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Appraisals of elderly community dwelling women : a qualitative study of their experience of a fall Patterson, Kathryn A. 2003-12-31

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APPRAISALS OF ELDERLY COMMUNITY DWELLING WOMEN: A QUALITATIVE STUDY OF THEIR EXPERIENCE OF A FALL By KATHRYN A. PATTERSON B.A., University of British Columbia, 1993 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE STUDIES The Department of Educational and Counselling Psychology, and Special Education We accept this thesis as conforming to the required standard THE UNIVERSITY <6Y BRITISH COLUMBIA October, 2003 © Kathryn A. Patterson, 2003 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of BjuCdh'^J- aS\d Courl&lllA'K \Sy<svulo<\u . # OMl. The University of British Columbia ^ University Vancouver, Canada Date Qjc,. tfj dOo'b DE-6 (2/88) 11 ABSTRACT Falls represent a major health problem for elderly women. In the present study, I conceptualized a fall as a distressing event and focused on the appraisal process depicted in Lazarus and Folkman's (1984) transactional model. Meaning is a key element in the appraisal process, thus I drew on the Satir Model because it offers a method for accessing the meaning elderly women make of a fall and ongoing concerns about falling in terms of their behaviors, feelings, perceptions, expectations, and yearnings. Fourteen community dwelling women, aged 75 to 94, took part in one of three 1 to 1.5 hour focus group meetings. Eleven of these women participated in a follow-up 1.5 hour personal interview. The focus groups and interviews were audio-taped and transcribed. The text was analyzed by means of the constant comparative method used in grounded theory (Strauss & Corbin, 1990). Data analysis methods included open coding, constant comparative analysis, and memo writing. Additionally, attention was paid to theoretical sensitivity throughout the analysis. Results revealed that, for the women in the study, there were complex psychological processes connected to the fall. From the women's descriptions, five meta-themes emerged representing the fall itself, the context of the fall, the wants that were at stake because of the fall, the changes related to the fall, and factors contributing to resistance and compliance of those fall-related changes. The meaning they made of the fall was suffused with feelings, perceptions, and expectations. Although yearnings were difficult to determine, behaviour played a key role in the meaning made of the fall. According to the women's accounts, the fall was distressing; however, they did not consider fall-related changes and limits as daily hassles. Instead, they placed an emphasis on adjusting to these changes and limits and moved forward with their lives. The findings highlighted the systemic, interactive nature of the appraisal process and the iceberg framework of the Satir Model. Understanding some of the psychological consequences of a fall within the context of these women's lives provides valuable information to help counselling psychologists when working with elderly women who have experienced a fall. J 111 TABLE OF CONTENTS Abstract ii Table of Contents iiList of Figures vDedication vii CHAPTER ONE: INTRODUCTION 1 CHAPER TWO: LITERATURE REVIEW 4 Falling in Old Age 4 Context: The Elderly 7 Elderly Women 11 Theoretical Overview: Stress and Coping Theory 12 Daily Hassles as Stressors 15 The Appraisal Process 6 Stress Discourse 8 Stress and Coping: Empirical Research 9 Stressors in old ageThe Appraisal Process in Old Age 22 The Satir Model 24 Conclusion 7 CHAPTER THREE: METHOD 30 Participants '. : 3Recruitment 3Procedure and Data Collection 1 Screening Interview 2 Focus GroupsFollow-up Interviews 4 Information Session 35 Ethical ConsiderationsData Analysis 6 Reflexivity 8 Interpretive Analysis of the Iceberg of the Satir Model 39 Windshield Survey 40 Biographies and Vignettes of Participants' falls 41 CHAPTER FOUR: RESULTS 8 Overview of Themes 4The Fall: The Story of an Unpleasant Event 51 Contextual 54 Contextual: Expectations of Aging 5 Contextual: Supportive Relationships 7 Contextual: The World is Still Open for Seniors 60 Wants 6Wants: Staying in the World 61 Wants: Doing for Self 2 Changes 64 Changes: Changing Perception of the Environment 6Changes to Lifestyle 65 Lifestyle disrupted vs. changing lifestyleBeing slow and careful 6 Using tools 7 New ways of functioning 68 Accepting helpChanging environmentsIncorporating exercise 9 Changes: Shifting Perception of Self 6Changes: Cultivating an Attitude 73 It is the attitude more than the physical 74 Using beliefs.. 7Carrying on 5 Making the best of things 6 Comforting self 7 Gaining perspective 8 Determined to heal 79 Resistance and Compliance 80 Resistance and Compliance: Pushing Self 8Resistance and Compliance: Fearing Future Falls 81 Rules 2 Interpretive Analysis of the Satir Model 4 Behaviour 6 Feelings 8PerceptionsExpectations : 7 Yearnings 8 Systemic Nature of the Iceberg 8CHAPTER FIVE: DISCUSSION 93 Falls 9Stress, Appraisal, and Coping 7 The Iceberg of the Satir Model 9 The Participants' Influence on the Researcher 101 Limitations 102 Implications for Practice 103 Suggestions for Future Research 5 Conclusion 6 REFERENCES 108 Appendix A: Personal Iceberg Metaphor 113 Appendix B: Informed Consent 114 Appendix C: Screening Protocol 7 Appendix D: Focus Group Protocol 118 Appendix E: Demographic Questionnaire 120 V Appendix F: Summaries of the focus group meetings 121 Appendix G: Follow-up questions for participants' interviews 124 Appendix H: Interview Protocol 127 Appendix I: Referral List 9 Appendix J: Windshield Survey 131 Appendix K: King Bruce and the Spider 132 VI List of Figures Figure 1. The three areas of literature that combine to form the research question: What meaning do elderly community dwelling women make of a fall in terms of their feelings, perceptions, expectations, and yearnings? 29 Figure 2. Overview of the meta-themes and themes that emerged from the elderly women's descriptions of the meaning of the fall 50 Figure 3. Interpretive analysis of the iceberg of the Satir Model indicating the components of the iceberg and corresponding themes. The corresponding themes are noted in brackets. The components are systemic 85 Figure 4. Interpretive analysis of the iceberg of the Satir Model indicating the themes and elements of themes related to "doing for self within the iceberg framework. The components of the iceberg are systemic 90 For my Granny woman who has strength of character And who has been my inspiration. 1 CHAPTER ONE INTRODUCTION Falls represent a major health problem for the elderly (Drozdick & Edelstein, 2001; Resnick, 1999; Shumway-Cook, Baldwin, Polissar, & Gruber, 1997; Tideiksaar, 1997; Tinetti, Speechley, & Ginter, 1988). However, despite falls being a major health concern for older people, the literature on the psychological consequences of a fall is sparse. Based on his vast clinical experience in dealing with falls in older adults, Tideiksaar (1997) suggests that some of the psychological effects of falling may include: depression, shame, loss of confidence, anxiety, and fear. In order to gain a holistic understanding of falling in old age, there needs to be a deeper, empirically based, understanding of the psychological implications of a fall within the context of elderly people's lives and their aging bodies. The likelihood of falling increases as one becomes more advanced in age (Tideiksaar, 1997) and, as Estes et al. (2001) indicate, old women tend to outlive and outnumber old men. If there are to be more women living to advanced ages, it suggests the importance of understanding what it is like for elderly, community-dwelling women to experience a fall. In fact, elderly women make up the majority of the participants for many of the studies on falls and fear of falling (Drozdick & Edelstein, 2001; Resnick, 1999; Shumway-Cook, Baldwin, Polissar, & Gruber, 1997; Tideiksaar, 1997; Tinetti, Speechley, & Ginter, 1988). Exploring the experience of a fall as well as the potential ongoing concerns about falling for elderly women may provide insight into contexts that create disharmony between the elderly women and their environments. This may have implications (e.g., difficulties maintaining independence) for women living in the community. According to Cavanaugh and Blanchard-Fields (2001), one way of interpreting the person-environment interaction is through the use of Lazarus and Folkman's (1984) transactional model of stress and coping. In terms of the transactional model, a fall can be described as a stressor if it is a specific event that is appraised as taxing and leads to a negative emotional reaction. The ongoing concerns elderly women may have about falling can be described as daily hassles because these concerns may impede or limit daily functioning. 2 The appraisal process is an important part of the stress process and it is closely connected with the meaning a person makes of a situation. Lazarus (1998) defines appraisal as an evaluation of the significance of what is happening for our well-being. "The person and the environment interact, but it is the person who appraises what the situation signifies for personal well-being" (Lazarus, 1999, p. 12). In other words, the extent to which an encounter between the person and the environment is stressful depends on the meaning an individual gives to that encounter (Folkman et al., 1991; Gruen, Folkman, & Lazarus, 1988). Without personal meaning, the situation may not be deemed stressful at all; therefore, exploring the meaning a fall has for an elderly woman's well-being may provide insight into what appraisals this population makes of a fall. Although Lazarus and Folkman's (1984) transactional model suggests that the meaning a person makes of an event impacts the appraisal process, the model does not offer a specific method for determining meaning. The Satir Model (Satir, Banmen, Gerber, & Gomori, 1991), a counselling model, has many components that make it an appropriate tool to assist the researcher in exploring the meaning-making process. According to Banmen (2002), most human experience is internal. Moreover, Banmen suggests a way of accessing a person's internal experience is through the use of the personal iceberg metaphor of the Satir Model (see Appendix A). That is, the intrapersonal components of the iceberg, specifically one's feelings, perceptions, and expectations, may account for the individualistic nature of the appraisal process. The universal component, one's yearnings, may account for what makes a situation or event important for a person. Therefore, exploring the meaning an elderly woman makes of a fall through the use of these components of the Satir Model enables us to encompass important aspects' of the appraisal process. The subjective nature of the meaning-making process and the unique lives of elderly women suggest the importance of understanding their experiences from their perspectives. Therefore, a methodological approach that allows exploration of the phenomenon of interest from the perspective of the elderly women is warranted. Exploring falls and ongoing concerns about falling in terms of elderly women's own descriptions may provide insight into the appraisals of these women. Understanding 3 whether a fall is stressful and, if so, what makes it stressful for elderly women has value for the design and implementation of falling-related counselling interventions with this population. The purpose of this study is to gain insight into the appraisals of elderly community dwelling women who have experienced a fall. Focusing on a specific stressful event, a fall, allows participants to describe the experience in detail, thus increasing the likelihood of obtaining rich information about the phenomenon of interest, specifically, information related to the context of the elderly women. A qualitative approach drawing on focus groups and in-depth interviews was used to understand what the experience of a fall was like for elderly women. A large part of determining the appraisals an elderly woman makes with regards to falling requires an understanding of what meaning she makes of the fall and of ongoing concerns about falling. Using the Satir Model, my goal was to answer the question of what meaning elderly community dwelling women make of a fall in terms of their feelings, perceptions, expectations, and yearnings. 4 CHAPTER TWO LITERATURE REVIEW Despite the increase in the aging population and the likelihood of the aged to fall, research on the psychological impact of falling in old age is sparse. Furthermore, there is a dearth of research on the appraisals elderly women make of potentially stressful events such as a fall. Therefore, in hopes of contributing to an area that lacks research, the purpose of this study is to gain an understanding of the appraisals of elderly community dwelling women who have experienced a fall. In the following sections, I first review the literature on falls. Next, what we know about the aging population, specifically the population of elderly women, is reviewed to provide a context for the experience of falling. In order to provide a framework to understand the fall, the conceptualization of stressors, hassles, and appraisals in terms of Lazarus and Folkman's (1984) transactional model is described; first, in terms of a theoretical overview of the model and, subsequently, in terms of empirical research. From this theory, I argue that a focus on the appraisal process will lead to a better understanding of the psychological consequences of a fall. Finally, I argue that the Satir Model offers a way of accessing the appraisals of these women. Focusing on each of the aforementioned areas helps highlight the importance of studying appraisals of elderly community dwelling women with regards to falling. Falling in Old Age Falls are a major health problem among the elderly (Drozdick & Edelstein, 2001; Resnick, 1999; Shumway-Cook et al, 1997; Tideiksaar, 1997; Tinetti et al, 1988). According to Tideiksaar (1997) a fall is defined as any event that results in a person coming to rest inadvertently on the ground or other lower level. In a one-year prospective study of risk factors for falls among community dwelling men and women over 75 years of age, Tinetti et al. (1988) concluded that over 30% of the 336 participants had fallen at least once. Women make up the majority of the participants in most of the studies on falls and fear of falling in the elderly (Drozdick & Edelstein, 2001; Murphy & Tickle-Degnen, 2000; Peterson et al, 1999; Resnick, 1999). Tideiksaar (1997) suggests that the apparent tendency for women to fall more frequently 5 than older men may be due to older women reporting their falls more often or to the fact that older women more often live on their own. Although women may be reported to fall more than men, in a theoretical paper on elderly women and falls in the home, Schlapman (1990) suggested that disadvantaged social status, difficulties being assertive, and viewing themselves as powerless may contribute to elderly women being less likely to seek help after a fall. Therefore, a specific focus on falls in elderly women may be warranted. Furthermore, a North Shore falls prevention project has identified seniors at high risk for a serious fall are community dwelling women, aged 75 - 84 living in North and West Vancouver (North Shore Health). Falls among elderly women can be attributed to internal or external causes. Some internal causes include visual and hearing impairment, impairment in balance control mechanisms, skeletal and joint mobility changes that occur with aging, neurological changes, acute illness, and, changes in gait. Some external causes include hazardous indoor and outdoor environments (e.g., slippery floors or uneven sidewalks), medication that may cause dizziness or drowsiness, and alcohol misuse (Resnick, 1999; Schlapman, 1990; Shumway-Cook et al., 1997; Tideiksaar, 1997). Factors associated with how or why individuals fall may be multiple and interrelated. In a descriptive study of 220 older men and women (mean age 86 years) living in a continuing care retirement community, Resnick (1999) found that falls occurred mostly in the home setting and mainly when walking or when transferring from one surface to another. In addition, Resnick (1999) found that cardiac problems, neurological impairment, living on one's own, and failing to adhere to a regular exercise program were factors associated with multiple falls. There are physical and psychological consequences of falls for elderly women. Possible physical injuries as a result of a fall include fractures, head trauma, soft tissue injuries, and abrasions (Tideiksaar, 1997). Falls may not always result in injury but they often begin a downward spiral leading to activity restriction, isolation, and loss of independence (Shumway-Cook et al., 1997; Tideiksaar, 1997). Based on his extensive clinical experience with elderly individuals who experience falls, Tideiksaar (1997) suggested that some of the psychological effects of falling might include: depression, shame, loss of confidence, anxiety, and fear. Moreover, he posited that, for elderly people, a fall may be their initial 6 confrontation with frailty and threaten their independence; or, lead to worries about how a fall will impact loved ones who care for them. A potential consequence of a fall that has recently gained attention in the literature is fear of falling. Fear of falling may be an ongoing concern that ultimately limits an older person's performance of daily activities and decreases quality of life (Legters, 2002; Tideiksaar, 1997). Although fear of falling may be a consequence of a fall, fear of falling is distinct from the experience of a fall because it can be present in an older adult who does not have a history of falling (Legters, 2002; Murphy & Tickle-Degnen, 2000; Peterson etal, 1999). Yardley and Smith (2002) conducted a prospective study of the relationship between feared consequences of falling and avoidance of activity in community dwelling men and women aged 75 years and older. The aim of their study was to identify the most commonly feared consequences of falling and to determine whether these motivated avoidance of activity for the elderly participants. In their study, a questionnaire was completed to assess feared consequences of falling. Their results revealed two dimensions related to the perceived negative consequences of falling. The first dimension related to physical harm and eventual incapacity and. loss of independence. The second related to social embarrassment and indignity and consequent damage to personal confidence and identity. Although Yardley and Smith's (2002) study yields some important findings concerning psychological consequences of a fall, due to the use of a questionnaire to collect the data it is difficult to understand the experience of a fall in the context of the participant's lives. In addition, their study does not reveal what is at stake for the participants if they fall, what meaning the fall may have for them, or whether a fall is a central concern in their lives. In their study on correlates of fear of falling in men and women over the age of 60 (the mean age was 74.35 years) who have experienced a fall, Drozdick and Edelstein (2001) conceptualized a fall as a stress-related health problem. They suggested that coping with a fall could be a variable that may explain which elderly people develop fear following falls; specifically, that use of avoidance as a coping strategy may be higher amongst those who have a greater fear of falling. They used the Ways of Coping Checklist - Revised that was developed by Vitaliano, Russo, Carr, Maiuro, and Backer (1985) to assess coping after 7 a fall. As is the case with most checklists, there is no contextual information to suggest the reason behind adopting certain coping strategies. Drozdick and Edelstein (2001) researched fall-related data on coping; however, none of these data gave an indication of the participant's internal states or thought processes. Analysis of variance revealed that there was no difference in coping strategies adopted by fearful and non-fearful fallers. Perhaps they may have had a different outcome if more than a self-report checklist had been used or if they had more of a focus on those individuals over the age of 75. Despite these limitations, Drozdick and Edelstein's (2001) conceptualization of falling as a stress-related problem suggests that the stress and coping framework may warrant attention in understanding falls. Focusing on the appraisals elderly women make of a fall as well as ongoing concerns about falling may provide valuable insight with regards to what is at stake for this population as well as what meaning they make of the event. Summary. Falls are a major problem for elderly women; therefore, increased understanding is needed with regards to what a fall and ongoing concerns about falling mean to elderly women. Gaining insight into the psychological processes with regards to a fall and ongoing concerns about falling may present ways to encourage elderly women's help seeking behaviour. Furthermore, a better understanding of falling-related beliefs may maximize acceptability, uptake, and adherence of fall-related counselling interventions for elderly women (Yardley & Smith, 2002). There are factors related to the context of the lives of the aging population and aging women, in particular, that may be relevant to falls in the older population. By conceptualizing falling as a stress-related problem, we are able to tap into a stressor that is representative of a person's stage of life. Context: The Elderly Life expectancy is increasing for both men and women and the proportion of elderly people in Canada is on the rise (Gutman, Wister, Carriere, & Tredwell, 2000). Therefore, to gain an increased understanding of what it means to be old in our society, it is important to examine the experience of elderly people. The elderly do not exist in a vacuum; therefore, research involving the aging population comes with the need to understand the context of their lives as well as how they perceive themselves and their environments. 8 There is a paucity of research focusing on individuals over 75 years of age. This may be due, in part, to factors associated with studying this age group that may make data collection more difficult. For example, participants may be experiencing visual decline or hearing loss, or may need to be screened for dementia. Regardless of these difficulties, it is imperative to gain a greater understanding of individuals over the age of 75 because this segment of the population is rapidly increasing (Gutman et al, 2000). A more thorough understanding of the elderly will hopefully lead to insight into appropriate clinical interventions, ways social policy might need to be changed with reference to this population, as well as insight into how society can work to improve the quality of life for individuals over 75 years of age. According to Butler and Lewis (1982), the selection of 65 years of age as the demarcation between middle and old age is an arbitrary marker adhered to for social purposes to determine the point of retirement and the point at which social services begin. With time, the marker of 65 years of age seems to have gained power and become fixed in Western society as the divider between young and old. The term elderly may be defined as individuals over 65 years of age; however, a majority of the research literature makes a distinction between the young-old and the old-old. The former descriptor refers to individuals between the ages of 65 and 74 and the latter refers to individuals over the age of 75. It is likely that as the population ages more terms to describe the elderly may evolve. For the purpose of this study, the term elderly refers to those individuals aged 75 years and older. Chronological age alone is not sufficient to describe the elderly population because people over 75 years of age make up a diverse segment of the population. Butler and Lewis (1982) refer to chronological age as a convenient, yet frequently inaccurate descriptor of an individual. Upon considering the variations in the elderly population coupled with the assumption that age-related changes are not the same for everyone, it becomes evident that although chronological age may be the marker indicating old age, chronological age itself is an inadequate descriptor of aging. On the other hand, chronological age is not totally without meaning, it does offer certain information with regards to the historical context of individuals. Date of birth indicates a common bond between individuals that can be described as one's cohort. Gatz (1998) describes cohort as the historical period within which one is born, matures, and ages. She believes that age and cohort are inextricably linked, 9 making it difficult to separate one from the other. People of a similar age share societal history. Many of those individuals who are presently 75 years and older have witnessed the evolving labor movement, the child labor laws, and women's suffrage. They have lived through two world wars, the Great Depression of the 1930s, industrialization, automation, and the evolution of technology. Although cohorts share the history of the larger world, individuals within the cohorts are highly diversified. Individuals of the same age are shaped by their own personal histories, family environment, and personality characteristics (Butler & Lewis, 1982). Changes occurring in old age can be conceptualized as biological, sociocultural, or related to how people interact with the environment (Vandenbos, 1998). The biological sphere includes physical and cognitive changes. For the elderly, it is the biological changes specific to advanced age that allow them to be recognized as a unique segment of the population. In addition, it is the biological changes that may contribute to the increased likelihood of people experiencing falls as they reach advanced ages. Physical changes occurring with age that may increase a person's risk of falling include changes in muscles, bones, joints, and sensory functioning. One's height normally decreases with advanced age and there may be a shift in where one carries weight (Cavanaugh & Blanchard-Fields, 2002; Whitbourne, 1998). With age, decreases in the amount of muscle may lead to decreases in strength and endurance and there may be deterioration of the protective cartilage in the joints, resulting in painful movements. The decline in joint functioning coupled with weakening of the muscles may result in less effective mobility. Changes in sensory functioning include declines in vision and hearing; however, the degree of impairment does vary from person to person. In addition, an older person may experience dizziness and vertigo due to changes in the vestibular system (Cavanaugh & Blanchard-Fields, 2002). According to Whitbourne's (1996) multiple threshold model of aging, the point at which an individual recognizes his or her age-related change can be referred to as the "threshold." Therefore, physical age-related changes may contribute to individuals viewing themselves as elderly. Changes in mobility and sensory functioning may increase the likelihood of an older person falling and may impact an individual's activities of daily living (Tideiksaar, 1997). Activities of daily living refer to basic self-10 care tasks such as eating, bathing, walking, and dressing; in other words, activities indicating whether individuals are able to function independently. According to Vandenbos (1998), the interrelationship between physical changes and psychological functioning takes on a more central role as one reaches advanced age. Cavanaugh and Blanchard-Fields (2002) suggested that the way our body is functioning tells us something about how we are doing; therefore, if our physical health and functioning are declining, it may lead to certain psychological reactions that impact how we perceive ourselves and our environments. For example, if an elderly person experiences a fall it could be the first time that person is confronted with her own frailty and it could lead to depression, shame, loss of confidence, anxiety, or fear (Tideiksaar, 1997). Cognitive processes are also affected by age; however, there is not the vast decrease in intellectual functioning that once was thought to occur in old age. In fact, elderly people may have improved judgment, accuracy, and general knowledge when it comes to intellectual functioning (Butler & Lewis, 1982). The elderly appear to have a slowed reaction time and their selective attention may be reduced when there are distractions present (Whitbourne, 1996). A slowed reaction time and reduced capacity for selective attention may contribute to a fall by making certain environments more hazardous for an elderly person (i.e., crowded places or activities that are fast paced). Biological changes are just one facet of the changes occurring with advanced age. Changes may also take place in the sociocultural sphere of a person's life (Vandenbos, 1998). Sociocultural change includes changes in social network and changes in family structure. As a person ages and needs more help with activities of daily living, there may be a shift in the relationships within the family. Familial relationships may take on more importance as a person reaches an advanced age. Many studies indicate that families are involved in providing care for their elderly members, playing an essential role in allowing frail elderly people to continue living in the community (Blasinsky, 1998; Blieszner & Alley, 1990; Connidis, 1989; Cummings et al, 1998; Demers & Lavoi, 1996; Kaasalainen, Craig, & Wells, 2000; Schmall & Pratt, 1989). Furthermore, Golden and Saltz (1997) refer to governmental pressure to decrease funding for health care and social services pertaining to the elderly, a social trend that will inevitably place more responsibility on the family to provide support for its elderly 11 members. Changes in family relationships may contribute to the psychological impact of a fall for an elderly person. Another realm of changes for the elderly population is that of their interaction with the environment. As age increases there may be changes in the way people interact with their environments. Due to health declines, an elderly person may not be able to interact as efficiently with the physical environment; for example, negotiating stairs may become a problem. Reduced efficiency within one's physical environment may increase the likelihood of falling. Furthermore, falls may result in elderly people restricting their participation in activities (Murphy & Tickle-Degnen, 2000; Tideiksaar, 1997), perhaps altering their involvement with family, friends, or community and, thus, changing their interaction with their social environment. Summary. Because life expectancy is increasing, it is vital to understand the experiences of the elderly in our society. The vast array of changes occurring in people's bodies and their environments may contribute to, and provide the context for, the experience of a fall. Understanding the context of their lives and their aging bodies may be the first step in determining what supports elderly people need. Perhaps counselling psychologists would be able to provide more adequate support for elderly people who have fallen if they have a better understanding of how changes occurring in late life affect the elderly person's experience of a fall. Elderly Women Estes et al. (2001) indicated that women who are 80 years and older comprise the fastest growing age group. She refers to this phenomenon as the "feminization of the older population" and concludes that aging is a gender issue because old women tend to outlive and outnumber old men. Findings from the 1996 Canadian Census revealed that more women than men live alone. These findings may be attributed to the gap in life expectancy, men marrying younger women, and men having a higher rate of remarriage than women (Gutman et al., 2000). For elderly women, the need for lifestyle adjustments such as adapting to independent living after the death of a spouse may influence what meaning they make of a stressful experience, specifically a fall. Furthermore, given women's greater longevity, they may 12 experience greater age-related declines than men and may be at greater risk for a fall than elderly men (Schlapman, 1990). Gingold (1992) suggests that due to the combination of ageism and sexism, the low profile in the community held by elderly women may result in their particular needs being ignored. Women who are presently 75 years and older may be a particularly vulnerable segment of the population because they are a segment of the population who, for the most part, played a large role in family life by staying at home to look after children. If they worked outside the home, women generally earned less than men, holding lower status jobs or lower paying jobs. Furthermore, many tended to work in the home or to work part time, therefore, not qualifying for pensions (Novak, 1988). As a result of lack of participation in the workforce coupled with the propensity to live longer than their husbands, women are more likely to experience a disadvantaged economic status when they are older (Estes, 2001). The 1996 Canadian Census supports this theory with the findings that, with regards to the elderly population, there are almost twice as many women than men living below the poverty rate. For women who are currently over the age of 75, negotiating the changes occurring with advanced age may be made more difficult if they are facing financial uncertainty. Therefore, it is imperative that the needs of elderly women who have experienced a fall not be ignored. Summary. The tendency for women to outlive men coupled with the likelihood of falling increasing as one ages suggests the need to focus on the experience of falling for elderly women. To accurately capture the experiences of elderly women, the individualistic nature of changes occurring in their lives must be taken into account. The variability of their life contexts, personal histories, and personal characteristics suggests the importance of understanding the experiences of elderly women from their own perspectives. Understanding the context of elderly women's lives may provide insight into what problems they may experience when interacting within their environments. Theoretical Overview: Stress and Coping Theory Conceptualizing the experience of a fall in terms of a stress and coping framework may facilitate the interpretation of the person-environment interaction (Cavanaugh & Blanchard-13 Fields, 2002). In the last 20 years, there has been a considerable amount of research focused on psychological stress. Lazarus and Folkman's (1984) transactional model of stress and coping provides a framework that has been explored in relation to numerous populations, for example, different cultures, minorities, students, women in the workforce, and bereaved caregivers (Aldwin, 1994; Long & Cox, 1997; Long, 1998; Slavin, Rainer, McCreary, & Gowda, 1991; Stein, Folkman, Trabasso, & Richards, 1997). Thus, suggesting the transactional model has a certain universality that makes it an appropriate framework in which to explore the interactions of the elderly in their environments. According to the stress and coping model postulated by Lazarus and Folkman (1984), stress is defined as a relationship between a person and his or her environment in which the person appraises the demands of the environment as taxing or exceeding his or her resources (Lazarus & Folkman, 1984). Within this framework, coping is defined as ongoing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person (Lazarus, 1993). The appraisal process is an important part of the transactional model. According to Lazarus (1998), cognitive appraisal refers to the evaluation of the significance of what is happening for our well-being. Cognitive appraisal is comprised of primary appraisal (e.g., what is at stake for the individual) and secondary appraisal (i.e., his or her ability to cope with the situation). In determining what is at stake, an individual's primary appraisal takes into account the meaning of the situation in terms of his or her well-being. Part of that meaning is the recognition that the individual's resources are about to be taxed. Secondary appraisal reflects a judgment about what can be done to deal with the situation that has been interpreted as a threat, harm/loss, or challenge (e.g., primary appraisals). The appraisal and coping process are interdependent because one cannot occur in the absence of the other. For example, in determining the stress appraisal an individual takes into account what resources are available to deal with that situation. Depending on the particular appraisal of the event, the individual will respond with coping strategies. The present study focused primarily on the appraisal of a source of distress for the elderly, specifically, what meaning is made of a fall. . 14 In Lazarus and Folkman's (1984) transactional theory, stressors, coping, and appraisal are linked in an intricate puzzle of interdependency. Keeping in mind that these parts of the stress process do not occur in isolation, it may be necessary to closely examine and understand the various parts of the process before understanding the stress process as a whole. A solid understanding of each facet of the stress process may be a better strategy than attempting to understand the whole process at once. Therefore, an in-depth exploration of appraisals, a key aspect of the stress response might allow us to gain a better understanding of the whole picture. According to Lazarus (1999), too much research is a-contextual. He posits that the situational context needs to be taken into account. Therefore, there is the need to acknowledge the interconnections and interdependences between the person and her environment. Viewing the concept of stress as a transaction between a person and her environment lends itself to a systems approach because there are a number of sub-systems at work in both the person and in her environment, any one of which may influence the stress process. The way a situation is appraised varies from person to person; therefore, individuals might view the same situation quite differently. There may be different interconnections and interdependencies within the person and that person's environment, making it imperative to take individual variability into account. As Pearlin (1989) argues, a person's context needs to be taken into consideration because life does not occur in a vacuum. Each person is unique with different experiences and characteristics; therefore, it is important to understand the stress process from the participant's point of view rather than have the researcher impose his or her own assumptions about how the participant may experience the world. There are many variables that may influence the stress response in individuals, suggesting that, when studying the stress process, there is the need to adopt an approach that allows individual differences to emerge. Taking a participant's context into consideration and exploring the meaning of a particular stressor (e.g., a fall) is a task suited to qualitative research (Aldwin, 1994). Summary. Lazarus and Folkman's (1984) transactional model provides a framework for exploring how elderly women interact with their environments. Studying the constantly changing interplay between an older woman and her environment allows for the investigation of conditions that 15 create disharmony between her and her environment (Lazarus, 1990). By studying the stress process of elderly women, specifically how elderly women view a fall, we may gain insight into how elderly women perceive and interact within their environments. Daily Hassles as Stressors Stressors have been conceptualized as life events and as daily hassles. Life events are described as identifiable changes in life patterns that disrupt an individual's usual behaviors (e.g., retirement from the workforce) whereas daily hassles are described as irritating, distressing everyday occurrences (e.g., missing the bus) (Lazarus & DeLongis, 1983). Although there is a distinction between life events and daily hassles, the two are not mutually exclusive. For example, one could experience a life event, such as the death of a spouse, and this life event could result in daily hassles in the form of financial strain due to loss of income. Daily hassles tend to be associated with current concerns a person is facing, which may lead to a shift in the types of hassles reported across the life span (Aldwin, 1992; Folkman, Lazarus, Pimley, & Novacek, 1987; Lazarus & DeLongis, 1983). For example, elderly women who are no longer raising children are less likely to report family-related hassles; however, they are probably experiencing declining health and are more likely to report hassles that are health-related. A fall may become a daily hassle if ongoing concerns about falling or injury sustained from the fall impede daily life. Daily hassles occur with more frequency than life events and, therefore, have the potential to impact one's life to a greater extent. Furthermore, daily hassles are reported to be more strongly associated with psychological symptoms than major life events (Holahan, Holahan, & Belk, 1984; Lazarus, 1990). In fact, in a study of 32 community dwelling men and 32 community dwelling women, Holahan, Holahan, and Belk (1984) examined the relationships among life stress, daily hassles, and perceived self-efficacy in adjustment to aging and found that daily hassles were more indicative of psychological distress for women than for men. Gruen, Folkman, and Lazarus (1988) posited that there are individual differences in personal significance of daily stressful events, that not all daily hassles are of equal significance for the person, and that those reflecting important themes in one's life may have more impact on the person. Central hassles are related to important patterns of goals, beliefs, and commitments. What is central for one person is not 16 necessarily central for another; it depends on how a person appraises the situation. Therefore, in order to be true to the individual differences among the elderly, a qualitative research approach may be needed. What is important to an individual cannot be assumed; therefore, as Gruen et al. (1988) suggested, procedures for measuring daily stress should differentiate between central and non-central experiences. If a qualitative approach is adopted, then participants could be asked about the importance of an experience in their lives, thus determining how central an experience it is for them. For example, falling may differ in terms of its centrality for elderly women, depending on the appraisal of the experience. Summary. The experience of a fall may provide age appropriate insight into how elderly women perceive a daily hassle. Declining health is a theme common in the lives of the elderly (Cavanaugh & Blanchard-Fields, 2002; Whitbourne, 1998); therefore, a fall as well as ongoing concern about falling may be a central daily hassle for an elderly woman because it touches on the theme of her health. In addition, declining health may mean that a person is not as mobile as she once was and, according to Pearlin and Skaff (1996), everyday hassles may be emphasized if one has physical limitations. Although many elderly women may have had falls, each experience of a fall may vary considerably from person to person; suggesting a need to uncover individual experiences of falls. The Appraisal Process In order to establish a deeper understanding of how elderly women view potential stressors (e.g., a fall), it is necessary to take into account their appraisal of the situation or event. Primary appraisal is closely connected with how one views a situation (e.g., what meaning a person makes of a situation) whereas secondary appraisal is closely connected to how one views one's coping resources. Although secondary appraisal has received more attention in the stress and coping literature (Dewe, 1993; Gall & Evans, 1987), primary appraisal is an important part of the stress process. The extent to which an encounter between the person and the environment is stressful depends on the meaning or significance the individual gives that encounter (Folkman et al, 1991; Gruen et al, 1988). Lazarus and Smith (1988) described primary appraisal as providing the "heat" in a transaction between the person and his or her environment and it is what makes the situation potentially emotional. The meaning of the situation, what is at stake for the individual, and the emotions experienced are intertwined in the appraisal process. 17 Appraisals may be the essence of the stress and coping process because, without personal meaning, the situation may not be deemed stressful at all. Dewe (1993) argued that to increase understanding of the stress process, researchers must be as concerned with exploring how individuals appraise events as they have been with identifying the events themselves. Awareness of stressors is not enough, further exploration as to what makes an event stressful for a person is needed. He goes on to suggest, "to ignore the idea of primary appraisal - the meaning given to events - is to ignore the most significant step in the stressor-stress relationship" (Dewe, 2001). Appraisal is subjective by nature. Because no two people are exactly alike, there is a high likelihood that no two individuals will make the same meaning of a situation. It has been suggested that cognitive appraisals of potential stressors are more important determinants of responses to stressors than the frequency of events, implying that the individual's perception of the stressor is key to the stress process (Gall & Evans, 1987). If a situation is thought to be closely connected to personal goals and if it has the potential to get in the way of what a person wants, then the appraisal will be likely to elicit negative emotions (Lazarus & Smith, 1988). Goals, concerns, and desires will likely vary from person to person, depending on his or her situation. Therefore, determining how a fall is appraised calls for an individualistic, qualitative approach to data collection and analysis. According to Lazarus (1998), due to an effort to be scientific, psychology has always been ambivalent about individual differences. He suggests it is time to move from a narrow approach of psychological science to one that delivers rich description of the phenomena of interest. With regards to subjectivism in stress and coping research, he argues that we are distinct individuals facing our own versions of life. He suggests that researchers focus on the meaning of the person-environment relationship for the individual. According to Dewe and Ng (2000), the meanings that individuals give to potential stressors are at the core of the stress process. Summary. The meaning a person makes of a situation is intertwined with how one's coping resources are viewed; however, it is the meaning that provides the "heat" of the appraisal process. Meaning determines whether a situation is deemed stressful. The subjective nature of the meaning-making process supports Lazarus's (1998) recent emphasis to focus on individual differences in the stress 18 and coping process. Therefore, exploring die meaning a fall has for elderly woman may result in a rich description of how a potential stressor impacts this population. Stress Discourse One of the challenges in uncovering the experience of the stress process for an elderly population may be whether or not they are attuned to the concept of stress. According to Pollock (1988), the concept of stress was only established in the last few decades. However, the concept of stress is now so widespread that academics and lay people alike have established theoretical frameworks to explain stress (Newton, 1995). Stress discourse is so common that it normalizes the experience of stress and, as a result, stress is viewed as a 'normal' and integral part of life (Carter, Long, Rostad, & Reynolds, 2002; Pollock, 1988). The prevailing stress discourse focuses on the individual and fosters an ideal in which an individual is expected to cope well with stress. In other words, the onus is placed on the individual who is viewed as having the ability to control his or her stress. Stress is considered to be omnipresent, affecting all aspects of life, particularly a person's health. This implies a connection between the psychological and the physiological realms. Whittaker and Connor (1998) interviewed 111 people and conducted seven focus groups involving a total of 45 people from a community in New South Wales, Australia, and reported that many of the adult participants talked about stress as an unavoidable part of modern living with serious consequences for one's health. Unfortunately, no age range for the study is mentioned; however, it is stated that the sample is reasonably representative of the community's adult population. As a result, the age of the oldest participants is unknown, making it difficult to generalize the findings to an older population. Furthermore, it is unclear as to whether there were any differences in how older participants talked about stress because there is no distinction made between the younger and older participants. Newton (1995) states that the ability to express feelings related to stress depends on the ability to learn the language of stress and the parameters of the stress discourse. Adolescents in the study conducted by Carter et al. (2002) were familiar with the term stress, and indicated that they would not be able to live their lives without stress. In contrast, people who are currently aged 75 years and older may 19 not adhere to the current understanding of the stress discourse prevalent in Western society. If the concept of stress came to fruition in the last few decades, it is possible that the elderly population may not have had the opportunity to become familiar with the language of stress. On the other hand, there may be elderly people whose lifestyles expose them to the stress discourse. Studying the stress process in the elderly may be difficult if the participants do not relate to the dominant discourse. If the language of stress is used, elderly participants may not understand what is being asked of them. For example, Aldwin, Sutton, Chiara, and Spiro (1996) conducted a study examining the age differences in stress, appraisal, and coping, with participants ranging in age from 48 to 91 years old. The researchers encountered problems with semantics when they asked some of the older participants for the most stressful problem in the prior week. They mention an example of an 84-year-old man who denied having stressful problems even though, upon more in-depth questioning, he admitted to being very worried about his older sister. He preferred to think of his stressful problem as a concern. As a result, the researchers revised the question and asked participants to identify the most serious problem or concern during the past week. Summary. Individuals presently 75 years and older may or may not be sensitized to the language of the dominant stress discourse. Regardless, it is imperative not to assume that elderly people understand the concepts of stress in the same way as the researcher, even if they appear to be familiar with the language of stress. Therefore, in the present study, I endeavoured to use language that was familiar to elderly women yet that still reflects the stress discourse. Stress and Coping: Empirical Research Stressors in old age. Although Solomon (1996) argues that there is no empirical support for the notion that stress is an inevitable consequence of old age, there are certain factors related to old age that seem inevitable. For example, declining physical health is a factor that may impact how individuals perceive themselves as well as their environments. Decline of physical health may contribute to the stressors in an older person's life (Aldwin, Sutton, Chiara, & Spiro, 1996; Caserta & Lund, 1992; Johnson & Barer, 1993; Lazarus & DeLongis, 1983; Pearlin & Skaff, 1996; Solomon, 1996). For example, a decline of physical health may increase an elderly women's risk of falling, thus, contributing to a 20 potential stressor in her life. Indeed, the inevitable onset of declining health may have far reaching implications for elderly people with the potential to affect all aspects of their lives and contribute to whether or not they view events as stressful. There is a tendency for the elderly not to report stressors or to report stressors as less stressful than their younger counterparts (Folkman et al, 1987; Heidrich & Ryff, 1992; Irion & Blanchard-Fields, 1987). Age-related interpretations of this phenomenon include: developmental, contextual, or cohort interpretations (Folkman et al, 1987). The developmental interpretation supports inherent, stage-related changes in the stress process as age increases. For example, the elderly population may have had more experience with stressful events throughout their lives and, therefore, may not consider certain events to be stressful. The contextual interpretation suggests age differences are due to changes in what people must deal with as their age increases, pointing to different sources of stress depending on one's age. Perhaps older people have fewer roles and activities in their lives, leading to a decrease in the number of hassles they report; however, this does not account for hassles being rated less stressful than those of their younger counterparts. The cohort interpretation is based on the belief that people of different ages differ in their reactions to stressors because of various historical conditions that impact them throughout their lives. For example, the older generation may have been raised in a time when one did not discuss one's problems. In addition, there is the possibility of elderly participants not being attuned to the current stress discourse. Each of these interpretations provides some insight into how an older person may appraise a stressful event, specifically a fall, in a certain way. Furthermore, these interpretations need to be kept in mind when it comes to exploring what meaning an elderly woman makes of a fall. Folkman et al. (1987) point to the need to know more about hassles in older adults. Their study of age differences in the stress and coping process sampled an older segment of the population, adults aged 65 to 74 years, and a younger segment of the population, adults aged 35 to 45 years, in an attempt to add knowledge to this area of research. In Folkman et al.'s (1987) study, a 46-item hassles scale was used to determine the hassles experienced by the participants. Use of a scale presupposes what may or may not be considered daily hassles by the participants and, therefore, may not address all of the daily hassles they experienced. Moreover, there is the need to ensure that lists of hassles are not skewed to 21 include more hassles pertaining to the lives of the younger generation, as has been the case with the life events scales (Lazarus & DeLongis, 1983). More accurate information may have been obtained from the participants if the researchers had considered the participants to be experts in their own lives and asked them to report what they considered to be daily hassles. In addition, Folkman et al. (1987) compared primary appraisals (what was at stake) for the younger and older participants with regards to a stressful encounter they experienced prior to being interviewed. Their findings indicated that there were age differences in hassles and coping. Although different scales were used to reflect differences in appraisals young and old people make, the use of scales is reductionistic and does not take the subjective nature of primary appraisal into account. Furthermore, a scale does not allow the meaning the event has for the participant to emerge. Unfortunately, many of the studies on the stress process in the elderly population either neglect to include individuals over 75 years of age or do not focus specifically on this segment of the population (Folkman et al., 1987; Hamarat et al., 2001; Heidrich & Ryff, 1992; Holahan, Holahan, & Belk, 1984; Kahana et al., 1995; Krause, 1994; 1998). With increased longevity and the potential for age-related declines of advanced age to affect the stress and coping process, it is important to focus on the experience of the stress process for individuals over 75 years of age. Individuals older than 75 years may have very different contexts and, thus, may make different meaning of a fall than individuals younger than 75 years; therefore, by neglecting old-old individuals, researchers may be missing valuable information about a growing portion of the population. There are very few studies in the literature that focus on the stress process for elderly women. Heidrich and Ryff (1992) conducted a study of 42 elderly women (mean age = 74 years, no age range is given), to determine what problems elderly women faced with aging and how they coped with real-life and hypothetical problems. As with most other studies in the stress and coping literature, the emphasis of this study was how the elderly women coped; consequently, of the 27 open-ended questions asked in the interview, only two were related to identifying day-to-day and major concerns. A strength of this study is the use of open-ended questions because they allowed the participants to report their experiences from their own perspective. 22 Content analysis of Heidrich and Ryff s (1992) interviews revealed that the elderly women in the study found household management and activity limitations to be the most frequent day-to-day concerns. The most frequent major concerns for the elderly women in the study were their own health and caring for others. Understanding problematic domains of life through use of the participants' descriptions provides insight into the perspectives of the elderly women; however, greater insight may have been obtained if they had attempted to do more than simply list the concerns of the elderly women. Heidrich and Ryff (1992) did not make an effort to determine the appraisals or the meaning the participants made of their day-to-day and major concerns and, therefore, their study failed to explore the concerns of elderly women in any depth. Summary. For the most part, research on stress and coping in the elderly tends to place an emphasis on coping with less emphasis on the stressors (Aldwin, 1991; Aldwin et al, 1996; Heidrich & Ryff, 1992; Johnson & Barer, 1995). Some studies that have focused on stressors use standard checklists and scales to determine what elderly people consider stressors (Folkman et al, 1987; Hamarat et al, 2001; Krause, 1994). However, if the stress response is considered in terms of an age-appropriate stressor, such as a fall and the daily hassles of ongoing concern about falling, then the practical utility of the research may increase. Considering a fall as a stressor is in keeping with the results from Heidrich and Ryff s (1992) study because a fall or ongoing concerns about falling may result in activity limitations and a fall may be related to how a woman views her health. However, simply determining whether or not a fall is a stressor offers no practical utility. What is needed is to understand what it is that makes a fall stressful for elderly women. In other words, there is a need to determine the appraisals they make of a fall. The Appraisal Process in Old Age. Surprisingly, to date there has been very little focus on the appraisal process of the elderly. Research on the stress and coping process of the elderly tends to focus more on how a person copes and includes very little information about how a person perceives the problem, what meaning he or she makes, or how he or she appraises the event or situation (Aldwin, 1991; Aldwin, Sutton, Chiara, & Spiro, 1996; Folkman et al, 1987; Heidrich & Ryff, 1992; Holahan et al, 1984). Some of the studies concluded that the stress process is subjective in nature, varying from person 23 to person, but they fail to focus on what it is that might account for the variability of the stress process, namely, the appraisal process (Hamarat et al., 2000; Krause, 1994; Roberts, Dunkle, & Haug, 1994). In one of the few studies that has examined appraisals in the elderly, Aldwin et al. (1996) examined the appraisals of men aged 48 to 91. Participants were asked to choose from a list of appraisals to determine which would best fit their current stressor. The list of appraisals included: threat, harm/loss, challenge, at a loss for what to do next, annoyed, and worried about others. According to Aldwin et al.'s (1996) findings, there seemed to be some commonalities among the types of appraisals the elderly participants made; however, there is the possibility that the commonalities among the types of appraisals made were an artifact of the forced-choice measure. If an open-ended interview was used to assess appraisals rather than an itemized list, then more variability in the way problems are appraised may be evidenced. The results of Aldwin et al.'s (1996) study revealed that the oldest participants were less likely to appraise their problems as challenges or feel annoyed by a problem than their younger counterparts. In addition, they found that, despite extensive probing, the older participants were less likely to report having had a problem in the last week. Understanding what meaning a problem has for the oldest participants in their context might account for these findings. Perhaps if attention had been paid to the primary appraisal process then reasons for older individuals differing from their younger counterparts would be more apparent. There have been other studies that measured appraisal through the use of checklists (Aldwin, 1991; Folkman et al., 1987). Hamarat et al. (2000) studied perceived stress and coping resource availability as predictors of life satisfaction. In their study, they measured perceived stress through what they refer to as an appraisal-based assessment scale. However, if appraisals are subjective and individualistic, then reductionistic measures are limited in their ability to identify appraisals, particularly within the individual's context. Similarly, in Aldwin et al.'s (1996) study, the results provided some information with regards to how elderly men viewed their problems; however, the checklist precluded an understanding of the meaning of the stressors in their unique context. Knowing what meaning a person makes of the problem is pivotal and could help explain other aspects of the stress process. 24 Summary. If, as Dewe (2001) suggested, the appraisal process is the key to understanding the stress process then the exploration of how elderly women make meaning of a stressful event such as a fall is needed. Both the aging process and the stress process are highly individualized. Exploring the appraisal process through the use of methods such as open-ended interviews rather than reductionistic methods such as checklists may result in a better understanding of the'stress process because subjective meaning and context are able to emerge. Because of the scarcity of literature on appraisals in elderly women and the subjective nature of the appraisal process it is essential to utilize a method that can deliver a rich description of elderly women's appraisals of a fall. The Satir Model To study appraisals, it is necessary to utilize the appropriate tools for exploring and understanding the meaning a stressful situation has for an individual. For this purpose, the joining of a counselling model and the stress and coping framework may facilitate this process. Lazarus and Folkman's transactional model of stress and coping suggests that appraisals are impacted by the meaning a person makes of the event but the model does not offer a specific method for determining what meaning a person makes. According to Lazarus (1998), we must stop avoiding the difficult task of studying meaning in human affairs and develop a new conceptual language, a language that is focused on the person-environment relationship and its meaning for the individual. The Satir Model (Satir et al, 1991) has many components that make it an ideal tool to assist a researcher in studying the meaning-making process. Satir's growth model is systemic in nature, it posits that any event is the outcome of many variables and events; therefore, it is necessary to look beyond the obvious event to understand its context and its contributing factors (Satir et al, 1991). According to the Satir model, there are the internal forces that occur within the person, and there are external forces that occur in the person's environment that may impact a person's meaning making (Banmen, 2002). In the present study, the events occurring in the person's environment are considered to the extent that they affect what is occurring within the person. According to Banmen (2002), most human experience is internal. A way of accessing a person's internal experience is through the use of the personal iceberg metaphor of the Satir Model (see Appendix A). According to Banmen (1999), this 25 metaphor is a way of conceptualizing the human experience. The iceberg consists of different components that stem from the self, a person's core being, that are interconnected and interact systemically to help a person make meaning of a situation. Components of the iceberg include: behavior, feelings, perceptions, expectations, and yearnings. Please note that, although usually considered part of the personal iceberg metaphor, the coping stances and the self are not included in the research question and do not appear in the figures depicting the personal iceberg. The coping stances are not included because they are difficult to determine, they change from situation to situation, their use is therapeutic in nature, and it may be difficult for participants to be explicit about their coping stances. The self is considered to be the deepest level of human experience (Satir et al., 1991) and, therefore it was questionable as to whether participants would be aware of and able to be explicit about "self; moreover, if meaning-making (e.g., behavior, feelings, perceptions, expectations, and yearnings) comes from the self, it would be confusing to include the self in the meaning-making process. Lee (2002) separates the components of the personal iceberg into three categories: interpersonal, intrapersonal, and universal. Behavior is considered interpersonal because it is outwardly observable and usually takes place between individuals. Although they give rise to behavior and communication, feelings, perceptions, and expectations are considered intrapersonal because they take place within the individual. The intrapersonal components are what make each person unique; therefore, tapping into the intrapersonal parts of the iceberg may help increase our understanding of the individual differences inherent in the primary appraisal process. Yearnings are considered to be human universals. Therefore, tapping into yearnings, may also increase our understanding of the primary appraisal process because they may represent goals that individuals are striving for, ways that people want to be. Whereas the intrapersonal components may account for the individualistic, subjective nature of the appraisal process, the universal component may account for what makes a situation or event important for a person. Emotions can be described as feelings and are part of the iceberg metaphor. According to Folkman et al. (1991), the appraisal process is suffused with emotion. The appraisal process can produce emotions such as sadness, anger, guilt, anxiety, and excitement. Determining what feelings are present as 26 well as the intensity of those feelings at the time of a stressful experience may provide insight with regards to how a person views the situation. Satir (Satir et al., 1991) also refers to feelings about feelings; these are the decisions people make about what they are feeling. For example, an older woman may have a fall and feel upset, she may realize she is feeling upset and get angry with herself for being upset. Perceptions represent another level of the personal iceberg. A distinction needs to be made between the use of the term perceptions in the stress and coping literature versus the use of the term in the Satir Model. The stress and coping literature refers to perceptions on a general level; whereas, the Satir Model regards perceptions as a specific part of an individual's personal experience. According to the Satir Model, perceptions interact with behaviors, feelings, expectations, and yearnings to help a person make sense of events. In the current study, perceptions are conceptualized in terms of the Satir Model. Perceptions are considered to be a result of beliefs, assumptions, subjective reality, thoughts, ideas, and values (Banmen, 1999). Thus, perceptions influence how an elderly woman sees herself as well as how she views a situation. As one ages and gains new experience, one's perceptions may be altered. Generally, no two people will have the same perceptions; therefore, no two people make the same meaning of a situation. Subsequently, it is important to determine what a person's perceptions are with regards to a distressing event in order to understand what meaning she makes of a situation. Having an older woman talk about an experience of a fall in terms of her beliefs, assumptions, and subjective reality may elicit some of the meaning the event has for her. Expectations can take the form of expectations we have of ourselves, expectations others have of us, and expectations we think others have of us (Satir et al., 1992). Expectations are different for each person; they represent the individualistic manifestation of universal yearnings. An emotional reaction may occur when expectations are not met and feelings of disappointment, anger, hurt, or fear may surface (Banmen, 2001). An older woman may have an emotional reaction to the experience of a fall because she may expect herself to be able to get from point A to point B easily; therefore she may be disappointed or upset with herself when this expectation is not met. Yearnings are universal human needs that underlie a person's expectations. Some examples of yearnings include: love, acceptance, belonging, and freedom (Banmen, 1999). Gruen et al. (1988) 27 suggested that "central hassles" deal with themes that are deeply important to the person. Therefore, central hassles may resonate with an individual's yearnings. Yearnings are universal and have the potential to impact all aspects of a person's life and well being, especially if those yearnings are not being met (Satir et al, 1991). Meaning is an abstract concept and perhaps this accounts for the lack of research with regards the meaning individuals make of a stressor. The challenge of studying the meaning and importance a stressor has for individuals may be realized through the use of the Satir Model's personal iceberg. The iceberg offers a way of accessing systems within individuals that contribute to how they view themselves and the world around them. An event like a fall has an impact on all components of the personal iceberg; therefore, by tapping into elderly women's feelings, perceptions, expectations, and yearnings about the event we may be able to gain insight into what meaning they make meaning of the fall, thus, gaining insight into an important aspect of the primary appraisal process. Conclusion More research is needed on the psychological impact of falls for elderly women. Given women's greater longevity, they may experience more age-related declines than men and may be more at risk for falling. In addition, more research is needed on appraisais elderly women make of stressful situations. Lazarus and Folkman's (1984) transactional model of stress and coping provides the theoretical framework for understanding the appraisal process. Exploring the meaning elderly women make of a fall and ongoing concerns about falling will provide insight into the psychological impact of falls for elderly women. The subjectivity of elderly women's constructions of meaning is highlighted if one considers what a diverse segment of the population the elderly represent (e.g., different environments, personality characteristics, past experiences and processes of aging). There are different internal systems within elderly women that may impact how she interacts with her environment, specifically, what meaning she makes of interactions with her environment. The Satir Model offers a way of accessing an individual's internal experience of a fall by focusing on feelings, perceptions, expectations, and yearnings. 28 This research combines three areas of literature (see Figure 1) falls, stress and coping, and the Satir Model to answer the question of what meaning elderly community dwelling women make of a fall in terms of their feelings, perceptions, expectations, and yearnings. 29 Figure 1. The three areas of literature that combine to form the research question: What meaning do elderly community dwelling women make of a fall in terms of their feelings, perceptions, expectations, and yearnings? 30 CHAPTER THREE METHOD Participants Participants were 14 women ranging in age from 75 to 94 years, with a mean age of 84. All of the participants were middle-upper-class Caucasian, with 3 women originating from Europe and the others from various parts of Canada. Twelve of the participants were widowed and 2 participants were living with their spouses. One participant lives in her own house, 1 participant in a suite in her daughter's house, 7 participants in apartments in seniors' residences, and 5 participants in apartment buildings that are not strictly for seniors. Thirteen of the participants have children; 10 of the women have children living close by, and 3 of the women do not have children living close enough to be able to help them with activities of daily living if such help is required. Inclusion criteria for participants in this study included: (a) being 75 years of age or older; (b) residing independently in North or West Vancouver; (c) having experienced a fall within the last year (the fall did not need to have resulted in injury); (d) fluency in English; and, (e) no severe hearing impairment. Hearing impairment was considered severe if it impeded the participant's communication, specifically, if the participant was not able to communicate effectively during the initial telephone call or during the screening interview. Because the participants resided independently in the community, I assumed that they were capable of understanding the nature of the study. Recruitment Participants were recruited from North and West Vancouver through the use of posters located in seniors' community centres and seniors' residences, and through word of mouth. In addition, the coordinater of one of the seniors' centres contacted several members to see if they were interested in participating in the study. Fourteen individuals interested in taking part in the study were contacted by telephone. During the initial telephone conversation, the potential participant was informed of the scope of the study; all 14 agreed to take part and a screening interview was arranged. The screening interview was a face-to-face 14 hour long meeting that took place in a location convenient for the respondent (e.g., their home or the community centre). During this meeting, I 31 explained the study in further detail and answered any questions. All fourteen volunteers were suitable, wished to take part in the study, and read and signed the informed consent (Appendix B). The consent form was printed in a large font; however, one of the participants had poor eye sight and was unable to read the informed consent and I read the informed consent to her. Another participant took the informed consent for her daughter to look at, this participant returned the informed consent at the time of the focus group meeting. The voluntary nature of both the focus groups and the interviews was emphasized so the participants understood that they have the right to refuse to answer any questions. In addition, I emphasised that they have the right to cease participating in the study at any point in time if they should wish to do so. Procedure and Data Collection I met with participants on three separate occasions, an initial screening interview, a focus group meeting, and a one-on-one follow up interview. Focus groups and interviews were conducted because the two methods complement each other in terms of the type of data they provide. Focus groups offer the participants an opportunity to engage in discussion, resulting less influence from the researcher. Although focus group meetings often provide rich information, there is the potential for valuable information to be lost if an individual is uncomfortable disclosing personal information in the group. Individual interviews can add to the depth of the data because there is the potential for an individual to divulge more personal information in an interview; furthermore, there is the potential for the interviewer to probe more extensively. Therefore, by combining focus group meetings and interviews there is the potential to garner a wider range of data than if only one method was used. In order to study the appraisal process, Lazarus and Smith (1988) suggest having participants provide retrospective accounts about how they thought, felt, or acted in real life stressful encounters. Therefore, during the focus group meetings and interviews, participants were asked to share their experience (e.g., thought, felt, acted) of a specific fall, as well as ongoing concerns about falling. Moreover, participants were asked to recount what meaning the fall had for them, what significance it had in their daily lives, and what made the fall distressing. The interview included questions about feelings, perceptions and expectations that were guided by the Satir Model. 32 Fourteen participants took part in the focus groups meetings; however, only 11 follow-up interviews were completed and used in the final analyses. Prior to being contacted for the follow-up interview, one participant had a bad fall and did not feel well enough to participate in the interview. Throughout the focus group, another participant kept saying that she could not remember her falls. Therefore, the accuracy of her responses with regard to a specific fall was questionable and'she was not asked to take part in an interview. The other participant did not return my phone calls about participating in the follow-up interview so it was assumed that she no longer wished to participate in the study. Screening Interview The initial screening interview (Appendix C) was an important part of the procedure. It allowed the participant to meet me, which may have eased any apprehension the participant felt about taking part in the study. The face-to-face meeting gave me a chance to further assess the potential participant's ability to communicate and her suitablity for the study. Finally, and perhaps most importantly, the meeting facilitated the establishment of rapport between the participant and myself. As a means of building rapport with the participant, I engaged her in conversation which revealed some of the context of the participant's life. The rapport established during the screening interview helped provide a foundation of trust, safety, and familiarity essential to the focus group meetings and the open-ended interviews. Focus Groups There are several reasons for conducting focus group research. Focus group meetings result in rich data because answers given by individuals during the course of the focus group may trigger thoughts in other participants, thus, resulting in an increased amount of information obtained. Moreover, focus groups ensure the "voice" of participants is heard because, although the researcher is facilitating the discussion, the participants determine the direction of the group (Palys, 1997). Conducting focus group research may benefit participants by allowing them to hear what their peers are experiencing and how their peers deal with distressing problems. Finally, in the present study, the focus group meetings allowed the participants to become better acquainted with the researcher, perhaps resulting in a greater level of comfort for the participant in the personal interview. 33 Three separate focus groups were conducted in locations convenient to the participants. The focus group meetings were held in rooms that offered privacy so as to maintain the confidentiality of the participants. The three focus groups consisted of 4, 6, and 4 participants. The meetings lasted for 1.5 hours with a 15 minute break in the middle, during which time refreshments were served. During the focus group meeting, participants were asked several questions about their experience of a fall (see Appendix D for the focus group protocol). The questions were asked verbally as well as written in large print on a flip chart. The meetings were audio-taped and the answers to the various questions were recorded on flip chart paper. Participants completed demographic questionnaires at the end of the focus group meeting (see Appendix E). The reasons for three separate focus groups being conducted were threefold. First, the groups needed to be small enough to promote safety and to facilitate discussion amongst the participants. Second, some of the participants have difficulties travelling any distance from their homes; therefore certain focus group locations were convenient for some and inconvenient for others. As a result, geographic location dictated the grouping of participants for the focus groups. Third, in my experience with previous focus group research, I learned that, due to the varying group dynamics and different personalities of participants, there can be variation in prominent themes from focus group to focus group. Therefore, by conducting three separate focus groups I was able to determine whether there were common responses to the questions asked in the focus group regardless of the varying group dynamics. During the focus group meetings, my role was to facilitate the focus group discussion. Specifically, I presented four main questions for discussion, made sure each person in the group had a chance to talk, asked for clarification if there was a need to understand a participant's comment in greater depth, and interjected and refocused the discussion if it strayed from the topic at hand. A co-facilitator (MA in Counselling Psychology, female) was present for the first focus group meeting in order to monitor the time and the equipment. In addition the co-facilitator made notes on the order in which participants spoke, smoothing the process of the transcription of the focus group. 34 Each focus group was transcribed, open coded, and summarized (see Appendix F). Before the follow-up interview, I re-read the participant's focus group transcript and made a note of any questions I had for the participant (see Appendix G). These questions were incorporated in the follow-up interviews. Follow-up Interviews At the time of the follow-up interview the participant was presented with a summary of the focus group discussion. The participant was asked whether the summary fit her experience of the focus group. All eleven participants reported that the summary fit their experience of the focus group. Next, each participant was asked more specific questions with regards to her experience of the fall, these questions were based on the Satir Model (see Appendix H for the interview protocol). Follow-up interviews were conducted with 11 of the participants ranging from 2 weeks to 6 months after their focus group participation. Although, for some of the participants, there was a considerable amount of time between the focus group meeting and the follow-up interview, their stories of the fall remained consistent. The participants were asked to read a summary of their focus group meeting before beginning the interview. This process refreshed their memories with regards to the previous part of the study and helped to establish a context for the interview. The interviews lasted for 1.5 hours and took place at a location mutually agreed upon by the researcher and the participant. All but one of the interviews took place in the participants' homes. The participant's home was an ideal location for the interview because it was convenient for the participant and it provided the participant a safe, non-threatening environment. The interview that took place outside of the participant's home was conducted in a location that was quiet, free from disruptions, and ensured the participant's privacy. Upon completion of the interview, the audio-tape was turned off and I conversed with the participant for up to Vi hour. Often the participants were interested in my research as well as what I am studying in university. The small talk following the interview helped draw a close to the meeting, enabled me to ensure the participant was feeling all right after sharing her experience of the fall, and it provided the participant with some social interaction. The interviews were audio-taped, transcribed verbatim, and 35 open-coded. Verbatim transcription included everything the participants said as well as indications of pauses and laughter; there was no attempt to alter grammar. All tapes, transcribed materials, and information pertaining to the participants in the study was kept in a locked filing cabinet. Any information about places or third parties was deleted from the transcription. Information Session Participants were informed that, upon completion of my thesis, I will be holding an information session in order to share my findings. This information session will be held during the day at a time and location convenient to the participants. At this time, I will share my findings verbally and will provide each of the paticipants with a briefwritten summary. For participants who are unable to attend the information session, a summary of my results will be mailed to them. Ethical Considerations Because there was the possibility that when describing the fall, the participants may become emotionally upset, at the end of each meeting and interview I checked with the participant to determine how talking about the fall was for her, and how she was feeling. To help bring the focus group to a close on a positive note, a short group exercise was conducted to enable the participants to appreciate the contribution they made to the study (see exercise at the end of the focus group protocol in Appendix D). In addition, I had a list of referrals available for any participant who appeared to be distressed at the end of the focus group or interview (see Appendix I). No referral list was given to participants. At no point did any participant become distressed or appear upset (e.g., tears, flushed, troubles talking). In fact, participants indicated they felt positive after the focus group meetings due to the support and empathy from group members. Another concern was that the participants might fear that providing details about their experience of a fall would be "grounds" to remove them to a care facility. I explicitly stated in the screening interview that information about participants in the present study would not be used against them. Furthermore, participants were told that confidentiality would be strictly maintained and that nothing they 36 share in the focus group meetings or personal interview would be relayed to family members or people from the community centers or seniors' residences. Although there was the risk that participants would become upset describing their falls, there were certain benefits to be derived from participating in the study. These benefits included: (a) hearing about the experiences of peers who have fallen and realizing that they were not alone in what they think or feel about a fall; (b) allowing the participants to view the experience of their falls from a different perspective; (c) hearing how peers deal with the consequences of a fall; and, (d) the satisfaction of making a contribution to the research on falls and to society in general. Napoles-Springer et al. (2000) conducted focus group meetings with elderly African American and Latino participants, ranging in age from 58 to 80 years old,- about the benefits and barriers to research participation. The findings showed that distrust of the researchers, lack of information, lack of follow-up if the participant was adversely affected, and fear of experimentation were what some of the elderly participants considered to be barriers to participating in research. Bearing these findings in mind, participants were informed of all aspects of the study during the screening interview and were given the chance to ask any questions. I ensured that the voluntary nature of research participation was emphasized. I reminded participants that they had the right to withdraw from the study at any point in time and that there would be no repercussions for refusing to participate. I emphasized confidentiality and reassured participants that no one other than myself and my research committee would have access to the data. Concrete examples of the voluntary and confidential nature of the study were given to ensure that the participants had a solid understanding of what these terms meant. Data Analysis Grounded theory is a qualitative method that has as its goal to inductively derive a mid-range theory from the study of the phenomenon it represents (Strauss & Corbin, 1991). According to Charmaz (1995), grounded theory methods are useful when studying personal experience and grounded theory provides a set of strategies for conducting rigorous qualitative research. Although 1 did not go as far as generating a grounded theory, a constant comparative method, used in the grounded theory method, was used to achieve conceptual ordering of the text from the focus group meetings and the personal 37 interviews. Conceptual ordering is defined as the organization of data into discrete categories according to their properties and dimensions and then using description to explain those categories. Data analysis methods included open coding, constant comparative analysis, and memo writing. Additionally, attention was paid to the presence of stress discourse throughout the stage of analysis. Open coding is the process of breaking the text down, examining, comparing, conceptualizing, and categorizing text (Strauss & Corbin, 1991). The text was broken down line by line so that each smaller chunk of text represented a discrete incident. Coding the text line by line kept me focused on the text, what the participants were saying, rather than imposing my own beliefs, thus, helping me remain attuned to the participant's perceptions while at the same time giving me the ability to examine the text critically (Charmaz, 1995). The incidents, or codes (e.g., jokes about fall with others, attitude helps her get over fall) were grouped into concepts. Each concept was given a name; that is, a conceptual label that represented the phenomena, was grounded in the text, and that had meaning for the analyst (Creswell, 1998; Strauss & Corbin, 1991). These concepts (e.g., a fall is not traumatic, humor, not looking back) were then synthesized into themes (e.g., cultivating an attitude). In other words, the themes were groups of concepts that pertained to the same phenomena (Charmaz, 1995; Straus & Corbin, 1991). The theme name was logically related to the data it represented and, therefore, helped develop the analysis. Open coding was conducted for three separate sets of data. Each set consisted of the focus group meeting and the subsequent interviews with participants from those focus groups; therefore, the participants' stories from the focus group meetings followed through to the individual interviews and allowed for continuity of the data. Furthermore, breaking the data into sets made it more manageable and allowed for comparison between sets as well as comparison within sets. According to Glaser and Strauss (1971), the defining rule for the constant comparative method is "while coding an incident for a category, compare it with the previous incidents in the same and different groups coded in the same category" (p. 106). Doing so allowed me to consider the diversity of the data and to begin thinking of the categories in terms of their dimensions and their other properties. True to the constant comparative method, analysis of the transcripts and data collection was done simultaneously. 1 alternated between collecting and analyzing the data from focus group meetings and personal interviews 38 in what Creswell (1998) refers to as a zigzag type process. This method of analysis allowed me to address questions that arose from the text in subsequent focus groups or interviews (e.g., What makes you say/think that falls are part of getting old?). By collecting, transcribing, and analyzing the text, I was able to closely examine the text and become aware of the subtleties of the participants' experiences and stories. Memo writing is the recording of ideas about the phenomena and is an important part of the process of analysis because it helps the researcher move from the reality of the data to abstract thinking about the data (Charmaz, 1995; Glaser & Strauss, 1971; Strauss & Corbin, 1991). I recorded memos from the inception to the end of the research process. They contained conceptual labels, paradigm features, and indications of process (Strauss & Corbin, 1991). When documented in an organized, consistent fashion, the memos showed how and when categories developed and changed; in other words, they provided a written account of the process of analysis. Theoretical sensitivity is the ability of the researcher to recognize what is important in the data and to give the data meaning (Strauss & Corbin, 1991). According to Strauss and Corbin (1991), theoretical sensitivity can be enhanced by familiarity with the phenomenon of interest. They suggest that knowledge of relevant literature, professional experience, personal experience, and interaction with the data are ways the researcher is able to increase familiarity with the phenomenon. In addition, they posit that periodically distancing one's self from the data and questioning what is going on, maintaining an attitude of scepticism, and following the research procedures will also enhance theoretical sensitivity. Reflexivity. Interpretation of data through qualitative methods may be influenced by the researcher's exposure to the phenomena of interest. Increased familiarity with the phenomenon of interest benefits theoretical sensitivity but also brings with it a degree of subjectivity. The data may be viewed quite differently depending on what kinds of experiences the researcher has had with the population and problem being studied and the biases or expectations brought to the research. Biases or expectations may stem from the theoretical lens of the researcher as well as knowledge and beliefs about the phenomenon of interest. Therefore it was important for me to be aware of the relevant personal experience and biases that I brought to this study. 39 My exposure to elderly women consists of spending time with my grandmothers and their friends as well as women in a seniors' support group I co-facilitated. I have made genuine connections with the elderly women in my life and, subsequently, my experiences with elderly women have been very positive. Most of the older women I know are vibrant and interested in life. I like and respect this population and see them as a valuable part of society. It is my experience that elderly women may not always disclose problems or things that are distressing to friends or family because they do not want to worry them. The biases I bring to the research come from the theoretical lens I use as a counsellor, beliefs about aging I developed as a result of a graduate course on aging I took throughout the year, and from knowledge about the stress discourse. The counselling model I use is the Satir Model (Satir, Banmen, Berber, & Gomori, 1991). One of the basic assumptions of the Satir Model is that humans have the ability to change, expand, and manifest growth (Satir et al., 1991). In accordance with the Satir Model, I bring to my research a belief in human potential, human inclination toward growth, and the strength of the human spirit. The aging course I completed helped me become aware of my own beliefs with respect to the aging process and elders. I believe cohort plays a large part of an individual's perceptions and beliefs. Furthermore, I believe that personal growth continues into old age and that elderly people have strength and wisdom that comes from life experience. In my second year of the Master's Program, I completed a graduate level course on Stress, Coping, and Appraisal, and I am currently involved in a research project studying stress, coping, and clerical workers. As a result, I am sensitive to how people talk about "stress." It is my belief that "stress" is an ambiguous term that is overused by people and is a "buzz-word" that runs rampant in the media. In its lack of specificity, the stress discourse masks the underlying emotions a person may have. Interpretive Analysis of the Iceberg of the Satir Model Although the Satir Model informed the interview protocol, when conducting the constant comparative data analysis, my knowledge of the Satir Model was bracketed (e.g., 1 tried to suspend my use of knowledge of the Satir Model). It was important for the categories and, ultimately, the themes to emerge from the data and for the themes to be true to the participants' words. However, the iceberg of 40 the Satir Model was used as a framework to answer the research question: What meaning did participants make of a fall in terms of feelings, perceptions, expectations, and yearnings? In order to interpret the findings in terms of the iceberg, 1 examined the themes corresponding with each component of the iceberg (e.g., behaviors, feelings, perceptions, expectations, and yearnings). Next, the connections between the components are considered in order to reflect the systemic nature of the iceberg. Then, to determine the extent to which the findings reflect the meaning of a fall, one theme is explored in relation to the components of the iceberg. Thus, the Satir Model, provided insight with regards to the meaning of the fall for participants. Windshield Survey Prior to each of the focus group meetings, I conducted a brief "windshield" survey. A windshield survey is a way of beginning to understand an area within a community by driving through the area and making organized observations (Cassells, 2001). In this study, the reason for conducting the windshield survey was to become familiar with the environments in which the participants live. This enabled me to establish and share (a) my knowledge of what participants' community environment is like and (b) my understanding of how they might interact within their environments and, thus, establish rapport. The locations of the focus group meetings were dictated by accessibility for the participants (e.g., within walking distance or a short drive); therefore, the windshield survey of the area surrounding where the focus group was to be held was also applicable for the individual interviews. The windshield surveys were based on questions to guide community observations (Cassells, 2001) (see Appendix J). There were commonalities amongst the three windshield surveys. With regards to community vitality, there were people visible in the community. They were walking, waiting for buses, shopping, driving, and cycling. The predominant ages were middle-aged and older adults, mostly Caucasian. The people in the community were all well dressed and appeared healthy. With regards to indicators of social and economic conditions, the homes were well kept, the lawns were taken care of and the houses well maintained. The areas were residential and included houses, apartments, and condominiums. Forms of transportation included: cars, buses, and bicycles. The 41 roads and sidewalks were well maintained. There were benches, trees, and flowers in the public areas. There were shops, malls, and restaurants in the areas. With regards to health resources, there were doctors' and dentists' offices, pharmacies, and nursing homes in all three areas. With regards to environmental conditions related to health, there were adequate traffic lights, signs, and sidewalks. The streets and parking lots were well lit. There was handicapped access to buildings, sidewalks, and streets. The areas included recreational facilities and community centres. With regards to social functioning, there was more than one generation present in each of the areas. There appeared to be a sense of community as evidenced by signs advertising community functions and by people talking to each other on the streets. Of note, the areas immediately surrounding the locations of the focus groups were flat; however, the areas where some of the participants lived were on hills. Biographies and Vignettes of Participants' Falls Biographies of the participants are included to provide a context with regards to their lives. Descriptive information include: approximate age, marital status, involvement in activities, whether children are involved in participants' lives, whether there are any health problems, and whether the participants have had previous falls. This information is pertinent to the participants' daily functioning within the community and is important to be aware of when considering the participants' falls. For example, a fall might jeopardize a participant's ability to continue living on her own if she does not have children close by to help if needed. If pertinent to the study, additional descriptive information was given. Vignettes of the participants' falls also provide information about the severity of the fall as well as long-term consequences. Pseudonyms were used to ensure confidentiality of participants. Participants chose their own pseudonyms; some based their pseudonyms on names of plants and flowers (e.g., Iris, Heather, Sweet Pea). The biographies are listed in alphabetical order, according to the pseudonym. Of note, Barbara, Lovely, and Sweet Pea did not take part in interviews and, as a result, their biographical information does not include as much as that of the other participants. Audrey is in her mid 80s. She is widowed and lives on her own in her own apartment. She has daughters living close by. She works one day a week at the seniors' center, goes on tours that are 42 organized through the center, and until recently she traveled regularly. Audrey talked of having other health-related problems (e.g., with her eyes). The fall she talked about took place in a coffee shop while she was on a day-trip with a group from the seniors' center. She was at the top of a flight of terra cotta stairs, she threw something in the garbage can that was located at the top of the stairs, turned, missed a step and fell down about 10 stairs. Because the fall occurred at the end of the day, the tour group bus driver drove straight home in order to get her to her local hospital as soon as possible. As a result of the fall she did not break any bones but she did slash her nose and her mouth. She ended up getting 10 stitches inside her mouth. In addition, she chipped a tooth and the impact of the fall caused some of her teeth to shift. She is still waiting to see if her teeth can be fixed. Barbara is in her mid 80s. She is widowed and lives on her own in a suite located in her daughter's home. She is active in the community and works one day a week at the seniors' center. She talked about having other health-related'problems (e.g., cataracts that limited her vision). She indicated falling a number of times previous to the fall she discussed in the present study. The fall Barbara talked about took place outside a row of shops. She was walking along an uneven, concrete sidewalk, not looking at her feet. Her foot caught on part of the sidewalk that was raised. She fell and smashed her face and broke her arm. At the time of her fall a woman came and helped her clean the blood off her face. Her daughter took her to hospital. As a result of the fall, Barbara had to wear a cast. Daisy is in her early 90s. She is widowed and lives on her own in an apartment. She hires someone to clean her place. She has a daughter who lives about 5 hours away. Daisy has an active lifestyle. She works at the seniors' center, takes art classes, writes stories, makes cards, and socializes with other members of the seniors' center. Daisy seems to be fairly adventurous, as evidenced by her stories of going for rides on the backof her nephew's motorcycle. She uses a cane. The fall Daisy talked about took place outside a grocery store; she tripped over the base of a big patio umbrella on her way into the store. According to Daisy, right after she fell she had people walking around her as she was lying on the sidewalk; one woman even suggested that someone "move her out of the way." Daisy talked of a kind young man who sat with her, called the ambulance from his cell phone, and waited with her until the 43 ambulance came. Daisy was in hospital for 3 weeks after her fall as she had broken her femur. Her daughter came to stay and help her after her fall. Fern is in her late 80s. She is widowed and lives with her cat in her own apartment, which is located within walking distance of a medical clinic, the bank, and the shops. She has three children; two of whom live near by. She feels very close to her family and says people are the most important ingredient in her life. Fern attends exercise classes and discussion groups at the seniors' center, belongs to groups in the community, attends church, plays bridge with friends, and visits with other people in her building. In addition to her fall, Fern talked about having other health-related problems (e.g., bladder infections). The fall Fern talked about took place in front of her apartment building; she and a friend had just come back from church. According to Fern, she turned to wave to her friend and fell flat on her face. She lay on the ground, unable to move. A stranger happened to be driving by and he took Fern to hospital. As a result of the fall, Fern broke her pelvis. She had to stay in bed for a few weeks after her fall, after which time she was able to move around with the use of a walker. At our first meeting, Fern was using a cane; however, at the time of our last meeting, her strength had improved and she did not need the cane. Frankie is in her late 80s. She is separated and lives on her own in an apartment in a seniors' residence. She moved into the residence because of reduced mobility after a fall and because the shops, bank, and her doctor are more accessible there. She has three daughters; two of her daughters live close-by and the other daughter lives outside of B.C. Frankie belongs to groups in the community and takes part in activities in the seniors' residence in which she lives. She has had previous falls and has also suffered a stroke. She presently uses a walker to help her mobility. She has a 'life-line' as well as an emergency button in her suite to call for help if needed. She has a homemaker come in to help her each week. The fall Frankie talked about took place in her bathroom; she fell backwards into the bathtub. Her homemaker was there at the time of her fall and called the ambulance. Frankie did not break anything as a result of the fall; however, she did hit her head and was treated for a concussion. Frankie's daughter stayed with her that night. There appeared to be no longer-term physical consequences of the fall. 44 Greta is 75 years old. She represented the youngest participant in the study. She is widowed and lives on her own in a two-story house that has a very steep driveway. She has 5 children; some are living in Vancouver and some outside of Vancouver. She appreciates the caring and concern from her children. She is active in the community, belongs to various groups, gets together with friends, and goes for walks with neighbors. Greta has had previous falls and, as a result of one particularly bad fall, she broke her wrist. In addition to previous falls, Greta talked about having other, health-related problems (e.g., heart problems). The fall she talked about took place in a theater. As she stood up after a lecture she became dizzy and fell to the ground. Greta said she bounced back up from the fall and reported the only thing she hurt was her pride. There appeared to be no longer-term physical consequences of the fall. Heather is in her mid 80s. She is widowed and lives in her own apartment in a seniors' residence. She has two sons; one lives in another province and the other lives near her. The son who lives near her is mentally challenged and he stays with her on weekends. Heather is rarely home during the days. She works at the seniors' center, socializes with other residents in her building, and attends church every weekend. Heather has had previous falls. She has a cane but said that she does not like using it. The fall Heather talked about took place on the bus. She stood up on the bus before it had stopped, the bus driver had to break suddenly, and she went "flying through the bus." When she fell, she said "the bus driver gave [her] hell" and she admitted the bus driver was right, she should not have been standing up. Other than a broken finger, there were no longer-term physical consequences of the fall. Iris is in her mid 80s. She is divorced, her ex-husband is no longer alive, and she lives with her dog and cat in her own apartment in a seniors' residence. She hires someone to clean her apartment. She has two sons who she sees regularly. Iris has an active life; she is a firm believer in exercise and swims a few times a week. She has friends living all over the world and enjoys writing letters to keep in touch with them. She is involved in charity work and enjoys going to concerts. During World War II, Iris was a prisoner in a concentration camp. She has had previous falls and has other health-related problems (e.g., problems with her right leg and back pain). Iris uses a cane and, at times, uses a walker. The fall Iris talked about took place when she was living in another apartment. She was taking the garbage to the basement and fell in the hallway. Her son took her to emergency where she found out that she had 45 broken her wrist. As a result of the fall she had to wear a cast and found it difficult to do activities of daily living such as dressing her self. After this fall Iris moved into the seniors' residence where she is still able to be independent but there is help available if needed. Lovely is in her early 80s. She is widowed and lives on her own in a seniors' residence. She has a daughter living close by. The fall Lovely talked about took place on her way home from the shops. She was standing on the corner waiting for the light to change and all of a sudden fell down, face first onto the sidewalk. She ripped her lip but did not break anything. Since that fall, Lovely said she had other falls like that, where she just fell down. Her daughter took her to have a medical check-up and it was determined that Lovely had high blood pressure. Marigold is in her mid 80s. She is widowed and lives in her own suite in her daughter's house. She works at the seniors' center one day a week and goes to the gym regularly. The fall Marigold talked about took place in her home. She stood on a stool to reach for something, lost her footing, and fell back. She "sat real hard on her rump." She was by herself and could not get up so she crawled to the phone. She managed to get in touch with a neighbor who came over and helped her up. The next day she went to the hospital. Marigold did not break any bones but sustained an injury that made it painful to stand or sit for too long and made it difficult to get around. At the time of the interview, 4 months after the fall, she was still suffering from the injury. She used a walker for a few months after her fall; however, she now uses a cane. Maud is in her 90s. She is widowed and lives on her own in an apartment. She does not have children living close by. She was born in England and lived through World War II. During the War she worked in a bank and also volunteered with the Red Cross, taking an active role in nursing wounded soldiers. Maud is active in the community, helps others through the church, attends church activities, and belongs to the seniors' center. Helping others is an important part of Maud's life. The fall Maud talked about took place in her bedroom. She fell backwards, knocked her head and jarred her neck. The fall aggravated a previous neck injury and she has been in pain ever since. As a result of her fall, Maud is unable to drive. 46 Robin is in her early 80s. She lives with her husband in their own apartment in a seniors' residence. Her husband is not in good health. She has children living close by who are able to help if needed. One of her daughters has Multiple Sclerosis and one of her grandchildren is dying of cancer. She has had previous falls. Robin talked about having other health problems that have "put [her] off kilter" (e.g., Polymyalgia Rheumatica, a debilitating inflammatory condition). She uses both a cane and a walker. The fall Robin talked about took place in her apartment. It was at the end of the day and she was walking to her bedroom. Although she had used her walker to get to the bedroom door, when she left her walker to take couple of steps, she "went down" and hit the electric plug in the hallway, knocking the plug casing out of the wall. She hit her head and knocked herself out. Her husband summoned the nurse from the adjoining care facility and she called the ambulance. Robin was not taken to hospital. According to Robin, the health professionals did not treat her fall as seriously as she thinks they should have. Robin said it was disturbing to not know the reason for her fall. There were no apparent longer-term physical consequences of the fall. Sunshine is in her late 80s. She is twice widowed and lives in her own apartment in a seniors' residence. She hires someone to come in and do the housework. She was born in England and lived through World War II. She moved here from England about a year ago. She has two sons who live close by and a daughter who lives in England. Sunshine talked about wanting to take part in activities offered at a nearby community center. She has had a number of previous falls. She indicated having problems with her legs and uses a walker to help with her mobility. The fall Sunshine talked about took place in her apartment. She held onto a chair in order to walk but overbalanced with the chair. Her legs did not hold her and she fell backwards. She bumped her head but did not break anything. A neighbor happened to be passing her door at the time and came in to help. A nurse was called from the adjoining care home. That evening the nurse said to not let Sunshine go to sleep because she might have had a concussion. Sunshine said she felt 'shaky' after the fall. There were no apparent longer-term physical consequences of the fall. Sweet Pea is in her mid 70s. She lives with her husband in a seniors' residence. She has daughters living close by whom, as Sweet Pea said, "worry about their mom." She talked about having a number of previous falls. The fall she talked about took place outside her building, she was standing on 47 the grass talking to someone who was on a balcony and she "went over backwards." Sweet Pea did not fracture anything as a result of that fall. There were no apparent longer-term physical consequences of the fall. 48 CHAPTER FOUR RESULTS The constant comparative analysis of the focus group meetings and the interviews revealed five meta-themes that emerged when participants described the meaning of the fall. The first theme, "the fall: the story of an unpleasant event" was described in rich detail reflecting the meaning of the fall as an event. A contextual theme emerged and included: "expectations of aging," "supportive relationships," and "the world is open for seniors." The contextual theme reflected the circumstances within which the fall occurred. Three additional meta-themes emerged: (a) "wants," (b) "changes," and (c) "resistance and compliance." Wants, what participants wanted from life, included themes of "staying in the world" and "doing for self." Changes, what participants changed in order to move forward with life after the fall, included the themes of "changing perceptions of the environment," "changes to lifestyle," "shifting perception of self," and "cultivating an attitude." The final meta-theme of resistance and compliance included themes of "pushing self and "fear of future falls." I present a conceptual ordering of these themes in Figure 2. Overview of Themes For participants in this study, a fall was considered to be an unpleasant event that represented a threat to certain wants, specifically, staying in the world and doing for self. A fall also meant that participants had to make certain changes in order to continue staying in the world and doing for self. In addition to changing their perception of their environment, participants altered their lifestyle in order help prevent future falls. The change in behaviour connected with changes to lifestyle after a fall led participants to experience a shift in their perception of self. Furthermore, they worked on cultivating an attitude that helped them accept the fall and changes occurring as a result of the fall. Some participants, resistant to the shifting perception of self, pushed themselves in an attempt to stay in the world and do for self in the same capacity as before the fall. However, fears of what a future fall might bring encouraged participants to comply with the changes in lifestyle that occurred as a result of the fall. Thus, the fear of falling influenced the participants' shifting perception of self. These processes take place in the context 49 of participants' expectations of aging, their supportive relationships, and their perception of a world that is "open" for seniors. 50 «.2 o a c 5 Cn-UJ >2 O o w a UJ o o m t .2 0 w a o :§:*: • C 03 J3 4= CD '> > o <N D M o C 'S E a o c CD E o "53 CD dt>z ' 1 5 _ :cz: . 51 Support for these themes is offered by way of quotations from participants. To ensure confidentiality for participants, pseudonyms were used throughout. If a participant was quoted or paraphrased, the transcript line number follows in parentheses (e.g., Daisy (213) said...) and if a quotation was taken from a focus group meeting then the letters "FG" are included with the line number (e.g., Daisy (FG: 213) said...). If needed, quotations were edited for clarity and words that were emphasized were italicized. The Fall: The Story of an Unpleasant Event The first theme that emerged from participants' descriptions of the fall was the event itself, the fall. For the women in this study, a fall was an event that had many underlying complexities; it was unpleasant, it could have physical consequences, it contained an element of surprise, and it often evoked a plethora of negative emotions. There was a difference in way the women in this study described a fall as opposed to how they described what happened in their lives after the fall. The fall was described as a story, a story that remained the same each time it was told (e.g., screening interview, focus group meeting, and interview). Furthermore, there were negative emotions connected to the fall not evidenced when participants talked about the consequences of the fall; therefore, suggesting the fall: the story of an unpleasant event was distinct from the other themes. It was the event that lead to certain changes in the participants' lives and gave birth to the meaning the fall had for these elderly women. As evidenced by the stories recounted by the participants, a fall was a concrete, physical action that could be described as unpleasant. Many of the falls described by the participants were events no one would choose to endure. For example, Barbara (FG: 180) shared her story of falling on the sidewalk outside some shops. Well, I fell on my face and my arm [went out in front of me]. And I went down like this onto my arm and face and that's what broke [my arm]...I was alone and I had a lot of blood running down my face and my nose was bleeding and I couldn't find anybody, there wasn't anybody around. Maud (FG: 215) shared her story of falling in her bedroom, I was putting a long dress away in my cupboard and my feet caught the end of it and 1 tripped and I went straight back, absolutely flat. I didn't hurt myself at all, except that my silly head hit the chest of drawers so hard that it knocked off the ridge that you take to open it ... It hit so hard ... the day after I had this terrible pain [in my neck, a repeat of an old whiplash injury.] 52 For participants, the fall was something that happened to their bodies and most reported physical consequences from the fall. Several participants were injured when they fell; some injuries included: a broken femur, dislodged teeth, a broken wrist, a broken pelvis, and bumps on the head. In some cases the physical consequences from the fall may not have been outwardly apparent to others. For example, participants talked of the physical pain resulting from the fall. Marigold (FG: 291) said: I fell back and sat real hard on my rump. It was very painful...I couldn't get up and I crawled and I went near the steps, there was a step there so that I could get my legs down....He [my neighbor] came over and, by then I had figured a way to get up but, and he helped me, but I couldn't move it was so painful. So I went to the hospital. Not the same time, the next day. And they took x rays and they said there was nothing broken but it would take a long time to heal because of my age. They said 3 months and I am still, it's 4 months now and I still have difficulty getting around. In some cases, participants did not appear to be injured yet reported feeling as if their systems were jarred as a result of the fall. Fern (68) said, "[A fall] sort of is a shock to your whole system." And, as Sunshine (FG: 449) said: I think you feel shaky, I mean it takes you a little while [to get over the fall], until you have had a cup of tea ... for a couple of days you sort of feel not with it ... you feel strange. These findings suggest that there does not have to be a specific physical injury for a fall to have an effect on these women. The surprising, unexpected nature of a fall contributed to its emotional impact. Participants described a fall as something that happened quickly and without warning. As Robin (13) said, "I don't wake up in the morning and think, I'm not going to make it, I'm going to fall." Because the falls often occurred without warning for these women, it came as a shock, they were caught off guard, and unprepared, as evidenced by Fern's (FG: 12) words: I turned to wave good-bye to [my friend] and [I was on] the cement sidewalk. As I turned, I took a step and went flat down. It was the most shocking, you know, flat, and 1 couldn't get up, I couldn't move. Frankie (FG: 186) talked of her fall happening suddenly, "I got •out of the bathtub, I had had my shower, I was getting dry, and suddenly I fell backwards into the tub." The shocking nature of the fall was accompanied by distressing thoughts and feelings. For participants, the fall had emotional consequences. Whether the fall resulted in an injury or not, participants were never at a loss when asked to describe what was distressing or upsetting 53 about the fall. In addition to feeling shaken, emotional reactions to the fall included: fear, feeling damaged, feeling stupid, anger and blame. Participants talked of being frightened immediately after the fall. Often, their fear was connected to how badly their bodies might be damaged due to the fall. As Fern (FG: 295) said, "The fall is frightening, you don't know what has happened or what you've done." Marigold (16) echoed this sentiment, "I thought, I wonder what is wrong with me now? If anything was broken, my bones, you know, because I fell so hard on my rump." For some participants, the fear was connected to the potential consequences of the fall. As Frankie (FG: 365) stated: I was frightened because I had fallen so many times. And I am so frightened that I will break my other hip because I've broken one, that I won't be able to look after myself, I'll have to move into a home. Many of the participants used the word "damaged" when they talked about what happened to their bodies as a result of a fall. According to the Oxford Dictionary (1958), the word damage can be defined as "injury impairing value or usefulness." Used in the context of an older person falling, it implies something in the body needs to be repaired and, as a result of the injury, the usefulness of the body is diminished. For example, Iris (99) said, "I felt injured, you know, damaged." Greta (319) also talked of a fall damaging her body. The fall that I had before that did damage me, uh, I didn't even think about it for a day or so and finally my children said "you should really go down to emergency and check that out" and [they] took me down and I had an x-ray and they did find that I had damaged, broken bones in my hand and my wrist. Almost all of the participants recounted feeling foolish or stupid to have fallen. As Audrey (155) said, "Well, I think mostly, what a stupid thing to do. You know these things all happen so quickly and you do think back and think, oh how could I have been so dumb to do a thing like that?" Greta (FG: 152) talked of breaking her "sense of self," when she fell. [1] didn't break a thing, except my sense of self. I felt sort of silly. I mean there were people all around saying 'are you all right? Are you all right?' and you know that you are all right and you feel like an idiot. For Greta, having others witness her fall contributed to her hurt pride and bruised self-image. 54 Most participants indicated feeling embarrassed to have fallen if there were others present at the time of the fall. For example, Audrey (FG: 493) said, "There were so many people so there was embarrassment along with it when I fell down." In addition, a few participants were reluctant to let others know they had fallen. As Sunshine (677) said, "[The fall] happened on the Monday and I stayed in my apartment till the Thursday....Saving face, 1 felt stupid for having this fall and I didn't want to go down for supper." Heather (250) talked of her embarrassment, "[After the fall] I was ashamed to tell the other people [in the building] what I had done and yet my hand was [swollen] out to here and I sort of felt that I had to tell them." Many participants, never intending to fall, took responsibility for their physical actions and were angry with themselves for having done something they considered to be stupid. They saw the fall as their own fault and took the blame. As Heather (61) said, "It was my own fault, I shouldn't have stood up [on the bus] and I felt I deserved [to fall]." As Barbara (FG: 451) said, "The thing that struck me was that I was angry with myself, really angry. [I thought] you stupid thing, why don't you pay attention?" Summary For the participants in this study, the meaning attached to the fall itself was very specific. The story of the fall itself included negative emotions that were not necessarily evident in the themes pertaining to the consequences of the fall. It was viewed as an unpleasant event that was experienced as both physical and emotional. The results of a fall were sometimes outwardly visible; for example, when an injury occurred and the body was damaged; however a fall also elicited feelings of shock, fear, stupidity, anger, blame, and, sometimes, embarrassment: Although the nature of the fall contributed to the meaning of the event, the meaning the participants made of the fall was more encompassing than the fall itself. Contextual The contextual meta-theme is comprised of outside forces in the participants' lives. Context can be described as the circumstances in which an event occurs. Those circumstances help give the event meaning. The themes subsumed under the contextual meta-theme included: "expectations of aging," .55 "supportive relationships," and "the world is open for seniors." They provide the context within which the fall occurred and they helped participants make meaning of the fall. Contextual: Expectations of Aging The first, and most important, contextual theme to emerge was "expectations of aging." For most of these women, having a fall was expected as part of the aging process. Some participants talked of a fall in connection with age-related health problems, some participants talked of their age being related to the severity of the fall and its consequences, and other participants talked of a fall as a reminder of their age and of their changing bodies. However, sometimes participants talked of a fall as an accident, and as such, the fall was separate from the aging process. Although participants described falls as happening unexpectedly in the moment, most of them described falls as expected in the process of aging. As Iris (532) said, "I don't think [a fall] is something unique or traumatic or dangerous. It is just part of getting older" and, as Robin (FG: 759) said, "The more falls I have, the more I realize that it's part of getting old." Greta (FG: 1136) talked of a fall as part of life for an older person. I think [a fall] is just part of the whole process of how you have to come to terms with your age and the change in your life and how you deal with it. It isn't necessarily set aside as something specific, you have to see it as part of the ongoing life experience. Participants were aware that falls may be more likely to occur in old age because their bodies were not functioning as well as they once did. As Sunshine (630) pointed out, "When you get older, things happen and everything wears out, you are getting older." For some participants, there were age-related health problems connected with the fall. As Barbara (FG: 149) said, "Prior to this I had-[surgery for] double cataracts and since then I haven't fallen. I believe that my eyes had a lot to do with [my falls]." Iris (77) said, "I get dizzy and I lose my balance, plus with this poor leg, I guess it is all a combination of things. At my age, I'm 83, you can expect this." Many of them believed health-related problems contributed to their fall (e.g., poor eye sight, changes in balance, and sleep deprivation). 56 It was common for participants to contemplate the reason for the fall and they stated it was distressing if there was no explanation for the fall. Robin (FG: 14) seemed worried because she was unable to ascertain the reason for her fall. I can't tell you why I fell, the doctors can't tell me why I fell....I just would like to know why we do these things. My blood pressure is normal, my heartbeat is steady and true, I have a very good haemoglobin count, I don't have any trouble with digestion, I do have trouble with walking, but then I have had PMR (Polymyalgia Rheumatica) for three years. In these cases, participants wondered if the fall was a symptom of an underlying age-related health problem, thus, solidifying the connection between the fall and their aging bodies. For example, as a result of having a number of similar falls, Lovely (FG: 416) had a medical check up and the test results revealed that she had problems with her blood pressure. For participants, their age was associated with the severity and potential consequences of the fall. Most participants were aware of the potential to break bones as a result of the fall. As Sweet Pea (FG: 269) commented, "I didn't fracture anything, I am very lucky." Several participants made references to the potential physical consequences of a fall, a reflection of their perceived connection between old age, a fall, and the potential to damage their bodies. As Barbara (FG: 459) pointed out, "1 think that when we fall now.. .we actually fall very hard and I think our bones are weaker too. We tend to break our bones." Although participants suggested that falling is not something that is unique to old age, as Audrey (FG: 623) said, "young people fall too." For participants, a fall had psychological consequences because it brought about thoughts of their age and their mortality. As participants (FG: 596) in one of the discussion group meetings discussed: Greta: [A fall] certainly makes you feel mortal, (laughs) Kathryn: So, makes you realize that... Maud: That you are getting older. Another age-related consequence of the fall was that it invited participants to change their expectations of their bodies. For example, Sunshine (556) talked of her body not working as well as it used to, "I know in my life I am going to have a fall. I mean, my legs are not that good and sometimes my legs give out." As Greta (FG: 598) stated, "As you get older, things can, and eventually will happen 57 and you have to start thinking in terms of how am I going to deal with [the fact that my body is changing]." A fall increased awareness of what their bodies were (or were not) able to do. As Greta (FG: 1048) said, "It [the fall] made me realize that I had become a bit more careful and that you do have to be aware in yourself that the things you used to take for granted you don't any longer." One participant resisted considering the fall within the context of her age. Audrey (56) said: Frankly, 1 don't think that [aging] had anything to do with [the fall]. I think I just turned and did not realize I was as close as I was to the top of the steps. So, I don't really feel it was [age-related] but, you know, maybe I am sticking my head in the sand. For Audrey, there was some contemplation as to whether her age had anything to do with her fall. Although Audrey (159) chose not to attribute her fall to old age, she was aware that others might do so. I think it's the only time in my life I have ever fallen down stairs, to my knowledge. And so you think, and you know right away people are going to equate that with your age. And that is why I sort of emphatically said, "no, I don't [think my fall was age-related]." And I'm not being, not trying to say it isn't age-related, I just think it was me, I just was careless. Summary. Most participants drew on the aging process as a way of making sense of their fall. Some of these women cited age-related health problems as the reason for their fall and, for several participants, the fall was an invitation to change their expectations of their aging bodies. Participants emphasized that falling was not something reserved for the elderly; however, they were aware that falls have physical and psychological consequences specific to their age. A fall was seen as one of the "complications" of aging because, when it occurred, it made life more difficult to live in an aging body. For these women, a fall complicated the aging process and, conversely, the aging process complicated the fall. Although not all participants considered their fall to be age-related, for most participants the meaning of the fall was connected to getting older. Contextual: Supportive Relationships The second contextual theme to emerge from participants' descriptions was that of supportive relationships. Participants indicated that doctors, friends, and family were part of their relationship network. Many of the participants talked of their doctors. Given the age-related changes to the body that many of the participants were experiencing (e.g., changes in balance or deteriorating vision) and the doctor's position of expertise with regards to the human body, it is understandable that their doctors ) 58 would be an important part of their relationship network. Many participants, such as Robin (138), talked highly of their doctors, "I have a doctor that is absolutely fantastic." As evidence of their faith in their doctors, participants described following through on falls-prevention suggestions or instructions from their doctors. For example, upon her doctor's suggestion, Iris (217) began using a walker when she did her shopping. Lovely (FG: 425) talked of her doctor pinpointing her high blood pressure as the reason for her numerous falls and of the advice he offered. So he [my doctor] says, "what you want to do is when you get up, get up slow, don't get up fast, and stay there first for a few minutes. Count to 10 or something and then you won't fall." Which is true, I haven't fallen since. Because of the participants' faith and trust in their doctors, the doctors had a considerable influence over the participants' health-related behaviour. Friends and family were important in the participants' relationship networks. When participants had a fall, it impacted the lives of their friends and family members. Greta (299) talked of a fall in terms of being encircled by friends and family. Now this might seem [like I am] going off on a tangent from what happens after you have had a fall, but it really isn't. It's part of all of what you think about, not just for your self but for everything that encircles you, your family and friends and how you interact with them. As Robin (478) recounted with conviction, "[Falls] are inevitable, they are not something you go out and look for, you aren't invincible. They are frightening, they are debilitating, they are a nuisance to yourself and your family and those you care for." After a fall, peers provided companionship and commiseration; furthermore, they helped the participants stay connected with the outside world. For Heather (317), it was important to know of her peers' falls so that she did not feel like she was the only older person to have had a fall. In fact, in talking with others about her fall she said she felt like "part of the club." Although, at the time of the fall, friends and peers played an important part in a participant's circle of relationships, for most participants, family offered a kind of unconditional support that was not expected of friends. For most participants, family meant adult children. Only two participants were currently living with their spouses. For those participants who were widowed and who did not have adult children living close by, family included a closer, more intimate circle of friends. Interestingly, participants who had 59 family living close by mentioned family, rather than friends, with much greater frequency throughout their interviews. Furthermore, when they talked of their own falls in terms of who they would turn to for support, they talked mostly of family. The relationship participants had with family allowed a greater scope for asking for help. As Marigold (198) said, "I wouldn't ask anyone outside the family [for help]." Sunshine (254) echoed Marigold's sentiment: [I had fallen on the floor and couldn't get up] you can't do anything. Anyway, I wouldn't ring anybody, when you have the gossip there is around [this building]. I mean someone could have come over, but. Anyway, I spoke with my son and he said, "mom, I'll ring back, just lay on the bed." So I laid back and waited for him to come....Anyway, my son was quite pleased that I rang him. If participants needed help after a fall, their family was supportive. Iris (7) said, "At the time I fell and I was knocked unconscious ... And then I called my son and he took me to hospital." Frankie (254) banged her head when she fell and talked of her daughter staying with her over night. [The people at the hospital] said I could go if somebody could go with me, otherwise I would have to stay in emergency because they have to watch you for 24 hours after you hit your head, for the concussion. And I thought, oh God, it's a nuisance because my daughter said she would stay over and I have no extra bed. And she said, "Mom, I've slept on the floor before." Family members of the participants took time out of their lives in order to help the participants at the time of the fall, thus, enabling the participants to feel supported and cared for. Participants talked of feeling secure knowing their husbands or children would be there for them if another fall should occur. As Greta (199) said: I am one of those lucky people who have children that, we're not in each other's back pockets all of the time but we are concerned for each other and they seem to be concerned for me....So, if I had anything more serious happen to me, I'm almost positive that I would not be alone for long. Robin (71) talked of the benefits of living with her husband. Well, I'm sure being alone puts quite a fear aspect to your condition. If you are alone and can't get to the [emergency] bell to pull it for the nurse to respond, I mean, that must enter into a lot of these ladies' minds. Where as I can always call for my husband. Participants who did not have children living close by to help them had adopted circles of friends who were like family. For example, Maud (148), who was not able to drive as a result of her fall, talked of friends from church. 60 One of them takes me [to church] every morning, she has something she has to do on Tuesdays and she said, 'I'll get someone else to take you back.' And so she asked and they all said they would be delighted to take me back. Heather (280) talked of people in her building, "I don't mind [asking others in the building for help] there are people here to help if I need it....it is like we are a family." Summary. For most participants, a fall meant turning to others for support. Understandably, their social networks were important at the time of the fall. Whether it was their doctor offering medical advice, friends offering commiseration, or family offering instrumental help, the relationships encircling the participants helped them feel supported. Participants who did not have family to help talked of friends with whom they had "family-like" relationships, thus, indicating the importance of family-like relationships at the time of the fall. Contextual: The World is Open for Seniors The third contextual theme that emerged was the world being open for seniors, the participants' perception of the world in which they lived. One participant spoke of the world being "open" for seniors, suggesting an awareness of opportunities and possibilities for elders in today's society. In addition, participants were aware of the context of their lives compared to the lives of people from previous generations (e.g., their parents). The women in this study took part in a number of activities outside the home; for example, art classes, volunteer work, church, bridge groups and various social groups. Furthermore, they talked about options that were available to them. For example, Heather (432) talked about going to elder-college and Sunshine (427) talked about wanting to do Tai Chi at the community center. Participants compared their longevity to previous generations. Marigold (FG: 795) said, "My mother was walking on the street, she had a heart attack and died and she was 57." Marigold (FG: 800) talked of her father, "He was 80 when he died. He wasn't very old by our comparisons." This revealed an awareness that their generation is living longer than previous generations. Some of the participants had parents who were active and who lived longer; however, participants viewed them as the exception. Summary. Participants had an awareness of the world being "open" for them in a way it was not for people of their parents' generation. A reflection of expectations from society as well as expectations 61 from themselves, participants viewed their world as full of possibilities. Their perception of their world being "open" impacted the meaning they make of a fall because a fall could threaten the participant's ability to take advantage of opportunities available to them. Wants The meta-theme of wants represents what participants wanted out of life, things they desired for themselves. For participants, their wants seemed to be age-specific goals, related to their position in the lifecourse. The themes subsumed under wants include "staying in the world" and "doing for self." Wants: Staying In the World With regards to the meta-theme of wants, the first theme to emerge from the participants' accounts was staying in the world. For participants, staying in the world meant being a part of life. After a fall, participants took part in many different pastimes and activities that allowed them to stay in the world. Sometimes a fall made it difficult for participants to stay in the world to the extent they would like. Pastimes and activities (e.g., working at the seniors' centre, taking classes, listening to music) helped participants stay engaged with life. They were a way for participants to stay connected with others. For example, Maud (111) said, "[writing letters] is harder to do [after the fall] but I still do it....it means something to me to keep in touch with people who have been very close and very dear." They were also a way for participants to stay interested in life. For example, Daisy (413) said, "[After a fall], I made cards and did things that didn't take a lot of energy, and read. I'm a fanatic reader. I read everything from the obituaries to the latest gossip (laughs)." Sometimes a fall made it difficult for participants to stay in the world as much as they would like or to the extent to which they were once able. As Frankie (372) said, "If I hadn't fallen, I wouldn't need a walker and I would be able to run around a lot better." Participants talked of a fall being the reason they were reluctant to travel. Frankie (FG: 608) said: Well, [the fall] made me realize that I can't do the things that I was planning on doing, I wanted to do....Well, I can't travel for one thing, I have a sister that lives back east and I go back every other year but I just can't do it now....unfortunately my sister is not well, she has Alzheimer's and she can't understand why I can't go back to see her. 62 As a result of not being able to travel, Frankie lost some of her connection with her sister. For some participants, a fall impeded their ability to stay in the world in a more everyday sense. As Maud (244) said, "[The fall] is a nuisance, it's a real nuisance.... because it is preventing me from doing the things that I love to do." For Maud, one of the things she loved to do was to drive older ladies around town and a fall stopped her from doing this. Maud's emphasis on the fall being a "nuisance" conveyed a sense of her frustration with not being able to stay in the world the way she once did. Greta (577) summed up the theme of staying in the world when she commented on how she experienced the other three ladies in her focus group. And it did cross my mind that this is a group of women who think of themselves as still being in the world. Nobody liked what happened to them but they were all making what adjustments they could to what had happened to them so they could continue living. Summary. Participants wanted to stay in the world and a fall meant that this desire was threatened. To stay in the world participants took part in activities and pastimes that allowed them to feel engaged with life and connected with others. If a fall impeded the manifestation of that desire, then sometimes a sense of frustration occurred. For some participants, a fall limited the way they were able to stay in the world. As Greta commented, participants had to adjust the way they stayed in the world after a fall. Wants: Doing for Self With regards to wants, the second theme to emerge was the desire to do for self. Whether in the realm of housework, transportation, or daily activities, participants valued their ability to do for self. It was connected to not wanting to be beholden, be a burden, or rely on anyone else. For participants, the concept of doing for self was connected with independence. Participants described wanting to do for self. As Maud (79) said, "That's the main thing, I just want to be on my own two feet. I want to be independent... .1 can do things for myself and as long as I can, 1 will do things for myself." Frankie (119) talked about friends who wanted to do everything for her, "I say [to friends], look, I've got to do it myself, I've got to make sure that I can do it." Participants did not want help from other people when they were able to do for self. Take Daisy (75) for example: 63 The cane has slowed me down a bit, otherwise I'm quite used to it now...The only thing is that I am always dropping the thing... it falls down and everybody is rushing to pick it up for me. I don't like being dependent (laughs) I would much rather reach down and pick it up myself. The theme of wanting to do for self was evident when participants talked about friends or family members offering help or not wanting the participant to do as much. It was then that participants emphatically stated their desire to do things on their own. Sunshine's (155) statement provided insight into the theme: My son told me one day, he said, "mom, don't be independent" and I said, "I'm not independent" and he said, "yes you are, you want to do it yourself, you can't do everything." But / want to do it for myself.. ..you don't want to ask other people to do it, you want to do it yourself. For many participants, doing for self was connected with not wanting to be beholden to others. In the focus group, Audrey (FG: 231) said, "After a few years of living on your own you are independent and really don't want to be beholden to anybody." Audrey (17) described beholden as "having to have someone to take care of me." The Oxford Dictionary (1958) defines beholden as "under obligation to." In agreement with Audrey, Barbara (FG: 461) said, "The old beholding, I am very much against that too....as long as I can do it, the longer the better." For participants, doing for self was connected with not wanting to be a burden on others. Greta (273) gave her definition of being a burden, "[it] is asking other people to take from their own lifestyle in order to support yours." As Iris (100) said, "I am a strong person and I don't want to be a burden to myself or other people. So I wanted to get back on my feet again." Participants would rather do things for themselves so as not to detract from their children's lives. As Marigold (492) said: Well, right after I fell, [my daughter] was down here a lot helping me...but I'm hoping I will be able to manage all by myself, I don't want to be a burden....You don't mind if they come once in a while and say "can I do something"....She's a very busy girl, my daughter, you can't imagine all of the things she does. Summary. The desire to do for self was common to all participants. For these women, doing for self was associated with independence, not wanting others to do for them when they were able to do for themselves, not being beholden to another, not becoming a burden on anyone else, and not relying on anyone else. In essence, doing for self was equated with participants being self-sufficient. For most of the participants, a fall meant that their ability to do for self was compromised. 64 Changes The meta-theme of changes represents what occurred in participants' lives as a result of the fall and in an effort to prevent future falls. Participants altered their behavior, their perceptions, and sometimes their surroundings. The themes subsumed under changes included: "changing perception of the environment," "changes to lifestyle," "shifting perception of self," and "cultivating an attitude." Changes: Changing Perception of the Environment Within the meta-theme of changes, one of the themes to emerge was a change in how participants perceived their environment after a fall. After a fall, different aspects of the participants' environment became important and, as a result, their surroundings took on a certain "newness." Moreover, participants became aware of physical supports and hazards to stability within their physical surroundings. Participants described an increased awareness of their surroundings. They were aware of objects to lean on or hold onto, in other words, environmental factors that offered stability. Sunshine (286) talked of her apartment building, "in the hall, there is nothing to grab onto." Heather (239) said, "I hold onto the walls (laughs) I make sure I am close to the wall and I do use my son quite often." Heather (233) also referred to her apartment, "In here we have bars to hang onto, it's very good." Most participants described their environment in terms of how they were able to function within it. Participants were wary of new environments because they had no knowledge of whether the new place would have elements that would reduce or increase their risk of a fall. As Frankie (18) said, "[A fall sometimes stops me from] going places that I'm not sure of the terrain [I wonder] whether it is easy to get around, and, if you can't take a walker, is my cane going to be enough support?" Marigold (FG: 991) talked of thinking ahead when she is going to a new place, "I think that too. How difficult is it to get there? And I ask around to see if there are lots of steps, you know, steps are very hard to get up and down." Participants were aware of how easy it was to fall and, as a result, increased their awareness of certain environmental factors that could be hazardous (e.g., stairs with no handrail, uneven sidewalks). As Barbara (FG: 551) said, "Leaves that fall, the wet leaves are bad. (The group agrees)." As Frankie (186) said, 65 I don't want to fall, watching before I walk on the sidewalk that there is nothing slippery there, you know, those plastic bags that you throw away, if you slip on one of those you will go down just as fast can be, so you have to be very careful that they are not on the floor in the stores or on the sidewalk or something. In fact, when participants talked about the fall itself, many of them included elements of their surroundings as part of the reason for their fall (e.g., the base of the umbrella in Daisy's story and the stairs in Audrey's story). An increased awareness of their surroundings meant that the participants' repertoire of behaviour came to include watching where they walked. As Marigold (FG: 539) said, "I walk this way [looking down] all the time, I'll get round shoulders....But it is better than falling." Barbara (FG: 523) said, "Now when I go out, instead of looking in the stores and all around, I will look just a little bit ahead, keep ahead, always looking." For participants, there was a need to be continually watchful and continually aware in order to prevent another fall. Summary. After a fall, participants were conscious of environmental factors that offered support and stability as well as factors that could be hazardous and increased the risk of a fall. As a result, a fall meant their environment took on new meaning. They perceived their environment in terms of its utility and their ability to function within it. Changes: Changes to Lifestyle Within the meta-theme of changes, a second theme that emerged from the participants' accounts was that the fall meant they changed various aspects of their lifestyle. Sometimes, participants' lifestyles were disrupted after a fall; however, this was different than the conscious choice to change their lifestyles. The theme changes to lifestyle encapsulated several elements: being slow and careful, using tools, new ways of functioning, accepting help, changing their environments, and incorporating exercise. In order to continue doing for self and staying in the world, participants incorporated new elements into their lifestyle. Together, these elements produced visible behavioral changes for the participants that reflected their desire to prevent future falls. Lifestyle disrupted vs. changing lifestyle. From the participants' stories, it was apparent that there was a distinction between the participant's lifestyle being disrupted because of the fall and the participant 66 changing her lifestyle because of the fall. Disruption in lifestyle was not a conscious change to their lifestyle and occurred when there was an injury from the fall. For example, Daisy (136) talked of her loss of social connection for the two weeks after her fall. Nobody knew I was in [hospital] and it was about 2 weeks later when I went back to the [seniors'] center to work on the Monday, and everybody said, "Where have you been?" And I said, "I've been in the hospital with a broken leg."...I had no visitors in the hospital because no one knew I was there. Marigold (589) talked of her lifestyle being restricted while she was recovering, "I couldn't do much, I couldn't move, it was too painful to do anything. So I was restricted." For these women, as with anyone recovering from an injury, the recovery period from the fall interrupted their everyday routine. On the other hand, when participants talked about changing their lifestyle, it suggested that the participants had a certain degree of control over what changed. Furthermore, it implied that participants made a conscious choice with regards to their altered actions; they weighed the situation and decided the best course of action to prevent future falls. For example, as a consequence of the fall, Iris (13) decided to take up swimming to improve her balance. Greta's (136) words summed how she changed her lifestyle after a fall: One of the things I was thinking about this morning, because tomorrow is garbage day and I have to take garbage all the way up to the top of the driveway. And I was thinking, 'now, how am 1 going to manage that from now on?' Well, I will take smaller amounts instead of taking maybe two loads in two hands, I will take one load and come back down and get the other and make more trips if I have to, to get the things up to the roadway. Simply because I now realize that it could be a little bit much for me and accepting that that it's OK to do that, that there are ways around getting things done. You just have to figure out how to do it. And that what you used to be able to do casually like carrying loads of things, you don't do anymore. But that's alright, it will get done it's just there is a different way of doing things. Being slow and careful. Participants described slowing down and being more careful after a fall; they made a concerted effort not to rush. As Iris (326) said: [If I was to fall again] I could break another limb. That would be horrendous. But I must, my movements have been slowed....I don't rush, they say, "oh we have to go now." And I say, just wait, I will go but I don't want to be rushed. Fern (FG: 1053) said, "I find you take your time on things, don't rush things. You know, do them slower and get your stuff together." Furthermore, some participants indicated a direct result of slowing down was being more organized (e.g., having clothes laid out the night before). If participants were more 67 organized, it diminished their need to rush. As Frankie (FG: 1090) said, "1 find if I know I am going out in the morning, fairly early, by 9:30 is early. I get everything ready the night before...! make my lunch the night before and get everything ready." Participants also talked about being more careful. Heather (FG: 947) talked of being more careful with her movement, "thinking twice before I step." As Audrey (FG: 973) said, "I think 1 am a little more careful or try, I would say I try to think about being more careful when there are steps and stairs now." Sunshine (FG: 151) talked of being more careful when she does housework, "I am very careful now, I can't do things like folding sheets because I've got to leave the walker and hold them up to do it." For Sunshine, being careful meant remembering her physical limitations. Using tools. Many participants used tools such as walkers or canes to help them continue to be mobile and maintain a certain degree of self-sufficiency. Sunshine (27) used her walker when doing housework, "At least with making the bed I have the walker." Participants incorporated tools (e.g., walkers) into their everyday life and developed a new way of doing daily activities. Marigold and Daisy "graduated" from walkers to canes; however, they kept their walkers and used them for household tasks. As Marigold (184) said, [I use my walker] when I have to carry things. I find it hard to carry things, you know, so I put them on the walker and take them in. And when I do my washing I put all of my dry things there and take them out to fold them. Things like that, household things. Although walkers offered support for those participants who needed it, some participants found using a walker to be limiting. Robin (19) said, "It [the walker] is a nuisance around a small apartment... .the walker wouldn't pull down enough to get into the car." And as Frankie (FG: 851) said, "I have to use a walker. Try getting on a bus with a walker." This indicated that, for participants, certain lifestyle changes made to prevent future falls had costs. In addition to canes and walkers, participants used other tools (e.g., grab bars, seats in the bathtub) to maintain self-sufficiency and to help prevent future falls. Sunshine (211) talked of the benefits of a table she used to use. The Red Cross had this table, two tier-like to put things on. When 1 was outside I could put some flowers on the table, take it in, I could take it to the bin, I could put the flowers on the table, put the flowers in the bin....it was on wheels....I.could use it for the washing. I would use it inside and 68 outside. I would take my washing out in the basket [on the table with wheels], put the basket on this table, I could just stand there, because I could grab onto the table. It was a sturdy table. New ways of functioning. Some of the participants did not need to incorporate tools into their lifestyle; however they developed new ways of functioning. For example, Greta (119) altered the way she gets up after sitting at a lecture. So, this time [after the lecture] when everybody got up I just stood for an instant and put my hand on the back of the chair to make sure my balance was there before I started to move to the aisle, and then I watched as I went down the steps. Sunshine (64) talked of new ways of doing daily activities. I've mastered lots of ...I've mastered the bed, well, I don't say it is always made to my liking, but at least it is made and Pm the only one who has got to sleep in it. (laughs) And my son said, "why do you stand and do the dishes?" Because I have a dishwasher, he said I should do the dishwasher a few times a week. So that's what I've been doing....I can't do the vegetables now, not without a seat, you know. Accepting help. In order to prevent future falls, most participants cut back on household tasks that may compromise their balance. As a result, participants had others help them with the things they could not do. Some participants hired people to help them with housework. As Iris (175) said, "once a week I have cleaners. They come and vacuum. I don't mind doing a bit of dusting....she [the cleaner] comes in and does my laundry." Participants also talked of family members helping with certain things around their apartments. Daisy (186) said: My windows were washed from the outside and a day later it poured and they were all dirty again....So, my son-in-law says, "well, next time I'm over I will do them." So he was over a couple of weeks later and he did all of these high windows and he did a wonderful job on them. So, there is always somebody to depend on. Sunshine (279) talked about her sons, "I always ask them to come and hang photos and things." As Marigold (198) said, "I would call either my grandson or my daughter if there is something I cannot do, you know. I will call and they will come down and help, you know, carry something." For most participants, accepting help from others became part of their lifestyle. Changing environments. Sometimes a change in lifestyle meant the participants changed their environment to help prevent future falls (e.g., re-arranging the furniture or moving into a seniors' residence). Frankie (281) talked of changes she made to her apartment after her fall. 69 A girl [from the hospital] came up after I had my last fall. She came in and looked at the bathroom and said that I needed another grab bar by the tub and that 1 should have a seat in the bathtub so that I can sit down while I am having my shower. Iris (10) talked of moving from her apartment in a building where young and older people live to an apartment in a seniors' residence: It was really then [after the fall] I knew I could not stay there; it was not safe for me there by myself, no older people. At least here we look after each other a little bit. I have all these mechanisms and things [emergency buttons]. I feel better at the moment than I did when I was still [in my old apartment]. My lifestyle seems to be better, I swim, I have a better diet....more social interaction. Incorporating exercise. The participants described how they exercised in order to prevent future falls. Iris (54) said, "It [my balance] is getting better with my swimming exercises." Marigold (117) talked of lifting weights at the gym. I go to the gym, you know....I did it before but I had stopped so now I have started again...So I go twice a week, on Monday and Thursday...I had a woman, you know those trainers? You have private lessons and I took them twice and she showed me what to do for what is wrong with me. To strengthen certain areas and it helps. My son was here tonight and he seems to think that I am walking better, I'm not so upright and he says, I wasn't carrying the cane, and he says, 'you are not holding things' and I says, 'well I am trying not to. I am trying to do what I can for myself.' (laughs) Otherwise I will be in a wheelchair if I don't do this, so I exercise every day at home, every morning I exercise. I do all of the work she told me to do. (Marigold: 1 17) As with Marigold, many participants indicated doing what they could to strengthen their muscles, improve their balance, and keep their health in hopes of avoiding falling in the future. Summary. For participants, a fall meant changes in their behavior and changes in their way of life. Changes to lifestyle varied from participant to participant, ranging from incorporating the use of tools to help them accomplish daily activities to incorporating exercise to help them prevent future falls. For participants, changes to lifestyle after a fall meant they took responsibility for their lives and learned how to stay in the world and do for self in a way that minimized their risk of having another fall. Changes: Shifting Perception of Self Within the meta-theme of changes, a third theme that emerged from participants' descriptions was that a fall influenced their perception of self. This theme is related to the theme of changes to lifestyle. For participants, the fall led to changes in their lifestyle, which, in turn, contributed to a shift in how participants saw themselves. These shifts fit into three categories: "used to," "have always been," 70 and "getting used to." Some of the shifts in perception of self that took place for participants included: shifting from a "giver" to becoming a "taker;" from being independent to having to rely on someone or something; from physically active to being more careful and slow; and from not thinking of one's self as old to beginning to see one's self as old. Some of these shifts overlapped with components from earlier themes (e.g., doing for self, being slow and careful, equating a fall with old age); however, inclusion in this theme is an indication of how deeply these components were experienced by participants. For example, although participants valued doing for self, at times they needed to rely on others and, thus began to see themselves as less independent. Not only were participants being slower and more careful, they began to identify themselves with these traits. Furthermore, not only did a fall remind participants of their position in the aging process, for some participants, it was the first time they thought of themselves as old. Participants often talked in terms of "used to," which indicated that they no longer saw themselves in a certain way. For example, Iris (246) commented, "I used to travel a lot." Robin (147) talked about how she used to be very active with her children, running a big house and entertaining, Daisy (323) talked about how she used to ride horses and Maud (80) talked about how she used to drive people around town; in fact, most participants mentioned activities that they used to do. Participants talked about themselves in terms of "have always been." This indicated part of their character that they were not ready to give up. For example, Daisy (32) talked about herself as "me who has always been so active." Furthermore, Daisy (265) said, "[I see myself] as a very independent type. I've always been that way, even as a child." Audrey (75) said: I have always traveled a lot; however, my friend that I traveled with a lot died last year so that's, you know, could be the reason [that I am not keen to travel], but I have this feeling....I don't know if I want to do that [travel] any more. Now whether that is because of the fall I don't know, I really couldn't say, but it is certainly there. As evidenced in Audrey's words, there was a shift occurring from have always been a traveler to used to be a traveler. Participants also talked of themselves in terms of "getting used to." This element included making a mental adjustment to accept how things were after the fall. As Marigold (235) said: 71 Everything takes longer now [after the fall]. To do my bed I have to go around and I didn't have that problem before. I seem to have accepted it, it doesn't bother me.... It annoys me when I can't [do things immediately] but I have to accept that it is going to take longer. For Marigold, there appeared to be a struggle for acceptance of certain limitations that came as a result of the fall. This suggested that getting used to was a process. Sunshine (732) talked about the frustration of her body not being able to do what it once did, "They [mind and body] don't match...It's the difference between wanting to do it and actually doing it." Getting used to seemed to be the intermediary between have always been and used to, the process of adjustment after a fall when participants were not able to do things in the same manner as before. One of the main shifts that occurred in participants' lives after a fall was from being givers of help to perceiving themselves as takers of help. It was difficult for participants to make the adjustment to ask others for help. As Greta (FG: 1157) said, "most of us have spent a lifetime organizing other people." However, there was the recognition that, at times, help was needed. As Fern (FG: 529) said, "When you get to our ages, you do need assistance, you do need help." Participants (FG: 712) in one of the discussion groups talked about not liking to have to ask others for help. An excerpt from the focus group is included because there is less influence from the facilitator and, furthermore, it highlights the agreement amongst participants that it is difficult to ask for help. Marigold: After the fall, yes, it is difficult to ask. Audrey: I don't like asking for help, I really don't. Marigold: It's hard to ask, you know, you feel you are being annoying or, so, I don't ask unless absolutely necessary. Fern (FG: 467) found it easier to accept help, as she said, "You give and you take when it is needed. And I feel that people want to help. They would be offended if you didn't accept their help....You have been the giver, and now you can be the taker." However, participants in her discussion group (FG: 467) found it difficult to accept help from others and were reluctant to accept Fern's way of thinking. .•••«•• 72 After a fall some participants had ways of thinking that eased the transition from giver to taker. For example, Frankie (54) was more willing to ask friends for rides if she knew they were honest about whether or not they were not able to give her a ride. As Greta (482) said: Don't let yourself think of yourself as an invalid and don't act like one. I mean, if you are really in need of help, accept it graciously but don't let anything that happens to you, a fall or anything as you get older, don't use that as an excuse to lean on people when it isn't necessary because that is taking something away from yourself and you should never let that happen. Asking for and accepting help was linked to the shift from participants seeing themselves as independent to beginning to see themselves as dependent. The elements of giving and taking are different from independence and dependence because, for participants, giving implied offering help to others whereas the concept of independence was related to doing things for themselves. The overlap between these two sets of elements occurred when participants talked about asking for help. They began to feel dependent when they asked for help. Greta (187) said: I hate asking for help and I think a lot of older people, especially those who have been really independent, that's one of the most difficult things to have to do, after you have had a fall or an illness or anything. Fern's (320) words indicated a shift that occurred for her after the fall, "That [fall] was a change in my life, I wasn't the same person after, you become depend on other people for help." Most participants struggled with the realization that they were becoming less independent. in addition to becoming more dependent on others, some participants were dependent on tools (e.g., walkers and canes). As Frankie (FG: 492) said about her walker, "I couldn't get along without it now," and, as Iris (540) said, "I can't live without a cane." Marigold (185) used her walker rather than calling her daughter to help, suggesting it was preferable for her to depend on an object rather than a person. As mentioned in a previous section, changes to the participants' lifestyle after a fall included slowed movements and being more careful. These changes in behaviour translated into shifts in how participants perceived themselves. For example, for Greta (551), being careful became part of who she was. That balance, or imbalance is still there so I am careful. When I was coming up and down stairs, I made sure I hung onto the railing. I may not, when I was younger, have thought of that nor even 73 put my hand out to the railing because I took for granted that my balance was good. I don't now.... It becomes just a part of who you are, as with anything else, you do it automatically, the more you do it, the more automatic it becomes. You have to think of everything you do at first and then after you have been doing it for a while, you do it so automatically because it's a part of how you operate. A few participants mentioned an awareness of how others perceive their slowed movements. Heather (73) talked about thinking that drivers must want to curse her when she takes a long time to cross at the cross walk. As Frankie (226) said: I'm slow when I come up to the counter, cash to pay, I try and have my money out ready to give, I'm slow in putting it back in and getting away and the girls behind the cash are very [nice], they don't bother looking at the person behind me, trying to get me to hurry up and go, you know. They give me time to get ready to leave.... If I make myself conscious of the person behind me [T think] "oh I've got to hurry" you know....[Then] I get annoyed with myself because I am going as fast as I can and if I go any faster, who knows what might happen? Not only were participants beginning to see themselves as slower and more careful, but they had an awareness that others are beginning to see them that way as well. Some participants indicated a connection between having a fall and beginning to see themselves as old. Heather (337) said, "The fall made me accept that fact that I am getting old (laughs). I think the fall really made that hit home." As Fern (106) said, [The fall] sort of made a big difference in that all of a sudden I became an old lady. And you just feel like all of a sudden like you've got a problem, or, you know, you can't get along and, up until then, I'd never felt like that. It changed my thinking of being elderly. I thought, you know, you think you are eternally young and you are not (laughs). And all of a sudden I realized I'm not. For Fern, her fall was the turning point between young and old, thus indicating the immense psychological impact the fall had for her. Summary. For participants a fall meant a shift in their perception of self. This shift was connected to the changes in lifestyle that occurred after the fall and it took participants through the stages of having always been, getting used to, and used to. As a result of the fall, many of the participants were engaged in the process of getting used to perceiving themselves as takers, as dependent, as slower and more careful, and as old. Changes: Cultivating an Attitude Within the meta-theme of changes, a fourth theme that emerged from participants' stories was cultivating an attitude. According the Oxford Dictionary (1958), to cultivate means to improve, develop 74 (person, mind, manners), pay attention to, or to cherish. This definition fits with how the participants' worked to develop attitudes that helped them move forward with life after a fall. For participants, cultivating an attitude did not mean changing their attitude; it meant using their attitude to change the meaning of the fall. Cultivating an attitude was made up of several elements: it is an attitude; using beliefs; carrying on; making the best of things; comforting self; gaining perspective; and, determination to heal. Of note, carrying on and making the best of things were beliefs that were central to the theme of cultivating an attitude; therefore, they are described in more detail. It is the attitude more than the physical. The importance of having the "right" attitude after a fall was evident in the words of the participants. When asked about how her outlook on life helped her get over her fall, Heather (511) replied, "It's an attitude. You have to cultivate it." As Greta (402) said, "It's just an attitude of mind, and that's not physical and it's a very important part of who you are, particularly as you get older and you know you are going to have things go wrong." Greta (770) went on to say, "It's not what happens to you but what you do with what happens to you that makes your life a good or a bad experience." Her words indicated the power she gave to her attitude. Using beliefs. Participants had overarching beliefs that influenced how they looked at life. Participants used these beliefs to cultivate an attitude with regards the fall and its consequences. A couple of beliefs that emerged when the participants talked about their falls were handling your own problems and living for today. Participants talked about the importance of handling their own problems. Robin (225) said, "If you can't handle your problems and you can't find a solution for them on your own, nobody else is going to find it for you. You have got to find it for yourself." Fern (457) talked about not making her own problems the focus of conversation. You don't fret and cry and tell people how terrible you are...you would be spreading the depression, what's the point? I mean you don't get anywhere with it, you might get a bit of sympathy. But you can change it...I think you are a master of your own fate, everybody makes their own world. Participants described the importance of living for today. Some of the participants alluded to not being able to control the future and, therefore, not worrying about what has happened or what might 75 happen to you. As Iris (120) said, "you never know how things are going to go." Daisy (394) said, "I'm not a worrier and if it is going to happen, it happens. And why worry about tomorrow or yesterday when you have today to live?" Heather (FG: 747) expressed a motto of hers, "Live for today, nor anxious be." Therefore, staying focused on the present was something that helped cultivate their attitudes. Carrying on. Many participants were matter-of-fact with regards to their fall. Although she broke her femur when she fell, Daisy (427) said, "It [the fall] is just one of those things that happens and you hope to forget about it (laughs)." Frankie (382) talked about a fall as another phase of life, something to work through. For a long time I thought I was very stupid to fall, because if you were watching what you were doing, you wouldn't fall. But, I've gotten over that, it is just something that happens it is just another phase of life. It is something else that you have to work through. Lovely (FG: 812) said, "It [the fall] stops you dead in your stride, in your tracks for a few minutes and, that's it. But life goes on." Participants agreed that the fall was not something to dwell on. As Audrey (556) said, "Once it was over it's over." In fact, many of them could not see the use in looking back, as Daisy (FG: 111) said: Three weeks [after the fall, I] came home and haven't looked back. I had a walker to start with but that really burned me up. Walking along like a little old lady, you know (group laughs) and I, so, I graduated to a cane about 3 days later. I still have the walker but all I use it for is to pile up a whole bunch of papers and take them down to the basement, (laughs) That's all it's ever used for.... What is the use of looking back if it [the fall] happened and I was stuck with it. I never felt that the world was unjust, it just happened and so it was a learning experience. Furthermore, participants did not ruminate about their fall. As Greta (FG: 165) said, "you just deal with it when it happens." After a fall, participants carried on with life, continuing to do for themselves and stay in the world. As Greta (783) said, "You only know what is happening to you now, so deal with it [the fall] and go on liking people, and no matter what age or what circumstance, stay in the world." Heather (133) said, "Each one of [the ladies who have had a fall] carries on the same...we go bowling once a week which is a big joke because that would be the place to fall (laughs) but we still go." As highlighted in the discussion between Fern and Greta (FG: 743), it was important for participants to carry on and move forward after a fall. 76 Fern: This is our life and we've got to live it...you've got to go forwards, you can't go backwards. You cannot go backwards. Greta: The only backwards is the memories that are good memories. Fern: That's right, that's right. From the outset, participants chose to move forward with life after a fall. As Frankie (353) said, "Just because we have fallen and damaged ourselves, so to speak, we still can carry on with our lives." Making the best of things. Participants took their fall, an event that could potentially begin a downward spiral, and highlighted some good in it. Some participants explicitly stated that they wanted to make the best of things after a fall. As Marigold (540) stated, "Because of this fall I had to give up certain things. Mentally, I had to accept what happened to me and make the best of it." Fern (475) said, "You live everyday to the very best you can, you just make the best and if you don't have everything you want, tough." Fern (480) indicated how she put this belief into practice when she was bed-ridden after her fall, "I've got a picture of me in the bedroom, they [family] were taking pictures, I was having a great time, I made fun." For some participants, their belief to make the best of things was evident in how they looked for the good with regards to the fall. Daisy (FG: 109) remembered her two-week stay in the hospital in a positive light, "I enjoyed the hospital, everybody was so kind, the nurses were wonderful, the food was good." As Greta (333) said: If you allow yourself to be open to the world, you know, there are always going to be positives and negatives and people who see the dark side of life, but if you look for the lighter side of life, it does tend to draw people. Many participants talked about how their falls could have been worse. As Audrey (FG: 19) said: 1 actually was very lucky because I didn't have a broken bone as a result of it [the fall]. What I did do was slash across my nose and my mouth and ending up with about 10 stitches inside the mouth as well as out. But, nothing that, you know, no after effects. And, as Daisy (FG: 641) said, "I'm glad I fell in public, a friend of mine fell in her kitchen and she was there for 2 days." (FG: Daisy: 641). These comments reflected the participants' ability to highlight what was good about a fall. Furthermore, participants appreciated the healing that took place after a fall. As Barbara (FG: 701) said, "I've come to the fact that 1 appreciate how well I have healed and I feel good 77 about it, that I've healed from the bumps and bangs." Thus, participants focused on the healing rather than the fall. Participants talked about a positive outlook as an asset after a fall. Barbara (FG: 840) said: Positive thinking will keep you younger.... And if you hurt yourself and you think it's going to get better, it's going to get better. Yeah, yeah, you might say "1 hope" once in a while but then you keep going....You apply it to your fall....If you are hurting and you have fallen [you say], "I will get better, I will get better," that's all. If you don't, it's too bad (laughs). Robin (575) talked about learning to make the best of things during the Depression. This indicated how long Robin had held this belief and suggested the influence of experiences in life and the era in which she was raised. There is always the downside if you want to dwell on it,... we were poor as church mice. My dad was a minister and his salary used to be a sack of wheat or a jug of buttermilk left on the doorstep, maybe a chicken or some eggs. It was during the Depression so no one had money so there were lots of times the offering plate was not full and there was no way the church would borrow to pay the pastor... .But we had the most fantastic childhood and youth. Our door was open and dad build a wooden skating rink in the back yard and everybody came and mother had 10 or 12 kids in her kitchen and she would have hot soup or coco or scones when we came in. I can remember we couldn't find 50 cents in the house one time. Comforting self. As part of cultivating an attitude after a fall, participants found ways to comfort themselves, the most common were through the use of humor and faith in God. Many participants used humor to help themselves through the fall. As Frankie (320) said, You do have to have a sense of humor, you have to be able to laugh at yourself even though you do feel like a nitwit (laughs)....It relieves a lot a tension and it makes it easier for those who are around you to work with you. Fern (FG: 738) said, "You have to have a sense of humor or you are down the tube." To this, Greta (FG: 741) replied, "Well, there are those who want to feel badly about things and who make a career of it. But that's such a waste of what's left of your life." Having a sense of humor was connected to looking on the bright side of things, as evidenced by Greta's comment. Some participants used humor as a way of sharing the story of their fall with others. Heather (370) said, "I think that it [my fall] is a joke more than anything now. You know, I'll bump into someone in the hall and say 'you know what I did...'(laughs)." For Heather, humor made it more comfortable to tell others about her fall. 78 Many participants indicated a belief in a higher power. Belief in God helped comfort these women when things went wrong because of a fall. When she was lying on the floor after her fall Sunshine (348) "said a little prayer." Fern (FG: 317) said, "[immediately after I fell] I was frightened... .And I said a prayer, it was Sunday, I had just come from church." Robin (FG: 735) talked about how her faith helped her in life. And so my theory is that since you can't control it, you try not to worry about it. And if you have a faith of any degree, you know that you are not in control anyway, God is. And, you know, that is your source of strength, as far as I am concerned. And what you can't fix and you can't mend, leave it alone. However, Robin (240) indicated not needing her spiritual beliefs to help her with regards to a fall, "I never thought of it [my faith] specifically with the fall. But without it I don't know how I would have gotten where I've gotten because we have had some difficulties." This suggested that perhaps, for Robin, a fall is not one of the more difficult things that she has had to deal with in her life. Gaining perspective. Part of cultivating an attitude was the participants' ability to view the fall within the context of their own lives, the ability to take a step back, gain perspective, and continue accordingly. Robin, for example, had a husband with health problems, a daughter with health problems, and a granddaughter with cancer. Robin (361) said, "They [falls] are just incidental, that's just part of living." Iris (411) talked about not taking falls seriously. I don't take it [my fall] all that seriously....I don't think it is something traumatic because I have been through much worse things. You know, the fall is just an accident. I've had other falls in my life, it is unpleasant, it is inconvenient but after what I have been through, it is a minor thing. And people just don't understand it....No, no, the worst thing is what I have been through. Iris said that a fall was nothing compared with some of the things she had already endured in life (a concentration camp). Other participants in the study had also endured hardship through their lives (e.g., England during World War II, and the Depression). In fact, having come through previous hardship, participants viewed themselves as survivors, as Frankie (FG: 209) said, " I've survived many things. To fall again!" Participants expected life to contain some suffering; therefore, a hardship like a fall was taken in stride. As Fern (450) said, "Through a lifetime you are going to suffer somewhere... .As I say, you go 79 through a life and nothing is perfect." Robin (522) said, "Life doesn't always turn out the way that you want it to. I don't know if we were ever promised a rose garden anyway." Robin (640) put her fall in perspective when she considered the fall in the context of her life, "You see, falling, to me is just a 5 second or 5 minute deal out of what 1 consider has been a very wonderful but very crowded, busy existence." As Greta (394) said: I think for me it [the fall] is a just a continuation of living. It's like going through another doorway; you go from one room to another room. The next room is different but it has interest too. And that's what I see as aging and incorporating the falling is just another aspect of life. Determined to heal. Participants who sustained injuries from their falls were determined to heal. Faith in their body's ability to heal fuelled the participants' determination. As Marigold (FG: 582) said, "I keep thinking it might get better." Iris (99) indicated faith in her body's ability to heal when she said: [After my fall] I felt injured, you know, damaged. But you get over it. If you are strong you don't have to stay in that situation if you don't want to. I am a strong person and I don't want to be a burden to myself or other people, so I wanted to get back on my feet again. A number of participants used exercise to speed their recovery and to prevent future falls. Maud (FG: 241) talked about her dedication to doing the exercises her physiotherapist set out for her because wanted to recover from a fall-related injury. Fern (45) talked about doing leg-strengthening exercises to help with her balance when she gets up from a sitting position. Summary. For participants in this study, cultivating an attitude helped them get over the fall by changing the meaning the fall had in their lives. If one is to take the metaphor of a cultivator, a machine that is used to break up the soil, to plant, and to uproot weeds; then cultivating an attitude to get over a fall might include participants uprooting any weeds of negativity and planting comfort, determination, and perspective to help them move forward. To develop an attitude, participants called on their beliefs to help them view the fall in a certain light. For many participants, these beliefs were long-held and influenced by the historical times in which they lived (e.g., the Depression). If, as participants espoused, a fall was more about the attitude than the physical, then participants used their attitude to help them move forward with their lives after a fall. For these women, cultivating an attitude allowed them to reduce the meaning of the fall as negative, unpleasant event and understand the fall within the broader context of their lives. 80 Resistance and Compliance The meta-theme of resistance and compliance represents the struggle of participants to accept fall-related changes in their lives. It indicates the push and pull of adjusting to life in an aging body. The themes subsumed under the meta-theme of resistance and compliance are "pushing self and "fearing future falls." Resistance and Compliance: Pushing Self From the meta-theme of resistance and compliance, one of the themes to emerge from participants' descriptions was that, after a fall, they pushed themselves to keep doing what they had always done. They had a strong desire to keep doing for themselves and did not want to rely on anyone or anything. For these women, their words reflected a struggle between continuing to be who they were and incorporating the shifting perception of self that came about as a result of the fall. After a fall, some activities were difficult for participants; however, they pushed themselves to continue with these activities, this helped participants stay in the world and keep doing for self. Maud (173) said, "I try and deal with myself and not wanting others, other people to have to deal with me... .1 make myself do things." Although she had a neck injury from the fall that made it difficult to sit and write, one of the things Maud (130) "made" herself do was write letters, this allowed her to stay connected with friends. There was a strong desire for participants to keep doing for themselves. For example, Sunshine (413) said, "I've got to, I've got to find my own way of doing it. I have to and if 1 can do it on my own, I've got to do it." She told the story of King Bruce and the Spider (see story in Appendix K), a fable that Sunshine used as a reminder to keep trying at a task (e.g., making her bed) in hopes that, in the end, she would succeed. As Marigold (220) said, "I have dinner here with my grandchildren I have difficulty carrying the dishes, but I do it anyway. I think it is good for me to push a little." Some of the participants talked about expectations of sameness, expectations from others for participants to keep doing what they had always done, regardless of the need to change their lifestyle (e.g., going slower or being more careful) to prevent future falls. As Greta (FG: 1327) said: 81 1 think my children look on me as being the strong one. It doesn't occur to them and I know it upsets them terribly if I have something [go wrong]....It makes you feel as if you want to stay strong because they expect it and maybe they need that in you. Robin (441) talked about wanting to do things for her dying granddaughter the same way she has always done (e.g., make a fuss over her). Audrey (80) talked about how her daughters think she should continue to travel, "My daughter says, oh mom, you've often gone [traveling] on your own, why wouldn't you?" Summary. Participants in this study pushed themselves to stay in the world and continue doing for themselves in ways that they had always done. However, if participants were to disregard their limitations and push themselves too much they risked falling again. Therefore, for most of the participants in this study, a fall meant a struggle between pushing themselves to continue moving forward with life after the fall and accepting their fall-related limitations. If participants accepted their fall-related limitations and altered their behavior accordingly, it reinforced their shifting perception of self. Resistance and Compliance: Fearing Future Falls A second theme of resistance and compliance that emerged from participants' accounts was the fears they have with regards to falling. For these women, falling represented a threat to their desire to stay in the world and do for self. The fear of what might happen if they were to fall again encouraged participants to comply with the changes in lifestyle brought about as a result of their fall. Participants feared losing their independence as a result of a fall. As highlighted by the firm agreement amongst participants in one of the focus groups (FG: 670), fearing dependence was present in the minds of participants. Marigold: [After a fall] you always think the worst... .you think, oh my goodness, I have to depend on people you know, I've always been independent, I never needed anyone, well, you know, generally. And so, now after I fell, [I had] my daughter, thank God for my daughter. And now, I don't need them [family] any more except for driving because I gave her my car. Audrey: I think that is probably one of the most important things, you know, that you feel you are going to lose your independence Marigold: Yeah, it's true Audrey: If you have anything like that. Marigold: It's horrible. 82 Heather (480) talked about the fear of becoming incapacitated by a fall, "I don't look forward to having another fall but I know that it is possible for me and I might become incapacitated.. ..Flat on [my] back (laughs)." For participants, becoming incapacitated was linked to not being able to do for self. Participants feared becoming a burden on their families. As Audrey (FG: 734) said, "You can be a burden after a while and I guess everybody knows that deep down in their hearts, you know, you could be a burden on your kids." Marigold (405) indicated a fear of resentment from her family if she were to be a burden, "I wish I didn't have to [rely on my family]. Sometimes I call my young grandson and I say, you must be getting tired of me." As Greta (264) said, "You don't want to get to the point of being a burden on other people and taking away from your enjoyment in life or doing anything that is going to take from other people's enjoyment." In order to ease their fear of future falls, participants adhered to changes in lifestyle they made after their fall. Marigold (165) said, "If! am going to the drug store, I have to have the cane just because 1 am, you know, afraid of falling." Heather (348) said: I take my cane with me because I know it [a fall] could happen again, you know, now I am really weary....I think it makes me realize that I have to limit the distance that I try to walk. Like, I mean if I walk 5 or 6 blocks I want to sit down and rest, so, you just have to accept your limitations. Rules. After a fall, many participants had rules, either self-imposed or from family members, to help prevent future falls. These rules contained gems of caring; however, many of them limited the participants' scope of behavior. Rules participants set for themselves sometimes stemmed from the fall itself. For example, Marigold (268) commented, "Well, I said to myself, 'I'll never do that [step up on the stool] again.' That was one thing I have never done since the fall." Echoing this sentiment, Sunshine (479) told herself after she had a fall, "Don't do the same silly thing again." Some rules were in relation to "not doing" and, therefore, limited the participant's actions. For example, Barbara (FG: 414) said, "Senior people should never get up on stools. I think that should be a fundamental rule." As Heather (110) said, "You have to remember what you can't do. You know there are things you want to do and you can't do them." Participants described the need to know their age-83 related limitations in order to determine the rules of avoiding future falls. As Marigold (293) said, "I know my limitations so I don't take chances. Since the fall 1 am really careful not to fall." Marigold (300) was matter-of-fact about what she was not able to do, "Well, there are a lot of things I can't do so, I say to myself, 'I can't do them, can't do it, that's it.' I don't mind. Maybe I would have minded if I was younger." She enforced the rules of what she could not do within the context other aging process. Other rules concerned behaviors the participants "must do" in order not to fall. These rules reflected the participants' adjustment to living in an aging body. The behaviors were not yet automatic; otherwise the participants would not need rules as a reminder. As Barbara (FG: 156) said, "I think you have to look ahead when you are walking and never take your eyes off [the ground]." As Heather (218) said, "I think the one thing, why 1 have fallen in most cases is because I haven't lifted my foot high enough, you know, that is something I must do." Participants talked of rules that came from others, usually family members. Sunshine (567) talked of "sermons" from her sons, I've had more sermons from the boys. "If you can't do it just leave it; we can be there in 2 minutes; if you can't do it, don't do it at all"....they have their sermons....I don't like it. Sometimes I do just sit there and listen and say, "Yes, yes, yes." As Lovely (FG: 1090) said: Well, I have had doctor's orders and my kid's orders that I do not get up on a chair. That's one thing. And it's hard because sometimes I have to get up there...I won't get up on a chair. You know, and there are all sorts of little things like that they have decided that I am not to do....l understand that they are (Sweet Pea chimed in) Concerned about you, (Lovely continued her sentence) they are doing the best for me that they can do. The sermons and orders from family members reminded the participants of their limitations and constricted their lifestyles to a certain extent because they did not feel free to do the things they once did. Summary. For participants, having a fall meant there was a possibility of having falls in the future and, with this awareness came a certain amount of fear. Many participants were conscious of how a fall could easily compromise their ability to do for self or to stay in the world. They feared becoming incapacitated, losing their independence, and becoming a burden on others. For women in this study, the fear of future falls encouraged compliance with regards to certain changes to their lifestyle that came about as a result of the fall. 84 Interpretive Analysis of the Iceberg of the Satir Model Although the themes illuminated how participants made meaning of a fall in terms of their behaviors, feelings, perceptions, expectations, and yearnings, I did not present the themes in such a framework. An interpretive analysis of the iceberg of the Satir Model (see Figure 3) enables the research findings to be represented according to the components of the iceberg and it provides insight into the research question: What meaning did participants make of a fall in terms of feelings, perceptions, expectations, and yearnings? Furthermore, to determine the extent to which the findings reflect the meaning of a fall, one theme is explored in relation to the components of the iceberg. 85 [Supportive relationships] [The world is open for seniors] [Changing perception of environment] [Shifting perception of self] [Cultivating an attitude] Expectations [Expectations of aging] [Staying in the world] [Doing for self] [Pushing self] Yearnings [Belonging*] [Connection*] [Freedom*] * not apparent; therefore had to be deduced Figure 3. Interpretive analysis of the iceberg of the Satir Model indicating the components of the iceberg and corresponding themes. The corresponding themes are noted in brackets. The components are systemic. 86 Behavior Although behavior was not included in the research question because it was not thought to be part of what meaning a participant would make of a fall, as the analysis revealed, it was an integral part of the meaning making process for participants. The theme corresponding with behavior is "changes to lifestyle." With reference to the iceberg (see Figure 4), the component of behavior is the only one above water, signifying it is the only component obvious to others. This fits with changes to lifestyle because, after a fall, the changes participants made were action-oriented and behavior-based and, therefore, outwardly visible to others. Furthermore, changes to lifestyle such as using a walker or moving slowly may mark a person as old. Changes to lifestyle provide an observable indication of how a person is working to prevent future falls. Therefore, part of the meaning participants made of the fall may be derived from their observable changes to lifestyle. Feelings The themes corresponding with feelings are "the fall: the story of an unpleasant event" and "fear of future falls." From participants' accounts, they used feelings to make meaning of the fall. Their feelings evidenced in the story of the fall included: shock, stupidity, foolishness, anger, and embarrassment. Given the onslaught of negative feelings, it reinforced the meaning of the fall as a distressing, unpleasant event. For participants, the feeling of fear connected with future falls was not really fear of the fall as an isolated event, but rather fear of what might happen in their lives if they were to have a fall that resulted in major injury. Some of the fears participants referred to were fears of not being able to look after themselves and having to rely on others, thus being beholden and a burden to people they cared for. Perceptions The themes corresponding with perceptions are "supportive relationships," "the world is open for seniors," "changing perceptions of the environment," "shifting perception of self," and "cultivating an attitude." The women in the present study had people in their social networks who offered help after the fall and, who therefore could be perceived as supportive: 87 Participants perceived their context, the world around them, as "open," meaning that there were many possibilities available to them. This indicates the subjective reality of their world and it had implications with regards to a fall. Participants recognized that a fall could threaten their ability to take advantage of a world that is open to them. After a fall, participants changed their perception of the environment in accordance with their goal of physical stability. They began to focus on elements within their environment that could offer them support (e.g., benches, walls, handrails) as well as elements that could contribute to a fall (e.g., uneven sidewalks or wet leaves on the ground). Not only did the fall alter their "outside" subjective reality (e.g., their view of the world around them) but the fall altered their "inside" subjective reality (e.g., how they viewed themselves). After the fall, participants began to see themselves as less independent, less of a giver, more of a taker, and as becoming old. Perceptions are also reflected in the theme of "cultivating an attitude." After the fall, participants used their beliefs, their knowledge of how to comfort themselves, their determination, and their ability to gain perspective. This altered their subjective reality and changed the meaning the fall had in their lives. Although the nature of the fall was unpleasant, and some of the consequences of the fall might have complicated their aging process, participants used their attitudes to move forward with life. Expectations Expectations were evident in the themes of "expectations of aging," "staying in the world," "doing for self," and "pushing self." With regards to the theme of expectations of aging, many participants said that falls were to be expected with aging; therefore, for some, having a fall meant they were getting older. Furthermore, after a fall, participants encountered new limitations with regards to their aging bodies and, thus, were invited to change their expectations of their bodies. Perhaps altering their expectations of what they were able to do after a fall helped participants accept their age-related limitations. Expectations are also described in the Satir Model (Satir et al, 1991) as "wants." The themes of staying in the world and doing for self strongly reflected participants' wants, thus, suggesting a firm connection with the iceberg component of expectations. These may have been expectations from society that influenced what participants wanted from life and, thus, they became expectations of self. For 88 participants, a fall posed a threat to these wants. In other words, a fall had the potential to prevent participants' expectations from being met. Furthermore, a fall may have resulted in participants having to change their expectations of themselves in terms of how they stay in the world and do for self. The theme pushing self is connected with the expectations of staying in the world and doing for self. Some participants explicitly stated that expectations from others and expectations of themselves had not changed as a result of the fall. This suggested that participants had expectations of sameness based on a desire to not change the way they stayed in the world and did for self. After a fall, participants expected themselves to do certain things and pushed themselves in order to do them. Yearnings There were no themes derived from the analysis that corresponded with participants' yearnings. According to the Satir Model, yearnings are universal longings (e.g., love, creativity, freedom). Furthermore, expectations are considered to be subjective manifestations of yearnings. Because staying in the world and doing for self are related directly to participants' wants, they represent the themes closest to yearnings. Therefore, it could be deduced that the participants' want to stay in the world was connected to participants wanting to belong and feel a connection with their fellow humans. The want to do for self could represent an underlying longing for freedom, freedom for participants to do what they want, when they want, without having to rely on anyone else. Systemic Nature of the Iceberg The components of the iceberg (e.g., behaviors, feelings, perceptions, expectations, and yearnings) do not function in isolation. The systemic nature of the iceberg reflects connections between various themes that emerged in the analysis. Contemplating the interactive nature of the themes in relation to the different iceberg components provides insight into how the themes might be related with regards to how the participants made meaning of the fall. A few examples that highlight the interactions are presented. For clarity, the corresponding component of the iceberg is indicated in parentheses after each theme. After a fall, the changes to lifestyle (behavior) impacted shifting perception of self (perceptions). For example, after a fall some women changed their lifestyle by incorporating a walker which may have 89 contributed to the women beginning to see themselves as old. In addition, shifting perception of self (perceptions) also impacted changes to lifestyle (behavior). For example, if the women accepted thinking of themselves as old, they may comply with behavioral changes such as slowing their movement. Furthermore, shifting perception of self (perceptions) impacts expectations of aging (expectations). For example, if the women began to see themselves as old, they may be more inclined to change their expectations of their aging bodies. After a fall, the changing perception of the environment (perceptions) impacted changes to lifestyle (behavior). For example, after a fall the women were aware of the possibility of an uneven sidewalk contributing to a fall, therefore they looked down and ahead when they were walking. The meaning these women made of a fall becomes more explicit when, in addition to the theme, elements of each theme are used (see Figure 4). This suggests that in order to have the framework of the iceberg reflect the meaning participants made of a fall it is it necessary to utilize the systemic nature of the iceberg; furthermore, it is important to represent the findings in sufficient detail. By incorporating elements of the themes into the iceberg, rather than just the themes, a more detailed picture of the meaning the women made of a fall is presented. 90 Behavior Using tools to do for self Asking for help Trying over and over again to complete a task Feelings Fear of not being able to do for self Fear of falling Useless if not able to do for self Frustrated if new way of doing takes longer Perceptions Self as a taker Self as less independent Beliefs: carry on, make the best of it Expectations Adjusting expectations of body Expectations of sameness Yearnings Freedom* \ not apparent; therefore had to be deduced Figure 4. Interpretive analysis of the iceberg of the Satir Model indicating the themes and elements of themes related to "doing for self within the iceberg framework. The components of the iceberg are systemic. 91 Summary. To answer the research question required a marriage of the themes that emerged from the text and the iceberg framework of the Satir Model. As evidenced in the five meta-themes that emerged, the meaning participants made of the fall was suffused with feelings, perceptions and expectations. Although no explicit evidence of participants' yearnings was found in the text, their fall-related behavior emerged as an element that helped them make meaning of the fall and its consequences. Participants made meaning of the event of the fall in terms of feelings. For them, the story of the fall was unpleasant and distressing. Interestingly, the feelings connected with the fall itself were not altered. When remembering the feelings at the time of the fall, participants did not seem to portray their feelings in a positive light. At the time of the fall, they recalled feeling stupid, embarrassed, and angry with themselves. The women in this study drew on their context to help them make meaning of the fall. For participants, the fall happened within the context of aging, relationships, and their view of the world; these were the elements outside of the women that influenced how they made sense of the fall. Their context influenced their meaning of the fall in terms of their perceptions. They perceived their families, friends, and doctors as supportive and this helped cushion the negative impact of the fall. Furthermore, they viewed the world as being "open" for seniors and this put pressure on them to remain engaged with life, regardless of the fall. Their context also influenced their meaning of the fall in terms of their expectations. Most participants had an expectation that falls would be a part of their aging process. For participants, a fall meant that certain wants were threatened. These wants (staying in the world, doing for self) were part of what these women wanted for themselves in life. Staying in the world and doing for self reflect expectations. These could be construed as expectations from society that have become ingrained in the participants and are, thus, interpreted as things they expect of themselves. A fall meant changes for the participants. In terms of their behavior, it meant changes to their lifestyle. These changes in behavior were the only changes that were obvious to others and their concrete nature contributed to the shift in how participants saw themselves. In terms of their perceptions, a fall meant changes in how they saw the environment, how they saw themselves, and how they viewed the consequences of the fall. To change their perception of what part the fall played in their lives, 92 participants cultivated an attitude. These women described their attitude as being a powerful ally that helped them move forward with life after a fall. As part of how they made sense of life after a fall, participants described resistance and compliance, in other words, negotiating their desire to continue to be the same and the changes in their lives as a result of the fall. These were negotiated in terms of their expectations. Participants pushed themselves because they expected to recover from the fall, continue staying in the world, and doing for self. However, at times they pushed themselves to remain the same, to continue doing for self and staying in the world in the same manner as prior to the fall. Life after a fall was also negotiated in terms of feelings. Participants feared future falls and this was something that encouraged them to adhere to the changes in their lives that were a result of the fall. Some themes seemed to correspond with more than one component of the iceberg; however, when the systemic nature of the iceberg is considered, the interconnections become obvious and any overlap actually provides insight into how the women made meaning of the fall. For the framework of the iceberg to be most effective in facilitating an understanding of what meaning the women made of a fall in terms of their behaviour, feelings, perceptions, expectations, and yearnings, themes and elements of the themes need to be included and attention must be given to the interaction between components of the iceberg. 93 CHAPTER FIVE DISCUSSION Falls represent a major health problem for the elderly (Drozdick & Edelstein, 2001; Resnick, 1999; Shumway-Cook et al., 1997; Tideiksaar, 1997; Tinetti et al., 1988) yet research on the psychological impact of women falling in old age is sparse, especially for women over the age of 75. Furthermore, there is a paucity of research on stress and coping for this population. Lazarus and Folkman's (1984) transactional theory of stress and coping posits that the appraisal process reflects what meaning is made of the potentially stressful situation; however, they do not offer a method of identifying meaning. The personal iceberg metaphor from the Satir Model of counselling, offers a framework for understanding how a person makes meaning of a situation. With a focus on women over the age of 75, this study drew from three areas of literature: falls, stress and coping theory, and the Satir Model. These intersected and gave rise to the research question: What meaning do older community dwelling women make of a fall in terms of their feelings, perceptions, expectations, and yearnings? Conversely, by exploring this question, the present study contributes to each of these areas of literature. It should be noted that certain characteristics (e.g., age, SES, marital status) of these women colour the findings. Women in this study ranged in age from 75 to 94 years (mean age 84 years), they were all middle-upper-class, all but two were widowed, they all lived independent, busy lives and most of them had children living close by. Falls The present study illuminates the psychological implications a fall has for some elderly women. It supports and furthers fall-related research; specifically, research with regards to the fall being the initial confrontation with frailty, how it impacts an elder's sense of independence, the family-fall interface, and fear of falling. Furthermore, the present study contextualizes the fall. The findings reveal the vast psychological impact a fall can have on elderly women. The women in this study described the fall in terms of feelings, perceptions, and expectations. These multidimensional psychological processes underlie the physical aspects of a fall. Although not all of the 94 participants sustained a physical injury from their falls, all of them described the fall as unpleasant and distressing and, furthermore, they described various ways the fall impacted them psychologically (e.g., the process of getting used to changes in lifestyle, shifting perceptions of self that resulted from the fall, the fear of future falls). In addition, participants named psychological processes that helped them get over a fall. Through cultivating an attitude, participants were able to use their beliefs and past learning to carry on with life after the fall. Therefore, by addressing the meaning the fall had for participants, a plethora of psychological processes became evident. The present study supports Tideiksaar's (1997) suggestion that, for older adults, a fall can represent their initial confrontation with frailty, threaten their independence, and lead to worry about how the fall impacts their loved ones. In terms of the present study, the fall did represent the first time some of the women saw themselves as "old." This finding supports Whitbourne's (1996) multiple threshold model of aging because, for some, a fall was the "threshold," or point at which they recognized their age-related changes. However, these women did more than recognize their age-related changes; the way they perceived themselves began to shift and this led to compliance with changes to lifestyle that helped prevent future falls. Women in this study were aware that a fall threatened their independence, their ability to do for self. Most of them were widows and, perhaps, having adjusted to independent living after the death of their husbands, their independence was more precious. In addition to threatening their ability to do for self, these women saw the fall as a threat to their ability to stay in the world and to take advantage of a world that was "open" for seniors. The interface between family and a fall was obvious in the present study. These elderly women were concerned about the impact a fall had on loved ones; they worried about burdening friends and family after the fall. However, they indicated that the presence of family and family-like relationships were important and offered instrumental support at the time of the fall. Moreover, the knowledge that their family would be there to offer assistance created a feeling of security in case of future falls. For these women, their families helped reduce the psychological impact of the fall by offering encouragement and support that helped the women continue staying in the world and doing for self after the fall. 95 Some literature suggests that, for older adults, a fall often begins a downward spiral leading to activity restriction, isolation, and loss of independence (Shumway-Cook et al, 1997; Tideiksaar, 1997). Although some women in the present study did limit or alter some of their activities after a fall and began to see themselves as less independent, they did not describe the fall or fear of falling with the degree of negativity apparent in some of the literature on falls among older adults (Legters, 2002; Peterson et al, 1999; Shumway-Cook et al, 1997; Tideiksaar, 1997; Yardley & Smith, 2002). They described the fall as an unpleasant event; however, they talked about continuing to do for self and stay in the world after a fall. For these women, a fall reminded them of their age and contributed to changes in their behaviour, perceptions, and expectations; however, they continued to be vital women who were engaged with life. Fear of falling has gained attention in the literature and is described as an ongoing concern that ultimately limits an older person's performance of daily activities and decreases quality of life (Legters, 2002; Tideiksaar, 1997). Women in the present study did fear future falls and the consequences of any future falls. Some described a number of ways that fear of future falls impacted their lives; however, they did not indicate that this decreased their quality of life in any way. After a fall, the women were conscious of following rules, set by themselves and by family members, to prevent future falls. That family members set rules was an indication that fear of falling also impacted family members' lives. The changes some women made to their lifestyle did limit their daily activities; however, they cultivated an attitude that helped them accept these fall-related changes in their lives. After a fall, participants engaged in a process of getting used to and accepting what they could no longer do as a result of the fall. Furthermore, according to the present study, fear of falling appeared to increase the women's compliance with fall-related changes to lifestyle. Women in this study described how fear of future falls might lead an elder to incorporate new activities into daily life. For example, after the fall, a number of women took up exercise in order to prevent future falls, demonstrating that fearing future falls could, in fact, expand an elderly woman's behaviour repertoire. For most of these women, a fall did not seem to be a central concern in their lives, falls were viewed as "incidental," and, although fear of falling was present for most, it did not stop them 96 from moving forward with life. They just moved forward with a different definition of staying in the world and doing for self. The present study supports Yardley and Smith's (2002) findings that one of the dimensions of perceived negative consequences of falling for older adults was the eventual incapacity and loss of independence. To this dimension, the present study adds fear of being a burden and being beholden to others. Moreover, the meaning of the fall was contexutalized by incorporating fall-related aspects of their relationships with others. In addition to relationships, the present study revealed that broad contextual factors such as aging and the world being open for seniors related to a fall. For example, the time of life in which a fall occurs dictates its meaning. A fall was seen as a complication of aging. For these women, it altered their behaviour, their relationships with others, and their interaction within their environment; thus, making the process of living more complicated. Moreover, support was found for Cavanaugh and Blanchard-Field's (2002) assertion that the way our body functions tells us how we are doing. For some of the women in this study, a fall was an indication that things were not alright with their bodies and it encouraged them to alter their behaviours, their perceptions, and expectations to make things "alright" and prevent future falls. However, some women in this study refused to accept that their falls and aging were connected, providing a reminder that falls are not always due to old age. Furthermore, to assume that all elderly women fall because of age-related factors may perpetuate negative stereotypes of older adults. In contrast to aging, the world being open for seniors was a contextual factor dependent on subjective perceptions connected to one's cohort. As described by women in this study, their perception of the world around them was thought to be different from how previous generations perceived the world; therefore, suggesting that some aspects of the fall-related context can vary depending on how they are perceived. In summary, as evidenced by participants' accounts, there were a number of complex psychological processes connected with a fall, the consequences of a fall, and fear of future falls. In contrast to the negative picture much of the literature paints of falls in old age, participants in this study 97 illustrated that a fall could mean they continue being interested in life, connected with others, and doing for self. Participants described making changes and cultivating an attitude in order to help them move forward with life after a fall. Stress, Appraisal, and Coping Findings from the present study are discussed in terms of Lazarus and Folkman's (1984) transactional model. With a focus on the appraisal process, I conceptualized the findings in terms of primary and secondary appraisals. Then, I consider of the utility of using the transactional model with regards to studying the phenomenon of interest. Upon conception of the present study, I assumed that participants would appraise the fall and its consequences as stressful. Only the fall itself appeared to be distressing. Women in this study described the fall as an event that was distressing and unpleasant, suggesting that, initially, they may have appraised the fall as taxing their resources. However, these women saw themselves as being able to deal with the consequences of the fall. For them, a fall was just "one of those things" to deal with. At no point did they question whether they had the resources to cope with the fall and continue moving forward with life. Of note, when participants made meaning of the fall, they drew heavily on their ability to cope and move forward with life after the fall. The emphasis on secondary appraisal (their ability to cope) supports previous studies that emphasized older adults' coping, rather than the specific stressor (Aldwin, 1991; Aldwin et al., 1996; Heidrich & Ryff, 1992; Johnson & Barer, 1995). Furthermore, I assumed that changes in the women's lives that resulted from the fall and the ongoing concern about falling would be framed as central daily hassles. However, most of the women in this study did not describe fall-related changes or limits as irritating or distressing. Rather, they indicated a desire to accept and incorporate these changes and limits into their daily functioning. A few of the participants expressed annoyance with fall-related physical limitations (e.g., not being able to drive, having to use a walker to aid stability), thus, offering support for Pearlin and Skaff s (1996) assertion that everyday hassles may be emphasized if one has physical limitations. For women in this study, their ability to do for self and their ability to stay in a world that was "open" for seniors was at stake. A fall threatened these wants. As they engaged in the process of getting 98 used to fall-related limitations and changes in their lives, their definitions of how they are doing for self and staying in the world changed. Therefore, by altering what it was that a fall could threaten, they reduced what was at stake for them. In their study of stressors in old age, Folkman et al. (1987) suggested three different age-related interpretations supporting the tendency for elders not to report stressors: developmental, contextual, and cohort. The present study found support for all three interpretations. Participants indicated not dwelling on the fall or its consequences because they had endured hardships at other times in their lives, thus, offering support for the developmental interpretation. Participants also suggested that, although younger people fall too, a fall had different consequences and could be more of a problem for people of their age, thus, supporting the contextual interpretation that posits that there are different sources of stress at different points in the life course. In addition, participants seemed to have acquired certain beliefs (make the best of things, carry on, life is not easy) as a result of living through the Depression and World War II, thus providing support for the cohort interpretation which is based on the belief that people of different ages differ in their reactions to stressors because of various historical conditions that impact them throughout their lives. In terms of its utility, the appraisal process of Lazarus and Folkman's transactional model contributed an understanding of the participants' experience; however, it also had some disadvantages. The present study highlights the dynamic nature of the appraisal process. By understanding the relationship between primary and secondary appraisals as a fluid, iterative process, it made sense that, when women in the present study described the meaning the fall had for them, they drew on coping as part of the meaning-making process. In addition, the present study highlights the importance of considering the stress, appraisal, and coping process over time. If they had taken part in the study at the time of, or immediately after the fall, the meaning of the fall might have had a somewhat different emphasis. A drawback of the transactional model is that it does not take an individual's context into account. As Oakland and Ostell (1996) suggest, due to the dynamic nature of the coping process, there is a need to know more about the context. The same holds true for the dynamic nature of the appraisal 99 process. For women in this study, the meaning of a fall was multifaceted and knowledge of their context was needed in order to understand what was at stake for them and their ability to cope. In addition, the labels used in the transactional model can be constrictive. For a researcher, there is the possibility of becoming "hooked" on the stress, appraisal, and coping process and, as a result, missing key findings. By analysing the text free of the bonds of stress and coping theory, consideration of other possibilities and processes were allowed to emerge. Ironically, the text was analysed without using the theory of the transactional model; however, evidence of Lazarus and Folkman's (1984) stress and coping theory was found, therefore, the theoretical underpinnings of the transactional model were supported. The main shortcoming of the transactional model is its failure to offer a method for conceptualizing meaning. Although in the present study I conceptualized the meaning participants make of a fall with the use of the Satir Model, there are many different ways to interpret how individuals make meaning. Therefore, by not having a specific method for determining meaning, a significant part of the appraisal process, further ambiguity is added to the study of stress, appraisal and coping. Although there is a need to study the stress and coping process in women who are 75 years and older, to do so using the language of stress poses a challenge. The findings from the present study suggest that this segment of the population might have been familiar with the language of the stress discourse; however, they did not appear to use this language voluntarily. The women did not appear to view "stress" as a "normal" part of everyday life (Carter et al, 2002; Pollock, 1988) because, although they described hardship after a fall, they did not use the language of the stress discourse. In fact, there was a distinct absence of the stress discourse in their focus group meetings and interviews. Instead, participants expressed specific, underlying emotions rather than the blanketing sentiments of the stress discourse. This allowed a greater understanding of what was distressing about a fall for these women. The Iceberg of the Satir Model The "iceberg" metaphor of the Satir Model (Satir et al, 1991) was used as a framework to interpret the meaning participants made of a fall. This framework does have utility for researching meaning; however, there are also a few disadvantages to its use. The iceberg framework is a 100 practical way of understanding the meaning-making process because it has "something for everyone." The components of the iceberg are presumed to be part of the human experience and, therefore, it is ideal for determining what meaning participants made of a fall. Furthermore, the Satir Model is a counselling model. Therefore, it provides a bridge between research and practice. As the systemic nature of the iceberg demonstrates, meaning is not just made by using one component of the iceberg; the components of the iceberg, as with aspects of human experience, are interconnected and influence each other. This allows for complexity. For example, findings from the present study indicated that participants did not just make meaning through their perceptions of the fall, their perceptions were influenced by their behaviour and their expectations. As a framework, the iceberg offers a way of contemplating the findings in a new way. In order to consider which themes corresponded with the various components of the iceberg, the meta-themes that emerged in the analysis were broken down, the themes were considered in isolation, and, as a result, new connections between themes became obvious (e.g., the world is open for seniors was connected to staying in the world). In addition, if it had not been for the iceberg framework, behaviour may not have been considered part of the meaning-making process of a fall. There were also disadvantages to using the iceberg framework to interpret the meaning participants made of the fall. Although the iceberg helped demonstrate the nuances and complexities of the participants' meaning making process, due to the countless interconnections between components of the iceberg, it was overwhelming to consider every possible connection between themes. Due to the number of possible interconnections between components of the iceberg, it was easy to form hypotheses about the women's meaning making and to lose touch with their stories. Although it is in keeping with the Satir Model's (Satir et al, 1991) emphasis on a person's internal process rather than the story about the problem, as a result of rearranging the themes to reflect the iceberg, it was easy to lose the participants' storylines. Therefore, it was important, as a researcher, to stay grounded in the text of the participants' accounts. Furthermore, to explain the results in terms of the components of the iceberg would result in losing some of the participants' language. 101 In addition, it was difficult to uncover evidence of the components of yearnings in the participants' words. There was the possibility that participants were not aware of their yearnings, making it difficult to include this component in the analysis. The iceberg framework is fairly abstract. Sometimes one theme corresponded with more than one component of the iceberg and this made it difficult to determine where the theme belonged. For example, it could be argued that the theme "the world is open for seniors" corresponded with perceptions because it was how participants saw the world around them; however, it could also be argued that it corresponded with expectations because it is societal expectations that encourage them to view the world in this way. Due to the systemic nature of the iceberg, these connections were made, but it was difficult to determine which came first, thus, confusing the interpretation in terms of conceptual ordering of the findings. The Participants' Influence on the Researcher As a researcher and as a fellow human, 1 have admiration for the women who took part in my study and I took in their wisdom that comes from a lifetime lived. As an "outsider," a person from a different generation, I did not have the bias of my own experience of being an elder and having a fall. T considered the women in my study to be the experts on falls in old age; therefore, they were able to teach me what the experience of a fall was like for them. I found them to be willing to share their stories with me in an honest, open manner. I learned many lessons from these women. As they talked about the meaning the fall had for them, they taught me about aging and about the frustration and joy of mastery that comes with learning to live in an aging body. They taught me about strength, perseverance, acceptance, and the importance of carrying on with life. Furthermore, they gave me a new awareness of the environment. Now, more than ever, I am aware of potential hazards and supports various environments offer. Perhaps, most importantly, they taught me that having a fall when you are old does not necessarily mean disengaging with life. 1 have a feeling most of the women viewed me as a non-threatening "granddaughter" figure. They seemed intent on being of help, they were supportive, and showed an interest in my studies. I felt a special connection with each of the participants and I believe that this connection fuelled my passion and enthusiasm for this research. 102 I was surprised that these women did not frame the fall as a traumatic event. They did not have a "Pollyanna" view of their falls but, at the same time, they did not dwell on the negative aspects of the fall. The participants were women in their 70s, 80s, and 90s who were continuing to grow mentally. To me, they are proof that, if you have strength of spirit, it will help you move forward with life, no matter what happens to your body. Through getting to know these women and hearing the stories of their falls, they reinforced my belief in hope, inspiration, and the human spirit. My contact with the women in my study inspired me to write the following poem. It is a testament to the strength of spirit I saw in each of them. When... When my bones are creaky, When my hair is grey, When my step is slower, What will others say? When they look at this old woman, What will they see? More careful, less agile, Will they pity me? They may see an aging body Shaky hands and wrinkled skin, Perhaps they'll fail to see The strength I have within. Limitations Participants in the present study were community-dwelling women residing in North and West Vancouver. There are many steep hills in North and West Vancouver, making it unique geographically and particularly hazardous to elders. No men were included in this study; therefore it is not possible to determine if the experience of a fall is different for men. Therefore, the findings may not be applicable to individuals in institutions, to individuals living in different geographic locations, or to men. The present study relied on recall of an experience that occurred within the last year. Given the decline in episodic memory for older people documented by memory research (Whitbourne, 1996), there is the possibility that some information may have been forgotten. However, it was assumed that if an individual feels strongly enough about the research topic to volunteer her time to participate, then she 103 sees the fall as having some significance in her life. Moreover, it was assumed that if the fall has significance in the participant's life, more detail will be remembered about the event. It is of note that participants remembered their falls in great detail and generally provided identical accounts of the fall on three occasions (e.g., the screening interview, focus group meeting, and in-depth interview). There can be limitations inherent in the use of focus groups. For example, there is the possibility that opinions expressed in the focus group were influenced by the group and did not reflect what the individual was thinking or feeling. In addition, there is the possibility that the women were hesitant to share highly personal information wheii peers were present. Yardley and Smith (2002) studied the relationship between feared consequences of falling and avoidance of activity in community-living older people aged 75 years and older. They found that disclosure of feared damage to identity was frequent in an anonymous questionnaire whereas in focus group meetings on the same topic only a few individuals admitted to this concern. In the present study, by conducting personal interviews after the focus group meetings, it was possible that the women shared information with me that they may not have felt comfortable sharing in the group. However, the majority of participants in the study claimed that they did not consider thoughts and feelings connected with the fall to be of a highly personal nature and, as a result were willing to share with others in the group. In accordance, 1 found strong consistency between what participants shared in the focus group meetings and what they shared in the interviews. Another possible limitation is the fact that all of the participants were very eager to help with the study. At various points during the focus group meetings and interviews participants explicitly stated that they wanted to make sure that they were helping me with my research. Although the questions asked in the focus group meetings and the interviews were not leading questions, there is the possibility of the participants answered questions in ways they thought would please me. Implications for Practice This study illuminates several possible implications for counsellors who work with elderly clients who have experienced a fall. The story of the fall as an event seemed to. take on important meaning for the participants; therefore, there may be clinical implications with regards to clients telling the story of their fall and having the story witnessed. 104 The complex psychological implications of a fall evident in the findings suggest a need for falls among older women to be taken seriously even if no apparent injury is sustained. Addressing the psychological implications of a fall in a way that helps older women know they are not alone, that others have similar thoughts and feelings with regards to a fall and its consequences may prevent the decline in self-efficacy that Peterson et al. (1999) suggest is evident in many individuals who have fallen. Women in this study experienced both behavioral and psychological changes; therefore, it is important to be sensitive to changes that older clients may be experiencing in the time after a fall. The interface between the women's context and the fall became apparent in this study, suggesting the importance of not thinking of an older person in isolation. It might be important to take their expectations of aging and their perceptions of the world and social relationships into account. Furthermore, this study demonstrated the importance of the older woman's relationship with her family; therefore, it might be important to explore the nature of an older woman's relationship with her family and how it might change as a result of the fall. Another area to explore with clients might be the fears connected to the possibility of future falls. In addition, participants in this study worked to cultivate a positive attitude to help them get over the fall and its consequences. It might be useful for a counsellor to explore how clients cultivate a positive attitude, focusing on their strengths. By taking the time to understand what it is like for an older woman to fall may help build rapport and, in addition, ensures that the counsellor is not assuming what the fall meant to the client. In light of the current study, using Folkman and Lazarus' (1984) transactional model as a clinical tool when working with this population has utility; however, it also presents certain obstacles. In terms of using the appraisal process with clients, it is beneficial to understand what clients think is at stake, this offers counsellors the opportunity to hypothesize what the client's underlying yearning is. In addition, the appraisal process highlights an individual's ability to cope with a stressor. In the present study, participants described a number of ways they dealt with the fall. However, in counselling, it is important to explore the meaning of the stressor before proceeding directly to coping. However, it is not enough to know what is at stake for a client and how she is going to cope; this does not enable the counsellor to understand the complexities of the situation. It is important to 105 understand the context of the situation. For example, in the present study, it was important to understand how participants made meaning of a fall in terms of their relationships with others, their own aging, and their perceptions of the world around them. A drawback of using the stress and coping paradigm is that not all clients understand the language of the dominant stress discourse. Furthermore, to use the language of the transactional model would be too vague to use with clients because, in counselling, clarity and specificity are needed. Suggestions for Future Research The findings of this study evoke a number of different avenues for future research. There is the possibility of gender differences with regards to what meaning is made of a fall; therefore, a similar study could be done with male participants. It is possible that a fall might be a very different experience for a man; therefore research on the meaning that men over the age of 75 make of a fall is warranted. This research focuses on a fall as the distressing event; therefore, further research is needed to determine whether the identified appraisals are similar for other types of potentially distressing events. In addition, the present study illuminated a number of psychological processes with regards to older women and falls, some of which warrant further research. Some of the women in this study found it difficult to accept their limitations, ask others for help, and shift from "have always been" to "used to be;" however, others seemed to make the transition with more ease. Future research could explore the process of acceptance of limitations and changes that come with a fall, focusing on what conditions facilitate the process of acceptance. Another area that warrants future research is the topic of resistance and compliance with fall-related changes to lifestyle. An understanding of factors encouraging compliance and lowering resistance could lead to falls-prevention programs that significantly reduce the number of falls in the elderly, thus reducing healthcare costs. One of the findings of this study suggested that there was a strong connection between the fall and beginning to feel old. Given the pressure in today's society to stay younger for longer, future research might explore more aspects of the link between falls, aging, and pressures of society. 106 According to this study, the fall not only impacted elderly women but it also impacted their family members. Future research could examine the impact a fall has on an elder's children. Research of this nature would contribute to an understanding of what sort of support is needed by adult children, who might be caregivers for their aging parents. Furthermore, it might provide insight into how the parent-child relationship is affected after the senior falls. Conclusion This study explored the meaning that 14 community-dwelling women, over the age of 75, made of a fall in terms of behaviors, feelings, perceptions, expectations, and yearnings. Moreover, it revealed that, for these women, there appeared to be complex psychological processes connected with a fall. As evidenced in the five meta-themes that emerged, regardless of the severity of the fall or how drastically their lifestyle changed after a fall, the meaning participants made of the fall was suffused with feelings, perceptions, and expectations. Due to lack of evidence of yearnings in the text, yearnings connected to the fall had to be deduced. However, behaviour emerged as a key component of the meaning the women made of the fall. For women in this study, as their meaning of the fall unfolded, they described a distressing event, followed by adjustment to fall-related changes that allowed them to move forward with life. Rather than focus on fall-related changes and limits as distressing or as hassles, these women focused their energy on healing and accepting their fall-related changes and limits. Theirs is a story of growth in later life and evidence that, for an elder, a fall does not necessarily mean disengagement with life. In order to understand the meaning of a fall for these women, this study combined aging, Lazarus and Folkman's (1984) stress and coping theory, and the Satir Model's personal iceberg framework. Aging provided part of the context of how these women made sense of a fall. Lazarus and Folkman's (1984) transactional model provided the opportunity to conceptualize the fall as a stressor with a focus on the appraisal process. The iceberg framework provided a way of tapping into the meaning-making aspect of the appraisal process. The transactional model and the iceberg framework of the Satir Model complimented each other because both are systemic and emphasize the need to consider an individual's internal process. As a 107 result, they drew attention to the importance of viewing meaning-making as dynamic processes. In addition, both models assume that people process information differently and that each individual is unique; thus, they highlighted the subjectivity inherent in the meaning-making process. A wealth of findings can be attained through contemplating how primary appraisal and secondary appraisal work together and, furthermore, how behaviors, feelings, perceptions, and expectations combine to help elderly women make meaning of a fall. 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Yardley, L., & Smith, H. (2002). A prospective study of the relationship between feared consequences of falling and avoidance of activity in community-living older people. The Gerontologist, 42 (1), 17-23. 113 Appendix A Personal Iceberg Metaphor Expectations (of self, of others, from others) Yearnings (universal) (love, acceptance, belonging, creativity, connection, freedom, etc.) These are the components of the personal iceberg metaphor of the Satir Model (Banmen, 1990) used in the present study. They are systemic in nature; therefore, each component is connected to and impacts the others. 114 Appendix B Informed Consent Form Title of Project: The meaning of a fall for elderly women The aim of this graduate thesis research is to understand what meaning women over the age of 75 make of the experience of a fall. The information you provide will help us understand more about the factors that cause an experience like a fall to be distressing for elderly women. As a participant you will take part in a discussion group consisting of 3-5 other women that will last 1-1.5 hours. Several days later, you will meet with me for a personal interview that will take approximately 1-1.5 hours. During the discussion group and the personal interview you will be asked several questions pertaining to your experience of a recent fall. I hope that taking part in the study will provide some benefit to you and to other elderly women who experience falls. I may use data from this project for subsequent analysis to address similar questions as posed in this study or to gain further understanding of what it is like for elderly women to take part in discussion groups. No data from this study would be used more than five years after it is collected. Informed Consent: This is to certify that I, , agree to voluntarily participate in this investigation of the experience of falls of elderly women. I understand that I do not 115 have to participate, and that I am free to withdraw my consent and terminate my participation at any time without jeopardizing my opportunity to participate in any other programs sponsored by the University of British Columbia. All information that I provide will be kept strictly confidential with regard to my identity - neither my name nor any other identifying information will appear on any published materials. Participants will be identified by pseudonyms only, and all tapes and transcripts of the discussion group and the personal interview will be kept locked in a file cabinet. The transcripts will be saved on computer discs and those discs will be kept in a locked file cabinet as well. Only the interviewer and three thesis committee members will have access to the files. The thesis committee members are all faculty members at the University of British Columbia. The importance of maintaining confidentiality will be emphasized in the discussion groups. Discussion group members will be asked to not talk to others about what occurred in the group; however, confidentiality is limited to the extent to which group members comply with this request. I understand that if I am distressed as a result of the discussion group or the personal interview, I may request a list of referral resources from the facilitator/interviewer. There is also the possibility that the facilitator/interviewer may offer me this list of referral resources if I disclose that my personal safety is at risk or if others are doing me harm. I have had a chance to ask any questions I want about this research project, and these questions have been answered to my 117 Appendix D Screening Protocol (Meaning elderly women make of a fall) Just to re-cap, volunteering to take part in this project would mean that you would take part in a discussion group. The discussion group would last for about 1.5 hours and would consist of 3-6 women, all over the age of 75 who have experienced a fall within the last year. I will be running the discussion group with the help of a colleague who is also in the process of completing her Master's Degree. During the discussion group I will ask several questions about your experience of a fall. A week or two after the discussion group I would meet with you individually for a follow-up personal interview. This interview would last for about 1-1.5 hours. During the interview I will ask you more questions about your experience of a fall. I will also ask you what it was like for you to participate in the discussion group. There is a chance I will contact you after the follow-up interview if anything needs clarification. Both the discussion group and the follow-up interview will be tape recorded and transcribed. I am planning to look for common themes that come out of the discussion groups and the interviews. All information, everything you say, is confidential and the tapes and transcripts from the discussion group and personal interview will be kept in locked file cabinets. That means that no one, other than the three university members who are on my committee and myself, will have access to your information. Confidentiality is a serious matter, so none of your personal information will be given to anyone. That means that if someone from your family or someone from the community center/Kiwanis Towers wanted me to tell them what you said in the discussion group or the interview I would not tell them. The information you volunteer would not be used against you. I will be writing a report on this study and may be publishing the results; however, no names or identifying information would be mentioned so you would remain anonymous. Do you have any questions about confidentiality? Taking part in this project is voluntary. That means that you have the right to stop participating at any time. There are no repercussions for refusing to participate. It is your right to not have to do anything you do not want to do. Do you have any questions about the voluntary nature of this project? Once my research is complete and if you are interested, I will send you a summary of my findings. Do you have any questions? Here is the consent form. If the type is not large enough, if you are unable to read it, let me know and I can read it for you. 118 Appendix D Focus Group Protocol (Meaning elderly women make of a fall) Introduction Welcome to the focus group/discussion group on experiences of a fall. Thank you all for coming here today. This group will last approximately 1.5 hours, from X (i.e., 2:00 p.m.) to Y (i.e., 3:30 p.m.). We will be taking a 15 minute break about halfway through. The bathrooms are (give directions to bathrooms). After the discussion group we will serve some refreshments. My name is Kathryn and 1 will be the facilitator of today's discussion, which means it is my job to make sure we stay focused on the questions at hand and that everyone gets an opportunity to speak. I would also like to introduce . She will be taking notes on the order in which people speak, watching time, and making sure the tape recorders are working. Purpose of the project and purpose of the discussion group The purpose of this project is to understand what meaning women over the age of 75 make of the experience of a fall. The reason we are using a group format is to stimulate discussion. Discussion groups are beneficial because, often, hearing other people's experiences may trigger your own thoughts on the subject at hand, providing us with a more in-depth understanding of the topic we are studying. We are hoping our 1 discussion here today will add to our understanding of the meaning older women make of an experience of a fall. Reminder of informed consent Consent forms have been signed by the participants prior to the discussion group. Participation in this focus group is voluntary. If at any point you wish to leave, please feel free to do so. Confidentiality is extremely important to us. All participants will be identified on the transcripts by a pseudonym. As well, any identifying information (ie company names, names of third parties) will be blocked out. Although this discussion will be audio- taped, information on these tapes will not be shared with anyone other than my three committee members. These tapes, as well as transcripts from these tapes, will be kept in a locked file cabinet. Bearing the importance of confidentiality in mind and, as some of the issues discussed here today may be sensitive in nature, we ask for your cooperation in keeping what is said in this discussion group confidential. So, please do not divulge any information contributed by your fellow group members. Format for discussion We have several questions for you today. We will start with the first question and go around the group in a round-robin fashion so that everyone has the opportunity to speak. Since we will be transcribing the discussion, it is helpful if only one person speaks at a time and board/poster paper. If at any point you would like me to repeat anything or do not hear something that has been said, please say so. Once each group member has had the opportunity to speak I will open the floor to any additional comments people may wish to contribute. We will then move on to the next question. At times 1 may ask for clarification in order to understand a comment in greater depth. I may interject and refocus the discussion if I think we are off topic; it is important to try and stay on track because of time considerations. Please remember that while we will be proceeding in a round-robin fashion we respect your right to not respond. Please feel free to pass on any question. 119 Questions Does anyone have any questions about anything I have covered thus far? Introduction of participants Before we begin our discussion it will be helpful to get acquainted with one another. As an ice-breaker, when it is your turn, please also tell the group one thing that you like to do; for example, a hobby, a sport, something you enjoy doing. Proceed with introductions in a round-robin fashion. Topic for discussion Let's begin. Here is the first question for today's discussion. Question #1: Briefly tell me the story of your fall Clarification: When did you have your fall? What happened when you fell? What happened in the time after you fell? Why did you have your fall? Question #2: What was the most distressing thing about the fall? Question #3: What meaning does the fall have for you? Question #4: What difficulties in your daily life occurred as a result of the fall? Closing It is time to start wrapping up the discussion. Does anyone have anything else they would like to add? Summarize themes that came up. Sometimes talking about upsetting experiences can bring up negative energy so before ending, I'd like to do a brief exercise so that you go away from here feeling energized. I would ask that everyone close their eyes for a moment (if this is comfortable for you) and take a deep breath. Pause for 15 seconds. Take in the positive energy from this group of women who have taken the time to share their thoughts and experiences. I'm going to count to three, and at three I'd like everyone to slowly stand up and give us all a standing ovation for participating today. One, open your eyes. Two slowly stand up from your seat. Three! Before we end I'd like to check-in with everyone and see how you're doing. How is everyone feeling after our discussion? Check-in with each participant. Are there any questions or concerns that came up for anyone? Thank you all for your valuable input. I appreciate the fact that you gave up your valuable time to contribute to my research. Serve juice and cookies/cake. Appendix E 120 Demographic Questionnaire The following information is meant to provide a description of the people who took part in this study. Please do not put your name on this sheet of paper. 1) When were you born? 2) What is the highest level of education you achieved? 3) What is your marital status? 4) Where were you born? 5) How many falls have you had within the last year? 121 Appendix F Summaries of the focus group meetings November 4, 2002 Discussion Group Summary* Question #1: story of the fall There was a range in stories of the participant's falls. One participant fell outside her building, another participant fell in a lecture hall, another participant fell in her bathroom, and another participant fell in her bedroom. Not all of the falls resulted in injury. Results of the falls included: a broken pelvis, a repeat of an old neck injury, and damaged self-esteem. Question #2: what was distressing about the fall? The range of emotions resulting from the fall include: • Feeling helpless, not knowing what has happened. • Feeling embarrassed, hurting one's pride. • Feeling frightened, not sure if something is broken. • Fear that the fall might lead to loss of independence, having to move into a home. • Being dependent on others for transportation. • Feeling useless, not able to do certain things for others. • Fear of falling again. Question #3: what meaning/consequences does the fall have? • Having to be more careful. • Having to be more organized, plan ahead for things. • Makes you feel mortal, makes you aware that you are getting older and that your body is changing. • Not being able to do the things you once enjoyed i.e. traveling. • Necessitates a change in lifestyle. • Makes you realize how many friends you have, you learn you are not alone, kindness of others. Question #4: what difficulties in your life have occurred as a result of the fall? • Difficulties getting around, doing housework. • Can't take things for granted. • Fitting in appointments (i.e. physiotherapy, doctor) Overarching themes: • A fall is something one must deal with and live through. • A fall fits into the process of life. • A sense of humor helps one get through a fall. • It is a waste to make a career of feeling badly. • Life is for living. * Please note: font size for this document has been reduced from 16 point to 11 point. 122 November 19, 2002 Discussion Group Summary* Question #1: story of the fall One participant fell in her bedroom, hit her head and was knocked unconscious. Another participant overbalanced herself with a chair, fell backwards in her living room and bumped her head. Another participant was standing in the bus and the bus driver came to a sudden stop, she fell and broke her finger. Another participant was outside her apartment building talking with someone on one of the balconies, she fell backwards. Another participant fell in the hallway of her home as she was taking the garbage down to the basement and she was knocked unconscious. Another participant fell face down at a crosswalk near her home and hurt her lip and her arm. Question #2: what was distressing about the fall? • Feeling shaky • Feeling stupid having others see you fall • Worry about having to go to the hospital • Not knowing why you fell • Worry about possible injuries from the fall • Being annoyed or angry with self • Not being able to do things for self i.e. house cleaning • Worry about the future • People making a fuss when there is nothing wrong with you after the fall Question #3: what meaning/consequence does the fall have? • Falls are a nuisance • Try not to let fall happen again • More careful about walking • There may be a hea|th-related cause of the fall • Falls make you aware of your limitations • Falls make you think of your aging • Loss of 'freelance independent spirit' • Support and concern from friends and family members Question #4: what in your daily life has changed? • Not being able to do the things you want or that you used to take for granted Overarching theme • A fall may stop you in your stride for a while but life goes on * Please note: font size for this document has been reduced from 16 point to 11 point. 123 December 6, 2002 Discussion Group Summary* Question #1: story of the fall There was a range in stories of the participant's falls. One participant fell down some steps in a coffee shop, two participants fell on sidewalks outside stores, and one participant fell after reaching for something in her kitchen. Results of the falls included: a slashed nose and mouth that needed stitches, a broken femur, a smashed face and broken arm, and a damaged tailbone. Question #2: what was distressing about the fall? • Feeling foolish • Feeling physically and emotionally shaken • Fear of being beholden to someone • Pain that occurred with the fall • Having another person be callous • Fear of loss of independence • Being alone when the fall occurred • Worry about what damage the fall had done • Feeling angry with self for having fallen Question #3: what meaning/consequences does the fall have? • Being apprehensive about falling again • Makes you realize your age • It brings an awareness that with age, your bones are more susceptible to breaking • It brings one's independence into question • The fall puts one in the position of having to ask for help • The fall raises the concern of one's children • Comparing self to your own parents when they were older • The fall helps you realize the power of positive thinking • The fall makes you wonder how your lifestyle is going to change • Something positive that came of the falls was the kindness from others i.e. the bus driver and the people on the bus, the young man who sat with one participant till the ambulance came, the woman who brought a participant napkins for her bloody face, and the neighbor from across the street who came to help the participant who fell in her home. Question #4: what difficulties have occurred in your daily life as a result of the fall? • Not much has changed in daily life as a result of the fall • It takes more time to do things, especially if using a walker or a cane • There is a sense of having to be more careful when walking, watching where you are going, taking it easy when climbing or descending stairs Overarching themes: • Getting on with life after the fall • An appreciation of the support and kindness from friends and family • Focusing on healing and getting better after the fall • A determination to remain as independent as possible * Please note: font size of this document has been reduced from 16 point to 11 point. 124 Appendix G Follow-up questions for participants' interviews (Based on their responses in the focus group meetings) Audrey: follow-up questions • What does it mean to you to be beholden? What would it take away from you or from the other person? • When you fell at the coffee shop, what do you think others thought when they saw you fall? • When you talk about thinking 'how could you be so dumb' and saying 'I guess it goes with the territory' - what is 'the territory'? • What does independence mean to you? What is so important about keeping it? • How do you see a fall fitting into the process of growing old? • How is a fall different for you vs. past generations? • How has the fall altered your lifestyle? • If you could use one word to describe the fall, what would it be? Daisy: follow-up questions • You mentioned the young man who helped you right after you fell and said you were very grateful -what were you most grateful to him for? • What was it like for you to be using a walker? What did you dislike the most about it? Was there anything good that came from using the walker? • You said that after the fall you didn't look back, what kept you from dwelling on the fall & injury? • In the discussion group there was some talk about doing housework & someone told you 'you shouldn't be washing your own windows'...what is it like to be told that you 'shouldn't' be doing something like that? What do you think you can still do after the fall that perhaps people tell you that you shouldn't? • By staying at home (not going to your daughter's) after the fall, what traits/characteristics in yourself were you reinforcing? • How would you define independence for yourself? What makes it so important? • Did your sense of independence change after your husband died? • If you could use one word to describe your fall, what would it be? • How did you make sure the fall didn't slow you down, physically? Emotionally? • What did you learn from the fall? • How much influence do past generations in your family have on how you see yourself today? • How has using a cane affected your lifestyle? • What was the great thing about graduating from a walker to a cane? Fern: follow-up questions • After a fall, what keeps you going forward? • Have you changed things around your apartment because of the fall? • If you could use one word to describe the fall, what would it be? Frankie: follow-up questions • Does fear of falling stop you from doing things in your daily life? • What makes it difficult to accept help (e.g., rides from friends)? • What else have you had to cut back on in your life because of your fall? • Re: "keeping everything in hand" have you changed things around in your apartment because of the fall? • If you could use one word to describe the fall, what would it be? 125 Greta: follow-up questions • What is it about a fall that makes you feel mortal? • How have you changed your lifestyle because of an awareness you might fall? • What in your daily life can you not take for granted because of a fall? Heather: follow up questions • It seems that you know of many people in your building who have fallen, you have helped many neighbors (you seem to be the one they turn to), has being part of so many people's lives who have fallen changed your thinking about falls? • What do you think is the hardest thing for people to deal with after a fall? • Others (friends) see you as always on the go, do you think that having the fall change the way they think of you? • What did the other passengers on the bus do after you fell? • What do you think was going through their minds when they witnessed your fall? • Is there anything you learned from your fall on the bus? • What helped get you through the time after your fall? • If you had to choose one word to describe your fall, what would it be? • How closely tied are falls and independence? Iris: follow up questions • You said that this fall was the worst of all the falls you have had, what made it the worst? How many other falls had you had up to then? Was this fall related to your move into this residence? • What was the biggest shock about this fall? • If you could only use one word to describe that fall, what would it be? • How was it for you to discover some of the reason behind your falls (connection with high blood pressure)? Marigold: follow up questions • What was going through your head when you were waiting for help? • Did your fall affect how your friend from across the street looks at you/thinks of you? • Is there anything you don't do since the fall because you are worried about falling again? • After the fall, were there things that others told you that you shouldn't do? That you think you shouldn't do? • Do you think there are certain 'rules' for seniors that are related to falls/preventing falls? • Has your behavior changed after the fall? • What sorts of things might you rely on others for since the fall? How is it for you to rely on others? • You mentioned thinking the worst about your injury after the fall.. .being like this for the rest of your life. What is the worst part for you about being like this? What fear is connected to being like this (in pain, relying on a cane) for the rest of your life? • Under what circumstances would you ask others for help? Do you think there are certain unspoken rules around asking people for help? • What is the main word you would use to describe your fall? • You mentioned graduating from a walker to a cane - what was it like to use the walker? What did you like/dislike about using it? 126 Maud: follow-up questions • How was the pain a nuisance? What does "nuisance" mean to you? • What makes it difficult to accept help from friends/others? • What day-to-day things can't you do (that you used to) because of the fall? • If you could use one word to describe the fall, what would it be? Robin: follow up questions • Do you think it is different for you when you fall, knowing that your husband is still alive/you are not living alone? (as compared to others whose husbands are not around any more) • You talked about not 'parading' problems to self, family, or friends. What are your reasons for this? • What makes you say/think that falls are part of getting old? • In the discussion group you talk about your theory of 'since you can't control the future, you try not to worry about it' - when did you begin thinking this way? • What is it like for you to have friends and family that are concerned for you? • Do your falls have a small, medium, big impact on your life? • If you could use one word to describe your fall, what would it be? Sunshine: follow-up questions • You mentioned you are very careful of falling now and can't do things like folding sheets. What other sorts of things can you not do? How does this affect you? • You said you get annoyed with yourself, not being able to do things for yourself. Can you say more about that? What is the fear behind not being able to do things for yourself? • What does a clean house signify? Represent for you? Say about you? • After the fall you asked JW for help. What is it like for you to ask a) neighbors for help? b) your sons for help? • How does the fall shake you up? (does it shake your image you have of yourself?) • What would others think if they saw you fall in the street? • If you could describe the fall in one word, what would it be? 127 Appendix H Interview protocol (Meaning elderly women make of a fall) Introduction Thank you for meeting me here today. This interview will take 1-1.5 hours. The purpose of this personal interview is to determine if my summary of the focus group you took part in fits your experience, to ask you a few more questions about your experience of the fall, and to find out how it was for you to take part in the discussion group. Reminder of informed consent Consent forms have been signed by the participants prior to the personal interview. Participation in this personal interview is voluntary. If at any point you wish to terminate the interview and withdraw your participation please let me know. There will be no repercussions if you choose to do so. This interview will be audio-taped and transcribed; however, confidentiality is very important, therefore, you will be identified on this transcript by your chosen pseudonym. As well, any identifying information will be blocked out. Information from this interview will not be shared with anyone other than my three committee members. The tapes and transcripts will be kept in a locked file cabinet. Do you have any questions or concerns? Please let me know if, at any point, you need to take a break. Questions 1) Briefly recap the story of your fall. Is there anything that needs to be added that you did not mention in the discussion group? 2) What feelings or emotions were connected with the fall? 3) How did the fall affect a. The way you looked at yourself? b. The way others looked at you? c. Expectations you have of yourself? d. Expectations others have of you? 4) Is there anything in your life that really matters that is at risk as a result of the fall? Conclusion Thank you for taking part in this personal interview. How are you feeling now? Do you have any questions or concerns that came up for you? Sometimes remembering a distressing event like the fall and thinking about all of the thoughts and feelings surrounding it can bring those feelings back. So, maybe what we could do is just a short relaxation exercise to bring you back to focusing on the present. 128 If you could close or lower your eyes and just focus on your breathing. Take a deep breath in, taking in positive energy. Now let that breath out. Let all of the negative energy out. Once more, deep breath in, positive energy in and let that breath out, negative energy out. Once my research is complete I will be conducting an information session to share my findings with everyone who has participated in my study. At that time you will be given a report of my findings. If you are unable to attend the information session, a report will be sent to you. Appendix I 129 Referral List Family Services of the North Shore 101 - 255 West 1st Street 604-988-5281 North Vancouver, BC, V7M 3G8 1410 Clyde Avenue 604-926-7851 West Vancouver, BC, V7T 1G1 A community based non-profit agency. Fees are set on a sliding scale according to your income. Counsellors have their Master's level training. They are experienced in working with individuals, couples, and families to address a wide range of issues that affect the quality of people's lives. North Shore Women's Centre 604-984-6009 944 W. 16th Street North Vancouver, BC, V7P 1R3 Drop-in visitors are welcome. Call for hours. Provides a drop-in resources center for women of all ages seeking information, education, resource material on various women's issues, and support and friendship. The center also has an active volunteer program, providing women with opportunities to learn new skills and make new friends. 130 SAFER 604-879-9251 (Suicide Attempt Counselling Service) 300 - 2425 Quebec Street Vancouver, BC, V5T 4L6 Provides counselling for individuals who exhibit suicidal behaviour. Offers individual counselling and workshops to family members and friends mourning a suicide death. Debriefing sessions are offered to nonprofit agencies where a recent traumatic event has occurred. No-fee. Referrals are made by calling between 8:30 am and 4:30 pm. SAFER services are not offered to individuals who are under age 13, under the care of another therapist, diagnosed with a major mental illness, or abusing drugs or alcohol. Also offers an education/training program for both suicide and bereavement issues. Vancouver Crisis Centre Distress/TTY: 604-872-3311 The distress line provides 24-hour telephone crisis counselling by professionally trained volunteers for people experiencing emotional distress. Access for non-English speakers is available in over 140 languages through an interpretation service. Crisis intervention service available to the hearing and speech impaired through a TTY machine. Nonprofit society. 131 Appendix J Windshield Survey Community vitality: > Are people visible in the community? What are they doing? > Who are the people living in the neighborhood? What is their age range? What is the predominant age? > What ethnicity is most common? > What is the general appearance of those you observed? Indicators of social and economic conditions: > What is the general condition of the homes you observe? > What forms of transportation do people seem to be using? > Is there public housing? What is its condition? Health resources: > Do you notice any hospitals? > Are there any clinics? > Are there doctors and dentists offices? > Do you notice any nursing homes, rehabilitation centers, wellness centers, etc.? Environmental conditions related to health: > Do you see evidence of anything that might make you suspicious of ground, water, or air pollutants? > What is the sanitary condition of the housing? > What is the condition of the roads? > Is there handicapped access to buildings, sidewalks, and streets? > Are there recreational facilities? > Do you see any restaurants? Social functioning: > Do you observe any families in the neighborhoods? > What evidence of community cohesiveness or neighborliness can you observe? > What type of churches, synagogues, or places of worship are there? > Is there anything that would make you suspicious of social problems such as gang activity? Questions were taken from: Questions to guide community observations during a windshield survey (Nies &McEwen, 2001). 132 Appendix K King Bruce and the Spider Robert Bruce, King of Scotland, was hiding in a hut in the forest. His enemies were seeking him far and wide. Six times he had met them in battle, and six times he had failed. Hope and courage were gone. Bruce had given up all as lost. He was about to run away from Scotland, and to leave the country in the hands of his enemies. Full of sorrow, he lay stretched out on a pile of straw in the poor woodchopper's hut. While he lay thinking, he noticed a spider spinning her web. The spider was trying to spin a thread from one beam of the cottage to another. It was a long way between the beams, and Bruce saw how hard a thing it was for her to do. "She can never do it," thought the king. The little spider tried it once and failed. She tried it twice and failed. The king counted each time. At length she had tried it six times and had failed each time. "She is like me," thought the king. "I have tried six battles and failed. She has tried six times to reach the beam and failed." Then starting up from the straw, he cried, "I will hang my fate upon that little spider. If she swings the seventh time and fails then I will give up all for lost. If she swings the seventh time and wins, I will call my men together once more for a battle with the enemy." The spider tried the seventh time, letting herself down upon her slender thread. She swung out bravely. "Look! look!" shouted the king. "She has reached it. The thread hangs between the two beams. If the spider can do it, I can do it." Bruce got up from the straw with new strength and sent his men from village to village, calling the people to arms. The brave soldiers answered his call and came trooping in. At length his army was ready to fight, and when the king led them in a great battle against the enemy, this time, like the spider, Bruce won. A Scottish tradition story taken from the 1914 book The Beacon Second Reader. Electronic enhancement of this fable © 2000, Antelope E-Books. 


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