The age group composed of individuals older than 85 years is the most rapidly expanding segment of the U.S. population (Bureau of the Census, 1993). At age 85, approximately 50% of elderly men are married. Comparatively, 80% of women in that same age group are widowed (Bureau of the Census, 1993). Elderly women as a group are more impoverished, are vulnerable due to fewer resources, and have uniquely different experiences when compared to younger age groups (65 to 85 years) and to men in the same age group (Pohl & Boyd, 1993). Furthermore, elderly women of diverse backgrounds have different life experiences, compared with mainstream society, because of the marginalizing effects of age, race, socioeconomic class, and gender (Feiten, 2000; Hall, Stevens, & Meléis, 1994). These different experiences may result in alternative meanings for concepts, compared with other groups.
Population projections suggest the cohort of women older than 85 will include greater numbers of women of color (Siegel, 1996). This is a new phenomenon, as American society has never before experienced an expanding cohort of women of color older than 85 (Bureau of the Census, 1993). When one considers issues of undercounting and failure to collect subpopulation data, it is likely that current official statistics underestimate this cohort.
The conventional definition of the elderly population refers to individuals age 65 to 74 as young-old, age 75 to 84 as old, and older than 85 as oldest-old (Wray, 1992). The oldest-old cohort, those most likely to need health care and physical support, are projected to be the fastest growing segment of the elderly population. In addition, by the year 2050, ethnic minority groups are projected to make up one third of the oldest-old cohort (Leigh & Lindquist, 1998).
The process of conceptualizing a clinical phenomenon eventually leading to clinical practice theory is ongoing. That is, an exact starting point of the process of conceptualization is difficult to pinpoint, as would be the announcement of a theory in final form without any need for revision. Exploration of concepts is part of the beginning process of theory development. This process continues further with the development of a rudimentary form of a theory, followed by more research and initial testing of the theory. Nursing theory development will lead to improved understanding of a phenomenon, help anticipate events and outcomes, and eventually lead to more appropriate care patterns (Meléis, 1997).
Grand nursing theories explain the nature, mission, and goals of nursing care (Meléis, 1997), usually applied to multiple clinical populations and settings. Middle-range theories have more limited scope and focus on specific nursing phenomena, often emerging from clinical practice (Meléis, 1987). A middle-range theory of resilience in women older than 85 could be used, after testing, to change nursing practice, based on the unique characteristics and experiences of a growing, diverse cohort.
Women older than 85 often must alter their lifestyles in response to loss, illness, or impairment. Although some women older than 85 suffer declines in function after illness from which they are not able to recover, others are able to rebound after illness. Resilience in women older than 85 is defined as the ability to achieve, retain, or regain a level of physical or emotional health after devastating illness or loss (Feiten, 2000). It is important here to note that the meaning of "devastating illness" for women older than 85 is a highly individualized phenomenon because a minor illness for one woman may have serious consequences in another.
Understanding how some women older than 85 are able to demonstrate resilience after illness when others cannot is an important focus for gerontological clinical research. After careful conceptual analysis, development of a specific theory of resilience therefore is possible to describe, explain, and understand this as it applies to the specific cohort of women older than 85. The purposes of this article are to:
* Explore the concept of resilience in diverse women older than 85.
* Propose the rudimentary elements of a middle-range theory of resilience applicable to that group of older adults.
ADVANCED PRACTICE-BASED GENERATION OF CERONTOLOGICAL NURSING THEORY
The clinical nurse specialist (CNS) is well situated to make practice-based observations leading to theory development, intervention improvement, and patient outcomes improvement. The first author is a gerontological CNS in full-time independent communitybased private practice. As an experienced ger ontologica! nurse, the first author observed that experiences, disease processes, and health responses of her most resilient, strongest older women clients were very different compared to younger women and men clients. The second author is a nurse scholar, researcher, and theorist with a strong background in theory related to marginalized, diverse women.
Concept Analysis Method
One commonly used strategy for concept analysis is that of Walker and Avant (1995), which includes describing antecedents and consequences and identification of a model example of the concept. This method of concept analysis is based on a mainstream generic approach, which assumes the meaning of a concept remains the same across all groups of people - one meaning fits all. Existing strategies of concept analysis provide limited opportunity to examine different realities, especially in diverse groups (Meléis, 1997). Wuest (1994) suggests an alternative feminist approach to concept analysis, recognizing the unique context and experiences women who are often marginalized outside of mainstream society.
Meléis (1997) suggests not using a rigid "recipe" strategy to concept analysis, advocating instead alternatives that use the clinical experiences of clinicians and researchers. Meléis offers an integrated strategy of using clinical observation as a source of analysis, describing a phenomenon, labeling, concept development, identifying assumptions, and communicating (1997). This concept analysis of resilience in women over age 85 is based on the strategy suggested by Meléis.
Following the strategy suggested by Meléis, this conceptualization of resilience has described how clinical observations from gerontological nursing practice formed a foundation of inquiry to study how and why some women older than 85 rebound after illness when others do not. The authors described and defined this phenomenon, giving it the name of "resilience in women older than 85."
A review of the literature follows describing resilience from the standpoint of other authors, providing an overview of how the concept has been previously described, and distinguishing the phenomenon in women older than 85. Theoretical assumptions are identified, along with an example from clinical practice. Lastly, this article itself serves as the communication component of ongoing concept development as suggested by Meléis.
Resilience has been extensively studied in children (Anthony & Cohler, 1987; Garmezy, 1991). However, connections have not been made to validate the meaning of the concept across age groups. Grace (1989) uses the term "quadruple jeopardy" to describe the intersection of age, race, socioeconomic class, and gender as risk factors affecting the health of older women, especially those of color. The interaction of age, race, socioeconomic class, and gender converge to shape experiences of women. Feminism and the women's movement have increased awareness of the diversities among women's experiences (Maynard, 1994).
In addition to age, race, class, and gender, women further diverge in relation to how disability and geographic location influence their specific experiences. Lack of health insurance and barriers to access, including culturally insensitive delivery., often means that health care may not be obtained in a timely manner, allowing disease processes to progress for these ethnically diverse women. Further, after age 85, frailty, widowhood and the sequela of functional impairment because of chronic disease begin to alter lifestyle, resulting in decline.
Understanding the experiences of resilience in women older than 85 who have been able to remain in the community late in life after devastating illness or loss will help to maximize their independence, improve outcomes, and foster effective community support of this cohort. Conceptualizing resilience in a specific population and a specific gender may lead to a more comprehensive, in-depth understanding of the ability to regain earlier levels of function in women older than 85.
Stress is defined here as a physical, chemical, or emotional influence that generates a response (Mish, 1999). Individuals respond differently to stress. One type of stress is illness or loss, analogous to downward motion or compression of a coil. Loss is defined as a reduction in physical, emotional, or social function incurred in situations including loss of spouse, significant other, or a pet; financial setbacks; disruption of social friendship networks; and devastating physical or emotional illness. When stress occurs, and an older woman experiences an illness or loss, the coil is compressed. The term "resilience" is related to the linguistic root of the Latin word to resile, to recoil (Mish, 1999), such as after compression.
Review of Resilience Research
Resilience has multiple definitions, from differing perspectives. Jacelon (1997) defines resilience as the ability to spring back after adversity. Dyer and McGuinness (1996) describe resilience as a process, to bounce back from adversity and go forward. Jacelon (1997) defines resilience as a trait as opposed to a process.
Polk (1997) identifies a taxonomy of several hundred resilient responses based on dispositional, relational, situational, and philosophical patterns across the lifespan, each supported in the literature. This taxonomy of patterns of resilience includes athletic competence, easy temperament, positive self -concept, cognitive skills, and willingness to seek support, just to name a few. Polk defines resilience as the ability to transform disaster into a growth experience and move forward (1997), a response to tremendous stress. Polk, however, does not describe resilience applied to a particular age group. The contribution of this work is the development of an initial taxonomy of resilient human responses, an important first step in identifying examples of what can be described as resilience.
O'Leary and Ickovics (1995) hypothesize that resilience is the ability to return to original shape after being compressed, stretched, or otherwise changed. They believe women's health concerns should be considered not related to illness or disease, but related to strengths in women's lives, the influences that mediate diseases in women, and ability to thrive in the face of adversity. They suggest definitions of resilience as the power to return to the original form after being bent, compressed, or stretched and the ability to recover strength, spirit, and good humor quickly. Although O'Leary and Ickovics (1995) make no distinctions related to resilience in women at different ages, their perspective calls for more study of different experiences in subgroups of women.
Ness and Kuller (1997) suggest a shift in women's health away from illness or deficit to differences in response to illness between men and women. They suggest that there be more study on the influences that mediate diseases in women than on the diseases themselves.
Heidrich (1998) suggests that an appreciation of the multidimensional nature of older women would help nurses assess sources of strength, not just disability. Based on a study of older White women's physical health, self-perception, and incidence of depression as quantitatively measured over 6 years, she underscores the need for research in the lives of older women beyond their 70s, into their most frail years.
Wagnild and Young (1990) offer two related definitions of resilience in older women. They define resilience in older women as:
* A unique human phenomenon distinguished by the lived experience of rebound in health after loss in women late in life.
* The ability to successfully adjust to major life losses.
Wagnild and Young postulate that resilience in older women is characterized by five themes (i.e., equanimity, self-reliance, existential aloneness, perseverance, meaningfulness).
Equanimity (Wagnild & Young, 1990) is defined as a balanced perspective related to one's life experiences, the ability to consider a broader range of experiences, modulating extreme response to adversity. Despite severe losses, an older woman demonstrating equanimity could find something positive in the loss experience, such as an opportunity to learn more about her own strengths (Wagnild & Young, 1990). The loss itself, in the right environment, may provide an opportunity to learn of one's power and test the skills to use it.
Figure. Model of resilience in women older than 85.
Perseverance is described as active persistence in spite of adversity or discouragement. Wagnild and Young (1990) further explain the theme of perseverance as a survival instinct, a continuation of the struggle to rebuild one's life. Self-reliance is the tendency to exhibit more independence and confidence after experiencing loss. Despite adversity, resilient older women had the opportunity to rebound in a tolerant, nurturing environment, perhaps unleashing heretofore unknown sources of energy or power and untested or undeveloped skills (Wagnild & Young, 1990). Meaningfulness is the ability to derive insight from experiences, gain renewed value in life, and transform negative events into personal growth opportunities (Wagnild & Young, Í 990).
The meaning of living in one's own home despite challenges or the threatened loss of home described by Porter (1994) are other examples of meaningful experiences that can serve as catalysts to generate the power to rebound in older women. Existential aloneness (Wagnild & Young, 1990) is an opportunity for creativity, aloneness, and self-acceptance. Existential aloneness provides the physical or mental space to bounce back after adversity.
Wagnild and Young's study is an important step in the study of resilience in older women as a specific age-gender group. Although this study of older women had a mean age of 74 years, because it was a first attempt to examine resilience in any particular age group of older women, results serve as a useful foundation for further development of a theory of resiliency in women older than 85. The Wagnild and Young study is limited, however, by the selection of predominantly middle-class European Americans frequenting a senior center.
CASE STUDY FROM CLINICAL PRACTICE
The following example, taken from the first author's clinical private practice, illustrates aspects of resilience in women older than 85. The case highlights the importance of the individually defined nature of resilience and, ultimately, the limited nature of resilience in women older than 85 because of the cumulative effects of repeated losses related to frailty and other overwhelming Stressors.
Mamie, age 87, lives in an elderly group home, not a skilled nursing facility. In her earlier years she was active as an officer in several community organizations. She worked for many years as an executive secretary at a large industrial firm. She was an avid golfer. Four years ago she was taking martial arts classes, putting on demonstrations in schools.
Her husband died several years ago, and her only son later committed suicide. All of her blood relatives died of heart disease at an early age. At age 85 she told her daughter she wanted a heart transplant. After some discussion with her physician and family, a transplant was ruled out. She now has severe congestive heart disease, depression, and a history of falls. Mamie speaks of unresolved feelings of anger, guilt, and uncertainty related to the decisions she made in Ufe. In sessions with her gerontological CNS, she expresses remorse in how she handled some situations, still not sure she did what was best.
She came to the group home after the home-care agency refused to continue to follow her due to repetitive falls. At the group home, she broke both of her hips within 18 months. Each time she experienced a physical or emotional loss due to illness, she was able to rebound well beyond the level expected by her care team. Mamie is the only resident at her group home to return from the hospital, and later the rehabilitation facility, after breaking both hips.
In the past year, her family sold her home to pay for her care, causing Mamie much sorrow. She feels she no longer has a real home to return to. Soon she suffered worsening transient ischemie attacks (TIAs). While hospitalized for a TIA, her only daughter died unexpectedly at age 68 of a chronic illness. After her daughter's death, infections began to occur more frequently. Since the daughter's death, she had not been able to rebound in health as she had in the past.
Numerous times, Mamie was able to improve in function despite severe illness and losses. Although Mamie demonstrated remarkable resilience despite repeated falls and two broken hips, her ability to rebound was eventually impaired by the death of her daughter and the sale of her home. The cumulative effects of these repeated physical and emotional devastating losses resulted in Mamie no longer being able to improve to her previous level.
Using the analogy of the coil, this older woman was very strong and able to rebound despite numerous downward compressions. The repeated number of compressions from Stressors such as the transient ischemie attacks, the second broken hip, and changes in the physical environment (loss of her home) eventually amounted to overwhelming strain from downward compression, resulting in the coil losing resilience.
The authors postulate the conceptual model of resilience in women older than 85 can be graphically symbolized by a coiled wire, enclosed within a box, such as a jack-ín-thebox. Environmental factors within the box could work to enhance or impede the ability of the wire to recoil. External factors that influence the ability of the wire to recoil include the structure of the box itself and the amount of stress applied.
The environmental factors within the jack-in-the box include frailty, determination, previous experience with hardship in learning how to cope, access to care, culturally based health beliefs, family support, self-care activities, caring for others, and functioning like efficiently working machines. These factors may act to enhance or impede the ability of a woman older than 85 to rebound - that is, to experience resilience after devastating illness. The environment, symbolized by the physical box that contains a coil, can either facilitate or impede the rebounding action of the coil (Figure on page 49).
Although researchers are just beginning to study the unique health and illness experiences of women in general, the health and illness experiences of older women have not been extensively researched. This leaves significant gaps in the knowledge base. The relational statements (Sidebar on page 50) and assumptions (Sidebar on page 51) of the proposed middle-range theory of resilience in women older than 85 are provided as part of the concept development strategy suggested by Meléis (1987). The assumptions and relational statements are derived from an integrated model of consideration based on the clinical manifestations of resilience in women older than 85 in relation to research and policy issues.
The authors propose a middlerange theory of resilience in women older than 85, incorporating the work of Wagnild and Young (1990) and expanding on the clinical observations and research of Feiten (2000). Unlike the abstract themes described by Wagnild and Young, Feiten suggested practical characteristics and strategies for use by women older than 85 to achieve resilience after devastating illness late in life. Resilience occurred as a result of a pìan or a strategy not by chance or coincidence.
IMPLICATIONS FOR THEORY DEVELOPMENT
The theory needs to be more fully developed and validated with women older than 85 in the community through research and further clinical observations. Because this theory is designed only for application to women older than 85 as a marginalized group, it has limited generalizability with other age groups or elderly men. As the profession of nursing prepares to provide services to a rapidly expanding cohort of women older than 85 in the next century and beyond, new approaches must be considered to guide practice. Knowledge of particular patient populations is gained from many instances of knowing individual patients within a given population (Tanner, Benner, Chesla, fit Gordon, 1993).
IMPLICATIONS FOR NURSING PRACTICE
Gerontological nurses have great opportunities to nurture and support resilience in women older than 85.
After a lifetime of independence, women may find it difficult to admit their own limitations. Delaying or ignoring early intervention preventive services can mean the difference between a minor problem and a debilitating UIness or accident resulting in decreased function (Feiten, 2000). Nurses need to talk with older women frankly about their risks for devastating illness or injury, such as with falls or drug interactions, and how to minimize them.
The will to survive is powerful. Interventions to help foster resilience include helping older women to be informed consumers, discussing their options, and giving them control (Feiten, 2000). Nurses should encourage older women to use energy within themselves as a source of healing.
Previous Experience With Hardship
Previous experience with hardship can help older women to better cope with devastation later in life. Timely referrals to community support agencies or even simply listening may help an older woman gain strength from past and present adverse situations. Counsel older women regarding past hardship as a means to work through present adversity.
Access to Health Care
Older women with low incomes and those with limited education may have poor health outcomes and less access to health care services (Leiman, Meyer, Rothschild, & Simon, Í997). Providing older women with information regarding resources before they may need them helps increase awareness of services, as well as increases access and provision of services in a timely fashion. Access to health care depends on services being readily available, affordable, and acceptable to those who use them.
The integration of specific cultural beliefs into an older woman's overall plan for care adds another therapeutic dimension, working with, not against, culturally based belief systems. Cultural beliefs shape an individual's response to health and illness. By respecting cultural beliefs and providing culturally sensitive care, nurses can use yet another source of healing strength in diverse older women.
Often in health care, nurses will speak more directly to family members, perhaps assuming they will take primary responsibility for health care decisions and care provision. Nurses must communicate with the older woman, remembering her position of honor and power within her family.
Nursing interventions focused on teaching the importance of good nutrition and exercise are important components to nurture resilience. Many older women do not participate in behaviors such as regular exercise, weight control, health screening, and abstinence from smoking (Leiman et al., 1997), which have great potential in limiting the effects of chronic illness late in life. Health promotion is never too late.
Care for Others
The importance of older women caring for others underscores and facilitates function. Allowing and encouraging older women to take an active role in nurturing and working with others, even during times of impairment, can provide a light of encouragement during times of dependence.
Efficiently Working Machines
Going beyond caring for others is one way older women described their function as efficient machines (Feiten, 2000). By denying older women the opportunity for gainful purposeful work late in life, one important source of life satisfaction and a reason for resilience from devastating illness is denied.
Understanding the different health experiences of women older than 85 from various cultural groups is important in planning for this growing, diverse population. As women are living longer, prevention of frailty and living with disability (Leiman et al., 1997) have become priorities in geriatric care. More study is needed related to older women's experiences of resilience in diverse groups and environments. In particular, the individual nature of what specific factors enhance or impede resilience in women older than 85 demands more study to develop a workable, clinically focused theory.
Nursing-based theory generation focused on a growing cohort of diverse women older than 85 can help reconfigure gerontological health care. To do so, as nurses, we must be able to conceptualize the diversity experiences of women older than 85 and then understand the characteristics of women who overcame adversity from illness or loss and were resilient. This article identifies a conceptualization of resilience in women older than 85 and suggests a rudimentary first effort toward the development of a middle-range theory of resilience for women in this age group.
- Anthony, J.E., & Cohler, BJ. (1987). The invulnerable child. New York: The Guilford Press.
- Bureau of the Census. (1993). We the American elderly (Publication No. WE-9). Rockville, MD: U.S. Department of Commerce.
- Dyer, J.G., & McGuinness, T.M. (1996). Resilience: Analysis of the concept. Archives of Psychiatric Nursing, 10, 276282.
- Fellen, B.S. (2000). Resilience in a multicultural sample of community dwelling women over age 85. Clinical Nursing Research, 9(2), 102-123.
- Garmezy, N. (1991). Resilience in children's adaptation to negative life events and stressed environments. Pediatrie Annals, 20, 459-466.
- Grace, L. (1989). Women in later years: Health, social, and cultural perspectives. New York: The Haworth Press.
- Hall, J.M., Stevens, P.E., & Meléis, A. (1994). Marginalization: A guiding concept for valuing diversity in nursing knowledge development. Advances in Nursing Science, 16,23-41.
- Heidrich, S.M. (1998). Older women's lives through time. Advances in Nursing Science, 20, 65-75.
- Jacelon, C-S. (1997). The trait and process of resilience. Journal of Advanced Nursing, 25, 123-129.
- Leigh, W., & Lindquist, M. (1998). Women of color health data hook: Adolescents to seniors (98-4247). Washington, DC: Office of Research on Women's Health.
- Leiman, J.M., Meyer, J.E., Rothschild, N., & Simon, LJ. (1997). Selected facts on U.S. women 's health: A chart hook. New York: The Commonwealth Fund Commission on Women's Health.
- Maynard, M. (1994). Race, gender, and the concept of "difference" in feminist thought. In H. Afshar & M. Maynard (Eds.), The dynamics of "race" and gender: Some feminist interventions (pp. 925). London: Taylor & Francis.
- Meléis, A.I. (1987). Revisions in knowledge development: A passion for substance. Scholarly Inquiry for Nursing Practice: An International Journal, 1, 5-19.
- Meléis, A. I. (1997). Theoretical nursing development and progress (3rd ed.). Philadelphia: Lippmcott.
- Mish, EC. (Ed.). (I999). Miriam-Webster's collegiate dictionary (10th ed.). Springfield, MA: Merriam.
- Ness, R.B., & Kulier, L.H. (1997). Women's health as a paradigm for understanding factors that mediate disease. Journal of Women's Health, 6, 329-336.
- O'Leary, V.E., & Ickovics, J.R. (1995). Resilience and thriving in response to challenge: An opportunity for a paradigm shift in women's health. Women's Health, 1, 121-142.
- Pohl, J.M., & Boyd, CJ. (1993). Ageism with feminism. Image: The Journal of Nursing Scholarship, 25, 199-203.
- Polk, L. (1997). Toward a middle range theory of resilience. Advances in Nursing Science, Í 9, 1-13.
- Porter, EJ. (1994). Older widows' experience of living alone at home. Image: The Journal of Nursing Scholarship, 26, 19-24.
- Siegel, J. (1996). Aging into the 21st century (DHHS Publication No. 100-95-0017). Washington, DC: Administration on Aging, U.S. Department of Health and Human Services.
- Tanner, C., Benner, P., Chesla, C., & Gordon, D.R. (1993). The phenomenology of knowing the patient. Image; The Journal of Nursing Scholarship, 25, 273-280.
- Wagnild, G., & Young, H.M. (1990). Resilience among older women. Image: Journal of Nursing Scholarship, 22, 252-255.
- Walker, L., & Avant, K. (1995). Strategies for theory construction in nursing. (3rd ed.). East Norwalk, Ct: Appleton-Lange.
- Wuest, J. (1994). A feminist approach to concept analysis. Western Journal of Nursing Research, 16, 577-586.
- Wray, L.A. (1992). Health policy and ethnic diversity in older Americans: Dissonance or harmony. Western Journal of Medicine, 157, 357-361.