Faculty Bibliography

Many times, informed consent is not a reliable guide in the care of critically ill patients. Previous refusal of consent is not relevant in all cases

The literature defines nondirectiveness as a genetic counseling strategy that supports autonomous decision-making by clients [Fine, 1993]. This study surveyed 781 full members of the National Society of Genetic Counselors (NSGC) between April and June, 1993, to assess how they define nondirectiveness, its importance to their practice, and how and why they are ever directive. Almost 96% of 383 respondents reported viewing nondirectiveness as very important, but 72% stated they are sometimes directive. The most common reasons for directiveness include: difficulties ensuring that verbal and nonverbal cues remain nondirective; to recommend testing; client is unable to understand; a better choice is clear; to recommend medical care or counseling; or when a client has difficulty making a decision. Nonsignificant Chi-square analyses indicated that counselor responses were independent of counselor demographics. While these findings suggest that nondirectiveness is a goal in genetic counseling, it is not the only goal. Recognition of the delicate balance between directing the process and defining the outcome of genetic counseling can enhance clinicians' ability to discern the circumstances under which directiveness is and is not appropriate.

OBJECTIVES: This study examined the importance that nursing home residents and nursing assistants ascribed to control and choice over everyday issues, the satisfaction of residents with their control and choice over these issues, and the nursing assistants' impressions of the extent to which control and choice exist for nursing home residents on everyday matters. DESIGN: Cross-sectional in-person interviews with a stratified representative sample of nursing home residents and nursing assistants using semi-structured interview protocols with both fixed-choice and open-ended questions. SETTING: A random sample of 25 nursing homes in the Twin Cities, MN area; a random sample of five nursing homes in North Little Rock, AR; all five nursing homes in Sante Fe, NM; and five purposively selected nursing homes in each of New York City and Los Angeles, CA. PARTICIPANTS: One hundred thirty-five cognitively intact residents, three from each facility, were selected and included the resident council chair, one randomly selected short-stay resident, and one randomly selected long-stay resident from each facility. Also participating were 134 nursing assistants (1 selected randomly from each shift from those employed at least two-thirds time and who had worked in the facility for at least 3 months). MEASUREMENTS: The most important measurements were ordinal-level ratings of the importance of choice and control for nursing home residents over 10 selected areas of everyday life; ordinal measures of residents' satisfaction with their choice and control over these areas; and nursing assistants' ratings of the extent to which they thought it possible for residents to achieve choice and control. Open-ended comments were also elicited. Also measured were demographic data, ADL status, frequency of trips away from the nursing home, frequency of receiving visitors, and (for nursing assistants) length of employment, wages, job satisfaction, and extent to which they knew the residents under their care. MAJOR RESULTS: Cognitively intact nursing home residents attach importance to choice and control over matters such as bedtime, rising time, food, roommates, care routines, use of money, use of the telephone, trips out of the nursing home, and initiating contact with a physician. Nursing assistants view such control as important to residents. Residents and staff differ significantly in the importance attached to particular items, with staff placing lower importance than residents on use of the telephone and personal expenditures and higher importance on control and choice over visitors and formal nursing home activities. Residents were not very satisfied with their control and choice, and nursing assistants viewed them as unlikely to experience control and choice. Nursing home, resident, and staff characteristics were not associated with the patterns of results. CONCLUSIONS: A self-defeating cycle has been identified where neither resident nor staff are optimistic about achieving more resident control and choice, which both groups perceive as desirable. To end this cycle, suggestions are offered for structuring the role of the nursing assistant, physician and nurse leadership, changes in nursing home routines and practices, and public policy changes.