No abstract

No abstract

Exchange theory assumes that people strive towards a balance in their personal relationships. The question is why the balance is not restored in unbalanced relationships where older adults receive more instrumental support than they give. The data are from a longitudinal study of 408 older adults and 2044 of their network members. At T1, the older adults received more instrumental support than they gave in 335 (17%) of their relationships. The instrumental support balance in these relationships at T2 was also assessed. The results of a multilevel regression analysis show that network members continue giving support to older adults who are in poor health. If the network member is in poor health, the balance is likely to be restored. Four other reasons for continuing the imbalance were also examined. No evidence was found to back the idea that a lack of instrumental reciprocity could be compensated by the older adults giving more emotional support. The second hypothesis (that close relationships often involve social norms that make it difficult to withdraw from unreciprocated support giving) was confirmed: in kin relationships and friendships, the imbalance persisted over time, while neighbor and other non-kin relationships returned to balance. Thirdly, it was hypothesized that if there were a small number of alternative supporters, it would be hard to withdraw from unreciprocated support giving. However, it was found that if the network was small, the imbalance was not likely to endure. Finally, as predicted, if there was generalized network reciprocity, the balance in particular relationships was not restored.

The objective of the article is to explore the impact quality management systems and quality assurance activities in nursing homes have on clinical outcomes. The results are based on a cross-sectional study in 65 Dutch nursing homes. The management of the nursing homes as well as the residents (N = 12,377) participated in the study. Primary survey-data about the implementation of quality management systems and quality assurance activities were collected in 1994/1995 and in 1998, and were combined with information on resident characteristics and the prevalence of undesirable clinical outcomes. The results demonstrate that there are differences between nursing homes in the prevalence of undesirable clinical outcomes. In the nursing homes with the lowest scores, undesirable outcomes occur approximately 10 times less often than in nursing homes with the highest scores. The multi-level analysis has demonstrated that the differences in outcomes are mainly caused by differences between residents and, to some extent, also by differences between nursing homes. Resident characteristics explain 48% of the differences between residents and 72% of the differences between nursing homes. The size of the nursing home, the involvement of a client council and the implementation of a quality management system could explain a small part of the remaining variation in the number of undesirable outcomes. It seems that the implementation of a quality management system and the involvement of a client council had significant influence on the number of undesirable outcomes. Approximately 50% of the undesirable outcomes cannot be explained by the selected resident characteristics, the size of the nursing home and the implementation of quality management systems or quality assurance activities.