Aunt Carrie, age 75, is recovering from a right knee arthroplasty. Her 81-year-old husband is in a local long-term care facility because of incapacities due to severe cognitive impairment. She manages to subsist on social security payments. Can you believe that she is soliciting food items and monetary contributions to help sponsor a holiday dinner for the 'poor old folks' in the neighborhood?" This lament came from one of our colleagues and exemplifies the attitude that the older individual in our society is not capable of offering to satisfy human needs on many levels.
During old age, as during earlier stages of development, individuals need to feel that they are active contributors in society. The quality and quantity of their contribution varies based on the quality and quantity of the desire, ability, and resources of the individual and the availability of a recipient for their contributions.
A reality for the majority of aged individuals is a lack of tangible or instrumental resources to contribute to others. However, many have expressive or affective resources that they have developed over the years. The older individual must be encouraged to share the knowledge and wisdom that have been gained through life experiences whenever possible. Kayser-Jones, I using concepts from exchange theory, observed that when institutionalized elders were forced into dependency, they were also forced into compliance with a resultant feeling of powerJessness. On the other hand, institutionalized elders who were encouraged to perform services (making crafts as gifts or to sell) felt more in control of their circumstances. Stack2 also observed the reciprocal nature of support that was exhibited in the black community that she studied.
Reciprocity of support encourages interdependence between individuals. The nature of the interdependence is based on the needs of each individual; it might be transportation in exchange for advice on a certain recipe, or finances in exchange for babysitting. The important point is that the older individual is exchanging a valuable resource or service for a needed service or resource.
The level of interdependence expressed is determined culturally. Industrialized societies tend to be more individualistic and oriented toward independent, autonomous behaviors. Members of less industrialized societies and of ethnic minorities are often part of a wide kin-kith network that relies heavily upon interdependence.
Elderly females from three different communities are discussed to show how they expressed their dependence, independence, or interdependence needs. The examples are not meant to be representative of all members of the groups. However, healthcare professionals must realize that cultural diversity among aging individuals demands culture-specific care delivery.
Cross-Cultural Implications of Developmental Needs
The aged individual's fulfillment of developmental tasks directly influences the nursing functions of advocacy, assessment, and intervention. Some of the primary developmental tasks for the aged person are learning to live with infirmities, coming to some kind of peace or satisfaction with self in terms of lifetime accomplishments, and preparing for death.3
Review of the developmental tasks of aging seems to emphasize the necessity for aged individuals to accept the fact that the body can no longer function as it did in youth, and that they must compensate for the continuously increasing losses.
Fulfillment of developmental tasks of the elderly vary between and within cultural groups, and these differences must be considered and addressed before any assessment or intervention can be planned. Summing up capabilities rather than losses within the sociocultural environment should be the first phase of nursing assessment.
Because elders have lived for a long time and responded to a great number of events, their needs are more complex. Care givers should therefore be knowledgeable about the interrelationship of all personal dimensions when making Healthcare decisions. A decision made without an understanding of the total individual risks being inadequate or even detrimental.
Treating elders as a homogeneous group makes no more sense than treating any other age group as a unit of like individuals. Attitudes toward the elderly are as varied as the number of nationalities and religions that exist in today's world.
It is counterproductive to treat clients alike. There are vast differences between black Americans and Polish Americans, Catholics and Protestants, women and men, and the physically handicapped and the physically able. There are many characteristics that the human species share. There are also some characteristics that are exclusive to some cultural groups. The secret to effective nursing is knowing the similarities as well as the differences between groups.4
Independence Needs of the Elderly
The number of aged in the population is expected to reach 8.3 million by 1991. To help the elderly maintain an independent and congenial lifestyle, their social circumstances and coping ability, despite medical ailments, must be examined.5 Interactions with frail elderly clients seem to point out that their primary concerns are loss of dignity and loss of independence. Independence needs must be considered in planning for the long-term care of older individuals who require assistance.
Independence connotes self-reliance and not being under the control of others. Some of the basic issues that affect the elder individual's independence include income, health, housing, and transportation. Without adequate income, the elderly cannot maintain their homes, their health, or travel to obtain the basic necessities for survival .
Retirement benefits in the form of social security and public and private pensions are first in importance as sources of income for the elderly. Income derived from wages is second, while assets in real estate and investments are third. The fourth ranking source is public assistance.4
Income of the elderly affects independence because the elderly require three times more healthcare finances than do younger people. Insurance plans defray some costs, but many of the elderly cannot afford health insurance. The elderly are often discouraged from using the benefits of Medicare and Medicaid.3
The elderly experience difficulties with transportation. Many are afraid to drive due to physical limitations. They manage to travel for subsistence needs, but little more.
Early retirement may not always support maintaining independent behaviors. When the health of an elder fails and institutional care is necessary, maintenance of independence becomes more difficult, if not impossible. The independence needs of the institutionalized client include privacy, the right to make choices, and other needs that living in close quarters makes difficult to meet. All healthcare providers must respect the rights of clients and take care to see that the right independence level is obtained.
Dependence Needs of the Elderly
The effects of the aging process can be seen clearly in changes in the independence to dependence ratio of the person's ability to function. Whereas the individual formerly may have been in control of daily living activities, the normal changes of aging might present impediments to this autonomy. How one subsequently seeks help and perceives the adequacy of this help is an ongoing issue among healthcare providers for the elderly.
Goldfarb6 categorized dependency traits into interpersonal, situational, personal, and behavioral components. The interpersonal component is described as a relationship in which one individual gives and the other receives. The situational component is determined by the abilities or disabilities of the individual that produce the need for help. The personal component refers to personality characteristics that direct the individual to seek out dependent relationships and manipulate relationships to satisfy the dependency needs of the individual. The fourth component is the behavioral element where changes due to aging have contributed to the profound impoverishment of self-image and have resulted in a reorganization of former behaviors in the search for assistance.6
The white American elder makes up the largest group of older people in the United States. All societies have a system that classifies individuals by age. The United States is a country of high social mobility and rapid change. The majority of Americans espouse the Horatio Alger work ethic, which implies that if one works hard, one will be successful. Independence is highly valued and all family members are expected to work hard and share in the success. Equal importance is placed on females in the family and they are expected to be self-sufficient even if financially dependent on males.
Parsons7 discussed the "sick role" in Western medical systems, noting that the individual in the role of "patient" is expected by "actors" in the system to recover from illness, or to make strong efforts to do so. The sick person is permitted to indulge in dependence needs under strictly regulated conditions, with the proviso that sickness should be only a temporary state. The elderly individual with chronic illness or intractable disease taxes his or her support system, which shifts the individual's role to that of an invalid; a term usually assigned to those who are unproductive and a burden on the family and community.
In the dominant culture, morality is intimately bound to self-reliance, which in turn is tied to work and productivity as well as to social and economic independence.8 In our society, it seems that each generation is thought to be primarily responsible only for supporting the succeeding one. Independence, highly valued at all stages in the family life cycle, has contributed to intimacy at a distance; telephone calls and letters replace frequent visits.
Mrs B ., a white American resident of a long-term care facility, is an example of the independence philosophy. She had a pulmonary disease and was dependent on nasal oxygen administration for life. Her activities were limited because of the short length of her oxygen tubing. She was fiercely independent and complained incessantly about being confined to her room. She lobbied constantly with the institution until she finally obtained a portable oxygen tank that was attached to her wheelchair. Mrs B. proved she had the ability and accepted the responsibility to alter her situation.
A neglected area of focus in research and service -related programs for the aged has been the preservation of independence during aging. Low expectations lead to low performance or functioning levels. A sense of worth allows people to live up to expectations. The white American believes it is a great mistake to do nothing; each person, regardless of age, is expected to perform to his or her fullest capabilities, regardless of age or sex.
In contrast to the white American majority, the aged Jewish female, from a kinship-based culture, has been socialized to dependency. Initially, it was a strong father or older brother who could be depended upon to satisfy needs; then it was a successful husband whose role it was to be a good provider and unchallenged decision maker. Her children were nurtured and protected in an environment where it was acceptable to have one individual give, and the others receive (Goldfarb's interpersonal component of dependency). There was an unspoken expectation that children grown to adulthood could be counted on to follow tradition. At that point, her chronological age and her culturally acceptable development contributed to an individual who was dependent because of situational components, personality characteristics, and behavioral elements.
Aged Jewish females, therefore, have dependency needs that may not be satisfied by strangers performing services. Her unsatisfied need encompasses the intense emotional pain of one always seeking another person who will be sent to take care of her. She waits and hopes for kin substitutes who can be counted on when she needs them. Ikeferably, that someone will speak Yiddish and have a similar background. so she can express any unresolved prejudices and regress a bit from the veneer of assimilation. She may needamotherdaughter figure to feel protected and, at the same time, allow her to nurture to assure continuity of tradition. There may be a need to share sacred history with someone who understands this Old World culture. She needs love, but receives services that leave her love needs unmet.
Can healthcare providers fill these needs or help her adapt to the deficiency? Possibly these dependency needs (personal, interpersonal, situational, and behavioral) were never satisfied. Healthcare providers can develop a cultural awareness; the client is being herself within a culture that may not be known or understood by the practitioner. Expression of dissatisfaction with services may be an adaptive strategy to assure that support services will continue and that she will not be abandoned by those who are charged to provide care.
Mrs L. was a resident of a long-term care facility. Although her physical needs were being met, she rejected all group activities developed to encourage socialization. She would often ask if the care giver was sent to take care of her because there was no one who was tending to her needs. Another client was community based, but required frequent hospitalization to bring congestive heart failure under control. She was noncompliant, stating that it was hard for her to manage her medications and there was no one to care for her. During each of these hospitalizations her son was summoned because her cardiac status was so precarious. Arrangements were made each time for visiting nurses and home health aide services when she returned to her apartment, but the cycle continued.
The deficit in services perceived by these Jewish women related more to having many nonkin contributing to total care than to having care provided, or at least supervised, by an individual with a bond of affection or familial obligation.
The elderly female, Aunt Carrie, who was discussed at the beginning of this article is a black American. She lives alone now that her husband is institutionalized. She is well-respected in the church and the community. During the recovery from her knee surgery, she had many friends and church associates who visited and who brought food, did her laundry, and ran errands for her. She has other friends who drive her to see her husband or to keep appointments with the physician. She reports that she gets a great deal of satisfaction from helping others. She feels that whatever she has is a blessing, and it is God's will for her to share. Through her involvement in the community and the church, Carrie has created interdependent relationships with others and she feels secure that when she needs help it will be available to her. She continues to help others through giving her time and limited resources.
Healthcare providers must evaluate carefully the interdependence, dependence, and independence needs of the elderly to assist them in meeting those needs. Nurses often talk about having the client participate in his or her own care plan, but few actually incorporate the client's assistance when carrying out the plan of care.
Developing a keen ability to assess the client's needs when they are unspoken and not clearly identified takes time and practice. Nurses must be caring enough and willing to invest both time and practice to identify effectively interdependence needs of the elderly across cultures.
- 1. Kayser- Jones J: Old, Alone, Neglected: Care of the Aged in Scotland and the United States. Berkeley, University of California Press, 1981 .
- 2. Stack C: All Our Kin: Strategies for Survival in a Black Community. New York, Harper & Row, 1974.
- 3. Butler R, Lewis M: Aging and Mental Health, ed 3, St Louis, C.V. Mosby Co, 1982.
- 4. Henderson G, Primeaux M: TYanscultural Health Care. Menlo Park, Calif, AddisonWesley, 1981.
- 5. Robertson C: Old people in the community. Nursing Times 1984; 80(35): 44-50.
- 6. Goldfarb A: The psychodynamics of dependency and the search for aid, in Kalish R (ed): 7"Af Dependencies of Old People. Ann Arbor, Mich, The University of Michigan - Wayne State, pp 1-15.
- 7. Parsons T: The Social System, Free Press of GIencoe, 1951.
- 8. Cowgill D, Holmes L: Aging and Modernization. New York, Appleton-Century-Crofts, 1972.