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HOPE AND THE ELDERLY INDIVIDUAL: -

CLINICAL ASSESSMENT AND HOPE FOSTERING ~__' “  ' 
STRATEGIES FOR THE ADVANCED PRACTICE NDRSE;

IN PRIMARY CARE

Scholariy ProjeCt for the Degree DfM S N .
MICHIGAN STATE UNIVERSITY “ .

KATHRYN CHAT. _
.1998 <7 '

 

 

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HOPE AND THE ELDERLY INDIVIDUAL:
CLINICAL ASSESSMENT AND HOPE FOSTERING STRATEGIES
FOR THE ADVANCED PRACTICE NURSE IN PRIMARY CARE

BY
Kathryn Gray

A SCHOLARLY PROJECT
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING

College of Nursing

1998

ABSTRACT
HOPE AND THE ELDERLY INDIVIDUAL:

CLINICAL ASSESSMENT AND HOPE FOSTERING STRATEGIES
FOR THE ADVANCED PRACTICE NURSE IN PRIMARY CARE

BY

Kathryn Gray

Hope has been described as a basic human need essential
for life. Hope as a concept specific to elderly individuals
is unique from hope experienced by others since expectations
for the future are less certain. Literature references the
obligation of nurses to instill, maintain and restore hope
to their patients. This responsibility requires that nurses
understand the essence of hope, recognize the observable
manifestations of hope and possess the resources to provide
interventions to guide hope for the elderly individual.

Hope assessment used by the Advanced Practice Nurse in
primary care is a means of evaluating quality of life of an
elderly individual. Quality of life equates a maximized
mind-body-spirit health potential for the elderly
individual.

The APN will strengthen hope for the elderly individual
by possessing knowledge of the multidimensional aspects of
hope, by using formulated questions designed to assess for
the presence of hope and by choosing strategies to
facilitate that hOpe. The APN can then enable the elderly

individual to mobilize hope for personally meaningful future

fulfillment.

“Hope” is the thing with feathers
that perches in the soul
and sings the song
without the words
and never stops
at all.

E. Dickinson

iii

ACKNOWLEDGMENTS

I would like to thank God for helping me to know hope.
I would like to thank my family for helping me accept hope.
I would like to thank my friends for fostering my hope. I
would like to thank my committee for helping me to write of

hope, especially Linda Keilman who always offered hope.

iv

LIST OF TABLES . . .

LIST OF FIGURES . . .

TABLE OF CONTENTS

INTRODUCTION . . . . . . . . . . . . . . . . . . . . .
The Problem . . . . . . . . . . . . . . . . . . . . . .
Problem Statement . . . . . . . . . . . . . . . .
Purpose 0 O O O O O O 0 I O O O O O O O O O O O 0
Definitions and Description of Term . . . . . .

Conceptual Framework . . . .

Review of

Hope Asses

Hope Assessment . . .

Conclusion
Evalu
Impli
Refle

LIST OF REFERENCES

Literature

sment and Strategic Interventions . .
Interpretive Questions for Assessment
Four Questions for Assessing Hope . .
Hope Fostering Strategies . . . . . .
HeHealth, the Experiential Process . .
O=Others, the Relational Process . . . . . .
P-Purpose, Spiritual Transcendence Process

E=Engagement, the Cognitive Process and GRACT

ation .
cations
ction . .

vii

p

NODQNH

44
44
48
54
54
55
59
62
63

68
68
7O
71

73

LI ST OF TABLES

Table 1: Chronology of Hope Studies Showing Application
and Attributes Used . . . . . . . . . . . . . . 25

Table 2: Hope: Assessments and Interventions . . . . . . 56

vi

Figure
Figure

Figure

Figure

LIST OF FIGURES

Watson's Model of Transpersonal Caring .

Adaptation of Watson's Model Showing the APN
and the Elderly Individual in Primary Care

Adaptation of Watson's Model and the HOPE
Framework . . . .

Adaptation of Watson's HOPE/GRACT Framework .

vii

15

17

21

24

INTRODUCTION

The_2rnblem

“Hope springs eternal.” “Where there is life, there is
hope.” Old proverbs, personal experience, philosophical and
theological references and current research studies of the
concept of hope lead one to believe that hope is a basic
human response essential to life (Stephenson, 1991). Hope

is associated with the meaning of life, “for we are saved by

hope,” Paul wrote in Romans 8:24, (Good News Bible [TEV].

1976, p. 210).

Hope is an accepted component of nursing care.
Obligations of the Advanced Practice Nurse (APN) are
frequently outlined in terms of instilling, maintaining and
restoring hope (McGee, 1984). Stephenson (1992) believes
that fostering hope is one aspect of the professional
nurse's role. Beginning with the writings of Florence
Nightingale (1859), many references describe the importance
of nurses understanding the concept of hope in their
patients. Watson (1979) has identified hope as both a
“curative and carativef force within the nursing process.
.Hope is considered to have therapeutic effects upon patient
outcomes and nurses are said to positively effect the hope

levels of their patients (Hinds, 1989).

1

2

The therapeutic value of hope has been implicated
across a broad spectrum of health related issues as a factor
in accepting illness-related infirmities such as cancer
coping strategies and regaining health during recovery in
spinal cord rehabilitation or substance abuse (McGee, 1984;
Dufault & Martocchio, 1985). Unfortunately, very few
authors have chosen to focus on the influence of hope for
the elderly individual. Currently, most studies on the
concept of hope have been based on adults of middle-age or
the young (Herth, 1993).

Clinical observations and patient care experiences
influence the belief that the concept of hope is an
essential component in caring for older adults, but the
empirical knowledge base about how to actually promote hope
in elderly individuals remains elusive (Farran & Popovich,
1990). With the population of persons over 65 increasing
dramatically, it is imperative that APNs, and other health
care professionals, understand the concept of hope in order
to assess an individual's hope status and to create an
environment of hopefulness for the elderly. Quality of life
is diminished when there is loss of hope combined with
narrowing of goals and expectations for life (Herth, 1993).
Problem.§tatement

Hope is an ill-defined concept. At best it is a
simple, universally understood human phenomenon. At worst,
it is “soft” and abstract, ethereal and difficult to

measure. The North American Nursing Diagnosis Association

3
(NANDA), (1992) delineates hopelessness as a nursing
diagnosis, but not hope. Studies do not exist which agree
on a definition of the concept of hope nor do studies
reflect a broadly accepted criterion instrument measure of
hope.

The APN may not consider hope as a quality of life
parameter nor possess a baseline of knowledge to recognize
the attributes of hope in the elderly individual.
Recognizing the observable manifestations of hope and
assessing for the presence of hopefulness is important for
the APN to plan interventions for instilling, maintaining
and restoring hope to the elderly individual. To avoid
hopelessness, to promote successful aging and optimize
quality of life for the elderly individual, the APN must be
able to intervene with strategies to promote hope.

Many nurse clinicians and researchers respect the
importance of hope in quality of life issues, yet a clinical
basis for evaluating hope of the elderly individual is
almost non-existent. Defining hope in relation to a future
of goal achievement, personal success and control may be
unrealistic to a generation of persons experiencing loss,
health problems and a decreasing ability to care for
themselves. Therefore, the problem of defining the concept
of hope is further complicated by the perspective of age.
Farran, Salloway and Clark (1990) suggest that for the older
adult, hope has a different meaning than for those of a

younger age strata. Older individuals may need to rely on

4
different methods and strategies for maintaining or
regaining hope.

Because elderly individuals are unique in hope
perspectives, the APN must possess a broad knowledge along
the continuum from hope to hopelessness. The presence of
hopelessness indicates that there is something awry
perceptually; that needs or goals have not been met, that
life or situations have become difficult or intolerable to
the elderly individual (Farran & Popovich, 1990).
Consequences of the absence of hope have been repeatedly
demonstrated in psychiatric research, associating
hopelessness with discouragement, despair, helplessness,
depression and suicide (Farran & Popovich, 1990). The APN
is challenged to recognize a negative expectancy of the
future and to intervene in ways that assist the elderly
individual to move through hopelessness toward hope.

The importance of quality of life health, inclusive of
mind-body-spirit is embraced by nursing. Farran & Popovich
(1990) suggest that hope can be maintained or regained for
the elderly individual when physical, psychological and
spiritual aspects of life are addressed. According to
Watson (1988), instillation of faith and hope does
facilitate the promotion of wholistic nursing care. The
relationship between the APN and the elderly individual
promotes hope through caring, a complex process with

potential for maximizing quality of life through finding

5

meaning in one's own existence and discovering inner power
and transcendence for self-healing (Watson, 1988).

The APN must appreciate the impact they themselves have
upon the perception of hope of their elderly clients.
During the patient-caregiver relationship» “the hopefulness
or hopelessness of either the patient or the caregiver
affects the other in the relationship," (Raleigh, 1992, p.
444). The therapeutic value of the APN as a source of hope
is not usually emphasized, however family, friends, God and
health care professionals are the most frequently identified
sources of hope (Herth, 1993). “The reality for some
isolated older persons is that professionals are the main
source of social support," (Farran & Popovich, 1990. p.127).
Recognition of this relationship component should heighten
awareness for’the APN of the responsibility inherent in
nurturing the elderly individual's perception of hope.

Statistics compiled by the American Association of

Retired Persons (AARP) reveal that the population of
individuals 65 years of age and greater, numbered 33 million
in 1994 and will more than double to 70.2 million by 2030
(Fowles, 1995). The older population itself is getting
older. The 65-74 age group was eight times larger than in
1900, but the 75-84 group was 14 times larger and the 85 and
older group was 28 times larger in 1994. Individuals live
longer and healthier which in turn reflect collectively more

life experiences, more intrusion of change, more potential

6

for loss and grief or more opportunity for growth through
the hope of personally meaningful future fulfillment.

Statistically, individuals over age 65 represent 12% of
the population and incurred 36% of the total health care
expenditures equaling over $162 billion (Fowles, 1995).
Less than 5% of the elderly are in nursing care facilities
or other institutional settings (Eliopoulis, 1990). This
means that the majority of older individuals will live out
their lives in the community. Many of these persons have at
least one and many have multiple medical conditions. Needs
that may arise for the elderly individual will be in the
areas of prevention, self-care education, support and
restoration for chronic problems. The needs are all within
the realm of the APN in primary care (Eliopoulis, 1990).

Elderly individuals striving for health of mind-body-
spirit and APNs who strive to assist them achieve optimum
quality of life need common parameters to appreciate the
importance of hope as a carative and curative factor. It is
essential that the concept of hope be understood and that
strategies be recognized and encouraged which may help the
older adult to maintain, instill or restore hope. If
clinical indicators are outlined for the professional
provider and hope fostering strategies are offered to the
elderly individual which contribute to the optimism of hope,
then the APN can utilize the opportunity to offer guidance
towards attainment of health and well-being of an ever-

growing, aging population.

7

“Nursing is accountable for managing the response to
actual or potential health problems, and hope is one
potential response," (McGee, 1984, p.43). Understanding the
importance of hope to the quality of life of the elderly
individual will enable the APN to identify specific
intervention strategies to instill, maintain or restore
hope. The APN can then act as a catalyst to create internal
and external conditions which foster hope, to develop and
promote hope resources and to minimize hope inhibitors.
Purpose

The purpose of this project is threefold: 1) to inform
the Advanced Practice Nurse (APN) about the
multidimensionality concept of hope as it applies to the
elderly individual; 2) to offer specific hope-assessment
questions to be used as guidelines during the psycho-social
history interview with an elderly individual to determine
the presence of hope during a primary care occasion; ad 3)
to identify hope fostering strategies which assist the APN
in selecting appropriate interventions to mobilize, support
and enhance hope for the elderly individual.

Hope is a health care parameter which can serve as a
basis for establishing quality of life dimensions. The more
clearly the APN in primary care conceptualizes hope, the
'more definitive the applications for fostering hope in the
care of the elderly individual. Assessment data on the
individual's perception of hope serves as a foundation for

estimating general well-being and optimum quality of life.

8
Interventions can then be designed to strengthen the hoping
process without giving unrealistic reassurance.

Specifically, four (4) questions were developed to be
asked of the elderly individual during the subjective
psycho-social history interview by the APN in a primary care
setting. These questions will be established as
representative assessment indicators of hope in the elderly
individual. These questions can serve as guidelines
allowing the APN to evaluate the presence of hope in the
elderly individual and, strengthened by guideline criterion,
prepare the APN to offer viable strategies to instill,
maintain and restore hope specific to the quality of life
needs of the elderly individual.

The APN in primary care is in a unique position to
positively impact quality of life for the elderly individual
and to encompass the wholistic health approach of mind-body-
spirit wellness. According to Watson, (1988), this reflects
the true essence of nursing.

E E' 'I' i . l' E I

“Hope" is derived from the Latin root speare, meaning

“to hope," (Webster, 1978). It is used as both a noun and a

verb. As a noun, hope is defined as (1) a feeling that what
one desires will happen; (2) the thing hoped for; (3) a
cause of hope, a person or thing that gives hope to others
or that others have hope in; (4) the ground for expecting
something/promise,” (Stephenson, 1991, p.1457). When used

as a verb, hope is defined as “trust, reliance, desire

9
accompanied by expectation or belief in fulfillment,
(Stephenson, 1991, p.1457).

Contextual usage of the word hope appears in literature
from theology, philosophy, psychology, psychiatry and
nursing. Hope is discussed as a theory, as a human
dimension necessary for progressive development and as a
source of meaning for existence. Implicit to the concept of
hope are two conditions: 1) the desire for some good and, 2)
the ability to look to the future with expectation (McGee,
1984).

Hope is considered an active process involving the
interaction of a person's thoughts, feelings, actions and
relationships. The cognitive component involves visualizing
a future that does not yet exist and the calculation of
outcome probabilities which provide grounding for the state
of hope (Dufault & Martocchio, 1985). Emotions associated
with hope reflect the state of feeling positive or feeling
‘good,' uplifted, inspired or nurtured. Hope is associated
with the “feeling of confidence diluted by a degree of
uncertainty,” (Stephenson, 1991, p.1458).

The behavioral aspects of hope are reflected in the
ability of hope to lead to self efficacy; the greater the
perceived expectation of goal attainment, the more likely
the individual is to achieve a goal (Stephenson, 1991).

This implies that hope is a prerequisite to effective coping
and adaptation behaviors. The resource relationship

component of hope stresses the belief that help is available

10
to the individual from God, from other people or from other
living entities (Dufault & Martocchio, 1985). Hope reflects
an internal sense that assistance exists and allows the
individual to move from a position of self-reliance toward
that of support seeking from another source.

Dufault and Martocchio (1985), conceptualized hope as
having two spheres of abstraction, the focus of hope being
either a generalized or a particularized object or outcome.
Generalized hope is the sense of a beneficial future, broad
in perspective and not linked to any specific concrete goal.
“Generalized hope protects against despair...and preserves
the meaningfulness of life...like an intangible
umbrella...that protects by casting a positive glow on
life," (Dufault & Martocchio, 1985, p.380).

In contrast, particularized hope is directed toward a
specific valued outcome or hope object. These objects of
hope may be abstract or concrete, explicitly stated or
merely implied (Dufault & Martocchio, 1985).

Characteristics of particularized hope include the
expectations that present circumstances can be improved
upon, desired expectations are attainable; that desired
circumstances will occur and what is currently valued in the
present can also be part of the future. The person
experiencing a particularized hope believes that unfavorable
possibilities will not occur, (Dufault & Martocchio, 1985).
For the operationalization of this project, the

definition of hope used was Stephenson's (1991): “Hope is a

ll
process of anticipation that involves the interaction of
thinking, acting, feeling and relating and is directed
toward a future fulfillment that is personally meaningful,”
(Stephenson, 1991, p.1457). This conceptual definition of
hope encompasses the attributes of hope for health of mind-
body-spirit and is generalizable to the unique needs of the
elderly individual for personal fulfillment without the
particularized restriction of specific goal achievement or
time orientation.

Quality of life is an attribute of health reflected by
optimum wellness of mind, body and spirit and is considered
in this project as distinct from quantity of life. Hope is
positively correlated with quality of life (Frankl, 1959;
Miller & Powers, 1988). Quality of life results in enhanced
physical, mental, and spiritual functioning and is vital for
promoting health and healing (Farran, Herth, & Popovich,
1985).

Elderly individuals are identified as those individuals
over 65 years of age and cognitively oriented. For the
purposes of this project, it is assumed that elderly
individuals have experienced changes in their health, self-
concepts or roles to render them susceptible to alterations
in levels of hope (Herth, 1990).

Primary care is defined as care that a client receives
when initially approaching the health care system and
maintained throughout the continuum of care (Flynn &

Heffron, 1988). Diagnosis and treatment of illnesses and

12
injuries, prevention of illness plus health promotion,
maintenance and management of health are responsibilities
of the APN. The APN as primary care provider functions as
client advocate with an emphasis on wellness. The
responsibilities of the APN in primary care include
assessment, planning and evaluation of family and clients'
abilities to cope, adjust and adapt (Given, 1996). APN
responsibilities encompass the need to assess for the
presence of hope, intervene to instill, maintain and restore
hope and evaluate the outcome of these hope strategies.

Clinical indicators are considered those assessment
guidelines by which an APN in primary care can find
direction for making a judgment or decision toward a course
of action during the assessment of hope. Hope fostering
strategies are those plans and directions advantageous in
facilitating the desired outcome of hope for the elderly
client.

These definitions are utilized to show that hope is an
essential quality of life parameter for the elderly
individual. The APN in primary care possesses the ability
to assess for the presence of hope in the elderly individual
and can instill, maintain and restore hope through strategic
interventions during a transpersonal caring occasion.
Wm);

Nurses care for persons inclusively of mind, body and
spirit. The concept of hope is explored as it occurs during

interactions in the primary care setting between the APN and

13
the elderly client. The importance of such a “caring
occasion? is emphasized utilizing the theory framework of
Jean Watson (1988).

Using the framework of Watson is helpful for the study
of hope since the philosophy of Human Science and Human Care
(1988) delineates hope as a nursing care guideline.

Watson's metaphysical theory requires the professional nurse
to work with persons in achieving a higher degree of harmony
within the mind, body, and soul by offering hope through
caring responsiveness to another's feelings and problems.
Watson (1988) places emphasis on the importance of hope as
caring component #2 within the ten ‘Carative Factor'
guidelines:

1. Forming and acting from a humanistic-altruistic system
of values

2. Enabling and sustaining faith-hope

3. Sensitivity to self and others

4. Helping-trusting human care relationship

5. Acceptance of expression of positive and negative
feelings

6. Systematic, creative problem-solving caring process

7. Transpersonal teaching-learning

8. Provision for a supportive, protective and/or

corrective mental, physical, sociocultural and
spiritual environment

9. Assistance with gratification of human needs

10. Allowing for existential-phenomenological and spiritual
dimensions of caring and healing

14

These carative factors are actualized during any
person-to-person contact as the APN participates with and
cares for the elderly individual, regardless of the type or
intensity of contact. The ‘transpersonal caring' model is
the basic principle of Watson's philosophy. The caring-
healing consciousness-experience between the APN and the
patient is a phenomenological experience contained within a
single caring moment when hope is maintained. Watson labels
this moment, “the actual caring occasion,” (Figure 1).

Watson (1988) states that the nurturing of faith and
hope facilitates the promotion of wholistic nursing care
through encouragement of an increased desire for wellness
and through promotion of positive healthcare behaviors. The
assumption follows that the APN can have a positive
influence in the manifestation of hope of the elderly client
during an actual caring occasion. The ultimate goal of the
APN is to identify “an optimal or motivational level of
hope,” and to augment physical, mental and spiritual coping
mechanisms (McGee, 1984, p.34).

This readily fits into the paradigm of Watson's theory
framework. From the causal past, the APN brings personal
experience of hope, knowledge of the concept of hope,
experience in assessing the person's level of hope, and
guidelines for instilling, maintaining and restoring hope to
the primary care setting. The elderly individual brings his
or her perceptions of the probability of achieving a given

outcome, which may range from hopefulness to hopelessness to

15

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16
the phenomenological field in the present moment. Then
together, during the actual caring occasion, the ‘self'
elderly individual and the ‘self' APN relate their
individual phenomenological fields through a discussion of
hope directed toward a future fulfillment that is personally
meaningful (Figure 2).

To place the concept of hope within Watson's model
inclusive of mind-body-spirit orientation, it is important
to understand the multidimensionality of hope as described
by such researchers as Dufault & Martocchio (1985). These
dimensions include recognition of hope as having separate
levels of cognitive and behavioral functioning, temporal
perception and relational perspectives to self, to others,
to the environment and to spirituality.

For the purposes of this project, the guiding framework
for assessment of hope for the elderly individual is based
upon the work of Farran, Herth, and Popovich, (1995) and
will be synthesized into the design model of Watson (1988).
This framework provides a helpful acronym, H-O-P-E. Each
letter of the acronym incorporates one of four central
attributes of hope synthesized from Dufault and Martocchio
(1985), to encompass the multidimensionality of the concept.

H- Health (the experiential process)

O= Other (the relational process)

P= Purpose (the spiritual/ transcendence process)

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Engaging Process (cognitive process)

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The H? in the HOPE acronym represents health. During
the caring occasion, the APN determines the older clients'
general health, taking into account the chief complaint, the
history of present illness and chronic conditions which
affect their physical and mental health. It is also
necessary to determine the patients' perceived state of
health or wellness, since the elderly individuals'
perception of health challenges their hope structures
(Farran, Herth, & Popovich, 1995). In other words, the
perceived state of the older clients' health will affect how
the individual experiences hope. Hr representing health
equates with the experiential component of the four
attributes.

The NY of the acronym framework represents othensi
The importance that others play in the maintenance of hope
is well supported in the literature (Dufault & Martocchio,
1985; Herth, 1989; 1992; 1993; Hinds, 1984; Leetun, 1996;
Miller, 1989; Raleigh, 1992; Stoner & Keampfer, 1985). It
is important for the APN to determine the connectedness of
the elderly individual to family, friends and community, and
to determine if the relationships are positive. The actual
and perceived state of the elderly individual's
relationships will affect how they experience hope. The NY
representing others relates to the relational component of
the four attributes.

The H? from the acronym designates purpose (Farran,

Herth, & Popovich, 1995). Meaning or purpose in life

19

relates to the transcendent aspects of spiritual or
religious beliefs. Faith and/or meaning in life are
regularly mentioned as sources of hope in research studies
(Farran, Herth, & Popovich, 1995; Herth, 1990; 1991; 1993;
Hinds, 1984; Miller, 1989). Assessment of purpose in life
for the elderly individual involves recognizing their source
of hope for spiritual reflection. Transcendent spiritual
consciousness for elderly individuals involves getting to
know parts of their lives that are unseen, delving inward
amidst a deepening connectedness with nature, God or a
Higher power (Leetun, 1996). The perceived state of the
older clients' spirituality will affect how the individual
experiences hope. The H” of purpose represents the
spiritual transcendence component of the four attributes.

H? in the HOPE acronym represents engagement and the
cognitive thought process (Farran, Herth, & Popovich, 1995).
Rational thought processing involves goal formulation and
outcome probability testing necessary for the elderly
individual to maintain hope. It also encompasses the
cognitive strategies such as affirmation, positive memory
recall, and hopeful visualization. Lightheartedness and the
use of humor are powerful cognitive strategies that can be
utilized if hope should vacillate or falter, or if goals
need to be refined or refocused (Gaskins & Forte, 1985;
Herth, 1990; 1993; Leetun, 1996; Miller & Power, 1988).
Goal perception and the use of these other cognitive

engagement strategies must be evaluated by the APN while

20
assessing the cognitive engagement process of the four
attributes (Figure 3).

The framework enables the APN to quickly assess the
presence of hope in a clinical setting during an actual
caring occasion. The HOPE acronym also allows the APN to
differentiate between the dimensions of mind-body-spirit
which may or may not be concurrent.

To facilitate the comprehensive assessment of the
cognitive dimensions, Farran, Herth, and Popovich (1995)
suggests a HOPE companion acronym: GRACT. This acronym
helps the APN to remember assessment of the elements of the
cognitive engagement process of HOPE, including the older
individuals' perception of goals, his/her resources, action
potential, and perception of control and of time.

G = Goal. Cognitive goal outcome or goal object
identification and the probability of achievement of those
goals includes priority setting among various goals,
flexibility of those goals and establishing that goals are
reality-based.

R = Resources. Both internal and external resources
possessed by the elderly client must be assessed. Internal
resources include personal attributes of courage,
determination and optimism plus knowledge and use of
cognitive strategies such as humor and positive self-talk.
An internal resource necessary for assessment of the elderly
is the level of energy and attention span. External

resources to consider for assessment include the

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22
availability and usefulness of support systems, both human
and material. It is also important to determine the elder
clients' willingness to utilize assistance that may be
available.

A = Action. Hope involves action (Farran, Herth, &
Popovich, 1995). This is in sharp contrast to hopelessness
which by definition is absence of activity toward a goal
(NANDA, 1992). It is important for the APN to assess the
elderly clients' initiation of activity towards achieving
the goal.

C = Control. The sense of control that the elderly
individual perceives has been implicated by several authors
as important to the maintenance of hope (Miller, 1988;
Nowotny, 1989). During assessment of control, the APN must
evaluate the individual's need for control, what specific
areas of control are desired and whether that desire for
control is realistic.

T = Time. Temporal orientation and the definition of
time must be assessed to determine whether hope for the
elderly individual is based on the past, present or future.
Past experiences are suggested by researchers as the basis
for confronting present and future experiences (Dufault &
Martocchio, 1985; Farran, Herth, & Popovich, 1995; Herth,
1993; Miller, 1989). The APN must be aware that time
passage to an aging individual is not necessarily minutes,
days or years, but may be in relation to activities

completed, events anticipated or the “eternal” future.

23

Using specific knowledge of the HOPE acronym for
assessment presence of the four attributes of hope and
remembering GRACT to more specifically assess cognitive
hope, the APN will enter the actual caring occasion with the
elderly individual in the primary care setting. From the
causal past, the APN brings personal experience of hope,
knowledge of the concept of hope, experience in assessing
the person's level of hope, and guidelines for instilling,
maintaining and restoring hope. The elderly individual
brings his or her perceptions of hopefulness or hopelessness
regarding a given outcome. Together, during the actual
caring occasion transpersonal relationship, the elderly
individual and the APN relate their individual
phenomenological fields through a discussion of hope
directed toward a future fulfillment that is personally
meaningful (Figure 4).

Review of Literature

The objective of this literature review is to provide a
synopsis of the research studying the concept of hope, the
meaning and definition of hope, the assessment of hope and
how assessment of hope relates to the elderly individual.
The hope research described in Table 1 includes the
population, the applications of hope for the particular
study and identifies hope attributes described.

A thorough review of the literature reveals no studies

relative to hope and the elderly individual in the primary

24

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25

 

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27
care setting. Similarly, there is a lack of research
regarding the assessment of hope by the APN. The literature
does reveal unanimous concurrence that nurses can impact the
concept of hope in their patients (Dufault & Martocchio,
1985; Farran, Herth, & Popovich, 1995; Gaskins & Forte,
1985; Herth, 1992; Raleigh, 1992; Stephenson, 1992; Watson,
1988;). Literature claims that the effects of hope
positively impact patient outcomes (Hinds, 1984). The
difficulty in substantiation of these assertions prior to
1985 was the lack of a therapeutic definition for hope.
Until the concept of hope was defined, it was not possible
to measure the presence of hope in a clinical setting.

For the purposes of this project, hope is defined as a
process of anticipation involving the interaction of
thinking, acting, feeling and relating directed toward a
personally meaningful future fulfillment (Stephenson, 1991).
This multidimensional definition assumes four central.
attributes of the concept: 1) that hope is an experiential
process; 2) that hope is a rational thought process; 3) that
hope is a relational process; and 4) that hope is a
spiritual transcendent process (Farran, Herth, & Popovich,
1995). How the definition of hope developed as researchers
probed the role that hope plays in affecting the human
condition will be presented. A chronological progression of
hope research branches into both qualitative and
quantitative methods as multidimensional definitions of h0pe

evolve. With inclusion of multidimensional attributes, hope

28
research more clearly embodied Watson's theory of mind-body-
spirit wellness and became clinically more pertinent to the
APN in primary care.

Hope research has been accomplished by sociologists,
psychologists, physicians and nurses. Much of it has been
conducted with psychiatric populations and focused on
hopelessness (Ferran, Herth, & Popovich, 1995). Many
standardized psychometric instruments have been developed to
explore constructs using physical and psychological
variables (Beck, Weisman, Lester, & Trexler, 1974; Farran &
McCann, 1989; Farran & Popovich, 1990; Greene, 1989; Miller
& Powers, 1988; Stoner & Keampfer, 1985). Qualitative
exploration has been done almost exclusively by nursing
(Farran, Herth, & Popovich, 1995), using a variety of
clinical populations at varying stages of health,
socioeconomic status and age and more often emphasized
definitions or aspects of hope itself (Dufault & Martocchio,
1985; Gaskins & Forte, 1985; Herth, 1992; Raleigh, 1992;
Stephenson, 1992).

Ironically, early studies of hope were invariably
written in relation to potentially hopeless experiential
situations of captivity, suffering and powerlessness
(Farran, Herth, & Popovich, 1995). In a noted seminal work,
Frankl (1959) equated hope with meaning and value of life.
His first-person observations of victims in Holocaust
concentration camps described how individuals who possessed

hope were able to endure the most inexplicable and degrading

29
circumstances, while those without hope soon perished.
Frankl came to equate hope with having “meaning" in life and
lack of hope as having no meaning. Nardini (1952) described
American prisoners of war in Japanese camps hopefully
transcending their suffering despite the hopelessness of
those surrounding them. Survivors relied upon having the
will to live and having the perception of self-worth despite
inescapable qualities of the environment.

Psychiatric populations are found to be the most
frequently examined cohort (Farran, Herth, & Popovich,
1995). Studies of hospitalized suicide attempters (N=294)
were studied and resulted in development of the Beck
Hopelessness Scale (HS), (Beck, Weisman, Lester, & Trexler,
1974). Beck evaluated negative expectancies of future
outcomes with hopeless individuals in a cross-sectional
study. Correlations of suicidal intent and feelings of
hopelessness prevailed. “Early studies frequently measured
hopelessness using a single measure...[and] virtually all
studies used the Hopelessness Scale” (Farran, Herth, &
Popovich, 1995, p.123).

Theories developed which linked hopelessness as both a
component and as a determinant of depression (Beck, Kovacs,
& Weisman, 1975). Using 384 suicide attempters and the HS
(Beck, Weisman, Lester, & Trexler, 1974), a correlational
study related suicide and depression. This resulted in
creation of the Beck Depression Inventory (BDI), still

widely used today as a predictor of patients more likely to

30
commit suicide (Farran, Herth, & Popovich, 1995). Although
items on the HS and the BDI were significantly correlated,
(r=0.69, p <.001), Greene (1989) found that this did not
account for a 50% variance in the responses to the two
scales among severely depressed female patients (N=60).
Women with high depression but low hopelessness patterns
were more likely to have young children or to have had
recent positive life events (Greene, 1989). Despite the
small sample size, the findings suggest that, depending upon
contributing conditions, individuals may be depressed but
not hopeless. This finding corresponds to the relational
attribute of hope and the process of connectedness, (Farran,
Herth, & Popovich, 1995).

Defining the concept of hope was the nexus of many
early studies. Twenty-five well and hospitalized
adolescents in a substance abuse program participated in
defining the concept of hope through semi-structured
interviews (Hinds, 1984). Grounded theory methodology was
used to achieve precise construct definitions. Beginning
with open-ended data gathering, coding and analysis of the
data identified increasingly structured characteristics or
categories of hope. The subjects described a continuum of
hope spanning four hierarchical levels of believing, from a
state of “forced effort"tx>“anticipation of a personal

future,” implying that hope occurs in incremental amounts

(Hinds, 1984, p.360).

31

Stotland (1969) was one of the first to pr0pose a
clinical theory of hope as a measurable and active process.
Stotland (1969) defined hope as having a probability greater
than zero of achieving a goal, consequently, hopefulness
reflected high expectation and hopelessness a low
expectation of success (Stotland, 1969). The narrow
conceptualization of hope as a single dimension of goal
achievement provided a necessary step in the direction of
single element measurement. However it does not conform to
the multidimensional construct of hope, and without
acknowledgment of the mind-body-spirit domains of hope,
Stotland's definition is too limited for the APN.

McGee (1984) studied h0pe as a factor influencing
crises resolution and offered an early multidimensional
definition of hope through synthesis of earlier concepts
(Stotland, 1969; Lynch, 1974). McGee defined hope
operationally by: 1) recognition that a stimulus for action
exists, 2) that the response to the stimulus may include
feelings, thoughts, expectancies or actions regarding a
state of being that is desired but not presently
experienced, and 3) that probability calculation for
successful solutions to the need is influenced by
situational variables. McGee stated that calculated hope
probabilities are the product of four aspects of the

personal being: cognitive, psychological, social and

physiologicalf (McGee, 1984).

32

Gains in nursing research were next evident with the
work of Dufault and Martocchio (1985). They described an
expanded model of the hope concept as a dynamic and
multidimensional construct (Dufault & Martocchio, 1985).
Data was collected through interviews and participant
observations from 35 elderly cancer patients in a
longitudinal 2-year study. Re-analysis during a second
longitudinal study with terminally ill persons (n=47)
allowed the authors to conceptualize hope as an active
process with two spheres; generalized hope and
particularized hope. The two spheres were contained within
six separate areas; the affective, cognitive, behavioral,
affiliative, temporal and the contextual dimensions.

The affective dimension of hope was described as
focusing on the broad emotions and sensations of the hoping
process (Dufault & Martocchio, 1985). This involves the
attraction of the individual to a desired outcome and the
personal significance of that outcome to the individual. It
also encompasses the feelings of confidence or the
uncertainty about the outcome (Dufault & Martocchio, 1985).
The cognitive dimension focuses on the thinking processes of
hope including identification of the hope object or the goal
and the assessment of reality in judging probabilities of
the outcome as realistically possible (Dufault & Martocchio,
1985).

The behavioral dimension refers to action taken in

relation to hope. The affiliative dimension focused on the

33
individual's involvement beyond the self to other-
connectedness. This included components of social
interaction, self-transcendence by relationships with other
persons or with a Higher Power/God. The affiliative
dimension is activated as the hoping person seeks help or is
willing to receive help from others.

The temporal dimension involves the individual's
perception of time, past, present and future (Dufault &
Martocchio, 1985). Keeping non-specific time is a
protective device guarding the individual from
disappointment if hope cannot be realized within a known
time frame or when there is a perceived precariousness of
time in relation to a limited lifespan, illness or age. The
contextual dimension is relative to the hoping person's
surrounding life situation including physical and emotional
well-being, functional abilities, relationships and the
ability to fulfill role expectations.

Variations on these six dimensions have evolved from
author to author, but later researchers allow for at least
three of the dimensions (Farran et al., 1995; Herth, 1987;
1992; Miller & Powers, 1986; Nowotny, 1986; Stoner, 1982).
Although the work of Dufault & Martocchio (1985) is
admittedly a very limited study without any attempt to
explain the collected ‘clinical data,‘ the construct of
dynamic multidimensional attributes of hope persist to

current theory. Dufault and Martocchio (1985) represent the

34
most commonly cited source of all early research on the
concept of hope.

Once a nursing model was synthesized to the multiple
dimensionality definition, instrument scales were developed
to measure the concept of hope. The Miller Hope Scale
(MHS), (Miller & Powers, 1988) was developed by nurse
researchers to measure multidimensional aspects of hope in
well adults (N=522). The MHS is a 40-item, 5-point Likert
scale with high scores related to high hope based on “ten
critical elements," which conceptually relate to the four
central attributes of hope (Farran, Herth, & Popovich,
1995). Strong internal alpha consistency was reported and
criterion-related construct validity was well established
(Miller & Powers, 1988). The MHS detects high levels of
hope in individuals screened to have no physical or mental
health problems and to those who report future goal
orientation (Miller & Powers, 1988) but is not generalizable
to the frail, elderly client with deteriorating health or
mental status (Farran et al., 1995).

Development of an instrument to measure hope in the
elderly individual evolved slowly as recognition became
apparent that aspects of hope differed with those persons
having limited energy or functional resources. Cancer
patients represented the next most studied cohort in the
examination of hope (Farran, Herth, & Popovich, 1995). The
complexity and intensity of nursing required to care-for

cancer patients stimulated the interest of nurse researchers

35
in examination of many variables including constructs of
anxiety, pain, fatigue, coping, psycho-social adjustment and
impact on family. Several hope instruments have been
developed specifically for cancer patient populations.
These include the Stoner Hope Scale (SHS) (Stoner, 1982);
the Nowotny Hope Scale (NHS) (Nowotny, 1989); the Herth Hope
Scale (HHS) (Herth, 1991), and the Herth Hope Index (HHI)
(Herth, 1992).

Stoner (1988) based collected data from cancer patients
upon the statistical theoretical formulations of Stotland
(1969) for instrument development. The SHS measures the
importance of 20-future-goal domains of intrapersonal,
interpersonal and relational achievements measured on a 4-
point Likert scale. Validity was established with a strong
negative correlation to the Beck Hopelessness Scale and
internal consistency was reported reliable in a small,
cross-sectional study with adult cancer patients (N=55).
Conceptually, the SHS best represents the central attribute
of hope consistent to the relational process, but is limited
by itemizing very specific goal achievement items (Farran,
Herth, & Popovich, 1995). It is also of questionable value
to the elder populations or the chronically ill since
several items measure the need for control of health and the
availability of family or friends, neither of which may be
within the elderly individual's realm (Stoner, 1982).

Scoring of the SHS is also fairly complex since the outcome

36
is designed to measure probability as well as the importance
of hope (Farran et al., 1995).

Nowotny (1989) developed the only multidimensional
scale to measure levels of hope designated by standard
deviations; hopeful, moderately hopeful, low hope and
hopeless. The NHS was administered with the Hopelessness
Scale (HS) (Beck, Weisman, Lester, & Trexler, 1974) to well
adults (n=156) and to adults with cancer (n=150).
Correlations for the 29 items demonstrated an internal
consistency of .90 and component analysis resulted in
identifying six factors: confidence, relations to others,
possibility of future, spiritual belief, activity and
involvement and hope that comes from within, (Nowotny,
1989). A strength of the NHS in use with the elderly is the
reference to transcendence of limitations, “I think I can
learn to adapt to whatever limitations I may have," (Farran,
Herth, & Popovich, 1995, p.62.), but there is no reference
to health status.

The HHS, (Herth, 1989) was specifically developed to
capture the multidimensionality of the hope concept in a
clinical setting and to be useful with individuals in acute,
chronic or terminal stages of illness. The Dufault and
Martocchio model of hope (1985) was the conceptual framework
used to create the HHS, a 30-item, Likert four-point scale
questionnaire. Herth (1991) combined the dimensions of hope
described by Dufault and Martocchio (1985) into a framework

of three “factors? for generating items on the HHS: 1)

37
cognitive/temporal factor- the perception that a positive,
desired outcome is realistically probable in the near or
distant future, 2) affective/behavioral factor- the feeling
of confidence with initiation of plans to affect the desired
outcome, and 3) affiliative/contextual factor- the
recognition of the interdependence and interconnectedness
between self and others and between self and spirit (Herth,
1992).

The HHS (Herth, 1989) was originally tested in three
populations of cancer patients: a convenience sample of
adults (N=20), a pilot sample of inpatients and outpatients
(N=40), and a sample of inpatients receiving chemotherapy
(N=120). Data from these studies were combined to further
evaluate the psychometric properties of the instrument.
Construct validity was achieved through factor analysis of
the three combined-dimension aspects of hope. Alpha
coefficients were .89, .85, and .84 for the cognitive/
temporal, affective/behavioral and affiliative/contextual
factors respectively (Herth, 1991).

Using the HHS (Herth, 1990), hope and grief resolution
was studied in a mail survey (N=75) intended to examine the
relationship of supportive networks, coping skills, past and
concurrent losses and hope. Elderly subjects who had been
widowed from 12-18 months were chosen through simple
stratified random sampling to assure that an equal number of
subjects were obtained according to three settings:

hospital, hospice and nursing home. A high hope level

38
accounted for 79% of the effective grief resolution
variance. Factors related to greater hope measurements
included adequate present income, good health, fewer than
two concurrent losses, a longer duration of spouse's
illness, and frequent visits by family members. Subjects
whose spouse had died in a hospice had significantly better
grief resolution and higher levels of hope (Herth, 1990).

Utilization of any of the hope indices clinically
requires reflection upon the amount of time, effort, and
energy required of persons competing these instruments.
Persons with potentially low hope levels such as the
terminal cancer patient or the grieving elderly individual
are necessarily persons with limited amounts of time and
energy. Additionally, the effort and anxiety potential of
the respondents confronting personal hope concepts and the
discomfort of self-disclosure required suggests that
researchers be cognizant of their subjects' vulnerability.
The complexity and length of most existing instruments limit
clinical utility for the frail elderly or for the client
with diminished attention span.

For these reasons, the Herth Hope Index (HHI) was
developed (Herth, 1992). The HHI is the adaptation that
evolved from the Herth H0pe Scale designed specifically for
clinical use with individuals having limited resources of
time, energy or effort (Herth, 1992). The objective of the
tool is to capture the multidimensionality of hope

represented by the HHS, but to reduce the number and

39
complexity of items and therefore render it more clinically
useful. Twelve items were synthesized for the shortened
instrument, paralleling the three dimensionality subscale
factors of hope in the HHS. Larger than normal print type
is used to improve readability for ill or elderly clients.
The Likert-format items are scored on an ordinal scale from
1 to 4, where a score of 1 indicates “strongly disagree” and
a score of 4 indicates “strongly agree” (Herth, 1992) .
Initially tested by a convenience sample (N=172) of ill
adults, criterion-related validity was demonstrated by a
high correlation with the original HHS (r=0.92), suggesting
that the HHI is as comprehensive and reliable as the longer
30-item version. Further construct validity involved use of
another comparison instrument, the Nowotny Hope Scale
(Nowotny, 1989) and strong negative correlation with the
Beck Hopelessness Scale (Beck, Weisman, Lester, & Trexler,
1974).

Support is given to the utility for clinical assessment
of hope by the Herth Hope Index (HHI): “The potential
usefulness [of the HHI] is great...and could potentially aid
researchers or clinicians in the assessment of hope states
within clients and in the evaluation of the effectiveness of
hope-enhancing strategies,” (Farran, Herth, & Popovich,

1995, p.63).
Because of its shortened length, multidimensionality
construct and strong validity scoring, the HHI has been used

repeatedly for hope assessment of elderly individuals.

40
Multiple studies of elderly populations accomplished in a
variety of physical settings from long term care facilities
to community based senior volunteers have been accomplished.
The HHI has also been used with a variety of physical and
mental capabilities of elderly individuals (Herth, 1992).

Older adults were studied to explore the meaning of
hope and to identify strategies to-foster hope (Herth,
1993). Sixty seniors were given the Herth Hope Index
(Herth, 1992) and interviewed from three community living
settings: private homes in urban areas, private homes from
rural areas and residents from a senior citizen housing
project. This study showed that the perceptions of hope
were influenced by place of residence and energy level
(Herth, 1993). With the exception of those experiencing
severe fatigue or those residing in a long term care
facility, these elderly individuals were found to experience
high levels of hope despite age, functional ability or
health status. Tukey HSD post hoc comparison procedure
indicated that participants residing in long-term care
facilities and experiencing high fatigue did have a
significantly lower level of hope (p> .05) than those in any
other category (Herth, 1993).

Herth (1992) believes that older persons rely on.
different methods of maintaining or regaining hope than
younger persons and that “an inner power ...facilitates the
transcendence of the present situation and enables a

reality-based expectation of a brighter tomorrow for self

41

and/or for others,” (Herth, 1993, p.151). This shift or
refocusing of hopes was apparent in participants
experiencing ill health or functional status decline.
Whereas plans for a long future were abandoned, hope in the
present was strong (Herth, 1992). Herth (1993) found that
elders view hope as a process that “facilitates the
transcendence of the present situation and enables a
reality-based expectationfl (Herth, 1993, p.151). Herth's
findings suggest that hope is not dependent upon functional
ability or health status since hopeful elderly individuals
are able toi“shiftf or refocus hope to the present moment.
In the process of overcoming stressful life events
inevitable with aging, such as illness, infirmity, loss and
grief, elderly individuals.“choose to realize that meaning
and purpose in life are possible despite the stripping
process that accompan(ies) aging..." (Leetun, 1996, p.60).

Herth's study (1993) also suggests that caregivers
extending hope fostering strategies can have positive impact
on the level of hope experienced by older and frail adults
(Farran et al., 1995). Herth elaborated eight categories of
hope-fostering strategies derived from the four attributes:
1) inter-connectedness with self/others/the world, 2)
purposeful activities, 3) uplifting memories, 4) cognitive
strategies, 5) hope objects, 6) refocused time, 7)
lightheartedness, and 8) spiritual beliefs/practices.

The concept of hope and elderly populations are used in

several other studies (Farran, 1985; Farran & McCann, 1989;

42
Farran & Popovich, 1990; Farran, Salloway, & Clark, 1990).
Using the Stoner Hope Scale (Stoner, 1982) and the Beck
Hopelessness Scale (Beck, Weisman, Lester, & Trexler, 1974),
Farran and McCann (1989) positively correlated physical and
mental health with levels of hope in 126 community-based
older adults. Individual factor analysis of the data from
the specific instruments chosen revealed that different
conceptual dimensions were reflected by each scale (Farran &
Popovich, 1990). This underscores the importance of
choosing the appropriate scale to evaluate conceptual
dimensions (Farran & Popovich, 1990).

Farran and McCann (1989) proposed using hope as a
function of all other variables including physical and
mental health, social support, personal control, stressful
life events, activities of daily living and religiosity.
Farran used the same older adults longitudinally 2 years
later despite a 43% attrition rate related to death, nursing
home placement and illness (Farran & Salloway, 1990).
Examination of variables from Time 1 and Time 2 revealed
that interpersonal control, stressful life events and
activities of daily living at Time 2 were the best
indicators of physical health at Time 2. Furthermore, hope
measured at Time 1 was the best indicator of mental health
at Time 2. The best predictors of hope at Time 2 were
mental health, religious beliefs and social supports at Time

2. This was felt to exemplify the complexity of the

43
relationships between hope and other physical and
psychosocial variables (Farran, Herth, & Popovich, 1995).

A creative study using photo-assisted interviews
identified sources of hope in older adults (Gaskin & Forte,
1995). A small convenience sample (N=12) of older adults
living in their communities were given a 12-exposure camera
with automatic flash and instructed to photograph anything
that gave them hope. The photos were coded into groups
representing specific themes. Spirituality was the theme
most frequently identified, and often referred to when
discussing pictures of nature. Although participants
identified very personal sources of hope, the associated
concepts represented consistency throughout the sample. A
strength of this limited study was the development of hope
fostering strategies developed from the theme clusters
including flexible visiting hours and overnight visits with
family members to Bible discussion groups and nature
exploration (Gaskin & Forte, 1995).

The development of instruments to measure the elusive
and intangible concept of hope is crucial to both the APN
researcher and the APN in clinical practice. From the
research perspective, the ability to assess the presence of
hope in the elderly contributes to understanding how and
when hope exists and the predictability of hope from
individual to individual. From the clinical perspective,
the ability to assess hope will guide planning and

intervention of hope strategies to instill, maintain and

44
restore hope for the elderly individual. A brief hope
assessment guideline would be useful for the APN to utilize
during the subjective psycho—social interview. An
assessment of the presence of hope can then be established
during intake history, on initial visit, or during the
history of present illness (HPI) at a repeat clinic visit
and used as a repeated measure evaluation by the APN in

primary care.

Hope Assessment and Strategic Interventions
W

This author has attempted to establish the importance
of hope as a quality of life parameter for the elderly
individual. Following, will be a method for assessing for
the presence of hope using formulated questions to be asked
during the history taking interview in a primary care
setting.

Assessment of hope is difficult because of the
elusiveness and complexity of the concept. The
multidimensionality of hope as a concept transcending mind,
body and spirit attests to its all-encompassing importance
to an individual but its essence is nearly impossible to
capture. Hope is dynamic; it fluctuates across time; it
changes as goals and expectations change; it varies across
the life span and from day to day. There are many factors

to consider when attempting to assess hope in elderly

individuals.

45

The APN in primary care accepts the variations which
may affect the presence of hope and must also recognize the
unique characteristics of the population. Variables of the
elderly individuals themselves, such as decreased attention
span, low energy levels due to illness or stress, or the
diminished ability to communicate due to physical or mental
impairment, affect hope assessment. Cultural orientation
may influence the concept and reflection of hope. The
elderly individual and the APN should be linguistically
conversant or employ the assistance of a compatible
translator to convey the abstract concept of hope. The
acceptability of discussing hope is influenced by ethnic
diversity.

Special characteristics of the clinical environment in
primary care can also affect the assessment of hope. Time
limitations in the practice setting to administer hope
assessment instruments, or to score and record the outcomes
necessitate a short, effective method. Privacy is a
consideration for the elderly individual, especially in a
busy clinical setting, when relatives or caregivers
accompany the patient into the examination suite.

Successful assessment of hope is also contingent upon
the skill and sensitivity of the APN. Combined with an
understanding of the nature of the concepts and a rapport of
trust and openness, an invitation to share personal
experiences must be offered during a transpersonal caring

occasion between the APN and the elderly client. The

46
“being” of the clinician is critical to the establishment of
a caring environment and sense of trust (Watson, 1992). The
APN is the instrument through which hope is assessed by
using critical clinical observation skills and by intuition.
The APN must actively listen for both the spoken and the
unspoken signs of hope. Nonverbal cues, tone of voice,
affect and body language can all be included in the charting
and reporting for the presence or absence of hope in the
elderly individual.

Being fully present in the moment by quieting inner
thoughts and actively listening, the APN focuses with
genuine caring in an accepting, nonjudgmental way. Active
listening may clarify the message of hope and create a
healing moment as the elderly individual is encouraged to
tell their story, “because within their life experiences
lies their hope," (Farran, Herth, & Popovich, 1995. p. 86).
“Hope is not given with a pill or a needle and cannot be
seen on the results of an X-ray or blood test, yet to meet
anothers' eyes is often to know a great deal about the level
of hope,” (Jevne, 1991, p.149). Farran, Herth, and Popovich
(1995) describe the effectiveness of combining the
clinician's intuitive sense with the use of a hope inventory
and of using interviews repeated over time in the assessment
of clients' varying levels of hope.

A basic premise of Watson's theory of Human Caring and
Humankind is the belief that the APN may have access to a

person's mind, emotions and inner self provided that the

47
physical body is not perceived or treated as separate from
the mind, body or soul (Watson, 1988). During the actual
caring occasion in primary care, the APN embodies the ideal
of nursing by utilizing the HOPE acronym to differentiate
between the dimensions of mind-body-spirit, which may or may
not be concurrent in the elderly individual. In the
phenomenological shared moments of transpersonal caring, the
APN and the elderly individual establish contact between
persons; “one's mind-body-soul engages with another's mind-
body-soul in a lived moment...[which] has the potential to
transcend time and space and the physical, concrete world,”
(Watson, 1988, p.46). As the APN assesses the elderly
individual for the presence of hope, both nurse and client
bring their unique causal past experiences and knowledge of
hope together. The present moment of transpersonal caring
can then affect hopefulness of the future, for both the APN
and the elder individual.

In summation, the elderly individual accesses the APN
for primary care, thus initiating a caring occasion. The
APN interviews the elderly individual to ascertain health
status information during the subjective portion of the
visit. Collected data includes the background and current
psycho-social history. Using the four multidimensional
attributes of hope through knowledge of the HOPE/GRACT
framework (Farran, Herth, & Popovich, 1995), the APN is able

to assess hope by incorporating questions into the psycho-

48

social history taking, which specifically evaluate the

presence of hope.

Internrefixe_Questions.£er_Assessment. Previous

discussion of measurement tools to assess the concept of
hope reveal that only one instrument, the Herth Hope Index
(HHI) was specifically designed to accommodate the clinical
setting (Herth, 1992). This abbreviated 12-item scale was
created to screen hope status with regard to the decreased
attention span and the fatiguability of the ill adult.
These factors appropriately address the limitations of the
elderly individuals seen in primary care. The HHI captures
the multidimensionality of the four attributes of hope,
allowing for the assessment framework of HOPE and GRACT to
be utilized by the APN.

The APN in primary care is constrained by time and
resources. To realistically evaluate the presence of hope
for each elderly individual visit per day, the APN would
necessarily need to administer the HHI to every client. It
is possible to give the instrument to each elderly
individual as they register at the intake desk, and even to
haVe clerical staff score the results. The utility of
incorporating hope assessment questions into the psycho-
social history taking of every interview. Much the same way
that clients are asked about mood, appetite and sleep
patterns to evaluate depressive status, the APN can employ
questions specific to hope evaluation for each elderly

individual. It may be an effective strategy to measure hope

49
initially using the survey instrument and then follow-up
with interview questions at subsequent visits or a specific
follow-up visit to expand on the data. Observation must
always be an ongoing process recorded at each visitu “The
key, no matter what method or methods are used [of assessing
hope] is the clinician's use of self," (Farran, Herth, &
Popovich, 1995).

Four hope assessment questions are recommended by this
author for use by the APN in primary care during the history
taking interview of the elderly individual at each visit.
These questions have been selected and synthesized from the
Herth Hope Index (Herth, 1992) the Herth Hope Index (HHI).
This instrument is representative of all four attributes of
hope and is consistent with the framework acronym HOPE for
assessing the concept. The four concepts represented by
HOPE are reiterated as: H-health, an experiential process;
O-others, a relational process; P-purpose, a spiritual
transcendence process and E-an engagement/cognitive process
(Farran, Herth, & Popovich, 1995).

The nature of the HHI “is such that the nurse is able
to examine the response to each item and associate the
individual's hope in relation to the particular area
representedf by the central attributes (Herth, 1992,
p.1257). All twelve items of the tool have significant
loading on one of the attributes conceptualized, although
the attributes were labeled as “Factors” by the author

(Herth, 1992). Construct validity of the HHI factor loading

50
was established using maximum likelihood factor analysis
with varimax rotation. Since each item is identified by
factor loadings, it is possible to select items
representative of the central attributes to incorporate into
the transpersonal caring occasion of the history taking
interview.

Item #4 of the HHI is, “I can see light in a tunnel”
(Herth, 1992, p.1256). This is a commonly heard phrase of
persons experiencing hope and positively reflects the
experiential process according to the strong factor loading
(0.81). Overcoming one's external circumstances of health
(H, of HOPE), be it physical, psychological, social or
spiritual health, requires overcoming the powerlesSness of
present situations to a future place of hope. The causal
past-suffering brought to the caring occasion between the
elderly individual and the APN, is potentially transformed
in the phenomenological future by asking; “Do you see light
at the end of the tunnel?"

Item #9 of the HHI states, “I am able to give and
receive caring/love," (Herth, 1992). The ability to give
and receive love and nurturing clearly reflects the
relational process of the four attributes, O = others. A
comparatively low value loading score (0.60) is reported by
Herth, perhaps due to the semantics describing the
relational process as the affiliative interconnectedness
factor (Herth, 1992, p.1256). This description seems to

muddy the relational borders of “self and others" with “self

51
and spirituality” and may account for the lower numerical
value. No other items on the abbreviated HHI address
relationship to others, although items on the Herth Hope
Scale (HHS) do attend the relational component with, “I feel
loved and needed,” (Item # 24) (Herth, 1989, [from Farran,
Herth & Popovich, 1995]). Ease of asking the elderly
client, “Do you feel loved and needed” may be smoother than
to ask “Are you able to give and receive love?" However, no
factor loading value score is available to evaluate
construct validity comparatively for this HHS item.

The ability of the elderly individual to give and
receive love recognizes the value of role expectation and
reflects a level self-worth, deserving of love despite
aging or infirmity (Herth, 1992). Item #9 also reflects the
caring of the APN during the actual caring occasion in the
phenomenological present moment. “The reality for some
isolated older persons is that professionals are the main
source of social support,” (Farran & Popovich, 1990, p.127).

Using Watson's (1988) model, the caring occasion can be
extended into the future and expectations may manifest for
potential change in experiential health. Physical health
and psychological well-being may improve to affect hope in
the future. Difficult relationships with significant others
may alter through awareness, renewed communication, conflict
resolution or self-forgiveness expanding through the present

moment into the future of hope for the elderly individual.

52

Item #5 of the HHI reads, “I have a faith that gives me
comfort? (Herth, 1992, p. 1256). This proposes that the
elder adult experiences a transcendence of spirit which
gives them hope. Theologians and philosophers both maintain
that hope has no basis without faith and that faith cannot
be sustained without hope (Farran, Herth, & Popovich, 1995).
Asking the elderly client, “Does your faith comfort you?“
the APN in essence asks” “Do you have ‘something' which
gives you the ability to ‘rise above' difficult
circumstances and which gives your life meaning?" The
purpose and meaning in life, recognized above the
limitations of aging, relate positively to the H? of the
HOPE acronym and describe the spiritual transcendence
process which Watson believes is imperative to wholistic
wellness (Watson, 1988). Deep faith brought from the causal
past is enough to sustain hope in the present moment and
secure hope for the future for some elderly individuals.

For others, the experience of spiritual strengthening
through interventions with the APN during the caring
occasion may enrich contemplation of hopefulness for the
future.

Despite the strong correlation noted above between hope
and faith, this author experienced decisional conflict in
using this question item. The word “faith" 'to some persons
is clearly linked to a Judeo-Christian religious base
(Farran, Herth, & Popovich, 1995). However, reliance upon

God or a Higher Power is not uniformly accepted as the only

53
means of spiritual connectedness. Conceptually differing
spiritual perspectives include Unity with Others, Nature, or
the Universe (Haase, Britt, Coward, Leidy, & Penn, 1992).
Factor loading for item #5 is relatively low (0.63), and may
reflect this dichotomy. However, when establishing
construct validity for the items selected for the HHI, Herth
describes a numerical.*value of >0.40 as the selected
criterion for allowed variance,” (Herth, 1992, p.1255). No
other items on the HHI relating to the spiritual
transcendency process were valued higher than item #5.

Item #1 of the HHI states “I have a positive outlook on
lifef (Herth, 1992, p.1256). This question is factor loaded
(0.76) towards temporality and future orientation and
therefore represents the attribute of Engagement through the
cognitive process (“E" of HOPE and “T” of GRACT) . It also
reflects anticipation of a positive future fulfillment, a
requirement by definition of the concept of hope
(Stephenson, 1991). For these reasons, asking the elderly
individual, “Do you have a positive outlook on life?"
represents an appropriate question to evaluate the presence
of hope. As a casual inquiry, the question can easily be
asked in context with other psycho-social information during
the history taking interview of a primary care visit.

A debatable second choice cognitive assessment question
is Item #11 of the HHI: “I believe that each day has
potential? (Herth, 1992, p.1256). It has relevance to the

definition for future orientation and may be more

54
generalizable to a variety of non-specific conditions of the
elderly including loss of control issues. Statistically,
Herth (1992) found the question to have a lower factor
leading value (0.54). The word.fpotentialf may be confusing
to cognitively challenged individuals or the word.“each'
(“...each day”) may be too limiting. Perhaps changing the

wording to “most days have promise” would be more positively

factor loaded.

WW- Therefore T there
are four (4) questions which the APN can ask of the elderly
individual during the actual caring occasion, to assess for
the presence of hope. These questions encompass the
central attributes of HOPE as an experiential, relational,
spiritual and cognitive process while recognizing the unique
qualities and specific limitations of the elderly
individual. These questions are based on literature review,
synthesized and reformulated for utility in a primary care
setting:

1) Do you have a positive outlook on life?

2) Do you see a light at the end of the tunnel?
3) Are you able to give and receive love/care
4) Does your faith comfort you?

HQne_£es;ezing_anze;egiee. Obligations of the APN
include fostering hope (McGee, 1984). If fostering hope is
one aspect of the APNs role, then intervention strategies
are necessary. This section proposes specific interventions

to mobilize, support and enhance hope in the elderly

55
individual. Hope fostering strategies discussed here are
those interventions which the APN in primary care would
offer to the elderly individual to instill, maintain, or
restore a hope using the HOPE framework (Farran, Herth, &
Popovich, 1995) (Table 2).

Bulechek and McCloskey (1992) developed a
classification system for nursing interventions which
include the concept of hope. Several specific strategies
were delineated to foster hope and prevent or diminish
hopelessness. This system is recognized as the first
attempt to classify potential strategies for nursing care
related to hope (Farran, Herth, & Popovich, 1995).

W. The APN asks of
the elderly individual, “Do you see a light at the end of
the tunnel?” to ascertain the presence of experiential hope
and to determine whether the person's current health status
is challenging their hope. The question is designed to
create an atmosphere that allows the elderly individual to
safely discuss hope, to express fears and to ask questions.
Interventions may include providing physical and emotional
support through the use of physical treatment plans,
ordering appropriate prescriptives or implementation of
medical durable goods (Farran, Herth, & Popovich, 1995).
Restoration of healing (Leetun, 1996) may include
collaboration with a multitude of other disciplines such as
dietitians, opticians, physical therapists, counselors or

physician specialists. Comfort measures may vary from

56

 

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59
personal hygiene to play. Massage may allow for relaxation
and°a restful sleep. A lively game of cards may stimulate
laughter or new friendships. The APN may foster hope by
giving the elderly individual permission to return to former
healthy pleasures such as music or gardening (Farran et al.,
1995).

The APN can strengthen the hope of the elderly
individual by sharing information about hope and the normal
aging process, explaining that the concept changes with
changes in life. Assisting the elderly individual to
express feelings about hope and to identify areas of hope
currently in their life helps them to accept the present
(Herth, 1993). Emphasizing health potential rather than
limitations allows the elderly individual to extend the self
beyond the boundaries of the immediate situation, realize

new perspectives and anticipate new experiences Leetun,

1996).

Q_s_Qthersl_the_Relaricna1_Presess. strategic
interventions to enhance an elderly individual in their
relationships with others are initiated by establishing a
positive relationship with the APN in an open caring
environment (Farran, Herth & Popovich, 1995). Central to
the instillation of hope is the establishment of a caring
reciprocal relationship between the APN and the elderly
individual (Herth, 1993). “Are you able to give and receive
love or caring?” is the specific question which invites the

elderly individual into a discussion of interconnectedness

60
and serves as a catalyst to create internal and external
conditions that foster favorable relationships with family
members, friends and other professional caregivers (Herth,
1993). The APN can create a vision of hope by actively
listening, demonstrating a willingness to share professional
expertise and relating personal experiences of the causal
past which engender the equality of humanness. This enables
the elderly individual to feel they are involved in a
genuine caring relationship.

The APN should encourage positive relationships with
family, friends, caregivers, pets and nature. Suggested
ways for the elderly individual to give of themselves in
supporting relationships with others include sharing a meal,
bartering their talents or mentoring others. The APN can
facilitate healing of relationships by embracing forgiveness
and encouraging family to share perceptions of events so
that distortions of events can be identified and countered
with accurate information (Farran, Herth, & Popovich,
1995). The APNs verification of perceptions may allow the
elderly individual to recognize limitations and find ways to
reach out for assistance from others. Emphasizing personal
strengths of courage, endurance and patience may help the
elderly individual and their family accept an unfavorable
diagnosis or an imminent death (Farran et al., 1995).

The APN can promote awareness of the world through
discussion of current events, hobbies, or family events with

the elderly individual. Encouragement should be given to

61
participate intergenerationally through storytelling,
singing or reading to youngsters, helping with homework,
teaching home economic skills such as baking or canning,
becoming a school or church volunteer for youth, or letter
writing to pen pals or politicians. The APN may support the
idea of feeding the birds, growing houseplants or visiting
nature. Pets are recognized as an important source of hope
for the elderly individual as a means of comfort,
communication, physical contact and unconditional love
(Farran, Herth, & Popovich, 1995; Gaskin, 1995; Herth, 1993;
Leetun, 1996).

Regular social contacts with nearby neighbors, clubs or
organizations, telephone calling or computer e-mailing with
acquaintances are strategies to stimulate conversation and
external interest for the elderly individual by outwardly
exhibiting concerns for the welfare of others. Many
churches enlist members to visit persons unable to travel
outside of their homes, encouraging the elderly individual
to visit or call, or to be visited or called, strategy which
increases social contact and broadens relationships with
others (Leetun, 1996). Suggestions to write or dictate
memoirs for future legacies enriches the past through
reminiscence. Photo journaling with grandchildren or other
young people allow the elderly individual to recount
valuable lessons and colorful stories from the past while

eduéating and entertaining for the future (Gaskin, 1995).

62

Connectedness for the elderly individual is encouraged
by helping them to expand boundaries introspectively. By
rediscovering and ultimately transforming the inner self,
perceptions of the past and present can be integrated into
hope for future fulfillment (Leetun, 1996).

Spirituality is the theme representing hope identified most
frequently by elderly individuals (Gaskins, 1995). “Does
your faith comfort you?" is the question offered by the APN,
leading to a discussion of hope through spiritual
transcendence. After determining the elderly individual's
source of hope, be it God, a Higher Power, Nature, self or
others, the APN can create an environment conducive to
expressing and practicing spiritual beliefs. This demands
that the APN be self-aware of personal beliefs of spiritual
transcendence and attain a comfort level in discussion of
those beliefs.

Facilitation of spiritual resource availability is a
strategic intervention to enhance hope through spiritual
transcendence. Appointments with a chaplain, priest, pastor
or rabbi, provisions for Bible study or readings of other
inspirational books and listening to liturgical music are
all methods which may renew the spiritual self (Farran,
Herth, & Popovich, 1995). Advocating to family and friends
the importance of the elderly individual's spiritual health
will validate their spiritual needs and may help to

encourage others to offer rides to church or synagogue or to

63
share prayer time or religious holiday observations.
Maintaining religious artifacts and rituals are vital
spiritual connections for many people. Religious dietary
considerations should be respected by the APN and
collaboration with the elderly individual to integrate these
restrictions or necessities into their treatment plan should
be attempted.

Advocating time alone for prayer, meditation or dream
interpretation is valuable for the elderly individual to
reflect upon the meaning and purpose of life and the meaning
of death and dying. A spiritual gratitude log or dream
journal keeping is a means some elderly individuals may use
to reach spiritual transcendence. Strength and inner
resources are developed through conscious introspection.
These activities of the human spirit which allow surrender
and spiritual connectedness beyond oneself should be
encouraged (Leetun, 1996). The APN must allow permission
for the elderly individual to achieve autonomy in selecting
their own unique avenue for seeking value in self and the
God of their personal understanding.

W The
APN determines if the elderly individual has expectations
for a positive future by asking, “Do you have a positive
outlook on life?” If the answer is affirmative, then an
open-ended question may follow to determine what goals and
aspirations the individual holds for hope. This is designed

to stimulate the cognitive process of short or long term

64

goal formulation and probability testing. This in turn
reflects the first letter of the acronym GRACT, (N? for
goals) and assists the APN to recall that the cognitive
process entails the consideration of goals, resources,
action, control and time (Farran, Herth, & Popovich, 1995).

The APN should encourage the elderly individual to
discuss anxieties and concerns, goals and hopes related to
the future (Farran, Herth, & Popovich, 1995). Conveyance of
a positive attitude is accomplished by identifying and
supporting the strengths and positive potentials of the
elderly individual to enhance their feelings of confidence
and hope. The APN may find it necessary to guide and
support the individual to modify, redefine or refocus goals.
Helping to determine whether current goals can be met by the
elderly individual or if modification or flexibility is
necessary is an obligation of the APN, given the person's
current abilities, past accomplishments, future capabilities
and available support system (Farran et al., 1995).

Assisting the elderly individual to identify and value
internal and external resources (HV- resources of GRACT) is
important for the APN to foster hope (Farran, Herth, &
Popovich, 1995). Reinforcing physical abilities (sharp
eyesight, good upper body strength) and emotional aptitudes
(courage, loyalty, acceptance) plus reflection on past
accomplishments may restore hope. Interventions to minimize
unnecessary energy drain and noxious stimulation should be

recognized. Priority setting of outside activities,

65
restricting unwanted distractions or implementing stress
reduction techniques may be enough assistance to allow the
elderly individual to restore hope. Likewise, increasing
the positive flow of energy through a physical exercise
program, nutritional management or encouraging playtime,
music or other creative expression activities may promote
optimism and increase hope (Leetun, 1996). Cognitive
reframing through positive affirmation or mental imagery,
positive self-talk, lightheartedness and humor are all
strategies that the APN can utilize to bolster hope in the
elderly individual (Farran et al., 1995).

Identifying available opportunity resources within the
family and within the community may benefit the elderly
individual and instill hope. The person's openness to
receive assistance is important for the APN to ascertain
while collaborating with the elderly individual and their
family to identify, assess, select, mobilize and access
external resources. Encouragement to avail themselves of
support networks, counseling, volunteer assistance or social
service plans may be the impetus needed to regain hope for
the elderly individual and their family. Resource
materials, books, videos, radio programs or public speaking
engagement schedules can be offered as external sources of
hope.

The APN will intervene to collaborate with the elderly
individual to make plans and take action in ways that

progress can be seen (UV— action of GRACT), (Farran, Herth

66
& Popovich, 1995). Reality surveillance skills should be
taught to help determine whether action is appropriate and
congruent to meet goals. Helping the elderly individual to
evaluate whether others are working effectively in their
behalf is also a strategy to be employed by the APN (Farran
et al., 1995).

Identification of small daily joys worthy of
celebration, such as a sunset or the smell of fresh linens
and the anticipation of enjoyable experiences such as the
visit of a friend, a favorite meal or the first snowfall
help to instill hope for the elderly individual. Object
identification of possessions with significant meaning can
stimulate actions of hopefulness such as the pasting of
photographs in the family album or restitching the hem of a
favorite heirloom quilt.

Control (T? of GRACT) is important to hope fostering
for the elderly individual even if the amount of control is
minute (Farran, Herth, & Popovich, 1995). Creative ways for
the APN to allow for control include discussion with the
person and family about self-determination of time
scheduling, the offering of food choices within a diet plan
or decisions concerning which clothing to wear. Respect for
the person's decision-making abilities and the APN's
commitment to helping them maintain control through self
actualization is essential. Assisting the elderly

individual and their family to identify those problems which

67
they cannot solve is helpful to avoid frustration and defeat
which may culminate in hopelessness (Farran et al., 1995).

The APN should be aware of the elderly individual's
orientation to time (Nr’of GRACT) and encourage their hope
in relation to life events and to the temporal dimension as
they perceive it (Farran, Herth, & Popovich, 1995). The
continuity of time between past, present and future is
altered with aging and frequently the APN must help the
elderly individual determine whether their hope is based on
past, present or future events (Farran et al., 1995).
Encouraging identification of joyful life events of the
past, recognition of pleasures of the present and
anticipation of fulfilling future events may instill hope.
Appreciation of each day as a gift to be celebrated is a
useful strategy to the APN.

During a transpersonal caring occasion in primary care,
the APN assesses for the presence of hope. Using the four
hope questions to establish the presence of hope, the APN
uses knowledge of the HOPE/GRACT acronyms to choose
appropriate strategic interventions to maintain, instill or
restore generalized hope to that elderly individual (Farran,
Herth, & Popovich, 1995). According to Watson's theory
(1985), the interaction of the APN with the elderly
individual during the caring occasion can positively

influence hope and therefore the quality of life for the

future.

68
Conclusion

Hope is a vital ingredient for enhancing quality of
life and for promoting health and healing (Farran, Herth, &
Popovich, 1995; Miller & Powers, 1988). Obligations of the
nursing profession and specifically the role of the Advanced
Practice Nurse require hope-fostering (Dufault & Martocchio,
1985; Hinds, 1989; McGee, 1984; Stephenson, 1991). The
population of elderly individuals is burgeoning (AARP, 1995;
Eliopoulos 1995; Hess & Markson, 1995). Elderly individuals
rely on primary care for their health maintenance
(Eliopoulos, 1995; Flynn & Hefron, 1988). Elderly
individuals are at risk for lowered hope levels due to the
losses attributed to age (Farran, Salloway, & Clark, 1990;
Herth, 1993). Therefore, the APN in primary care is
professionally obligated to understand the concept of hope
as it applies to the elderly individual and be prepared to
intervene with strategies to maintain, instill and restore
hope as a quality of life parameter.
Wu

Recognition that hope assessment is important as a
quality of life parameter for the elderly individual is the
first hurdle for the APN. If the APN in primary care is
convinced that hope is a basic and essential life response,
then hope assessment will be implemented into practice.
Evaluation of assessment implementation will be difficult
unless documentation of hope is initiated. Documentation is

unlikely until standards of nursing care reflect hope as a

69
nursing diagnosis, perhaps as the opposing continuum of
hopelessness (NANDA, 1986).

By asking the hope assessment questions, the APN
invites the elderly individual to share feelings, beliefs
and hopes in an actual caring occasion. This interaction
itself can engender hope through the relational process (TY
others of HOPE) and therefore fulfills the intervention
criterion of simply encouraging the elderly individual to
interact with others. Evaluating this actual caring
occasion as a hope fostering strategy can be done by noting
the elderly individual as they respond; by the actual
answers to these questions, by facial expression, by
enthusiasm or reluctance to reveal their feelings, and by
eye contact and body language. This should be documented in
the objective data of the general survey. On repeated
visits to the primary care setting, the elderly individual
can be reassessed by the APN using the HOPE/GRACT framework
questions and an improved quality of life can be established
through discussion.

The interest shown by the APN concerning quality of
life aspects of the elderly individual, should positively
affect the evaluation of hope. The mind-body-spirit caring
demonstrated by inquiring about the elderly individual's
hope status, the sharing of strategies to instill, maintain
and restore hope and the process of mutual goal setting
directed toward future fulfillment, should help the elderly

individual anticipate a personally meaningful sense of hope.

70

An important consideration of hope evaluation is the
recognition that these hope questions are not designed to
reflect a quantitative measure of hope. There are no “good”
or “bad” amounts of hope. It may be necessary for the APN
to allow an elderly individual unrealistic high hope so that
they may cope with a particular situation. It is the
presence of hope which determines quality of life.

I 1. I'

Hope assessment of the elderly individual has several
implications for the APN in clinical practice. Knowledge of
the concept of hope specifically pertinent to the elderly
individual should be introduced to all APN students in
graduate curriculum and assessment of the presence of hope
should be taught as an indicator of quality of life. Hope
assessment questions should be included in the requirements
of APN students during the psycho-social history data
gathering format of a primary care visit. Hope assessment
of the elderly individual should be repeated at each primary
care visit by the APN in practice. Interventions which
foster hope for the elderly individual should be taught to
the student and presented to the practicing APN at clinical
conferences. Strategies to maintain, instill and restore
hope should be a consideration of the treatment plan at
every primary care visit. Documentation should reflect hope
fostering strategies offered to the elderly individual and

their family by the APN. Hope goals expressed by the

71
elderly individual should be documented on the chart along
with medical and nursing treatment goals.

Clinical studies are needed which utilize repeated
measure assessments of hope of elderly individuals in the
primary care setting. Reflection of hope as a measurable
concept using an instrument such as the Herth Hope Index,
(Herth, 1992), which is designed for clinical use and
appropriate for the specific needs of the elderly would be
helpful to evaluate the effectiveness of the strategic
interventions listed in this project. Development of other
tools which ask questions more conducive to the brevity and
fluidity of the history taking interview would be
beneficial. Further studies to measure the validity and
reliability of those questions would be necessary.

Investigations of hope need to address the APN role
specifically as they affect the enhancement of hope in
relation to outcome-specifically wellness, response to
treatment and quality of life for the elderly individual.

However, these specific hope assessment questions can
be incorporated into data gathering by any health care
professional. The enhancement of hope and offering of hope

strengthening strategies are important for all health care

providers.
Reflection
Norman Cousins (1989) believes that hope is the healing

power of the human spirit, the strongest ally that health

72
care providers possess. He believes that hope is the hidden
ingredient to any treatment and all prescription(s).

I believe that life is hope. Hope is the manna of
strength which allows one foot to be placed in front of the
other along the path. As APN's, it behooves us to be
comfortable with this powerful treatment mode, to understand
this human apothecary, to offer this bread of strength. We
never know when the morsel of hope we offer during a caring
moment will be the strength needed to carry on. Hope that
is offered caringly is not lost to the APN, but reflected
back by the elderly individual.

Jeunce (19845) has a vision of how caring should be.
Where caregivers would touch patients gently - and not only
physically. That every tough, every smile, every word,
every fingerprint leaves a mark and makes a difference.
Because caring makes a difference....caring gives hope.

Norman Cousins (1989) states that hope functions as a
healing power of the human spirit. He maintains that hope
is the strongest ally that health care workers have and that
hope is the hidden ingredient in any treatment or
prescription as the best human apothecary.

Hope is moving towards wholeness, considering all the
offers; understanding that there will be meaning and
despair, connectedness and separateness, commitment and

freedom, head and heart, faith and doubt, life and death
(Jevne, 1984).

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