Relationship between perceived empowerment care and quality of life among elderly residents within nursing homes in Taiwan: A questionnaire survey

Relationship between perceived empowerment care and quality of life among elderly residents within nursing homes in Taiwan: A questionnaire survey

ARTICLE IN PRESS International Journal of Nursing Studies 43 (2006) 673–680 www.elsevier.com/locate/ijnurstu Relationship between perceived empowerm...

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International Journal of Nursing Studies 43 (2006) 673–680 www.elsevier.com/locate/ijnurstu

Relationship between perceived empowerment care and quality of life among elderly residents within nursing homes in Taiwan: A questionnaire survey Yu-Ching Tua, Ruey-Hsia Wangb,, Shu-Hui Yehc,d a

Shu-Zen College of Medicine and Management, No. 452, Huan-Chiu Rd., Lu-Zhu, Kaohsiung Country 821, Taiwan b School of Nursing, Kaohsiung Medical University, No. 100, Shih-Chuan 1st Road, Kaohsiung City 807, Taiwan c Chang Gung Institute of Technology, 12F, No.123, Ta-Pei Rd., Niao-Sung, Kaohsiung Hsiang 833, Taiwan d Chang Gung Hospital at Kaohsiung, Taiwan Received 5 January 2005; received in revised form 27 July 2005; accepted 13 October 2005

Abstract Background: It is essential for nurses to have a solid understanding of what may influence the quality of life (QOL) among elderly residents within nursing homes. Although many factors have been demonstrated to be related to the QOL among elderly people, the relationship between perceived empowerment care and QOL among elderly residents within nursing homes has not been investigated thoroughly. Objectives: The aim of this study is to explore how demographic characteristics, perceived empowerment care and functional status affect perceived QOL among the elderly residents who reside in nursing homes. Design: This study employed a cross-sectional design. Settings: Eight nursing homes throughout southern Taiwan were recruited into this study. Participants: One hundred and two residents aged 65 years or older residing in nursing homes for at least 6 months, who did not have moderate to severe obstacles in cognitive ability, were recruited as participants. Methods: A questionnaire including demographic data, a physical function scale, an activity of daily living (ADL) scale, a patient empowerment scale, and a QOL index was used in this study. Results: The results showed a medium rating level of QOL among elderly residents. Elderly residents did not feel excessively disempowered care. Perceived empowering care, ADLs and marital status were significant predictors of QOL, which explained 45.3% of the total amount of variance in QOL. Perceived empowering care was the most important predictor of QOL. Conclusions: Nurses should pay attention to the effect of empowering care on QOL of elderly residents within nursing homes. Empowering care should be considered as a strategy of nursing care in nursing homes. r 2005 Elsevier Ltd. All rights reserved. Keywords: Quality of life; Empowerment; Nursing home residents

Corresponding author. Tel.: +886 7 3121101x2641; fax: +886 7 3218364.

E-mail addresses: [email protected] (Y.-C. Tu), [email protected] (R.-H. Wang), [email protected] (S.-H. Yeh). 0020-7489/$ - see front matter r 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2005.10.003

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What is already known about this topic? Demographic variables and functional status influence QOL in elderly residents within nursing homes.

What this paper adds This paper provides new insight about perceived empowerment and QOL of elderly residents in Taiwanese nursing homes. Perceived empowering care, ADL, and marital status were significant predictors of QOL. Additionally, empowering care is more important than ADL in influencing QOL.

1. Background The elderly population is the fastest growing cohort in Taiwan. Owing to the increasing number of doubleincome families, incapacitated elderly are put into nursing homes because of the lack of available family members to care for them. This trend is reflected in the increasing number of nursing homes, which have increased five-fold from 1996 to 2001 in Taiwan (Taiwan Association of Long-term Care Professionals, 2002). For elderly residents in nursing homes, in addition to receiving good care and attaining a strong physical condition and a healthy mental state, preserving and promoting quality of life (QOL) is important (Kane et al., 2003). In this regard, nurses should be especially attentive to improving the QOL of elderly residents within nursing homes. QOL is a general and abstract concept, and it should be evaluated from multilevel dimensions (Lawton, 1991). Lawton (1991) proposed that the components of QOL should include behavior competence, perceived QOL, environmental dimensions and psychological well-being. Ferrans and Powers (1992) defined QOL as self-satisfaction with important events, and a subjective perception of happiness and satisfaction. Oleson (1992) described QOL as a level of satisfaction in health and function, psychological/spiritual, family and the socioeconomic domains. He developed a scale, Quality of Life Index-Nursing Home Version, to investigate the QOL of nursing home residents in the United States. A study using this instrument in Taiwan showed that the rating level of QOL for elderly residents within nursing homes was only in the medium rating level (Tseng and Wang, 2001). Understanding the related factors of QOL for elderly residents within nursing homes could provide information for their nurse to improve the QOL of them. Quality of care has been identified as a factor that can affect the perceived QOL of nursing home residents (Holtkamp et al., 2000). Empowerment care is

advocated through a number of professional and governmental initiatives as a vital ingredient in the provision of quality of care (Hewitt-Taylor, 2004; United Kingdom Central Council for Nursing Midwifery and Health Visiting, 1992). However, few studies have been conducted to understand the relationship between perceived empowerment care (empowering care vs. disempowering care) and the QOL of elderly residents within nursing homes. Empowering patients involves recognizing, promoting, and enhancing the patients’ abilities to meet their own needs, so that they feel in control of their own lives. Rodwell (1996) believed that, in the process of empowerment, patients have the power and freedom to make choices and to take responsibility for their choices and actions. Empowering care helps patients maintain or regain self-control of their lives and of their own care (Anderson et al., 2000; Kuo et al., 2002; Paterson, 2001). Empowering care can help patients become more independent and autonomous (Faulkner, 2001; Gibson, 1991). It was noted that empowering care improved metabolic control and QOL for diabetics (Anderson et al., 1995). Gibson (1991) reported the consistent idea that empowerment improved one’s physical health and overall QOL. Furthermore, several studies have indicated that institutionalized patients are often exposed to circumstances that disempower them (Faulkner, 2001; Grau et al., 1995). Disempowering care ranges from mildly negative interactions, such as invading residents’ privacy or disturbing them during rest, scolding them, or putting them under physical restraint. Such disempowering care tends to make patients feel their lives are beyond their own control (Conwill, 1993). Both empowering and disempowering care are important when considering their relationship with QOL. Some demographic data have been found to be correlated with QOL, and they should be taken into consideration when investigating the relationship between perceived empowerment and QOL. Older age (Oleson, 1992; Tseng and Wang, 2001), higher levels of education (Tseng and Wang, 2001), male gender (Lu and Chang, 1998), having a spouse (Lin et al., 2002), higher socioeconomic status (King, 1996), and having religious beliefs (Krause, 2003; Oleson et al., 1994) were found to be positively correlated with QOL. Better functional status, such as activities of daily living (ADLs) and physical function, also has a positive influence on QOL (Chiang and Lo, 2002; Morgan et al., 2002; Tseng and Wang, 2001). The aims of this study are the following: (1) to provide a profile of QOL and perceived empowerment care for elderly residents within nursing homes in Taiwan, and (2) to determine to what extent the variance in overall QOL is explained by demographic data, functional status, and perceived empowerment care.

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2. Methods 2.1. Participants This study employed a cross-sectional design. Purposive sampling was used to select participants. Sample size was predetermined in advance by using power analysis based on the medium effect size (r ¼ 0:30) between perceived empowerment care and QOL. The a level was 0.05, and the power was 0.80. Eighty-eight was determined as an adequate number of subjects for testing the hypotheses of this study (Polit and Hungler, 1999). Assuming the response rate is 90%, the minimal number of participants would be 96 in the study. Residents within nursing homes aged 65 years or older, living in nursing homes for at least 6 months, were considered to be eligible participants. Since participants needed adequate cognitive ability in order to answer the questions, a Short Portable Mental Status Questionnaire (SPMSQ) developed by Pfeiffer (1975) was administered to all eligible participants. A Taiwanese criterion (Liu et al., 1996) was used to exclude elderly residents who had moderate to severe obstacles in cognitive ability. Eight nursing homes in southern Taiwan agreed to participate in the study. Nurses in the nursing homes selected 112 eligible participants for the researchers. Among these elderly residents, 10 refused to participate. In the end, 102 participants completed the questionnaire. The rate of participants among elderly residents in each nursing home ranged from 18.6% to 23.8%. To avoid overwhelming the participants, the data were collected during one to three visits within 3 days, depending on the condition of each participant. The investigators ensured that there were no factors that might have influenced the responses to any of the scales. It took 45 min–2 h for each participant to complete the questionnaire. The data were collected by one researcher from the research team, and the study was conducted from October 2002 to January 2003. 2.2. Instruments The structured questionnaire including demographic data, a QOL index scale, an empowerment scale, a physical function scale, and an ADL scale was used for data collection. 2.2.1. Demographic scale Demographic data were obtained by collecting participants’ age, gender, marital status, religious beliefs, educational level, socioeconomic status, length of residence in nursing home, and primary diagnosis of disease. 2.2.2. Quality of Life Index-Nursing Home Version Quality of Life Index-Nursing Home Version, a 33item scale, designed by Ferrans and Powers (1985) was

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used in the study. The QOL index includes a two-part subscale that rates satisfaction response and importance response for each item. Examples of these items include, ‘‘How satisfied are you with the amount of control you have over your life?’’ and ‘‘How important to you is having control over your life?’’ Items were scored with Likert-type scales, rated from one point (very dissatisfied/very unimportant) to six points (very satisfied/ very important). A response of ‘‘not applicable’’ was provided if an item was not applicable to participants. The not applicable item was not included in the score calculation. overall QLI scores were computed by the use of the established procedure. Each satisfaction response was weighted with its corresponding importance rating. Weighting was done by subtracting 3.5 from each satisfaction response to center the satisfaction scale on 0. This procedure made 0 the midpoint. Each recorded satisfaction item score was multiplied by its paired importance score. The product of these two scores ranged from 15 to 15. To calculate overall scores, weighted items were summed and divided by the number of items answered. To eliminate negative values, a constant of 15 was added to calculate the final score. The possible range of overall QOL index scores was 0 to 30, with a higher score indicating better perceived QOL. Two items, including ‘‘your relationship with your spouse/significant other’’ and ‘‘your sex life’’ were excluded because 76% and 79% of participants, respectively, reported that these two items were not applicable to them. A total of 31 items were included in the study. 2.2.3. Patient empowerment scale The Patient Empowerment Scale (PES) (Faulkner, 2001), including an empowering subscale and disempowering subscale, was employed in the study. The researchers obtained permission from the original authors to revise it for use in this study. There were 20 items in each subscale, measuring participants’ perceived frequency of empowering care and disempowering care. Originally, PES was a three-point scale. According to the suggestion of the original authors, each item was revised to rate on a four-point scale with responses of ‘‘never’’ (one point), ‘‘rarely’’ (two points), ‘‘sometimes’’ (three points), and ‘‘often’’ (four points). A response of ‘‘not applicable’’ was provided if an item was not applicable to a particular participant by the suggestion of experts. The not available item was not included in the score calculation. According to the opinion of the experts, one item from the disempowering subscale, ‘‘Do staff members take care of you without asking your permission?’’ was discarded because this situation is not allowed in Taiwan. Another item from the disempowering subscale, ‘‘Do staff members prevent you from making decisions about your planned care?’’ was excluded in data analysis because 87% of participants

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reported that it was not applicable to them. A total of 20 items from the empowering subscale and 18 items from the disempowering subscale were included in this study. The mean item score of the empowering subscale and disempowering subscale was calculated by summing the scores of each individual response item in each subscale and dividing them by the number of response items in each subscale. The possible mean item score of each subscale ranged from 1 to 4. Higher scores for the empowering subscale indicated that participants perceived a higher frequency of empowering care, whereas higher scores in the disempowering subscale indicated that participants perceived higher frequency of disempowering care. 2.2.4. Physical functional scale and ADL scale The physical functional scale and ADL scale developed by Shyu et al. (1993) were employed to measure the functional status of participants. The physical function scale consisted of six items that assessed the function of vision, hearing, talking, sleeping, urination control, and bowel movement. Each item was rated from ‘‘damaged function’’ (one point) to ‘‘normal function’’ (five points). The total possible score ranged from 6 to 30, with a higher score indicating a better level of physical function. The ADL scale consisted of 9 items that assessed the performance of daily tasks such as dressing, taking medication, eating, etc. Each item was rated from ‘‘totally dependent’’ (one point) to ‘‘independent function’’ (five points). The total possible scores ranged from 9 to 45, with a higher score indicating better ADLs. 2.3. Validity and reliability After obtaining the permission of original designers of the patient empowerment scale, the investigators translated the scale into Chinese. A linguistic expert completed a backward translation. No wording problems were encountered in the translation of items of the scale. Five professional experts in nursing and public health examined the content validity of the scales. Five elderly residents from nursing homes were asked to review the scales. Twenty participants were interviewed to examine the test–retest reliability of the scales with a 2-week interval. The test–retest reliability was 0.82 for the empowering subscale and 0.75 for the disempowering subscale. In order to avoid an additional burden on participants, test–retest reliability of the QOL index was not performed in this study. However, a previous study in Taiwan demonstrated that test–retest reliability is 0.85 for elderly residents within nursing homes using a 2week interval (Tseng and Wang, 2001). In this study, Cronbach’s a of internal consistency was 0.92 for the QOL index, 0.78 for the empowering subscale, and 0.61 for the disempowering subscale.

2.4. Ethical issues Participants were informed that they had the right to refuse to participate in or withdraw from the study at any time, and that their decision would not affect their present or future care. Only participants signing a consent form were administered the questionnaire. 2.5. Data analysis The Statistical Package for Social Sciences (SPSS) version 10.0 for Windows was used for data analysis. Statistical methods included mean, standard deviation (SD), one-way analysis of variance (ANOVA), the Bonnferroni comparison procedure, Pearson’s correlation, and stepwise multiple linear regression. In all tests, p values of less than 0.05 were interpreted as statistically significant.

3. Results Distribution of gender, marital status, religious beliefs, educational level, and socioeconomic status are shown in Table 1. The age of participants ranged from 65 to 95, with a mean age of 78.45 (SD ¼ 6.55) years. The length of residing in a nursing home ranged from 180 days to 3546 days, with a median of 416 days. Ninety-one participants (89.57%) had multiple chronic diseases. Fifty-nine participants (57.80%) were diagnosed as having cardiovascular illnesses. The mean score of QOL was 18.04 (SD ¼ 3.80), which indicates that the participants perceived a medium rating level of QOL. The mean scores for physical function and ADL were 25.11 (SD ¼ 3.50) and 35.33 (SD ¼ 7.50), respectively. The functional status of the elderly residents was not unacceptably low in this study. Distributions of each item in the empowering subscale are shown in Table 2. The mean item score for the empowering subscale was 2.26 (SD ¼ 0.43). This indicates that patients’ perceived empowering care was within a medium rating level. The lowest score occurred in ‘Do staffs provide you with information about your future care options?’ The second lowest score occurred in ‘Do staffs make sure that you are able to perform activities by yourself?’ Distributions of each item in the disempowering subscale are shown in Table 3. The mean item score for the disempowering subscale was 1.25 (SD ¼ 0.22). This indicates that participants gave a low rating level to perception of disempowering care. Additionally, ‘Do staffs attend other tasks even when they realize you need help?’, ‘Do staffs dispense treatment without telling you what they entail?’ and ‘Do staffs respond slowly to your complaints of being in pain?’ had higher scores than other items.

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Table 1 The distribution and ANOVA analysis of demographic data on quality of life(N ¼ 102) Variables

Gender Male Female Marital status Unmarried Have spouse Widowed Religious beliefs None Buddhist/Taoist Christian/Catholic Educational level Illiterate Elementary, junior high school High school and above Socioeconomic status I, II, III IV V

Quality of life n

M (SD)

55 47

17.89 (3.63) 18.21 (4.03)

15 28 59

15.84 (2.79) 18.48 (4.06) 18.38 (3.77)

24 56 22

17.88 (2.82) 17.36 (4.14) 19.94 (3.33)

24 49 29

18.39 (3.91) 17.46 (3.66) 18.74 (3.94)

23 23 56

18.15 (4.44) 18.50 (3.41) 17.80 (3.73)

F/t value

p

t100 ¼ 0:42

0.67

F 2;99 ¼ 3:05

0.08

F 2;99 ¼ 3:87

0.02

Bonnferroni test

Christian/Catholic 4Buddhist/Taois F 2;99 ¼ 1:16

0.32

F 2;99 ¼ 0:28

0.76

Table 2 The distribution of perceived empowering care(N¼ 102) Items

M (SD)

Do staff allow you time to answer questions? Do staff seek your permission prior to conducting nursing tasks? Do staff allow you time to finish food or drink before it is cleared away? Do staff respect your choices? Do staff show understanding when discussing your problem? Do staff make sure that your nurse call bell is within reach? Do staff make themselves available after realizing that you need help? Do staff treat you quickly after you have complained of pain? Do staff listen to what you have to say without interrupting? Do staff explain their actions throughout nursing tasks? Do staff answer the questions you ask about your care clearly? Do staff work quietly at night to help you get to sleep? Do staff resolve your complaints? Do staff make sure that you are clear about your choices? Do staff give you encouraging remarks for achieving specific goals? Do staff provide you with relevant information about your illness? Do staff check to make sure that information given to you has been understood? Do staff familiarize you with your surroundings? Do staff make sure that you are able to perform activities by yourself? Do staff provide you with information about your future care options? Mean item score

3.35 (0.56) 3.31 (0.59) 3.26 (0.67) 3.11 (0.78) 3.07 (1.00) 3.03 (0.99) 2.89 (0.95) 2.88(1.03) 2.79 (1.08) 2.50 (1.13) 2.47 (1.34) 2.33 (1.12) 1.96 (1.39) 1.47 (0.99) 1.40 (0.67) 1.28 (0.49) 1.27 (0.75) 1.12 (0.83) 1.02 (0.69) 1.01 (0.09) 2.26 (0.43)

Participants who had Christian/Catholic beliefs reported a higher QOL score than those with Buddhist/ Taoist beliefs (MD ¼ 2.58, SE ¼ 0.93, p ¼ 0:02) (Table 1). Physical function (r ¼ 0:27, po0:01), ADL

(r ¼ 0:48, po0:001), and perceived empowering care (r ¼ 0:61, po0:001) were both significantly and positively correlated with QOL. Perceived disempowering care was significantly and negatively correlated with

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Table 3 The distribution of perceived disempowering care(N ¼ 102) Items

M (SD)

Do staff busy themselves with other tasks when they realize you need help? Do staff dispense treatment without telling you what they entail? Do staff respond slowly to your complains of being in pain? Are staff noisy at night stopping you from sleeping? Do staff conduct nursing tasks without explaining their actions? Do staff use dominant postures when talking to you (i.e. placing hands on hips)? Do staff dismiss your complains? Do staff talk down to you as though you were a child? Do staff make remarks, which lower your self-esteem (self regard)? Do staff insist you eat or drink when you do not want to? Do staff give information at a rate too fast for you to understand? Do staff move your bed and locker to different parts of the ward against your wishes? Do staff remove food or drink from your table before you have finished? Do staff fail to assist you with tasks you cannot do? Do staff ask you to do things, which you cannot do because of your illness or disability? Do staff invade your privacy whilst you are performing a personal activity? Do staff order you to take part in activities against your wishes? Do staff disclose private information in an area where it may be overheard by other patients? Mean item score

1.83 1.72 1.47 1.38 1.37 1.30 1.27 1.16 1.15 1.12 1.11 1.08 1.06 1.06 1.04 1.03 1.01 1.00 1.25

(0.76) (1.05) (0.77) (0.79) (0.87) (0.61) (0.99) (0.41) (0.50) (0.45) (0.34) (0.24) (0.45) (0.31) (0.17) (0.10) (0.10) (0.10) (0.22)

Table 4 Stepwise multiple linear regression of quality of life (N ¼ 102) Variables

b

SE(b)

R2

R2 change

F

Empowering care Activities of daily living Marital status (never married vs. married) Constant

0.453 0.289 0.158 1.474

0.816 0.044 0.821 1.863

0.372 0.430 0.453

0.372 0.058 0.024

59.113*** 37.283*** 27.066***

Note: b, standardized regression coefficient. ***po0:001.

QOL (r ¼ 0:53, po0:001). Participants who had better physical function, had better ADL, perceived a higher level of empowering care, and perceived a lower level of disempowering care had better QOL. Stepwise multiple linear regression analysis was conducted to examine the important predictors of QOL. Marital status, religious beliefs, physical function, ADL, perceived empowering care, and perceived disempowering care were taken as independent variables. Marital status was dummy coded as 0 for never having been married and 1 for married (with spouse or widowed). Religious belief was dummy coded 0 for atheism and 1 for having religious beliefs. A stepwise multiple linear regression was performed. The correlation matrix and collinearity diagnostics were carried out to examine the collinearity among independent variables. The results showed that there was no collinearity among independent variables. Linear regression analyses showed that the important determinants of QOL were perceived empowering care, ADL, and marital

status. These explained the total 45.3% of variance in QOL (Table 4). Participants who perceived higher empowering care had better ADL, and those who were married, showed a better QOL. Additionally, perceived empowering care is the most important predictor of QOL and accounts for the 37.2% of the total 45.3% variance explained by the linear regression.

4. Discussion In this study, elderly residents within nursing homes were not with high QOL. This indicates that there is a gap between residents’ needs and care provided by health professionals within nursing homes. Health professionals need to satisfy the needs of elderly residents and improve their QOL. The level of perceived empowering care was only measured at a medium level in this study, which indicates that elderly residents might not be treated in such a way to sufficiently empower

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them. In Taiwan, National Health Insurance does not reimburse for care in nursing homes. Financial problems of the residents might put pressure on nursing homes to operate at lower costs. Nursing homes might be organized around efficient provisions for routine physical care that might disregard the psychosocial needs of residents. In addition, the high workload of the nursing staff may limit their time to provide empowering care to residents. Fortunately, elderly residents did not perceive being treated in such a way that seriously disempowered them. However, the distribution of items in the empowering and disempowering subscales provides an easy tool for evaluating the extent to which elderly residents perceive empowering care and disempowering care. For the items of the empowering subscale, participants scored lowest on the item ‘‘Do staffs provide you with information about your future care options?’’ A previous study found that the majority of nurses were unwilling to share their decision-making powers with patients (Henderson, 2003). Nurses should facilitate resident’s control by providing them information and involving residents in their care plan. Participants also did not score high on ‘‘Do staffs make sure that you are able to perform activities by yourself?’’ In order to increase the efficacy of care, nurses often do all the physical care for the residents without assessing residents’ abilities. It will diminish the independence of elderly residents. Nurses should encourage residents to perform activities by themselves as much as possible. For the perceived disempowering care, items of ‘‘Do staffs busy themselves with other tasks when they realize you need help?’’, ‘‘Do staffs dispense treatment without telling you what they entail?’’ and ‘‘Do staffs respond slowly to your complaints of being in pain?’’ had higher scores than other items as reported by Faulkner (2001). It indicates that patients of different culture may have the same disempowering experiences. The results of this study provide information to nurses on how to improve their care in the future. Nurses should be sensitive to the needs of elderly residents to provide them better care. In a study by Tseng and Wang (2001), ADL, social support from nurses, socioeconomic status, and physical function were important determinants of QOL. Additionally, ADL was the most important determinant of QOL, making up about 24.1% of the variance in the QOL (Tseng and Wang, 2001). In this study, before adding ADL and marital status to the model, the perceived empowering care accounted for 37.2% of the variance in the QOL, and ADL accounted for only 5.8% of the variance of the QOL. This indicates that perceived empowering care is more important than physical function in predicting QOL in elderly residents within nursing homes. Additionally, perceived empowering care is more important than perceived disempowering care to QOL as a determinant of QOL. All the results of this study indicate that empowering care plays an

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important role in the QOL of elderly residents within nursing homes. Although residents’ perceived QOL is also partly a product of their health, social support, and personality, nursing staff within nursing homes can improve the QOL of elderly residents by providing empowering care. Providing tailored care that satisfies the needs of individual residents is a good strategy for empowering residents (Campbell, 2003). Nursing staff also need to create a culture and environment in which residents can feel valued as people. Mok et al. (2004) claimed that nurses’ personalities and skill embedded in the nurse–patient relationship constitute an important source of empowering care. Compassion and caring are two important professional nursing behaviors that empower residents in nursing homes (Campbell, 2003). Nurses need more training in how to provide empowering care to elderly residents within nursing homes. Chang et al. (2004) used dialogical interviewing including building rapport, assessing disempowerment issues, facilitating critical thinking, joint creation, resource connecting, and positive feedback to empower cancer patients. Their results showed good outcomes for the patients. Nurses can apply dialogical interviewing to build partnerships with elderly residents and help them to overcome the suffering caused by disease and frailty. To the best of our knowledge, little study has been conducted on the relationship between perceived empowerment care and the QOL of elderly residents within nursing homes. These results provide new data that are useful in charting new directions for nursing care in order to improve the QOL of elderly residents within nursing homes. 4.1. Limitations Some possible limitations that might have influenced the generality of the findings should be mentioned. First, the patient empowerment scale should be subjected to full psychometric testing, because it was first used in Taiwanese elderly and there was low internal consistency of the disempowering subscale. However, with the limitation of small sample size, the psychometric testing of the patient empowerment scale could not be addressed in the study. The psychometric characteristics of the Chinese version of the patient empowerment scale should be evaluated in the future. Second, convenience sampling was performed from nursing homes in Kaohsiung and Tainan, which agreed to participate, and this may have excluded nursing homes with poorer quality services. Third, elderly residents with moderate or serious cognitive ability deficits were excluded. Therefore, the results cannot be generalized to the entire elderly resident population within nursing homes. As the residents of nursing homes become increasingly cognitively frail, how can empowerment be applied to this population merits

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further studies. Finally, future research needs to move beyond cross-sectional analyses. The effect of empowering care on the QOL of elderly residents within nursing homes should be further investigated.

Acknowledgments We would like to thank the supervisors and nursing staffs from the nursing homes for their assistance with this study. We would also like to thank the elderly residents within the nursing homes who generously shared their experiences with the researchers.

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