The nursing process involves a series of decisions aimed at selecting actions to accomplish a health goal. The process begins with assessment, which is a systematic gathering and interpretation of data to determine the need for action. Once problems have been identified, goals are established, and an intervention plan is formulated. The quality of this intervention can only be as good as the assessment on which it is based.
The purpose of this discussion is to consider the assessment of older clients from the perspective of advocacy. Advocacy is action designed to help the powerless acquire and use power to make social systems more responsive to recipient needs.1'2 The case for linking assessment and advocacy rests on the recently delineated rights for consumers of health services - specifically the right to obtain from health professionals, complete, current information concerning diagnosis, treatment, and prognosis in terms understandable to them* and the right to participate in the decision making regarding their health care.4 Juxtaposing assessment and advocacy implies that something has to be added to the assessment process, if it is to qualify as an advocacy activity. Assessment linked with older adult advocacy further implies adaptations to assessment. In this case, the adaptations are based on developmental characteristics. The major questions explored in this discussion are: Why should and how can nurses help older clients acquire and use information during assessment? Each of these questions will be considered in turn.
The Nursing Process and the Decision Maker
Traditionally, client participation in nursing decisions has been severely restricted. Clients generally have been allocated the role of simply accepting or rejecting nursing decisions. Often they are deliberately excluded from any discussion of health care options and their consequences. Although client collaboration in assessment has always been regarded as desirable, it has also been viewed as optional.5 Little has been done to increase either the client's ability or motivation to be an effective collaborator. In other words, the ascribed role of making defensible, health -related decisions has not been accompanied by the patient education needed to make responsible decisions.6 However, since the client, or his delegate, is the ultimate decision maker, it would seem that a primary function of the nurse should be to provide the conditions that facilitate effective problem solving.
Advocacy activity is characterized by a redistribution of power. In the assessment situation the power that is being reallocated is information. Rational decision making depends on the understanding of pertinent information. During assessment, the nurse has the opportunity to teach health information by explicitly indicating how the areas being assessed relate to health and by interpreting the client's health profile and health prescription to him. In addition, by making explicit the rationale behind the health prescription, the client is exposed to systematic problem solving techniques. The power of health information and of problem solving skills lies in their potential for increasing a person's sense of control over the outcome of the precipitating health event.
Older persons are particularly prone to feelings of powerlessness in their contacts with the health care system. Nurses are not extempt from the prevailing negative perceptions of aging and the aged.7 These attitudes are reinforced by a medical system operating on an authoritarian power structure and geared more toward obliterating disease than promoting health. Among the remedial factors delineated by Bengtson8 for fostering competent aging, were encouraging a sense of self-determination and building adaptive problem solving. The paternalistic attitude of "older people do not know what is best for them" needs to be replaced with "older people can be taught to decide what is best." Such teaching begins with assessment.
Information Acquisition and Use
Client control over the outcome oí assessment necessitates changes in both nursing and client behaviors. Five aspects of these changes will be discussed: preparation, cognitive set, goal formulation, learning conditions, and decision counseling.
The nursing assessment begins with a review of the client's health record. Often the client is asked to repeat health and social data that are already available. Multiple requests for the same information by each member of the health care team are boring and nonproductive for the client. Since assessment is generally higher priced than intervention, this repetition is also costly. Older adults are motivated to participate in activities that are meaningful to them.9 If the nursing assessment is perceived as a mere repetition of a previous assessment situation, it is likely that the quality of the information obtained will suffer. The rule of thumb is to begin the nursing assessment where the client's health history ends, unless your purpose is to establish the accuracy of the client's recorded history.
Much repetitious assessment could also be avoided if professionals working with the elderly in a particular community agreed to use and share a standard instrument for collecting core health and social data. Using the core data base for background information, more specialized, disciplinary assessments can begin immediately. Thus, one gets to the business of unique nursing assessment and intervention sooner. Rapport is easily established with the older client, when the nurse shows that she has prepared for the session by becoming familiar with the client's previous information sharing efforts.
Another technique for relieving the client from having to reiterate his life history, is to help him write his own health history. This can then be duplicated and either sent in advance or carried in hand to various assessment encounters.
In summary, making use of available information shows respect for the client, enables the nursing assessment to start at a more in-depth level, and is costeffective.
If the older client is to become a collaborator in decision making, he must be made aware of how he is expected to behave. A lifetime of encounters with the health system has habituated the older client to being passive and reserved. When the rules of the game are changed, he needs to be notified. Inducing an appropriate cognitive set is particularly important with older clients, since they have difficulty shifting or changing roles.
In assessment for advocacy, the attitude is conveyed that the client is expected to make a decision regarding maintaining or promoting his health. The older client needs to understand that you will help him identify his problems, goals, and options, but that he must decide on the course of action. Making this explicit is particularly important, since research has demonstrated that older adults prefer to avoid situations entailing risk. However, if they recognize that risk is unavoidable, they can come to grips with it."
The cognitive set for decision making designates the older client as controlling the outcome of assessment. In view of the multiple losses associated with aging and their influence on self-image, this affirmation of the older client's responsibility for promoting his health is a potentially powerful therapeutic agent in and of itself. The advocate reinforces the idea that the older client is an autonomous, mature person capable of influencing his own health status. The establishment of high expectations for older adults has been shown to result in improved performance.12
Expectations regarding the content and nature of the assessment also need to be given. What areas will be covered? How are these areas related to health? Which involve interviewing? Which require performance testing or physical examination? Providing an overview assists in reducing the anxiety associated with evaluation. It also helps the older client to organize the information for use in decision making.
In summary, by giving the older client control over the assessment through establishing a cognitive set for decision making, nurses facilitate information gathering and increase the client's self-confidence.
During assessment, more time should be spent formulating, validating, and planning to implement the client's goals than in discussing his problems. Nurses' orientation to diagnosis stems from the medical model that emphasizes problem definition and causation. Once a problem has been identified and a cause has been discovered, remedial action is instituted to remove the precipitating problem. Nurses working with the aged generally do not deal with problems that can be resolved in this way. Rather their concern lies in managing daily life in spite of severe handicaps. Thus, problem-oriented assessment is rarely as productive as it is within the medical model and frequently leaves the nurse feeling as helpless as the client.13
The challenge to the advocate then, is to help the older client turn problems into goals. Goals describe what the client wants to have happen as a result of his encounter with the nurse. Once a goal has been determined, problem information is needed to judge the feasibility of the goal, and the factors that will retard its achievement. Older adults have difficulty searching for information in an orderly manner, sorting relevant and irrelevant information, and ignoring irrelevant facts. u Using goals as the focus of assessment provides a heuristic for organizing information.
Since the goal directs the assessment, it also limits the scope of the problem information needed. At the same time, it emphasizes the health factors that the client possesses that may compensate for illness or disability factors. Informing a client of the functional abilities that he possesses, which off-set his problems, is a vital part of the ethics of communication. If the aged leave our clinics feeling psychologically worse than when they came in, we are giving little health care. As an advocate, the nurse assists the client in formulating a balanced image of his wellness-illness status.
In summary, by focusing the assessment on goals rather than problems, and abilities rather than disabilities, the nurse helps the older client adapt to living with a chronic condition.
If learning is to occur during assessment, the assessment situation needs to be treated as a learning situation. For the older client, compensations have to be made for age-related changes influencing learning. Sitting closer to and facing the client is a practice commonly instituted for managing losses in hearing and vision. However, encouraging the older client to write down important points during the assessment is rarely done. Notes can serve as a memory prosthesis and thus counteract age-associated difficulties in recall.
All too often because something has been said to the client, it is assumed that it has been learned. One cannot forget what has not been learned to begin with. In communicating with older persons, care should be taken in the choice of words. Medical terms and contemporary colloquialisms may convey little meaning. Important points bear repetition. Through repetition the client is assisted in selecting data that are worth remembering. Having the client summarize the discussion and interrelate changes in various behavioral areas care mechanisms for evaluating comprehension.
Another finding from education that warrants incorporation into the assessment situation is selfpacing.15 Decision making requires thinking time and older clients need more time to think. Let the client set the pace for the assessment. Although less ground may be covered in this way, more learning may occur. A supportive emotional tone is preferable to a neutral or challenging one.16 In the case of the hospitalized client, it is particularly important to establish the right time and place for assessment. Frequently this occurs almost immediately after admission, when the client may well be experiencing confusion and heightened anxiety.
In summary, nurses may promote the exchange and assimilation of information during assessment by: sitting within the auditory and visual range of the client, encouraging note-taking, obtaining feedback, permitting self-pacing, being supportive, and scheduling the session at a convenient time in a low distraction environment.
Decisions resulting in critical health consequences are frequently a part of the nursing process. Such decisions are best made by applying an optimizing approach to decision making. !T This requires consideration of a broad range of alternatives and the selection of intervention that promises the highest pay-off.
Several techniques have been developed to foster use of the optimizing strategy. One, which merits examination for inclusion in the nursing process, consists of comparing alternatives through a data matrix. Once a goal has been clarified, a grid, which graphically portrays the various means to achieve the goal and the criteria against which the various options are to be judged, is constructed.13'17'18 Nursing knowledge is needed to introduce options and criteria that the client may not think of or may seek to avoid considering. Each alternative is then rated by the client on each of the desirable dimensions. It is beneficial to have the client vocalize the rationale for his ratings, since the nurse can then clarify any factual errors involved in a judgment. The alternative that most closely matches the desired characteristics would be the optimal choice. Once a choice has been made, the decision-making process continues by specifying who will do what and when and where it will be done.13
Another technique for improving the quality of decision making is outcome psychodrama.17 This requires the client to project himself into the future and to experience, via imagination, his anticipated life under each available option. It is particularly effective in aiding individuals to become aware of emotionally charged considerations that otherwise might not enter into conscious deliberation.
The advocate is obligated to support the decision of the client or his delegate. This becomes difficult if the client's priorities have led to choices that you either do not see as optimal or perceive as calculated to do harm. It is then that the full implicaüons of a participatory model of service delivery are highlighted. Traditionally, the older person's health status has been regarded as too fragile and the health professional's liability too great to permit reliance on the older client's judgment.19 This view has been held in spite of the lack of consensus about the kind of information that should enter into health decisions and the evidence that suggests that health professionals using the same data base frequently arrive at different conclusions.20 In the advocacy model, the sense of personal adequacy achieved by the older person in controlling decisions affecting him and his activities is viewed as too significant to disregard. The teaching involved in the advocacy model proposed here attempts to monitor risks arising from health informational deficits and decisional skill dysfunctions, and hence, to circumvent the deleterious effects of induced dependency.
In conclusion, the nurse serves as an advocate for the older client during assessment, when she respects his right to obtain complete information concerning his health in words he can understand and his right to participate in the decision making involved in his care. These rights are acknowledged by making use of available information before the nursing assessment is initiated by inducing a cognitive set for decision making, emphasizing goals rather than problems, providing an environment conducive to learning, and training in systematic decision making strategies. In so doing, the assessment of problems, goals, and interventions becomes an advocacy activity that is designed to help the older client to acquire and to use information effectively in making decisions regarding his health.
This paper is based on a presentation made October 5. 1978. at a conference sponsored by the Department of Continuing Education, School of Nursing, State University of New York at Buffalo, entitled, Assessment: The Key to Advocacy for the Elderly.
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