Nursing Care for the Whole Person in Older Age

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When a nurse looks at an elderly person, he or she views history. Both literally and figuratively, our elders contain within them the evidence of their own decades of life and those of their community. Given the heterogeneity (Weinert & Timiras, 2003) of experience and health issues that older patients bring to any nursing encounter, it is critical that their medical personnel regard them with as broad, insightful, and bias-free a perspective as possible. This applies to specific issues such as isolation, as well as to their overall quality of life. The person-centered approach to care (Current Theories, 2011) (McCance, McCormack, & Dewing, 2011) offers one useful guide to nursing interactions and interventions (McCormack, 2004 ).

Elderly persons arrive at their senior years with a wide range of experience and exposure. These can affect how they function, and perceive their lives. For example, consider potential exposure (possibly unknown) to carcinogens/pathogens, e.g., asbestos, tobacco, or tuberculosis. Consider, too, the impact of a sedentary or physically demanding job on long-term musculoskeletal health and cardiac fitness. Seniors may have had consistent medical care, or almost none. Arriving at their later years, they may be surrounded by a flock of relatives or have no family anywhere nearby. They may have a hectic volunteer life or be couch-potatoes. Every such difference may affect their dignity and comfort in old age. Each such unique feature should be considered by nursing personnel to provide best assistance towards optimal aging.

In achieving this goal, nursing personnel may be hampered by societal stereotypes, often reinforced by the popular media. Ageist images seem widespread in media, in the workplace, and in the very structures of our communities. Miniscule label typeface and complex packaging baffle anyone with limited vision and dexterity. Staircases without railings, poor public lighting, shopping and services located an obligatory car ride away from most housing; these thoughtless choices send an unwelcoming message to seniors and often consign them to admittedly pleasant-seeming but sequestered enclaves (Wick & Zanni, 2009 ) or institutions (Bookman, 2007). The elderly are portrayed as dithering, insane, or selfish, in movies and television programs such as Sanford and Son, All in the Family, Golden Girls, and Throw Momma from the Train. Advertisements often stereotype the elderly as either sick or helpless (“I’ve fallen and I can’t get up” (LifeALert, 2002)).

The workplace and our role in it are important determinants of self-worth in our culture, which also often exclude the elderly (Peretti & Wilson, 1975) (Phelan, 2008) (Perry, 2010). Retirees may feel left out in many subtle and not so subtle ways. In the United States, one notes anecdotally that one asks a newly introduced individual, “What do you do?” and the answer expected is not gardening, painting, bird-watching or walking unless these are professional, paid activities. As another example, most volunteer organizations meet in “non-working” hours, excluding the elderly who may, for mobility or safety reasons, prefer not to travel by dark or at night. Since a retiree’s income growth is necessarily limited, there is a subtle status shift. Financial advisors tend not to target retirees in the same way that they target potential customers with many years of increasing assets ahead of them.

The recent decade has seen workplace age bias (Manor & Taylor, 2001), whereby older, better paid employees are forced into unwilling retirement, making way cheaper new hires. Thus, retirement may be voluntary, or decidedly unwelcome. It appears, perhaps unsurprisingly, that voluntary retirement is a better preparation for good outcomes (McGoldrick, 1994 in print, 2008 online). The possible reasons seem logically apparent; a voluntary retirement, like anything undertaken of one’s own volition, from a roller coaster ride to surgery, has a better chance of being associated with advance planning, mental acceptance of the event, and a sense of control of one’s life (Minkler, 1981). How can nursing care help people in this period in their lives to be and do the most and the best? The notion of person-centered care offers a potential way to address many of the issues that elders face, and has been described as, “synonymous with best quality care.” (Edvardsson, Fetherstonhaugh, Nay, & Gibson, 2010) This means looking at an older person not just as a set of symptoms in isolation, but as a whole person. This whole person has a biography (McCormack, 2004 ), a set of skills, a community (even if not currently accessible), a family (even if mostly absent or deceased), and potential for contributing in some way.

Appreciating and understanding an elder in this larger context may require substantially more involvement with them and their allies, but the rewards, for both nurse and client, are potentially also substantial. In order to achieve this more in-depth familiarity, it may be necessary to interview them at length and not just about their medical complaints. This may help nurses to perceive an older adult as more than just a “problem to be addressed”, with all their problems “medicalized” (Bookman, 2007).

Open-ended questions about background, education, training, the kind of informal, volunteer, and paid work that they have done, hobbies and interests, will provide a more three dimensional view. Understanding how they spend their time will, additionally, offer clues to their degree of physical activity, and suggest ways to increase it, if needed.

An important element in planning eldercare is the nurse’s understanding of the elder’s existing support network. Interviewing adult children or neighbors may require making oneself available in non-working hours. However, without knowing who the elder’s allies are, it is challenging to plan care, especially since eldercare personnel seem to be in chronically short supply (Kovner & Harrington, 2002)¹.

This greater knowledge of the individual and their potential support network may be needed because, if the goal of nursing care is to contribute to successful aging, it is necessary to comprehend what that term means for each specific elder. Successful aging has long been defined in terms of absence of illness or limited financial assets (McCarthy, 2009). However, this does not take into consideration what the individual considers to be successful. What one person would welcome in terms of assistance, another might consider intrusion.

One area where nursing care can often go deeper in understanding an individual as a whole person is in evaluating isolation. Because isolation has been correlated with greater mortality, it deserves attention (Nicholson, 2008). Informal observation suggests that individuals differ all through life in their need for company. Isolation and loneliness are as complex in elders as is any other discomfort (Nicholson, 2008). One obvious reason for aloneness is loss of spouse, partner, and/or age mates to death. One’s children move away. Neighbors move away. Additionally, many illnesses and disease processes can contribute to isolating an elder, even if they are innately a sociable and companionable sort of person. Loss of hearing, vision, mobility, and cognitive function (Penrod, et al., 2007), all can shut a person into their own skull. All of these factors and more should be reviewed in assessing whether an elder is indeed isolated, or just enjoys their own company.

Viewing elders as more than a walking set of symptoms increases the potential for ‘aging in place’ (Davitt, et al., 2008) (Bookman, 2007). In addition to home and community-based services, monitoring and tele-health technologies (Tang & Lee, 2010) make this alternative to institutionalization increasingly feasible, safe, and comfortable, even with mobility or cognitive impairments (Crossen-Sills, Toomey, & Doherty, 2009) (Hatt, et al., 2009).

Elders are as variable in their embrace of computers as in any other characteristic. Even those who eschew computing, however, might benefit from what Lindenburger terms, “intelligent assistive technology” applied in a, “multi-layered, lifelong process of individualization” (Lindenberger, Lövdén, Schellenbach, & Li, 2008). Demonstrating the possibilities in an elder’s home, if at all possible, with minimal disruption of furniture and plugs and outlets, in the presence of family/allies, could be a powerful inducement to adopt some new technological aids.

All of the above is based on a nursing theory of care that views the older patient as a person in context. With fuller knowledge of their life and personality, both past and present, their network of potential formal and informal supports, and a judicious introduction of smart technology, nursing can help elders age gracefully.

References

Bookman, A. (2007). Keynote Address for the Community, Work and Family II International Conference: Innovative models of aging in place: Transforming our communities for an aging population. ‘Making Connections in a Global Context’, CIES-ISCTE, Lisbon, Portugal, 12_14 April 2007, (p. 435). Lisbon, Portugal.

Crossen-Sills, J., Toomey, I., & Doherty, M. (2009, June). Technology and home care: implementing systems to enhance aging in place. Nurs Clin North Am, 44(2), 239-46.

Current Theories. (2011). Jean Watson’s Philosophy of Nursing. Web.

Davitt, J., Sullivan-Marx, E., Steinberg, H., Schlossberg, D., Wormley, D., Kerman, L., & & Cohen, R. (2008). Care management: Building community capacity to support aging in place. Geriatric Care Management Journal, 18(3 ), 10-15.

Edvardsson, D., Fetherstonhaugh, D., Nay, R., & Gibson, S. (2010, Feb). Development and nitial testing of the Person-centered Care Assessment Tool (P-CAT). International Psychogeriatrics, 22(1), 101-8.

Hatt, W., Vanbaak, S., Jimison, E., Hagler, H., Hayes, T., Pavel, M., & Kaye, J. (2009). The exploration & forensic analysis of computer usage data in the elderly. Conference Proceedings of the IEEE Engineering Medical Biology Society, 1216-9. Web.

Kovner, C. M., & Harrington, C. (2002). Who cares for older adults? Workforce implications of an aging society. Web.

LifeALert. (2002). Patent No. 2630737. USA.

Lindenberger, U., Lövdén, M., Schellenbach, M., & Li, S. (2008). Psychological Principles of Successful Aging Technologies: a mini-review.

Manor, R., & Taylor, T. S. (2001). Age-bias complaints up sharply. The Chicago Tribune. Web.

McCance, T., McCormack, B., & Dewing, J. (2011). An Exploration of Person-Centredness in Practice. The Online Journal of Nursing, 16(2).

McCarthy, V. L. (2009). A New Look at Successful Aging: Exploring a Mid-range Nursing Theory Among Older Adults! in a Low-income Retirement Community. Journal of Theory Construction and Testing, 15(1), 17-23.

McCormack, B. (2004). Person-centredness in gerontological nursing: an overview of the literature. Clinical Nursing, 13(3a), 31-8. doi:PMID:

McGoldrick, A. E. (1994 in print, 2008 online, November). The impact of retirement on the individual. Reviews in Clinical Gerontology, 4 , pp. 151-160.

Minkler, M. (1981). Research on the Health Effects of Retirement: An Uncertain Legacy. Journal of Health and Social Behavior, 22, pp. 117-120. Web.

Nicholson, N. J. (2008). Social isolation in older adults: an evolutionary concept analysis. JOURNAL OF ADVANCED NURSING, 65,(6), 1342–1352.

Penrod, j., Yu, F., Kolanowski, A., Fick, D., Loeb, C.-S. J., I, T.,… JE, H. (2007). Reframing person-centered nursing care for persons with dementia: Review. Res Theory Nursing Practice., 21(1), 57-72.

Peretti, P. O., & Wilson, C. (1975). Voluntary and Involuntary Retirement of Aged Males and Their Effect on Emotional Satisfaction, Usefulness, Self-Image, Emotional Stability, and Interpersonal Relationships. The International Journal of Aging and Human Development, 6( 2), pp. 131 – 138. Web.

Perry, L. (2010). The Aging Workforce: Using ergonomics to improve workplace design. Professional Safety. Web.

Phelan, A. (2008). Elder abuse, ageism, human rights. Nursing Inquiry, 15(4), 320–329.

Tang, F., & Lee, Y. (2010). Home- and community-based services utilization and aging in place. Home Health Care Service Quarterly, 29(3), 138-54. doi:PMID:

Weinert, B. T., & Timiras, P. S. (2003). Invited Review: Theories of aging. Journal of Applied Physiology , 95 ( 4), pp. 1706-1716.

Wick, J., & Zanni, G. (2009 , November). Aging in place: multiple options, multiple choices. Consult Pharmacist, 24(11), 804-6, 808, 811-2.

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Nursing Care for the Whole Person in Older Age

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