The challenges of an aging population facing health care professionals are becoming clearer. The literature points toward increased interest in health promotion and disease prevention services for the older adult (Alford & Futreil, 1992; Ebersole & Hess, 1998; Murray & Zentner, 1997; Schaf er, 1989). The U.S. Department of Health and Human Services' (2000) new Healthy People 2010 goals and objectives continue to build on the HealthyPeople 2000 (U.S. Department of Health and Human Services, 1991) initiatives. Healthy People 2010 has set as one of its two overriding goals to help increase the span of healthy life for various age groups. Specific goals for the 65year-old group continues to range from increasing participation in organized health promotional programs and screening services in community based-settings to reducing chronic disabling conditions and the accompanying dependency. The intent of these goals is not only to lengthen life but, more importantly, the improvement of functional independence of older adults (Ebersole & Hess, 1998).
Health education and promotion and disease prevention for senior adults is a relatively new field in comparison to similar efforts for younger age groups. Only recently have elderly individuals and aging been included in considering health in a positive manner. Exclusion of older adults from health promotion trials can be attributed to widely held myths, which have discouraged such efforts. Among the myths are (Heckler, 1985; Kolcaba & Wykle, 1994; Ory, 1988; Robertson, 1991; Walker, 1989):
* Health promotion means the prevention of disease rather than improving health status.
* Many health conditions of older adults are perceived as irreversible.
* Efforts could be better spent on younger adults who have their whole lives ahead of them.
* Older adults are not able or willing to change their health attitudes, behaviors, or lifestyles.
* Older adults are difficult to recruit into health promotion programs and difficult to evaluate.
* Behavioral or lifestyle changes in late life will have only minimal impact on the health and functioning of older adults.
* Intervention is not cost effective for the elderly population.
Contrary to these myths, older adults should have the same opportunity to accept responsibility for health and to make informed choices about lifestyle behaviors as younger people.
Another problem facing a movement toward a greater number of health promotion and prevention of disease programs is the limited number of available services and the need to compete for limited financial resources. Reports such as the Healthy People 2010 can be credited with stimulating widespread interest in changing lifestyle as a strategy for both health promotion and disease prevention. However, currently the federal government spends as much as 75% of its health care budget on treating individuals with chronic illnesses, such as heart disease, stroke, and cancer (Ebersole & Hess, 1998).
This accounts for nearly $5,000 per person, per year to support the nation's illness care system (Gebbie, 1997). At the same time, the government spends less than .5% for the prevention of such diseases (Whitner fie Sweeney, 1992). It is further estimated that only 6% of the national health care dollar is spent on prevention and early detection services (Hooyman & Kiyak, 1996). Medicare and most private insurance plans do not pay for preventive services. Most health promotion efforts have been funded through short-term, publicly funded demonstration projects or by private donations. With a social climate deeply concerned with the higher cost of health care for the increasingly older population, the programs dealing with health promotion must be directed where positive outcomes can be expected (Dychtwald, 1999; Gebbie, 1997; Hickey fie Stilwell, 1991).
An increased emphasis on selfcare is one initiative projected as a possible solution to the ever-growing threats to the health of older adults and the increasing cost of medical care. Many researchers believe that by allowing older adults to make knowledgeable choices about medical services and individual health practices, the resulting appropriate self-care decisions have the potential to reduce the use of unnecessary and expensive medical care. Research has shown that health-related behavioral and lifestyle choices shape one's health in a positive manner. Practicing selfcare can bridge the gap between health care needs of older adults and the current expensive health care system (Mettler & Kemper, 1993). This translates into older adults taking personal responsibility for their own health through knowledge and behavioral change.
HEALTH PROMOTION INITIATIVES
Since the early 1980s, nursing researchers have been calling for greater orientation toward health promotion for older adults. In a policy paper published by the American Academy of Nursing and the American Nurses Association, 10 recommendations were made regarding the promotion of healthy lifestyles and supportive public policy to effect a change from an illness focus to a wellness focus with older adults in a variety of settings (Alford & Futrell, 1992). One of the recommendations included a directive toward consolidating multiple services for older persons in existing facilities such as senior centers, retirement housing and other longterm care environments.
Demonstration projects were encouraged to determine the feasibility of such centers and how the disciplines would coordinate services for older persons. Further recommendations included lifelong learning for health and wellness and positive health behaviors. These recommendations were consistent with the Healthy People 2000 and 2010 objectives and other researchers who suggested that any proposed health promotional model must be designed to help older adults maintain their functional independence and autonomy for as long as possible (Ebersole & Hess, 1998; Hickey & Stilwell, 1991). Ultimate goals for older adults are to delay illness, prevent the ill from becoming disabled, and assist those who are disabled to function and prevent further disability.
The potential for senior centers as a locale to provide preventive services has been frequently recognized (Johnson, Igou, Utley, & Hawkins, 1986; Walker, 1989; Wallace et al., 1998). A major Healthy People 2000 objective was:
to increase to at least 90% the proportion of people aged 65 or older who had the opportunity to participate during the preceding year in at least one organized health promotion program through a senior center" (U.S. Department of Health and Human Services, 1991, p. 102).
With the current availability of senior centers in most communities and the increasing use of the senior centers by older adults, such community-based sites can be a viable alternative to deliver cost-effective health care. Previous studies have suggested that social facilities such as senior centers are optimal sites for health promotional programs (Dychtwald, 1986; Wykle & McDonald, 1999). Such sites are viewed as assessable, nonthreatening, and supportive environments for older adults. The philosophy of the senior center supports an atmosphere of wellness and learning. Services frequently offered in senior centers include screening for hypertension, diabetes, and glaucoma; providing educational materials; and individual counseling.
The purpose of this pilot study was to examine the effectiveness of a nurse-managed wellness center, which stressed the establishment of a clinical nursing site in a multipurpose senior citizens center. This ongoing nursing clinic program has provided older adults with a variety of educational and medical services, which serves to enhance their independence and health knowledge. More specifically, the study investigated the effects of the wellness center on measures of healthy behavior, emotional well being, increased health knowledge, and perceived independence.
NURSE ON DUTY (NOD) PROJECT DEVELOPMENT
The School of Nursing at Middle Tennessee State University developed the wellness center described here. In 1991, several interested nursing faculty developed a proposal to design and implement a health and wellness clinic center for older adults. The proposal was initiated as a result of community interest demonstrated by a needs assessment survey addressing local health care needs. Key community leaders and health care providers were involved in the initial planning, funding, and implementation of a nurse-centered model. The decision was made to house the wellness center in the local multi-purpose senior center and a partnership was arranged between the management of the center and the School of Nursing. To emphasize the significant role of nursing in the endeavor, the chosen weUness model was referred to as the Nurse on Duty (NOD) model. The NOD model contains a philosophy for health promotion and identified the target population and their potential needs.
Managed by a nurse clinician from the School of Nursing, the year-round clinic is open one day each week for the purpose of promoting an optimal level of wellness for each individual. The nurse explores both developmental and situational events affecting the individual's ability to carry on activities of daily living, and to assist in maintenance of the highest possible level of functioning, preserving dignity and independence. The NOD program has provided early detection of those risks common to older adults, nursing management for long-term conditions, and referral to other health care providers.
The target population was composed all adults age 60 and older residing in the city and the outlying geographical area within which the senior center normally serves. A number of public service and newspaper advertisements announced the NOD program to the community. An open-house was held at the senior center to officially announce the opening of the wellness clinic. Eighty-two client records were officially opened in the first year of the program's existence. Many other clients who did not wish to receive all of the comprehensive services offered, but wanted only an occasional blood pressure reading or other screening service, were also seen. The number of senior adults participating in the free nurse-run clinic has increased each year. Currently, more than 300 senior adults have active client records with the NOD program.
SiLP-REPORTED HEALTH CHANGES OF PARTICIPANTS INVOLVED IN NURSE MANAGED WELLNESS PROGRAM (W=111)
NURSE ON DUTY PROJECT DESCRIPTION
The general philosophy developed for the NOD program emphasizes client participation and preventive health care. The NOD program has attempted to integrate knowledge related to healthy aging with the processes of behavioral change to enhance independent living and a higher quality of health within the population served. The NOD program has attempted through the years to help older adults make informed decisions about their health and lifestyles.
DEMOGRAPHIC PROFILE OF NOD CLIENTS (N = 111)
In doing so, the NOD program provides a broad range of screening services, individual counseling services, health educational programs, and management services for chronic diseases. The participants are offered a weekly clinic where they have the opportunity to see the nurse-manager. In conjunction with the clinic, the NOD program provides, among others, the following direct client services:
* Compiles admission histories with baseline assessment data.
* Monitors weight, blood pressure, heart rate, and blood glucose levels.
* Performs a general physical assessment of heart, lung, ear, nose, throat, skin, and joints.
* Evaluates medication therapies and information on individual drugs.
* Performs a nutritional assessment.
* Provides basic foot care for those not under the care of a podiatrist.
* Counsels for life changes associated with aging.
* Teaches clients to manage chronic health problems.
* Refers individuals for services to assist in maintaining current levels of health and independence.
* Provides referrals to private physicians as needed.
Periodic health educational programs are also sponsored by the wellness center. These monthly educational programs (i.e., Coffee Break with NOD) are offered on the second Wednesday of each month. The programs focus on health promotion, prevention of illness, and management of chronic health problems. A variety of health professionals in the community conduct the educational programs. Support group sessions are routinely offered for individuals coping with problems such as depression, weight management, and smoking cessation. Comprehensive health fairs are sponsored biannually to provide additional screening services from other health disciplines. Finally, the NOD program sponsors a variety of exercise and fitness programs.
The nurse-managed wellness center has also been a clinical site for baccalaureate nursing students to practice assessment, communication, and teaching skills on well older adults. Student nurses routinely provide assistance to the weekly nursing clinic, as well as helping with the health fairs and other special screening sessions. This community-based rotation site provides students the opportunity to develop additional insights into the aging process beyond the medical model found in traditional structural clinical sites. Exposure to older adults in such settings can have a positive influence on student attitudes toward elderly individuals and influence career preferences in geriatric nursing (Aday & Campbell, 1995).
The outcome data collection instrument included a variety of open- and closed-ended questions. One section of the questionnaire included a checklist used to record participation in NOD-related services during the previous year. The "yes" or "no" checklist included blood pressure screening, cholesterol screen and follow-up, blood sugar check, nail and foot care, weight monitoring and management, and drug management. A similar checklist was used to gather information on use of NOD-sponsored educational programs. These activities included health fairs and other education programs focusing on such issues as "Protecting Your Eyes," "Heart Smart, Heart Wise," "Managing Your Cholesterol," and "Dangers of Skin Cancers."
The authors developed a number of measures to explore changes in healthy behaviors and emotional well-being as a result of participating in the nurse-managed program (Table 1). The Health and Wellness Inventory included two separate subscaies. One group of 17 statements focused on a variety of health behaviors. Respondents were asked to answer the following question, "Since participating in NOD services, have you changed any behaviors to help you stay healthier?"
To keep the responses simpler for the elderly sample, participants were asked to "agree" or "disagree" with each statement. Possible scores ranged from O to 17. The reliability was evaluated using Cronbrach's alpha procedure. A coefficient of 0.85 indicates a high degree of internal consistency for the health behavior items. A total of seven emotional well-being statements comprised the second subscale. Possible scores ranged from O to 7. Again, an alpha coefficient of 0.86 provided a strong measure of internal consistency.
The final section of the instrument included a demographic profile. Open-ended questions requested participants to report their age, sex, ethnic origin, marital status, education level, current living arrangements, and perceived health status. Respondents were also asked to describe their health status and compare their health to last year. Other statements measuring perceived health knowledge, degree of independence, and influence of the NOD program on physical and mental health were also included, as shown in Table 1 .
Use of NOD Program
In January of 1998, a survey was mailed to 205 older adults who participated in NOD services and programs the previous year. A sample of 111 respondents (54% return rate) provided a self-report of their participation and impressions of the nurse-managed wellness program. Demographic characteristics of the participating subjects are shown in Table 2. The mean age was 75 years, with approximately 30% of the sample reporting to be 80 years or older. The majority of NOD participants were women (71%), and about half were married. Most were White (90.1%) and high school graduates (45.5%). An almost equal number either lived with their spouse (42.4%) or lived alone (43.2%). Most respondents reported themselves to be in good or excellent health.
Table 3 provides a summary of the various NOD services and activities. On average, older adults reported participating in 4.8 services during the previous year. However, the data collected did not provide information stating precisely how frequently the clients participated in each service. Some 48% of those responding to the survey indicated they attended specific educational and wellness-oriented programs during the past year.
Of this group, 36% indicated they attended one wellness program, 29% attended two, and 35% attended three or more. The most frequent program attended was the biannual health fair (e.g., health screening, educational programs) which, in each case, was attended by approximately 67% of those participating in wellness programs. Twenty-four percent also attended the educational program on maintaining their cholesterol.
A variety of direct services are provided by the wellness clinic. Blood pressure screening was the most frequent wellness service received during the past year. Other widely used services included blood sugar analysis (70.3%), monitoring weight (68.5%), cholesterol screening (48.6%), nail and foot care (35.1%), help with weight management (23.4%), and help with drug management (12.6%). In addition, more than 80% of senior participants received personal consultations from the nurse and consultations from other health professionals were also common.
UTILIZATION OF NOD SERVICES (Af= 111)
HEALTHY BEHAVIOR CHANGES
Respondents reported a significant number of changes in their daily habits to stay healthier. The mean number of healthy behavior changes reported was 7.5 with a possible range of 1 to 1 8. Table 3 provides a general descriptive analysis of those variables used to measure self-reported health and health knowledge level, changes in health practices, and emotional well-being. As indicated, more than one third of those responding indicated they had lost or maintained weight (60%), increased or started exercising regularly (49%), lowered salt intake (50.2%), and increased use of vitamin and mineral supplements (63.6%). One third also lowered their fat or cholesterol level (34%), increased water intake (50%), reported a lowered blood pressure (42.2%), and followed a more healthy diet (58.2%).
BIVARIATE CORRELATIONS AMONG HEALTH, SOCIAL, AND EMOTIONAL VARIABLES (Af =111)
Table 1 also reports additional behavioral changes recorded by the participants, including reduced smoking and alcohol intake. Interestingly, 35.2% of this sample reported they visited their physician more regularly since participating in the nurse-managed weüness program. As a result of these changes in health practices, 81.7% reported their physical health is better since participating in the NOD program.
Respondents were also assessed for whether their involvement in the nurse-managed wellness program improved their overall emotional well-being. With seven items (range, O to 7) measuring emotional wellbeing, participants reported a mean of 3.3. As Table 1 shows, a significant portion of the sample did feel more secure about their life in general. Approximately half of the sample indicated they felt better about their health and their ability to cope with stress, and more satisfied with their life.
Also, approximately 74.4% reiterated that their mental health was better since participating in the nursemanaged program. Approximately two thirds (59.7%) felt the NOD program had enhanced their ability to maintain a greater degree of independence. This is supported by a significant number of respondents (47.3%) reporting they felt better about their ability to remain in their current living arrangements.
Table 4 illustrates the bivariate correlations among the variables significantly associated with the various outcome measures. Practicing healthy behavior was positively associated with the number of sponsored educational programs attended (r = .44, p < .01) and wellness services received (r = .32,/» < .03). Participating in specific nurse consultations was also found to be significantly associated with changes in behavior leading toward a healthier lifestyle (r = . 37, /><. 03).
The nurse seems to play a significant role in reinforcing healthy behavioral practices by imparting important health-related knowledge. For example, as participants spent more time in consultation with the nurse, their health knowledge was also likely to increase (r = .41, p < .01).
Also of significance among the bivariate correlations is the strong association between practicing healthy behaviors and emotional well-being. It appears that as participants made positive changes in their lifestyles, they enjoyed a more positive outlook on life and took comfort in assuming self-care initiatives (r = .73,p<.01).
To examine further the importance of nurse consultations on the overall health and emotional wellbeing of seniors participating in the nurse-managed program, two special categories were created. One category (N = 57) consisted of participants who engaged in NOD clinic activities either weekly or several times each month. This group was compared to seniors who participated in the nurse-managed program a few times a year or only occasionally (N = 54). When comparing the two groups, the results of a series of f tests indicated that senior participants who visited the nurse clinic more frequently were also more likely to participate in other NOD programs and services (i = 2.29, ¿/= 208, p<. 002).
An additional comparison revealed that senior adults who consulted more frequently with the nurse on a more regular basis reponed a greater degree of Ufe satisfaction (i = 3.15, df= 108, p < .002). Further results also indicated that those who visited the nurse more frequently reported their physical health (t = 2.45, df= 108, /»< .005} and mental health (i = 2.33, df 108, p < .003) were much improved. In addition, frequent visits to the NOD created a greater sense of independence and control of their life (i = 3.30, df= 108, ? < .001). Additional i tests conducted to determine whether any differences existed between men and women who participated and the primary outcome variables proved insignificant.
The primary purpose of this study was to evaluate the effectiveness of a nurse-managed wellness center on the health and emotional well-being of a group of older adults served by the center. The findings from this study confirm the notion that the model described here can provide impetus for generating positive changes in the lifestyles of older adults. Although the self-reports of participating older adults indicated a number of healthy behavior improvements, the inferences drawn from this study reveal that the most frequent changes in behaviors of healthy diet and exercise were consistent with previous research on health promotional life styles practiced among older adults (Schafer, 1989). The NOD participants who practiced healthier behaviors were also positively associated with sponsored programs attended and wellness services received.
The results presented here also demonstrated a relationship between healthy behavior changes and emotional well-being. These findings are consistent with previously cited studies which suggest psychological well-being plays a significant role in the preservation of physical health and functional capacity (Grant, 1996; Zautra, Maxwell, & Reich, 1989). Findings from this sample also suggest that as seniors increase their practice of healthy behaviors, they feel more in control of their lives. This is exhibited by participants" positive feelings about their sense of independence and ability to stay in their present living situation. This sense of personal autonomy tends to enhance their psychological wellbeing.
Additionally, a sense of control results from the belief that certain healthy practices will lead to improved health (Beck, 1991). This is an important concept when considering the aging process. A sense of helplessness in elderly people can frequently lead to a decrease in motivation and self-esteem. These findings were similar to previous research which suggested that education on areas such as problem-solving, positive self-talk, and reinforcing effective coping behaviors were important nursing interventions for promotion of healthy, independent, and productive lifestyles among older adults (Fitch & Slivinske, 1988; Zauszniewski, 1997).
This study clearly demonstrates the effectiveness of the nurse's role as a promoter of healthy lifestyles. For example, participants who consulted with the nurse on a consistent basis were more likely to express increased life satisfaction and improved mental and physical health. These findings were consistent with the research reported by Keidler, Campbell, Lanik, Gray, and Conrad (1994). It demonstrated that simply screening an older client in a clinic did not create enough motivation to make changes, but increasing regular nursing involvement brought about desired behavioral changes. The NOD model provides clients an opportunity to discuss health issues and to promote health and wellness issues.
As the graying of America continues, changes in attitudes and policies toward aging will be necessary. The rapidly changing population demographics is challenging the role of nursing to redirect its focus (Scott & Rantz, 1997). Inherent in the aging of America is the absolute need for people to grow old with the highest levels of health, vitality, and independence. For this to occur, nurses will need to incorporate core goals of gerontological nursing into their practices, including the importance of positively influencing older adults to maximize their potential for living independently for as long as possible. Nurse case management models for enhancing the successful aging of older adults in nontraditional settings are an emerging solution to the challenges of the health care revolution (Ebersole & Hess, 1998; Scott & Rantz, 1997).
By working in nontraditional clinical settings such as senior centers, assisted living facilities, adult daycare, and other community alternatives, nurses can assist older adults to exercise self-reliance in promoting ego integrity and overall quality of life in old age. New partnerships can be implemented along the health care continuum as management of older clients expands into the community.
Social policy related to the delivery of health care can no longer be construed in the traditional manner of medical care or illness management. Nurses are in a position to shape and restructure the health care system, as well as gerontologicai nursing practice (Wykle OC McDonald, 1999). A more comprehensive view, including a holistic framework of caring for the aging, must be the model of health and wellness care for the 21st century (Alford & Futrell, 1992). This view should be addressed by nursing educators. Nursing curriculums need to reflect this more comprehensive approach.
Planning to include a greater emphasis on health promotion and wellness interventions for all age groups and instructions on multiple strategies to maximize independence, self-reliance, and high qualities of life are essential in new designs. Nursing must become more consistent in incorporating various gerontological concepts, policy information, and practice opportunities into their curriculums.
In the past, older adults have not been viewed as being suitable targets for health-promotional activities. With disease viewed as an unavoidable accompaniment of aging, the older adult was not seen as having a future for which health promotion would be relevant (Walker, 1989). To change the effects of past societal and political policies toward the aging, an increased effort from all health care professionals is necessary. Nursing is in a position to take a leadership role in stressing the value of health education and wellness promotion. WyUe and McDonald (1999) reinforce this view by stating, "the leadership role of the gerontological nurse will be as the 'hub of the wheel,' managing and coordinating all providers instrumental in promoting the health of older adults" (p. 131).
Through health education, the older adult can learn the importance of healthy behaviors and discover resources within the health care system to enhance healthy choices (Kauf man, 1996; Shamansky & Hamilton, 1979). To enhance health promotional efforts, the politics of health care delivery represented in managed care must be addressed. Nursing should play a major role in redesigning Medicare and the managed care industry to insure health education and prevention measures are valued within the new system.
Recent research by Rowe and Kahn (1998) on health promotion activities and successful aging should be a catalyst for enhancing the importance of continued research in this area. Nurses are in a unique position to become more involved in researching and identifying successful approaches to health promotion. There needs to be further identification of important factors serving to motivate older adults to participate in new healthy behavior patterns. In addition, studies addressing the impact of variables such as age, gender, race, and social class on self-care behavior are still lacking. The experimental research model also needs to be more fully used in future research. Gathering baseline data and following program participants longitudinally to determine change over time would strengthen research outcomes. The use of control groups would serve to document significant differences between program participants and nonparticipants. Finally, more information needs to be disseminated to the public related to validated strategies which effectively reduce risks of illness and promote well-being.
Nursing needs to seek new approaches supporting the older adults movement toward selfresponsibility. Exploring the use of existing community-based sites such as senior centers is one important approach. It has been noted that senior centers are excellent sites for community-based health promotion interventions (Wallace et al., 1998). Interest and participation in such wellness programs appear to be excellent, and feasible interventions can be designed for this setting.
Frequently, such programs do not require large additional expenditures and can be easily integrated into the center's programs. In addition, the activities already provided at senior centers may further enhance their health-promoting potential. Thus, a community-based health promotion program may be a viable means to meeting some of the Healthy People 2010 goals, enhancing independent functioning in older adults.
An additional benefit of the senior center environment is the relaxed atmosphere for student nurses to develop skills in communication, assessment, and health education. Research on the role of a nursemanaged center has shown that this setting should be an ideal site for student practice and learning (Alford & Futrell, 1992; Fehring, Schulte, & Riesch, 1986; Frenn, Lundeen, Marón, Riesch, & Wilson 1996). This relaxed atmosphere also promotes a setting where positive attitudes toward older adults can be established (Spier, 1992). The addition of this type of communitybased site will allow students an opportunity to see the aging population engaging in health promotion and disease prevention activities rather than in a critical care environment receiving medical treatment. Working in community-based centers provide students a more complete picture of the aging process.
The project described in this article demonstrates that an emphasis in weliness, health promotion, and disease prevention can make a significant contribution toward healthier aging. The nurse as a health professional can help older adults develop an awareness of weliness behaviors and assess older adults* health practices. It has also been suggested that nurses need to be more visible and aggressive in promoting health and assisting older adults to make changes in health habits and lifestyle practices (Schaf er, 1989). The nurse must realize more fully that selfresponsibility is a crucial requirement for the achievement of wellness.
More than ever before, older individuals are likely to view themselves as most responsible for their own health.. Older adults must have services available to support both weliness and self-care for healthy aging into the 21st century. As the nation faces a dramatic increase in longevity, the geriatric nurse will be instrumental in keeping the nation healthy as it ages (Wykle & McDonald, 1999). The gerontologicai nurse in the 21st century will be engaged heavily in education and prevention models, and will participate in a variety of communitybased collaborative efforts.
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SiLP-REPORTED HEALTH CHANGES OF PARTICIPANTS INVOLVED IN NURSE MANAGED WELLNESS PROGRAM (W=111)
DEMOGRAPHIC PROFILE OF NOD CLIENTS (N = 111)
UTILIZATION OF NOD SERVICES (Af= 111)
BIVARIATE CORRELATIONS AMONG HEALTH, SOCIAL, AND EMOTIONAL VARIABLES (Af =111)