Journal of Gerontological Nursing

HOPE, CHRONIC ILLNESS AND THE ELDERLY

Anita Beckerman, ARNP, CS, EDD; Celeste Northrop, ARNP, CS, DNSC

Abstract

Hope is a concept which knows no geographical boundaries. It is reflected in religious writings, in everyday language, in the hospital setting and during difficult international negotiations. To hope is to look ahead to some event, with the expectation of fulfillment; it nudges men through time.

Recognition that hope plays an integral role in health and disease is now encouraging researchers to look at various aspects of this concept. Professional nurses as caregivers see the effects of hope and hopelessness on clients. Nurse scholar J. Miller (1986) constructed a scale hypothesized to measure an individual's level of hope. In this study Miller defined hope as a "state of being, characterized by anticipation for a continued good state, and improved state, or a release from a perceived entrapment" (p. 52). The sample population for Miller's study was the young, healthy adult. This study utilized Miller's definition of hope.

PURPOSE OF THE STUDY

Watson (1979) identified instilling faith and hope as one of ten carative components in a humanistic model of nursing. This idea plus the felt need to understand how the older adult viewed hope were the motivations for the present study. The purpose of this study is to validate the psychometric ability of the Miller Hope Scale (MHS) to measure levels of hope and associated factors in elderly clients with chronic physiologic disease. It was an assumption of the investigators of this study that identification of the level of hope and associated factors will assist the nurse in formulation of the client's plan of care. Concepts of hope present that are correlated with positivism could be enhanced and those correlated with negativism decreased, thus promoting activities that encourage and initiate achievement of high levels of hope. Society would benefit because higher functioning, more positive thinking elderly are more independent and more aware of the how's and why's of accessing the health care system to achieve optimal levels of health (Sapp & Bliesmer, 1995).

The following hypothesis was established for the study: The psychometric properties of the Miller Hope Scale (MHS) are as valid when applied to an elderly population with chronic disease as when applied to a young well population, the sample in the original Miller (1986) study.

LITERATURE REVIEW

Nurses in their daily interactions with elderly clients and their family speak informally to the interrelationship of hope, the elderly, and chronic disease. Research and publications on the interdependence and interrelationship of hope, the elderly, and chronic illness are limited. A computerized search of the literature of a combination of these variables, in both the Index of Allied Health and the Psychological Abstracts, had negative results. Any reference to these variables were found only as surrounding statements in publications on the topic of hope alone.

The review of the literature supports the importance of the construct of hope as it is felt to influence the quality of life. The studies reviewed used tools measuring hopelessness, morale, coping strategies, but none, other than the study by Miller (1986) utilized a tool specifically formulated and validated to test the variable of hope.

Although not all elders are incapacitated with chronic illnesses, many are faced with living with disease processes which may impair their thinking, feeling, and behavior. Felton and Revenson (1984) conducted a study exploring the coping strategies employed by clients in dealing with chronic illness. They looked at the influence of coping strategies on the mental health status of these clients. They evaluated the impact of clients using information seeking strategies and wish-fulfilling fantasies on their level of coping with chronic illness. Their findings suggest that information-seeking strategies had a high…

Hope is a concept which knows no geographical boundaries. It is reflected in religious writings, in everyday language, in the hospital setting and during difficult international negotiations. To hope is to look ahead to some event, with the expectation of fulfillment; it nudges men through time.

Recognition that hope plays an integral role in health and disease is now encouraging researchers to look at various aspects of this concept. Professional nurses as caregivers see the effects of hope and hopelessness on clients. Nurse scholar J. Miller (1986) constructed a scale hypothesized to measure an individual's level of hope. In this study Miller defined hope as a "state of being, characterized by anticipation for a continued good state, and improved state, or a release from a perceived entrapment" (p. 52). The sample population for Miller's study was the young, healthy adult. This study utilized Miller's definition of hope.

PURPOSE OF THE STUDY

Watson (1979) identified instilling faith and hope as one of ten carative components in a humanistic model of nursing. This idea plus the felt need to understand how the older adult viewed hope were the motivations for the present study. The purpose of this study is to validate the psychometric ability of the Miller Hope Scale (MHS) to measure levels of hope and associated factors in elderly clients with chronic physiologic disease. It was an assumption of the investigators of this study that identification of the level of hope and associated factors will assist the nurse in formulation of the client's plan of care. Concepts of hope present that are correlated with positivism could be enhanced and those correlated with negativism decreased, thus promoting activities that encourage and initiate achievement of high levels of hope. Society would benefit because higher functioning, more positive thinking elderly are more independent and more aware of the how's and why's of accessing the health care system to achieve optimal levels of health (Sapp & Bliesmer, 1995).

The following hypothesis was established for the study: The psychometric properties of the Miller Hope Scale (MHS) are as valid when applied to an elderly population with chronic disease as when applied to a young well population, the sample in the original Miller (1986) study.

LITERATURE REVIEW

Nurses in their daily interactions with elderly clients and their family speak informally to the interrelationship of hope, the elderly, and chronic disease. Research and publications on the interdependence and interrelationship of hope, the elderly, and chronic illness are limited. A computerized search of the literature of a combination of these variables, in both the Index of Allied Health and the Psychological Abstracts, had negative results. Any reference to these variables were found only as surrounding statements in publications on the topic of hope alone.

The review of the literature supports the importance of the construct of hope as it is felt to influence the quality of life. The studies reviewed used tools measuring hopelessness, morale, coping strategies, but none, other than the study by Miller (1986) utilized a tool specifically formulated and validated to test the variable of hope.

Although not all elders are incapacitated with chronic illnesses, many are faced with living with disease processes which may impair their thinking, feeling, and behavior. Felton and Revenson (1984) conducted a study exploring the coping strategies employed by clients in dealing with chronic illness. They looked at the influence of coping strategies on the mental health status of these clients. They evaluated the impact of clients using information seeking strategies and wish-fulfilling fantasies on their level of coping with chronic illness. Their findings suggest that information-seeking strategies had a high correlation with ability to cope with chronic illness, while wish-fulfilling fantasies had a negative correlation.

Rideout and Montemuro (1986), in studying hope, morale and adaptation in patients with chronic heart failure, used Lynch's (1965) definition of hope as "an expectation greater than zero of achieving a goal, characterized by the belief mat there is a way out and that with help, the individual can manage changes in his being" (p. 429). The study was not limited to elderly patients, although the mean age of the study sample was 66. This descriptive study used the Beck Hopelessness Scale (Beck, Weissman, Lester, & Trexler, 1974), the Philadelphia Geriatric Center Morale Scale (Lawton, 1972), and a 13-point scale, devised by Lee and colleagues (1982). The study revealed moderate to good correlation between hope and morale, which was an expected finding, since the questions on these scales were very similar in their content and intent. No positive correlation was found between hope and chronic heart failure, a finding that could be due, the author states, to the fact that the sample population were all from a Heart Failure Clinic, receiving very intensive treatment and follow-up. The study results suggested that "patients who are more hopeful maintain their involvement in life regardless of physical limitations imposed by heart failure" (p. 437).

The increasing number of elderly clients in the health care system has resulted in a parallel increase in the number of nurses interested in hope and older individuals. In 1989, Whall stated that in the elderly, hope is defined as belief and trust in the future. Although one may not be in the best of physical condition and have multiple handicaps, there are still opportunities to be enjoyed. This frame of mind impacts upon the choices and seeking of alternatives, while taking into account both positive and negative functional ability.

Miller (1985) concurs that there is a definite relationship between how one responds to illness and the personal belief (hope) that one will and can still live as full a life as is possible and that crises are an opportunity for growth. Faith, significant relationships with others, positive selfconcept, and a feeling of still being an active contributor to society, are all sources of hope that caregivers must assess and address. Hope as a concept is a part of the human cognitive process, regardless of age.

METHOD

Setting and Sample

A convenience sample of 94 elderly adults residing in a 500-bed nonsectarian progressive care nursing facility in Southeast Florida, with chronic physiological disorders agreed to be interviewed. Only residents who were identified as cognitively and affectively able to answer questions on the tool having a diagnosis of a chronic illness for at least six months were included in the study.

Instruments

The original Miller Hope Scale (1986) consists of a 40-item generalized measure of hope and a one-item scale which inquires into the respondent's state of hope at the time the questionnaire is completed. An eight-item illness subscale developed by Miller at the same time is also part of the current tool. Miller (personal communication, October 10, 1995) states that the "illness subscale items were developed from knowledge based in terms of chronic illness and what it meant to deal with chronic health problems and an uncertain, sometimes downward health trajectory."

Content and construct validity of the MHS (1986), without the illness subscale, is described in the original Miller study. A demographic data collection sheet was also designed and administered with the MHS.

Procedure

Clients meeting inclusion criteria were identified by the head nurse or primary nurses and referred to the investigators at the time of initiation of the study. The eligible clients were approached by the investigators on an individual basis, within their own room settings, taking into account the comfort of the participants. Explanation of the study was given and written consent obtained, with each participant aware that he or she could withdraw from the study at any time. The selection, consent, and data collection process met the guidelines for research at the institution.

Demographic data relating to age, marital status, education, functional role (occupation), support system, and ethnic identification was asked and documented for each participant.

The average time to complete each questionnaire was estimated to be 20-30 minutes with the interviewer aiding the client when necessary if any questions needed clarification and/or repetition. The actual average time was 1 hour to 1 hour, 15 minutes. Approximately 40% of the resident sample required assistance in completing the forms due to physical limitations of sight or hand tremors.

RESULTS

Ninety-four residents voluntarily consented and completed the demographic data sheet and Miller Hope Scale. The age range of the sample was 58 to 100 years old, with a mean age of 88.75 (SD=6.26). Eighty-seven percent (82) of the sample were female; 12% (12) were male and 1% (6) did not specify. In the original Miller population, the age range was 18 to 52, with a mean age of 21.45 (SD=4.66).

The presence of chronic illnesses was apparent in interviews with the elders. This was also corroborated through documentation in the residents' medical records. Most common illnesses noted were:

*coronary artery disease,

* sight disorders,

*hypertension, and

*degenerative joint disease

Completion of formal education varied widely, from a few grades of elementary school to earned doctorates. When asked how the elders identified themselves ethnically, the majority, or 51%, replied AmericanHebrew, followed by 45% EuropeanHebrew, and 4% not designated. When queried about the presence of a support system, whether local or at a distance, 75% stated that they had a support system available as needed. Telephone availability made distance not as critical. Individuals identified as the support network included sons, daughters, grandchildren, grand nieces and nephews, trust officers and attorneys. Twentythree percent of the residents responded that they did not have any support system due to "outliving" significant others or that the "support net" they thought would be present did not materialize when they needed it.

During data collection, the investigators observed how sharing a room with a peer was received by residents. Many residents realized that having a roommate was primarily a financial decision and were content with sharing a room with another. One set of sisters shared a room and were very attentive to each other. Two married couples who shared rooms did so in a seemingly obligatory fashion. A summary of demographic data in an elderly population with chronic illnesses as compared with the summary of demographic data in the younger, healthy population from Miller's original study is presented in Table 1.

Also listed for comparison are the mean scores of the original Miller population and the current elder population. The original Miller Hope Scale was based on a fivepoint response to the items. The current scale was revised by Miller to offer a six-point response option. In order to compare the two population means, the original mean was adjusted mathematically for that purpose. A higher score represents a higher hope value. A summary of the responses of the elders on the three sections of the Miller Hope Scale are seen in Table 2.

Table

TABLE 1Comparison of Demographic Data and Mean Scores on MHS in Original Miller Population and Current Population

TABLE 1

Comparison of Demographic Data and Mean Scores on MHS in Original Miller Population and Current Population

Table

TABtE 2Descriptive Data on Hope Instruments in Elderly Population

TABtE 2

Descriptive Data on Hope Instruments in Elderly Population

Of interest to the researchers is how the elders ranked the first 40 items in the Hope Scale in terms of importance to them and which items were of least importance to them. As seen in Table 3, the participants above all valued their freedom (to choose) and noted least important (Table 4) spending time planning for the future. They in effect were "living their planned future" each day.

The responses to the eight questions on the illness subscale were ranked according to how strongly they agreed or disagreed to the concepts presented. As seen in Table 5, they were more optimistic when comfortable, but had few reasons to keep positive about their health. They seemed to present a sense of "I know what's ahead, so what's to be positive about?"

The "Hope Now" Subscale, the ten-point response to how the respondent saw their level of hope that moment, with one representing "no hope" and ten representing "most hope" revealed the elder population's mean to be 6.25. Some elders did not always see a state of "no hope" as being problematic but "realistic."

Reliability is the ability of a tool/test to produce consistent measurements across populations. A measure of the reliability of the Miller Hope Scale in an elder population, using Cronbach's Coefficient alpha, revealed an alpha of .95 on the 40-item Hope Scale. An alpha of .89 was obtained on the eight-question illness subscale. The combined alpha in the original young adult population was .93.

A correlational analysis among hope and six variables was completed. The six variables included: age, sex, perception of external support, and the three subscales of Hope, Illness and Hope Now. Pearson correlation coefficient revealed significant positive correlations between the residents' perceptions of support and various subscale items. These subscale items correlating with perception of support included: feeling positive about aspects of life, able to imagine positive outcomes, intending to make the most of life, being satisfied with life, being needed by others, feeling loved, and being hopeful even though one sees no improvement.

T tests by sex for age, mean Hope, mean Illness, Hope Now and the total Hope score were not significant. T tests of perception of support were calculated on the Miller Hope Scale, with the six above noted variables. T test results did corroborate the significance of the perception of support, with a higher mean Hope and Hope Now. In other words, the elders who felt the presence of a support system were more hopeful.

A two-way ANOVA by perception of support and sex revealed no difference in the elder respondents by sex on the Hope Scale or on the Illness Subscale. Women did not feel any more or less hopeful than the men in the sample. T tests for support were significant with specific statements such as: I am positive about aspects of life, I am able to imagine positive outcomes, I intend to make the most of life, I am satisfied with life, I am needed by others, I feel loved, there are better days ahead, and I am hopeful even though I see no improvement.

The purpose of factor analysis is to reduce a large set of variables into a more manageable set of measures. Factor analysis extract then reassemble factors into manageable sets of measure. One method of factor extraction is maximum likelihood techniques.

Table

TABLE 3Ranking of 4O Item Hope Scale by Elderly Population of Five Mosi Important Statements

TABLE 3

Ranking of 4O Item Hope Scale by Elderly Population of Five Mosi Important Statements

Table

TABLE 4Hanking of 4O Item Nope Scale by Elderly Population of Five Least Important Statements

TABLE 4

Hanking of 4O Item Nope Scale by Elderly Population of Five Least Important Statements

In the original study, with young adults, a maximum likelihood factor analysis with oblimin rotation using BMDP statistical software (Dixon et al., 1985) was used to explore the underlying dimensions of the scale. A three factor solution best reproduced the correlations among the observed items in the young adult population. The first factor was labeled "Satisfaction with self, others, and life/' the second "Avoidance of hope threats," and the third "Anticipation of a future." An initial factor analysis of the responses of the elder population was also initiated using the small study sample to see if any dimensions began to emerge.

Although the sample of 94 elders was considered "middling" for a factor analysis (where a N of 400 would be sought, Nunnally, 1978), these preliminary results revealed emergence of a 3 factor solution, with 48.9% of the variability explained by three factors. The first and second factors appeared similar to the original younger, healthier Miller population. The third factor was dissimilar. The original third Miller factor was labeled "Anticipation of a future/' which as demonstrated in the elderly is not a priority and does not merge as Factors 1 and 2.

Table

TABLE 5Ranking of Agreement with Statements on Illness SuJbscafe

TABLE 5

Ranking of Agreement with Statements on Illness SuJbscafe

DISCUSSION

The Miller Hope Scale was designed to provide health care providers with an objective tool to assess the concept of hope in individuals. The interface of the concept of hope with other aspects of our experience has yet to be explicated, although we know it is essential to our existence. In designing the Miller Hope Scale, its creator utilized a variety of qualitative and quantitative methods to distili the essence of hope. The resulting tool was validated on a population of young adults and made available for others to utilize with varying populations. In the current study, the investigators sought the input of older individuals residing in an open nursing care facility. Ninety-four elders agreed to complete the Miller Hope Scale. The results of this study revealed the emergence of a number of similarities as well as differences in the application of the MHS to an older population. These variances may be of interest to individuals who have an interest in applying the tool to various populations.

Not surprising, the mean results of the Hope score in an older population was lower than that of a well, younger population. The importance of a support system was very important to the elder who had survived other relatives and saw this resource shrinking in comparison to the younger adult whose life resources was growing. The presence of some support resource was influential in the individual's Hope score, coping with illness, and current state of hope.

Like the original younger Miller population, the elders' foundation of hope included satisfaction with self and life, and avoidance of threats to hope. Unlike the younger population, the elders' anticipation of a future was not an important component of hope. For the elder, each day lived was the lived concept of future.

Potential limitations of the study relate to the sample population interviewed, i.e., a majority of the participants were of the Hebrew faith. Replication of the study with different religious and cultural populations, as well as a larger sample for factor analysis, needs to be considered.

Could the basic definition of hope change with age? Is there a developmental hierarchy for the concept of hope? The need for further study using the Miller Hope Scale may uncover such a hierarchical concept.

NURSING IMPLICATIONS

How can these preliminary results be utilized in concept by the caregiver? As the investigators discovered in the data gathering stage, the needs of the individual must be taken into consideration when administering a questionnaire. Agerelated concerns may need to accommodate for sight or hearing difficulties. Arthritis makes it difficult to hold a common writing instrument. Isolation and loneliness may find a data gatherer a person to tell stories and visit with, whether anticipated or not by that person. The investigators anticipated a 30 minute per elder time frame. In actuality, that far underestimated the actual time required to meet with each elder.

Nursing staff should encourage the networking of support systems with the elder. The elder should be encouraged to enjoy each day in itself. The staff should obtain the elder's concept of wellness and illness. Finally, the staff should not be afraid of broaching the subject of how the elder sees dying as a part of life processes.

The more we understand the concept of hope, the more we should be able to identify specific interventions to apply, based on the developmental and social needs of the individual.

REFERENCES

  • Beck, A. Weissman, A., Lester, D., & Trexler, L. (1974). The measurement of pessimism: The Hopelessness Scale, journal of Consulting and Clinical Psychology, 4, 861-865.
  • Dixon, W.J., Brown, M.B., Engelman, L., Frane, J.W., HiU, M.A., Hennrich, R.I., & Toporek, J.D. (1985). BMDP Statistical Software. Berkeley, CA: University of California Press.
  • Feiton, B.F., & Revenson, T.A. (1984). Coping with chronic illness: A study of illness controllability and the influence of coping strategies on psychological adjustment. journal of Consulting and Clinical Psychology, 52, 343-353.
  • Lawton, M.P. (1972). The Philadelphia Geriatric Center Morale Scale: A revision. Journal of Gerontology, 30, 85-89.
  • Lee, D., Johnson, R.A., Bingham,. J.B., Leahy, M., Dinsmore, R., Goroll, A-, Newell, J.B., Strauss, W., & Haber, E. (1982). Heart failure in outpatients. The New England Journal of Medicine, 306, 699-705.
  • Lynch, W.F. (1965). Images of hope: Imagination as healer of the hopeless. Baltimore, MD: Helicon.
  • Miller, J.F. (1985). Hope. American journal of Nursing, 85, 23-25.
  • Miller, J.F. (1986). Development of an instrument to measure hope. Unpublished doctoral dissertation, University of Illinois, Chicago.
  • Nunnally, J. (1978). Psychometric theory. New York, NY: McGraw-HiU.
  • Rideout, E-, & Montemuro, M. (1986). Hope, morale and adaptation in patients with chronic heart failure. Journal of Advanced Nursing, 11, 429438.
  • Sapp, M., & Bliesmer, M. (1995). A health promotion/protection approach to meeting elders' health care needs through public policy and standards of care. In M. Stanley & PG. Beare (Ed.), Gerontological nursing (pp. 3-12). Philadelphia, PA: F.A. Davis.
  • Watson, J. (1979). Nursing: The philosophy and science of caring. Boston, MA: Little, Brown and Company.
  • Whall, A.L. (1989). The importance of hope in the care of the elderly. Ceropsychiatry, 15, 38.

TABLE 1

Comparison of Demographic Data and Mean Scores on MHS in Original Miller Population and Current Population

TABtE 2

Descriptive Data on Hope Instruments in Elderly Population

TABLE 3

Ranking of 4O Item Hope Scale by Elderly Population of Five Mosi Important Statements

TABLE 4

Hanking of 4O Item Nope Scale by Elderly Population of Five Least Important Statements

TABLE 5

Ranking of Agreement with Statements on Illness SuJbscafe

10.3928/0098-9134-19960501-07

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