Discussion 5.1

Aging, Frailty, and Resilience Successful aging is a goal that be-comes increasingly salient as one ages. Historically, old age was viewed as a process of decline and so-cial disengagement, notions that gave rise to negative stereotypes of older adults. With more than 12% of the global population older than 60, es-timates project that by 2050 this pro-portion of older adults will increase to 21% (United Nations, 2014). This surge in the aging population has prompted concerns about how the health care, social, and psychological needs of this diverse group will be met. Studies suggest that living to advanced old age may not be the chief goal for many older adults if these aging years are accompanied by chronic disease, recurrent acute illness, and disability (Cramm & Nieboer, 2016). More than 80% of individuals older than 65 have at least one chronic health condition, and the average 75-year-old individual has at least three (Ward & Schiller, 2013). For many, quality of life takes precedent over quantity of years lived, especially if those years are excessively burdened by multimorbidity and dis-ability. Unfortunately, successful aging will elude many older adults because of health disparities or accelerated aging due to hardships arising from adverse circumstances across the life course. Features of successful aging as originally proposed by Rowe and Kahn (1987) that include high levels of physical and mental function, absence of disease and disabilities, and active engagement with life, counteract stereotypes about “usual aging” (i.e., age-related and in-evitable accumulation of chronic con-ditions and functional impairments) and underscore resilience in success-ful aging (McCann Mortimer, Ward, & Winefeld, 2008). However, recent opinions caution against framing suc-cessful aging as the absence of disease, disability, and risk factors and point to signifcant omissions in this model, in-cluding consultation with older adults themselves about these issues (McCann Mortimer et al., 2008; van Abbema et al., 2015). Life course principles in-form human development as a dynamic lifelong process, embedded in histori-cal time and place, and infuenced by the web of social relationships, cul-tural contexts, and structural forces that infuence later life well-being and functioning (Stowe & Cooney, 2015). Hence, it is necessary to consider suc-cessful aging as a holistic process, and not as the sole result of micro-level fac-tors, such as individual behaviors, but also infuenced by macro-level factors that contribute to health-promoting (or health-threatening) environments, including the physical space that is conducive to mobility and safety, em-ployment, education, social interac-tion, and access to resources. The current special issue of the Jour-nal of Psychosocial Nursing and Mental Health Services presents four articles that elaborate on the themes of ag-ing, frailty, and resilience, and offers insights and evidence for factors that contribute to successful aging. Frailty is a topic that has achieved a robust body of scientifc evidence and may be considered the antithesis of successful aging. Frailty has been defned as a bio-logical syndrome represented by mul-tisystem physiological dysregulation and impaired physiological homeosta-sis that creates excess vulnerability to adverse health consequences beyond what might be expected in normal aging (Rodríguez-Mañas & Sinclair, 2014). Frailty has also been widely used as a term to describe someone who is very old, disabled, and afficted with multiple chronic and disabling condi-tions; or ascribed to individuals living in a nursing home. More recent studies on the concept of frailty have consid-ered the fipside of frailty, or resilience. Instead of focusing on the negative aspects of human functioning, there is interest in understanding what fortifes older adults in the face of stressors, as internal and external resources for re-silience would be empowering for older adults and serve as important targets for intervention (van Abbema et al., 2015; Whitson et al., 2016). Two articles in this special issue address frailty and highlight its psy-chosocial and spiritual aspects. Lekan, Hoover, and Abrams (2018) explored perceptions of frailty in focus groups of African American older adults residing in senior public housing. The majority of frailty assessment tools in the litera-ture have been derived from biomedi-cal frameworks (Rodríguez-Mañas & Sinclair, 2014) and developed with-out input about biopsychosocial as-pects from frail individuals themselves. Lekan, Hoover, et al. (2018) found that participants characterized frailty by objective physical features, such as disability, weakness, and imbalance. However, subjective psychosocial as-pects, including positive attitudes, so-cial support, and spirituality, motivate healthy self-care behaviors that foster Copyright © SLACK Incorporated 2

r .J Guest Editorial resilience to not only prevent frailty but also mitigate or reverse its negative effects. Although most participants in the study were classifed as frail based on the single screening marker of gait speed, none self-identifed as frail; they were able to describe their ideas about what it meant to be frail and how to prevent or postpone frailty (Lekan, Hoover, et al., 2018). The second article by Lan, Xiao, Chen, and Zhang (2018) explored meaning in life and life satisfaction in frail Chinese older adults residing in a nursing home. In this study, frailty was determined by the frailty phenotype (e.g., measurement of grip strength, gait Too little stress limits opportunities to adapt, too much stress can be compromising, but just the right amount of stress facilitates adaptation and growth. speed, fatigue, weight loss, and physical inactivity) (Fried et al., 2001; H. Xiao, personal communication, April 27, 2018). A life review intervention was delivered in weekly one-on-one nurse-led sessions that resulted in signif cant improvement in participants’ life satis-faction. Life review is an empowering tool that can be used to strengthen self-affrmations and reconcile and learn from past challenges to achieve feelings of competence as well as greater psy-chospiritual well-being, and has been advocated as a criterion for successful aging (McCann Mortimer et al., 2008). Life review holds potential as a tool to explore individual resilience and resilience-promoting strategies. In the third article in this special issue, which addresses the relation-ships between forced retirement and mental health, Sheppard and Wallace (2018) found that involuntary, forced retirement has a detrimental effect on mental health and poses a consider-able threat to women’s psychological well-being. Retirement is an important benchmark that delineates middle age and older adulthood and marks the transition to the “golden years,” a time that is anticipated to be punctuated by less stress and more opportunities to pursue leisure and personal interests. In this study, forced retirement was related to minority status and age (Sheppard & Wallace, 2018). Notably, a diagnosis of cognitive impairment was reported in a signifcantly greater proportion of forced retirees compared to women who retired voluntarily. Preparing for successful aging through planned re-tirement and resilience enhancement is essential for all women to promote mental health outcomes (MacLeod, Musich, Hawkins, Alsgaard, & Wicker, 2016), but may be particularly impor-tant for minority women and women who have been challenged by socioeco-nomic disadvantages and subjected to the damaging effects of chronic stress (Geronimus, Hicken, Keen, & Bound, 2006). Stress is central to the aging process and human development, and most individuals can think of examples of good stress that has resulted in growth. However, resilience has become in-creasingly recognized as an important life skill that helps cultivate the abil-ity to withstand higher stress loads and promote mental health and well-being (MacLeod et al., 2016; Windle, 2011). Nevertheless, even the most robust sys-tem will be subjected to a force that it cannot endure. One of Aesop’s fables provides a good analogy for resilience and weathering adversity (Simondi, 2017). It describes the mighty oak that is uprooted in a strong wind, while the resilient reed is able to bend without breaking, returning upright after the storm. Too little stress limits oppor-tunities to adapt, too much stress can be compromising, but just the right amount of stress facilitates adaptation and growth. Nurse educators have begun to recognize the attribute of resilience in nursing students as a crucial ele-ment for academic success and a smooth transition into clinical practice (Reyes, Andrusyszyn, Iwasiw, Forchuk, & Babenko-Mould, 2015). In the f-nal article, Lekan, Ward, and Elliott (2018) explore resilience in senior level baccalaureate nursing students, many of whom are older, second-degree students. Nursing students experience unique stressors related to not only the rigor of the nursing curricula but also exposure to intense patient care situations in their clinical practicum. Faculty might anticipate that these older, more mature students would be advantaged by more opportunities to develop a fuller repertoire of resilience strategies to cope with life’s adversities; however, only one third of students were resilient according to the Connor-Davidson Resilience Scale (Connor & Davidson, 2003). Helping nursing students develop resilience fosters the development of habits of practice that buoy academic success. This early re-silience enhancement also provides a foundation for weathering a multitude of challenges in complex clinical con-texts as new graduate nurses and sets the stage for successful aging through-out a long nursing career. The study by Lekan, Ward, et al. (2018) adds to the emerging evidence of the imperative for nurse educators to address resilience enhancement for students in the nurs-ing curriculum, although pedagogically driven, evidence-based teaching inno-vations are still in early stages of devel-opment (Sanderson & Brewer, 2017). JOURNAL OF PSYCHOSOCIAL NURSING � VOL. 56, NO. 7, 2018 3

Guest Editorial The articles in this special issue call attention to important issues across the life span and add to the growing litera-ture on aging, frailty, and resilience in relation to successful navigation of sig-nifcant transitions, such as academic matriculation for professional devel-opment, retirement, and congregate living in older years in community-based and long-term care settings. Research that demonstrates strong linkages among cumulative stress, im-paired resilience, and accelerated ag-ing cautions one to harness protective resources that can be deployed during turbulent times (Geronimus et al., 2006; McEwen, 2003). There is a need to expand our understanding of how individuals of various ages and social circumstances view successful aging and the presumed failure of success-ful aging, frailty (McCann Mortimer et al., 2008). Attributes of successful aging such as life satisfaction, growth, engagement with life, and negotiating independence/interdependence portray a more productive or active aging with implications that later life can be a time of sustained health and vitality despite biological limitations (Martin et al., 2015; van Abbema et al., 2015). The role of resilience needs to be fur-ther explored to learn how individuals “bounce back” and apply adaptive at-titudes and behaviors that allow one to remain physically and psychologically sound, or even to thrive, after expo-sure to stressful events (Whitson et al., 2016; Windle, 2011). Moving forward in our understanding of these concepts requires further research using different study designs and methods of data col-lection in larger scale studies in diverse groups. Developments that are concep-tually grounded and methodologically rigorous will lead to strategies that will improve outcomes for target popula-tions. REFERENCES Connor, K.M., & Davidson, J.R. (2003). Develop-ment of a new resilience scale: The Connor-Davidson Resilience Scale (CD-RISC). Depression and Anxiety, 18(2), 76-82. Cramm, J.M., & Nieboer, A.P. (2016). Is “disease management” the answer to our problems? No! Population health management and (disease) prevention require “management of overall well-being.” BMC Health Services Re-search, 16, 2-6. doi:10.1186/s12913-016-1765z Fried, L.P., Tangen, C.M., Walston, J., Newman, A.B., Hirsch, C., Gottdiener, J.,...McBurnie, M.A. (2001). Frailty in older adults: Evidence for a phenotype. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 56, M146-M156. Geronimus, A.T., Hicken, M., Keene, D., & Bound, J. (2006). “Weathering” and age pat-terns of allostatic load scores among blacks and whites in the United States. American Journal of Public Health, 96, 826-833. Lan, X., Xiao, H., Chen, Y., & Zhang, X. (2018). Effects of life review intervention on life sat-isfaction and personal meaning among older adults with frailty. Journal of Psychosocial Nursing and Mental Health Services, 56(7), 30-36. doi:10.3928/02793695-20180305-01 Lekan, D.A., Hoover, E., & Abrams, S. (2018). Perspectives of frailty among African Ameri-can men and women. Journal of Psychosocial Nursing and Mental Health Services, 56(7), 20-29. doi:10.3928/02793695-20180619-05 Lekan, D.A., Ward, T., & Elliott, A.A. (2018). Resilience in nursing students: An ex-ploration. Journal of Psychosocial Nursing and Mental Health Services, 56(7), 46-55. doi:10.3928/02793695-20180619-06 MacLeod, S., Musich, S., Hawkins, K., Alsgaard, K., & Wicker, E.R. (2016). The impact of resilience among older adults. Geriat-ric Nursing, 37, 266-272. doi:10.1016/j. gerinurse.2016.02.014 Martin, P., Kelly, N., Kahana, B., Kahana, E., Willcox, B.J., Willcox, D.C., & Poon, L.W. (2015). Defning successful aging: A tangible or elusive concept? The Gerontologist, 55, 14-25. doi:10.1093/geront/gnu044 McCann Mortimer, P., Ward, L., & Winefeld, H. (2008). Successful ageing by whose def nition? Views of older, spiritually affliated women. Australasian Journal of Ageing, 27, 200-204. doi:10.1111/j.1741-6612.2008.00305.x McEwen, B.S. (2003). Interacting mediators of allostasis and allostatic load: Towards an understanding of resilience in aging. Metabo-lism, 52(10 Suppl. 2), 10-16. Reyes, A.T., Andrusyszyn, M.A., Iwasiw, C., Forchuk, C., & Babenko-Mould, Y. (2015). Resilience in nursing education: An integra-tive review. Journal of Nursing Education, 54, 438-444. doi:10.3928/01484834-20150717-03 Rodríguez-Mañas, L., & Sinclair, A.J. (2014). Frailty: The quest for new domains, clini-cal defnitions and subtypes. Is this justif ed on new evidence emerging? Journal of Nutri-tion, Health & Aging, 18, 92-94. doi:10.1007/ s12603-013-0433-9 Rowe, J.W., & Kahn, R.L. (1987). Human aging: Usual and successful. Science, 237, 143-149. Sanderson, B., & Brewer, M. (2017). What do we know about student resilience in health pro-fessional education? A scoping review of the literature. Nurse Education Today, 58, 65-71. doi:10.1016/j.nedt.2017.07.018 Sheppard, F., & Wallace, D.C. (2018). Women’s mental health after retirement. Journal of Psychosocial Nursing and Mental Health Ser-vices, 56(7), 37-45. doi:10.3928/02793695-20180619-07 Simondi, T. (2017). Fables of Aesop: A complete collection: The tree and the reed. Retrieved from https://fablesofaesop.com/the-tree-and-the-reed.html Stowe, J.D., & Cooney, T.M. (2015). Examin-ing Rowe and Kahn’s concept of success-ful aging: Importance of taking a life course perspective. The Gerontologist, 55, 43-50. doi:10.1093/geront/gnu055 United Nations. (2014). Population facts: Popu-lation ageing and sustainable development. Retrieved from http://www.un.org/en/ development/desa/population/publications/ pdf/popfacts/PopFacts_2014-4.pdf van Abbema, R., Bielderman, A., De Greef, M., Hobbelen, H., Krijnen, W., & van der Schans, C. (2015). Building from a concep-tual model of the resilience process during ageing, towards the Groningen Aging Resil-ience Inventory. Journal of Advanced Nursing, 71, 2208-2219. doi:10.1111/jan.12685 Ward, B.W., & Schiller, J.S. (2013). Prevalence of multiple chronic conditions among U.S. adults: Estimates from the National Health Interview Survey 2010. Preventing Chronic Disease, 10, E65. doi:10.5888/pcd10.120203 Whitson, H.E., Duan-Porter, W., Schmader, K.E., Morey, M.C., Cohen, H.J., & Colón-Emeric, C.S. (2016). Physical resilience in older adults: Systematic review and development of an emerging construct. Journals of Geron-tology. Series A, Biological Sciences and Medical Sciences, 71, 489-495. doi:10.1093/gerona/ glv202 Windle, G. (2011). What is resilience? A re-view and concept analysis. Reviews in Clini-cal Gerontology, 21, 152-169. doi:10.1017/ S0959259810000420 Deborah A. Lekan, PhD, RN-BC Assistant Professor University of North Carolina at Greensboro School of Nursing Greensboro, North Carolina The author has disclosed no potential conficts on interest, fnancial or otherwise. doi:10.3928/02793695-20180619-01 Copyright © SLACK Incorporated 4 Guest Editorial The articles in this special issue call attention to important issues across the life span and add to the growing litera-ture on aging, frailty, and resilience in relation to successful navigation of sig-nifcant transitions, such as academic matriculation for professional devel-opment, retirement, and congregate living in older years in community-based and long-term care settings. Research that demonstrates strong linkages among cumulative stress, im-paired resilience, and accelerated ag-ing cautions one to harness protective resources that can be deployed during turbulent times (Geronimus et al., 2006; McEwen, 2003). There is a need to expand our understanding of how individuals of various ages and social circumstances view successful aging and the presumed failure of success-ful aging, frailty (McCann Mortimer et al., 2008). Attributes of successful aging such as life satisfaction, growth, engagement with life, and negotiating independence/interdependence portray a more productive or active aging with implications that later life can be a time of sustained health and vitality despite biological limitations (Martin et al., 2015; van Abbema et al., 2015). The role of resilience needs to be fur-ther explored to learn how individuals “bounce back” and apply adaptive at-titudes and behaviors that allow one to remain physically and psychologically sound, or even to thrive, after expo-sure to stressful events (Whitson et al., 2016; Windle, 2011). Moving forward in our understanding of these concepts requires further research using different study designs and methods of data col-lection in larger scale studies in diverse groups. Developments that are concep-tually grounded and methodologically rigorous will lead to strategies that will improve outcomes for target popula-tions. REFERENCES Connor, K.M., & Davidson, J.R. (2003). Develop-ment of a new resilience scale: The Connor-Davidson Resilience Scale (CD-RISC). Depression and Anxiety, 18(2), 76-82. Cramm, J.M., & Nieboer, A.P. (2016). Is “disease management” the answer to our problems? No! Population health management and (disease) prevention require “management of overall well-being.” BMC Health Services Re-search, 16, 2-6. doi:10.1186/s12913-016-1765z Fried, L.P., Tangen, C.M., Walston, J., Newman, A.B., Hirsch, C., Gottdiener, J.,...McBurnie, M.A. (2001). Frailty in older adults: Evidence for a phenotype. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 56, M146-M156. Geronimus, A.T., Hicken, M., Keene, D., & Bound, J. (2006). “Weathering” and age pat-terns of allostatic load scores among blacks and whites in the United States. American Journal of Public Health, 96, 826-833. Lan, X., Xiao, H., Chen, Y., & Zhang, X. (2018). Effects of life review intervention on life sat-isfaction and personal meaning among older adults with frailty. Journal of Psychosocial Nursing and Mental Health Services, 56(7), 30-36. doi:10.3928/02793695-20180305-01 Lekan, D.A., Hoover, E., & Abrams, S. (2018). Perspectives of frailty among African Ameri-can men and women. Journal of Psychosocial Nursing and Mental Health Services, 56(7), 20-29. doi:10.3928/02793695-20180619-05 Lekan, D.A., Ward, T., & Elliott, A.A. (2018). Resilience in nursing students: An ex-ploration. Journal of Psychosocial Nursing and Mental Health Services, 56(7), 46-55. doi:10.3928/02793695-20180619-06 MacLeod, S., Musich, S., Hawkins, K., Alsgaard, K., & Wicker, E.R. (2016). The impact of resilience among older adults. Geriat-ric Nursing, 37, 266-272. doi:10.1016/j. gerinurse.2016.02.014 Martin, P., Kelly, N., Kahana, B., Kahana, E., Willcox, B.J., Willcox, D.C., & Poon, L.W. (2015). Defning successful aging: A tangible or elusive concept? The Gerontologist, 55, 14-25. doi:10.1093/geront/gnu044 McCann Mortimer, P., Ward, L., & Winefeld, H. (2008). Successful ageing by whose def nition? Views of older, spiritually affliated women. Australasian Journal of Ageing, 27, 200-204. doi:10.1111/j.1741-6612.2008.00305.x McEwen, B.S. (2003). Interacting mediators of allostasis and allostatic load: Towards an understanding of resilience in aging. Metabo-lism, 52(10 Suppl. 2), 10-16. Reyes, A.T., Andrusyszyn, M.A., Iwasiw, C., Forchuk, C., & Babenko-Mould, Y. (2015). Resilience in nursing education: An integra-tive review. Journal of Nursing Education, 54, 438-444. doi:10.3928/01484834-20150717-03 Rodríguez-Mañas, L., & Sinclair, A.J. (2014). Frailty: The quest for new domains, clini-cal defnitions and subtypes. Is this justif ed on new evidence emerging? Journal of Nutri-tion, Health & Aging, 18, 92-94. doi:10.1007/ s12603-013-0433-9 Rowe, J.W., & Kahn, R.L. (1987). Human aging: Usual and successful. Science, 237, 143-149. Sanderson, B., & Brewer, M. (2017). What do we know about student resilience in health pro-fessional education? A scoping review of the literature. Nurse Education Today, 58, 65-71. doi:10.1016/j.nedt.2017.07.018 Sheppard, F., & Wallace, D.C. (2018). Women’s mental health after retirement. Journal of Psychosocial Nursing and Mental Health Ser-vices, 56(7), 37-45. doi:10.3928/02793695-20180619-07 Simondi, T. (2017). Fables of Aesop: A complete collection: The tree and the reed. Retrieved from https://fablesofaesop.com/the-tree-and-the-reed.html Stowe, J.D., & Cooney, T.M. (2015). Examin-ing Rowe and Kahn’s concept of success-ful aging: Importance of taking a life course perspective. The Gerontologist, 55, 43-50. doi:10.1093/geront/gnu055 United Nations. (2014). Population facts: Popu-lation ageing and sustainable development. Retrieved from http://www.un.org/en/ development/desa/population/publications/ pdf/popfacts/PopFacts_2014-4.pdf van Abbema, R., Bielderman, A., De Greef, M., Hobbelen, H., Krijnen, W., & van der Schans, C. (2015). Building from a concep-tual model of the resilience process during ageing, towards the Groningen Aging Resil-ience Inventory. Journal of Advanced Nursing, 71, 2208-2219. doi:10.1111/jan.12685 Ward, B.W., & Schiller, J.S. (2013). Prevalence of multiple chronic conditions among U.S. adults: Estimates from the National Health Interview Survey 2010. Preventing Chronic Disease, 10, E65. doi:10.5888/pcd10.120203 Whitson, H.E., Duan-Porter, W., Schmader, K.E., Morey, M.C., Cohen, H.J., & Colón-Emeric, C.S. (2016). Physical resilience in older adults: Systematic review and development of an emerging construct. Journals of Geron-tology. Series A, Biological Sciences and Medical Sciences, 71, 489-495. doi:10.1093/gerona/ glv202 Windle, G. (2011). What is resilience? A re-view and concept analysis. Reviews in Clini-cal Gerontology, 21, 152-169. doi:10.1017/ S0959259810000420 Deborah A. Lekan, PhD, RN-BC Assistant Professor University of North Carolina at Greensboro School of Nursing Greensboro, North Carolina The author has disclosed no potential conficts on interest, fnancial or otherwise. doi:10.3928/02793695-20180619-01 Copyright © SLACK Incorporated 4