The World Health Organization defines health promotion as "the process of enabling people to increase control over and to improve their own health."1 Education in healthy living is one component of health promotion that is gaining increased recognition as an essential service offered by hospitals for both inpatients and outpatients.2 In terms of the older population, the well elderly living in the community are viewed as being the most appropriate candidates for health education programs.3 Well elderly are often the active, newly retired "young elderly."
Nevertheless, there are many very elderly persons in the community who have multiple active medical problems and resulting limitations. They live with a supportive spouse, in the homes of their children, or in semi-protective accommodations for seniors. The persons who attend the Day Treatment Unit (DTU) at the Baycrest Geriatric Day Hospital in North York, Ontario are among this latter group of community living elderly citizens.
Over half of the DTU elders are over 80 years of age. Most have several active medical problems and rehabilitation needs and are often not thriving well out in the community. In addition to investigative tests and therapeutic regimes, they require education aimed at fostering quality of life within the limits imposed by their medical conditions and the aging process.
Nurses in the DTU have developed a series of weekly one-hour health education classes in order to:
a) assist members to develop preventive and coping strategies for problems frequently encountered with advanced age and/or deteriorating health;
b) encourage independence in specific aspects of self care; and
c) foster the exchange of knowledge and ideas among elderly persons who share common concerns.
Topics for the classes include normal changes of aging, medication management, nutrition, home safety, stress management, foot care, oral hygiene, sexuality, exercise, and misconceptions about aging.
Because adults tend to learn best when actively involved in the learning process, group discussion was considered to be an essential component of each class. Initially, the nurse leaders feared that members might be hesitant to participate. Classes were very carefully organized with a presentation by the leader interspersed with structured questions to stimulate group participation. After a few sessions, however, it became evident that most learners were eager to participate verbally and enjoyed the opportunity to be involved. The leaders gradually assumed a less didactic role, with greater emphasis on facilitating group process.
Calling on individuals to recount personal experiences related to the topic under discussion has been consistently effective in involving even the most withdrawn persons. Both healthy practices and "old wives' tales" are recounted and members are often quick to challenge each other on the value of strongly held beliefs and actions. In a nutrition class, there was a lively discussion regarding the nutritional value of brown eggs versus white eggs. Some people said they had always purchased brown eggs because they were more nutritious than white. Others said there was no nutritional difference - it was simply a matter of what type of chicken laid the egg! It was up to the nurses to resolve the dispute by checking the literature.
Reminiscing over events of the past is a natural starting point for discussion. Burnside has cited the value of reminiscing in permitting the aged to assume a teaching role and in increasing their self esteem.4 It is essential that the leader be flexible and empathically responsive to the learners' input. Although lesson plans with learning objectives and content outlines are important, they serve only as a framework. It is the ideas, issues, and experiences emerging from the interactions that form the substance of the classes.
The leader must avoid becoming agenda-bound and must be free to flow with the learners' need to reminisce. The leader assists group members to use their reminiscences as aids in exploring the topic at hand. In a discussion of parent-child role reversal, for example, group members tended to recount stories about their parents raising them or about raising their own children. After this pleasant reminiscing, it was easy to reintroduce the original topic with the question, "And now that you are older and your children are grown up, how have these behaviors changed between you?" One woman responded, "Now they tell me what to do!" The rest of the discussion was right on target.
Working in a hospital setting with very old persons tends to make one acutely aware of the losses accompanying advanced age. Through the health education classes, leaders and members have become more aware of the real persons still inside the failing bodies. Brundage indicates that when adult learners and teachers interact, their behaviors affect and modify each other.5 This phenomenon has been evident in the classes. In sharing very personal thoughts, feelings, and experiences the group members have helped the nurses become more comfortable in discussing emotion-laden issues with older people.
In one session, the discussion centered on coping with the losses that had recently occurred in the lives of group members. Mrs. P. who had had a recent stroke and who had been quite withdrawn, took this opportunity to share her distress. She spoke of the humiliation she feels when she uncontrollably bursts into tears in social situations. The nurses were able to respond supportively and, at the same time, teach the group how to deal with the emotional lability frequently accompanying strokes.
Through these kinds of interchanges the nurses have grown in their ability to listen and respond comfortably. After classes they take a few minutes to talk about how they felt and how appropriate their responses were. The members' openness and enthusiasm has helped motivate the nurses to put the necessary energy into further development of the education series incorporating members' suggestions for topics.
The genuine interest of the nurses in the members has in turn helped members feel comfortable in sharing experiences, feelings, and concerns. One woman whose speech was impaired by a stroke commented that people generally treated her as if she were mindless. In the classes, however, she said that people listened and she felt respected.
Initially members addressed their comments only to the nurses. After a short time in the group, members began to address each other. They confronted one another for non-productive behavior, such as focusing on somatic complaints or being inactive. The nurses pursued the theme of individuals taking as much control as possible over their own health and well-being. For each topic discussed, the nurses used their group leadership skills to help members focus on ways to compensate for losses and maximize assets.
Adults are capable of learning throughout their entire lifetime.5 The belief that octogenarians with disabilities are uninterested in learning and change can no longer be accepted. The responses of the group members in a class on sexuality is a good example of their openness to explore issues. Members viewed a film in which an elderly woman in a nursing home had spent the night in bed with a male resident. The staff threatened to evict her unless she discontinued the practice.
Group members explored the issue from several perspectives and were equally divided as to whether the woman's behavior was acceptable. They argued the issue on the grounds of morality, propriety, duty to follow residential rules, and responsibility to set proper example. There was discussion of the value of intimacy, with or without sexual intercourse, for the elderly. Members were eager to learn that many residential settings have residents councils as an avenue for introducing changes in policy regarding issues such as privacy and sexuality.
Several challenges had to be met in order to make group discussion the positive experience that it has been. Most of the members are of European Jewish background with their first language being Yiddish, Polish, Hungarian, French, or Italian. The nurses are of Irish-Canadian background. The potential for language and cultural barriers was tremendous.
Consequently, the leaders use basic English vocabulary and restate members' comments and questions. Restating not only ensures that the leaders have understood, but it also provides a second opportunity for other members to hear and to comprehend what was said. Hearing deficits frequently result in several people speaking simultaneously.
A gentle touch by a leader and a nod in the direction of the first speaker is helpful in decreasing the problem. Because of memory and attention deficits, some group members tend to go off track. The leaders acknowledge what has been said and then redirect the member back to the topic.
Hearing and visual acuity usually diminish with age.6 A hearing deficit can make participation in group learning situations a frustrating and counterproductive experience. To diminish this problem, the leaders initiate the education series with a session on coping with hearing loss. Through role play, two nurses demonstrate the misunderstandings and sense of isolation that can result when a hearing person fails to use proper communication techniques with a person who has hearing loss.
Many group members identify with the behaviors and feelings portrayed. One nurse then turns to a group member with moderate to severe hearing loss and again demonstrates communication techniques, such as getting the listener's attention, watching the lips of the speaker, and rephrasing misunderstood statements. In one session, the group was surprised when the member responded to the nurse's questions appropriately in English. Several of them had thought he neither understood nor spoke English.
Members are encouraged to apply the techniques with each other in the group sessions and throughout the day. For members whose hearing loss is so great that they cannot hear in spite of good communication skills, audio amplification devices are supplied.
Use of audio-visual aids to augment discussion has had mixed results for members with hearing and visual impairment. Overhead transparencies with large print and sharp outlines are viewed well by most members and supplement the verbal parts of the class. The response of group members to films has varied. Some persons with hearing impairment or poor vision tend to lose interest when the lights are turned down. Nevertheless, for others the films stimulate serious reflection on their own related problems. Short films with good quality sound are most effective.
Using flip charts to summarize major points has worked well. Printing with wide tipped black felt markers on beige paper is quite visible. Positioning learners so that light from the classroom window falls on the chart and not in their eyes has been crucial. Magnifiers are supplied for reading small print on pamphlets or medication bottles.
Older adults have the same right to health information as other individuals. Nurses have a duty to engage in health teaching appropriate to the needs and abilities of their elderly clients.7
Elderly persons attending the DTU enjoy learning about healthy living through group discussion and become actively involved when teaching strategies are adapted to their needs. They express appreciation for both the intellectual and social stimulation experienced. They look forward to the next class and encourage the nurses to keep the program going.
- 1 . World Health Organization. Health promotion: A world health organization document on the concept and principles. Canadian Public Health Association Digest 1984; 8:101-102.
- 2. Ross C, Sherman S, Berg K, Radbill L. et al: Health promotion programs flourishing: survey. Hospitals 1985; 59:128-135.
3 . Barr G : Educators play crucial role in promoting healthy aging. Health Education 1983; Winter:2-7, 11.
- 4. Burnside I: Working with the Elderly. Group Process and Techniques. Monterey, Wadsworth, 1984.
- 5. Brundage D, Macheracher D: Adult Learning Principles and their Application to Program Planning. Toronto, Ministry of Education, 1980.
- 6. Bates B: A Guide to Physical Examination. Philadelphia, JB. Lippincott, 1983.
- 7. Rendon D, Davis D, Giorella E, et al: The right to know. The right to be taught. J Gerontol Nurs 1982; 12:33-38.