Health has historically been a major focus of nursing practice. This focus dates back to the beginning of the profession when Florence Nightingale defined the laws of nursing as the laws of health. ' Despite this focus, health promotion has only recently been recognized as an important priority for nursing practice and research.2,3 This current view represents a significant shift in nursing philosophy from a view of health as the absence of disease and illness to a holistic view of health that includes emotional, social, environmental, and self-actualization needs.4
Although health promotion is a current focus of nursing practice, Kleinman asserts that many nurses do not perceive the elderly as a population that could benefit from health promotion efforts.5 Kleinman views nursing as continuing to emphasize symptomoriented care for older people rather than emphasizing self-care, independence, and healthy lifestyles.5 In a recent review of gerontological nursing research, Adams found a paucity of research on health promotion and health maintenance for older adults.6
According to Walker, there are several reasons why the older population has not been viewed as an appropriate focus for health promotion: disease has been viewed as an unavoidable aspect of old age; poor health resulting from years of detrimental health practices has been believed to be irreversible; older people have been perceived as being unwilling to make changes and as set in their ways; and old age has not been seen as a time for which health promotion would have any importance or application.7
These beliefs, however, are changing, and recent research has shown that making healthy lifestyle changes decreases the risk of disease at any age.5,8 Our society is beginning to address the importance of geriatric health promotion.
Although the application of principles of health promotion to older people is relatively new, a number of health promotion efforts focusing on lifestyle changes for older adults are now in progress throughout the country.9·10 Among these are the US Public Health Service and the Administration on Aging initiative, which has helped state and local agencies develop their own health promotion programs; a National Public Education Program called the Healthy Older Persons Campaign, which has encouraged older people to adopt health-promoting lifestyles10; and the National Institute on Aging initiative, which is currently requesting research that focuses on the psychosocial aspects of health in middle and later years.9
In addition, the federal government's increased support for health promotion over the past decade resulted in the Year 2000 Health for the Nation Objectives report, which includes health promotion priorities and strategies for older adults.7 Recently, the first Surgeon General's Workshop on Health Promotion and Aging was held; recommended focus areas included smoking cessation, physical fitness and exercise, dental health, alcohol, injury prevention, medication, mental health, nutrition, and preventative health services.10
The expanding aging population is a major reason for the increased interest in health promotion for older adults. By the year 2020, the population of persons 65 years old or older is estimated to increase by 2% to 3% a year; in contrast to the 1 % rate for the general population. This translates into an increase of about 750,000 older people annually and an estimated 54 million elderly people by the year 2020. n The elderly make up the fastest growing segment of the American population, and by 2020, every fourth American could be 65 years old or older.12
It becomes imperative, therefore, for the nursing profession to readjust its thinking and practice to include health promotion strategies and interventions for this older population. This concern is reflected in the recently developed Standards for Gerontological Nursing Practice, which emphasize the importance of the nursing role in health promotion for the elderly.13 According to Kleinraan, promoting healthy lifestyles in the older population is a top priority in nursing.5 Kleinman urges nurse researchers to determine which health promotion programs are the most beneficial and which strategies are the most effective.5
Despite a growing focus on health promotion for older adults, the institutionalized elderly comprise an important but neglected segment of this population. Haight recently reviewed the literature on nursing research in longterm care facilities and found that no study focused on health promotion; instead, the research emphasis was on physical problems.14
This finding is of concern for several reasons. Although only 5% of older adults are institutionalized at any given time, an estimated 25% of those 65 years old or older will spend some time in a nursing home before they die.15 In addition, it is estimated that, for 25% to 40% of all older people, the long-term care institution will be their last home.16 Nursing home environments have been found to negatively influence lifestyle and have been credited with causing a variety of psychological and physical problems. These problems include hopelessness, withdrawal, disorientation, loss of identity, increased dependence, and stimulus deprivation.17
Several experts have addressed the need for health promotion approaches in nursing home settings. Minkler asserts that many institutionalized elderly could benefit greatly from health promotion strategies and recommends that nursing homes provide health education and opportunities for self-care, problem solving, and autonomy.15 Ebersole and Hess emphasize that high-level wellness can be attained by aged individuals regardless of chronic illness, disability, or institutionalization. They also encourage nursing interventions that incorporate the five dimensions of wellness, identified by Travis: self-responsibility, nutritional awareness, physical fitness, stress management, and environmental sensitivity (sensory and memory enhancement).17'18 Fallcreek and Mettler concur and suggest programs focusing on exercise and body movement, stress reduction, self-awareness, social skills, and interest-building strategies.19
This article examines nursing and non-nursing research that has been conducted on health promotion for the elderly in general, and more specifically, in nursing home settings. A hand search of the Cumulative Index to Nursing & Allied Health Literature (CINAHL) was done from 1970 to 1983, followed by a computer search of ONAHL from 1983 to June 1990. In addition, computer searches were conducted of Mediine from 1984 to September 1990, and of Nurse Search from 1985 to 1988.
Research on Health Promotion
Six studies were found that focused on health promotion for older adults: three were exploratory studies that focused on correlates of health, and three were health promotion intervention studies. All of these studies used samples drawn from noninstitutional populations except one sample in which 30% of the subjects were institutionalized.20 With the exception of one study,21 all of these studies were conducted by nurse researchers.
Of the three exploratory studies found, two focused on the relationship of social support and the health of older adults. The third study focused on social support as one of the correlates of longevity. Fuller and Larson studied a random sample of 50 well, older adults living independently in the community. Results were inconclusive; there was no evidence that emotional support would assist one in dealing with stressful life events. Emotional support, however, was found to have a positive effect on feelings of loneliness and dissatisfaction.22 In a study by Schank and Lough, results showed that elderly women in self-reported excellent or good health had a greater degree of social support than those women reporting fair or poor health status. Additional findings indicated that higher levels of education and greater financial resources were positively related to better reported health.23
Hogstel and Kashka explored the correlates of longevity and health. In a sample of 302 adults, aged 85 years and older, these researchers examined the relationship between exercise, nutrition, health assessment, rest and relaxation, limited use of chemicals, and support systems on longevity. Findings showed that none of the independent variables was significantly correlated with age. These researchers concluded that the instrument used (Lifelong Health Practices Scale) was not a good predictor of longevity. Other findings indicated that subjects who lacked good social support systems were the most physically impaired and the most dependent (30% of this sample lived in nursing homes). Subjects also ranked physical and mental activity as the primary factor contributing to longevity.20
Of the three intervention studies that were found, two investigations focused on the effects of a comprehensive health promotion program. In a quasiexperimental study of 67 older adults, Higgins examined the effects of a health promotion program on physical health changes in the areas of cardiovascular, musculoskeletal, and nutritional status. This program focused on nutrition, medical management, social habits, stress, exercise, smoking, alcohol use, and safety. Results showed that the experimental group experienced a significant increase in high density lipoprotéine and flexibility, and significant decreases in blood pressure, resting pulse rate, weight and skin fold measures, and total cholesterol. These researchers concluded that this wellness program had a positive effect on the physical health status of the study sample and that lifestyle change is the key to improved well-being for older adults.24
A less rigorous investigation on the benefits of a health promotion program was conducted by Kutlenios. Although the program was as comprehensive as the Higgins program, a pre-experimental design was used. Despite this limitation, those older adults who participated in the health promotion program were positive about what they had learned, and they reported that they enjoyed exercising, felt less stressed, and gained strength from practicing imagery and engaging in reminiscing.25
The third intervention study attempted to determine which characteristics of older adults are associated with successful or unsuccessful outcomes of health promotion interventions. Using an experimental design, Fitch and Slivinske found that the best predictors of wellness were those persons who had participated in the experimental health promotion program, had higher initial levels of perceived control, had greater muscular flexibility and strength, and had higher incomes. Subjects who believed that they had less control over their environments had less muscular flexibility and strength, had lower incomes, and were less able to benefit from health promotion programs. These findings suggest that it may be possible to identify older individuals who may or may not benefit from health promotion approaches.21
Research in Nursing Home Settings
Despite an increased research focus on health promotion for older adults, only two quantitative studies were found that examined this issue for institutionalized older adults; a nurse was a researcher in one of these studies.26 In addition, several demonstration projects were found that focused on health promotion programs in long-term care settings.
Slivinske and Kosberg investigated the effect of a holistic health-care program on the health and well-being of 67 older adults. A modified nonequivalent control group design was used. The experimental group consisted of 43 volunteer retirement home residents and 10 volunteers from the surrounding community. The control group consisted of 14 randomly selected residents from one retirement facility. Results showed significant increases in wellness scores, muscular strength, and flexibility for program participants as compared with the control group. Additional findings indicated that study participants perceived improvements in their morale, ability to cany out daily activities, physical health, spirituality, and economic resources. Findings suggest that a holistic health-care program can improve the health and well-being of retirement home residents.27
Using a pretest/post-test experimental design, Becker and colleagues studied the benefits of a program called Project Elder Find. This program was designed to identify institutionalized elders who show capacity for increased independence and to develop a personalized plan to reduce dependence and increase self-management. This model incorporates a multidomain assessment of function and an interdisciplinary approach to care. Post-test results showed slightly improved or stable levels of function for the experimental group and a decline or no change in status for the control group. Findings also showed that the experimental group had 30% fewer hospitalization days than the control group.26
The majority of research on health promotion in nursing home settings consists of program evaluations of demonstration projects. Historically, the 1970s was a decade of national funding of long-term care projects around the country. Examples of such projects include the Senior Actualization and Growth Explorations Project in Berkeley, California,28 the Live Oak Project in Oakland, California,29 and Project Centercare in Baltimore, Maryland.30 When federal monies were curtailed in the early 1980s, these projects either went out of existence (SAGE: Hill K. Personal communication, January, 1990) or became private programs within individual nursing homes (Live Oak Project: Barkin B. Personal communication, January 18, 1990; Project Centercare: Grant F. Personal communication, January 18, 1990). Previous evaluations of these programs indicated that they were successful in lowering stress, improving serf-esteem, increasing coping skills,28 improving physical and mental health, improving staff morale,29 and enhancing the social and intellectual well-being of nursing home residents.30
As a result of the lack of federal monies to fund health promotion programs in long-term care settings, some states, such as Michigan and Kentucky, have developed their own projects. Michigan's Nursing Home Enrichment Program funds 1 1 projects serving approximately 15,000 residents in 142 homes throughout the state. These projects encourage activities that are emotionally and intellectually stimulating and encourage social and emotional connectedness with residents and staff. Increasing self-esteem and Ufe involvement is emphasized. No empirical evaluation data were available on resident outcomes (Sprey D. Personal communication, February 8, 1990).
Kentucky's program is oriented more to physical fitness. The Kentucky Senior Games is a nonprofit, statefunded program that provides a fitness and health promotion program for all Kentuckians 55 years of age or older. This program is available to residents of long-term care settings as well as to older adults living in their own homes. Begun in 1987, there are now about 38 nursing homes involved in the project. The focus is on maintaining and enhancing health through staying physically and socially active. This is the only senior games in the country that includes frail and disabled people. Evaluations of this program have shown an increased interest among residents to participate and an increased interest among nursing home staff to provide senior games within their facilities. No resident outcome data were available (Daniel C. Personal communication, January 16, 1990).
SUMMARY AND CONCLUSION
Although institutionalized adults have not been prime targets for health promotion research, evidence suggests that health promotion efforts positively correlate with improved physical and psychological parameters of health for older adults. It is also evident from several demonstration projects that institutionalized elderly benefit from humanistic approaches and that lifestyle enhancement is possible in nursing home settings.
IMPLICATIONS FOR NURSING PRACTICE AND RESEARCH
The paucity of health promotion research in long-term care settings demonstrates the need for increased focus in this area. This review has shown that, although nurses are conducting health promotion research for older adults in noninstitutionalized settings, they are not actively conducting health promotion research in nursing home settings. This finding is of concern because nursing homes are essentially nurse-managed facilities. Nurses largely determine the kind of care that is given and thus can influence the quality of rife that nursing home residents experience.
Long-term care nurses are in a unique position to empirically investigate the benefits of health promotion programs in the institutional setting and to evaluate the efficacy of health promotion interventions and strategies. In the words of former Surgeon General C, Everett Koop, "We have the extraordinary opportunity to help [older people] not only to live a few years longer, but also to make those extra years - and indeed all the years of their lives - good and healthful years." 10
- 1. Nightingale F. Notes on Nursing; "What It Is and What h Is Not. New York: Dover Publishing, Ine; 1969.
- 2. Pender NI Health Promotion in Nursing Practice, 2nd ed. Norwalk, Ct: Appleton & Lange; 1987.
- 3. Polit D, Hungler B. Essentials of Nursing Research: Methods. Appraisals, and Utilization, 2nd ed. Philadelphia: JB Lippincott Co; 1989.
- 4. Laffrey S. Health promotion: Relevance for nursing. Topics in Clinical Nursing. 1985; 7(2):29-38.
- 5. Kleinman L. A healthy aging America. Journal of Geronlological Nursing. 1986; 12(1 1):3.
- 6. Adams A. Aging: Gerontological nursing research. In: Werley H, Fitzpatrick J, Taunton R, eds. Annual Review of Nursing Research, vol 4. New York: Springer Publishing Co; 1986.
- 7. Walker SN. Health promotion for older adults: Directions for research. American Journal of Health Promotion. 1989; 34):4752.
- 8. McGinnis JM. Year 2000 health objectives for the nation. In: Surgeon General's Workshop: Health Promotion and Aging Proceedings. Washington, DC: US Department of Health and Human Services; 1988.
- 9. Heckler M. Health promotion for older Americans. Public Health Rep. 1985; 100:225-230.
- 10. Koop CE. Keynote address. In: Surgeon General's Workshop: Health Promotion and Aging Proceedings. Washington, DC: US Department of Health and Human Services: 1988.
- 11. National Institute on Aging: Personnel for Health Needs of the Elderly. Washington, DC: US Department of Health and Human Services; 1987.
- 12. Dychtwald K. The aging of America: Overview. In: Dychtwald K, ed. Wellness and Health Promotion for the Elderly. Rockville, Md: Aspen Systems Corp; 1986.
- 13. American Nurses' Association. Standards and Scope of Gerontological Nursing Practice. Kansas City, Mo: Author; 1987.
- 14. Haigbt BK. Nursing research in long-term care facilities (1984-1988): Nursing and HealthCare. 1989; 10:147-150.
- 15. Minkter M. The nursing home: A neglected setting for health promotion. Family and Community Health. 1985; 8(l):46-58.
- 16. Ebersole P, Hess P. Toward Healthy Aging: Human Needs and Nursing Practice. St. Louis: CV Mosby; 1985.
- 17. Ebersole P, Hess P. Toward Healthy Aging: Human Needs and Nursing Practice, 2nd ed. St. Louis: CV Mosby; 1990.
- 18. Travis J. Wellness Workbook: A Guide io High-Level Wellness. Mill Valley, Ca: Wellness Resource Center; 1977.
- 19. Fallcreek S, Mettler M. A Healthy Old Age: A Sourcebook for Health Promotion with Older Adults. New Yoik: Haworth Press; 1984.
- 20. Hogstel MO, Kashka M. Staying healthy after 85. GerìatrNurs. 1989; 10(1):16-18.
- 21. Fitch VL, Slivinske LR. Maximizing effects of wellness programs for the elderly. Health Soc Work. 1988; 13(l):61-67.
- 22. Fuller SS, Larson SB. Life events, emotional support, and health of older people. Res Nurs Health. 1980; 3:81-89.
- 23. Schank MJ, Lough MA. Maintaining health and independence of elderly women. Journal of Gerontological Nursing. 1989; 15(6):8-11.
- 24. Higgins PG. Biometrie outcomes of a geriatric health promotion programme. J Mv Nurs. 1988; 13:710-715.
- 25. Kutlenios RM. Healing mind and body; A holistic perspective. Journal ofGeronlologicalNursing. 1987; 13(12):8-13.
- 26. Becker MA, Ferrara BE, Ashford JW, Zee RF. Project elder find, phase II: Validation of the model through a randomized controlled study. New Horizons in Lang Term Care (Abstracts). Springfield, D: Illinois Department of Public Aid; 1987.
- 27. Slivinske LR, Kosberg JI. Assessing the effect of a personal health management system within retirement communities: A preliminary investigation. Gerontologist. 1984; 24:280-285.
- 28. Dychtwald K. The SAGE project: A new image of age. Journal of Humanistic Psychology. 1978; 18(2):69-74.
- 29. Barkin B. The Live Oak regenerative community. Aging. 1981; (September- October)2-7.
- 30. Hirsch CS. Integrating the nursing home resident into a senior citizens center. Gerontologist. 1977; 17:227-234.