Removing powerlessness from the nursing home.

RESIDENT APATHY CAN CAST A PALL OVER THE NURSING HOME ENVIRONMENT. HERE ARE WAYS TO DISPEL IT

Nursing home residents often express lack of interest in their environment and in socialization with others. Residents may see themselves as powerless to change that which they do not desire. This may then progress to a response of helplessness. They often say, "No one listens to me anyhow," and "I don't want to complain." Inconsistent caregiving staff can help lead them to these conclusions.

Literature has suggested that classic symptoms of powerlessness are: apathy, depression with emphasis toward chronic illness, expressions of no control over a situation, non-participation, indecisiveness and passivity. Caregiving staff and family members may also exhibit these symptoms. These symptoms may eventually block successful cooperation among residents, caregiving staff and family members.

Kjervik and Weisensee[1] have noted that keeping elderly people empowered as long as possible will decrease their dependency on those around them. Positive health promotion in the nursing home can enable elderly residents to increase their sense of control over and ability to improve their own health. Additionally, by encouraging elderly residents to assume more of the responsibility for their care, they themselves can control conditions which may impede their progress.[2]

What are the conditions necessary for empowerment in the elderly? A concept analysis by Carol Comb[3] addressed this question. Comb noted that empowerment is a difficult concept to define since it takes on different forms in different people. It is easier to understand by its absence: powerlessness, helplessness, hopelessness, alienation, victimization, subordination, oppression, paternalism, loss of a sense of control and dependency.[4] Gibson[5] has noted that empowerment is often associated with other, more positive concepts such as coping skills, mutual support, competence, self-sufficiency and self-esteem.

When empowered, elderly persons feel personally fulfilled, energized, socially meaningful and effective.[6] Without empowerment, these same persons can be coerced and manipulated. Furthermore, their consent may be violated and autonomy ignored.[7] One might suggest that nursing home residents are unable to be empowered since many of them have cognitive impairments. Empowerment, however, addresses the strengths, rights and abilities of each elderly resident, rather than his or her deficits and needs. It is a positive, dynamic and developmental concept. It denotes the ability of elderly residents and their caregivers to change their tomorrows.

What are the necessary conditions for empowerment to occur? They are autonomy, knowledge, positive self-concept and independence.[3] Each will be explained and some strategies discussed in order to facilitate the necessary change.

Autonomy

Autonomy, or the capacity for self-determination, is indeed difficult to achieve for elderly nursing home residents, many of whom are cognitively impaired and/or have multiple physical needs. Health professionals who think they are helping the elderly resident may in fact impede autonomy. For instance, the resident's selection of daily dress may be facilitated, but in fact is usually determined by the caregiving staff, giving no thought to what the resident would like to wear. A way to increase autonomy would be to offer a choice of clothing, thereby helping the resident feel good about his/her decision-making skills. In this example, the health professional is giving information to the resident as to which clothes are hers/his - and information is an important strategy for increasing autonomy.[8]

It must be remembered that often the elderly resident may decide to delegate decision making to another. In this situation, however, it is important to ensure that the resident has not been coerced into selecting a certain person to act as surrogate. Additionally, although a surrogate decision maker is chosen, the resident should continue to be asked for his/ her viewpoint when a decision is to be made.

Knowledge

Most people would agree that with knowledge comes power. The knowledge that elderly persons bring with them into the nursing home may be faulty or forgotten. It is the duty of the health professional to make sure that the resident has an adequate knowledge base in order to make an informed decision. All alternatives should be explored. For instance, in the earlier example of clothing choice, the knowledge offered might concern the ease with which the resident could put on the clothes, helping to enable the decision-making process. A resident may have difficulty pulling up a zipper, therefore the health professional would point out that tie pants could be easier to manage. Likewise, a woman might have difficulty with zippers or buttons on the back of a blouse and therefore be offered blouses with front closures. When elderly residents are able to make some choices in daily life, their self-concept may be enhanced.

Self-Concept

Self-concept is also developed through experiences and relationships with others. A positive self-concept is imperative. In order to make choices, it is necessary to feel that we are able to make a decision that will benefit us. Without this ability, decision making is willingly conceded to others, contributing to feelings of powerlessness.

Many older persons residing in nursing homes believe that their lives are over and that they have nothing to offer to themselves or others. Since self-concept is reinforced through relationships with others, it is important that health professionals reinforce a positive self-concept through all interactions. If we refer back to the example of clothing choice, self-concept can be enhanced when we show the resident the outcome of his/her choice. For instance, pointing out the ease with which a female resident closes a front-button blouse can help enhance a positive feeling/self-concept. Likewise, the male resident who no longer has difficulty with a pants zipper can feel good about his decision to use a different garment.

Independence

In the nursing home the expectation is that residents will be dependent on others for care - or why else would they be there? In fact, if a resident shows too much independence, he/she may be considered disruptive. Too often well-meaning health professionals take over all care responsibilities for the resident, thereby adding to powerlessness. Families also add to this by demanding that everything possible be done for their loved ones.

Older residents, however, do not want to be dependent if they are able to participate in some of their care. Kapp[8] stated that through independence elderly persons have the opportunity to participate in making decisions and to refuse services that are not acceptable to them. Of course, if we agree that independence is desired, then elderly residents may desire to be dependent on others concerning some of the decisions they are ethically or legally entitled to make.[1] It is when elderly residents' desires are ignored that powerlessness is an outcome. In the clothing example explored throughout this paper, a sense of independence would be enhanced by this daily decision-making activity.

Conclusions

Residents in nursing homes must be afforded the same rights and responsibilities as those older persons residing in the community. This may be difficult to do, as most nursing home residents tend to be quite dependent on others for their daily needs. The challenge for health care professionals is to determine the strengths and abilities that the elderly resident maintains and to capitalize upon them. This will enable elderly residents to be more "in charge" of their lives, even while in an institutional setting. It will remove powerlessness from the environment.

References

1. Kjervik D, Weisensee M. Empowering older people is a perioperative nursing challenge. AORN Journal 1992;55(4):1086-1089.

2. Maglacas A. Health for all: Nursing's role. Nursing Outlook 1988; 36(2):66-71.

3. Comb C. Empowerment in the elderly: A concept analysis. Unpublished paper 1992, The Ohio State University, Columbus, Ohio.

4. Wallerstein N. Powerlessness, empowerment, and health: Implications for health promotion programs. American Journal of Health Promotion 1992; 6(1):197-205.

5. Gibson C. A concept analysis of empowerment. Journal of Advanced Nursing 1991; 16:354-361.

6. Banja J. Rehabilitation and empowerment. Archives of Physical and Medical Rehabilitation; 71:614-615.

7. Kjervik D. Medical empowerment of the elderly. Journal of Professional Nursing 1990; 6(20):74.

8. Kapp M. Medical empowerment of the elderly. Hastings Center Report 1989; 19(4):5-7.

Dorothy I. Meddaugh, PhD, RN, is a long-term care consultant based in Lancaster, OH. Barbara Peterson, MS, RN, is director of nursing at the Northland Terrace Nursing & Rehabilitation Center, Columbus, OH.