Journal of Gerontological Nursing

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Assessing an Environment for Safety First

Harriet Seigel, RN, MS

Abstract

ABSTRACT: The environment of the elderly is assessed through a community health perspective. This paper examines man's complex interrelationship with the environment, defines environment in a broader sense, reviews some epidemiological data that can assist in environmental assessment, explores areas within the elder's community and home environment that require nursing expertise, and presents some nursing implications from the data covered.

Abstract

ABSTRACT: The environment of the elderly is assessed through a community health perspective. This paper examines man's complex interrelationship with the environment, defines environment in a broader sense, reviews some epidemiological data that can assist in environmental assessment, explores areas within the elder's community and home environment that require nursing expertise, and presents some nursing implications from the data covered.

The many roles of the nurse as teacher, consultant, role model, care provider, facilitator, and patient advocate can provide an opportunity for environmental assessment and intervention that leads to greater adaptation on the part of the elderly person. Our elders are especially vulnerable to negative environmental influences.

Wherever the nurse works - whether it be in the hospital, the home, a long-term care setting, the clinic, or industry - she lays the groundwork in health upon which our elderly population can progress along life's continuum. In order to understand more clearly what the responsibilities of the nurse are in environmental assessment, this paper will focus on several aspects of environmental safety: the interrelationship of man and the environment, some epidemiological data that can help in focusing energies during the assessment process, the areas within the environment that require assessment, and the implications of this assessment data to the nurse.

DEFINING ENVIRONMENT

Webster's unabridged dictionary defines environment as "the whole complex of climatic, edaphic, and abiotic factors that act upon an organism . . . and ultimately determine its form of survival."1

Examination of the Figure demonstrates the complex environmental issues for which the nurse may be responsible. There are external variables2 such as the general and immediate physical environment which includes air pollution, bacteria, thermal stimuli, water pollution, soil contamination, population density, room design and color, and noise pollution. Internal variables of the environment include genetic inheritance, intelligence, biological rhythms, sex, age, race, self-concept, and the mind-body relationship. There also are those such as the psychological, sociocultural, physiological, and socioeconomic variables that straddle the internal and external environment.

All of these are environmental issues and have a bearing on health, behavior, and longevity. HansSelye was absolutely right when he said "nobody ever died of old age."

ENVIRONMENT AND HEALTH

Studies have shown how important a role environment plays in health. Migrants who move from one geographic area to another develop the cancer pattern of the new geographic area.3 Mortality rates from cancer differ according to geographic region.4 Many sociocultural changes can trigger illness, as evidenced by the research Holmes and Rahe5 developed with their social readjustment scale. Even extreme fluctuations in weather are known to increase the mortality of the elderly.

FigureTHE PERSON'S INTERRELATIONSHIP WITH THE ENVIRONMENT

Figure

THE PERSON'S INTERRELATIONSHIP WITH THE ENVIRONMENT

A more striking testimony to the impact of environment on man is some epidemiological data from around the world. The United States likes to think of itself as the leader in health, but the data in Table 1 point out several countries that are ahead of the United States in life expectancy for both men and women. Ethiopia and Yemen are in the Table to help retain perspective. From these data it can be seen that at least eight countries (Canada, Israel, Japan, Czechoslovakia, Finland, Netherlands, Sweden, and United Kingdom) surpass the U.S. life expectancy for men and at least four of the same countries surpass die U.S. life expectancy for women. Since U.S. technology in the health field is unsurpassed, the reasons for the disparity may be related to maladaptation to environmental influences.

Other data that should cause some thought about the future direction of nursing assessment and intervention in the environment are presented in Table 2. By now there is improvement in these data7 but there is concern that disparity will continue to exist among racial groups in the United States. Such differences in life expectancy should be unacceptable.

All these data demonstrate how poverty, inflation, housing, ethnic conflict, crime, accidents, family problems, and urban transportation contribute to a multitude of problems that lead to premature death.

Today's nurse can not separate the individual from the forces of the environment. The impact of die elderly's environment on their level of wellness as well as their illness and its etiology, diagnosis, prognosis and treatment is well documented.8'9 In addressing the assessment of the elder's home, the broad sense of the word home is used - neighborhood and living quarters. By assessing both areas, the nurse gains a true picture of the safety and functional ability of the older person. The nurse must never lose sight of the larger context of environment in assessing the community and home.

COMMUNITY ASSESSMENT

The community assessment guide (Table 3) summarizes several areas to assess10 in the neighborhood: overall features, population characteristics, service facilities, and environmental safety conditions. The depth of the data collection will depend on the frequency and duration of the nurse's contact with a specific elderly person or persons in that community. Sometimes the data is collected from the older person and not from first-hand observation. However the data is collected, the nurse has a responsibility to analyze it and assist the older person in managing the environment.

In addressing the overall features of the environment, the nurse needs to be aware of the climate and terrain, since that information can help in understanding the outside mobility of the elder. The types of roadways surrounding the client's place of residence also influence mobility. If a busy street has no traffic light, the elderly person may not have the speed to cross the road to shop or participate in activities. Even with a traffic light, a street can pose problems for those with less agility.

Population characteristics can give the nurse an idea of the support network of the neighborhood. The "old family homestead" can either trap the elder in a changing neighborhood or nurture the elder among people of a variety of ages and races.

Accessibility to service facilities can promote the independence of our older population. Some large stores send weekly buses to bring the older shopper to the store if there is no neighborhood store. Libraries can send the bookmobile on regularly scheduled stops. Nurses also have a role in assessing the adequacy of service facilities. Transportation to health care providers and social activities can be a problem for many elders. A combination of volunteer groups and special subsidized projects can help here.

Environmental and safety issues include significant assessment areas. For example, should trie air quality be poor, the client with respiratory problems will suffer needlessly. Although crime statistics do not show the elderly to be victimized more often than younger people, elderly clients are locked in their homes just as tightly by fear. They feel more vulnerable and they are right!

HOME ASSESSMENT

Table 4 speaks to safety assessment in the homes of the elderly.' In reviewing the home assessment bear in mind that 67% of the older people in the United States own their own homes.11 Furthermore, about one third of the elderly live alone, either in their own home or apartment.12 Areas to assess here are roles and relationships, comfort and convenience, and safety.

Roles and relationships within the home may be a moot point for a person who is socially isolated and lives alone. However, even a relationship with a pet makes a difference in how people view themselves and their role.13 The complete dependence of the pet and its absolute acceptance of the elderly person can result in an enriching and positive experience. Friends and family enable many elderly people to remain in their homes for a longer period of time than otherwise might be possible. According to a report14 to the Congress, 50-70% of the services received by elderly people are provided by family and friends. That speaks very well to our society's nurturance. The myth that our elderly are abandoned by society is unfounded.

Table

Table 1LIFE EXPECTANCY AT BIRTH IN SELECTED COUNTRIES

Table 1

LIFE EXPECTANCY AT BIRTH IN SELECTED COUNTRIES

Table

Table 2LIFE EXPECTANCY 1968 IN THE UNITED STATES

Table 2

LIFE EXPECTANCY 1968 IN THE UNITED STATES

Table

Table 3COMMUNITY ASSESSMENT GUIDE

Table 3

COMMUNITY ASSESSMENT GUIDE

Table

Table 3COMMUNITY ASSESSMENT GUIDE

Table 3

COMMUNITY ASSESSMENT GUIDE

Table

Table 4HOME ASSESSMENT GUIDE

Table 4

HOME ASSESSMENT GUIDE

Comfort and convenience issues impinge upon safety issues. If an elder lives in the family homestead over a number of years, the cost of heating or upkeep of a large home may be prohibitive. Disrepair can lead to safety hazards. Large areas in the home may need to be traversed to complete chores, leading to fatigue. On the other hand, if an elder has moved into a small apartment, keeping many cherished possessions, then crowding becomes an issue. There may be little room to move around comfortably, much less safely. Even the colors used in the decor of a home influence safety, since perception of blue and green is diminished in the elderly. Thus, stairs, darkened hallways, and unseen objects can become hazards.

The data in Table 5 show that accidents are the sixth leading cause of death for men and the seventh for women over the age of 65. i5 One of the most dangerous places for the elderly to be is in their own home, for that is where many accidents occur.

Table 6 shows that men are more prone to accidents than women.16 Moreover, falls are the number one killer for both sexes. Motor vehicle accidents are also a problem for the elderly, while fires play a smaller but still significant role in death rates. Where housing is inadequate and the day-to-day living more of a struggle, fires and falls do occur more often.17 These data speak to the nurse in the larger role of patient advocate. For example, the nurse may find herself lobbying for legislation requiring a driving test at the time of renewal of a driver's license after age 65.

Interestingly enough, 90% of all accidents are attributable to something a person does or does not do. 17 People frequently fail to pay proper attention to objects and/or practices in their environment. Equipment failure rarely causes accidents.

Hypothermia is a very real threat to our elders, considering their normal decrease in thermoregulation ability. Most vulnerable are those elders living in the community, especially if one or more of the following risk factors are found: those over 75, those living in substandard housing, those living alone with infrequent visitors, those taking certain drugs (phenothiazines), those with chronic illnesses, and those who consume substances that accelerate loss of body heat (salicylates and alcohol, for example).

Feist19 found other risk factors that make older people more susceptible to accidents. These include transient ischemic attacks; muscle weakness; interference with a sense of balance; poor eyesight; urinary frequency; unsteady gait due to pain, fatigue, or arthritis; improper footwear; improper clothing; improper use of wheelchairs and walkers; mental confusion; mental depression; and hostility and anger at confinement.

The bathroom, the kitchen, and the bedroom are especially hazardous. Lighting and furniture arrangement also influence safety. Room heaters, used more often since the energy crisis, must be evaluated for placement and use. The telephone is the lifeline of the elderly and they should not try to save money by not having one. Many telephone companies have special rates for limited calls. Locks on doors and windows should be of the best type to decrease the anxiety of clients and their families. The use of smoke alarms also assists in maintaining safety. Medication storage and use should be investigated. Safe storage of valuables and documents decreases fear about victimization and loss. The development of an emergency plan, should the older person fall or become trapped by a bad winter storm, eases the concerns of the older person and those who worry about him/her.

Most accidents are preventable since they are a result of the combination of human error, disability, and hazard in the environment. Questions must be asked and inspections made of a home to safeguard the elderly where they live. Some nurses may think inspection/questioning is not their role. However, the bio-psychosocial care that nurses hope to give is based on a total assessment. Since environment impinges to a great extent on health and well being, nurses can rest assured that they are doing their job in promoting health through these assessments. The client also must become a part of the environmental assessment. This aspect is made even more important since 80% of those 65 years of age or older have one or more chronic conditions.20

Table

Table 5LEADING CAUSES OF DEATH IN PEOPLE 65 YEARS AND OLDER FOR 1976

Table 5

LEADING CAUSES OF DEATH IN PEOPLE 65 YEARS AND OLDER FOR 1976

Table

Table 6MORTALITY FROM LEADING TYPES OF ACCIDENTS 1975-1976, AGES 65 YEARS AND OLDER

Table 6

MORTALITY FROM LEADING TYPES OF ACCIDENTS 1975-1976, AGES 65 YEARS AND OLDER

Nurses are oriented to the health needs of the total patient. Nurses are not victims of the medical model and its orientation to illness and medical diagnoses; therefore, they are in the perfect position to be role models for other professions as well as for their clients. The nurse's unique contribution to the health care of our elders rests on several areas of responsibility among the community, the family, and the individual

NURSING IMPLICATIONS

As a result of the broad responsibilities of the nurse, the following nursing implications are suggested.

* First, anticipatory guidance with elders is necessary. The nurse needs to prepare older clients for the changes they can expect both physiologically and psychologically. Nurses are familiar with formulating anticipatory guidance with mothers of young children and teaching developmental milestones for infant and child. How much more meaningful aging will be to families with older members as well as to the older person if they can be prepared for changes and assisted in problem solving for anticipated developmental needs.

* Second, nurses need to utilize their skills as health educators. The individual, the family, and the community lack of knowledge about the illnesses that can occur with old age, about accident prevention for our elders, about what constitutes normal aging versus illness in old age, and about how to compensate for sensory and mobility, changes and/or losses. Assistive devices of every kind - from the talking microwave oven to the paraplegic wheelchair moved by puffs of air - are available. Nurses need to share knowledge with families and the community.

* Third, the nurse has a responsibility to collect systematically large amounts of data about the environment. Whether collected alone or utilizing the family and/or client or other professionals, the assessment of the client's environment must be as broad as possible.

* Fourth, the nurse's responsibility in assessment does not end with the data collection. Responsibility then extends critical analysis of the data for gaps in environmental safety.

* Fifth, the elder and his/her family need to set realistic mutual goals and to close gaps uncovered in the assessment process with the nurse. Here, the nurse's expertise in locating resources and developing support networks either in the private or public sector is invaluable. Referral to other services may be necessary.

* Sixth, the nurse and the client together evaluate what has been done and what needs yet to be accomplished to meet the safety needs of the client.

* Seventh, the nurse acts as a patient advocate in the assessment process. The nurse may need to facilitate communication between the older client and other services. On a larger scale, a fight for legislation to protect the elderly clients may be necessary.

* Eighth, the entire diagnostic process can be used as a teaching tool by the nurse for the older person. As data is collected, analyzed, and shared, learning can take place for those being assessed.

* Lastly, nurses need to build upon the elderly's strengths, natural cautiousness, and familiarity with the environment to balance the unsafe aspects of that environment.

CONCLUSION

In re-examining the Figure of man and the environment, it may become even clearer why "nobody ever died of old age." There are so many other factors. Therefore, the nurse must bring to bear sophisticated problem-solving skills to increase longevity and the quality of life. A different perspective is needed on the part of the nurse and the elder. In this way, man's complex relationship with the environment can be understood, and understanding is the first step in mastery.

REFERENCES

  • 1. Webster's Third New International Dictionary, unabridged. Springfield, Massachusetts, GC Merriam Company, 1964.
  • 2. Murray R, Zentner J: Nursing Concepts for Health Promotion, ed 2. Englewood Cliffs, New Jersey, Prentice Hall, 1979, p 350.
  • 3. Higginson H: A hazardous society? Individual versus community responsibility in cancer prevention. Am J Public Health 1976; 66:359-366.
  • 4. What causes cancer. Newsweek, January 1976, pp 62-67.
  • 5. Holmes T, Rahe R: The social readjustment rating scale. / Psychosom Res 1967; 11:213-217.
  • 6. United Nations. Demographic yearbook. New York, United Nations, 1980.
  • 7. Butler R: Why Survive? Being Old in America. New York, Harper & Row, 1975, p 6.
  • 8. Cassell J: Physical illness in response to stress. In Levine S, Scotch N (eds): Social Stress. Chicago, Aldine, 1960.
  • 9. Lawton MP, Cohen JH: The generality of housing impact on the well being of the elderly. / Gerontol 1974; 29:194.
  • 10. Rauckhorst L, Stokes S1 Mezey M: Community and home 'assessment. Journal of Gerontological Nursing 1980; 6:319-327.
  • 11. Butler R, Lewis M: Aging and Mental Health: Positive Psychological ApApproaches. St. Louis, CV Mosby, 1973. pp 186-187.
  • 12. Oyer H. Oyer E (eds): Aging and Communication. Baltimore, University Park Press, 1976. ? 44.
  • 13. Mugford R, McComisky J: Some recent work on the psychotherapeutic value of cage birds with old people. In Anderson R (ed): Pet Animals and Society. London, Bailliere Tindall, 1975.
  • 14. Home Health - The Need for a National Policy to Better Provide for the Elderly. Report to Congress by the Comptroller General of the United States. HRD 78-19. Washington, D.C., General Accounting Office, December 30, 1977.
  • 15. Facts on Life and Death. DHEW publication number (PHS) 79-1222. Washington, D. C, U.S. Government Printing Office, 1978.
  • 16. Statistical Bulletin Metropolitan Life Insurance Company. July-September, 1978.
  • 17. Willgoose C: Environmental Health. Philadelphia, WB Saunders, 1979, p 340.
  • 18. Ebersole P, Hess P: Toward Healthy Aging. St. Louis, CV Mosby, 1981, p 260.
  • 19. Feist R; A survey of accidental falls in a small home for the aged. Journal of Gerontological Nursing 1978; 4:15-17.
  • 20. Healthy People. The Surgeon General's report on health promotion and disease prevention. USDHEW number 79-55071. Washington, D.C.. U.S. Government Printing Office, 1979, p 71.
  • BlBLIOGRAPHY
  • Burnside I: Nursing and the Aged, ed 2. New York, McGraw Hill Book Company, 1981.
  • Epidemiology of Aging. Proceedings of the second conference, National Institutes of Health. Publication number 80-969. Washington, D. C, U.S. Government Printing Office, 1980.
  • Ford A: Is health promotion affordable for the elderly? Family and Community Health 1981; 4:29-38.
  • Jette A: Functional capacity evaluation: An empirical approach. Arc h Phys Med Rehabil 1980; 61:85-89.
  • Lawton MP: The impact of the environment on aging and behavior. In Birren J, Schaie KW (eds): Handbook of the Psychology of Aging. New York, Van Nostrand Reinhold, 1977.
  • Rogers J: Advocacy: The key to assessing the older client. Journal of Gerontological Nursing 1980; 1:33-36.
  • Williams S: Issues in Health Sendees. New York. John Wiley, 1980.
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Table 1

LIFE EXPECTANCY AT BIRTH IN SELECTED COUNTRIES

Table 2

LIFE EXPECTANCY 1968 IN THE UNITED STATES

Table 3

COMMUNITY ASSESSMENT GUIDE

Table 3

COMMUNITY ASSESSMENT GUIDE

Table 4

HOME ASSESSMENT GUIDE

Table 5

LEADING CAUSES OF DEATH IN PEOPLE 65 YEARS AND OLDER FOR 1976

Table 6

MORTALITY FROM LEADING TYPES OF ACCIDENTS 1975-1976, AGES 65 YEARS AND OLDER

10.3928/0098-9134-19820901-06

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