Addressing issues related to geropsychiatry and the well-being of older adults
The goals of nursing aimed at promoting health are encompassed in the overall goal of human flourishing, which is defined by the National League for Nursing (2014) as “an effort to achieve self-actualization and fulfillment within the context of a larger community of individuals, each with the right to pursue his or her own such efforts” (p. 1). Human flourishing can be described as a state of mental health and living at an optimal range of human functioning, in which the individual is actively striving to live well rather than merely feeling good (Momtaz, Hamid, Haron, & Bagat, 2016). Flourishing individuals experience positive emotions and enthusiasm for life and actively contribute to society.
The concept of flourishing provides an especially important context for nurses working with older adults. Many older adults emphasize the difficult mental and physical challenges of aging, noting that it is not fun to get old. Flourishing older adults present an alternative view; they exhibit a sense of personal growth in the sense that they are, even at an advanced age, evolving and changing. Flourishing, mentally healthy older adults experience high levels of emotional, psychological, and social well-being, and tend to see their lives as having a purpose. This tendency is illustrated by Browne-Yung, Walker, and Luszcz's (2017) qualitative study of 20 older adults (ages 88 to 98) in Australia. Most participants developed purposeful strategies for coping with problems during the aging process. Even at their advanced age, they continued to find meaning and purpose in their lives. Their stories demonstrated a clear self-identity with an integrated past, present, and anticipated future, as illustrated by one participant, Belinda (age 95): “I have so many things that I like to do, or want to do that I still do” (Browne-Yung et al., 2017, p. 286).
Determinants of Human Flourishing
VanderWeele (2017) proposed five domains to consider in human flourishing: (a) happiness and life satisfaction, (b) mental and physical health, (c) meaning and purpose, (d) character and virtue, and (e) close social relationships. It is important to think of flourishing not as a momentary state, but as something that is sustained over time; resources must be sufficiently stable so that what is going well in each of the five domains is likely to continue into the future. Financial and other resources are not viewed as ends in themselves but may be important in the preservation of domains related to flourishing.
VanderWeele (2017) proposed that there are four major pathways that have important effects on each of the five domains: family, work, education, and religious community. VanderWeele (2017) also noted that there are other pathways related to flourishing in the five domains, such as engagement with the arts or community involvement other than through religion, but they are not as common. The four pathways are not meant to be exhaustive, and they must not all be present in an individual to ensure a flourishing state, but they are considered to be common and important pathways toward flourishing. Efforts to support, improve, and promote participation of older adults in these pathways can have a substantial positive impact for human flourishing.
Even with declining marriage rates, approximately 80% of Americans 25 and older at some point in time have been married and thus have formed a family structure broader than their family of origin (VanderWeele, 2017). Engagement with family can have a profound impact on human flourishing. Studies consistently show that marriage is associated with greater happiness and life satisfaction, physical and mental health, personal growth, and longevity (Momtaz et al., 2016; VanderWeele, 2017). Marriage is also associated with higher levels of meaning and purpose in life, positive social relationships, better financial outcomes, and lower levels of loneliness (Momtaz et al., 2016; VanderWeele, 2017).
Older adults often face profound changes in family structure. As they age, they are likely to experience loss of a spouse, other family members, and/or friends who were important to their human flourishing. Research on effects of bereavement in older adults has focused on the importance of positive emotions to facilitate adaptive recovery, limiting or undoing potentially harmful responses generated by negative emotions (Ong, 2008).
Recent research suggests that friendships become even more important as individuals age and may be more important than family relationships (Chopik, 2017). In studies involving approximately 280,000 individuals, Chopik (2017) found that friendships were a stronger predictor of health and happiness than relationships with family members, especially for older adults. Social networks may shrink as older adults lose family members and friends and may not be able to readily meet with others outside their home. Participants in Browne-Yung et al.'s (2017) study described how they purposefully expanded their social networks to remain actively engaged in their communities. Mary (age 90), stated, “Well, if you're lucky enough to be still alive, well, your friends begin to get smaller” (Browne-Yung et al., 2017, p. 286). To stay connected to her social network even with increasing physical disabilities that prevented her driving, she maintained her mobility with a motorized mobility scooter.
Employment is more than a source of income and financial stability; it is a fundamental social role contributing to a sense of purpose in life, providing a source or identity, self-concept, and social relations (Brand, 2015), which may be why older adults are working longer. In 2014, approximately 23% of men and 15% of women 65 and older were still in the labor force. These percentages are projected to increase by 2022 (Mather, 2016).
Job loss and unemployment can have far-reaching implications for older adults. Research has demonstrated that individuals who are employed have higher levels of life satisfaction and self-reported physical and mental health (VanderWeele, 2017). Thus, it is important to consider how the loss of employment affects older adults' state of flourishing. Using data from a variety of sources, including the National Center for Health Statistics, researchers found that when individuals ages 55 to 61 experienced unemployment, it had a negative long-term effect on their health, including decreased longevity (Leith, 2014). In addition to loss of income, many individuals lose their employer-provided health insurance and may not be able to afford health coverage until they become eligible for Medicare at age 65. Researchers found that negative long-term health effects for individuals experiencing unemployment at age 65 and older were markedly reduced, possibly because the availability of Social Security at age 62 provided a “buffer” for loss of income and health insurance. Increasing evidence exists that resilience in older adults helps mitigate the negative impacts on health caused by loss of employment (Jason, Carr, Washington, Hilliard, & Mingo, 2017). Thus, interventions designed to enhance resilience in older adults may also enhance the ability to adapt to loss of employment.
Research suggests that higher levels of education are associated with higher levels of happiness and life satisfaction (VanderWeele, 2017). Education levels are increasing for older adults. In 1965, only 5% of individuals 65 and older had completed a bachelor's degree or higher; by 2014, this rate increased to 25% (Mather, 2016). The rate of college enrollment for older Americans is rising faster than for students of typical college age, as individuals see education as a pathway to a desired lifestyle and/or increased income. In 2009, students 25 and older comprised approximately 40% of all college students; that number is expected to continue to rise as an estimated 9.6 million older students head to college in 2020 (“Back to school,” 2014).
There are a variety of reasons for the rise in older adults pursuing new educational opportunities. Some individuals find themselves out of the workforce earlier than they had anticipated; one survey showed that 58% of retirees 70 and older retired earlier than planned (“Back to school,” 2014). Some older adults may need to sharpen their skill sets to be eligible for a new job or a second career that will be personally meaningful to them. Online educational programs offer the flexibility of learning from home and also minimize a perceived stigma of being seen by younger students as too old. Various financial options may be available to facilitate returning to college. State and institutional 529 plans are for students of all ages and contributions are even deductible from taxes in some states (“Back to school,” 2014).
Increasing evidence suggests that religious community, especially religious service attendance, has substantial positive effects on various aspects of flourishing (VanderWeele, 2017). Approximately 89% of Americans state that they believe in God or a universal spirit and 78% consider religion a fairly or very important part of life (VanderWeele, 2017). Multiple research studies suggest that participation in a religious community is associated with better health, as well as greater longevity. VanderWeele (2017) concluded that attending religious services, rather than private practices or self-assessed spirituality, is most strongly associated with better health. It appears to be the communal nature of religious practice that is important in causing these outcomes.
Because participation in a religious community is an important determinant for human flourishing, it is important to consider difficulties that older adults may find in maintaining their connections to this community. Physical disabilities may make travel to churches or synagogues difficult. Mental conditions, such as Alzheimer's disease, may prevent older adults from participating in religious communities as they had been used to doing. As older adults experience increasing physical and/or mental disabilities, they may become more isolated from their religious community at a time when they most need these spiritual connections. Personnel in religious communities must be sensitive to the needs of older adults who are attempting to stay connected. A study of older adults with Alzheimer's disease in a faith community identified strategies for maintaining connections with older adults who may be isolated (Tompkins & Sorrell, 2008). For example, one group within the congregation who regularly brought meals to shut-ins stayed to visit and brought any concerns that arose to the attention of an appropriate individual in the church.
Implications of a Broader Conception of Human Flourishing for Health Professionals
Because family, work, education, and religious community are important determinants of various aspects of human flourishing, they have important implications for health care professionals working with older adults. Research is needed to better understand how the concept of human flourishing can be used to promote the well-being of older adults (Momtaz et al., 2016). This concept was tied to health as long ago as the work of Aristotle, who argued that one cannot flourish in an isolated state; a human requires rationality to flourish and social engagement is needed for rationality (Allmark, 2017). Although Aristotle explored the relationship of flourishing with health, the concept of flourishing is a relatively recent subject of study in gerontology (Momtaz et al., 2016).
Ong (2008) noted that scientific progress in understanding what constitutes human flourishing and how it begins has lagged behind what is known about human illness, dysfunction, and disease. Research related to human flourishing in the social and biomedical sciences has often focused on narrow outcomes, such as income or a specific disease state. But if a central goal of research in these disciplines is to contribute to a broader notion of human well-being, the causes and interventions that most contribute to human flourishing should be studied within a broader context that includes mental and physical health, happiness and life satisfaction, life meaning and purpose, character and virtue, spirituality, and close social relationships (McEntee, Dy-Liacco, & Haskins, 2013; VanderWeele, 2017).
VanderWeele (2017) advocates for changes in societal structures, policies, laws, and incentives that contribute to strengthening the impact of family, work, education, and religious community on human flourishing. Programs could be established to assist older adults in maintaining social engagement, meaningful work and societal contributions, education, and spiritual connections. Keyes (2007) noted that the absence of mental illness does not signify the presence of mental health, warning that a national strategy of focusing on curing or eradicating mental illness will not guarantee a mentally healthy population because mental health represents a separate continuum from mental illness. Keyes (2007) advocated that the determinants of true health—those that help one flourish—are distinct processes from those that prevent mental illness.
Research suggests that high levels of human flourishing are associated with improved immune system functioning, cardiovascular recovery, lower health care costs, and an overall healthier lifestyle (Momtaz et al., 2016). Thus, nurses and other health professionals can play key roles in helping older adults identify and implement important measures that promote flourishing in their later years. Health care professionals who understand the determinants of human flourishing can help older adults develop healthful pathways that integrate a lifetime of hope, regret, achievement, loss, illness, suffering, and coping.
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