**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 and six elements. This provided an understanding of how daily life decisions were made, from entry into the home to continuing to be involved in decision-making after becoming familiar with the homes. At the heart of the findings lies the extent to which residents were able to negotiate daily decisions in their life or whether they were required to compromise their needs and accept the routines of the home itself.

include. She suggests that residents and families should be involved in initiatives to consider the homes as a positive choice, such as facilitating trial visits. Clearly this did not happen in

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Of some resonance to this current study, but taking a different approach to 'familiarity' is the work by Reed and Payton [40] which described 'constructing familiarity' as an active process undertaken by residents to adapt to the new home environment over a six-month period. Based on the sparse information that was usually obtained on arrival, residents were found to actively create their own knowledge of the home and focused their efforts on constructing relationships with fellow residents in order to make the home less strange. The authors suggest that 'constructing familiarity' is a potential useful strategy for dealing positively with a major disruption in a person's life; in this case, moving into the homes. The findings were limited to a consideration of residents' knowledge of the physical locality of the home and residents who lived there, with other aspects of adjustment to daily life such as physical needs not being considered. In contrast to this study, gaining familiarity in the homes was primarily concerned with an overall understanding of their daily operation and its influence on all aspects of the resident's life, from which residents could begin to examine their own

Clearly 'familiarity' is a potentially important concept that needs more careful elucidation as to its meaning and how this unfolds over time. This study focused on the period immediately following admission up until 3 months. The process of gaining familiarity may, as already noted, begins before entry and continues beyond 3 months. The literature would suggest that familiarity is important in a time period varying from a few weeks prior to a move to up to 6 months post-move [41–42]. There are benefits in involving residents earlier and becoming

'Finding out what I can do and want' was the second process in exploring residents' capabilities, expectations, and preferences in making some decisions through the processes of 'trial and error testing' and 'asking and questioning'. The processes of trial and error marked the onset of negotiation. While residents were still settling into the home, negotiating and compromising did not feature in the earlier processes of 'observing', 'being told' and 'trial and error testing'. Therefore, the key processes of negotiating-compromising emerged when they began 'asking and questioning'. An interesting finding was that not all residents had expectations to make changes, but they all aspired to find out their capabilities and when would they be able to perform activities alone, and when supervised assistance was needed. This suggested that it was less important for residents to make decisions solely on their own, but rather by knowing the possibilities they could make a choice about whether to pursue independent action or to let staff do things for them. The main activities residents liked was the opportunity to perform alone or with minimal supervision related to physical care, and making personal possessions/purchases. Only when residents had a chance to trial an activity and were absolutely sure of their competence, would they consider proceeding to negotiate with staff. In situations when they were less competent to go it alone or did not think that they would be allowed to do so, they allowed staff to intervene and compromises were made. Little is known in the existing literature about how these negotiations occur and

the present study.

decision-making potential.

familiar with the home before becoming a resident.

Across the homes the decision-making processes and related patterns of Chinese residents revealed the influence of staff and family members, as opposed to residents solely making autonomous decisions. This supports the definition of Circielli [17], who defined decisionmaking as 'a process where individuals … make them (decisions) with others in dyads or groups' (p. 33). This was true for most of the residents in this study. Residents proceeded through three decision-making processes: 'making the unknown familiar', 'finding out what I can do and want', and 'negotiating-compromising the past to fit the present' to become familiar with the home first before becoming involved in daily life decisions.

'Making the unknown familiar' was the first process concerned with assisting residents and families to settle in by using strategies to accompany, supervise, tell and observe. It marks the process of learning from staff to become familiar with the routines, rules and policies of what was possible and allowed. While this provided limited opportunities for residents to participate in decision-making, it was important in laying the grounds for different decisionmaking patterns that developed when residents were engaged in later decision-making. Practices across the homes were in place to facilitate the processes of telling and observing the residents. Whilst they varied somewhat across the homes, these systems were intended to enable more staff to know about the residents' health condition, personality, preferences, and desires to be involved, and thereby begin to form judgments of the resident's decisionmaking ability and potential, and the degree of supervision/help to provide. These systems emphasized interaction with the residents to get to know their needs. However, especially in the early period discussion and information exchange tended to be brief and superficial as both staff and residents described the challenges of finding time to talk in the busy regime. Indeed rather than focusing on individual needs processes served to reinforce the importance of group living and forming reciprocal relationships with everyone to maintain harmony and cooperation. It was in this interaction that the balance between negotiation, partial and total compromise emerged. It was not surprising for residents, especially in home three and to a lesser in extent in home two, to perceive that decision-making was primarily made by staff and there was no longer a need to make major decisions now that they were institutionalized. As families were new to the setting, like the residents they had to settle in, and relied on staff to tell them the 'rules'.

There is relatively more literature concerning the process of 'making the unknown familiar' compared with the other two processes, with literature highlighting the need to ease the transition to a care home for newly-admitted residents [36–39]. These studies emphasize that the pressure and losses surrounding the move into the home should be offset by providing appropriate information and support to enable residents and families to play a full and active role in the life of the home. In easing the transition, O'May [38] mentions being able to 'maintain ownership of decisions about the future', although says little about what these decisions can include. She suggests that residents and families should be involved in initiatives to consider the homes as a positive choice, such as facilitating trial visits. Clearly this did not happen in the present study.

and six elements. This provided an understanding of how daily life decisions were made, from entry into the home to continuing to be involved in decision-making after becoming familiar with the homes. At the heart of the findings lies the extent to which residents were able to negotiate daily decisions in their life or whether they were required to compromise

Across the homes the decision-making processes and related patterns of Chinese residents revealed the influence of staff and family members, as opposed to residents solely making autonomous decisions. This supports the definition of Circielli [17], who defined decisionmaking as 'a process where individuals … make them (decisions) with others in dyads or groups' (p. 33). This was true for most of the residents in this study. Residents proceeded through three decision-making processes: 'making the unknown familiar', 'finding out what I can do and want', and 'negotiating-compromising the past to fit the present' to become famil-

'Making the unknown familiar' was the first process concerned with assisting residents and families to settle in by using strategies to accompany, supervise, tell and observe. It marks the process of learning from staff to become familiar with the routines, rules and policies of what was possible and allowed. While this provided limited opportunities for residents to participate in decision-making, it was important in laying the grounds for different decisionmaking patterns that developed when residents were engaged in later decision-making. Practices across the homes were in place to facilitate the processes of telling and observing the residents. Whilst they varied somewhat across the homes, these systems were intended to enable more staff to know about the residents' health condition, personality, preferences, and desires to be involved, and thereby begin to form judgments of the resident's decisionmaking ability and potential, and the degree of supervision/help to provide. These systems emphasized interaction with the residents to get to know their needs. However, especially in the early period discussion and information exchange tended to be brief and superficial as both staff and residents described the challenges of finding time to talk in the busy regime. Indeed rather than focusing on individual needs processes served to reinforce the importance of group living and forming reciprocal relationships with everyone to maintain harmony and cooperation. It was in this interaction that the balance between negotiation, partial and total compromise emerged. It was not surprising for residents, especially in home three and to a lesser in extent in home two, to perceive that decision-making was primarily made by staff and there was no longer a need to make major decisions now that they were institutionalized. As families were new to the setting, like the residents they had to settle in,

There is relatively more literature concerning the process of 'making the unknown familiar' compared with the other two processes, with literature highlighting the need to ease the transition to a care home for newly-admitted residents [36–39]. These studies emphasize that the pressure and losses surrounding the move into the home should be offset by providing appropriate information and support to enable residents and families to play a full and active role in the life of the home. In easing the transition, O'May [38] mentions being able to 'maintain ownership of decisions about the future', although says little about what these decisions can

their needs and accept the routines of the home itself.

238 Gerontology

and relied on staff to tell them the 'rules'.

iar with the home first before becoming involved in daily life decisions.

Of some resonance to this current study, but taking a different approach to 'familiarity' is the work by Reed and Payton [40] which described 'constructing familiarity' as an active process undertaken by residents to adapt to the new home environment over a six-month period. Based on the sparse information that was usually obtained on arrival, residents were found to actively create their own knowledge of the home and focused their efforts on constructing relationships with fellow residents in order to make the home less strange. The authors suggest that 'constructing familiarity' is a potential useful strategy for dealing positively with a major disruption in a person's life; in this case, moving into the homes. The findings were limited to a consideration of residents' knowledge of the physical locality of the home and residents who lived there, with other aspects of adjustment to daily life such as physical needs not being considered. In contrast to this study, gaining familiarity in the homes was primarily concerned with an overall understanding of their daily operation and its influence on all aspects of the resident's life, from which residents could begin to examine their own decision-making potential.

Clearly 'familiarity' is a potentially important concept that needs more careful elucidation as to its meaning and how this unfolds over time. This study focused on the period immediately following admission up until 3 months. The process of gaining familiarity may, as already noted, begins before entry and continues beyond 3 months. The literature would suggest that familiarity is important in a time period varying from a few weeks prior to a move to up to 6 months post-move [41–42]. There are benefits in involving residents earlier and becoming familiar with the home before becoming a resident.

'Finding out what I can do and want' was the second process in exploring residents' capabilities, expectations, and preferences in making some decisions through the processes of 'trial and error testing' and 'asking and questioning'. The processes of trial and error marked the onset of negotiation. While residents were still settling into the home, negotiating and compromising did not feature in the earlier processes of 'observing', 'being told' and 'trial and error testing'. Therefore, the key processes of negotiating-compromising emerged when they began 'asking and questioning'. An interesting finding was that not all residents had expectations to make changes, but they all aspired to find out their capabilities and when would they be able to perform activities alone, and when supervised assistance was needed. This suggested that it was less important for residents to make decisions solely on their own, but rather by knowing the possibilities they could make a choice about whether to pursue independent action or to let staff do things for them. The main activities residents liked was the opportunity to perform alone or with minimal supervision related to physical care, and making personal possessions/purchases. Only when residents had a chance to trial an activity and were absolutely sure of their competence, would they consider proceeding to negotiate with staff. In situations when they were less competent to go it alone or did not think that they would be allowed to do so, they allowed staff to intervene and compromises were made. Little is known in the existing literature about how these negotiations occur and the findings from this study have important implications for those involved in determining resident's decision-making abilities and potential following entry to residential care homes. These findings challenge beliefs from other studies in HK that all residents are willing to accept help from staff, and are happy being passive recipients of care, and to conform to the dependent role [43]. This perception is in consistent with Confucian ethics and moral obligations to assist and take good care of chronically ill Chinese older people in old age [44–45]. This did not seem appropriate to many residents in this study. Indeed, only those residents in home three were seen to be less active in seeking to perform personal tasks and apparently wanted to be cared for. But this may primarily have been the result of their early learning about the strict 'regime' implemented in this home. An exploratory study by Low et al. [46] had already indicated that many Chinese residents were using their own efforts to support themselves in the homes. Yet, there is again a tension here between residents wanting to maintain privacy in their lives and the Chinese cultural belief in maintaining balance and harmony in relationships. Such findings shed new insights into the creation of social identity and acceptable behaviors for older people in care homes within a Chinese cultural context.

The first two domains are of particular relevance to residents in the homes as they capture the dynamic interaction between individual and interactional elements of negotiation/compromise found in this study. An important consideration is the implicit dilemma of when to hold on and retain control of the situation and when to relinquish that control to others. Paying sensitive attention to understanding an individual person's personal qualities and attributes may be necessary to help assess resilience capabilities and enable residents to continue main-

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

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

241

Similar to the results from this study Cook [47] concludes that 'participants (are) engaged in deliberate decision-making and careful planning to influence their life in the home' (p. 271); for example, modifying their own space, and introducing personal items. Whilst continuing to participate in the daily life in care homes, she revealed how frail residents tried to actively reconstruct their life to do the things that were important to them in order to retain their unique identity to 'live meaningful, purposeful and enjoyable lives' (p. 270). In the process of

• Resident-initiated/resident implemented strategies: the person identifies what is needed to

• Resident initiated/other executed strategies: the person identifies what needs to take place

• Resident negotiation to identify possibilities for living in the home and ways to achieve these: the person participates in decision-making processes such as care planning and resi-

These strategies above resonate with the decision-making patterns emerging from this study but in the Hong Kong context there appeared to be more emphasis on the second set of strategies. Cook [47] mentions that residents may know their needs, but their influence in meeting them may be reduced, and therefore there is a reliance on others to help them to follow up on the negotiated issue or to compromise their decisions. Conversely, in situations where residents were less competent to go it alone, they allowed staff to intervene and compromises were made.

The wider literature on decision-making highlights the analytical deductive or the intuitive decision-making approaches to reaching decisions [51]. While the intuitive approach is a quicker, relies on non-analytical reasoning, and makes association with prior learning/memory of similar situations that is context based, the analytical deductive approach is in contrast slower, rule based, systematic logical thinking and context-free [52]. Findings of this study identified that daily lifestyle decisions were residents' main concerns and that in reality decisions involved a combination of both approaches. Residents have to learn the new 'context', compare it with similar experiences (usually often limited) as well as becoming familiar with the rules, both implicit and explicit operating in the homes. If things are to improve there is a need for far greater awareness among families and staff of the delicate processes at play. It

taining a degree of independence [49]. Home staff could learn much from this.

reconstructing a new home life, they implemented three resident-led strategies:

influence their life and takes action to achieve them.

dent committees with staff to influence their home life.

and seeks support from staff, family and friends.

**5. Conclusion**

In understanding resident's decision-making potential and abilities, findings of this current study demonstrate the delicate processes of negotiation and compromise necessary in order to successfully 'negotiate-compromise the past to fit the present' so as to create a way of life that would be familiar and comfortable for the residents. The actions of the resident, family and staff enacted within the dominant pattern of decision-making in the home shaped the extent to which the resident's wishes were either accommodated or compromised. Residents challenged boundaries of the rules and policies of the home to enable them to make judgments about how much flexibility and control they could have over aspects of their lives. In many circumstances, efforts were abandoned as they complied with the prevailing practice of the home. This often followed a process of negotiating and compromising with their requests until an agreed decision was reached. Findings from this current study revealed that when homes operated a rigid-constrained regime, discussions and negotiations were minimal and after experiencing early failure no more efforts were made by the residents to suggest further changes to their lifestyle. This raises important questions about the extent to which residents can operate with a degree of independence or whether in reality the needs of the 'home' will largely always hold sway.

A number of studies have explored the experiences and well-being of the resilient older person who is relatively active in retaining their unique identity when faced with major threats in later life [47–50]. Among older people receiving long-term community care, Janssen et al. [49] identified sources of strengths to buffer against stressful situations. These are:


The first two domains are of particular relevance to residents in the homes as they capture the dynamic interaction between individual and interactional elements of negotiation/compromise found in this study. An important consideration is the implicit dilemma of when to hold on and retain control of the situation and when to relinquish that control to others. Paying sensitive attention to understanding an individual person's personal qualities and attributes may be necessary to help assess resilience capabilities and enable residents to continue maintaining a degree of independence [49]. Home staff could learn much from this.

Similar to the results from this study Cook [47] concludes that 'participants (are) engaged in deliberate decision-making and careful planning to influence their life in the home' (p. 271); for example, modifying their own space, and introducing personal items. Whilst continuing to participate in the daily life in care homes, she revealed how frail residents tried to actively reconstruct their life to do the things that were important to them in order to retain their unique identity to 'live meaningful, purposeful and enjoyable lives' (p. 270). In the process of reconstructing a new home life, they implemented three resident-led strategies:


These strategies above resonate with the decision-making patterns emerging from this study but in the Hong Kong context there appeared to be more emphasis on the second set of strategies. Cook [47] mentions that residents may know their needs, but their influence in meeting them may be reduced, and therefore there is a reliance on others to help them to follow up on the negotiated issue or to compromise their decisions. Conversely, in situations where residents were less competent to go it alone, they allowed staff to intervene and compromises were made.
