Professional hope in working with older adults.

Spano, Richard

Writings about hope within gerontological literature assume social workers already possess hope that they can use in their practice. The purpose of this article is to challenge this assumption and to examine ways in which social workers can sustain hope in personal life, in their agencies, and in the reform of larger social structures that impact older adults. The authors examine culture change in nursing homes as an emerging approach that can be more fully developed by applying the strengths perspective to interpersonal work with elders, agency change and broader structural change.

Keywords: hope, growth, culture change, and strengths perspective

Introduction

At first glimpse, professional hope in older adults' capacities for ongoing growth and change appears pretentious and not based in reality. Although some human development models or theories describe growth and change in old age (Smith, & Freund, 2002; Atchley, 1989; Kuypers, & Bengston, 1973; Mead, 1934), many continue to describe aging as a life stage fraught with multiple health problems, an accumulation of losses (e.g., loss of friends, housing, or life partner), and decreased access to financial, social and other resources. Older adults are often not able to sustain let alone surpass current levels of growth and development (Gray, 2003; Herth, & Cutliffe, 2002; Cheavens, & Gum, 2000; Rowe, & Kahn, 1998; Farran, Wilken, & Fidler, 1995).

These negative views of older adult growth and development permeate the hope and aging literature. This literature emphasizes how professionals can instill hope in the older adult who is facing negative and difficult challenges such as a terminal or chronic illness, bereavement, and depression (Westburg, 2003; Duggleby, 2000; Forbes, 1999; Roberts, Johnson, & Keely, 1999; Tennen, & Affleck, 1999; Klausner, Clarkin, Spielman, Pupos, Abrams, & Alexopoulos, 1998; Nekolaichuk, & Bruera, 1998). Few writings address the role of hope in physically or emotionally healthy older adults (Zorn, 1997; Herth, 1993).

Consistent with negative views of older adult growth and change, virtually no gerontological writings discuss how professionals develop and sustain hope in working with older adults. In order for professionals to believe in older adults' capacities for growth and change it seems paramount to cultivate this professional hope. The purpose of this article is fourfold. First, the authors will examine ways in which hope is described in the gerontological literature as compared with the larger social sciences literature. Second, strategies are presented that gerontological social work professionals can use to develop and sustain hope in personal life and professional work. Third, the use of hope-inducing models or theories of human development are presented for use in social work curricula and in agency-based practice to help gerontological social workers develop and sustain hope. Fourth, culture change in nursing homes, often described as the enlistment of resident and direct-care staff involvement in institutional decision-making, is critiqued as an example of larger social structural reform that can develop and strengthen professional hope. Social workers are encouraged to facilitate advocacy efforts that involve multiple stakeholders (i.e., staff, residents and families) for the purpose of changing the culture in nursing homes.

Although physical capacities eventually diminish in old age, human beings are comprised of multiple and overlapping components (e.g., social, psychological and spiritual) that may contribute to enhanced growth and development in old age. For example, older adults may strengthen friendships and support, develop wisdom and increased well-being, and may enhance their capacity for self-transcendence and a sense of life meaning. Our contention is that gerontological social work professionals can have hope in older adults' capacities to grow even in the face of physical and other limitations. Furthermore, social workers can participate in coalition building, policy reform, and other advocacy efforts to modify social structures to reflect hopeful views aging.

Literature Review

Descriptions of Hope

With some notable exceptions, descriptions of hope in the aging literature are similar to descriptions of hope in the broader social sciences literature (i.e., psychology, social work and nursing). Hope is depicted as a one-dimensional concept (i.e., a cognitive process involving motivation and achievement in reaching goals; Snyder, 2000) and as a multidimensional concept that incorporates multiple and overlapping components of hope, e.g., behavioral, affective, environmental, time-oriented (e.g., immediate or long-term), cognitive, and spiritual (Nekolaichuk, Jevne, & Maquire, 1999; Herth, 1992; Dufault, & Martocchio, 1985).

However, gerontological writers have noted some exceptions or cautions for applying broader social science descriptions of hope to older adult growth and development. First, describing hope as achievement, success and control is problematic for older adults who experience the loss of a spouse or friends, moving from home, or a reduction of physical capacity (Herth, & Cutliffe, 2002; Nekolaichuk, & Bruera, 1998). Contrary to hope studies with younger populations, older adults may not have hope in controlling or successfully resolving these difficult situations. Instead, older adults may develop or reinforce their hope to manage these situations through enhanced coping skills (i.e., strengthening support networks) and improved capacities to transcend these difficult, immutable situations (i.e., stronger spiritual or religious beliefs). Second, describing hope as future-oriented ignores the emphasis older adults may place on immediate life situations. Some hope and aging studies suggest that older adults engage less in long-term planning and are more involved in goal setting that is short-term and affects their immediate circumstances (Gray, 2003; Cheavens, & Gum, 2000).

For our purposes, we have chosen to describe hope as a multidimensional concept that includes the following components: (1) behavioral (e.g., using coping skills to deal with life challenges (Cheavens, & Gum, 2000; Klausner, et al., 1998); (2) spiritual as an inner power that facilitates transcendence and the endurance of present difficulties such as health problems and other losses (Herth, & Cutliffe, 2002; Duggleby, 2000); (3) cognitive as the motivation and development of goals with an emphasis on short-term goal attainment (Snyder, 2002); (4) environmental as possessing economic resources and supportive family and friends (Westburg, 2001; Snyder, Cheavens, & Sympson, 1997); (5) time-orientation meaning that older adults often use hope to address immediate concerns with less emphasis on future orientation (Smith & Freund, 2002; Herth, 1993; McGill, & Paul, 1993); and (6) affective as feelings of confidence in facing the future and the use of humor to foster hope (Westburg, 2003; Fehring, Miller, & Shaw, 1997). This multidimensional description of hope is consistent with a belief or hope in older adults' capacities to grow and change across many facets of their lives. Furthermore, this hope description can be used to explore how gerontological social workers can best develop and sustain hope in their personal life and work.

Application of Older Adult Hope to Personal and Professional Hope

Personal Hope

We believe that it is difficult, if not impossible, for social workers to develop hope in older adults' capacities to grow and change, if they have limited awareness of the role of hope in their personal lives. For example, many social workers and other professional helpers have experiences of loss or illness that may involve suffering, but also contribute to their development and use of hope. As a young adult, one of the authors was in a motorcycle accident which contributed to back injuries and subsequent surgeries. These physical impairments were tempered by friends and family who supported his physically active lifestyle and enabled him to be hopeful about his immediate and long-term health and ability to manage chronic pain. This support also strengthened his confidence in setting goals; and, he has competed in handball tournaments throughout adult life. In this brief example, the environmental (social support), cognitive (goal setting and motivation), behavioral (acting on plans to stay physically active and compete in handball tournaments) and emotional (self-confidence) components of hope worked together to help him cope with and grow in spite of physical impairments.

The time-orientation and spiritual components of hope can be illustrated using another example. A social worker became involved in meditation as a way to manage communication difficulties with her teenage son. As she learned how to breathe while meditating, she also learned how to slow down and savor moments in her personal life. By becoming more aware of each moment, this social worker was able to transcend frustrations with her son's behavior. She became more positive and hopeful about her son's ongoing growth and development--and their communication improved. Through the use of numerous and interacting components of hope, these two examples demonstrate how hope begins and is sustained in personal life. Developing personal hope in the face of loss, change and adversity may be paramount to having hope in elders' capacities for growth.

The following questions that correspond with the previously described components of hope are provided to foster professional self-reflection on the relevance of hope in personal life:

1. What is your experience with developing goals?

2. How have you used hope to deal with your current circumstances?

3. What has helped you learn to be aware of hopeful moments?

4. How do your emotions affect your growth and use of hope?

5. What kinds of relationships with older adults and others have fostered your hope?

6. What kinds of relationships with the environment have fostered your hope?

7. What is the role of spirituality or self-transcendence in helping you to develop and sustain hope?

8. What actions have you taken in your personal life as a result of hope in your capacities to change?

In summary, carefully attending to our beliefs and experiences about hope in our personal lives provides important information that shapes the development of hope in professional work with older adults.

Professional Hope

Gerontological social workers are challenged to integrate ideas, values and skills that focus on the complex interactions between people and their environments. In addition, practice challenges are exacerbated by the fact that many elders have been marginalized by the larger social, political and economic institutions that so deeply shape their personal experiences. In order for social workers to sustain their hopefulness regarding professional growth and development, we need to examine the role hope plays in their education as well as the agencies in which they practice.

Professional Education

Rarely do we examine what theories, models or perspectives say about the role of professional hope in helping relationships. In those instances where hope is examined, it's examined in the context of how to induce hope in clients, assuming professionals have hope related to clients' capacities for change and growth. Aging literature is even more problematic. In the area of human behavior theory, the social gerontological literature describes changes in late adulthood by emphasizing problems, pathologies and deficits rather than possibilities, promise and potential. For example, in their 1999 review of the literature on aging theories, Hooyman and Kiyak provide a comprehensive examination of social theories that are used to inform practice in the field of aging. These approaches start with very different foci and each capture a small piece of the interactions of elders in their social context. Unfortunately, many of these theories or perspectives frame late adulthood as a psychological process of loss, grief and disengagement or as a time period fraught with barriers to full participation in political, economic and social life. These perspectives, as currently conceived, are not conducive to fostering hope in the professionals who use them.

However, some have the potential to be adapted in ways that can reintroduce hope related to growth and change as a central element of practice with elders. These include continuity theory (Atchley, 1989) and interactionist perspectives (Gubrium, 1973; Kuypers, & Bengston, 1973; Mead, 1934). For social workers, these two approaches are important because they address the interactions between persons and environments and emphasize the role of growth and change throughout the life span. Further, they are potentially congruent with social work's stated purpose of enhancing the fit between individuals and their environments as they attempt to reach their potential.

Continuity theory (Atchley, 1989) asserts that there is continuous development over the life span. Older adults actively adapt to changing situations and show consistency over time in their thinking and patterns of behavior. This theory introduces internal continuity (internal values and beliefs) and external continuity (the environment) suggesting these need to be connected for healthy growth. It also links biological, psychological, social and spiritual components in elders' lives. Each of these elements focus workers' attention on people and their environments, presumes change and growth are "naturally occurring" in elders, and rests on a health promotion philosophy of practice (strengths-based) rather than a residual (deficit-based) philosophy of practice.

The interactionist perspectives (e.g., symbolic interaction) assert that both the person and society are able to change and create new alternatives for their interactions which can lead to growth and development (Kuypers, & Bengston, 1973). Social reconstruction (Gubrium, 1973), as one type of interactionist perspective, suggests that focusing on environmental changes can have a significant impact on the lives of older people. Thus, addressing problems of inadequate housing, poor health care and poverty with a view toward elders' active roles in developing strategies to overcome these barriers creates opportunities for growth and development. Social reconstruction more directly opens the door to advocacy, planning and the social reform of institutional structures and is consistent with social work's commitment to social justice.

Beyond the human behavior component of social work education there is an emerging literature in policy and practice that begins to address alternative approaches that have the potential to reintroduce hope inducing models into our professional preparation (Saleebey, 2002; Jones, & Bricker-Jenkins, 2002; Rapp, 1998; Chapin, 1995). With each of these perspectives, we need to assess their contribution to developing hope by examining the following questions:

1. What do specific perspectives, models and/or theories (e.g., cognitive, behavioral, narrative, psychodynamic, ecological, existential, feminist, and crisis intervention) suggest about how professionals support older clients' efforts to develop and reach their own goals?

2. What do these models suggest about how to identify and sustain opportunities for growth?

3. What do they say about the impact of the professional's emotional awareness and availability in working with older clients?

4. How do they inform us about creating environments that support and sustain growth?

5. How do these models integrate spiritual or self-transcendent elements of our work with older clients?

6. What do they suggest about actions that can be taken that engender hope in our relationships with clients, colleagues and supervisors?

7. Finally, what do they suggest about the nature of growth and change?

Agency-Based Practice

The authors are currently involved in practice with agencies as well as teaching cohorts of students who are in a variety of aging, health and mental health agency settings. Certain themes emerge in conversations with students in classrooms as well as agency-based interactions. Students describe being cautioned by agency practitioners not to trust their clients because it opens the door to manipulation or worse, clients are not able to judge what is in their "best interests", therefore, their participation is devalued in the helping process. Some students are assigned to clients whose situations have major challenges or who in the past have shown little progress and staff has given up hope that these situations are amenable to change.

Many agencies that serve elders have developed a "siege" mentality in response to ever increasing demands and shrinking resources. While national debates are shifting attention to the "crisis" in Social Security, little attention has been focused on the lack of resources for the broad range of aging services--from in-home care to skilled nursing care. Current public discussions frame the changing demographics in our society as a "problem" that creates "burdens" for younger members of the community. Such characterizations further marginalize elders, creating more vulnerability for those elders who are poor and therefore dependent on publicly funded programs. More specifically, the general impact of ageism is layered in with gender and race to create a subset of elders who are most likely to be in poverty and thus more vulnerable to reductions in resources provided under public auspices (Crown, 2001). This more vulnerable group within the larger population is a natural focus for social workers' attention.

Nursing homes provide an example of an agency structure which epitomizes many of the challenges to creating and sustaining hope in the field of aging. Until the very recent past, nursing homes have solely used a medical model to create their agency structures, policies and programs for residents and not with residents. Vladeck's (1980) critique of nursing homes entitled, Unloving Care, identifies confusion about the role and identity of nursing homes as health care facilities and/or residential facilities. In more recent writings, he notes:

 Nursing homes continue to be organized as
 health care facilities ... they continue to be
 organized around health care professional
 hierarchies, although relationships in nursing
 homes should be very different from those
 in other parts of the health care sector. Core
 planning is still driven by an enumeration of
 residents' deficits, not their capabilities ... These
 negative attributes of nursing home culture
 are reinforced by governmental regulation
 and payment mechanisms, as a part of
 mutually-reinforcing and naturally symbiotic
 relationships between government and the
 nursing home industry (Vladeck, 2003, p. 3).

The ongoing dominance of the medical model within nursing homes creates an environment where problems, deficits and pathologies stifle any possibility for creating hope among staff about agencies and residents' capacities for growth and change. However, there are some more recent developments that may provide an alternative approach for working with nursing homes.

There are a number of writers (Fagan, 2003; Reynolds, 2003; Deutschman, 2001) who are developing "culture change" as a way to guide their attempts to reform nursing homes. Most of the writings on culture change have been put forward by health care providers who have been frustrated by the limitations of the medical model as the foundation for conceptualizing delivery of services in nursing homes. According to Fagan (2003), culture change is an in-depth change in systems that requires transformation of individual and societal attitudes toward aging and elders, transformation of elders' attitudes toward themselves and their aging, changes in attitudes and behaviors of caregivers toward those for whom they care and changes in governmental policies and regulations as they relate to aging. This comprehensive view of culture change needs to be anchored in practice models yet to be fully developed by its proponents who are transitioning from a medical model to a more strengths based model which posits hope as a central ingredient for change and growth.

This is a place where social work can make a significant contribution to radically altering the way we achieve genuine culture change proposed by Fagan (2003). Unlike many health care professionals, nursing home social workers have been prepared to focus their attention on the interactions between people and their environments (both proximal and distal). If culture change goals include creating a "culture of aging that is life affirming, satisfying, human and meaningful", significant structural changes need to be made to achieve these goals. These efforts need to be spearheaded by professionals and staff who believe (hope) such changes are possible. A central question is: What can be done to develop, sustain and rekindle hope in our work with elders?

Social workers have always known that client growth and positive change are facilitated within a helping relationship, but also dependent upon changes that need to occur in our social environment and in our social agencies. Social workers warn that we have aborted our purpose--if we ignore the impact of social and cultural forces upon the hope that can be generated in the helping relationship and within our social agencies. Towle (1946) emphasized the negative impact of adverse social and cultural circumstances upon the professional/client relationship. She stated that the helping relationship "cannot compensate for basic environmental lacks, meager services, and restrictive agency policies" (p. 170). Better adaptations, growth and change occur when older clients have better experiences in the agency-based helping relationship and in their relationship with the social environment. Consequently, professional hope in client growth and positive change must be cultivated in our social agencies as microcosms of the larger social environment. The following questions are provided to help gerontological professionals examine their practice context as it relates to the cultivation of hope:

1. What are we doing in our agency to encourage workers and older clients to articulate their goals and develop service plans to achieve those goals?

2. How do we create flexible structures and policies to enable the agency to adapt to meet current and future goals?

3. How do we create an atmosphere that celebrates achievement of goals and instills confidence by recognizing successes in our agency?

4. What do our administrative structures and agency policies do to create opportunities for staff to rejuvenate themselves and for the organization to review and re-envision its mission?

5. Are we asking ourselves what we can do rather than dwelling on barriers we always face when trying to promote positive growth and change in our work?

Turning our attention to these questions provides professionals with a focus on what we can do in the face of challenging situations that continue to shape our practice with older adults.

Implications

In each of the preceding sections we have raised questions designed to assess hope in our personal lives, professional education and in our agency-based practice as they apply to work with elders in nursing homes. Our implications will apply the strengths perspective as it relates to the following culture change components (1) interpersonal work with elders; (2) agency change; and, (3) the broader system change necessary to redress the impacts of ageism in the larger society.

The Strengths Perspective

The strengths perspective, in contrast to deficit or problem-based models, identifies four fundamental principles that are applicable to the role of hope in practice. First, it refocuses the attention of the professional (worker, supervisor, educator) and the person seeking help (client, supervisee, student) on the capacities, possibilities, and resources that they bring to their work. Second, this perspective reunites social workers with their rich conceptual history (Smalley, 1970; Taft, 1962; Towle, 1946) by putting hope in the context of the social environment. Many current writers strip the contextual or environmental components from their discussion of hope and aging; however, the strengths perspective as envisioned by Saleebey (2002) reconnects the traditional view of person-in-environment as central to the growth and change process (Jones, & Bricker-Jenkins, 2002). Third, the strengths perspective redefines the nature of a professional relationship on what can be accomplished and how to accomplish client-driven goals. Fourth, the strengths perspective is applicable beyond direct practice. It can inform us about new ways to foster hope in our interactions with colleagues and the agency/community context within which we practice.

Fledgling efforts surrounding culture change in nursing homes provide opportunities for social workers to use their two decades of experience in developing the strengths perspective as it applies to work in nursing homes. Fagan's (2003) leadership in the Pioneer Network, which is a national grass roots network of individuals in the field of aging who are working for deep systematic culture change through evolutionary and revolutionary means, provides a framework for the application of strengths-based practice. The Pioneer Network identifies approaches that guide their work: (1) individualized care which promotes residents as unique individuals, advocates for maintaining a resident's familiar routines and recognizes the importance of maximizing self-determination in daily activities; (2) resident-directed care which involves restoring control and decision making to residents through the use of a flattened hierarchy within the organization; and, (3) the regenerative community which focuses on creating a consciously conceived community as an avenue for restoring meaning and providing a sense of belonging, a collective voice, opportunity for growth and to be of service to peers.

Individualized care

To achieve the Network's first objective which focuses on work with individuals, social workers and other staff could be armed with human behavior theories or models (e.g., interactionist perspectives and continuity theory) to shape their relationships with clients. These hope inducing approaches create an expectation for growth and change as a part of the aging process. They connect individual growth and change to the removal of barriers in the immediate environment that need to be overcome, thus creating opportunities for greater self confidence and autonomy. Network innovations such as encouraging individuals to actively participate in making their needs known to staff and the introduction of changes in the nursing home environment, i.e., children, plants, colorful surroundings represent small, but important shifts in the relationships between staff and clients. However, their writings are silent on the balance between sustaining familiar routines and the importance of growth in response to new situations. Furthermore, the Network falls short of addressing the more fundamental structural changes necessary to achieve their stated goals.

Resident-directed care involving agency change

A second level of change noted above addresses the immediate agency structures which reflect the dominance of the medical model in nursing homes. Although Fagan (2003) observes that a "flattened hierarchy" is important to increasing opportunities for meaningful participation by clients and direct care staff, this notion is minimally addressed in the nursing home literature. However, a flattened hierarchy is embedded in and more fully articulated by some strengths-based social work writers in the field of mental health. Among the social workers who have written about this idea, Rapp (1998) provides a useful guide for translation. Rapp's critique of traditional agency structures challenges us to create opportunities to "invert" existing hierarchical structures, with directors at the top and line staff on the bottom and no mention of client anywhere in the organization's structure, to one that places clients at the top of the hierarchy and the directors at the bottom. Rapp asserts that the function of management at any level is not to impose compliance but to help the next higher rung do their job effectively, and effectiveness is measured by achieving client driven outcomes.

In essence, the measures for success of the agency are guided by the goals articulated by clients in their relationships with workers. This emphasis on goal setting, developing means to achieve goals and celebration of success runs directly parallel to the central themes in the literature. While not explicitly identified in this literature, a manager's ability to communicate hope to workers, and workers' hopefulness in their relationships with older residents is a central component to clients achieving their goals which becomes a shared definition of success.

Regenerative community. Fagan's (2003) third approach on creating a "regenerative community" focused on restoring meaning, a sense of belonging, a collective voice, opportunity for growth and service to others suggests a need for a perspective that is in contrast to the medical model. In order to create a "regenerative community", we need to address the connections between nursing home "communities" and the larger communities within which they exist. Clearly, culture change writers acknowledge the existence of ageism in the larger society, but they fall remarkably silent on the connections between the larger social context and its impact on their nursing home communities.

Current writing tends to fragment the problems facing nursing homes by addressing agency issues (funding based on social policy), workers (low wages, no benefits high turnover) or clients (inadequacy of services) as though each segment of the community is facing its own separate barriers. This leads to separating, not creating connections among the members of these communities who may in fact have shared interests. Traditional approaches to policy analysis and research further exacerbate divisions among the segments of the nursing home communities obscuring potential common areas of interest that could be developed to unite clients and their families with staff and management to improve these communities. For example, many gerontological writers focus on policy analysis and advocacy (Blancata, 2004, Cohen, 2004; Hudson, 2004; Kane, 2004; McConnell, 2004; Rother, 2004, Stone, 2004). Each of these authors provides a different analysis of the challenges related to advocacy in aging, but each of them base their critique on one component of the nursing home community, namely the elders and their needs.

Another theme in the nursing home literature is the employment of direct care workers in the industry. Many authors identify an array of challenges faced by nursing homes including low wages, high worker turnover, inadequate staffing, and poor job quality (Lipson, & Regan, 2004; CLTC, 2003; Dawson, & Surpin, 2001, DCA, 2000). What makes these writings more promising is that they have begun to look at connections among various groups in nursing homes. In their national conference proceedings (2003), Citizens for Long Term Care (CLTC) identifies the lack of a national policy for long term care. They state:

Both private and public insurance programs must be redesigned--increasing resources and consumer choice, while ensuring protections for both consumers and direct care staff (emphasis added). Only a system designed around the relationship between the long-term care client and his or her worker will ensure both quality jobs for direct care workers, and quality of service for long term care consumers (p. 3).

This acknowledgement of links between the fate of consumers and those of workers could be used to fundamentally challenge the dominance of the medical model by providing a critique based on the political and economic realities facing both consumers and health care workers. Such an analysis could place social justice at the heart of the "culture change" efforts.

Two groups, CLTC and the Direct Care Alliance (DCA) have initiated analyses that move away from more traditional medically driven models to political and economic analyses that connect the interests of consumers and workers. In its 2003 Executive Summary from its national conference, CLTC makes broad recommendations for ways to address various crises in long term care. While some of the recommendations seem suspect (exploring expanded immigration to increase the direct care workforce), what they do accomplish is to begin to connect low wages, lack of health care and opportunities for advancement to the quality or lack of quality care created by vacancies, turnovers and costs associated with training new staff.

In the emerging critiques of nursing home care where coalition building is emphasized, MSW social workers could play a pivotal role. In order to achieve lasting structural/institutional change, social workers would need to step out of their current narrowly defined roles as case managers and individual client advocates to use community development skills to address linkages between barriers within nursing homes and those in the larger community which create these barriers. Ageism, sexism and racism all converge to create poverty among both nursing home staff and residents. An approach to creating connections between immediate concerns and these broader social issues is exemplified in the work of Jones & Bricker-Jenkins (2002) where research is defined as a political process designed to empower clients to act collaboratively with others to address fundamental issues that create barriers in their lives.

In conclusion, we believe that inserting hope as a criterion for assessing existing and new practice models is one way to redefine the relationships between workers and clients; between workers, clients and agencies; and between their agencies and the larger social systems in which they practice. Practitioners using hope-inducing models that emphasize growth and change serve to energize their encounters at all levels of practice. This energy is central to translating potential into significant change for individuals and social institutions.

References

Atchley, R. C. (1989). A continuity theory of normal aging, The Gerontologist, 29, 183-190.

Blancato, R. B. (2004). Advocacy and aging policy: The prognosis, Generations, 28, 65-69.

Chapin, R. T. (1995). Social policy development: The strengths perspective, Social Work, 40, 506-514.

Cheavens, J., & Gum, A. (2000). Gray power: Hope for the ages, In C. R. Snyder, Handbook of Hope: Theory, Measures and Applications (pp. 201-221). San Diego, CA: Academic Press.

Citizens for Long Term Care. (2003). Long-term care financing and the long-term care workforce crisis: Causes and solutions. Bronx, NY: CLTC & Paraprofessional Health Care Institute.

Cohen, E. S. (2004). Advocacy and advocates: Definitions and ethical dimensions, Generations, 28, 9-17.

Crown, W. (2001). Economic status of the elderly. In R. Binstock & L. George (Eds.), Handbook of Aging and Social Sciences (pp. 352-368) (5th ed.). San Diego: Academic Press.

Dawson, S. L., & Turpin, R. (2001). Direct-care healthcare workers: You get what you pay for, Generations, 25, 23-28.

Deutschman, M. (2001). Interventions to nurture excellence in the nursing home culture, Journal of Gerontological Nursing, 27, 37-43.

Direct Care Alliance. (2000). The launch of the direct care alliance: A report on the conference proceedings. Bronx, NY: Paraprofessional Healthcare Institute.

Dufault, K., & Martocchio, B. C. (1985). Hope: Its spheres and dimensions, Nursing Clinics of North America, 20, 379-391.

Duggleby, W. (2000). Enduring suffering: A grounded theory analysis of the pain experience of elderly hospice patients with cancer, Oncology nursing forum, 27, 825-831.

Fagan, R. M. (2003). Pioneer network: Changing the culture of aging in America, Journal of Social Work in Long-Term Care, 2, 125-140.

Farran, C., Herth, K., & Popovich, J. (1995). Hope and hopelessness: Critical clinical constructs. Thousand Oaks, CA: Sage Publications.

Farran, C., & Popovich, J. (1990). Hope: A relevant concept for geriatric psychiatry, Archives of Psychiatric Nursing, 4, 127-130.

Farran, C., Wilken, C., & Fidler, R. (1995). A study of hope in geriatric patients, Journal of Nursing Science, 1, 16-26.

Fehring, R. J., Miller, J. F., & Shaw, C. (1997). Spiritual well-being, religiosity, hope, depression, and other mood states in elderly people coping with cancer, Oncology Nursing Forum, 24, 663-671.

Forbes, M. A. (1999). Hope in older adults with chronic illness. Advanced Nursing Science, 22, 74-87.

Gray, L. A. (2003). Hopeful thinking within aspects of successful aging: A study of older adults, Dissertation Abstracts International, Volume (Issue), anothernoB. (UMI No. 3100428).

Gubrium, J. F. (1973). The myth of the golden years. Springfield, Ill: Charles C. Thomas.

Herth, K. A., & Cutliffe, J. R. (2002). Concept of hope. The concept of hope in nursing 4: Hope and gerontological nursing, British Journal of Nursing, 17, 1148-1156.

Herth, K. (1993). Hope in older adults in community and institutional settings. Issues in Mental Health Nursing, 14, 139-156.

Herth, K. (1992). Abbreviated instrument to measure hope: Development and psychometric evaluation, Journal of Advanced Nursing, 17, 1251-1259.

Hudson, R. B. (2004). Advocacy and policy success in aging, Generations, 29, 17-25.

Hooyman, N. R., & Kiyak, H. A. (1999). Social gerontology: A multidisciplinary perspective (4th ed.)., Boston: Allyn & Bacon.

Jones, J. C., & Bricker-Jenkins, M. (2002). Creating strengths-based alliances to end poverty, In D. Saleebey (Ed.), The strengths perspective in social work practice (3rd ed., pp.186-212). Boston: Allyn and Bacon.

Klausner, E. J., Clarkin, J. F., Spielman, L., Pupos, C., Abrams, R., & Alexopoulos, G. S. (1998). Late-life depression and functional disability: The role of goal-focused group psychotherapy. International Journal of Geriatric Psychiatry, 13, 707-716.

Kuypers, J. A., & Bengtson, V. L. (1973). Social breakdown and competence: A model of normal aging, Human Development, 16, 181-201.

Lipson, D., & Regan, C. (2004). Health insurance coverage for direct care workers: Riding out the storm, Better Jobs Better Care (Issue Brief, No. 3). Washington, DC: Institute for the Future of Aging Services.

McConnell, S. (2004). Advocacy in organizations: The elements of success, Generations, 28, 25-30.

McGill, J., & Paul, P. (1993). Functional status and hope in elderly people with and without cancer, Oncology Nursing Forum, 20, 1207-1213.

Mead, G. H. (1934). Mind, self, and society: From the standpoint of a social behaviorist. Chicago: University of Chicago Press.

Nekolaichuk, C. L., Jevne, R. F., & Maguire, T. O. (1999). Structuring the meaning of hope in health and illness, Social Science and Medicine, 48, 591-605.

Nekolaichuk, C. L., & Bruera, E. (1998). On the nature of hope in palliative care, Journal of Palliative Care, 14, 36-42.

Rapp, C. A. (1998). The strengths model of case management with people suffering from severe and persistent mental illness. New York: Oxford University Press.

Reynolds, W. E. (2003). Policy values and culture change in long-term care--The role of state government in catalyzing change, Journal of Social Work in Long-Term Care, 2, 397-410.

Roberts, S. L., Johnson, L. H., & Keely, B. (1999). Fostering hope in the elderly congestive heart failure patient in critical care, Geriatric Nursing, 20, 195-199.

Rother, J. (2004). Why haven't we been more successful advocates for elders?, Generations, 28, 55-58.

Rowe, J. W., & Kahn, R. L. (1998). Successful aging. New York: Panthenon.

Saleebey, D. (2002). The strengths perspective in social work practice (3rd ed.), Boston: Allyn and Bacon.

Smalley, R. E. (1970). The functional approach to casework practice, In R. W. Roberts & R. H. Nee (Eds.). Theories of social casework (pp. 79-128), Chicago: University of Chicago Press.

Smith, J. & Freund, A. M. (2002). The dynamics of possible selves in old age, Journal of Gerontology: Psychological sciences, 57B, P492-P500.

Snyder, C. R. (2002). Hope theory: Rainbows in the mind, Psychological Inquiry, 13, 249-275.

Snyder, C. R., Cheavens, J., & Sympson, S. C. (1997). Hope: An individual motive for social commerce, Group dynamics: Theory, research and practice, 1, 107-118.

Stone, R. (2004). Where have all the advocates gone? Generations, 28, 59-64.

Taft, J. (1962). A conception of the growth process underlying social casework practice, In V. Robinson, Jessie Taft: A professional biography (pp.325-342), Philadelphia: University of Pennsylvania Press.

Tennen, H., & Affleck, G. (1999). Finding benefits in adversity, In C. R. Snyder (Ed.). Coping: The psychology of what works (pp. 279-304). New York: Oxford University Press.

Towle, C. (1946). Social casework in modern society, Social Service Review, 20, 165-179.

Vladeck, B. C. (2003). Unloving care revisited: The persistence of culture, Journal of Social Work in Long-Term Care, 2, 1-9

Vladeck, B. C. (1980). Unloving care: The nursing home tragedy. New York: Basic Books.

Westburg, N. G. (2003). Hope, laughter, and humor in residents and staff at an assisted living facility, Journal of Mental Health Counseling, 25, 16-32.

Westburg, N. G. (2001). Older women: Hope and approaches to life, Journal of Adult Development and Aging: Theory and Research, 32, 131-139.

Zorn, C. R. (1997). Factors contributing to hope among noninstitutionalized elderly, Applied Nursing Research, 10, 94-100.

TERRY KOENIG

RICHARD SPANO

School of Social Welfare

University of Kansas