Since the early work on a Theory of Thriving approximately 10 years ago, the Theory has evolved from a gerontologie theory to a life span theory. Originally based on the concept of failure to thrive (FTT) in older adults (Newbern & Krowchuk, 1994) and infants (Lobo, 1992), thriving is now applicable to many life span issues. However, for the purposes of this article, the Theory of Thriving will be discussed as one that fills gaps within the theories of aging. The Theory will be applied to a person's life in a nursing home environment.
In a 1996 issue of The Gerontologist? Lynott and Birren examined the state of gerontologie theory and reported little growth in the area during the past 10 years. Since Birren and Bengston (1988) published the classic volume, Emergent Theories of Aging, there has been little additional work in gerontologica! theory development. Birren and Bengston assessed and compiled a variety of theories of aging and discussed not only the older theories of disengagement and activity, but also introduced new ideas such as Reker and Wong's (1988) Theory of Personal Meaning and Kenyon's (1988) Basic Assumptions in Theories of Human Aging. This book was the only theory book available for graduate study until 1998 when Bengston and Schale produced a second volume called Handbook of Theories of Aging. Only a limited few theories address the process of aging in a multkUscipUnary and holistk manner.
Gerontologists have been remiss in creating models and concepts that link variables together and serve as blueprints for conducting studies and exploring ideas. Life span development theories have served as aging theories, but other than addressing the progression of time in relation to the development of individuals, aging theories do not link variables. There is little emphasis placed on theory development or presentation by gerontologie journals that publish research findings. Perhaps this absence of a holistic gerontologie theory exists because gerontology is derived from several other fields, specifically biology, psychology, and sociology. Each of these fields has developed separate explanatory theories, but there are no multidisciplinary explanatory theories that combine the fields and examine aging as a whole over time.
FAILURE TO THRIVE
In the 1960s, gerontologists became fascinated with the losses that occur at the end of life. Palmore and Cleveland (1976) reported declines in health, intelligence, and activities in persons older than age 60. Riegel and Riegel (1972) reported death was preceded by a decrease in cognitive function during a 5-year period in aging participants. Suedfeld and Piedrahita (1984) noted varying declines during the time preceding death in older adults.
Within the past 10 years, theorists in aging have begun to examine the phenomenon of FlT in older adults, where there is sharp decline for no real physical or illness-related reason. In England, the phenomenon is referred to as the "Dwindles. " Older adults lose weight, decline in function, and withdraw socially (Egbert, 1996). Sarkisian and Lachs (1996) point out FTT has its own International Classification of Disease, 9th revision (ICD-9) code and is seen as a clinically meaningful diagnosis. They warn that this diagnosis can reinforce fatalism and intellectual laziness.
Failure to thrive is a syndrome in older adults characterized by limited coping, decreased function, decreased mental acuity, and nutritional deficiencies (Berkman, Foster, & Campion, 1989). The FTT syndrome is similar to the psychogenic mortality syndrome that involves object loss, resulting in depression and illness (Maizler, Solomon, Oc Almquist, 1983). Decreased competence, control, perception, and performance characterize the period preceding psychogenic mortality.
Figure 1. Model of failure to thrive.
There is an adaptive depression with patterns of emptiness and a paucity of relationships. Engel (1968) says the important variable in this giving-up complex is not the external situation, but the response of the individual to the external situation. The syndrome is characterized by hopelessness, decreased self-esteem, decreased gratification in relationships, and a reactivation of early giving up memories.
When other researchers closely examined the physical attributes of FlT, unexplained weight loss was always mentioned. Verdery (1990) noted that providing nutrient intake did not always reverse the cachexia in older adults; thus, cachexia was not solely related to nutrient intake. Decreased mobility and increased incontinence were also listed as accompanying this predeath phenomenon (Isaacs, Gunn, McKechan, McMUIan, & Neville, 1971), as were decreased weight, anorexia, dehydration, decline of initiative, apathy, and decreased mental status (Osato, Stone, Phillips, Si Winne, 1993). Rapid functional decline was also noted in those who "took to bed" (Clark, Dion, Si Barker, 1990). Verdery (1995) reviewed the literature and stated the label was correct and widely used.
Newbern and Krowchuk (1994) analyzed the concept of FTT and agreed with the preceding discussion. They defined seven critical attributes to FTT, four under the heading of problems in social relatedness (i.e., disconnectedness, inability to give of oneself, inability to find meaning in life, inability to attach to others) and three under physical/ cognitive dysfunction (i.e., consistent weight loss, depression, decline in cognitive function). From this analysis, they created a model of FTT, shown in Figure 1.
In 1999, the North American Nursing Diagnosis Association (NANDA) accepted FTT as a formal diagnosis (Burnett, 1999) (Table 1). Several of the defining characteristics in the NANDA diagnosis reflect those described by Newbern and Krowchuk (1994) in their conceptual analysis of FTT.
Several years ago, a nursing research group was brought together by the originator of the FIT model (Newbern) to further explore the phenomenon. The group worked collaboratively to link separate projects in various universities that shared a common thread. The common thread was FlT across the life span and was based on the work of Newbern and Krowchuk (1994). As the group changed and evolved, members began to see FTT as one end of a continuum instead of as an entity in itself. The group broadened its vision from the syndrome of FTT to a more holistic life span concept called Thriving. Failure to thrive represents one stationary end of the Thriving continuum.
Thriving is a positive concept that exists as a continuum. Maslow (1954) described the positive end of Thriving as self-actualization, where individuals have peak experiences. A thriving person is living life fully. Life has a span - a beginning and an end. Along this continuum, individuals grow and develop at different rates and in different ways based on interactions with the environment and the ongoing development of self.
Thriving is fluid and all factors that influence Thriving continually change and interact. The ability to change in a fluid way accommodates the life span and the environmental factors that influence the life span. The factors continuously change and influence each other, and the resulting gestalt is the person who either thrives or does not thrive. The three interacting factors in a Thriving continuum are:
* The person.
* The human environment.
* The nonhuman environment.
Each of these factors is ongoing, dynamic, and continually changing as the human and nonhuman environments affect each other. Elements of the human environment, the variety of humans who enter in and out of the person's environment at different phases of Ufe, can either manipulate the environment and person to contribute to optimum growth, or interfere with the environment to hinder thriving and growth.
Contributing humans may be family members, friends, professionals or others. At birth, there are parents, doctors, and nurses in an environment that should be conducive to thriving. During adulthood, humans interact with growing family, work, and social connections. For older adults in nursing homes, caregivers represent important elements of the human environment. Each member of the human environment may have a negative or positive impact on an individual. As life progresses chronologically, there can be burgeoning growth as the individual grows and thrives or there can be a lack of growth, or a failing caused by negative humans and a negative environment. Definitions for Thriving and for the three interacting factors are in Table 2.
The critical attributes of Thriving reflect those of FTT - social relatedness and physical/cognitive function. However, in the Thriving Theory, physical/cognitive function encompasses physical function and cognitive/affective function. On the positive side of the continuum of Thriving, social relatedness becomes a connectedness with involvement, attachment, and a sharing of self. As the person thrives, there is increased ability to care for oneself, and to maintain optimal weight. In the cognitive/affective function, there is an improved mood state and a meaning to life, with the individual having a clear cognitive ability. The continuum of Thriving is depicted in Figure 2.
22.214.171.124 ADULT FAILURE TO THRIVE (1998)
DEFINITIONS IN THEORY OF THRIVING
Relational ties, independence, pride, engagement, and self-care are defined as the antecedents of Thriving in older adults. Critical attributes of Thriving are defined as social connectedness, ability to find meaning in life and to attach to one's environment, adaptation to physical patterns, and positive cognitive/affective function. Consequences of Thriving are identified as medical, social, and psychological resilience.
The person is a psychosocial biological entity. As the person emerges, one can begin to label inherent factors. Biologically, gender is assigned and appearance and body build are programmed, but subject to change. Heredity may contribute to one's predilection toward chronic illnesses such as diabetes, hypertension, or Alzheimer's disease. The parameters of intelligence are set, and babies are born with a particular disposition. For example, some babies seem happier than others, some are explorers, and others are timid. Considering each of these contributions, the person may be predisposed to thrive or not to thrive, depending on the impact of the human environment and the nonhuman environment as the person travels along the life span.
Figure 2. Continuum of Thriving.
Some people thrive more easily than others because of existing internal strengths. For example, Wagnild and Young (1990) discussed resilience among older women as a characteristic of successfully adjusted older women. They described resilience as the elusive force that makes a difference in the way people respond to life and identified the components of resilience as self-reliance, meaningfulness, existential aloneness, perseverance, and equanimity.
Haight and Hendrix (1998) described similar personality characteristics in women with high life satisfaction. The satisfied women mirrored the resilient women in many ways. They encountered difficult life circumstances, but an inner strength and earlier positive environmental contacts allowed them to grow and maximize their abilities to adapt.
People affect people. Throughout life, there is a constant interplay between people, and each of these human exchanges influences change in individuals. Many books have been written about relationships and personal traits. The popular Mars/ Venus designation for man/woman attempts to identify trait differences between men and women at birth and then teaches men and women how to relate to one another despite these differences (Gray, 1992).
Social psychology shows us that people do not exist in isolation. Some aging scholars have even hypothesized that women outlive men because of their ability to reach out and adapt (Bengston, Burgess, & Parrot, 1997). Life span studies demonstrate that the environment provides barriers or enablers to influence life span development over time.
When life begins, it is necessary to consider the needs of the individual and whether or not the human environment meets those needs. For example, babies are helpless bundles of needs, and they depend on the responsiveness of the people around them to meet those needs. Erikson (1950) alludes to this interaction when he describes the development of trust in his first stage of the ages of man.
Bowlby (1979) addresses the baby's attachment needs in his description of the interplay between mother and child that results in bonding and the ability in the individual to bond and love others throughout life. There is a great body of literature on attachment that substantiates Bowlby's claim that attachment is key to positive growth and development in individuals.
The human environment is comprised of positive and negative humans. Positive humans interact with goodness. The new mother rocking her baby to sleep or providing warmth and closeness by nursing is a positive influence on the baby's growth and development.
A new mother who is drug dependent may not only be ignorant of how to respond to her baby, but also may not care. When the baby is wet or hungry, it is ignored or punished. The baby then detaches. Erikson (1950) calls it mistrust, Bowlby (1979) calls it failed bonding, and it can also be called the beginning of FTT. The human environment then is having a strong negative impact on the baby and is discouraging growth and contributing to FTT.
Human-environmental interactions continue molding the person's humanness throughout life, regardless of age. For example, the teenager who is constantly criticized at home has limited opportunity to develop good self-esteem. Regardless of the successes encountered and obtained, there may always be an inner uneasiness that says, "Am I really worthy? Can I really do this?"
When the human is a frail older adult with multiple functional deficiencies who resides in a nursing home, the human environment consists of caregivers, family and friends, and other residents. These interactions can be positive or negative, contributing to or hindering growth and development. Caregivers may provide compassionate care, families and friends may visit often and be supportive, and other residents may be helpful and friendly.
On the other hand, the human environment may be cold, uncaring, and isolating. Caregivers themselves may feel unimportant and have poor self-esteem. Families and friends may be frightened and powerless in the face of the frail older adult's helplessness and the depressing atmosphere. Other residents may be severely cognitively impaired, depressed, or chemically restrained.
An individual may reach old age with an inner core of resilience or hardiness gained from positive human interactions during younger years. Thus, older adults should be able to develop and maintain healthy relationships, feel self-assured, and generally satisfied with life. A negative human environment erects barriers to Thriving, and these barriers may actually contribute to FTT.
The conceptual model of Thriving in Figure 2 does not consider the nonhuman environment. The world in which we live is the nonhuman environment, with all surrounding influences, including economic, psychological, and social factors. Personal genetic factors intermingle with environmental influences to set the stage for Thriving or FTT. Economic status influences one's ability to be healthy, educated, and successful.
These three entities - person, human environment, and nonhuman environment - come together to form a theory that has synergy. The many subtle interchanges of person, human environment, and nonhuman environment not only shape personality, but also provide insight into current behaviors. These interchanges are a person's history. It is impossible to separate one from one's life history. With a life span focus, an individual can be tracked from birth to death. Positive interactions enhance growth and thriving, whereas negative interactions stunt growth and contribute to FTT.
Figure 3. The Thriving Model.
The Thriving Model proposed in this article addresses all that has been discussed thus far - a continuum, a person, human environment and nonhuman environment, and the life span. Thriving is achieved when the person, human, and nonhuman environment are in concordance, that is, when they are mutually engaged, supportive, and harmonious. Failure to thrive occurs when there is discordance among the person, human environment, and nonhuman environment - a failure of engagement and mutual support, and disharmony.
Because concordance and discordance are not absolutes, Thriving exists on a continuum from perfect Thriving (e.g., perfect harmony) to complete FTT (complete disharmony). Circles representing person, human environment, and nonhuman environment that appear in varying relationships depict the Thriving continuum. Overlapping of the circles represents concordance, agreement, engagement, harmony, and mutual support - the state of Thriving. Disjunction of the circles represents discordance, lack of engagement and support - the state of FTT. The circles are open, depicting the ability to interact and exchange as open systems (Figure 3).
There are multiple variables within the person, human environment, and nonhuman environment that contribute to or detract from life. Contributors may be fresh air, effective health care, and an effective educational system. Detractors may be poverty, crowded living conditions, no health care, and poor education. These factors may interact in ways that are not understood or predictable. Two people might have dramatically different responses to similar circumstances (e.g., divorce, poverty) because of the interaction of variables, such as individual personalities, genetic predispositions, previous experiences, and concurrent life circumstances.
People are born at different points in the Thriving continuum. A healthy baby with supportive parents would be expected to begin life on the positive, thriving side. An unwanted baby with congenital defects would be expected to begin at a lower point. Individuals move through various points of the Thriving continuum throughout the life span. Some people may vary little, while others may have drastic ups and downs. If an individual has a peak experience, it would occur at the topmost of the model and be a Thriving experience. Conversely, a negative experience can send one down below the midpoint in a negative spiral and contribute to failure. Devastating failure is worse than death and occurs at the bottom of the model.
A researcher or practitioner can depict each person's experience across the life span and draw a picture of that life. The data derived from the life and the Theory can either be qualitative or quantitative. The qualitative data tell the story. The quantitative data measure the impact of the experience and assign a number to it, thus allowing the researcher to make comparisons between and among people.
The numbers will change as the story changes. The Theory of Thriving needs to be analyzed more fully and hypothetically applied to research issues to test its utility in exploring antecedents, consequences, and linkages among variables. To be a useful theory, it must integrate knowledge, relate variables, address the life span, predict outcomes, and be supported in empirical testing.
A need exists for aging theories to become holistic and multidisciplinary with a life span focus. Some attempts have been made to explicate aging as theory and to build an accumulated knowledge base that relates new knowledge to past knowledge in an overall explanatory framework. Bengston, Parrott, and Burgess (1996) say a theory is the construction of explicit explanations in accounting for empirical findings. A good theory integrates knowledge, tells how and why phenomena are related, leads to prediction, and provides process and understanding. In addition, a good gerontological theory must be holistic and take into account all that impacts a person throughout a lifetime of aging. Based on these criteria, Thriving is offered as a holistic life span perspective for studying people as they age in their environments.
As a theory, Thriving focuses on the person and encounters between the person and the human and nonhuman environment. Assumptions evident in this Theory include:
* Humans grow and change.
* Humans are open, freely choosing beings.
* Humans are in mutual process with the environment, creating patterns of relating.
* Thriving is an open process humans experience throughout the life span either positively or negatively.
* Thriving is a process of human-environment interactions.
* Humans can describe their own experiences in ways that enhance knowledge of human thriving.
* Synergy occurs when all elements of Thriving come together.
Application of the Theory of Thriving
This Theory of Thriving depicts a life span framework that may be applied cross culturally. It is postulated that people will thrive through continuous mutual process with the human and nonhuman environment. The human and nonhuman environments provide for companionship, variety, diversity, harmony, spontaneity, and the opportunity for mutual interactions to facilitate Thriving.
The Theory may also be applied to younger people as they age and in old age, it represents an accumulation of experience. One can look at the beginning of the trajectory, postulate the future, and pinpoint changes that must be made to help an individual thrive. An example of a single application is shown in Figure 4, as it is used to tell the following story about Mary (Figure 4 is used to guide the numbering).
The Thriving Theory provides a description of a concept during a life span continuum. The Theory itself is still evolving. The Theory addresses the person, the environment, and the life span. The questions gerontological nurses must ask as they apply this Theory are:
* Does the Theory integrate knowledge, relate variables, predict outcomes, and address the life span?
* What are the clinical implications for gerontological nursing?
* How will the Theory guide practice?
Repeated use and additional reports from other gerontological nurse practitioners and researchers applying this Theory will predict the utility of Thriving as a guiding framework for research with older adults.
Figure 4. Thriving across a lrfespan: Mary's story.
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DEFINITIONS IN THEORY OF THRIVING