Relationship between caring nurses and elderly loneliness.

Background: Elderly people tend to experience biological, psychological, social, and spiritual changes due to the aging process. Changes in their psychology lead to a feeling of loneliness and depression, which have a negative impact on their physical health and overall well-being. Nurses as care providers, need to ensure they are always beside the elderly to prevent them from being lonely. This study, therefore, aims to determine the relationship between caring nurses and the level of loneliness of elderly. Design and
Methods: This is an observational analytic design study with a cross sectional approach. Simple random sampling was used to obtain data from a total of 113 elderly people in home care. Furthermore, the CBI 24 Items and UCLA Loneliness Version 3, were used for data collection, while Spearmen's Rho Test with a level of ρ <α = 0.05 was used for its analysis.
Results: The results showed that caring nurses tend to prevent the emergence of loneliness in the elderly with a Spearmen's Rho test P at 0.00015 (P≤0.05) and correlation coefficient r of -0.686. Conclusions: In conclusion, there is a relationship between caring nurses and the level of loneliness in the elderly. ©Copyright: the Author(s).

Introduction

Aging process is associated with biological, psychological, social, and spiritual processes. However, these elements are often overlooked, leading to anxiety and often to depression. An elderly person is someone above the age of 60.[1] Margalit defined loneliness as a psychological problem mostly experienced by the elderly due to isolation from other people.[2]

According to research, the population of the elderly across the globe is approximately 962 million people and it is expected to increase by 2 billion in the nearest future. A 2017 census stated that there are 549 million elders in Asia, and this number is expected to increase by two times by 2050.[3] Indonesia is a country with rapid population growth, with an elderly population of 23 million in 2017, which is 8.97 percent of the total population. Among the ledrely, 9.47% are women and 8.48% are men. This data is separated based on their age, with 5.65% between the ages of 60-69, 70-79 years in the middle and 80 years upward as the elderly.[4] In the East Java Province in 2017 the elderly population reached 12.92 % (5 million people) of the total population of the region.

There are differences in social situations between the elderly living in the home environment and those living in Social Institutions such as nursing homes. Those that experience changes in life tends develop to the assumption that they are no longer productive, that their role in society has decreased and they are less involved emotionally.[5] The elderly living in nursing homes tend to experience limited family support, therefore, they are vulnerable to loneliness and stress. This study aims to determine the relationship between caring nurses with the level of loneliness and the elderly.

Design and Methods

This is an observational analytic design study with a cross sectional approach. Simple random sampling was used to obtain data from a total of 113 elderly people in home care. The instruments used in this study were the Caring Behavior Inventory (CBI) 24 Items and UCLA Loneliness Version 3. In addition, the data obtained were analyzed using the univariate and bivariate analysis of the Spearmen’s Rho test.

Results and Discussion

Table 1 shows that most of the elderly aged 60-75 years (55.7%), were male (53.4%), that they have lived for 2 years (43.5%) without being visited by their family (64.9%). Table 2 shows that the majority of nurses have a good level of caring behavior: 73.3% of respondents stated that they are in the good category, and the remaining 26.7% in the enough category.

Table 1.

Characteristics of respondents.

Demographic characteristics	N=131	%
Age
60-75 Years	73	55.7
>75-90 Years	58	44.3
Gender
Man	70	53.4
Woman	61	46.6
Length of stay
1 Year	22	16.8
2 Years	57	43.5
3 Years/more	52	39.7
Frequency of visit
Often	10	7.6
Rarely	36	27.5
Never	85	64.9

Table 2.

Identification of caring level of nurses.

No	Caring level	Frequency	Percentage (%)
1	Enough	35	26.7 %
2	Good	96	73.3 %
	Total	131	100 %

The details of each aspect of caring nurses in this study are analysed through the 10 carative factors according to Jean Watson, listed in Table 3. Table 3 shows that the highest scoring caring behavior of nurses is the “using problem solving in decision making”, with a percentage of 67.2%, while the lowest caring behavior of nurses is a factor called “helping in meeting basic needs” with a percentage of 55.0%.This shows that making decisions on the problems experienced makes the elderly feel comfortable. According to Watson, nurses need to be able to make a creative decision by using scientific and systematic problem solving methods. [6] A research by Gurusinga reported that majority of respondents stated that nurses were in the good category in terms of knowledge and professional skills. They tend to show cheerful attitudes to patients, pay special attention during official duties, and ensure the elderly are satisfied.[7]Based on the results of the research, 88 respondents (67.2%) stated that nurses were good enough to implement approaches to the elderly by allowing them to express themselves in accordance with the services provided, illness, etc. This occurs due to the establishment of a belief and communication, which is the basis for someone to understand the feelings of others and recognize the problems that inflict pains on them. According to Watson, interpersonal relationships are behaviors that need to be applied by a nurse by establishing a relationship of mutual trust, honesty, and empathy.[6,7]Nurses as caregivers have the opportunity to carry out any activity demanded by the elderly as long as these acts do not endanger them and are acceptable. They accept their type of work, avoid being reproachful, communicate or speak in a friendly and gentle manner, and provide opportunities to socialize or gather with other people, which is expected to reduce the withdrawal attitude and loneliness experienced at the Nursing Home.[8]

Table 3.

caring behavior based on 10 carative factors Jean Watson.

Carative Factor	Frequency (%)
	Good	Enough
Humanistic and altruistic	66.4	33.6
Growing patient expectations	60.3	39.7
Grow your own sensitivity	58.8	41.2
Developing helping true relationships	62.6	37.4
Receive expressions of feeling	63.4	36.6
Use problem-solving in decision making	67.2	32.8
Improve the learning process through interpersonal	55.7	44.3
Provide a supportive environment	58.8	41. 2
Helps in meeting basic needs	55.0	45.0
Provide opportunities to study the phenomena that occur	64.9	35.1

The factor with the second highest percentage is “humanistic and altruistic system formation between nurses and patients” with a percentage of 66.4%. This form of manifestation includes respecting the elderly as a whole individual, being willing to listen to complaints, understanding their feelings, and encouraging them to keep taking care of themselves, stay healthy, and exercise regularly. This is also a function of the home care in housing and taking care of the elderly through various programs designed to keep them productive.[9]

The results of the study showed the least scoring among the carative factors were from the 9th factor, which is related to helping in fulfilling the basic needs of the client. Observations showed that the biophysical, psychosocial, and interpersonal needs of the elderly conducted by nurses in providing timely meals, clean clothes, and healthy environment have been properly carried out and implemented. However, these factors, contribute to a low percentage as reported by the elderly in the questionnaires provided. This is because it only measures the speed of the nurse in responding to the elderly’s calls, and helps reduce their pain, therefore, these items do not show an in-depth meeting on the basic needs of the elderly.[10]

From the questionnaires distributed to the elderly and from their complaints during the interview process, it emerged that the low scores were based on the slow response of nurses to their various needs. For example some of the sick residents complained that they requested for their medication from the nurses through their friends and were turned down. When nurses were asked to clarify this factor, they said such procedure was not allowed to prevent drug abuse, and monitor of the sick.

Loneliness is a painful situation and tends to emerge when someone feels isolated from the group and the environment. Most times, this state is not noticed by the people around, and the residents do not have someone to share their feelings and experiences. Table 4 shows that 63.4%, 22.9%, 11.5%, 2.3%, of the respondents respectively experienced none, mild, moderate, and severe loneliness. The fact that 83 respondents (63.4%) did not experience loneliness was due to many factors, including the frequency of family visits and social support such as social interaction and caring from nurses.

Table 4.

Identification of elderly loneliness levels in the Surabaya Social Service Work Area.

No	Loneliness Level	Frequency (f)	Percentace (%)
1	Not Lonely	83	63.4%
2	Mild Loneliness	30	22.9%
3	Moderate Loneliness	15	11.5%
4	Heavy Loneliness	3	2.3%

This result is supported by the results of crosstabulation between the length of stay and the level of loneliness in the elderly that did not experience loneliness, with the results of 11, 37, and 35 respondents that lived in the facility for 1, 2 years, and 3 years respectively. According to analysis, this result is due to the fact that the elderly, being in the same age community, acquire social support from caring nurses that conduct activities such as making crafts and light games, reading and writing activities of Al-Quran, gymnastics, and healthy walking activities to keep them active and productive.

These results are in line with research conducted by Eskimez, Demirci, TosunOz et al., which states that approximately 86% of the elderly people living in social institutions did not experience meaningful loneliness due to the large amount of social support from peers, institutional staff and nurses.[11]

The long-lived demographic data obtained showed that elderly respondents that are frequently visited by families in the span of 1 month are 10 respondents (7.6%), those rarely visited once every 2 months were 36 (27.5%), and those never visited were 85 (64.9%).

Those never visited by family members, were asked to state the reasons for it, and most reasons were that they had no family, or that they were abandoned by the children because of their tight work schedule. According to Ikasi and Hasanah, the fear of loneliness is a dominant symptom that occurs in the elderly that are influenced by the quality of family support. Those that are continuously exposed to the social support by both family and friends hardly feel lonely because they feel cared for and valued.[12]

For the elderly that have never been visited by their family because they do not have any, the decision to live in a nursing home is the best choice. This is reinforced by the results of the study conducted by Sanjaya and Rusdi, which stated that the elderly prefer to live in nursing homes rather than having to live alone in their homes.[13]

A total of 15 respondents (11.5%) stated that the elderly experienced moderate loneliness due to the poor support from family and find it difficult to adapt to the new environment. This is reinforced by the results of crosstabulation between the frequency of visits by families in the elderly experiencing moderate loneliness, and the results of the 15 elderly respondents never visited by family. The elderly believe that the nursing home is a place of seclusion, which affects the process of adaptation. Another reason is found in social care institutions, which are mostly inhabited by people that experience psychiatric disorders, therefore, healthy elderly people find it difficult to socialize with people around them. This result is reinforced by the statement of Ikasi and Hasanah, who claimed that families play a huge influence on the level of loneliness of the elderly. Those that live with their families receive information, and support on factors likely to cause an illness, receive awards as decision makers, acquire attention, and assistance.[12,13] It was found that the three respondents experienced severe loneliness and this led to the incidence of depression and poor adaptation. The process of poor adaptation is indicated by deviant behaviors such as high emotional level, more contemplation and solitude.

This result is supported by a study conducted by Azizah, using Bram’s theory. According to this research, the factors causing loneliness in the elderly is age because as people get older, a person’s development brings many changes likely to affect their expectations and desires for a relationship.[14]

Table 5 shows that the high level of caring for nurses tends to reduce the loneliness experienced by the elderly while living in home care. The statistical test of Spearmen’s Rho, the value of ρ = 0.00015 (ρ≤0.05) and the correlation coefficient r = -0.686, shows that there is a strong relationship (0.60-0.80) between nurses caring variables and the loneliness level of the elderly. The results of the Spearmen’s Rho test with a significant level of 0.05 shows that the hypothesis is accepted, which means that there is a relationship between caring nurses and the loneliness level of the elderly in the Surabaya Social Service Work Area.

Table 5.

Relationship between caring nurses and elderly loneliness.

Variable	r	P-value
Caring nurse – Lonely elderly	-0.686	0.00015

Based on these results, it can be concluded that the better the quality of nurses in providing care to the elderly, the lower the level of loneliness. However, the elderly are bound to feel lonely despite receiving good caring behavior from nurses due to social environmental factors and the absence of family support. Although the research data shows that caring attitudes of nurses is good, some elderly people still feel lonely due to physical limitations or immobilization. Those that use sticks or wheelchairs when moving said they have difficulty following some programs implemented by nurses, hence, they see these activities without being able to participate. Therefore, nurses need to create programs that are followed by all and special ones for those with difficulty moving their bodies to avoid them feeling lonely due to such physical limitations. According to a research conducted by Ariyani, the elderly that chose to live in nursing homes believed that the health services of doctors and nurses is an added value that maintains and improves the quality of their health and life.[15]

The importance of nurse caring behavior in meeting the needs of the elderly is also one of the indicators of service quality of the Social Institution. This is central to nursing practice in addition to hospital services, as a dynamic approach method, where nurses work to further increase their sense of care for the elderly. The results of the study from Joranson et al. stated that the loneliness level of the elderly tend to decrease after being provided with group play therapy by nurses.[16] They stated that they feel happy and not bored after attending group therapy. Research from Windle, Francis, and Coomber showed that to address loneliness in the elderly is far more effective using group therapy because this helps them to communicate and interact with one another.[17]

Conclusions

It can be concluded that there is a strong relationship between caring nurses and the level of loneliness of the elderly. Therefore, the greater the caring behavior of nurses the smaller the loneliness perceived by the elderly.