University of Groningen
Perspectives on health and health promotion in community-dwelling older people
Marcus-Varwijk, Anne Esther
DOI:
10.33612/diss.171365999
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Publication date:
2021
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Marcus-Varwijk, A. E. (2021). Perspectives on health and health promotion in community-dwelling older
people: a mixed-methods study. University of Groningen. https://doi.org/10.33612/diss.171365999
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general
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This dissertation has contributed to the existing body of knowledge on health promotion and disease prevention interventions targeting community-dwelling older adults with augmented risks of adverse health outcomes. In addition, the personal views and experiences of the participants, the community-dwelling older adults, regarding healthy aging were studied. More specifically, in this dissertation we evaluated the nurse-led health promotion and preventive intervention called “Community Health Consultation Offices for Seniors
(CHCO)” (in Dutch Consultatiebureau voor Ouderen). This intervention targeted community-dwelling older people aged 60 years or older, with increased risk of frailty and/or unhealthy behavior patterns. Participants who were at risk of adverse health outcomes were invited to a consultation with the community health nurse. Participants were asked to fill in a comprehensive health assessment questionnaire before meeting with the community health nurse. During the first consultation the nurse checked the assessment questionnaire and, if agreed, biometric measures were performed. Based on this information, the nurse was able to provide tailored advice and refer people to other health professionals, if needed to support daily functioning or enhance health outcomes. After the first consultation, a follow-up and annual consultation would follow if necessary. Our research aims were:
1.
to evaluate a nurse-led health promotion and disease preventive intervention for community-dwelling older people with augmented risks of adverse health outcomes from various research perspectives, namely:a. investigating whether a minimal intervention by the Community Health Consultation Offices (CHCO), targeting community-dwelling older people with augmented risks, could improve older people’s health and stabilize care needs-related outcomes (Chapter 2, quantitative);
b. exploring the experiences and views of older people participating in a (nurse-led) health promotion and disease prevention intervention
(Chapters 3&4, qualitative);
c. evaluating the extent to which the nurses used Motivational Interviewing (MI) within the Community Health Consultation Offices for older adults with augmented risks of adverse health outcomes (Chapter 5, quantitative).
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to gain insight into the views and experiences of community-dwelling older adults regarding healthy aging in general (Chapters 3&4, qualitative).143
In this chapter, we first summarize our main findings and conclusions. Next, the quantitative and qualitative studies are combined and interpreted into a more coherent whole; this is the final phase of our mixed-methods design. Next, methodological considerations are addressed. Lastly, implications and recommendations for further practice, education and training, research, and policy are described in this chapter.
Main findings
Our first study is described in Chapter 2. This study included a quasi-experimental design, in which we evaluated the CHCO intervention on health-related and care needs-related outcomes in community-dwelling older people (≥60 years). We included a care-as-usual group of community-dwelling older people who participated in an observational study. Older people who received the intervention were (pre-)frail, overweight, or smoking. Study data were obtained at baseline and at a 1-year follow-up in the intervention and care-as-usual group. In both groups, care needs related and health-related outcomes were collected on self-reported health status and falls and fractures. Care needs-related outcomes included: levels of dependency and progression of care needs as measured by transitions in the segmentation of the health profiles (vital, psychosocial coping, physical and mobility, and multidomain). In the intervention group, additional health-related data was collected on biometric measures (blood pressure, blood glucose, height, weight, and waist circumference) and health-related behavior (smoking behavior, alcohol consumption, balanced diet, and physical activity). The intervention group and the care-as-usual group included 403 seniors and 984 seniors, respectively. No significant changes in self-reported health status and falls and fractures were recorded in either group. The CHCO intervention did not show a significant improvement in health-related outcomes or stability in care needs-related outcomes in older persons measured after a one-year follow-up. With the CHCO intervention, we managed to reach community-dwelling older persons with increased risk of frailty and/or unhealthy behavior patterns on a large scale.
In Chapter 3, we explored older adults’ perspectives on healthy living and their interactions with professionals regarding healthy living. Knowledge of this perspective is necessary for nurses when they engage in health promotion and disease prevention interventions. Semi-structured interviews (n=18) were carried
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out with older adults (aged 55-98) living in the Netherlands. We found that older adults experience healthy living in a holistic way, preferring to live active and independent lives. Older adults prefer an equal relationship of trust with health professionals. They also value a focus on positive health outcomes, such as autonomy and self-sufficiency, when communicating about healthy living. In Chapter 4, we aimed to specifically investigate the views and experiences of older adults on their participation in the CHCO intervention and continued to investigate their views on healthy aging. This study contributed to our understanding of the “black box” of health promotion and disease prevention by providing in-depth information and rich data about the views and experiences of older adults in the context of the CHCO intervention. Dutch older adults aged 62 to 92 years participated in interviews (n=19). This study showed that older people have holistic views on health. They mentioned their ability to adapt to the challenges that they face while growing older. The diverse representation of older adults expressing a variety of expectations and views reflected a heterogeneous group. Older adults indicated that they experienced the interaction with the nurse as friendly and professional. In the interaction between the nurse and the older adult, certain skills and competencies such as listening, honesty, being supportive, and creating a positive atmosphere were highly appreciated. Older adults also felt they had been given professional advice which the nurse considered best practice during the consultations. There was significant variety in how older adults experienced the advice that was given, which holds true for the decision-making processes as well.
Part of the protocol of the CHCO-intervention was that nurses would use MI techniques for guiding possible changes in unhealthy behavior in community-dwelling older people. The care organization provided a single workshop, with additional information for self-study, for nurses to learn MI skills. In Chapter 5, we evaluated the extent to which nurses used MI during the CHCO intervention consultations. We selected 17 audio work samples of consultations between nurses and older people. These samples were coded using the MI Treatment Integrity 4.2.1 instrument and reflected treatment fidelity. This study showed that nurses used some elements of MI at a beginner proficiency level during the consultations. This was found for the global scales on the relational (partnership, empathy) and technical (cultivating change talk, softening sustain talk)
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components of MI. Although the nurses listened to the clients, the depths of their understanding did not reach the beginner proficient level yet. Our results implied that the nurses did not explicitly validate the older adults’ opinions or strengthen their autonomy. This study showed that even in a setting in which nurses are aware of the need for health promotion, providing short training instructions on MI was not sufficient for nurses to implement MI skills effectively.
Combining and integrating the main findings of
the quantitative and qualitative studies
We used a parallel mixed-method design, in which we collected and analyzed the quantitative and qualitative data separately, considering the qualitative and quantitative data of equal weight1,2 to achieve the aims of our study. To integrate our findings, we took inspiration from the ‘methodological metaphor’ of triangulation as argued by Erzberger and Kelle.3 The methodological metaphor of triangulation provides researchers with a frame to describe the relationships between the quantitative and qualitative results on a deeper level, to explain the phenomenon that has been studied. The basis of the frame presents the empirical findings of both quantitative and qualitative findings. The empirical findings lead to the theoretical level, which describes theoretical propositions. In this dissertation, we explain ‘theoretical propositions’ as conclusions that can be drawn from relationships between findings that are derived from the empirical data (quantitative and qualitative), based on how these findings relate to each other logically. The sides of the triangle illustrate the interactions between the empirical findings and the propositions.3 The ‘triangle’ varies in shape since outcomes from quantitative and qualitative studies can vary. The outcomes of the quantitative and qualitative studies can either be convergent, complementary, or divergent.3 In the next section, we show how we used the application of the metaphor of triangulation as a framework (see Figure 1). We will describe three propositions (see Figure 1 as illustrated in the blue box) that we have derived from quantitative and qualitative empirical findings (see Figure 1, illustrated in the green box, and described in the previous section, Main Findings), and how these are supported by the logical relationships as demonstrated by the black arrows (see Figure 1). After each proposition, a paragraph of critical reflections on that specific proposition follows.
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Proposition 1 Even though the procedure of the CHCO intervention selecting olderpeople with augmented risks on adverse health outcomes proved feasible, the CHCO intervention did not improve older people’s health-related outcomes, nor stabilize care needs-related outcomes. A possible explanation is that the minimal intervention and the minimal training of the nurses led to low treatment fidelity for the adherence to Motivational Interviewing (MI) in the implementation of the CHCO intervention.
Quantitative data showed no significant improvement in health-related
outcomes, and did not show stability in care needs-related outcomes after
one-year follow-up in community-dwelling older adults who participated in the CHCO intervention. The GFI and questions related to BMI and smoking proved highly functional in terms of selecting high-risk (pre-) frail community-dwelling older people.
Quantitative data showed that most of the participants in the CHCO intervention group scored self-reported health as “good”, also after
one-year follow-up, irrespective of living with high risk factors such as
hypertension, a chronic disease, or coping with psychosocial issues. Quantitative data showed that Motivational Interviewing (MI) was
only implemented to a certain extent, achieving beginner proficiency levels
based on global scores for most conversations. However, scores on the behavioral counts showed that the conversations did not reach fair levels
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Figure 1. Illustrating and integrating the quantitative and qualitative findings of our study, using the methodological metaphor of triangulation
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Proposition 2To older people, healthy living means staying active and engaged, physically, socially, and mentally. Good health, as reported by older adults, coexists with a life with a chronic disease, or high-risk factors. Older people highly value personal autonomy. Older people experience challenges in anticipating opportunities and limitations while aging.
Proposition 3
Older adults value reciprocity, trust, and a personal and positive approach, in which they stay autonomous while interacting with a nurse. Some experienced the CHCO intervention as a physical check-up and receiving general advice. Others felt they received personal support and tailored advice. A plan of action aiming for behavioral change or improved health was implemented only exceptionally.
Qualitative data showed that to older adults, healthy aging or living means living their lives actively and autonomously. They have diverse and holistic views on health and talk about staying physically, mentally
and socially active (engaging in life). As they age, they feel the need
to anticipate new opportunities and constraints, which can be quite challenging and is unique to every single person.
Qualitative data showed that older adults prefer to talk about their health with nurses (health professionals) they trust. They value
reciprocal trust. Older adults highly appreciate being listened to, being supported, experiencing a positive atmosphere, and honesty. Not all older
adults see health or talking about their health as a priority; they point out that other important aspects in life matter more.
Qualitative data showed that participating older adults in the CHCO intervention described diversity in experiences.
a. Participants experienced the intervention as a physical check-up, receiving general advice.
b. Participants felt a connection with the nurse, receiving tailored advice and personal support. Shared decisions or making a goal-oriented plan was only mentioned exceptionally.
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Proposition 1
Even though the procedure of the CHCO intervention selecting older people with augmented risks on adverse health outcomes proved feasible, the CHCO intervention did not improve older people’s health-related outcomes, nor stabilize care needs-related outcomes. A possible explanation is that the minimal intervention and the minimal training of the nurses led to low treatment fidelity for the adherence to Motivational Interviewing (MI) in the implementation of the CHCO intervention.
Using the Groningen Frailty Indicator and two supporting questions on smoking and weight proved effective in selecting older adults with risks of adverse health outcomes. A relatively large group of participants were at risk of frailty, as reported in Chapter 2, showing significantly higher levels of frailty in the intervention group compared with the care-as-usual group. This is an important finding since global aging includes an increase in frailty, and frailty is positively associated with adverse health outcomes and high health care costs.4
Our empirical finding that the CHCO intervention was not effective in improving health-related outcomes, nor in stabilizing care needs-related outcomes, is in line with other research that shows that interventions focusing on frail or pre-frail community-dwelling older people to enhance their health outcomes show little or no improvement in health and care-related outcomes.5-9
A first explanation could be that usual care in high-income countries such as the Netherlands or the United Kingdom includes extensive geriatric services and well-organized primary care.10 From this point of view, minimal interventions, such as the CHCO intervention, do not complement or contribute to care-as-usual.5-10 In addition, changing health-related behavior is difficult. On the one hand, this could be explained by the assumption that it is difficult to change health-related behaviors that have been entrenched for a long period in older adults’ lives. On the other hand, changing behavior involves cultural and social changes that might take years, whereas most interventions are not carried out for several years and have a low-intensity program.11 This was also the case for the CHCO intervention, where older adults received up to 2-3 consultations in a year, and there was no clear follow-up.
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Finally, another explanation could be derived from our empirical findings, as described in Chapter 5, that reflected on treatment fidelity. Our study showed that MI was only implemented to a certain extent. Nurses did reach beginner proficiency levels but were not able to reach high-quality MI during the CHCO consultations. We could argue that not all consultations included conversations about what the older adults were especially concerned about, or what was really important for them. In addition, the focus of the CHCO intervention on health-related behavior and functional abilities may not have been in line with the focus that older adults have for themselves. Knowledge of what matters most to the participating older adults could have contributed to more tailored ‘advice.’ This could also have led to an improved understanding of the context of the older adults’ own experiences and possible goals related to, for example, health-related behaviors. To conclude this proposition, we could argue that stable change in health-related behavior in community-dwelling older adults, and stable change in MI practice behavior in nurses participating in the CHCO intervention, requires sustained and long-term monitoring and feedback to actually reach behavior change in both groups.12
Proposition 2
To older people, healthy living means staying active and engaged, physically, socially and mentally. Good health, as reported by older adults, coexists with a life with a chronic disease or high-risk factors. Older people highly value personal autonomy. Older people experience challenges in anticipating opportunities and limitations while aging.
Our second proposition about the perception of healthy living while aging shows that older adults’ own perception of health differs from the measured health indicators that researchers and health professionals tend to use. The quantitative data (Chapter 2) showed that at baseline and 1-year follow-up, the majority of the participating older adults who were in the CHCO intervention group scored their self-reported health status as “good”. This seems to be in line with our outcomes that showed that a substantial part of these older people are living with high risk factors such as hypertension or one or more chronic conditions. The sample of older adults that we interviewed in our qualitative studies also included older people who lived with one of more chronic conditions or were living with high risk factors (Chapters 3 and 4). The qualitative findings from that sample showed that
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when they talked about health, they mentioned staying active (including being physically, mentally, and socially active), being able to do things independently, and being able to adapt to new circumstances as subjective expressions of healthy living. Older adults appeared to have a holistic view on health, and perspectives on healthy living could vary between persons. From these findings, we might conclude that older people’s subjective perception of health may well be different from objective/clinical measurements of health that health professionals,
researchers, or policymakers use. This means that older adults who live with chronic diseases may still perceive themselves as healthy or successful since healthy or successful aging includes more than physical well-being and is also about social and psychological well-being.13
These findings relate to other studies investigating individual perceptions of concepts such as healthy aging and successful aging. While in research literature, there are often discussions about the differences between successful aging, aging well, active aging, and healthy aging, older people themselves describe interrelation between these concepts. For example, when asked about healthy living, older people talked about staying active (physically, mentally, and socially), and that could be contributed to one of the core components of the successful aging concept, namely, active engagement in life.14 This finding also relates to a study by Huijg et al.15 on the desires of older people, in which the majority of the respondents stated that they desire an active, engaged, and healthy life. Our second proposition also refers to personal autonomy (staying independent) and adaptation. Another qualitative study, generating knowledge on older people’s needs and preferences, reports that autonomy is a recurring theme.16 The results of this study show that older people prefer to keep a sense of control as they age and that this sense of control could be improved by allowing and enabling them to do the things they are still able to do.16
Lastly, our study’s finding reflects the challenges that older adults face in practicing healthy behavior because of the physical and social changes while aging. Therefore, they have to find ways to accept and adapt to new situations. Other researchers also noted the importance of adaptation, considering it an important concept for older adults while aging.15,17 These outcomes relate to the discussion about the conceptualization of health, in which researchers18,19 report
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on the idea that health includes “the ability to adapt and to self-manage” rather than a focus on complete physical, social, and mental well-being.20
Proposition 3
Older adults value reciprocity, trust, and a personal and positive approach, in which they stay autonomous while interacting with a nurse. Some experienced the CHCO intervention as a physical check-up and receiving general advice. Others felt they received personal support and tailored advice. A plan of action aiming for behavioral change or improved health was implemented only exceptionally.
Our first proposition states that the minimal CHCO intervention did not result in better health-related outcomes, nor did it stabilize care needs-related outcomes in community-dwelling older people with augmented risks of adverse health outcomes after the one-year follow-up. The third proposition, on which we will elaborate in this section, enhances our understanding of the “black box” of the CHCO intervention. The findings from the Chapters 3, 4, and 5 contribute to our knowledge on
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understanding the experiences and perceptions of older people participating in health promotion and disease prevention interventions;2.
understanding how the community health nurses implemented MI during the consultations for older adults.The qualitative findings from Chapters 3 and 4 showed that older adults prefer to talk about their health with health professionals they trust, and prefer to be treated as equal partners. Older adults indicated that they experienced the interaction with nurses as friendly and professional. In the interaction between the nurse and the older adult, certain skills and competencies such as listening, honesty, being supportive, and creating a positive atmosphere were highly appreciated. Not all older adults saw health or talking about their health as a priority; they prefer to sort things out for themselves and talk about other, more important things than their health. We found considerable variety in the experiences of participating older adults in the CHCO intervention concerning advice and decision-making processes. On the one hand, older adults experienced the intervention as a physical check-up, receiving general advice. On the other
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hand, some older adults felt that they had received tailored advice, felt a connection with the nurse, and perceived the consultations as personal support. Only a few older adults said they talked about their personal considerations and preferences during the decision-making process, or developed a shared goal or action plan to improve health-related behaviors during the consultations. The results of the study on the use of MI by nurses during the consultations as is reported in Chapter 5 support these qualitative findings. More specifically, in the MI study, we found a large variety in scores on the non-adherent statement of persuading. This indicates that some nurses gave advice without asking for permission, and others did ask permission before giving advice. Low frequencies of seeking collaboration and emphasizing autonomy were also found in the MI study. This supports the qualitative findings that a shared plan of action or goal was implemented during the consultations only in exceptional situations. Our third proposition builds on the second proposition of this dissertation. As described in the third proposition, we found again that older people preferred to stay autonomous, including in their interactions with nurses or other health professionals concerning health promotion and disease prevention interventions. Staying autonomous could also mean, that the extent to which older adults wish to participate in all decisions, may vary. The choice of an older adult to prefer to delegate certain decisions, is also a possibility. In that case, the question is how to solicit the older adults’ preferences in decision-making and tailor the consultations appropriately.21
We want to emphasize that reciprocity and trust are fundamental aspects for older adults in their interaction with nurses or other health care professionals.22-24 Other aspects that relate to a trusting relationship are personal attention, the feeling of being seen by the other as a unique person in a unique context.25 These values are in line with those of the person-centered approach, and have a central role in MI and shared decision-making if effectively delivered in health promotion and disease prevention interventions.26 Our study findings from the qualitative studies, as well as from the MI study, underline the conclusion of proposition 1, that it has proved difficult to implement effective elements of shared decision-making and MI, in practice, when feedback and supervision are not available to nurses with respect to gaining and improving MI and shared decision-making competencies.26
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Methodological considerations
We conducted a parallel mixed-method design concurrently, acknowledging the strengths of both qualitative and quantitative research.27 This enabled us to understand the existence and significance of the natural world (in which the interventions are carried out), together with the importance of the older adults’ personal experience.1 This, in turn, allowed us to study the CHCO intervention setting from various perspectives.27 The quantitative study offered insights into the measured concepts of health-related and care needs-related outcomes. In addition, a quantitative coding instrument to reflect on treatment fidelity of the nurse consultations was used: the MI Treatment Integrity 4.2.1 instrument. The qualitative studies gave participants the opportunity to share their experiences on the received intervention and to reflect on healthy living and healthy aging. The users’ experiences and views provide researchers and health care professionals with a deeper understanding of the complexities of behavior and the context of health promotion and disease prevention interventions.
A strength of our study was the multidisciplinary approach. Using mixed methods has facilitated a multidisciplinary team, in which a variety of researchers
(epidemiologist, psychologist, geriatric, gerontologist, health scientist) with a variety of methodological backgrounds and expertise, were part of the collection, analysis, and interpretation of the data of both the qualitative and quantitative studies.27 For analyzing qualitative data, the team approach is highly recommended to enhance the quality of the discussion and, therefore, contribute to the trustworthiness of the findings.28 Furthermore, in our striving for credibility, the researchers wrote observations and narrative reports related to each interview considering the participant’s context. The researchers also performed observations during the nurse and older adults consultations and wrote short reports after these observations.
However, some limitations and weaknesses are worth noticing. The findings of our qualitative studies showed the variety and richness of the narratives obtained during the interviews. However, we want to point out that the number of migrant participants in our sample was rather small. As a result, we were unable to report on cultural diversity issues that undoubtedly matter when asking about perceptions on healthy living, healthy aging, and about the nurse-client interaction. We did not distinguish between the oldest old and the young old
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either.29 In addition, we did not explicitly look at differences in social-economic status, or explore high or low levels of health literacy among the participants. Since we did not look into the specific viewpoints of these groups, we may need to take into consideration that personal views on health or views on the interaction with health professionals may differ from the views that we have reported in our study. In our quantitative design, we did not look into the group of older people who were lost in the follow-up, nor did we gather information on the older people who did not respond to the invitation to visit the consultation offices. Information on these groups could have added to our understanding of why they did not continue their participation in the intervention or what their reasons were for not participating at all. Lastly, with a view to understanding the elements of the CHCO intervention from diverse perspectives, we need to acknowledge that we did not report on the providers’ (nurses’) perspectives. Their views and experiences could add a broader understanding of the phenomena studied in this dissertation.
Recommendations
In primary care, the appropriate strategy for health promotion and disease prevention in community-dwelling older people with augmented risks of adverse health outcomes would be the adoption of health-related behavior.4 However, the findings of our thesis show that implementing effective interventions to improve health-related and care needs-related outcomes in community-dwelling older people remains challenging.
Our first recommendation involves both practice and research. Although interventions that are developed in practice are valuable, we argue that these interventions should always be evaluated and monitored when implemented, using a variety of research methods. We argue that professionals working in practice, and researchers, should work together on the design, monitoring, and evaluation of interventions. In this process, adjustments can be made to improve the working of the intervention. Equally importantly, we argue that the involvement of (pre-frail) community-dwelling older adults is essential in the design, implementation, and evaluation of disease prevention and health promotion interventions. This could imply that the interventions are developed in co-creation with older adults.5,30 Their involvement should have an impact
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on the intervention development and could, therefore, lead to changes in the intervention design and lead to an intervention that is more acceptable and relevant to older adults themselves.
Following this, we provide further specific recommendations for nursing practice, nursing education, future research, and policy. Where we write about nurses, our recommendation might also be valuable or relevant to other health professionals (e.g., social workers, nutritionists, geriatricians) who carry out health promotion and disease prevention interventions for community-dwelling older adults. Recommendations for practice
The findings presented in this dissertation show that health promotion and disease prevention interventions do not always match older people’s perspectives and experiences concerning the received interventions or their personal
views on healthy aging. There are various recommendations to improve these interventions toward better-tailored health promotion and disease prevention interventions for community-dwelling older people.
1.
We recommend that health promotion and disease prevention interventions should be embedded in or solidly connected to medical care systems using geriatric care models. In this way, interventions could be combined, and collaboration with other health professionals (e.g., general practitioner, geriatrician) is highly recommended.31 Especially in primary care, nurses should know their professional network, work collaboratively with General Practitioners in order to refer older adults appropriately. In this way, the long-term monitoring of older adults with augmented risks on adverse health outcomes and efforts to enhance their health is more likely to be secured.2.
Nurses should focus on building an equal relationship of trust. Older people should be approached as experts, or equal partners, in the consultation. Older adults are experts of their medical, social, and life history. This knowledge is important, and interventions should offer a stage for exchanging knowledge and experiences between older adults and nurses.32 To apply this in practice, we would refer to the tables of Van de Pol and Van Iersel33 on improving communication with older adults, and for executing medical, social, and life history.156
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Nurses need to remain open to and be aware of older adults’ uniqueexperiences and holistic perspectives about healthy living, healthy aging, and their ideas about interacting on these themes with diverse professionals. This is important since older adults’ experiences and views appear to influence to what extent older adults are willing and able to change health-related behavior when needed. To find out what is still important for older adults, nurses could ask questions to elicit their current wishes. Nurses could ask, for example: “What matters most to you when you think about your health?”34 or:
“What kind of activities are pleasurable for you?”35 It might also be important to elicit current concerns by asking: “What is bothering you most?”33
Recommendations for education and training:
Our recommendations for education and training are in line with the Bachelor of Nursing 2020 in the Netherlands, in which the CanMEDS roles of the Communicator, Collaborator, and Health Advocate are well described.36 More specifically, in this section, we want to emphasize elements that should receive more attention in training and education for nursing practice.
Our findings show that older adults have unique views on health and healthy aging. It is therefore valuable for bachelor students to adopt an open attitude toward the various experiences and perspectives that older adults have on health. The experiences and views of young students might be around 70 years apart from an older adult of 90, who has lived in a completely different time. It would certainly be helpful if students took time to understand and be interested in the stories of older adults about their lives, and what matters to them, in order to grow in empathy. Also, as described earlier, nurses should work collaboratively with other professionals to support older adults as they age. Nurses need interprofessional education in which they learn to share responsibilities with other professionals and efficiently take part in integrated and well-coordinated care for older adults.37
Our findings showed that a single workshop was not enough to achieve a stable change in MI practice behavior in nurses. This is in line with former studies showing similar conclusions that learning MI skills takes more intensive practice and supervision.38-42 MI techniques, such as evoking (eliciting the older adult’s own motivations) to reveal important issues during a consultation, could help
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nurses in supporting older people in healthy aging. MI training for nurses or students should also emphasize partnership (establishing an equal relationship) and evoking. Furthermore, the use of MI-adherent behavior skills, such as persuading with permission, seeking collaboration, affirmation, and using complex reflections, are highly recommended to provide tailored consultations. Since our study shows that, in practice, only a few nurses used concrete planning (formulating a specific plan of action), we would argue that teaching how to formulate a (shared) plan of action or goals deserves more attention. How could nurses be supported in effective skill acquisition, and improve practice proficiency? We would emphasize that (care) organizations should be aware of their responsibility to provide a supportive environment for nurses to acquire good MI skills. Therefore, nurses should be provided with the right materials, methods, training, and supervision to reach good levels of MI. To be specific, in order to acquire MI skills, supervision and feedback should be based on direct observation of nurses’ behavior during MI consultations.12,43 Coding audio-recorded or video-recorded work samples with the MITI can facilitate personalized coaching and feedback since nurses/students have individual learning curves.44 In this way, nurses can set personal learning goals, which will improve practice proficiency.12 Such coding takes much time but is especially important to improve skills and improve the quality of interventions that are meant to provide MI.12
Recommendations for future research
As our findings indicate, perspectives on health are diverse and not always the same as the outcome measures that researchers use. For example, a study on pro-active, integrated care for community-dwelling frail older people in the Netherlands found that the intervention was not beneficial in terms of health outcomes and functional abilities, but did have a positive effect on older people’s quality of life in terms of love and friendship.6 Therefore, as researchers, we should reflect on relevant outcomes and include older people in this process. What are relevant outcome measures for older adults with augmented risks of adverse health outcomes? On a broader scale, older adults should be asked what they consider to be elements that work or do not work while participating in health promotion and disease prevention interventions. Developing further qualitative research to deepen our understanding of these subjects is highly recommended, to find what research outcomes are relevant for older people
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themselves. Other research methods such as participative research or action research are also needed to involve older people in intervention design, monitoring, and evaluation.45,46
Another important issue is whether culture, age, gender, and socio-economic status influence older peoples’ perspectives on healthy aging and influence their (felt) experiences with nurse-led health promotion and disease prevention interventions (for example, in MI). Qualitative research is needed to better understand the role of culture (especially of non-western migrants), what views and experiences older people have concerning healthy aging, and how older people with different cultural backgrounds experience the interaction in health promotion and disease prevention interventions. This is also true for older people with a lower socio-economic status. It could well be that older people who have a low socio-economic status experience stressors, or matters that they are concerned about and that they do not feel they have the ability or space to reflect or even act upon their lifestyle.47,48 These interventions should not focus on health-related behavior per se but also on the social network and on improving autonomy.
In our research, we did not examine the role of age either (the young old, or the oldest old) or look specifically at gender issues. We recommend further qualitative research to deepen our understanding of the age-specific and gender-specific issues and to add these findings to the body of knowledge on what elements work or do not work when older people from various backgrounds participate in health promotion and disease prevention interventions. Next, research on the perspectives and experiences of nurses who provide health promotion and disease preventive interventions for community-dwelling older people with risks of adverse health outcomes could contribute to our understanding of the phenomena that have been studied in this dissertation. Possible research questions include: What are possible barriers that nurses experience in practice when providing health promotion and disease prevention interventions? What do they consider successful elements for health promotion interventions?
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Recommendations for policy
Promoting healthy aging for older adults should be an important topic on the (inter)national agenda of policymakers.49 We want to mention that health promotion and disease prevention intervention for older adults would be more successful if integrated into an age-friendly society. Since health is determined by various factors (e.g., economic, social, environmental, and behavioral), policy to improve healthy living in older adults should include interventions in all these domains. Furthermore, health promotion and disease prevention interventions are needed across the life course31,50 since this approach is most likely to
compress morbidity, lower health care costs and lower care needs in the future.51
Concluding remarks
This study contributed to the existing body of knowledge on whether or not components of health promotion and disease prevention interventions targeting community-dwelling older adults with augmented risks of adverse health outcomes work. Improving health-related or stabilizing care needs-related outcomes in community-dwelling older adults requires more than a minimal intervention. Sustained and long-term monitoring in a multidisciplinary setting is needed to actually improve health-related and care needs outcomes in older adults. This is also true for providers of health promotion and disease prevention intervention; they need more training and long-term supervision and coaching to achieve effective (MI) skills and competences. In addition, we described the personal views and experiences of community-dwelling older adults regarding healthy aging and their participation in these interventions. This knowledge that the various and unique perceptions of healthy aging of older adults are an important starting point for the design of new health promotion programs is an important point.
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