Supporting resilience in older people: implications for nursing practice

Advancements in healthcare provision mean that older people will live longer, but may also experience the effects of long-term physical illness or mental distress, which have the potential to negatively impact their quality of life and wellbeing. Older people make up a large proportion of health care consumers across the continuum of care and this is set to increase in line with demographic changes worldwide (World Health Organization, (WHO) 2020). Traditional healthcare practices have focused on older people living well with chronic conditions through symptom control, stoping or slowing condition progression, health education and self-management. However, the general focus has been on single-condition approaches, despite the increased likelihood of multi-morbidity in later life, with estimations of the number of people affected ranging from 55% to 98% (Marengoni et al, 2011). Less emphasis is placed on helping older people adapt to the changing circumstances that they encounter in later life by harnessing their resilience and supporting personal growth when situations of adversity are encountered, thereby creating conditions where they can thrive (Pruchno et al, 2015). The aim of this article is to advance the understanding of nurses working with older people in relation to the concept of resiience, how it is conceptualised and how it can be applied in the provision of person-centred care. The article will also examine the factors that influence resilience, and by using a case study, will provide some strategies that nurses can use to support resilience in older people.

Understanding the concept of resilience

Resilience has been defined as a noun and a process. When defined as a process, it has been referred to as dynamic, changing over the course of one's lifetime and in response to the specific context where individuals find themselves (Windle, 2011; Resnick, 2014; Pruchno et al, 2015; Angevaare et al, 2020). Newman (2005) defines resilience as a human ability to adapt and flourish despite exposure to trauma, tragedy and other adversities. Meanwhile, Dyer and Mcguinness (1996) described resilience in psychological terms and discussed its nature as individuals bouncing back from adversities and getting on with their lives. Resnick (2014) further describes different types of resilience including health resilience, emotional resilience, physical resilience and dispositional resilience. Arising out of a concept analysis, Windle (2011) emphasises resilience as a process and identifies three conditions that are necessary for resilience to occur:

• The presence of a significant risk, adversity, or trauma
• The availability of resources to counter the adversity
• Avoiding negative outcomes or adapting positively to the adversity.

Writing specifically about older people, Angevaare et al (2020) suggest that the conditions necessary for resilience described by Windle (2011) and others are similar across the lifespan, however, it is the context in which resilience occurs that has the most variability. In their review, older people's lived experiences and their belief in their own abilities to overcome adversity were important factors, along with the availability of social support, which was central to their resilience (Angevaare et al, 2020). The different interpretations outlined above demonstrate that although resilience is referred to frequently in the literature, the term itself can lack clarity and that this concept has varying perspectives.

Use of the socio-ecological model

The social ecological model offers nurses one way of undestanding resilience by emphasising policy and environmetal contexts as well as identifying social and psychological influences (Sallis and Owen, 2015). Within this model, a framework is provided which helps nurses and other health professionals to acknowledge and understand the relationship between the person and their individual contexts (Stokols, 1996). This allows for the integration of different systems which supports the deeper analysis of health problems, as it integrates multiple intersecting domains which situate the person within personal, social and environmental contexts (MacCosham et al, 2021). This means that in a social ecological context, it is not just the person's knowledge, beliefs, values and attitudes that are important, but their relationships with society, institutions, and the wider community also need to be considered (Murdaugh et al, 2018). This broadens the scope for intervention and helps to provide a more nuanced approach that can meet the individual needs of the person. Drawing from the social ecological model, ldwin and Igarashi (2012) have proposed a transactional model of resilience in later life. They argue that at the heart of resilience is the individual's ability to cope with stress. Stress can occur in several ways, either through the emergence of major traumas such as illness, loss or disability, which emerge over the course of one's life, or from day-to-day stresses and strains that the older person faces. Within the model, general resistance resources are the coping mechanisms that older people learns during their lives and these assist in the management of encountered stresses. In addition, managing stresses, whether from major traumas or from general life experiences, create coping resources that older people can draw from during future stressful episodes. Therefore, resilience occurs within a context where stresses are multi-layered, varied in intensity and duration, and require responses that not only resolve current stressors, but also can help to build new coping skills (Aldwin and Igarashi, 2012). Furthermore, resilience is nested within a framework of sociocultural, contextual and individual resources which may interact with each other to create risks or can result in healthy adaptations (Aldwin and Igarashi, 2012). An overview of Aldwin and Igarashi's (2012) ecological model of resilience is presented in Figure 1.

Sociocultural, contextual, and individual resources

Older people are a diverse group and one must be careful not to homogenise their individual characteristics and experiences. However, it is commonly understood that ageing can involve several key life transitions, such as retirement, that can be perceived as stressful. In addition, some older people are also vulnerable to losses across multiple domains which may impact their ability to maintain independence and affect their quality of life. For example, adjusting to poorer health due to chronic conditions disproportionally affects older people and may be perceived as a specific stressor where coping is required. Moreover, ageing may alter the older person's sociocultural and contextual resources, which may also affect their ability to cope with stressors, compromising their ability to be resilient in the face of cumulative challenges. Using Aldwin and Igarashi's (2012) model helps nurses to not only understand how a physical or mental health difficulty can impact the older person, but also the relationship this has with the environment in which such a person can be situated. Table 1 provides examples of sociocultural, contextual and individual resources which can be considered when working with older people. Nurses working with older people need to be aware of how these interact in terms of supporting resilience or addressing individual risk factors. They need to also be aware of the diversity that exists among people and to respond with interventions that are meaningful, tailormade and person-centred. Support for older people needs to be nested within this framework and to do this, nurses will need to immerse themselves in the lived world of the older person, drawing from interventions that not only relate to the older person's physical or mental health needs, but also their immediate support networks, community and the opportunities that lie therein. While an understanding of the social determinants of health will go some way to understanding and supporting the needs of older people, the ecological model helps to augment our understanding of resilience and provide a more holistic approach to meeting their will, preferences and any needs identified during comprehensive assessments.

Role of the nurse

Nurses are ideally placed to support resilience in older peple, but they need to understand what resilience is and what it is not (Morse et al, 2021). Firstly, nurses need to recognise the potential for resilience among older people despite the adversities that they might face. Person-centred relationships fuelled by hope, optimismand belief in the person's ability to succeed are necessary to create an atmosphere for resilience to flourish. While writing in the context of rental health, Higgins and McBennett (2007) describe the petals of recovery and many of the ‘petals’ overlap with the conditions which can promote resilience. These conditions move away from biomedical perspectives, which were traditionally dominant in the management of chronic illness to focus on the meaning of the illness to the older person. The petals of recovery are presented in Figure 2.

Another issue that needs to be considered by nurses are the factors that influence resilience in older people. The role of the nurse in supporting resilience in older people is complex and this complexity is heightened when individuals present with multiple chronic and long-standing conditions. While nurses will be most familiar with a person's resources, they may be less familiar with how they interact with the older person's social and community environment. For example, an older person with newly reduced mobility may not be able to navigate and access the social and community resources that were previously available to them. Nurses will need to acknowledge and address how this individual characteristic interacts with the contextual resources, working with the person to address risk factors, build resilience and capitalise on existing strategies to overcome the identified challenges. Therefore, understanding how the older person responded to stressors throughout their life is necessary to predict coping reactions and the ability to bounce back from adversity. Furthermore, understanding personal life-histories may point to approaches that are most likely to assist or succeed in identifying vulnerabilities in terms of education or accessing healthcare needs. Nurses may feel that they have less control over sociocultural resources such as policy. However, nurses both individually and collectively, are a political entity and can influence policy in terms of design and its implementation at the national and the local level; however, they have struggled at the design level (Rasheed et al, 2020). Furthermore, awareness of policy and the use of evidence-based interventions will support the older person's individual resources through the use of the latest technologies, under-pinned by contemporary philosophical approaches such as shared decision-making and making every contact count (O'Brien and Scott, 2016; Public Health England, 2016; National Institute for Health and Care Excellence, 2021). While Aldwin and Igarashi's (2012) ecological model of resilience provides a framework for conceptualising these factors, nurses need to be attuned to the individual factors for each older person that they work with. Central to this will be the establishment of a relationship with the older person which will form the basis for all interventions. Resnick (2014) has provided an overview of psychometric scales that have been developed to evaluate aspects of resilience, and nurses could use these as part of a holistic assessment. Assessing resilience in older people can also be achieved qualitatively by asking open-ended questions that centre on how the older person finds meaning from their experience, which can guide the identification of personalised strategies for intervention (Resnick, 2014). Asking open-ended questions will also support the development of relationships with the older person, while respecting and enabling them to speak out, which gives nurses an opportunity to listen to the person's narratives with the intent of supporting resilience. To demonstrate the role of the nurse in supporting resilience, a case study is now presented to illustrate the application of the concepts identified in this section (Box 1).

Box 1.Case studyMr. Paul Smith, a 70-year-old, is admitted for review to your community care team following a fall at home. Smith is known to your service as he has previously undergone a comprehensive geriatric assessment with the older person care team and was identified as experiencing pre-frailty. He is recently retired, single and divorced for the last 5 years. He lives in a bungalow next door to his son and his family. This is his third fall in the last year. He explains he has become careful when moving around and only goes out when he must, to avoid any further falls. Mr. Smith explains that he is seeing his friends less and not participating in his twice-weekly bowls matches, which he really enjoyed as it kept him physically active and socially connected. He states that he wishes to regain his confidence and reconnect with his interests and friends.

Mr. Paul Smith's presentation outlined in Box 1 is not unusual and highlights several issues that can impact on older people. While the comprehensive geriatric assessment will provide data about Mr Smith's physical, psychological, functional, and social needs, it may place less emphasis on helping him to adapt to his present circumstances or helping him build and exercise resilience as aspects of his care plan. In addition, it may prioritise physical safety interventions considering his recurrent falls, and redress his physical frailty. While Mr. Smith's physical health is of paramount importance, the nurses working with him also need to incorporate a resilience lens to identify how they can facilitate the use of the contextual, community and individual resources available to him to foster health, well-being, and his desired social re-engagement. Such an orientation represents a whole person, strengths-based, approach to nursing and the support of citizenship. According to Siltanen et al (2021) resilience may support people to maintain higher levels of activity despite walking difficulties, which further underscores the importance of understanding and fostering it in this example. Building Mr. Smith's confidence and supporting him to reconnect with his friends will contribute to the tenacity that Tourunen et al (2020) discuss as contributing to enhanced participation in leisure activities. Other individual resources such as maintaining self-esteem and self-efficacy, making sure that he retains the locus of control, facilitating hope, supporting his personal goals and a sense of purpose, which as outlined by Resnick (2014), will provide an atmosphere that will support positive adaptation, effective coping, and mastery (Earvolino-Ramirez, 2007). Person-centred approaches are key here, as seeing the world through Mr. Smith's eyes and being considerate to his conceptualisations of health and wellbeing are central to harnessing the generalised resilience resources that Mr. Smith has built over his life.

Furthermore, positive adaptation to the fall-related trauma drawing on individual, contextual and socio-cultural resources will also support adaptation to future stressors, so it is imperative that personal growth and learning are considered as health goals within the overarching framework. As such, recognition of the contextual resources that are available to support Mr. Smith, such as his son and his friends, and encouraging them to maintain social participation, building confidence, and helping him to stay physically active are necessary to augment individual resources. This could be achieved by involving Mr. Smith's son in the care planning processes or arranging transport to attend bowl matches.

In addition, setting realistic goals with Mr. Smith that are achievable and realistic will help to build his confidence. Furthermore, nurses being attuned to some of the sociocultural contexts, will ensure that core concepts under-pinning practice support the mutually agreed interventions with Mr. Smith. For example, knowledge about the social prescribing framework produced by the Health Service Executive (HSE, 2021) will facilitate referral to a range of non-clinical services within the local area specific to Mr. Smith's needs and preferences.

Conclusion

Older people are vulnerable to multiple factors which can create adversity and negatively influence a person's quality of life with physical, psychological, and social factors often interacting to produce concurrent stressors. However, many older people are resilient and thrive in the face of adversities, assimilating their effects, adapting to them, and achieving a sense of personal growth. Nurses working with older people need to recognise this and adopt ways to weave resilient building strategies into their nursing practice. This requires nurses to work closely with older people to understand the meaning that is attached to personal adversities and the internal, contextual and sociocultural resources that are available to support resilience Understanding resilience in this context will assist nurses to see that health outcomes include adaptation, learning and personal growth. Such outcomes offer the potential to enhance the well-being and quality of life of older adults.

Key points

• Older people are vulnerable to chronic conditions which negatively impact their quality of life
• Healthcare practices have focused on helping older people live comfortably with these conditions through self-management and other strategies
• Less emphasis is placed on the need to support older people to adapt and grow from related adversities through the support of resilience
• Resilience has been defined as the ability to adapt, flourish, and bounce back following adverse or traumatic experiences
• The social ecological model provides a framework to understand resilience and the multiple contexts that can support it
• Nurses are in a key position to recognise adversity and to facilitate resilience by harnessing the older person's resources to promote adaptation and personal growth.

CPD reflective questions

• With reference to your nursing role, can you identify the opportunities to support resilience building for the service users you work with?
• With one of the older service users you work with in mind, identify the individual, contextual, and sociocultural resources that are available to them to support resilience.
• Reflect on your current knowledge and competency in relation to resilience. How will you address any related learning needs you may have to enhance your nursing practice with older adults?
• What specific local resources could you signpost older adults towards to enhance resilience and wellbeing?