Find out how this framework based on sodo/economic factors can help you formulate and implement more effective care plans for the aged.
Aging in late adulthood is a healthy, inevitable, and irreversible process. Aging is not illness. On the contrary, aging during this developmental period is often characterized by both endurance and serenity.
Aging in late adulthood can be defined as a series of normative biopsychosocial change processes that advance a gradual and idiosyncratic decline in the speed of physical functioning, an inward directed focus of mental activity, and a decrease in the scope of social interactions. These processes have meaningful adaptive purposes in relation to an acceptance of the approaching termination of life.
The purpose of this article is to present a conceptual framework for an understanding of aging in late adulthood useful to professional nurses. This conceptual framework primarily derives from a social/ecological perspective. It rests on the assumption that aging is a process of wellness and biological events that are not viewed as pathological. The focus of the framework is on social interaction and awareness. It has been constructed to provide concerned professional nurses with a theory-based framework from which they can create highly individualized nursing care plans. This conceptual framework is compatible with several conceptual models of nursing, such as Johnson's Behavioral System Model, Orem's Self-Care Model, and Roger's Life Process Model.1,2,3 Additionally, the framework can provide a source of hypotheses for nurse researchers and may lend direction to nurse educators for curriculum development in gerontological/geriatric nursing.
Both a personal philosophy and a theoretical foundation undergird this conceptual framework. The major belief Ì hold in relation to aging in late adulthood is that the realization of spiritual growth and expanded self awareness is more likely at this time than during any other developmental period. This belief derives from a philosophy of humanism and liberation as opposed to one of abandonment. Liberation means freedom from occupational roles at retirement as an entitlement and an opportunity to enter the last stage of life without the obligation to contribute to economic productivity.4
CONCEPTUAL FRAMEWORK OF AGING IN LATE ADULTHOOD
Late adulthood is a time of earned privilege, a time when choices can relate to the quantity and quality of involvement in society. It is a philosophy focused on integrity, not despair. Peacefulness with self and world is not reached by all of the aged. However, the possibility of a serene, supported, separation from life, a separation not marred by abandonment and chaos, is a potentially realizable goal and one well worth seeking.
In this conceptual framework of aging in late childhood, four theories provide a structure for the development of selected, interrelated concepts. They are the General System Theory, the Need Theory, the Social Exchange Theory, and the Disengagement Theory.58 Taken together, these four theories contribute to a social/ecological perspective of aging in late adulthood.
The term "social/ecological" refers to the total interaction of the person in late adulthood (the organism) with both formal and informal groups and the physical world (the environment). The patterned interactions among person, groups, and physical world constitute that person's ecosystem. The ecosystem constitutes a wholeness of organismic and environmental interchanges.
Within the ecosystem, subsystems are open to information and resource exchange (General System and Social Exchange Theory). The ecosystem is the source of supplies for need satisfaction (Need Theory) and is available to the individual for sustenance relative to the degree that the individual is engaged or disengaged from society (Disengagement Theory). The ecosystem of the person in late adulthood differs from the ecosystem of persons in other developmental periods. The differences can be delineated as the four major concepts of this framework are discussed.
Needs - The definition of need is borrowed from Masini. The term refers to "those human requirements calling for a response that makes human survival and development possible in a given society."9 Needs are experienced as states of felt tension. They motivate goal-directed behavior.
The basic human needs of aging persons in late adulthood are similar to the needs of other people. What may differ notably, however, is this population's access to need satisfiers in the environment. The elderly have usually endured more losses than people in earlier developmental stages.
Loss of occupational role through socially imposed retirement policies can be viewed as a transitional period for entry into old age. While some theorists view this change in role status as abandonment on the part of society, others view it as liberation.4 Regardless of the theoretical perspective, retirement has the potential to pose a threat to the need for "belongingness." Even when privacy, autonomy, and increased leisure are valued components of retirement, if highly cathected support networks are disrupted abruptly, the need for belonging will be altered.
Other environmental satisfiers for this need must now be strengthened, rediscovered, or created if the need for belongingness is in jeopardy. Similarly, the exodus of the last child from home occurs increasingly near retirement age as dual-career couples postpone parenthood until they are well into their 30s and even 4Os.10 Additionally, jobrelated moves for the offspring frequently occur at this time. Geographical barriers may limit easy access to kin. Intimacy at a distance may be a desirable state of affairs for middleaged adults in relation to their young adult children.4 However, me person in late adulthood has the need for kin in relatively close proximity for emotional support and for the purpose of establishing linking systems to bureaucratic resources.11 The concept of linkage is closely related to need satisfaction and will be examined in this framework.
Decreased mobility frequently occurs in late adulthood. When the car keys are abandoned, when the gait slows, and when public transportation is not readily available, the physical world indeed narrows. The need for mobility persists if belonging needs are to be satisfied through membership in groups and reunions with significant others. Visits to health-care and other social agencies increase for many during this period. Transportation for the elderly is essential.
Other needs are threatened toward the end of the lifespan. The need for safety may demand additional environmental satisfiers such as handrails, firm flooring surfaces, and ambulation devices. The need for dignity is threatened if the elderly person is infantilized by insensitive, though perhaps wellintentioned, agency personnel. The need for self-determination is threatened by interacting others who are overly solicitous, overly protective, and overly controlling. The need for security is threatened when inflation wreaks havoc with the fixed income of the elderly. The need for self actualization may be thwarted by a society with an instrumental, utilitarian mentality primarily focused on material productivity.
Finally, the need for closure of life and acceptance of one's own death may be blocked by a death-denying society where shared awareness of dying is more the exception than the rule. If such conditions prevail, and if these needs are to be satisfied with grace and dignity, the aged will need sensitive supporters who can serve as buffers and linkers between themselves and their suprasy stems.
Although the physical world may appear to shrink, an inner expansion of awareness and spirit can develop in late adulthood. Herein may lie joy and serenity for the aged. There is a need in late adulthood to discover the enduring and essential "I. " This need is accomplished through a meandering, yet purposive, life review. Uninterrupted time is needed for this task. The needs for privacy, autonomy, and personal space take on new importance.
There is also a need for autonomy in deciding what intrusions will be allowed to enter personal time and space. This need for teleological reflection is a powerful motivator for positive partial disengagement. It fosters letting go with contentment.
The final stage of growth in late adulthood centers around the need to develop the belief that one's life had design and purpose; that this life was and now is a miniaturized representation of the wholeness of the universe.
Thus, human needs do not diminish in late adulthood. However, access to the resources that can be need satisfiers may shrink. Tasks that confront the aging person in late adulthood are to attain and maintain such access, to keep the system open, and to participate in those social exchanges that are desired. The problem of acquiring continued need satisfaction can be better understood by examining the concepts of social exchange, power, and linkages.
Social Exchange - Human needs, beyond those related to sheer physiological survival and teleological reflection, are satisfied through social processes. Social exchange is ubiquitous. It occurs in both the public domain and in the small group domain of the family. Its efficacy and integrity rests on mutual trust, one of humankind's most basic needs. The reciprocity inherent in the social exchange process is a crucial determining factor of the kinds of associations that will develop between the interactants.
According to Blau, people are motivated to ensure a continuation of benefits. They feel a need to reciprocate even though the exact nature of the returned favor is not stated in advance. Social support as well as instrumental support is frequently sought, obligations develop and, when not honored, may exclude the person from future exchanges. Gratitude and the need for social approval operate to maintain social exchange. Mutual trust, along with the building of credits, strengthen the social exchange process.7
These principles have implications for the relationships of the elderly with family, groups, and bureaucracies. If the elderly are unable to mobilize and draw upon resources that are valued by interacting individuals or groups, they may be at a distinct disadvantage as they try to obtain need satisfaction. Costs may exceed assets. Additionally, decreased mobility may bar the older person from pursuing the option of seeking alternative need satisfiers.
Cognizant of these factors, Sussman has stressed the value of intergenerational solidarity for the elderly, stating that "the extended nuclear family is an all-purpose care taking system."12 Norms of loyalty within the family system operate to maintain unconditional acceptance. The pooled resources of the family remain the most reliable source of support for its older members. Over the years, various and sundry debts have been accrued by offspring and now may be repaid to the elder in need.
While love itself may be the motivating factor behind family assistance, its lack or impoverished state will not necessarily negate support. Powerful norms of pride and allegiance and the need for social approval function to mobilize the family into action. Mostly, however, "the family is structured favorably to provide an emotional environment which allows for the development of intimacy, love, and solidarity."11 Intimacy, love, and solidarity, powerful needs for all humankind, are especially superordinate for the elderly in the final years of life. The traditional family remains the most stable satisfier of these vital needs. The ability to "care about" is equally important to the ability to take "care of" if the person in late adulthood is to thrive.
Outside the family context, the elderly negotiate additional needs in social exchanges with formal and informal groups. When need satisfaction deficits limit the older person's ability to engage directly in transactions, this individual operates at a disadvantage. This disadvantage can be understood by examining the concept of power, and its remediation by discussing the concept of family-organizational linkages. Aging persons who relinquish or are relieved of power are in a highly vulnerable position in relation to social exchange.
Power - Power can be viewed as the successful negotiation of enlisting cooperation for some mutual benefit. Power is inherent in social exchange, but not solely in a win/lose sense. Mutuality of benefits and complementarity of needs generally characterize social exchange. Nevertheless, during the process of exchange, imbalances related to power arise. Power is not quite as symmetrical as described above when the net ability of one person or group to withhold benefits consistently exceeds that of interacting others. This is clarified by Blau, who notes that the source of asymmetrical power is onesided dependence. Blau's definition of power is adopted for this framework and refers to the "ability of persons or groups to impose their will on others despite resistance through deterrence either in the form of withholding regularly supplied rewards or in the form of punishment."7
Unilateral dependence and its concomitant loss of power occurs when a person is the recipient of supplies that cannot be repaid.7 When reciprocity ceases, a power imbalance is in effect. Thus, it is in the interest of the elderly person to retain independence in order to maintain power over external resources required for need satisfaction. Or, it is in the interest of the elderly person to retain at least interdependence and mutual influence over desirable resources so that power is not an issue, or is at least symmetrical.
Blau outlines four basic alternatives to avoid powerlessness: 1) to provide service in return for service, 2) to obtain needed benefits from other sources, 3) to secure benefits by force, or 4) to renounce the need for benefits.7 When these four basic alternatives are absent, the person is subordinated to the power of others and must enter into a dependent and compliant relationship.
These four alternatives to powerlessness can be examined vis-à-vis the elderly. First, services are readily received when economic resources are available for payment. Lacking financial assets, a system of bartering can be considered. Bartering networks, which cover a wide array of needs and services, are experiencing a renaissance in this country and are a potential source of support for those on fixed or limited incomes. Fewer material benefits may be desired, especially in dyadic relationships or small groups, with emphasis on expressions of love, tenderness, respect, joy, or simple gratitude. In relation to formal groups, the very act of participation legitimatizes the group's existence and often suffices as service returned. The obligation of the formal group to dispense services is a source of power for the knowledgeable consumer. Participation in informal and formal groups is essential to retain power.
PROPOSITIONS DERIVED FROM THE CONCEPTUAL FRAMEWORK
Second, the elderly person can obtain need satisfiers from alternative sources. While duplication of services is not particularly cost effective, it works to the consumer's advantage. The possession of information related to a variety of resources empowers the informed older person or this person's linkage system. Third-party persons or groups can constitute potent mediating structures between the aged person and the bureaucracy. Knowledge of alternate sources of benefits gives the older person a competitive edge and is an antidote to a sense of powerlessness in all relationships, whether formal or informal, professional or intimate.
Third, to secure benefits by force is still another option. Force, in this instance, refers to political pressure. The formation of the elderly as a political aggregate is a potential source of significant power. As the proportion of elderly have grown, benefits for this group have expanded, suggesting that the younger view these benefits favorably and with projected self-interest.4 The fact that votes can be garnered for benefit packages to the elderly, and the fact that taxpayers are somehow absorbing the costs, suggest that political activism is a desirable route. Joined with other groups with the same common disadvantaged denominator, a powerful political group could emerge to influence power imbalances.
Last, renouncing benefits and the need for them may occur through the process of reframing or disengagement. In reframing, a perceived need, upon reflection and ongoing change, turns out to be a want or desire of less intensity than a human need. In other words, a person may reassess his or her felt need, reframe its importance, and relegate it to a passing, waning wish.
Disengagement can foster renunciation of some needs and benefits. Energy expended in their direction is withdrawn and conserved. Disengagement is accelerated by ego changes in which self-identity depends increasingly less on the current reflected appraisals of others, and more and more on reminiscences of past events. Energy is directed inward, interiority is valued, and psychosocial needs are affectively and cognitively satisfied in the recapitulation of a life meaningfully spent.
Thus, some alternatives to powerlessness are available to the elderly. Frequently, power retention for the person in late adulthood is most realizable and available when a concerned facilitator intervenes and functions as a linkage between the aging elder and his or her relevant organizational resources.
Linkages - Sussman wrote extensively on the value, need, function, and implication of family-organizational linkages. According to Sussman, linkage is both a condition and a process of connectedness between primary groups and bureaucratic organizations.11 One of its major functions is to enable families to release the full powers of the organizational system on their behalf.
Linkages are a chain between two systems, tying them together. They operate as a feedback loop keeping the two systems open and interactive. Linkage systems function to match the needs of the represented individual with the powerful resources of the bureaucracy through social exchange. It is a system characterized by complementarity, recriprocity, accommodation, and bargaining. Its origins are grounded in the inherent conflict that exists between primary groups and bureaucracies, each of which have different patterns of interrelated structure and function. Conflict is reduced through the recognition of supraordinate goals. These goals tie the two systems, primary group and organizational group, together.11
An awareness of the value of linkage for family members of the aged adult is crucial when power is needed to unleash external resources. Family members are successful linkers when they are well-informed of the structure and services of the bureaucracy, and are cognizant of the needs of their elder member. The need for human services arises frequently in response to transitional periods and situational events in the life of the older person. Examples are retirement, death of a spouse, illness, relocation, and approaching death. The family is best equipped to respond to the emotional crises, the bureaucracy to the requisite goods and services. The aged person needs the support of both, and the two systems need one another.11
Nursing has addressed its role as liaison between clients and agencies. The question arises of whether or not nursing can function as effective linkers. The answer is both yes and no. When the nurse is employed by the bureaucratic agency, he or she is subject to its norms related to efficiency, rationality, procedures, and practices. The nurse may be restricted by sheer numbers of clients, time, and the need to preserve the structure and functions of the organization. The nurse may be less encumbered to fill the role of linker when functioning as an independent practitioner, though time restraints may still be a deterrent.
The nurse's role may be most meaningful and productive in relation to linkage when he or she provides resource information and support to the potential family member linker. Acting as a third party, the nurse assists and encourages the family to interpret the aged person's needs and to relay them to appropriate agencies. The nurse supports the support system.13
The nurse can be in a unique position to foster family solidarity and to unleash bureaucratic goods and services. He/ she is knowledgeable of. the goals and purposes of the organization and aware of the assessed needs of the client. It could be said that the nurse is linker once removed. This role is the balancer. One does not want to be either too close or too distant in the affective domain when it comes to effecting important exchanges that result in satisfactions for family and organizations. The family cannot do the job of the organization nor can the organization do the job of the family.11
The thread of awareness runs through the discussion of concepts related to a social/ecological understanding of aging in late adulthood. The professional nurse must be aware of the needs of the older person, of the social exchange processes related to need satisfaction, of the vicissitudes of power related to acquisition of benefits, and of the use of linkage systems to facilitate delivery of goods and services to translate the framework into appropriate nursing practice.
The aware, well elderly will negotiate their needs with minimal assistance. When limitations are imposed due to illness or the normal biological decrements associated with advanced aging, the professional nurse must be aware of clients' needs in order to plan and implement responsive and responsible nursing care. To counteract despair and premature disengagement, the needs of the elderly must be identified, communicated, and addressed. This is a task for nursing.
Family members can be sensitized not only to their elder member's needs but to their own needs as well . The aged parent requiring care places a great strain on the family. He/she poses physical, financial and emotional burdens on a system which, though it usually can rise to the task, needs all the support that can be mustered to remain in equilibrium. Aware professional nurses will direct their energies toward research and social action in this area in an attempt to find solutions to this problem. It is in one's own best interest and society's best interest to do so.
The concepts of human needs, social exchange, power, and linkages build a quadrivial framework that structures the ecosystem of the person in late adulthood. The social/ecologie perspective that emerges is useful for nursing in developing hypotheses for empirical testing, in delineating content areas for curriculum development, in planning nursing care, and in providing direction for responsive social action with and for the aged.
- 1. Johnson DE: The behavioral system model for nursing, in Riehl JP, Roy C: Conceptual Models for Nursing Practice, ed 2. New York, Appleton-Century-Crofts. 1980.
- 2. Orem DE: Nursing: Concepts of practice, ed 2. New York. McGraw-Hill. 1980.
- 3. Rogers ME: Nursing: a science of unitary man, in Riehl JP. Roy C: Conceptual Models for Nursing Practice, ed 2. New York, Appleton-Century-Crofts. 1980.
- 4. Baum M, Baum R: Growing Old. Englewood Cliffs. NJ, Prentice-Hall Inc. 1980.
- 5. von Bertalanffy L: General systems theory and psychiatry, in Arieti S (ed): American Handbook of Psychiatry, vol 1. New York, Basic Books, Ine, 1974.
- 6. Lederer K (ed): Human Needs. Cambridge, Oelgeschlager, Gunn, and Hain, Inc. 1980.
- 7. Blau P: Exchange and Power in Social Lifo. New York, John Wiley & Sons, Inc. 1964.
- 8. Damianopoulous E: A formal statement of disengagement theory, in Cummings E, Henry WE (eds): Growing Old: The Process of Disengagement. New York, Basic Books, Ine, 1961.
- 9. Masini E: Needs and dynamics, in Lederer K (ed): Human Needs. Cambridge, Oelgeschlager, Gunn, & Hain, Inc. 1980.
- 10. Daniels P. Weingarten K: The Timing of Parenthood in Adult Lives. New York, WW Norton and Co, 1982.
- 11. Sussman MB: Family-organizational linkages, in Hargin H (ed): The Psychiatric Hospital and the Family. Spectrum, 1982.
- 12. Sussman MB: The family life of old people, in Binstock RH, Shanas E (eds): Handbook of Aging and the Social Sciences. New York, Van Nostrand Reinhold, 1976, pp 218-243.
- 13. Northouse LL: Who supports the support systems? J Psvchiatr Nurs 1980; 18(5):11-15.