o

..•.

.. ". ...:...... ~ ..-::". :", .... ::.

",

,.",------------------------.----.-----------1

The causeofthepatient'sdependencymayshapegourbehaviar-whetheryou know itornot.

Ms, J, 95, was admitted to a short~stay skilled nursing facility ajlerasix-day acute hospital admission. Prior to her hospitalization, shelladbeen experiencing increasing numbers of transient ischemic auach athome 'and hadfallen several times. On admission to the skillednur.facility, she was able to ambulate with a walkeranddemonstratedmod'l!.,...ate initiative and ability to be independent in ADLs.

Ms. J's son was concerned about herfalls andtoldthe staffhe belieV1!1Jthat his mother was no longer able to live alone. Basedon this belief. !hecontactedthesocial worker regarding nursinghomeplacement.Wlrell11Iesocial workerdiscussed the possibleplacement with Ms. }, she/oukedomthe window the entire time andasked no questions.

As Ms. J's stay in the skilled nursing facility continued. she requestedmore and more assistance with tasks she was physically capable ojper­forming: "Here, put my teeth in a cup with hot water. .. Nurse. open mycoffee cup. .. My pil/ow is in the wrollg position,fixit.•,

When thenursingstaffencouragedherto return to herpreviousjndepe.~dence, she responded, "Why? It doesn't makeanydifference. lean'tdo;;tright any more. I'm tired. I just want to belejt alone...

Ms. W, 72, was admitted to a rehabilitation/acility after a 25~day acu.tqhospital stayfor a thoracic laminectomy. She conscientiously went co aliiphysical and occupational therapy sessions and the therapists reportedthat she was working very hardtowardher rehabilitation goals. Howl!YQb,.on the nursing unit, she often requested assistance from the nurses forADLs that she was physically capableofperforming.

"Honey, could you help me change mydress? My husband is comingtonightand1 want to look nice. .. 1know1coulddo it, butyou~resupposedto behereto help meandit willgofaster ifyou do it. .. Can'tyou seel'minahurry?IfI rush todo it. Jwillbetoo tiredforagood visit . . Whycan'tyoujust dress me like the other nurses do and stop wastingboth our time?"

He!ping Those \t\lh~ .. 1Don t Help Themselves, \

LYNDA SLIMMERJOY EDWARDS-BECKETTJOAN LESAGEJANETELLORMARTITA LOPEZ

Professional nurses in long­term care facil~ties frequentlysee elderly residents who are

passive and dependent. Several stud­ies have suggested that health careprofessionals contribute to the devel­opment ofsuch behaviors.

Solomon, for example, observedthat nurses who stereotyped elderlyas dependent responded not tO,howresidents behaved but to their per­ceptions of the residents' needs( 1).Eventually, the residents began to be­have as if they were dependent, per­petuating the nurses' perception.

Avorn and Langer, as well, foundthat staffcan inadvertently cause de­pendence by helping elders do thingsthey are able to do alone, which, inturn, reduces the residents' ability toperform tasks(2). Schulz and Ader­man have contended that an elderlyresident's perception that the institu­tion is demanding passivity results inpassive behavior(3).

Nurses, trying to counteract iatro­genic dependency in the institution­alized elderly, often base their inter­ventions on the assumption that pas­sive, dependent behavior indicatesdepression and is a maladaptivereaction to perceived lack of con­trol(4).

The theoretical model most widelyused to explain the dependency asso­ciated with depression related to per­ceived lack of control is the learnedhelplessness theory, which states: In­dividuals who are exposed to uncon­trolIable events, who believe that

L)'nda W. Slimmer, PhD, RN, is associate pro­fessor, Elmhurst College Elmhurst, IL. JO)' Ed­wards-Beckett, PhD, RN, is a doctoral candi­date at Rush University, Chicago, IL. Joan Le­Sage, PhD, RN, is chairperson, department ofgeriatric/gerontological nursing, Rush Univer­sity College of Nursing, Chicago, IL. Janet R.Ellor, MS, RN, is administrator, ExtendedC~reCenter, V. A. Edward Hines, Jr. HospitlH;Hmes, IL. Martita Lopez, PhD, is assistantprofessor in the department ofpsychology andsocial sciences, Rush Medical College, Chica­go, IL. This study was supported by the RobertWood Johnson funded Rush-Hines V. A.Teaching Nursing Home Program. The inves­tigators thank the participating gerontologicalnurses for their support.

they can do nothing to change theoutcome of those events, and whodevelop the inappropriate expecta­tion that outcomes of future eventswill also be beyond their control, de­velop a condition ofhelplessness.

However, dependency and passiv­ity in an institutionalized elder maynot always evince learned helpless­ness, but rather instrumental help­lessness-adaptive behaviors repre­senting an effort to control what ishappening(5). Or, the dependencymay be a secondary control strategycharacterized by an external locus­of-control orientation(6).

Can nurses discriminate amonglearned helplessness, instrumentalhelplessness, and secondary controlbehaviors? Some' preliminary datasuggest that, although nurses can

identify helplessness in elderly insti­tutionalized residents, they oftencannot differentiate between instru­mental and learned helplessness(7).

Or Can The)'?

This qualitative, descriptivestudy-part ofa research project in­vestigating learned helplessness inthe institutionalized elderly-com­pared nurses' attitudes and interven­tions to passive, dependent behav­iors induced by learned helplessnesswith nurses' reactions to dependencenot induced by learned helplessness.

The case studies of Ms. J and Ms.W were distributed to 16 RNs at ateaching hospital's center for the el­derly and 9 RNs at a midwesternVeterans Administration hospital'sextended care units. The nurses weregiven no theoretical definition of ei­ther instrumental or learned help­lessness prior to responding to thecases.

Ms. J typified a resident with themotivational, cognitive, and emo­tional deficits characteristic oflearned helplessness. The case ofMs.W described a resident who was dem­onstrating dependent behaviors, butwho was in control of when and towhat degree she was dependent.

After reading each vignette, thenurses were asked to complete a se­mantic differential, "My FeelingsAbout Ms. J's Behavior" and "MyFeelings About Ms. W's Behavior."Both semantic differentials includedthe same 24 scales, each composed ofa pair ofantonyms, with seven even­ly divided spaces between each anto­nym. Positive ratings were scored 5,6, 7; negative ratings as 1, 2, 3; andneutral ratings as 4. (See table on nextpage.)

The first eight scales (evaluationcomponent) measured a nurse's be­lief about the desirability of the de­pendent behaviors. The next eight(activity component) were used toidentify a nurse's specific descriptionof the behaviors. The last eight (po­tency component) measured anurse's feelings about the overall im­portance of the behaviors.

The nurses were also asked to an­swer the folIowing open-ended ques­tion: If this were your patient, howwould you respond to her behavior?

Geriatric Nursing January/Fcbruary.t990 21

The nurses rated Ms. W's dependency not related to learned helplessness as morenegative ("bad:' "unnecessary" and "unexpected"), and Ms. J's dependency relatedto learned helplessness as more sad, less controlling, more passive, and moresignificant than instrumental dependency.

For Ms. J, who typified learned helplessness, the 25 nurses listed 57 interventions.Of these, 44 percent were emotionally supportive, designed to increase her self-esteemor allow her to talk about her feelings. More than a quarter would encourage Ms. J tobe more independent in her daily activities.

For Ms. W, the 25 nurses listed 54 interventions, nearly half (41 %) encouraging Ms.W to be more independent. Nearly a quarter of the nurses would emphasize thephilosophy of rehabilitation. Only 3 advised emotional support.

--.

How Nurses Described HawTheyThe Dependency Would Intervene

Ms.J Ms.W W"dbMs.J Responses

SemanticDifferentials MB.an* Mean" emotional suppon 25Encourage independence

£valuaflc)/JCompl1nent inAOl.$ 14S,r;I-GOOll 3.72 2.&0 FaclDtate nursingu~ntctssa~-Necessa~ 4.48 3.36 bOme-placement 6unexR,ect'_ -Expecter;l 5.24 3.88 Talkwfth family 5$~~- ~ppy 2;04 ~U4 Discuss attemative-,nconvenient-COnvenlent a.~ 4.1.2 to nurslhghome 3N~tlV8"POSltl'ie 2.16 e.84 Other 6UtiealthY.l:fealthy 3.08 2..96 TOTAL 51HannfYl-I~enefietal 2.84 3.e4Ar:ti1ti:K,ComPDnentt:ie.lHJI uced'OIher lnducer;l 4.S~ 2058l)ependenHnd~pemlent 2.44 2,96 W"JtbMs.W ResponsesRlgl(}-R~le 3M 3.56Noncompliant-Compliant 3;:68 3.04 Encourage independenceCbnt;roUed"control6ng 5;00 5;~ inADLs' 22pasSlg;.AttiYe 3.08 4.$4 EmphaslZephDosophyBoring-J;x,lting 3.80 4.28 of rehabilitation 13AP-alhlc>Emotionat 4.04 4.48 fleihforce patient'SPDtencyComponent accomplishments InFT 1Cold·Hol 4.12 4.44 Plan more consistentImpOtent-Powerful 4;04 4.92 staffapproaCh 5Temporary-Permanent 3.32 S.44 Provide emotionalUnimportant-Important 6.28 5.3"6 SUpport 3Trildal.$lgniflcant 6.20 5.40 Other 4Far·Neat 4.44 4.44 TOTAL 54SmaIJ-Great 4.80 4.64weak-Strong 4.24 5.04·On a scale from inostposItiVe (1) to most negative (7)-For the&aalrs in~. the difference Of the meanscores tween de~ndence related to learnedhelplessnessand 0 r dependence was~nlficant atthe O.Crl levelo'probabllity.

A content analysis ofthe answers wasused to categorize nurses' interven­tion responses.

The means, modes, and standarddeviations for each of the 24 seman­tic differential scales were calculatedfor both vignettes. Twenty-four t­tests were computed to examine dif­ferences between responses

What Does It Mean?

The results demonstrate severalstatistically significant ditre'iences(shown abo~'e) between nurses' atti­tudes toward dependent behaviorscharacteristic oflearned helplessnessand dependence not related tolearned helplessness.

The data suggest that professional

22 Geriatric Nursing January/February 1990

nurses are sensitive to different typesof dependency in the institutional­ized elderly. Although they perceivedependency as a generally harmful,unhealthy behavior, they judge de­pendency unrelated to learned help­lessness as more negative than de­pendency associated with learnedhelplessness. Likewise, althoughthey recognize that dependency inthe elderly is a behavior worthy oftheir professional attention, they aremore concerned about dependencyrelated to learned helplessness thandependency not related to learnedhelplessness.

It is important to note that thenurses in this study described bothtypes of dependency as behaviors

that control others rather than be­haviors resulting from being con­trolled, a perception contrary to thetheory oflearned helplessness.

A very significant finding is thatnurses' sensitivity to differences independency is reflected in their inter­vention responses. When dependen­cy is associated with learned helpless­ness, the most cited response was toprovide emotional support. In con­trast, when dependency is not asso­ciated with learned helplessness, themost frequent response was to workon the dependent behaviors.

This finding contrasts with the re­sults of a previous study in which,whether nurses attributed dependen­cy to attention-getting tactics or tolack of motivation and the "giving­up syndrome," the planned interven­tion was the same: encourage inde­pendence in ADLs(7).

Interestingly, the major differencebetween then and now is that in theprevious study the nurses were re­sponding to actual resident behav­iors, while in this study they were re­sponding to hypothetical situations.Thus, although this study suggeststhat nurses can discriminate betweenhypothetical behaviors, we need tolook further to document that suchdiscrimination occurs in the clinicalpractice.

ReferencesJ. Solomon, K. Social antecedents of learned help­

lessness in the health care setting. Gerontologist22:282-287, June 1982.

2. Avorn, J., and Langer, E. Induced disability innursing home patients: a controlled trial.J.Am_Geriatr.Soc. 30:397-400. June 1982.

3. SChulz, R., and Aderman, D. Effect of residentialchange on the temporal distance to death oftermi­nal cancer patients. Omega_' J.Death I1ying 4: 157­162, Summer 1973.

4. Langer, E. J., and Rodin, J. The effects of choiceand enhanced personal responsibility for the aged:a field experiment in an institutional selling.J.Pers.Soc.Psyehol. 34:191-198, Aug. 1976.

5. White, C, and Janson, P. lfelplessness in Institu­liona/ Seuillgs: Adaption or Iatrogenic Disease?Paper at the meeting of Gerontological Society ofAmerica, at San Antonio, TX, Nov. 12, 1984_

6. Rothbaum, F.,and others. Changing the world andchanging the self: model of perceived control.J_Personal.Soc.Psychol. 42:5-37, Jan. 1982_

7. Slimmer,l. W., and others. Perceptions oflearnedhelplessness. J.Geron.Nurs_ 13:33-37, May 1987.

8. Abramson,l. Y., and others_ Learned helplessnessin humans: critique and reformulation. J.Ab­norm.Psrchol. 87:49-74, Feb. 1978.

9. Halberstadt, L.• and others. Helplessness, hope­lessness, and depression. In Personalit}· and Be­hal'ioral Disorders. Vol. I, ed. by N. S. Endler andJ. M. Hunt. 2nd ed. New York, John Wiley andSons, 1984. pp_ 373-411.