Assisted living (AL) stresses the importance of resident autonomy in the provision of good quality care. Resident autonomy has been linked to better resident well-being, less reliance on supportive services, and greater participation in social activities. Little is known, however, about factors that foster resident autonomy in AL. This article reviews what is currently known about organizational determinants of resident autonomy in AL. The open-natural systems approach to organizational effectiveness, which views organizations in relation to their environment, provides a broad conceptual framework for this analysis. Factors that influence resident autonomy in AL are classified into two categories: (a) external environmental conditions (e.g., ownership status, chain membership, regulatory environment) and (b) internal organizational structures and processes (e.g., facility size, residents' functional ability, resident social resources, and staff work environment). Environmental conditions represent the most antecedent set of factors that influence resident autonomy, indirectly through their effects on internal organizational structures and processes. Internal organizational factors influence resident autonomy through their impact on policies that enable resident choice and control in the facility. More research is needed to better understand the complex mechanism(s) through which organizational factors influence resident autonomy.
Keywords: assisted living; resident autonomy; long-term care; quality of care
Assisted living (AL) is a rapidly growing residential alternative for the elderly population but one that involves tradeoffs between organizational rules and resident autonomy. Intentionally designed around a philosophy of resident autonomy, AL is one model of care for frail elderly that could mitigate the rising costs of nursing home care and improve quality of life. As a combination of housing and services, AL aims to support residents' autonomy (Ball et al., 2004; Utz, 2003). Relatively little is known, however, about how much autonomy AL residents actually have, or how organizational factors influence residents' autonomy.
Our purpose here is to review what is currently known about the relationships among organizational and other factors and how they influence resident autonomy in AL environments. The intention is to identify factors that influence the encouragement of resident selfsufficiency and the exercise of personal choice and self-direction in their daily lives. The open-natural systems perspective to organizational effectiveness, which focuses on the role of the external environment and internal organizational processes and structures, provides the conceptual framework for this analysis (Scott, 2003).
Our specific aims are to determine what is presently known about the effects of external environmental conditions (e.g., facility ownership, chain membership, regulatory status) and internal organizational factors (e.g., facility size, level of care, resident characteristics, and staff work environment) on resident autonomy in AL. A secondary purpose is to identify gaps in our knowledge of these topics that seem promising as future research directions. Clearly, knowledge about these relationships can help program evaluators, managers, and staff create environments that maximize the quality of resident life in AL.
BACKGROUND AND SIGNIFICANCE
In 2000, more than 34 million Americans (12.6 % of the total U.S. population) were 65 years of age and older. By 2030 the elderly population is expected to surpass 70 million (20% of the total) (U.S. Bureau of the Census, 2002). The projected increase in the absolute number of functionally limited elderly (from 10 million in 2000 to 15 million in 2020) will have substantial effects on the delivery of long-term care (LTC) (Wright, 2005). The costs of LTC are also growing rapidly. Nursing home costs represent about 70% of LTC expenditure and are projected to reach $20 billion by 2020 (Levit et al. …