The Efficacy of Elderly Caring Among Nurses

By: Reynario Cabezada Ruiz Jr.

REVIEW OF RELATED LITERATURE AND STUDIES

“The present challenge is not adding years to one’s life, but rather to

improve the quality of an extended life span.”

(Deluane and Landner, 2004)

As a growing individual and a nursing student, one may have

preconceived ideas about caring for older adults. True to the Filipino culture

and its being a family oriented living, these ideas are influenced by one’s

observation of one’s family members, friends, neighbors and media and their

own experience on older adults. This universal phenomenon called aging has

some type of meaning, whether or not people have taken the time to

consciously think about it.

The Old and Ageism

The impact of change is constant and permanent to every life form.

This change is commonly measured by time which is a concrete determinant

of showing age. Aging as a topic involves a variety of dimensions involving

evident changes in physical, mental, psychosocial and spiritual aspect of a

human person. The human person measures its life by the laps of living time,

of how long one has lived his life. Objectively, aging is observed more by the

physical change it produces, much of which is getting an old age.

Long life, this has been a quest during the past, many of which did not

succeed to realize the secret of its longevity. Before the 1900, men lived a

life expectancy of 47, and relatively only few people reach the age of 50.

Factors of this short life expectancy are much to be blamed to the health

status of aging population. Until in the last centuries, great strides were

made in medicine, sanitation, hygiene and control of infectious diseases.

People have learned to live life longer, with life expectance reaching 75

years or even more, but are still trying to learn how to live well (Deluane and

Landner, 2004).

Mary Kalfoss and Liv Halvorsrud (2008) of Diakonova University

College studied the Important Issues to Quality of Life (QoL) Among

Norwegian Older Adults: An Exploratory Study where the concluded that All

importance issues were found to be moderate to highly important for older

adults with the exception of sex life. Highest mean importance was given to

the ability to perform ADL activities, ability to move around, sensory abilities,

health, and home environment. There are significant differences in the

importance given to various aspects of QoL by younger old and older old and

for women and men. Similarly, there are differences in areas of importance

for those partnered and not and for persons hospitalized and not

hospitalized. Understanding what is important to older adults’ QoL can help

nurses in setting priorities in policy and treatment strategies for ageing

populations. Future application of the importance questions could facilitate

understanding and recognition of importance issues in subgroups of older

adults. Further research is needed to assess how the importance ratings vary

in other elderly populations and cultures.

Many young people today, especially in western countries, have little

personal contact with older family members such as grandparents; also

health care providers usually see only older people who are acutely or

chronically ill and hospitalized or live in a long term care setting (Hogstel,

2010). Older adults are being stereotyped as being ill, bald, hard of hearing,

forgetful, rigid, grumpy or boring simply on the basis on their age and

regardless of their competencies and individual characteristics. The way

people view aging and older adults is often a product of the environment and

experiences to which people are exposed. Ageism or the negative attitudes

towards aging of ten arise in the same way from negative past experiences

(Mauk, 2010).

Getting older is a natural process but many would try to resist it. So

when does old age begin? The most obvious measure of age is a person’s

chronological age, or the exact age of a person from birth. According to the

National Institute of Aging in 2000, ages ranging 65 to 74 years are classified

as young old, 75 to 84 as old, 85 to 94 as old-old and 95 and older are the

elite-old or the chronologically gifted. In 2003, approximately 36 million

people in America are at the age of 65 and older, this is according to the

American Association of Retired Persons (AARP). As the fastest-growing

segment of the population, the number of adults over the age of 65 is

projected to be approximately nine million in the year 2030.

Successful aging can be defined as the enjoyment of health and vigor

of the mind, body and spirit into middle age and beyond (Wagnild, 2003).

Nowadays, the graying of baby boomers demands an enormous impact on

health care in this century especially to nurses requiring them to increase

their sensitivity to and understanding, of the needs, requirements and the

capabilities of the older adults.

Theories of Aging

Theories of aging attempts to completely embrace and explain all the

many facets of change and two of them are popular to us. The Biological

theories address the physical changes of aging one of which is the Stress

Theory suggests that irreversible structural and chemical changes occur in

the body as a result of stress throughout the life span and that individuals

must learn to adapt to these changes. The Cross Linkage Theory describes

the deterioration of tissues and organs as the cause of loss of flexibility and

functional ability that occurs with aging. The Somatic Mutation Theory takes

a similar cellular level approach in stating the changes in DNA that are not

repaired lead to the replication of the mutated cell, which brings about

decreased cellular functioning and loss of organ efficiency. The Programed

Aging Theory states that life span is determined by heredity and that internal

genetic clock is responsible for the rate at which an individual develops, ages

and eventually dies (Deluane and Landner, 2004).

Psychosocial theories on aging present the position that many factors

in addition to genetics contribute to the aging process. The Disengagement

Theory posits that as individual ages, they inevitably withdraw from the

society and the society withdraws from them in a process of separation. The

Continuity Theory suggests that an individual’s values and personality

develop over a lifetime and that goals and individual characteristics will

remain constant throughout life; an individual thus learns to adapt to

changes and will tend to repeat those reactions and behaviors that brought

success in the past. The Activity Theory proposes that an individual’s

satisfaction with life depend on involvement in new interests, hobbies, roles

and relationships. Volunteering is one way that many retirees stay connected

to the community. In addition to providing social connection, volunteer

activities provide a daily routine, a way to make a contribution and a sense

of being needed (Deluane and Landner, 2004).

Perspectives of Caring

There are numerous theoretical concepts relative to caring in nursing.

Some of the major ideas were postulated in Watson’s theory of human caring

where she had her major concepts such as caring is central to nursing

practice, the emphasis of caring is on the dignity and worth of individuals,

each person’s response to illness is unique, caring is demonstrated

interpersonally and caring involves a commitment to care and is based on

knowledge (Watson, 1991).

According to Leininger (2002), caring is the essence of nursing, caring

is universal occurring in all culture, caring behaviors are determined by and

occur within a cultural context. Benner (2001) stated that caring is central to

all helping professions, caring is the foundation of being, people and

interpersonal concerns are important, caring is communicated through

actions, problem solving is a major component of caring and that advocacy is

caring.

In the Nursing Circles of Care, Core and Cure as the central concepts of

Lydia Hall’s theory (1964), care alludes to the “hands-on”, intimate bodily

care of the patient and implies as comforting, and nurturing relationship.

While intimate physical care is provided, the nurse and the patient develop a

close relationship representing teaching and learning aspect of nursing.

Along with the different roles of gerontological nurses, caring is a main

component that connects the nurse to the recipient of service. A study by

Lui, Shwu-Jiaun in 2004 described what caring meant to geriatric nurses. The

researcher concluded that for geriatric nurses, the meaning of caring

included several concepts: deliberation, concern, tolerance, sincerity,

empathy, dedication and initiative. The author suggests that caring for the

elderly should be natural and not superficial in order for the elderly to feel

cared for.

Gerontology and Geriatrics

Quality of life is gaining more emphasis in today’s aging society and

the trend is in fact for people to live longer and healthier lives. Outlook and

adaptation contribute to the high quality of life enjoyed by many older adults

today. Although many people over 65 have some kind of chronic health

problem, most have found ways to keep these ailments from interfering with

their enjoyment of life. Older people accept a certain amount of declining

health as a normal, expected part of aging, but do not allow health issues to

interfere with the vigorous pursuit of enjoyment. In a study in 2003

conducted by S.J. Loeb, S. Frankstern, S.H. Guelner and L.W. Poon titled

“Supporting Older Adults Living with Multiple Chronic Conditions” they found

out that chronicity was a highly personal experience for the older adults.

Seven major categories of coping strategies were determined: relating with

healthcare providers, medicating, exercising, changing dietary patterns,

seeking information, relying on spirituality and religion and engaging in life.

This study provided a view of coping strategies from the client perspective. It

revealed what older adults do every day as they live with multiple chronic

conditions.

Statistics show that the majority of nursing career will include caring

for older adults. As Mathy Mezey, director of the John A. Hartford Foundation

Institute for Geriatric Nursing at New York University, stated, “the population

of older Americans is exploding, Geriatric patients are not one subgroup of

patient but rather the core business of health systems (Mezey, 2005).

Providing quality care to elders requires knowledge of the intricacies of the

aging process as well as unique syndromes and disease conditions that can

accompany growing older.

The Alliance for Aging Research (2002) reports that the average older

adult has three chronic medical conditions. Consequently, more nurses are

needed to care for the increasing number of older adults with chronic illness.

Gerontology is a broad term used to define the study of aging and/or

the aged. This includes the biopsychosocial aspects of aging. Under the

umbrella of gerontology are several subfields including geriatrics, social

gerontology, geropsychology, geropharmachology, financial gerontology,

gerontological nursing, and gerontological rehabilitation nursing and etc.

Geriatrics is often used as a generic term relating to the aged, but

specifically refers to the medical care for the aged. For this reason many

nursing journals and texts have chosen to use gerontological nursing instead

of geriatric nursing. Gerontological nursing then falls within the discipline of

nursing and the scope of nursing practice. It involves nursing advocated for

the health of older persons in all levels of prevention. Gerontological nurses

work with healthy elderly persons in their communities, acutely ill elders

requiring hospitalization and treatment and chronically ill or disabled elders

in long term care facilities, skilled care, home care and hospice (Mauk,

2010).

The scope of practice for gerontological nursing includes all older

adults from the time of “old age” until death. Gerontological nursing is

guided by standards of practice. It is commonly assumed that any nurse can

take care of older adults. However, with the increasing population of older

adults there has been an increase in the amount in specialized geriatric

nursing knowledge needed to care for this population. Not only are more

nurses needed to care for older adults, but nurses competent in the care of

older adults will be needed to meet the enhanced needs of the older

population. Rosenfeld, Bottrel, Folmer and Mezey (1999) report that “Today,

a nurses’ typical client is an older adult,” and “It behooves the nursing

community to ensure that every nurse graduating from a baccalaureate

nursing program has defined level of competency in the care of eldrly.

Gerontological nursing like other nursing specialty has defined roles in

a given setting. In the role of caregiver or provider of care, the gerontological

nurse gives direct, hand-on care to the older adults in a variety of setting.

Older adults often presents with atypical symptoms that complicate

diagnosis and treatment. Thus the nurse as a care provider should be

educated about disease processes and syndromes commonly seen in the

older population. This may include knowledge of risk factors, signs and

symptoms, usual medical treatment, rehabilitation and end of life care

(Mauk, 2010).

Ann Gallagher and colleagues conducted a research in 2007 in titled

“Dignity in the care of older people – a review of the theoretical and

empirical literature.” The paper critically reviews the theoretical and

empirical literature relating to dignity and clarifies the meaning and

implications of dignity in relation to the care of older people. If nurses are to

provide dignified care clarification is an essential first step. The group

reviewed a range of theoretical and empirical accounts of dignity and

identify key dignity promoting factors evident in the literature, including staff

attitudes and behaviour; environment; culture of care; and the performance

of specific care activities. Although there is scope to learn more about

cultural aspects of dignity the researchers know a good deal about dignity in

care in general terms. As a conclusion the researchers argue that what is

required is to provide sufficient support and education to help nurses

understand dignity and adequate resources to operationalize dignity in their

everyday practice. Using the themes identified from our review we offer

proposals for the direction of future research.

An essential part in nursing is teaching. Gerontological nurses focus

their teaching on modifiable risk factors and health promotion. Many

diseases and debilitating conditions of aging can be prevented through

lifestyle modifications such as healthy diet, smoking cessation, appropriate

weight maintenance, physical activity and stress management. Nurses have

the responsibility to educate the older adult population about ways to

decrease the risk of certain disorders such as heart disease, cancer and

stroke; the leading cause of death for this group.

Geronlogical nurses act as managers during everyday practice as they

balance the concerns of the patient, family, nursing and the rest of the

interdisciplinary team. Nurse Managers must be skilled in leadership, time

management, building relationship, communication and managing change.

Nurse managers may supervise other nursing personnel.

As an advocate, the gerontological nurse acts on behalf of older adults

to promote their best interests and strengthen their autonomy and their

decision making. Advocacy may take many forms including active

involvement at the political level or helping to explain medical or nursing

procedures to the family members on a unit level. Nurses may also advocate

for patients through other activities such as helping family members choose

the best nursing home for their beloved ones or listening to family members

vent frustrations about health problems encountered. Whatever the

situation, gerontological nurses must remember that being an advocate does

not mean making decisions for older adults but empowering them to remain

independent and retain dignity even in difficult situations.

The appropriate level of involvement of nurses at the baccalaureate

level is that of research consumer. Gerontological nurses must remain

abreast of current literature, reading and putting into practice the results of

reliable and valid studies. Using evidence-based practice, gerontological

nurses can improve the quality of patient care in all settings.

Evaluation and Efficacy of Care

Evidence-based practice (EBP) is a problem-solving approach to the

delivery of health care that integrates the best evidence from studies and

patient care data with clinician expertise and patient preferences and values.

Health care that is evidence-based and conducted in a caring context leads

to better clinical decisions and patient outcomes. Gaining knowledge and

skills in the EBP process provides nurses and other clinicians the tools

needed to take ownership of their practices and transform health care. Key

elements of a best practice culture are EBP mentors, partnerships between

academic and clinical settings, EBP champions, clearly written research, time

and resources, and administrative support. (Fineout-Overholt E, 2005)

While there is a extensive development to improve the care of the

elderly especially in the bulk of theoretical knowledge in gerontological

nursing, experts are also aware that there is a need for evaluation and

constant monitoring of its results in the clinical nursing practice.

Evaluating care involves determining the client’s progress toward

achievement of expected outcomes. Effective planning is essential if

evaluation is to be effective. In other words, the planned outcomes are the

yardsticks by which effectiveness of therapies are being evaluated. If there

are no stated expectations of care, how can progress be measured?

The purposes of evaluation include determining the client’s progress or

lack of progress toward achievement of expected outcomes, to determine

the effectiveness of nursing care in helping clients achieve the expected

outcomes, to determine the overall quality of care provided and to promote

nursing accountability.

The nurse who successfully evaluates nursing care uses a systematic

approach that ensures thorough, comprehensive collection of data.

Evaluation is an orderly process consisting of steps such as establishing

standards, collecting data, determining goal achievement, relating nursing

actions to client status, judging the value of nursing interventions,

reassessing the client status and modifying the plan of care (Deluane and

Landner, 2004).

Evaluation is performed at the individual and institutional level.

Organizational evaluation examines the overall ability of the agency to

deliver quality care. Evaluation can be classified according to what is being

evaluated: the structure, the process, or the outcome. Structure evaluation is

a determination of the health care agency’s ability to provide services

offered to its client population. Process evaluation is the measurement of

nursing actions by examination of each phase of the nursing process.

Outcome evaluation is the process of comparing the client’s current status

with the expected outcomes. This type of evaluation examines all direct care

that affects the client’s currents health status. Outcomes evaluation focuses

on the change sof the client’s health status (Kozier et al., 2004).

A Survey of the Quality of Nursing Care in Several Health Districts in

South Africa by Leana Uys and Joanne Naido in 2002 revealed that The

average scores on the different aspects varied from 11% (for nursing

records) to 73% (for management of chronic diseases). Specific problems

became evident. In one district three out of four hand-overs between shifts

of nurses scored less than 50%. In all three districts the use of protective

gear scored low (43%). While the average score for management of chronic

illnesses were high at 73%, the blood pressures of only 23% was within the

target range, and the blood sugar of only 38% of patients were controlled.

Patient satisfaction averaged 72% across the three districts. They also

conclude that study has pointed to a number of problems in the quality of

care given by nurses in three health districts in South Africa. It has

highlighted specific problems in each district and also general problems

across all three districts. Some of these problems might be amenable to

training and education. However, other management strategies also seem to

be indicated. Regular monitoring and feedback to nursing teams, monitoring

meetings in the format of perinatal mortality review meetings, and special

incentives for higher quality might be considered.

Recently there has been emphasis by the nursing profession on

evaluating outcomes. Nurse researchers (Moorhead, Johnson and Maas,

2004) at the University of Iowa have developed classifications of client

outcomes, the Nursing Outcomes Classification (NOC). The NOC provides a

standardized language that can be used to measure the effects of Nursing

practice on client outcomes. The NOC outcomes which are used extensively

in the United States and other countries are constantly undergoing research

to validate application to the clinical practice. Just as the North American

Nursing Diagnosis Association (NANDA) and the Nursing Interventions

Classification (NIC) are continuing to develop a standardized nursing

language relative to diagnosis and intervention, the NOC is striving toward a

similar goal of standardized language for classifying nursing outcomes. The

NOC can be used to enhance decision making in the clinical practice and

research. “Analysis of outcomes may lead initiatives for quality

improvement” (Charters, 2003).

In a study by Gudmundsdottir, Delaney, Thoroddsen and Karlsson in

2004, “Translation of and Validation of the Nursing Outcomes Classification

Labels and Definitions for Acute Care Nursing in Iceland”, revealed that 181

of 260 NOC were perceived as being relevant to clients in the critical care

areas. The Icelandic version of the NOC survey is a comprehensive tool that

can be used for critical care nursing research. NOC outcomes are applicable

to clients in acute care settings in Iceland.

The Nursing Outcomes Classification taxonomy focuses on function,

physiology, psychosocial aspects, health knowledge and behavior and

perceived self-health and family health. The NOC system, which defines over

330 client outcomes that are sensitive to nursing interventions, allows nurses

to evaluate client status over time. The NOC (2004) also listed selected

outcomes relevant to safety maintenance for an elderly client being cared for

in the home. Few of which are namely the description of fall prevention

measures, description of risk reduction measures, description of home safety

measures, description of emergency procedures and description of

community safety risks. Strengthening the links between nursing

interventions and client outcomes will benefit not only clients, but nursing as

well. Having solid evidence that documents the effectiveness of nursing care

on client outcomes will influence political and financial decisions relative to

nursing.

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Related Studies

Abrito III, S., et al. (2007) Quality of Nursing Care and Patient’s Satisfaction:

Proposed Seminar, Unpublished Thesis, Nursing Research, University of

Cebu-Banilad

Naidoo, J., and Uys, L., (2004) A Survey of the Quality of Nursing Care in

Several Health Districts in South Africa, School of Nursing, University of

Natal, Durban, South Africa BMC Nursing 2004, 3:1doi:10.1186/1472-

6955-3-1,

Ruiz, R. Jr., (2010) Patient’s Satisfaction on the Nursing Services at Severo

Verallo Memorial District Hospital, Unpublished Thesis, Nursing

Research, University of Cebu-Banilad

Ann Gallagher, Sarah Li, Paul Wainwright, Ian Rees Jones and Diana Lee

(2008) Dignity in the care of older people – a review of the theoretical

and empirical literature. BMC Nursing 2008, 7:11doi:10.1186/1472-

6955-7-11