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The Administration on Aging1 forecasts that by the year 2020, approximately fifty-five million adults in the U.S. will be aged 65 and older, many of whom will come in contact with a nurses as they seek healthcare for a variety of reasons. Many older adults are likely to live alone, suffer from chronic illness, spend more years and a greater percentage of their lifetime disabled, and have limited income.1 The process of aging and the experience of older age reflect lifelong interactions of individuals and their environment. As a person ages, their health needs become more complex, and recognition of personal resources and social contextual resources as a basis for purposeful participation in the attainment of health goals may be limited. Our knowledge concerning the potential role for health promotion efforts to manage chronic illness and to promote well-being in older adults remains relatively limited. Further, there is a paucity of intervention studies promoting well-being in older adults. Awareness of personal and social- contextual resources appear to play an important role in promoting well-being in older adults who experience chronic illness.2 Access to resources may be particularly important among older adults, representing a critical area for intervention by community health nurses. The challenge for nurses is to effectively facilitate awareness of and access to personal resources and social- contextual resources. The purpose of the manuscript is to describe a theory driven approach to developing an intervention designed to foster personal resources and social contextual resources through the promotion of health empowerment and purposeful participation in goal attainment, enhancing well-being in homebound older adults. The Health Empowerment theory guided the development of the Health Empowerment Intervention (HEI).
The theory of Health Empowerment2–4 is based, in part, on Rogers’ Science of Unitary Human Beings.5, 6 Particularly influential is Rogers’ principle of integrality5 perspective of human beings as integral with their environment in their daily living and health experience; characterized by pattern, self-organization, diversity and innovative change; and as holding individual values and views about health. The theory identifies health empowerment as emerging from a synthesis of personal resources and social-contextual resources.2 Personal resources reflect unique characteristics of older adults such as self-capacity. Social-contextual resources include support from social networks and social service support. Empowerment from this perspective is a dynamic health process that emphasizes “purposefully participating in a process of changing oneself and one’s environment, recognizing patterns, and engaging inner resources for well-being.”7 Health empowerment emphasizes facilitating one’s awareness of the ability to participate knowingly in health and health care decisions.3, 4 The HEI is a theory-based intervention designed to promote the use of personal resources and social contextual resources with the goal of enhancing well-being in homebound older adults. Health empowerment theory is expressive of a human health pattern of well-being and is viewed as a relational process that emerges from the recognition of personal resources and social contextual resources3, 7. This process facilitates purposeful participation in the attainment of health goals and the promotion of individual well-being.
Older adults, particularly homebound older adults, are a vulnerable population at risk of losing their independence as their health declines.8 Challenges of aging among older adults include economic security, access to community services, and health care.1 According to Bolnick,9, 9 older adults with declining health related to chronic conditions often have multiple unmet social and health care needs. These needs may best be met through informal and formal home care services as a basis for delaying or preventing institutionalization.9 Studies suggest that older adults prefer to stay in their homes for as long as possible, but are unaware of resources in their community to help them remain in their home.10 As adults age, their health needs become more complex, and recognition of personal resources and social contextual resources to achieve health goals may be limited due to their limited awareness and access to resources. The growing number of older adults and associated social and health care needs underscore the importance of facilitating awareness of and access to personal and social contextual resources to promote well-being. Despite vulnerabilities, older adults also have strengths that can be built upon to promote well-being.11 Strengths include personal resources, specifically, self-capacity,2, 12 social contextual resources, specifically, social networks,13 and social service utilization.14
Research with older adults has identified personal resources as including unique characteristics, which comprise more than demographic characteristics.2 In a study of older women, Shearer found that personal resources reflected unique characteristics such as self-capacity. Self-capacity included promoting change and growth through acknowledging personal strengths and advocating for self. Acknowledging strength included the participants’ perception that they were strong individuals, had a purpose in life, and were protectors and caregivers to their family. As a personal resource, recognition of self-capacity enhanced their ability to participate in problem solving to make meaningful changes in their well-being.
Social contacts and supportive networks are essential to the health of older adults.15 The extent of social networks and support available for older adults are related to a number of physical and psychological health outcomes that impact well-being.16 Decreased or lack of social network function is consistently associated with risk of dependency and a reduced level of function.17, 18 In those aged 80 and older, Camacho and colleagues19 found that consistent involvement with others in the community led to higher levels of functioning. Qualitative research has found mentoring relationships or supportive peer relationships as necessary ingredients for the empowering process to progress theory.20–22
In a study of participants in a senior congregate meal program, Shearer and Fleury14 found that social resources fostered health empowerment through consistent availability and support in negotiating life changes within the aging process. Support included providing information, feedback, and reinforcement as well as acknowledging and encouraging the open expression of feelings. For participants, contextual resources included community and organizational structures, which built individual and collective capacity through opportunities to remain active in the community, to create and sustain valued friendships, and to stay physically and mentally active. These structures included but were not limited to neighborhood resources and clubs, government-funded programs such as senior centers and social service programs, transportation in the form of dial-a-ride or cab connection, and other government-funded social services programs.
Awareness of and access to resources may be particularly important among homebound older adults with chronic illness, representing a critical area for intervention by community health nurses. However, the needs of many older adults are not being met because they do not possess skills essential to identify and obtain key resources. Given older adults’ increased likelihood of living alone, suffering from chronic illness, spending a greater percentage of their lifetime disabled, and living in poverty, relevant, specific interventions are needed that focus on fostering the recognition and awareness of, and ability to access personal resources and social contextual resources. The HEI is one such intervention developed to increase older adults’ access to personal and social contextual resources.
Health empowerment is a relational process that emerges from the person’s recognition of their own personal and social contextual resources. The objective of the HEI is to facilitate the engagement of the older adult in the process of recognizing personal resources, social contextual resources including social network and accessing social services, and the identification of desired health goals and the means to attain these goals. Enhancing the older adult’s health empowerment is based on critical aspects of treatment including: (1) facilitating recognition of and building self-capacity, (2) facilitating recognition of supportive networks and encouraging the building of social supportive networks, and (3) facilitating recognition of social services and social service utilization. The HEI focuses on purposeful participation in individualized goal attainment by incorporating a focus on the homebound older adult’s concerns and preferences in determining health goals.
To promote self-capacity, the HEI incorporates reminiscence activities in which each participant is encouraged to recall a time that they felt able to change, and improve or participate in determining health goals. Reminiscence is used for life review in which participants have an opportunity to enjoy remembering the richness of their past in order to enrich present life experiences. Thus, memory release may promote a “pouring out” of life changing experiences that could be used to facilitate self-capacity building. Intervention activities also include recognition of one’s strengths, purpose in life, personal growth, and self-acceptance.
The HEI promotes the participants’ acknowledgement of strengths and the use of self-talk to promote positive thinking through the use of thought restructuring of negative messages sent to oneself. Thought restructuring is a strategy used to foster positive, realistic optimism. The HEI facilitates the participants’ identification of life goals as reflecting purpose in life and the identification of experiences that reflect one as growing and expanding. Using thought restructuring, the participant is taught to interrupt negative thoughts by using the verbal command STOP. After sending the stop message, they restructure the thought so that it is more positive. If a message is difficult to change, the participant is taught a breathing technique to help them relax. After they feel relaxed they restructure the negative thought into a positive one that focuses on their strengths and what they have accomplished throughout their life. Finally, through reminiscence activities the participants has the opportunity to think about their past life and acknowledge the good and bad qualities of the self while recognizing the positive aspects.
In the HEI, social network building is fostered through guided strategy formation designed to increase awareness of social contextual resources and reinforce recognized social resources. Participants are encouraged to identify social networks including supportive persons. After identifying people turned to in the past for social support, the individual may recognize benefits or limitations of the support provided. Problem-solving techniques are introduced, in which the participant identifies other social supportive persons and engages in social network building.
In the HEI, building social service utilization includes the recall of social services used in the past, as well as developing strategies for increasing awareness and access to new resources specific to the older adult’s needs. Information is provided regarding available resources within the community and how to access these services, including needed material resources (e.g., transportation, finances, and management of their health needs) and access to needed services. The use of problem-solving techniques for identifying, and accessing, social services related to needed resources are also incorporated. Role-playing is used as a strategy to facilitate reconnecting with others, seeking needed help, contacting and communicating with social service agencies in order to access material resources. For example, even though homebound older adults are receiving home delivered meals, they may need additional resources to access groceries. If the older adult is unaware of specific resources such as grocery delivery or food stamps, this information and strategies on how to access the services is discussed.
To facilitate the dimensions of health empowerment, HEI content is delivered over 6 weeks in a one-on-one format, using three teaching modes: didactic, individualized discussion, and “hands-on” experience. The HEI takes place in the home of the participant, scheduled at a time that is convenient for the participant. Culturally relevant information individualized to the older adult’s identified health goals are provided throughout the intervention sessions. The importance of building trust and rapport with homebound older adults, asking questions that focus on what barriers might keep them from accessing resources, and maintaining a person-centered approach to the intervention is emphasized throughout.23
Emerging from the health empowerment process is a transformation in which the older adult recognizes their ability to purposefully participate in goal attainment and facilitates awareness of and access to needed health and material resources, thereby promoting well-being. The intended effect of the HEI is changes in the perceived well-being of homebound older adults. Achievement of this outcome is contingent on changes in instrumental outcomes, increased purposeful participation in goal attainment. In turn, for positive changes in purposeful participation in goal attainment, the older adult should increase in the intermediate outcome of health empowerment.
Health empowerment is viewed as a relational process that emerges from the person’s recognition of their personal resources and social contextual resources. This view involves a shift from a paternalistic perspective in which the healthcare provider establishes the goals to one in which the homebound older adult purposefully participates in determining and progressing toward attainment of personal health goals, thus promoting well-being. This theoretical view of health empowerment is based upon four principles: (1) empowerment is power that is inherent in the individual and ongoing;24 (2) empowerment is a relational process, expressive of the mutuality between person and environment; (3) empowerment is an ongoing process of change that is continuously innovative; and (4) empowerment is expressive of a human health pattern of well-being.7 In the HEI, health empowerment is viewed as a theoretical mediator which characterizes the process underlying the intervention. Health empowerment emerges that emerges from the recognition of personal resources and social contextual resources and leads to purposeful participation in goal attainment, thereby, promoting well-being.
Based on the findings in the literature and findings from preliminary research, purposeful participation in goal attainment is a theoretical mediator between the health empowerment relational process and the health outcome well-being. Purposeful participation in goal attainment is manifested through awareness, choices, freedom to act intentionally, and involvement in creating change. According to Barrett,25 the concepts of awareness, choices, freedom, and involvement are interrelated. Awareness and freedom to act intentionally guide one’s participation in making choices and determining health goals.26 Shearer3, 4 supported the transforming belief in one’s ability to purposefully participate in health and healthcare decisions, manifesting itself in one’s behavior and awareness of one’s choices to participate in change as a core component of the health empowerment process. In another study, Shearer2 found that homebound older women associated purposeful participation in change in identifying health goals with social contextual resources and personal resources, including self-capacity in the form of strength and the ability to participate in change.
From a health empowerment perspective, well-being is viewed as the ultimate health outcome. Well-being is generally defined as life satisfaction and harmony.27 From a nursing perspective, facilitating health empowerment in order to promote well-being represents a dynamic human health process, one of many that nursing seeks to understand for the betterment of society.7 At the conceptual level, the health outcome well-being reflects the construct health. Changes in well-being are expected to take place between 6 weeks and 12 weeks following initiation of the program and only after improvement in perceived resources, health empowerment, and purposeful participation in goal attainment are achieved.
In the HEI, factors identified which might impact the receipt and development of resources consistent with health empowerment and purposeful participation in goal attainment include prior experiences identifying and developing personal and social contextual resources, physical and emotional health, and the presence of co-morbid conditions which might limit receipt or action on information. Intervention curriculum and delivery are sensitive to these factors. The HEI is conducted in the older adult’s home, which might be considered less stressful for some older adults; participants are encouraged to engage in the intervention in their setting of choice.
In the HEI, the material resources needed include: a meeting area in a safe quiet setting which will allow for individual discussion and interaction, and written materials and picture diagrams that summarize the information provided. A manualized protocol to guide intervention delivery and evaluation of treatment fidelity has been developed. The nurse interveners participate in a training program and are asked to adhere to the intervention protocol in order to maintain consistency in program implementation.
Empowerment emphasizes engaging inner resources for well-being in which an older adult optimizes the ability to transform self through the relational process of nursing.7 A nurse practicing from a health empowerment perspective incorporates strategies that foster awareness of and access to personal and social contextual resources. Nursing actions are directed at helping an older adult become aware of and engaged with their resources in order to purposefully participate in working toward the attainment of health goals. The nurse in concert with the older adult engages in a participatory process in which the nurse listens and encourages the older adult to talk and share their health goals.
The nurse may use constructive reminiscence to encourage the older adult to talk about a situation and challenges faced in the past. Building on their recollection of past situations, the nurse talks with the older adult and encourages them to identify their personal strengths as a resource and how personal strengths used in the past can be used to reach their current health goal. Other resources such as social contextual resources may be needed to attain identified goals. The nurse may serve as a resource by providing support, information, feedback, open exchange of feelings and strategize problem solving skills, as well as facilitating the older adult’s awareness of and how to access supportive persons, networks and agency resources.
National Institutes of Health-National Institute of Nursing Research: R15 NR009225-01A2
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