role being to present opinions and offer different choices to them:

In the constrained atmosphere of home three, families initiated and supported residents in the rehabilitation process and helped them to realize the capabilities by arranging elders to attend additional physical/acupuncturist sessions and organized private transport to take them. Indeed involvement of the family, whilst valued in all the homes, was especially appreciated in home three. As families became well-aware of their duties to visit and take residents out for meals, the phone calls lessened as their visit became a weekend activity:

*She does not want a lot – only asks when we'll take her out to have meals and dim sum. It's reasonable. She's stuck in the home every day and has nothing to do.* (NSH, son, R4).

Regardless of their abilities, residents were strictly prohibited from going out alone and moving beyond the vision of staff. Some families found this reassuring:

*They have a door bell and the code to enter the home. I totally agree with this arrangement. If not, they'll escape from the home.* (NSH, son, R4).

However such regulations and the general attitude among staff to do things for residents made some feel useless and ashamed:

*I feel ashamed when others help me to wash my face and brush my teeth. I am not very old. One brings me into the toilet on a wheelchair. One twists a towel for me. One holds the mouth wash cup for me. I feel useless. Now, I can only pull a blanket over myself.* (NSH, elder, E6A).

#### *3.3.3. Negotiating-compromising the past to fit the present*

Only the able and articulate residents could engage in efforts to negotiate/comprise and even then opportunities were limited. Indeed, action was limited even when a group of them joined forces and raised shared concerns. This is described below and highlights something approaching a sense of relative helplessness in the face of limited action by staff and the absence of realistic alternatives:

*A naughty resident always disturbs us with a stick when we are sleeping. She does not sleep and walks around with her stick. She keeps the five of us awake by playing with the remote control that raises and lowers the beds. What can we do? I do not want to change rooms – what if there's another naughtier resident? Staff have done nothing, only told her not to disturb us. What can they do? This is an aged home. If we are healthy, we will not be here.* (NSH, elder, E6A).

Another issue that elicited suggestions from residents related to food choices. Some comments about what to eat were sought in a resident meeting, which enabled the few 'smart and well-spoken' residents the liberty to express their food preferences and tastes. But the existence of structures to seek views at this home did not mean that action followed and the need for safety and conformity seemed to prevail.

*Do you think they have the right to choose what they eat here? Meals are set in advance. They suggest food they cannot eat. It's only their desires. We think of safety, difficulties eating it, and can others eat it, too. (NSH, health worker, S2).*

The monthly resident meeting (with low attendance) was a regular activity bringing together superintendent, social worker, nurses and families. But these were largely symbolic rather than actively managed to ensure optimal attendance and a contribution from all. Over time, families learned to recognize and approach individual staff with whom residents had forged relationships on a one-to-one level to get updates about the resident's daily care. While staff believed that families must be told of the resident's current lifestyle and condition, there was a perception among staff that building relationships with families was difficult because they were very busy people with little time to spend wanting to know about the home. In fact, to the contrary, some families were highly interested in what went on at the home, and took the limited opportunities to interact with the staff:

residents to either make the effort to keep in good health or to choose to maintain contacts with the outside community. There was a high enrolment in the few in-house exercise sessions available and many of the residents made a conscious decision to include physical ther-

In the constrained atmosphere of home three, families initiated and supported residents in the rehabilitation process and helped them to realize the capabilities by arranging elders to attend additional physical/acupuncturist sessions and organized private transport to take them. Indeed involvement of the family, whilst valued in all the homes, was especially appreciated in home three. As families became well-aware of their duties to visit and take residents out for

*She does not want a lot – only asks when we'll take her out to have meals and dim sum. It's reasonable.* 

Regardless of their abilities, residents were strictly prohibited from going out alone and mov-

*They have a door bell and the code to enter the home. I totally agree with this arrangement. If not, they'll* 

However such regulations and the general attitude among staff to do things for residents

*I feel ashamed when others help me to wash my face and brush my teeth. I am not very old. One brings me into the toilet on a wheelchair. One twists a towel for me. One holds the mouth wash cup for me. I* 

Only the able and articulate residents could engage in efforts to negotiate/comprise and even then opportunities were limited. Indeed, action was limited even when a group of them joined forces and raised shared concerns. This is described below and highlights something approaching a sense of relative helplessness in the face of limited action by staff and the

*A naughty resident always disturbs us with a stick when we are sleeping. She does not sleep and walks around with her stick. She keeps the five of us awake by playing with the remote control that raises and lowers the beds. What can we do? I do not want to change rooms – what if there's another naughtier resident? Staff have done nothing, only told her not to disturb us. What can they do? This is an aged* 

Another issue that elicited suggestions from residents related to food choices. Some comments about what to eat were sought in a resident meeting, which enabled the few 'smart and well-spoken' residents the liberty to express their food preferences and tastes. But the existence of structures to seek views at this home did not mean that action followed and the

*Do you think they have the right to choose what they eat here? Meals are set in advance. They suggest food they cannot eat. It's only their desires. We think of safety, difficulties eating it, and can others eat* 

meals, the phone calls lessened as their visit became a weekend activity:

*She's stuck in the home every day and has nothing to do.* (NSH, son, R4).

*feel useless. Now, I can only pull a blanket over myself.* (NSH, elder, E6A).

*3.3.3. Negotiating-compromising the past to fit the present*

*home. If we are healthy, we will not be here.* (NSH, elder, E6A).

need for safety and conformity seemed to prevail.

*it, too. (NSH, health worker, S2).*

ing beyond the vision of staff. Some families found this reassuring:

apy sessions into their week to stay in good health.

236 Gerontology

*escape from the home.* (NSH, son, R4).

made some feel useless and ashamed:

absence of realistic alternatives:

*I want to know what's happening here and its development, whether it'll build 10 more floors or cut the manpower. There's no channel to converse with them.* (NSH, son, R2).

Generally families were in agreement that residents should make their own decisions with the families' role being to present opinions and offer different choices to them:

*You must rely on yourself and make your own decision. The decisions are still made by the elders. Apart from meal times, things like resting, getting up, brushing teeth and washing face can be decided by him.*  (NSH, wife, R1).

Overall, and despite the obvious limitations, especially in home three it was felt that the resident should still be given choice to make decisions:

*He can make many decisions and do things for himself. It's just the physical functioning of his upper and lower limbs are degenerating. There's no problem with his ability to be reason and think logically. When you give him choices, he can still make a decision on what choice he wants.* (NSH, son, R2).

In reality, there were few opportunities for discretionary choice in home three and despite the constrained-rigid leadership style that enforced staff to regularly report the resident's progress to families blunders did occur that affected family-staff relationships and impacted the families' level of confidence in staffs' decision-making. Unlike the other two homes which were praised for providing families with reassurance, unsatisfactory blunders in handling the residents' health and medical concerns, including mismanagement of follow-up appointments and communication breakdown among staff, were beginning to surface at home three and resulted in families becoming dissatisfied. Misunderstanding often arose when messages about the resident's care were not always correctly conveyed. Moreover, as families were not formally informed about different staff members' roles, they formed their own perceptions of staff's job responsibilities that were not always correct. This could result in further confusion and misunderstanding.
