Introduction

Independence is a concept that is not often discussed or defined in the clinical environment as a beginning point of care. You will notice in practice that the nursing assessment of an older person measures their needs with regards to what they can and cannot do for themselves, consequently highlighting dependency. This chapter explores the concept of independence, dependence and interdependence and questions whether any human being is truly independent. It also briefly considers the concept of autonomy and quality of life as each of these concepts are interlinked. Initially it explains why the promotion of independence in old age is important both for nurses and other health and social care professionals.

Policy for promoting active ageing and independence

It has long been acknowledged that what are known as developed countries have an ageing population, and that with this increased age comes increased risk of chronic illness and disability. Both of these place a burden on the economy and health and social care resources of a country, resulting in poor quality of later life for older people. Therefore, as the new millennium approached, global and national political rhetoric changed as plans to reduce dependency in the ageing population were set in motion by governments worldwide.

(See Box 13.1 for some definitions of ageism and age discrimination which will help you to understand some underpinning issues concerning independence in later life.)

The United Nations put forward principles, based on the human rights of older people (Tanner & Harris 2008). These human rights principles were adopted by the World Health Organisation (WHO) and its members, and brought about a change in health policy in many countries.

One initiative that has developed from this initial work has been The Global Alliance for the Rights of Older People (see http://www.rightsalliance.org/ (accessed February 2012)) which has membership from nine international organisations related to older people, including Age UK.

The new policy direction in many countries moved away from a reactive needs-based approach for older people’s health and social care towards a proactive health promotional approach. This supported individuals’ rights to receive interventions that promoted autonomy, independence and activity. The British government of the day introduced the National Service Framework (NSF) for Older People (Department of Health (DoH) 2001) and, later, the report Our Health, Our Care, Our Say (DoH 2006), in which the emphasis was on prevention of chronic illness and disability and early intervention, which had a significant impact on care of people in the community.

Closely linked with the change policy was the goal of promoting independence and wellbeing of older people, with the long-term aim to reduce the cost of caring for an increasing ageing population. This was to be achieved by improved access to health-promotion programmes, and in the use of a multi-agency approach to care and support for older people and, when appropriate, their families and carers (Drennan et al 2005).

The concept of independence

The concept of independence is difficult to define because it has multiple meanings in relation to age, culture and gender. In general, it equates to the absence of reliance on others. People who are independent can be described as being self-governing and self-determining. It can also mean not dependent on others for financial support, and independent in both thought and action. However, the notion of independence is seen as a marker of successful ageing (Secker et al 2003) and in quality of life for older people. Nonetheless, reliance on others does not necessarily suggest unsuccessful ageing.

Similar to independence, successful ageing has multiple meanings. For example, biomedically it includes optimum life expectancy while minimising mental and physical disability, whereas psychosocial healthy ageing is attributed to participation and functioning in daily life and related activities.

The concept of independence appears to have far greater implications for older people than it does for any other age group in British society. For a number of years the focus of global research has been on the burden of an ageing population (Gignac & Cott 1998), the causes of chronic illness and disability and strategies that would help health and social care agencies to cope with the perceived demand. Likewise, medical and social discourse is known to use independence as a term to measure the need for support or care. Hence, independence in health terms is often associated with the ability to function physically, and the assessment of someone’s independence is frequently reduced to how well someone is able to perform the activities of daily living (Smith et al 2007).

It is hard to measure a person’s level of independence because it is a subjective concept and it has a numbers of components, such as physical, psychological, social and economic factors, that all contribute towards an individual’s perceived independence. For many older people, their lived experience is calculated against their desired outcomes and closely linked to their personal identity. However, as people age and their abilities diminish, they make adjustments to their lives so that they can remain independent. Consequently, their perception of independence will vary with the type of activity and the level of adaptation required.

You will at some stage in your placement undertake an assessment of an older person, either in a hospital setting or as part of ongoing assessment in a community context. This latter assessment could be undertaken in the person’s own home or in a care home. In any setting, you will undertake this assessment with the supervision of your mentor.

If using a nursing model such as Roper, Logan and Tierney (Holland et al 2008), you will know that of the five concepts of the model, the dependence/independence continuum and lifespan are two important aspects to be considered in the assessment process. The other three are: activities of living; factors influencing the activities of living; and individuality in living. Roper, Logan and Tierney (Holland et al 2008) also identify five factors influencing the activities of living which are also important in determining both individual needs and care, and which reflect the complexity of how to measure level of dependence in individuals. These factors are biological, psychological, sociocultural, environmental and politicoeconomic.

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