Most of us have crossed bridges. But crossing the bridge from independent living to assisted living often is daunting to older persons. Consider Jan.
Jan* was an 85-year-old retired perioperative nurse, weary of home maintenance, but in reasonably good physical health and still driving. On the surface, she seemed suited for independent living. Encouraged by friends, she sold her home and moved into an independent living apartment in a retirement community. A few months later, Jan still had difficulty finding her way to and from the common dining room, and her car had more than a few new dents.
Was independent living still the best setting for Jan? The change from independent to assisted living may present an unsettling challenge for individuals and family members. Despite the hurdles, this life transition presents an opportunity for Christian nurses to carry out Jesus' words: "I was sick, and you looked after me" (Matthew 25:36, NIV). Faith community nurses (FCNs) can have an effective role in this phase of life by considering this transition as a process-like crossing a bridge-rather than as an event. Acting on observations, engaging in meaningful conversation, advocating, and using assertive communication will enable FCNs to support those considering a transition for themselves or a loved one.
This article reviews the conceptual meaning of transition, describes one framework with a spiritual dimension, and suggests how Christian nurses can help ease the transition to assisted living. The apostle Paul's letter to New Testament believers reminds us, in response to God's grace, to "clothe yourselves with compassion, kindness, humility, gentleness, and patience" (Colossians 3:12, NIV). These qualities further equip an FCN to walk across the bridge with older adults facing a life transition.
TRANSITION: AN UNSETTLING PROCESS
Why is this transition so unsettling? Senior adults may hesitate to initiate this life change because they do not want to leave familiar surroundings, they feel dread at the prospect of downsizing, have preconceived ideas about assisted living, and/or view the transition as an inevitable, unwelcome step toward the end of life. Moving to a less-independent situation is often perceived as a loss (Jacob, 2020).
Family members can be hesitant to broach the need for the transition or to discuss the financial impact, which may reach $50,000 per year (Genworth Financial, 2020). Also, family members may feel ill-equipped to handle the resistance and anger which may ensue.
Nursing theorist A. I. Meleis (1975) studied transitions in nursing. In her classic work with a colleague (Schumacher & Meleis, 1994), she suggested four types of transitions: developmental, situational, health-illness, and organizational. Moving from independent living to assisted living may be considered a health-illness transition. The authors theorized what we now understand-health-illness transitions occur across time.
Saunders and Heliker (2008) interviewed in depth five women as they transitioned into assisted living. The researchers built on Schumacher and Meleis' (1994) work, finding four themes: deciding to move, becoming dependent, remembering what was and yearning for the past, and creating a new community. Figure 1 depicts the transition bridge supported by these themes, see Supplemental Digital Content, Figure S1, http://links.lww.com/NCF-JCN/A94.
Since the initial research, the concept of transition as a process has been echoed in newer studies. Scott and Mayo (2019) interviewed 17 women in assisted living to understand this transition from their perspectives. Their findings confirmed Saunders and Heliker's (2008) view that preplanning, execution, and adjustment were necessary to promote the health and well-being of older adults making transitions.
Couture et al. (2020) also contributed to the evidence in their qualitative systematic review. The authors examined factors from the perspective of caregivers that both helped and hindered the decision making about a new living environment for a person with dementia. Synthesizing findings from 31 publications, themes included residents' current living arrangements, potential living arrangements, and the degree to which a change would be acceptable. In sum, these types of transitions are indeed a process.
THE TRANSITION TO ASSISTED LIVING
The American Healthcare Association and National Center for Assisted Living (AHCA/NCAL, n.d.) describe assisted living as "part of a continuum of long-term care services that provides a combination of housing, personal care services, and health care designed to respond to individuals who need assistance with normal daily activities in a way that promotes maximum independence" (p. 2). The National Center for Assisted Living (NCAL, 2019) reported that more than 810,000 Americans reside in assisted living; more than half are 85 years and older. The number is expected to exceed one million by 2050, complicated by polypharmacy and comorbidities (Bergman & Saltsman, 2018).
Older adults who transition to assisted living also experience psychological transition, including the loss of self-identity (Saunders & Heliker, 2008) and self-efficacy (Bandura, 1997). These facts create an imperative for Christian nurses to understand how to bridge the transition. Starting the conversation, though challenging, can involve multiple people who speak from different viewpoints. Many caring persons are involved, including members of the interprofessional healthcare team.
One suggestion (Barnett, 2021) for FCNs and others is to begin by asking specific questions related to health, self-care, mental health, and community (Sidebar, http://links.lww.com/NCF-JCN/A93). These four areas cover biopsychosocial spheres, providing the beginning of a holistic approach to concerns about transition to assisted living. The questions also tap the evidence-based 4M's of age-friendly systems: mobility, mentation, medication, and what matters (Pettis, 2020). Although these questions address a wide portion of key issues, one area should be added the spiritual dimension.
A SPIRITUAL FRAMEWORK
Faith community nurses, with their whole person care approach, are in an optimum position to walk alongside older adults facing a life transition, including offering spiritual care. Lepherd et al. (2019) observed that spiritual care may help senior adults to cope better with the transition to residential aged care. In their qualitative study exploring spirituality among older adults in residential care, the researchers asked, "How do older people describe their spirituality and its relevance to assisting them during their residence in an aged care facility?" (Lepherd et al., 2019, p. 2).
Although the researchers observed that the term spirituality defies universal definition, they agreed that spirituality can engender resilience, easing the change in setting and lifestyle. Reflecting that "there is a need for a greater focus on the spirituality of older people to better support them and lead them to an enhancement of inner peace" (p. 2), the researchers proposed the Connect-Explore Model as a way to talk with older adults about spirituality. Five themes emerged that resulted in these conversation topics: people, something or someone higher, creativity, place, and self.
Shelly (2000) suggested asking additional questions to assess the person's spiritual dimension through a Christian lens. For example, ask questions (a) to understand a person's beliefs about God; (b) to determine the person's involvement in religious practices; (c) to assess spiritual resources; (d) to assess whether a person's resources for hope and strength are reality-based; and (e) to offer the person an opportunity to accept spiritual help.
Spirituality is an important aspect of holistic care, a concept at the heart of faith community nursing. Ziebarth and Campbell (2016) described holistic care:
Human experience of optimal harmony, balance, and function of the interconnected and interdependent unity of the spiritual, physical, mental, and social dimensions. The quality of wholistic health is influenced by human development at a given age and an individual's genetic endowments, which operate in and through one's environments, experiences, and relationships. (p. 114)
REVISITING JAN
Jan found fault with many things, rarely expressed a positive comment, and showed signs of depression. She was aware of her advancing years and felt her independence slipping. She primarily spent time alone. She did not want to "play those silly games" and believed that assisted living staff would make her have fun whether she wanted to or not. Paperwork and mail covered her kitchen table, so she ate off a tray rather than clearing the space. Neighbors expressed concerns about Jan's ability to care for herself. Clearly, Jan needed someone to walk with her as she crossed this bridge.
At the FCN's suggestion, Jan reluctantly attended a community reception to welcome new residents at an assisted living home, but left when the introductions were over. Later, a friend offered to help Jan clean her refrigerator; she found many containers of spoiled food. Another friend reported that Jan mistakenly put laundry soap in the dryer instead of the washer. Neighbors observed that Jan wore the same shirt for many consecutive days and needed her walker more than ever.
One day while driving, Jan miscalculated on an off-ramp and ran off the road. Later, she reported she just did not see well and was under the care of an ophthalmologist. She agreed to stop driving and began to ask others to purchase items for her or take her with them to shop.
IMPLICATIONS FOR FAITH COMMUNITY NURSES
"Health advocacy, care coordination, and transitional care are key concepts in nursing," according to Jacob (2020, p. 310). These roles include advocating for appropriate levels of care for vulnerable populations such as older adults (Jacob, 2020; American Nurses Association and Health Ministries Association, 2017). As FCNs begin conversations with older adults who show signs of needing more care, applying basic steps in advocacy is helpful. Advocacy can be described as "journeying with rather than doing for" (Jacob, 2020, p. 140) and begins with assessing the needs of the individual. One assessment tool is using the questions in the sidebar (Questions to Determine Need for Assisted Living, http://links.lww.com/NCF-JCN/A93) which could be supplemented with suggested spiritual interview questions (See Supplemental Digital Content, Table 1, http://links.lww.com/NCF-JCN/A92). Austin et al. (2018) suggest other instruments to measure spirituality.
After the needs assessment, the FCN can undertake additional advocacy steps: establishing mutual goals with economic impact; negotiating an action plan; identifying available resources; assessing receptivity; serving as a navigator; establishing boundaries; recognizing the resilience of the individual; implementing the plan; and evaluating outcomes (Jacob, 2020).
Along with advocacy, the FCN must clearly speak truth in love (Ephesians 4:15) and with assertiveness. Koch and Haugk (1992) suggested that individuals capably speaking the truth utilize assertiveness, which is in line with 2 Timothy 1:7: "The Spirit that God has given us does not make us timid; instead, his Spirit fills us with power, love, and self-control" (TEV).
Godly assertiveness is declaring what needs to be said or doing what needs to be done for the benefit of someone else. It is not simply airing one's grievances or complaining to an audience. It is not demanding rights or angrily telling someone off. It is motivated by agape love, not by selfishness or a wish to dominate others. (Got Questions, 2021 para 6)
Two of Jan's friends and a family member began to suggest to her that she consider moving to assisted living. At first, she resisted, saying she had found a level of living that she could tolerate if she did not drive. Her family member asked Jan's doctor to begin the conversation about a transition, which proved helpful. The FCN suggested that a staff member at the proposed assisted living center ask Jan if she would accept a visit from the finance office to talk about resources. During that visit, Jan learned that her financial resources were sufficient to make this move.
Friends, family, the FCN, providers, and facility staff members treated Jan with respect and patience until she decided she should move. With that decision made, Jan and her support team began the moving process.
At Jan's next birthday, soon after her move to assisted living, the same encouragers gathered around her. Their presence assured her that, although her living setting had changed, the important people in her life would still be there for her.
CONCLUSION
Recognizing transition as a potentially difficult but ultimately beneficial process, the FCN engages in conversations, employs an evidence-based framework, assesses spiritual concerns, and collaborates with an interdisciplinary care team and the family (Fields et al., 2012). The goal is to foster a smooth transition to assisted living, with God's ever-present help. Discussions of a spiritual nature may help ease an elder's transition by reassuring him or her that Jesus will always abide with us (Hebrews 13:5). Transitional times are trying regardless of age. Faith community nurses can walk alongside those experiencing change and assist in matters related to spiritual care.
Web Resources
* Aging Life Care Associationhttps://Aginglifecare.org
* American Health Care Association/National Center for Assisted Livinghttps://www.ahcancal.org/Assisted-Living/Provider-Resources/Pages/default.aspx
* American Society on Aginghttps://www.asaging.org/
* Center for Excellence in Assisted Livinghttps://www.theceal.org/
* Nurses Improving Care to Healthsystem Eldershttps://nicheprogram.org/
* The Society for Post-Acute and Long-Term Care Medicinehttps://paltc.org/resources
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