One recurring theme in this chapter is the problem of financing health care interventions in later life for people in the United States. The Current Controver­sies feature raises several key points about the costs of nursing homes in the United States and the lack of ways to finance those costs. With the aging of the baby-boom generation, it is possible that the coming wave of older adults will be unable to afford the level and quality of care they expect to receive.

This is not the way it is in other countries. For example, U. S. health care expenditures as a percent­age of its gross domestic product are nearly 5 times greater than they are in Singapore, but Singapore’s health care is more effective as measured by the World Health Organization in terms of health attainment of the average resident, affordability, and responsiveness (Murray & Evans, 2003). As such, mere expenditures are not a good indicator of quality.

International funding models for long-term care reflect a wide variety of approaches, including social insurance, universal coverage through public services, financial need based systems, and hybrid approaches. Similarly, there is an equally wide array of ways for limiting expenses. Many countries provide services from in-home through skilled nursing care, and some have formal evaluation procedures to determine the best approach to care for each individual.

What is clear is that there is an array of successful models of providing long-term care to older adults that range from those completely supported by taxes to those that combine public and private contribu­tions. The key is that each has advantages (and disadvantages) that could inform discussions in the United States. It is equally clear that the current U. S. model is not sustainable financially, and that without serious attention there will be major difficulties faced by the coming generation of aging baby boomers.


5.1 Describing Person-Environment


What is the competence-environmental press


• Competence is the upper limit on one’s capacity to function.

• Environmental press reflects the demands placed on a person.

• Lawton and Nahemow’s model establishes points of balance between the two, called adaptation levels. One implication of the model is that the less competent a person is, the more impact the environment has.

• People can show proactivity (doing something to exert control over their lives) or docility (letting the situation determine their lives).

What is the congruence model?

• Kahana’s congruence model proposes that people search for environments that best meet their needs. Congruence between the person

and the environment is especially important when either personal or environmental options are limited.

• The congruence model helps focus on individual differences and on understanding adaptation in nursing homes and other long-term care facilities. Giving people a sense of control over some aspect of their lives is key to successful adaptation.

Where People Live: Person-Environment Interactions 179

What are the major aspects of stress and coping theory relating to person-environment interaction?

• Schooler applied Lazarus’s model of stress and coping to person-environment interactions. Schooler claims that older adults’ adaptation depends on their perception of environmental stress and their attempts to cope. Social systems and institutions may buffer the effects of stress.

What are the common themes in the theories of person-environment interactions?

• All theories agree that the focus must be on interactions between the person and the environment. No single environment meets everyone’s needs.

• Everyday competence is a person’s potential ability to perform a wide range of activities considered essential for independent living.

• Everyday competence forms the basis for deciding whether people are capable of making decisions for themselves.

5.2 The Ecology of Aging: Community Options

What is aging in place?

• Aging in place reflects the balance of environmental press and competence through selection and compensation.

• Throughout adulthood people compensate for change; aging in place represents a continuation of that process.

• Aging in place has resulted in a rethinking of housing options for older adults.

How do people decide the best option?

• The best placement options are based on whether a person has cognitive or physical impairment, the ability of family or friends to provide support, and whether intervention, if needed, can be provided in the current residence or a move is necessary.

How can a home be modified to provide a supportive environment?

• Modifying a home can be a simple process (such as adding hand rails in a bathroom) or extensive (such as modifying doorways and entrances for wheelchair access).

What options are provided in adult day care?

• Adult day care provides support, companionship, and certain types of services. Programs include social, health care, and specialized services.

• Introduction of adult day care needs to be done carefully with persons who have cognitive impairment.

What is congregate housing?

• Congregate housing includes a range of options, which provide social support and meals, but not ongoing medical care.

What are the characteristics of assisted living?

• Assisted living provides options for adults who need a supportive living environment, assistance with activities of daily living, and a modest level of medical care.

• The philosophy of care emphasizes personal control, choice, and dignity.

• Research shows that assisted living is especially helpful for frail older adults.

5.3 Living in Nursing Homes

• At any given time, only about 5% of older adults are in nursing homes. Such facilities are excellent examples of the importance of person-environment fit.

What are the major types of nursing homes?

• A distinction within nursing homes is between skilled nursing care and intermediate care.

• Costs of nursing home care are very high, and only certain types of insurance cover part of the costs.

Who is likely to live in nursing homes?

• The typical resident is female, European American, very old, financially disadvantaged, widowed/divorced or living alone, has no children or family nearby, and has significant problems with activities of daily living.

• Placement in nursing homes is seen as a last resort and is often based on the lack of other alternatives, lack of other caregivers, or policies


governing the level of functioning needed to remain in one’s present housing. It often occurs quickly in the context of a medical crisis.

What are the key characteristics of nursing


• Selection of nursing homes must be done carefully and take the person’s health conditions and financial situation into account.

• Person-centered planning is the best approach.

What are special care units?

• Special care units provide a supportive environment for people with specific problems such as dementia.

• Residents of special care units tend to be younger and more impaired than the rest of the nursing home residents.

Can a nursing home be a home?

• Residents of nursing homes can come to the conclusion that this can be home. Home is more than simply a place to live: Coming to the feeling that one is at home sometimes entails reflection on what one’s previous home was like and recognizing that a nursing home can have some of the same characteristics.

How should people communicate with nursing

home residents?

• Inappropriate speech to older adults is based on stereotypes of dependence and lack of abilities. Patronizing and infantilizing speech are examples of demeaning speech, which are rated very negatively by older adults. The communication enhancement model has been proposed as a framework for appropriate exchange. This model is based on a health promotion model that seeks opportunities for health care providers to optimize outcomes for older adults through more appropriate and effective communication.

How is decision-making capacity assessed?

• The Patient Self-Determination Act (PSDA) requires people to complete advance directives when admitted to a health care facility. A major ethical issue concerns how to communicate this information to people with cognitive impairment in nursing homes.

What are some new directions for nursing


• The Eden Alternative, the Green House concept, and the Pioneer Network have a commitment to viewing older adults as worthwhile members of society regardless of their physical limitations.

Review Questions

5.1 Describing Person-Environment Interactions

• What are person-environment interactions?

• Describe Lawton and Nahemow’s theory of environmental press. In their theory, what is adaptation level?

• Describe Kahana’s congruence model. In what settings is this model especially appropriate?

• Describe the application of the stress and coping model to person-environment interactions. What kinds of things buffer stress?

• What are the common themes expressed by the various theories of person-environment interactions?

• What are the key components of everyday competence?

5.2 The Ecology of Aging: Community Options

• What is aging in place?

• What factors should people use to make decisions about the most supportive environment in which to live?

• How can homes be modified to support older adults?

• What services are provided at adult day care centers?

• What is congregate housing?

• What services are provided at assisted living facilities?

5.3 Living in Nursing Homes

• How many older adults live in long-term care facilities at any given time?

• What types of nursing homes are there?

Where People Live: Person-Environment Interactions 181

• Who is most likely to live in a nursing home? Why?

• How have the characteristics of nursing homes been studied?

• Why do special care units often reflect better placement for people with significant physical or cognitive impairment?

• How does a resident of a nursing home come to view it as a home?

• What are the characteristics of inappropriate speech aimed at older adults? What is an alternative approach?

• How does the Patient Self-Determination Act relate to residents’ decision-making capacity?

• What do the Eden Alternative, the Green House concept, and the Pioneer Network have in common?

Integrating Concepts in Development

• What do the demographics about the aging of the population imply about the need for long-term care through the first few decades of the 21st century?

• How do the theories of person-environment interaction include the basic developmental forces?

• How might a better financing arrangement for alternative living environments be designed?

Key Terms

adaptation level In Lawton and Nahemow’s model, the point at which competence and environmental press are in balance.

adult day care Designed to provide support, companionship, and certain services during the day. assisted living facilities Housing options for older adults that provide a supportive living arrangement for people who need assistance with personal care (such as bathing or taking medications) but who are not so impaired physically or cognitively that they need 24-hour care.

competence In Lawton and Nahemow’s model, the theoretical upper limit of a person’s ability to function. congruence model In Kahana’s model, the notion that people need to find the environment in which they fit and that meets their needs the best. docility When people allow the situation to dictate the options they have and exert little control. ecology of aging Also called environmental psychology, a field of study that seeks to understand the dynamic relations between older adults and the environments they inhabit. environmental press In Lawton and Nahemow’s model, the demands put on a person by the environment.

everyday competence A person’s potential ability to perform a wide range of activities considered essential for independent living. infantilization or elderspeak Also called secondary baby talk, a type of speech that involves the unwarranted use of a person’s first name, terms of endearment, simplified expressions, short imperatives, an assumption that the recipient has no memory, and cajoling as a means of demanding compliance. patronizing speech Inappropriate speech to older adults that is based on stereotypes of incompetence and dependence.

person-environment interactions The interface between people and the world in which they live that forms the basis for development, meaning that behavior is a function of both the person and the environment. proactivity When people choose new behaviors to meet new desires or needs and exert control over their lives.

zone of maximum comfort In competence – environmental press theory, area in which slight decreases in environmental press occur. zone of maximum performance potential In

competence-environmental press theory, area in which increases in press tend to improve performance.



www. cengage. com/psychology/cavanaugh

Visit the companion website, where you will find tutorial quizzes, glossary, flashcards, and more. You can also access the following websites from the companion website.

The Centers for Medicare and Medicaid Services home page includes links to several important sites, including information about Medicare and an outstanding guide to selecting a nursing home. This site provides several very helpful guides in various formats.

The Eden Alternative, the Green House Project, and the Pioneer Network are dedicated to changing the culture concerning older adults. They have developed informative websites about their values, mission, and resources.

Eldercare. gov provides information about services available to older adults in communities in the United States.


Bornstein, R. F., & Languirand, M. A. (2009). When someone you love needs nursing home, assisted living, or in-home care. New York: Newmarket Press. Guide for family members to help them navigate through the eldercare system. Easy to read.

Kidder, T. (1994). Old friends. Boston: Houghton.

Mifflin. A moving story of two older men adjusting to life in a nursing home. Easy reading.

Schor, J. (2008). The nursing home guide: A doctor reveals what you need to know about long-term care. New York: Penguin Group. A guide to nursing homes by a physician expert in geriatric medicine. Easy to read.

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