PAG-USWAG, PAGKAUSA UG PAGSUSTENER: UTILIZING THE THEORY OF THRIVING IN CARING FOR THE PHYSICALLY ABUSED ELDERLY Carren Maris

N. Paculaba Cebu Normal University College of Nursing Class 2013

Introduction Abuse of the elderly refers to any form of mistreatment that results in harm to or the loss of an elderly (National Committee for the Prevention of Elder Abuse [NCPEA], 2008). One type of elderly abuse, according to NCPEA, is physical abuse, referring to the physical force that results in bodily injury, pain, or impairment. Physical abuse can include hitting, beating, pushing, kicking, pinching, burning, or biting. It can also include such acts against the older person as over- or under-medicating, depriving the elder of food, or exposing the person to severe weather-deliberately or inadvertently.The personal losses associated with this form of abuse can be devastating, as they include poorer health, the loss of independence, shelter, life-savings, dignity, and security (Bain, Spencer, 2009). Most elderly abuse takes place at home (American Psychological Association [APA], 2012) where a great majority of older people live on their own or with their spouses, children, siblings, or other relatives. Family situations that can contribute to elder abuse include discord in the family created by the older person's presence, a history and pattern of violent interactions within the family, social isolation or the stresses on one or more family members who care for the older adult, and lack of knowledge or caregiving skills. Abuse has a significant impact on people at any age, but older adults can be especially vulnerable. In general, older adults have less physical strength and less physical resilience. Some older adults may be very frail, or already have disabilities or impairments that leave them particularly vulnerable. Physical injuries that may be a result from abuse includes sprains, dislocations, fractures, abrasions, burns, pain, bleeding, bruises and traumatic hair and tooth loss. When questioned about these injuries, the elderly and his/her family often provide implausible explanations (Bain, Spencer, 2009). Older adults also often experience worry, depression, or anxiety. These signs may be mistaken for memory loss or illness, when they are actually the effects of stress or worry. An older adult may also feel hurt, shame, guilt, or embarrassment that someone in the family or someone close has harmed them. As such, many abused elderly tend to be socially withdrawn impeding not only the elderlys relationship with his/her family, but with the environment and society as well (APA, 2012). The elderlys coping ability then plays a big factor in his/her ability to thrive. According to the World Health Organization (2011), around 21,000 to 72,000 elderly have experienced some form of abuse at home. As of June 2012, crimes of physical injury in the Philippines have amounted to 23,372 (National Statistics Office [NSO], 2012), but crimes pertaining to the elderly are not specified, giving indication that elderly abuse is given little recognition in our country, as such it becomes harder to identify. This is attributed to the fact that the elderly may not report such incidents, in

fear of damaging the reputation and privacy of their family (WHO, 2011). Furthermore, in a survey conducted by Carlos (1999), medical workers for a non-governmental organization (NGO) revealed that some elderly sought treatment for bruises and welts, the causes of which they could not provide a plausible explanation of. However, despite being initially reluctant to reveal the true causes of their injuries, the elderly eventually confessed. A physically abused elderly, aside from having physical injuries, faces psychosocial turmoil as his or her domestic relationships are also at stake. There appears to be a failure to thrive (Newbern, 1992) due to discord between the elderly, his/her personal relationship with others and his/her physical state. The central purpose of this study, therefore, is to guide nurses in promoting successful adaptation for the elderly who are physically abused utilizing the Theory of Thriving. Theoretical Framework

Figure 1.The Thriving Model.

The Thriving Model (Figure 1) reflects the thriving continuum and the factors that influence an elderly person to achieve either thriving or the failure to thrive. Thriving is defined as the ongoing process of growing through continuous human environment interactions, resulting in social, physical, and psychological resilience and growth. The three interacting factors in a Thriving continuum are the person, the human environment and the nonhuman environment.Failure to Thrive occurs when there is discordance among the person, human environment, and nonhuman environmenta failure of engagement and mutual support, and disharmony (Haight, Barba, Courts &Tesh, 2002). The person is a complex social, physical, psychological, spiritual being in mutual process with the human and nonhuman environment. 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. In this paper, the elderly, including his/her coping abilities and physical injuries associated with abuse, constitute the person. The human environment, on the other hand, refers to the persons external human surroundings and the persons perceptions of the presence, feelings, values, and beliefs of other surrounding humans.The human environment is comprised of positive and negative humans. Positive humans contribute to thriving through positive interactions with the person while negative humans predispose the elderly to failure to thrive due to negative interactions (Haight, et. al., 2002). In a physically abused elderly, the human environment usually consists ofthe family. Due to caregiver stress, a history and pattern of violent interactions within the family and its resulting social isolation of the elderly, the human environment may be cold and uncaring, hindering the elderlys growth and development. This is a contributing factor to the elderlys failure to thrive. Thus, to achieve thriving, older adults should be able to develop and maintain healthy relationships, feel self-assured, and generally satisfied with life. Nonhuman environment is the physical and ecological surroundings of the person, including finances, home environment, natural and built surroundingsand economic, psychological, and social influences/factors (Coddington, 2007). In this case, the determinant factor for a disharmonious nonhuman environment rests on the physical environment and the uneasy access of the elderly with which to avail of healthcare services. These three factorsperson, 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. The Theory of Thriving not only explains the thriving continuum but it also encourages the elderly to move (pag-uswag) towards promoting pagkausa or synergy of the three factors and in sustaining (pagsustener) that synergyto achieve successful adaptation. Theoretical Application in the Nursing Process The physically abused elderly, as previously mentioned, have discordance among the person, the human environment and the nonhuman environment. However, to identify the degree of discordance, proper and holistic assessment should be done involving physical, mental, emotional, psychological, spiritual, cognitive and social domains.In physical assessment, the nurse should promote emphasis on integumentary and musculoskeletal areas as signs of physical abuse are evident there. In assessing the mental, psychological, emotional, spiritual, cognitive and social areas, the nurse could use therapeutic communication and observation techniques. The nurse should also assess the clients familial role and usual daily routine as well as identify the clients caregivers and the clients relationship with them. The elderlys ability to access healthcare services and other social institutions should also be identified. If permissible, the clients family could also be assessed through interview. Failure to Thrive is an accepted nursing diagnosis by the North American Nursing Diagnosis Association (Doenges, Moorhouse&Murr, 2010). In their published pocket guide, Failure to Thrive is described as the diminished ability of the individual to live with multisystem diseases, cope with ensuing problems, and manage his/her care. This

diagnosis may be applied to the situation. However, in diagnosing the physically abused elderly, the nurse is encouraged to explore other possible options and consequently implement proper prioritization of identified nursing problems. It is important to diagnose a problem based on the subjective and objective cues exhibited by physically abused elderly, and not solely based on the nurses perspective. Problem identification, done in cooperation with the client, will not only revolve around the physiological, but with the psychological, emotional, spiritual, and socioeconomic aspects as well. In planning, the nurse and the client should have a collaborative approach in identifying the goal/s to be achieved. The plan of care should be based on the prioritized nursing diagnosis and identified concerns related to thriving. The plan of care should take into consideration the age-related changes, accompanying and/or perceived complications and actual problems of the individual. The general goal of care is to minimize discordance between the person, the human environment and the nonhuman environment in order to achieve positive thriving. Several nursing care plans could be made with more specific goals that address physical, mental, emotional, psychological, spiritual, cognitive and social aspects separately. Since responses to physiological and psychosocial concerns vary, goal/s should be both short-term and long-term. In this regard, it would be best if the nurse encourages the client to engage in long-term goals. If permissible, involvement of the clients significant others and family members is highly encouraged and should be included in the goal to achieve synergy of the human environment. Interventions should be consistent with the different nursing diagnoses and goal/s identified. Since positive thriving entails synergy of the person, human environment and nonhuman environment, different nursing care plans could be implemented simultaneously. Nursing care is focused on treating the injuries sustained, preventing complications, educating the elderly about available health and social services, engaging the involved parties in family therapy, encouraging recreational/social activities, teaching ways to promote a safe physical environment, reinforcing safety measures and maintaining proper quality of life of the elderly. Evaluation should be done frequently to assess the movement or the pag-uswag of the 3 factors towards synergy or pagkausa. It is also done to assess the efficacy of the interventions performed. If the goals are met, evaluation may function as a factor in assessing sustainability or the pagsustener of the health teachings implemented by the nurse. This tells the nurse that the client has achieved positive thriving and is equipped with positive coping abilities.Frequent evaluation could also determine an ineffective intervention. In which case, the nursing care plan/s could be modified accordingly. References Books: Doenges, M.E., Moorhouse, M.F., Murr, A.C. (2010). Nurse's Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales. 12th edition. FA Davis Company.

Articles:

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