UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

Life review and the institutionalized elderly Gurm, Balbir Kaur 1990

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
831-UBC_1990_A8 G87.pdf [ 5.22MB ]
Metadata
JSON: 831-1.0055837.json
JSON-LD: 831-1.0055837-ld.json
RDF/XML (Pretty): 831-1.0055837-rdf.xml
RDF/JSON: 831-1.0055837-rdf.json
Turtle: 831-1.0055837-turtle.txt
N-Triples: 831-1.0055837-rdf-ntriples.txt
Original Record: 831-1.0055837-source.json
Full Text
831-1.0055837-fulltext.txt
Citation
831-1.0055837.ris

Full Text

L I F E R E V I E W AND THE I N S T I T U T I O N A L I Z E D E L D E R L Y B y B A L B I R K A U R GURM B . S . N . T h e U n i v e r s i t y o f B r i t i s h C o l u m b i a , 1983 A T H E S I S S U B M I T T E D I N P A R T I A L F U L F I L L M E N T OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS i n THE F A C U L T Y OF GRADUATE S T U D I E S ( D e p a r t m e n t o f A d m i n i s t r a t i v e , A d u l t a n d H i g h e r E d u c a t i o n ! We a c c e p t t h i s t h e s i s a s c o n f o r m i n g t o t h e r e q u i r e d s t a n d a r d THE U N I V E R S I T Y OF B R I T I S H C O L U M B I A O c t o b e r 1990 B a l b i r K a u r G u r m , 1990 5 -3 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 Administrative. Adult, and Higher Education The University of British Columbia Vancouver, Canada D a t e October 12, 1990 DE-6 (2/88) ABSTRACT i i Using a pre- and p o s t - t e s t design w i t h both experimental and c o n t r o l groups, the research was conducted t o see i f l i f e review improved the independence, depression, and i n t e g r a t e d f u n c t i o n i n g of the i n s t i t u t i o n a l i z e d e l d e r l y . The e l d e r l y on the long term care u n i t of an acute care h o s p i t a l w a i t i n g to be placed i n a long term care f a c i l i t y were s t u d i e d using a pre- and p o s t - t e s t design. P a t i e n t s who were not depressed and could communicate i n E n g l i s h were in c l u d e d i n the study. They were randomly assigned t o the experimental and c o n t r o l groups when p o s s i b l e . P a t i e n t s i n the experimental groups attended e i g h t l i f e review sessions over a four week p e r i o d while the c o n t r o l groups c a r r i e d on w i t h the usual a c t i v i t i e s on the u n i t . Three s c a l e s , the G e r i a t r i c Depression Scale, A c t i v i t i e s of D a i l y L i v i n g E v a l u a t i o n Form, and the G e r i a t r i c Rating Scale were administered before the four week p e r i o d and a f t e r . Data was a l s o c o l l e c t e d during the sessions on group process using the Group Process Observational C h e c k l i s t on the experimental groups. Demographic data was c o l l e c t e d on a l l the p a t i e n t s i n the study. I t was found t h a t the experimental group d i d become more independent, i n t e g r a t e d and l e s s depressed. This study i n d i c a t e d t h a t l i f e review i s b e n e f i c i a l f o r the i n s t i t u t i o n a l i z e d e l d e r l y but, i t could not show e x a c t l y what v a r i a b l e s i n the l i f e review process c o n t r i b u t e d to these p o s i t i v e r e s u l t s . R e p l i c a t i o n s t u d i e s are needed t o v a l i d a t e these f i n d i n g s . i i i TABLE OF CONTENTS P a g e A b s t r a c t i i T a b l e o f C o n t e n t s i i i L i s t o f T a b l e s v i L i s t o f F i g u r e s v i i A c k n o w l e d g e m e n t s v i i i C h a p t e r 1 T h e P r o b l e m 1 B a c k g r o u n d o f t h e P r o b l e m 1 P u r p o s e o f S t u d y 2 R e s e a r c h D e s i g n 2 D e f i n i t i o n o f T e r m s 3 L i m i t a t i o n o f S t u d y 4 J u s t i f i c a t i o n o f S t u d y 4 C h a p t e r I I R e l a t e d L i t e r a t u r e 6 R e m i n i s c e n c e 6 L i f e R e v i e w 11 B e n e f i t s o r F u n c t i o n s o f L i f e R e v i e w 12 A d a p t i v e a n d M a l a d a p t i v e C o n s e q u e n c e s o f L i f e R e v i e w 13 T r i g g e r s 23 B e n e f i t s o f G r o u p T e c h n i q u e 26 B e n e f i t s o f I n d i v i d u a l T e c h n i q u e 28 I n s t i t u t i o n a l i z e d E l d e r l y 29 Summary 31 C h a p t e r I I I M e t h o d o l o g y 3 2 S a m p l e a n d S e t t i n g 3 2 I n s t r u m e n t s 34 D a t a C o l l e c t i o n 3 8 H y p o t h e s e s 43 I n d e p e n d e n t - D e p e n d e n t V a r i a b l e s 43 E t h i c a l C o n s i d e r a t i o n 44 C h a p t e r I V R e s u l t s 46 D e m o g r a p h i c s 46 R e s u l t s 47 H y p o t h e s i s N u m b e r One 48 H y p o t h e s i s N u m b e r Two 52 H y p o t h e s i s N u m b e r T h r e e 60 H y p o t h e s i s N u m b e r F o u r 66 i v TABLE OF CONTENTS CONTINUED P a g e C h a p t e r V D i s c u s s i o n , C o n c l u s i o n s , a n d R e c o m m e n d a t i o n s 68 D i s c u s s i o n 69 C o n c l u s i o n s 7 5 W e a k n e s s e s t o b e C o n s i d e r e d 7 6 R e c o m m e n d a t i o n s 7 7 B i b l i o g r a p h y 80 A p p e n d i x A G e r i a t r i c R a t i n g S c a l e (GRS) 8 8 A p p e n d i x B A c t i v i t i e s o f D a i l y L i v i n g ( A D D E v a l u a t i o n F o r m 93 A p p e n d i x C G e r i a t r i c D e p r e s s i o n S c a l e (GDS) 95 A p p e n d i x D G r o u p P r o c e s s O b s e r v a t i o n a l C h e c k l i s t 97 A p p e n d i x E D e f i n i t i o n o f B e h a v i o r s 98 A p p e n d i x F B a l e s G r o u p P r o c e s s C a t e g o r i e s 99 A p p e n d i x G D e m o g r a p h i c D a t a S h e e t 100 A p p e n d i x H L i f e R e v i e w a n d t h e I n s t i t u t i o n a l i z e d E l d e r l y G e n e r a l C o n s e n t 101 A p p e n d i x I L i f e R e v i e w a n d t h e I n s t i t u t i o n a l i z e d E l d e r l y P h y s i c i a n C o n s e n t 102 A p p e n d i x J L i f e R e v i e w a n d t h e I n s t i t u t i o n a l i z e d E l d e r l y E x p e r i m e n t a l C o n s e n t 103 A p p e n d i x K Q u e s t i o n s f o r L i f e R e v i e w S e s s i o n s 104 A p p e n d i x L D e m o g r a p h i c s o f P a t i e n t s i n C o n t r o l G r o u p 105 A p p e n d i x M D e m o g r a p h i c s o f P a t i e n t s i n E x p e r i m e n t a l G r o u p 107 A p p e n d i x N Summary o f P r e - a n d P o s t - t e s t S c o r e s o f t h e t h e G e r i a t r i c D e p r e s s i o n S c a l e ( G D S ) , A c t i v i t i e s o f D a i l y L i v i n g E v a l u a t i o n F o r m ( A D D , a n d t h e G e r i a t r i c R a t i n g S c a l e (GRS) f o r t h e C o n t r o l G r o u p 109 V TABLE OF CONTENTS CONTINUED Page Appendix 0 Summary of Pre- and P o s t - t e s t Scores of the G e r i a t r i c Depression Scale (GDS), A c t i v i t i e s of D a i l y L i v i n g E v a l u a t i o n Form (ADL), and the G e r i a t r i c Rating Scale (GRS) f o r the Experimental Group 110 Appendix P N a r r a t i v e Data Appendix Q Number of Group Sessions Attended by Subject 111 115 v i LIST OF TABLES Table Page 1 Pearson C o r r e l a t i o n C o e f f i c i e n t s Among the Behaviors on the Group Process Observational C h e c k l i s t 55 2 Pearson C o r r e l a t i o n C o e f f i c i e n t s Among Frequency of Speech, Time Length of Speaking, and Number of Major L i f e Events 59 3 Pearson C o r r e l a t i o n C o e f f i c i e n t s of the Group Process Behaviors w i t h Frequency of Speech, Time Length of Speaking, Number of Major L i f e Events, G e r i a t r i c Depression Sca l e , A c t i v i t i e s of D a i l y L i v i n g E v a l u a t i o n Form, and the G e r i a t r i c Rating Scale 61 4 Pearson C o r r e l a t i o n C o e f f i c i e n t s of Frequency of Speech, Time Length of Speaking, and Number of Major L i f e Events w i t h G e r i a t r i c Depression Scale, A c t i v i t i e s of D a i l y L i v i n g E v a l u a t i o n Form, and the G e r i a t r i c Rating Scale 65 5 Pearson C o r r e l a t i o n C o e f f i c i e n t s Among the G e r i a t r i c Depression Scale, A c t i v i t i e s of D a i l y L i v i n g E v a l u a t i o n Form, and the G e r i a t r i c Rating Scale 67 v i i L I S T OF F I G U R E S F i g u r e P a g e 1 D i a g r a m m a t i c R e p r e s e n t a t i o n o f S t u d y 40 2 M e a n S a m p l e S c o r e s o f t h e G e r i a t r i c D e p r e s s i o n S c a l e 49 3 M e a n S a m p l e S c o r e s o f t h e A c t i v i t i e s o f D a i l y L i v i n g E v a l u a t i o n F o r m 51 4 M e a n S a m p l e S c o r e s o f t h e G e r i a t r i c R a t i n g S c a l e 53 v i i i ACKNOWLEDGEMENTS F i r s t of a l l , I would l i k e to thank a l l the p a t i e n t s who p a r t i c i p a t e d i n t h i s study. Without them, t h i s study would not have been p o s s i b l e . I would l i k e t o thank my t h e s i s s u p e r v i s o r Dr. James E. Thornton f o r a l l h i s guidance, support and time spent e d i t i n g ; and the members of my committee, Dr. Thomas Sork f o r h i s guidance and encouragement, and Dr. Robert Conry f o r the enourmous amount of time spent on s t a t i s t i c a l a n a l y s i s . Without Dr. Conry t h i s p r o j e c t would have never been completed. I would a l s o l i k e t o thank T i l l y Bara f o r her i n i t i a l involvement i n the p r o j e c t i n h e l p i n g d e f i n e the problem. Others who deserve thanks are the nursing s t a f f on the u n i t ; E l s i e B r i n d l e , Mary Joo, Darlene MacRae, Martha Sanchez and Nola Waynor, who completed the s c a l e s and a s s i s t e d the p a t i e n t s from t h e i r rooms t o the meeting area, and Marie Pourbaix who c o l l e c t e d data during the l i f e review se s s i o n s . A s p e c i a l thank you to my s i s t e r , Harvinder Sandhu, who typed my e n t i r e t h e s i s twice because I l o s t i t i n the computer. F i n a l l y the encouragement and support of my husband has been g r e a t l y appreciated i n seeing t h i s p r o j e c t t o i t s completion. 1 CHAPTER I THE PROBLEM Background of the Problem Various p r o f e s s i o n a l s have attempted t o improve the q u a l i t y of l i f e of e l d e r l y c l i e n t s using d i f f e r e n t methods of as s i s t a n c e . Two methods i n p a r t i c u l a r , l i f e review and reminiscence, have r e c e i v e d considerable a t t e n t i o n over the l a s t three decades. Numerous review a r t i c l e s on t h i s t o p i c have appeared i n the l a s t few years, (Beuchel, 1986; Kastenbaun, 1982; Merriam, 1980; M o l i n a r i & R i e c h l i n , 1985; Pincus, 1970; Romaniuk, 1981; Thornton & B r o t c h i , 1987). Most have claimed t h a t l i f e review helps i n d i v i d u a l s adapt b e t t e r t o l i f e circumstances. In some of the l i t e r a t u r e the terms " l i f e review" and "reminiscence" have been used interchangeably. Studies by B o y l i n e t a l (1976), Havighurst and Glasser (1972) and Romaniuk (1981) suggest t h a t l i f e review helps i n d i v i d u a l s i n a s t a t e of t r a n s i t i o n or c r i s i s t o adapt. One such group i n t r a n s i t i o n may be the e l d e r l y e n t e r i n g long term care. K i e r n a t (1979) s t a t e d "the i n s t i t u t i o n a l i z e d e l d e r l y have a s p e c i a l need t o review the past i n order to s u c c e s s f u l l y cope w i t h the s t r e s s l e v e l s a s s o c i a t e d w i t h t h e i r i n t e r n a l and e x t e r n a l environments" (p. 307). The e l d e r l y i n long term care f a c i l i t i e s have u s u a l l y j u s t come from an acute care f a c i l i t y or the community w i t h some s o r t of p h y s i c a l or ps y c h o s o c i a l l o s s and are w a i t i n g 2 f o r placement. The i n d i v i d u a l s are i n a new p l a c e , have u s u a l l y s u f f e r e d a l o s s of t h e i r home, community, s o c i a l support, p r i v a c y , freedom and sometimes even t h e i r spouse. These i n d i v i d u a l s i n t r a n s i t i o n need h e l p t o cope w i t h t h e i r p r e s e n t s i t u a t i o n as evidenced by the h i g h r a t e of d e p r e s s i o n (20-50%) (Hawranik & Kandratuk, 1986, p. 26). Purpose of Study The purpose of the r e s e a r c h was to study the i n f l u e n c e of l i f e review s e s s i o n s w i t h the e l d e r l y on i n t e g r a t e d f u n c t i o n i n g , independence and d e p r e s s i o n . There are two quest i o n s t h a t need t o be answered. 1) Do l i f e review s e s s i o n s , when s y s t e m a t i c a l l y conducted u s i n g c r i t i c a l l i f e events, enhance i n t e g r a t e d f u n c t i o n i n g and independence and decrease depression? 2) I f l i f e review s e s s i o n s enhance i n t e g r a t e d f u n c t i o n i n g , independence and decrease d e p r e s s i o n , then what aspects of the l i f e review process enhance independence and i n t e g r a t e d f u n c t i o n i n g and decrease depression? Research Design A q u a s i - e x p e r i m e n t a l r e s e a r c h d e s i g n was employed (Campbell & S t a n l e y , 1963). The sample was s e l e c t e d from the longterm care u n i t of a 250 bed community h o s p i t a l . P a t i e n t s who c o u l d communicate i n E n g l i s h and were not depressed were s e l e c t e d and randomly a s s i g n e d t o the c o n t r o l and 3 experimental groups when p o s s i b l e . Pre- and p o s t - t e s t s t o measure i n t e g r a t e d f u n c t i o n i n g , independence, and depression were administered t o the sample. Demographic data was c o l l e c t e d on a l l p a t i e n t s . Group process data was c o l l e c t e d on the experimental group during the e i g h t l i f e review sessions which they attended. D e f i n i t i o n of Terms Reminiscence - i s the process of r e c a l l i n g one's past, e i t h e r v e r b a l l y or mentally ( i n one's mind) a t anytime w i t h or without purpose. L i f e review - i s the process of v e r b a l r e c a l l of the past f o r a s p e c i f i c purpose. I t i s a subset of reminiscence. Independence i n A c t i v i t i e s of D a i l y L i v i n g - the a b i l i t y t o bathe, dress, t o i l e t , t r a n s f e r and eat without a s s i s t a n c e as measured by the A c t i v i t i e s of D a i l y L i v i n g E v a l u a t i o n Form (Katz e t a l 1963) . Group I n t e r a c t i o n s - i s the process of communication w i t h another i n a s t r u c t u r e d s e t t i n g . Integrated Functioning - the a b i l i t y to f u n c t i o n i n a h o l i s t i c manner as defined by the G e r i a t r i c Rating Scale ( P l u t c h i k e t a l , 1970). Depression - f e e l i n g of unwellness and lowered a f f e c t measured by the G e r i a t r i c Depression Scale (Yeasavage & B r i n k , 1983). Major- L i f e Event - a s o c i a l t r a n s i t i o n p e r i o d i n an 4 i n d i v i d u a l ' s m a t u r a t i o n process, a l i f e stage. L i m i t a t i o n s of Study The study was r e s t r i c t e d t o the men and women on the long term care u n i t of a community based f a m i l y p r a c t i c e o r i e n t e d h o s p i t a l i n Vancouver, B r i t i s h Columbia. The study was f u r t h e r r e s t r i c t e d t o o n l y those p a t i e n t s who c o u l d t o l e r a t e a c t i v i t y f o r f o r t y - f i v e minutes and those who c o u l d s o c i a l l y i n t e r a c t i n E n g l i s h . P a t i e n t s who had been m e d i c a l l y diagnosed w i t h d e p r e s s i o n were not i n c l u d e d i n the study. A few p a t i e n t s were not able t o p a r t i c i p a t e i n a l l s e s s i o n s due t o some u n d e r l y i n g d i s e a s e p r o c e s s . J u s t i f i c a t i o n of Study Most e l d e r l y i n long term care u n i t s have gone through many changes and l o s s e s a s s o c i a t e d w i t h i n s t i t u t i o n a l i z a t i o n and aging. Depression, decreased s e l f - e s t e e m , decreased independence and l o n e l i n e s s and i s o l a t i o n are common symptoms amongst them (Matteson & Munsat, 1982; N o r r i s e t a l 1982). V a r i o u s authors s t a t e d t h a t l i f e review decreases d e p r e s s i o n , and i n c r e a s e s s o c i a l i z a t i o n , independence and the q u a l i t y of l i f e . Other authors have claimed t h a t l i f e review has many b e n e f i t s . Lappe (1987), Parsons (1986), Perschbacher (1984), and Ryden (1981) looked a t the e f f e c t s of group " r e m i n i s c i n g " on v a r i o u s outcomes. Not a s i n g l e study on the use of Bale's group process c a t e g o r i e s w i t h l i f e review groups i n an 5 i n s t i t u t i o n a l s e t t i n g could be found i n the l i t e r a t u r e reviewed. I f the process can be s y s t e m a t i c a l l y s t u d i e d and b e n e f i t s i d e n t i f i e d perhaps i t can be incorporated i n t o the care of the e l d e r l y to enhance t h e i r independence and decrease t h e i r depression and c o n t r i b u t e t o the q u a l i t y of t h e i r l i f e . 6 CHAPTER II RELATED LITERATURE Many a r t i c l e s on l i f e review have been published based on Butler's concept of l i f e review and Erikson's theory on l i f e stages (Babb de Ramon, 1983; Boden & Bielby, 1983; Boylin, Gordon, & Nehrke, 197 6; Butler, 1963; Butler, 1974; Buechel, 1986; Coleman, 1974; David, 1990; E l l i s o n , 1981; Green, 1983; Havighurst & Glasser, 1972; Kiernat, 1979; Jones & Zeiss, 1984; Lewis, 1971; Lewis & Butler 1974; Lo Gerfo, 1980; McMahon & Rhudick, 1967; Perotta & Meacham, 1981; Poulton & Strassberg, 1986; Romaniuk, 1981; Taft & Nehrke, 1990; Tarman, 1988; Webster & Young, 1988). Reminiscence has been defined i n various ways i n the l i t e r a t u r e and d i f f e r e n t benefits c i t e d . Most of the studies, whether group or in d i v i d u a l , have focussed on the adaptive value of l i f e review. In t h i s chapter d e f i n i t i o n s of l i f e review and reminiscence are presented. Some benefits of l i f e review are ci t e d . The adaptive and maladaptive consequences of l i f e review are discussed followed with an explanation of tri g g e r s . Benefits of i n d i v i d u a l and group techniques are described and the chapter concludes with a description of the i n s t i t u t i o n a l i z e d e l d e r l y . Reminis cence In the l i t e r a t u r e , l i f e review and reminiscence are used interchangeably. Hence, a l i t e r a t u r e review of both concepts 7 was undertaken. Though the purpose of t h i s paper was t o study l i f e review, i n the l i t e r a t u r e review s e c t i o n both l i f e review and reminiscence are summarized because some authors b e l i e v e the terms to be synonymous. Moreover, s i n c e l i f e review i s a subset of reminiscence, the term reminiscence can be used i n place of l i f e review, but not v i c e v e r s a . Reminiscence has been described i n d i f f e r e n t ways by d i f f e r e n t people i n the l i t e r a t u r e . Webster's d i c t i o n a r y (1980) define d reminiscence as the a c t of r e c a l l i n g or r e t e l l i n g the past. Hughston and Merriam (1982) define d i t as c a l l i n g t o mind experience or f a c t (p. 140). Beaton (1980) b e l i e v e d reminiscence t o be "an aimless wandering of the mind" (p.272 ). Coleman (1974) d i v i d e d reminiscence i n t o two c a t e g o r i e s : "simple reminiscence" the r e c a l l of the past, and " i n f o r m a t i v e reminiscence" a way of using the past to emphasize important matters. Beaton (1980) described f o u r types of reminiscence. 1) V a l i d a t i n g - i s a r e t r o s p e c t i v e process p r o v i d i n g reassurance t h a t because a person once had competence and worth t h i s i s s t i l l t r u e (p. 273). 2) I n t e g r a t i n g - i s the balance between a c h i e v i n g present s a t i s f a c t i o n and l o o k i n g ahead (p.275). 3) Guiding - i s the p r o v i s i o n of d i r e c t i o n f o r the younger generation (p. 276). 4) Connecting - i s the i n t e r a c t i o n between person 8 and environment (p.278). McMahon and Rhudick (1967) d e s c r i b e d t h r e e types of rem i n i s c e n c e : 1) t h a t which g l o r i f i e s the p a s t and be r a t e s the p r e s e n t 2) s t o r y t e l l i n g which n e i t h e r g l o r i f i e s the p a s t nor b e r a t e s the p r e s e n t and 3) e v a l u a t i v e r e m i n i s c e n c e ( l i f e r eview i n B u t l e r ' s terms). Lo Gerfo (1980) b e l i e v e d t h e r e are t h r e e d i f f e r e n t types of r e m i n i s c e n c e . 1) Informative - the r e l i v i n g and r e t e l l i n g of p a s t events f o r l e i s u r e and t o i n c r e a s e s e l f - e s t e e m . 2) E v a l u a t i v e - a means to come t o terms w i t h o l d g u i l t , c o n f l i c t s and d e f e a t s t o f i n d meaning i n one's l i f e . 3) Obsessive - i s when r e m i n i s c i n g becomes d y s f u n c t i o n a l because an i n d i v i d u a l does not r e s o l v e h i s pa s t . The i n d i v i d u a l ends up i n d e s p a i r and may become a g i t a t e d , depressed or s u i c i d a l (p. 40). Reminiscence may be guided or u n s t r u c t u r e d ( B u t l e r , 1963; F r y , 1983; Lewis, 1973; Pincus, 1970). Reminiscence may be done s i l e n t l y o r a r t i c u l a t e d t o another person. Lewis (1973) b e l i e v e d t h a t t o achieve p s y c h o l o g i c a l g a i n s , r e m i n i s c i n g may r e q u i r e another person as an audience. H a v i g h u r s t and G l a s s e r (1972) summed up the d e f i n i t i o n : " a l l of us from time t o time l o o k back over our l i v e s , r e c a l l i n g people and events, thoughts and f e e l i n g s . 9 Sometimes, such r e c a l l comes unbidden, as i d l e thoughts, and daydreams. Sometimes we purposely t h i n k back t r y i n g t o remember and r e c o n s t r u c t . Such r e t r o s p e c t i o n , both purposive and spontaneous, may be c a l l e d reminiscence" (p. 245). Most authors b e l i e v e reminiscence i s some k i n d of r e c a l l of past events (Coleman, Hughston & Marion, McMahon & Rhudick and Webster). Beaton i s the only one who b e l i e v e s t h a t reminiscence i s "an aimless wandering of the mind." The author disagrees w i t h Beaton. The sequence of r e c a l l may not always have meaning f o r the l i s t e n e r , but i t may be very s i g n i f i c a n t f o r the r e m i n i s c e r . Beaton makes the above statement, but l a t e r defines f o u r types of r e m i n i s c i n g . His d e f i n i t i o n s are not very c l e a r (p. 9). In f a c t he r e a l l y descibes f o u r d i f f e r e n t reasons why people reminisce: to increase s e l f - w o r t h , t o become balanced w i t h the environment, to provide i n f o r m a t i o n and t o come to g r i p s w i t h r e a l i t y . McMahon and Rhudick describe what they c a l l three d i f f e r e n t types of reminiscence (p. 10), but again they are j u s t d e c r i b i n g three reasons f o r r e m i n i s c i n g : t o g l o r i f y the past (increase s e l f - w o r t h as s t a t e d by Beaton), t o simply t e l l a s t o r y (could be the same as in f o r m a t i o n g i v i n g described by Beaton) and to evaluate one's l i f e (may be same as t o come to g r i p s w i t h r e a l i t y d escribed by Beaton). This t h i r d purpose f o r reminiscence appears to be s i m i l a r to B u t l e r ' s l i f e review. Again i n Lo Gerfo's three types of reminiscence (p. 10) there i s one s i m i l a r to l i f e review (to r e s o l v e o l d 10 c o n f l i c t s ) . A l l t h e s e a u t h o r s b e l i e v e t h e y a r e d e s c r i b i n g t h r e e d i f f e r e n t t y p e s o f r e m i n i s c e n c e , b u t t h e y a r e r e a l l y d e s c r i b i n g t h e d i f f e r e n t p u r p o s e s f o r r e c a l l i n g e v e n t s o f t h e p a s t . R e m i n i s c s e n c e i s t h e r e c a l l o f p a s t e v e n t s . When t h e s e e v e n t s a r e r e c a l l e d f o r a s p e c i f i c p u r p o s e , t h e n i t i s c a l l e d l i f e r e v i e w . R e m i n i s c e n c e o c c u r s m o r e f r e q u e n t l y i n t h e e l d e r l y i s i t f i c t i o n o r f a c t ? B o d e n a n d B i e l b y ( 1 9 8 3 ) f o u n d t h a t i n t w e l v e m i n u t e s e s s i o n s u n i m p a i r e d c o m m u n i t y e l d e r l y d y a d s ( o v e r t h e a g e o f 62 ) t a l k e d m o r e a b o u t t h e p a s t t h a n d y a d s f r o m a f r e s h m a n s o c i o l o g y c l a s s . L i e b e r m a n a n d F a l k ( 1 9 7 1 ) f o u n d e l d e r l y (mean a g e 79 ) e n g a g e d m o r e i n r e m i n i s c i n g t h a n t h e m i d d l e a g e d (mean a g e 4 9 ) . R e v e r e a n d T o b i n ( 1 9 8 0 ) f o u n d t h e e l d e r l y ( a g e s 6 5 - 1 0 3 ) w e r e m o r e i n v o l v e d i n t h e i r p a s t t h a n m i d d l e a g e d p e r s o n s ( a g e 4 5 - 5 5 ) . I n c o n t r a s t E s o n a n d G r e e n f i e l d ( 1 9 6 2 ) f o u n d n o r e l a t i o n s h i p b e t w e e n a g e a n d r e c a l l i n t h e i r s a m p l e o f a d o l e s c e n t a g e s u b j e c t s a n d e l d e r s ( a g e d 60 a n d o v e r ) . C o l e m a n ( 1 9 7 4 ) a l s o f o u n d n o l i n k b e t w e e n a g e a n d f r e q u e n c y o f r e m i n i s c i n g . A c c o r d i n g t o H a v i g h u r s t a n d G l a s s e r ( 1 9 7 2 ) r e m i n i s c i n g i s a u n i v e r s a l p r o c e s s w h i c h c a n o c c u r a s s o o n a s t h e c h i l d h a s t h e a b i l i t y t o r e m e m b e r t h i n g s . A l t h o u g h a g r e a t n u m b e r o f e l d e r l y t a l k a b o u t t h e p a s t w h e n g i v e n t h e o p p o r t u n i t y , t h e r e i s l i m i t e d e v i d e n c e t h a t t h e y r e m i n i s c e a n y m o r e t h a n a n y o t h e r a g e g r o u p a n d t h e r e s e a r c h i s c o n t r o v e r s i a l a n d i n c o n c l u s i v e . In summary, reminiscence i s the r e c a l l of past memories t h a t occurs a t any age. This r e c a l l may be a r t i c u l a t e d t o another person or not. I t may be purposeful or spontaneous. Reminiscing can be done w i t h or without a f a c i l i t a t o r . I t in c l u d e s l i f e review. L i f e Review L i f e review, the term f i r s t coined by B u t l e r i n 1963, r e f e r s t o an " a c t i v e e v a l u a t i o n " of one's past l i f e t o achieve e g o - i n t e g r i t y t h a t occurs between the s i x t i e s and o l d e r years of l i f e (Lewis & B u t l e r , 1974). B u t l e r (1963) defined l i f e review as "a n a t u r a l l y o c c u r r i n g , u n i v e r s a l mental process c h a r a c t e r i z e d by the p r o g r e s s i v e r e t u r n t o consciousness of past experience and p a r t i c u l a r l y , the resurgence of unresolved c o n f l i c t s . Simultaneously, and normally, these r e v i v e d experiences and c o n f l i c t s can be surveyed and r e i n t e g r a t e d " (p. 63). L i f e review r e s u l t s when the r e a l i z a t i o n occurs t h a t l i f e i s f i n i t e (Buechel, 1986). Coleman (1974) s t a t e d t h a t l i f e review i s one type of reminiscence where an i n d i v i d u a l reworks or reanalyze's past experience to achieve i n t e g r a t i o n and acceptance of ones l i f e . Romaniuk (1981) s t a t e d t h a t l i f e review can be done p r i v a t e l y . According to Boden and B i e l b y (1983) l i f e review i s a process f o r h e l p i n g someone remember the past. Jones and Zeiss (1984) s t a t e d t h a t the term l i f e review i s u s u a l l y used to r e f e r to the review, o r g a n i z a t i o n and e v a l u a t i o n of 12 the o v e r a l l p i c t u r e of one's l i f e (p. 6). The author b e l i e v e s l i f e review i s a subset of r e m i n i s c e n c e . L i f e review i s the r e c a l l of p a s t memories f o r a s p e c i f i c purpose. I t i s an e v a l u a t i o n of the p a s t i n l i g h t of the p r e s e n t . L i f e review can be done alone o r w i t h a f a c i l i t a t o r . While i t i s a p a r t of reminiscence, i t does not i n c l u d e the whole phenomena. B e n e f i t s or F u n c t i o n s of L i f e Review The l i t e r a t u r e c l aims t h e r e are many p s y c h o s o c i a l b e n e f i t s of l i f e review. B u t l e r (1963) b e l i e v e d the f u n c t i o n of l i f e review i s to s u c c e s s f u l l y complete E r i k s o n s e i g h t h l i f e stage of e g o - i n t e g r i t y versus d e s p a i r . Lewis (1971) s t a t e d t h a t " . . . r e t r o s p e c t i v e memories seem t o p r o v i d e the raw m a t e r i a l f o r working through l o s s e s , f o r crowding out unpleasant thoughts and f o r r e e s t a b l i s h i n g a secure s e l f -i d e n t i t y based on p a s t e x p e r i e n c e s " (p. 121). Along the same l i n e Romaniuk (1981) s t a t e d " s u c c e s s f u l r e s o l u t i o n of each c r i s i s r e s u l t s i n the a c q u i s i t i o n of new ego s k i l l s , a t t i t u d e s and b a s i c v i r t u e s w h i l e u n s u c c e s s f u l r e s o l u t i o n can r e s u l t i n f r u s t r a t i o n " (p. 312). I f s u c c e s s f u l , the i n d i v i d u a l s gained wisdom, but i f the person was d i s s a t i s f i e d a f t e r a review of h i s l i f e then d e s p a i r r e s u l t e d (Romaniuk, 1981). King (1981) r e i t e r a t e d t h a t reminiscence (meaning l i f e review) h e l p s m a i n t a i n and enhance s e l f - e s t e e m , develop and m a i n t a i n r e l a t i o n s h i p s and decrease l o n e l i n e s s and 13 i s o l a t i o n (p. 23). Increased s m i l i n g , i n c r e a s e d i n t e r e s t i n p e r s o n a l hygiene and i n c r e a s e d communication are some o t h e r b e n e f i t s a s s o c i a t e d w i t h l i f e review (Baker, 1985; King, 1982; L e s s e r , Lazerus, F r a n k e l , & Havasy, 1981; Lo Gerfo, 1980; Matteson & Munsat, 1982; Perschbacher, 1984; Rosenthal, 1982). A l l these b e n e f i t s h e l p promote the p s y c h o l o g i c a l w e l l being of the person ( F r o e h l i c h & Nelson, 1986). Boden and B i e l b y (1981) agreed t h a t the r o l e of l i f e review i s t o achieve p e r s o n a l i n t e g r a t i o n and understand p r e s e n t day l i f e circumstances (p. 310). P o l l a c k (1981) b e l i e v e d t h a t the e l d e r l y review t h e i r l i f e t o g a i n i n s i g h t i n t o t h e i r own behaviour. Pincus (1970) s t a t e d f u n c t i o n s of reminiscence ( s p e c i f i c a l l y l i f e review) are t o h e l p cope w i t h the process of aging, h e l p a l l a y s t r e s s e s and a n x i e t i e s and work through p e r s o n a l l o s s e s . In oth e r words the v a r i o u s authors s t a t e d l i f e review serves an a d a p t a t i o n a l f u n c t i o n . Adaptive and Maladaptive Consequences of L i f e Review What i s adaptation? A d a p t a t i o n i s the a b i l i t y t o cope w i t h p r e s e n t l i f e problems. S u c c e s s f u l a d a p t a t i o n i n the e l d e r l y means m a i n t a i n i n g s e l f - e s t e e m while some i n t e l l e c t u a l and p h y s i c a l a b i l i t i e s are d e c l i n i n g . I t means being able t o cope w i t h g r i e f , i l l n e s s , change i n environment and s o c i a l s t a t u s . I f the l i f e review process has adapt i v e consequence i t h e l p s the i n d i v i d u a l cope w i t h l i f e s t r e s s e s ; otherwise i t 14 i s maladaptive. Many papers have been p u b l i s h e d on the a d a p t a t i o n a l s i g n i f i c a n c e of l i f e review. However, v e r y l i t t l e c o n s i d e r a t i o n has been gi v e n t o i t s maladaptive consequences. The l i t e r a t u r e i s g e n e r a l l y b i a s e d i n showing t h a t l i f e review i s adaptive and b e n e f i c i a l . An attempt has been made t o uncover ada p t i v e and maladaptive q u a l i t i e s of l i f e review i n t h i s paper. Some s t u d i e s showing the adapt i v e v a l u e of l i f e review and r e m i n i s c e n c e are c i t e d . McMahon and Rhudick's study (1964) was the e a r l i e s t study conducted t o show the adaptive v a l u e of re m i n i s c e n c e . McMahon and Rhudick's sample c o n s i s t e d of 25 v o l u n t e e r s between the ages of 78 and 90 from a war vete r a n ' s c l i n i c . They had hour long n o n - d i r e c t i v e i n t e r v i e w s w i t h each s u b j e c t t h a t were taped and the data was analyzed i n terms of present, p a s t and f u t u r e o r i e n t a t i o n , d e p r e s s i o n and l o s s of s e l f - e s t e e m and degree of i n t e l l e c t u a l d e t e r i o r a t i o n , t o determine t h e i r r e l a t i o n s h i p t o remini s c e n c e . T h e i r f i n d i n g s i n d i c a t e t h a t r e m i n i s c e n c e i s not d i r e c t l y r e l a t e d t o i n t e l l e c t u a l d e t e r i o r a t i o n , but i t i s p o s i t i v e l y c o r r e l a t e d w i t h s u c c e s s f u l a d a p t a t i o n through maintenance of s e l f - e s t e e m , freedom from d e p r e s s i o n , r e a f f i r m i n g one's sense of i d e n t i t y and working through l o s s e s . Lewis (1971) looked a t the r e l a t i o n s h i p between reminiscence and a d a p t a t i o n . He hyp o t h e s i z e d t h a t " r e m i n i s c e r s " : 1) would have a g r e a t e r c o n s i s t e n c y between 15 p r e s e n t and p a s t s e l f concept, 2) i n the face of a s o c i a l t h r e a t would decrease t h e i r d i s c r e p a n c y between p a s t and present s e l f concept, and 3) when giv e n a chance t o r e m i n i s c e a f t e r the s o c i a l t h r e a t , the d i s c r e p a n c y would decrease more between the p r e s e n t and p a s t s e l f - c o n c e p t . Lewis conducted a two s e s s i o n study w i t h twenty-four community e l d e r l y men (mean age s e v e n t y - t h r e e ) . In the f i r s t s e s s i o n he ad m i n i s t e r e d two Q-sor t s , f o r t y - e i g h t items each on pr e s e n t and p a s t s e l f - c o n c e p t and then had s u b j e c t s t a l k f o r t h i r t y minutes about what they thought was important i n l i f e . In the second s e s s i o n the s u b j e c t s were asked t o t a l k about a student r e v o l t and the Q-sorts were r e a d m i n i s t e r e d . Lewis found those t h a t were c l a s s i f i e d as r e m i n i s c e r s and those who were c l a s s i f i e d as non-reminiscers both had no change i n s e l f - c o n c e p t through the experiment. A s i g n i f i c a n t l y g r e a t e r number of non-reminiscers regarded the p a s t i n n e g a t i v e terms than d i d r e m i n i s c e r s . A s l o , r e m i n i s c e r s , when t h e r e o p i n i o n was threatened, showed a s i g n i f i c a n t c o r r e l a t i o n between t h e i r p a s t and pr e s e n t s e l f - c o n c e p t s compared t o non-r e m i n i s c e r s (t=2.16, p<.025). I t appears t h a t e l d e r l y who r e m i n i s c e are b e t t e r a b l e t o m a i n t a i n t h e i r s e l f - e s t e e m i n a t h r e a t e n i n g s i t u a t i o n . H a v i g h u r s t and G l a s s e r (1972) conducted an e x p l o r a t o r y study on middle c l a s s educated community e l d e r s . They c o l l e c t e d s e l f r e p o r t s from 204 men and 325 women on the frequency, a f f e c t i v e q u a l i t y , content and f u n c t i o n of r e m i n i s c e n c e . The q u e s t i o n n a i r e s had open and c l o s e d ended q u e s t i o n s . They d i d not g i v e a d e s c r i p t i o n o f how these q u e s t i o n n a i r e s were scored. H a v i g h u r s t and G l a s e r found: 1) t h e r e were s i g n i f i c a n t gender d i f f e r e n c e s between frequency and a f f e c t i v e q u a l i t y of rem i n i s c e n c e ; 2) h i g h frequency of reminiscence and p o s i t i v e a f f e c t were p o s i t i v e l y c o r r e l a t e d w i t h p o s i t i v e e v a l u a t i o n of the experience; 3) content of re m i n i s c e n c e v a r i e d between groups; and 4) reminiscence served d i f f e r e n t f u n c t i o n s f o r d i f f e r e n t people. They concluded t h a t r e m i n i s c e n c e i s a phenomena caused by a m u l t i p l i c i t y of f a c t o r s i n the p e r s o n a l i t y and the l i f e e xperience of a person (p. 253). B o y l i n , Gordon, and Nehrke (1976) m o d i f i e d the q u e s t i o n n a i r e developed by H a v i g h u r s t and G l a s s e r (1972) to use w i t h a sample of 41 e l d e r l y war veterans (mean age 64.37 years) t o determine i f ego adjustment i s r e l a t e d t o r e m i n i s c i n g . They found a s i g n i f i c a n t c o r r e l a t i o n between frequency of r e m i n i s c i n g and scores on a measure of ego adjustment based on E r i k s o n ' s theory. T h i s f i n d i n g suggests t h a t r e m i n i s c i n g can serve an ada p t i v e f u n c t i o n f o r the o l d e r person a c c o r d i n g t o E r i k s o n ' s c r i t e r i a of s u c c e s s f u l adjustment t o o l d age. Coleman (1974) looked a t the r e l a t i o n s h i p of t h r e e types of r eminiscence (simple, l i f e review and i n f o r m a t i v e ) t o a d a p t a t i o n . He t a l k e d t o 48 London community r e s i d e n t s between the ages of 69 and 92. Of these 23 were men and 25 17 were women. The subjects were v i s i t e d s i x times each over a one and one-half t o two year p e r i o d and an hour long tape r e c o r d i n g was done f o r each subject. Questionnaires were given i n the l a s t s e ssions. Coleman found 41% f i t i n t o simple reminiscence, 19% t o l i f e review and 27% t o i n f o r m a t i v e reminiscence. He d i d not f i n d a r e l a t i o n s h i p between present adjustment or recent l o s s e s and l i f e review. But data d i d support t h a t l i f e review i s r e l a t e d t o adjustment i n the presence of d i s s a t i s f a c t i o n w i t h the past. He a l s o found t h a t men t a l k e d more about g l o b a l events and women more about f a m i l y . K i e r n a t (1979) found t h a t some behaviour changes on a "ward behaviour s c a l e " were noted a f t e r 20 l i f e review sessions conducted w i t h 22 nursing home r e s i d e n t s . The r e s i d e n t s d i d not attend r e g u l a r l y and there was no c o n t r o l group. The f i n d i n g s suggested t h a t h i g h attendance was c o r r e l a t e d w i t h g r e a t e s t improvement on a "ward behaviour s c a l e " measuring such t h i n g s as f a c i a l expression, extent of conversation, a t t e n t i v e n e s s to group a c t i v i t y , and presence of nonpurposeful behaviour. F a l l o t t (1980) s t u d i e d the impact on mood of v e r b a l r e c a l l of the past compared to t a l k i n g about the present or f u t u r e i n a group. He s t u d i e d a group of 36 females between the ages of 46 and 85. He s t a t e d t h a t s e l f r e p o r t s on mood were more p o s i t i v e a f t e r r e m i n i s c i n g than a f t e r t a l k i n g about the present or f u t u r e . From these r e s u l t s he concluded t h a t 18 r e m i n i s c i n g may serve an a d a p t a t i o n a l f u n c t i o n i n l a t e r l i f e . Revere and Tobin (1980) found t h a t m y t h i c i z i n g , remembering the past i n such a way t h a t i t makes the person appear "her o i c and immortal", serves an a d a p t a t i o n a l f u n c t i o n . The e l d e r l y see themselves as they want to and not n e c e s s a r i l y as they were. In t h i s way "the past becomes unique, and i n the myth becoming a r e a l i t y , one's l i f e becomes j u s t i f i e d " (Revere & Tobin, 1980, p. 15). In t h e i r study of 35 e l d e r l y (ages 65-103) and 25 middle aged (ages 44-55), they found the e l d e r l y m y t h i c i z e d more about the past than the middle aged. P e r o t t a and Meacham (1981) used a pre- and post- t e s t c o n t r o l group design to see i f r e m i n i s c i n g i n t e r v e n t i o n a l t e r e d depression and self-esteem. P e r o t t a and Meacham c a l l i t r e m i n i s c i n g but i n f a c t , they used l i f e review - the group members met i n d i v i d u a l l y w i t h the researcher f o r 30-45 minutes f o r f i v e sessions over a f i v e week p e r i o d . At these sessions the experimenter helped i n t e r p r e t and evaluate the person's l i f e . One group had no sessions and the t h i r d group had sessions on cu r r e n t events. The dependent v a r i a b l e s depression and self-esteem were measured by the Rosenberg Self-esteem Scale and a modified v e r s i o n of Zung's Depression Scale. No d i f f e r e n c e was found i n pre-and post measures and the hypothesis was not supported. Fry (1983) s t u d i e d the e f f e c t s of s t r u c t u r e d and unst r u c t u r e d reminiscence and depression among the e l d e r l y (162 C a u c a s i a n s between the ages of 65 and 80). The i n v e s t i g a t o r met w i t h each s u b j e c t i n d i v i d u a l l y f o r about 90 minutes. The two treatment groups t a l k e d about past l i f e events and the c o n t r o l group members were v i s i t e d i n t h e i r homes and some mutually s a t i s f y i n g a c t i v i t y was done w i t h them such as watching t e l e v i s i o n , d i s c u s s i n g programs or cur r e n t events. Fry found t h a t s t r u c t u r e d r e m i n i s c i n g ( l i f e review) s i g n i f i c a n t l y (p<.05) decreased depression, and increased f e e l i n g s of s e l f - c o n f i d e n c e and personal adequacy. Greene (1983) discussed the use of l i f e review i n adapting to f a m i l y r o l e s . She s t a t e d l i f e review can help w i t h major adjustments t h a t are r e q u i r e d i n o l d age such as adjustment to r e t i r e m e n t , change i n s o c i a l s t a t u s , change i n environment, change i n r e l a t i o n s h i p w i t h spouse and change i n d a i l y l i v i n g p a t t e r n . Lappe (1987) compared the e f f e c t s of a c u r r e n t events group and a l i f e review group i n terms of self-esteem using the Rosenberg Self-esteem Scale. A l l her subjects were from four p r i v a t e l y owned long term care i n s t i t u t i o n s . She had 8 3 subjects w i t h a mean age of 82.6. She had a " r e m i n i s c i n g group" [meaning l i f e review] and one "current events group" a t each i n s t i t u t i o n . Each group had 8-14 s u b j e c t s . Some groups met once a week and others met twice a week. She concluded t h a t group sessions u t i l i z i n g l i f e review increased the self-esteem scores of i n s t i t u t i o n a l i z e d e l d e r l y to a 20 greater degree than current events groups. She stated that whether the group meet once a week or twice a week did not e f f e c t the self-esteem scores yet her diagram (p. 14) appears to indicate that the "reminiscing group" that met twice a week scored the highest self-esteem score. Also she c a l l e d her groups reminiscing groups but they could be more accurately l a b e l l e d l i f e review because the researcher decided on the themes fo r discussion and photographs and other memorabilia were used to stimulate discussion. T a f t and Nehrke (1990) studied reminiscence, l i f e review and ego i n t e g r i t y i n nursing home residents. Their sample was drawn from four nursing homes, and consisted of f i f t e e n men and f i f t e e n women aged s i x t y - f i v e and older with a mean age of 84.13 and a standard deviation of 9.42. The respondents were given the twenty-five item reminiscence, l i f e review, and ego i n t e g r i t y scales. A c o r r e l a t i o n matrix was done between the dimensions of reminiscence and l i f e review, frequency of reminisence and ego i n t e g r i t y . Only the measure of l i f e review correlated p o s i t i v e l y with ego i n t e g r i t y [r=.56, p<.001]. David (1990) looked at reminiscence, adaptation, and s o c i a l context i n old age. She interviewed 43 subjects from two retirement communities. The subjects consisted of widowed men, widowed women and single women ages sixty-eight to n i n e ty-five. Using taped interviews where the subjects were asked to describe three memories. In the second part, the respondents were asked s p e c i f i c questions about t h e i r memories and experiences of r e m i n i s c i n g . Then they were given two s t r u c t u r e d s c a l e s on l i f e s a t i s f a c t o n and s e l f -esteem. Scores on the measures of reminiscence and adaptation were compared across s i n g l e women, widowed women, and widowed men using the Mann-Whitney t e s t . The only s i g n i f i c a n t d i f f e r e n c e was found on the l i f e s a t i s f a c t i o n s c a l e . S i n g l e women had s i g n i f i c a n t l y (p<.05) higher l i f e s a t i s f a c t i o n scores than widowed men . Poulton and Strassberg (1986) i n an a r t i c l e d e s c r i b i n g the t h e r a p e u t i c uses of reminiscence, summarized the adaptive consequences of reminiscence as: " 1) r e s o l u t i o n of p r e v i o u s l y unresolved c o n f l i c t s and the r e i n t e g r a t i o n of p e r s o n a l i t y ; 2) maintenance of s o c i a l r o l e s , s t a t u s and p u b l i c esteem; 3) maintenance of g o a l - d i r e c t e d behaviour and the p e r c e p t i o n of i t s meaningfulness; 4) maintenance of self-esteem and personal s i g n i f i c a n c e ; 5) r e d i s c o v e r y of l o s t s k i l l and reengagement on l o s t a c t i v i t i e s and, 6) i n coping w i t h l o s s or g r i e f " (p. 384-387). These consequences apply e q u a l l y w e l l t o l i f e review. From the review of the l i t e r a t u r e i t can be concluded t h a t reminiscence i n general and l i f e review i n p a r t i c u l a r has adaptive consequences. Therefore, l i f e review has important i m p l i c a t i o n s as an educative i n t e r v e n t i o n w i t h the i n s t i t u t i o n a l i z e d e l d e r l y . L i f e review and reminiscence are not always adaptive. Various authors have l i s t e d depression, h o s t i l i t y , g u i l t , g r i e f , despair, worthlessness and hopelessness as possible negative consequences of l i f e review and reminiscing (Ebersole, 1976; E l l i s o n , 1981; Lewis, 1971; Lewis & Butler, 1974; Lo Gerfo, 1980; McClosky, 1985; Perschbocher, 1984; Poulton, 1976;& Schnase, 1982). However, the poten t i a l negative e f f e c t s of eithe r have received very l i t t l e experimental attention. Only a single study (Tobin, 1972) could be found that reported negative consequences. Tobin (197 2) questioned the i n s t i t u t i o n a l i z e d e l d e r l y about reminiscing. Many of them stated that they l i k e d to reminisce but t r i e d not to because they did not want to burden other people. The e l d e r l y f e l t that those around them viewed reminiscing negatively. Therefore, they f e l t g u i l t when they reminisced. Butler (1980) talked about three types of individ u a l s that may not benefit from l i f e review. The f i r s t type was those that were future oriented and achievers. The second type was the criminals- those who i n t e n t i o n a l l y injured other people. The t h i r d type was those individuals described as arrogant and f u l l of pride. These types of individ u a l s may not be able to resolve t h e i r c o n f l i c t s and despair may r e s u l t . According to Lo Gerfo (1980) obsessive reminisence may r e s u l t from a stress such as death. The person may not be able to stop from mourning f o r he or she may not be able to f i n d a replacement for- the lo s s . This obsessive 23 r e m i n i s c i n g t h a t can r e s u l t i n d e s p a i r i s caused by g u i l t , s t r e s s o r g r i e f . P o u l t o n and S t r a s s b e r g (1986) s t a t e d t h a t t h e r e a r e t h r e e m a l a d a p t i v e consequences o f r e m i n i s c e n c e : 1) av o i d a n c e o f p r e s e n t s i t u a t i o n , 2) e x a c e r b a t i o n o f g u i l t and inadequacy, d e p r e s s i o n , p a i n and o b s e s s i v e r u m i n a t i o n s and 3) a l i e n a t i o n from o t h e r p e o p l e . These consequences may a p p l y e q u a l l y t o l i f e r e v i e w . I t appears t h a t l i f e r e v i e w and r e m i n i s c e n c e can be m a l a d a p t i v e i f i t i s t o o e x c e s s i v e o r used w i t h i n a p p r o p r i a t e c l i e n t s . I f i n d i v i d u a l s r e c a l l p a s t e v e n t s c o n t i n u o u s l y w i t h o u t r e i n t e g r a t i o n and e v a l u a t i o n t h e n d e s p a i r r e s u l t s . T h e r e f o r e , when u s i n g l i f e r e v i e w i t s m a l a d a p t i v e e f f e c t s s h o u l d n o t be i g n o r e d . Triggers Jones (1984) d e f i n e d t r i g g e r s as "any form o f s t i m u l i t h a t w i l l prompt memory r e c a l l " ( p . 7 ) . These s t i m u l i u s u a l l y have s p e c i a l s i g n i f i c a n c e t o t h e i n d i v i d u a l . There a r e two t y p e s o f t r i g g e r s : major l i f e e v e n t s , and p e o p l e , o b j e c t s and e v e n t s . M a j o r l i f e e v e n t s a r e s o c i a l t r a n s i t i o n s (Romaniuk & Romaniuk, 1981, p. 488). The d e p r e s s i o n , war, m a r r i a g e , and d e a t h a r e some major e v e n t s t h a t have been used. I t i s b e l i e v e d t h a t t h e e l d e r l y r e c a l l c h i l d h o o d e x p e r i e n c e s b e t t e r t h a n e v e n t s w i t h i n t h e l a s t y e a r , b u t s i g n i f i c a n t e v e n t s such as m a r r i a g e , d e a t h o f a spouse, a f i r s t house and t h e b i r t h o f a c h i l d a r e always remembered 24 b e s t (Baker, 1985; Coleman, 1974). A c c o r d i n g t o Funch and M a r s h a l l (1984) l i f e events are to be used c a u t i o u s l y . In t h e i r study u s i n g a l a r g e n a t i o n a l sample, they s t u d i e d f a l l - o f f r a t e s . F a l l - o f f r a t e i s the i n a b i l i t y t o r e c a l l events t h a t have o c c u r r e d , and i s g i v e n as a percentage. They found t h a t f a l l - o f f i s r a p i d i n the f i r s t 12 months and then l e v e l s o f f . A l s o they found some events such as the death of a spouse, marriage, and b i r t h of a c h i l d show no f a l l - o f f w h i l e o t h e r events such as death of a f r i e n d and i l l n e s s i n the f a m i l y have immediate and severe f a l l - o f f . The second type of t r i g g e r s are o b j e c t s , people, and events. Lewis and B u t l e r (1974) l i s t e d v e r y s p e c i f i c o b j e c t type t r i g g e r s i n t h e i r paper such as p i l g r i m a g e s , r e u n i o n s , v i s i t a t i o n s t o c h i l d h o o d p l a c e s , and genealogy. Other t r i g g e r s have been used i n d i f f e r e n t s t u d i e s . McCloskey (1985) used music; Buechel (1986) and K i e r n a t (1979) used a c t i v i t y . Any o b j e c t such as "a p i c t u r e of a sewing machine, a notebook from h i g h s c h o o l , or a f a v o r i t e q u i l t can e l i c i t memories ( E l l i s o n , 1981; p. 531). Ruth Perschbacher (1984) asked the e l d e r l y t o r e c a l l h i s t o r i c a l events. McCormack (1979) gave the s u b j e c t s a word and asked for- the f i r s t event they r e c a l l e d and put i t on a l i f e l i n e . Donahue (1982) used l i f e events i n a p a r t i c u l a r p e r i o d as a t r i g g e r . Others have used o b j e c t s , music, a r t , p o e t r y , f a m i l y albums, scrapbooks, customs and c r i t i c a l l i f e events (Baker, 198 5; B u t l e r , 1974; Job, 1983; Lo Gerfo, 1980; P o l l a c k , 1981; T a y l o r , Jones & Z e i s s , 1983; Wysocki, 1983). Any person, o b j e c t or t h i n g t h a t can prompt r e c a l l can be used as a t r i g g e r . The o n l y study found on t r i g g e r s i n the l i t e r a t u r e s e a rch was done by Romaniuk and Romaniuk i n 1981. They s t u d i e d r e m i n i s c e n c e f u n c t i o n s and t r i g g e r s . T h e i r purpose was "to determine i f h y p o t h e s i z e d f u n c t i o n s and t r i g g e r s of r eminiscence c o u l d be supported e m p i r i c a l l y through the development and t e s t i n g of a Reminiscence Uses S c a l e and Reminiscence T r i g g e r s S c a l e , and 2) to determine i f t h e r e were any p r e d i c t a b l e r e l a t i o n s h i p s between what t r i g g e r s r e m i n i s c e n c e a c t i v i t y and the way i n which these memories are used by a sample of e l d e r l y i n d i v i d u a l s " (p. 479). In other words, they r e c o r d e d whatever i n i t i a t e d r e c a l l and the reason f o r the review of l i f e . They c o l l e c t e d data from 91 e l d e r l y r e s i d e n t s of a r e t i r e m e n t community. A f a c t o r a n a l y s i s of the Reminiscence Uses S c a l e y i e l d e d t h r e e s u b s c a l e s : s e l f -regard/image enhancement, p r e s e n t problem s o l v i n g , and e x i s t e n t i a l / s e l f - u n d e r s t a n d i n g . The Reminiscence T r i g g e r s S c a l e y i e l d e d f i v e s u b s c a l e s : a w a r e n e s s / r e s i g n a t i o n , death awareness-other, r e a l i z a t i o n of goals/accomplishments, changes/threats t o body, and change i n c a r e e r / l i f e ' s d i r e c t i o n . "A m u l t i p l e r e g r e s s i o n a n a l y s i s i n d i c a t e d t h a t s e l f - r e g a r d / i m a g e enhancement was p r e d i c t e d by r e a l i z a t i o n of goals/accomplishments and reminiscence frequency. Present problem s o l v i n g was p r e d i c t e d by death a w a r e n e s s / r e s i g n a t i o n 26 and e x i s t e n t i a l / s e l f understanding by changes/threats t o body and l i f e review" (p. 472). They found t h a t death of a s i g n i f i c a n t person was the g r e a t e s t t r i g g e r , f o l l o w e d w i t h change o r t h r e a t t o body and then change i n c a r e e r or l i f e d i r e c t i o n . There are many d i f f e r e n t types of t r i g g e r s , however, the most meaningful t r i g g e r s are o b j e c t s or events t h a t h o l d s p e c i a l meaning f o r the i n d i v i d u a l . B e n e f i t s of Group Technique L i f e review u s i n g group technique has been documented s i n c e the 1960's. K l e i n , Le Shan and Furman (1965) suggest t h a t groups encourage s o c i a l i z a t i o n and h e l p the e l d e r l y remember and i n c r e a s e s e l f - e s t e e m . Many b e l i e v e group technique i n c r e a s e s s o c i a l i z a t i o n and f e e l i n g s of belongingness (Baker, 1985; E l l i s o n , 1982; K i e r n a t , 1979; Matteson & Munsat, 1982). Lewis and B u t l e r (1974) b e l i e v e d groups can promote r e c a l l of the p a s t . They suggested having a c r o s s - g e n e r a t i o n a l group and having the e l d e r l y draw from memory to h e l p s o l v e c u r r e n t f a m i l y problems. Lewis (1971) s a i d t h a t w ithout s o c i a l bonds c r e a t e d i n group c o n t a c t , the e l d e r l y may l o s e t h e i r i d e n t i t y and become "hopeless" and depressed. E b e r s o l e (1973) s t a t e d t h a t group r e m i n i s c i n g may i n s t i l l a sense of s o l i d a r i t y and importance not a v a i l a b l e t o an i s o l a t e d person, p a r t i c u l a r l y i n a c u l t u r e which puts l i t t l e v a l u e 27 on the aged i n d i v i d u a l . . . opportunity f o r c a t h a r s i s i n the group s e t t i n g enhances cohesiveness and i s a c o r r e c t i v e emotional experience, w h i l e candid consensual v a l i d a t i o n of g u i l t , inadequacies, f a i l u r e s and successes r a i s e self-esteem (p. 226). Baker (198 5) s a i d t h a t p a r t i c i p a t i n g i n a group gives the e l d e r l y a sense of belonging and helps develop a p o s i t i v e a t t i t u d e . I n f a c t group s o c i a l i z a t i o n i n f l u e n c e s i n d i v i d u a l behaviour f r e q u e n t l y beyond the o r i g i n a l goal f o r which i t was f i r s t brought together (Hare, 1962, p. 75). In a pre- and p o s t - t e s t design Parsons (1986) showed t h a t l i f e review using group technique decreased depression i n the e l d e r l y . Sherman (1987) conducted a study on 104 community s e n i o r s t o see i f a s t r u c t u r e d l i f e review group f o c u s s i n g on l i f e c y c l e s and a group fo c u s s i n g on memory r e c a l l over a three month p e r i o d increased l i f e s a t i s f a c t i o n and s e l f concept. The L i f e S a t i s f a c t i o n Form Z and the Mange Self-Concept Measure were administered before the f i r s t s e s s i o n and a f t e r the l a s t or t e n t h s e s s i o n . S i g n i f i c a n t p o s i t i v e changes i n l i f e s a t i s f a c t i o n , and s e l f concept were found i n a l l groups, but a group fo c u s s i n g on memory r e c a l l r e p o r t e d more l i f e s a t i s f a c t i o n . F r o e h l i c h and Nelson (1986) compared v e r b a l and a c t i v i t y groups. Two of the groups engaged i n r e m i n i s c i n g w h i l e the other two groups d i d meaningful a c t i v i t y (made drawings and c o l l a g e s ) w h i l e r e m i n i s c i n g . A f f e c t i v e meaning d i d not d i f f e r s i g n i f i c a n t l y between the v e r b a l and a c t i v i t y groups. P o u l t o n and S t r a s s b e r g (1986) s t a t e d t h a t group technique i s an e f f e c t i v e t o o l t o use w i t h e l d e r l y c l i e n t s . I t h e l p s w i t h the r e o r g a n i z a t i o n of the p a s t i n coping w i t h the p r e s e n t . I t h e l p s i n c r e a s e s o c i a l i z a t i o n and s e l f - e s t e e m (Poulton & S t r a s s b e r g ) . A c c o r d i n g t o these authors l i f e review u s i n g group technique h e l p s promote the p s y c h o l o g i c a l w e l l b e i n g of the i n d i v i d u a l . B e n e f i t s of I n d i v i d u a l Technique Most of the l i f e review l i t e r a t u r e d e a l s w i t h groups. Although s i m i l a r b e n e f i t s can be o b t a i n e d w i t h i n d i v i d u a l s o n l y a few a p p l i c a t i o n s c o u l d be found i n the l i t e r a t u r e . L i f e review i n one of i t s o l d e s t forms, autobiography, has been around f o r more than 200 years (Gunn, 1982). B u t l e r (1987) s t a t e d t h a t autobiography i n c r e a s e d s e l f esteem. Donahue (1982) i n t e r v i e w e d s i x nurses between the ages of 61 to 80 f o r the purpose of o b t a i n i n g h i s t o r i c a l i n f o r m a t i o n . Donahue concluded t h a t many of the same b e n e f i t s were seen i n her sample as those c i t e d i n the l i t e r a t u r e f o r groups. The nurses s t a t e d they enjoyed the experience (p. 275). Lewis and B u t l e r (1974) have worked w i t h i n d i v i d u a l s one-on-one to f a c i l i t a t e the r e m i n i s c i n g process t o h e l p i n d i v i d u a l s r e a c h E r i c k s o n ' s stage of ego-i n t e g r i t y . They have noted t h a t some i n d i v i d u a l s " p r e f e r to work a l o n e w i t h a t a p e r e c o r d e r o r p e n c i l and paper" (p. 172). W r i t i n g , a c c o r d i n g t o B u t l e r (1987), can h e l p e s t a b l i s h an i n d i v i d u a l ' s s e l f - w o r t h and p s y c h o l o g i c a l w e l l -b e i n g . These i n d i v i d u a l s w o r k i n g a l o n e , however, would n o t g a i n s o c i a l i z a t i o n b e n e f i t s . When t h e i n d i v i d u a l t e c h n i q u e i s u s ed t h e p e r s o n has more t i m e t o speak o r w r i t e , t h u s may show b e n e f i t s i n a much s h o r t e r t i m e . I n a group, t h e time p e r p e r s o n d e c r e a s e s as group s i z e i n c r e a s e s . A l t h o u g h s i m i l a r b e n e f i t s can be a c h i e v e d t h r o u g h i n d i v i d u a l t e c h n i q u e , t h e group t e c h n i q u e i s more o f t e n used because i t i s c o n d u c i v e t o h e l p i n g t h e i n d i v i d u a l m a i n t a i n s o c i a l i d e n t i t y and i t i s more c o s t e f f e c t i v e . I n s t i t u t i o n a l i z e d E l d e r l y The e l d e r l y on l o n g t e r m c a r e u n i t s a r e t h o s e w a i t i n g f o r assessment and placement u s u a l l y t o an i n t e r m e d i a t e c a r e o r an exte n d e d c a r e f a c i l i t y . These e l d e r l y may have t r a n s f e r r e d from an a c u t e c a r e h o s p i t a l o r t h e community f o l l o w i n g some k i n d o f p h y s i c a l o r p s y c h o l o g i c a l l o s s and a r e w a i t i n g f o r placement. These e l d e r l y a r e i n a new environment w i t h o u t t h e i r u s u a l s o c i a l s u p p o r t system and e x p e r i e n c e l o s s o f t h e i r home, independence, community, p r i v a c y , s e l f - e s t e e m , and p e r s o n a l b e l o n g i n g s ( P a r s o n s , 1986). Due t o numerous p h y s i c a l and p s y c h o l o g i c a l a i l m e n t s t h e e l d e r l y f r e q u e n t l y s u f f e r from p a i n , have d i f f i c u l t y b r e a t h i n g , have b l a d d e r and bowel e l i m i n a t i o n problems and a 30 decreased l e v e l of a c t i v i t y . They are not able t o walk, get i n and out of bed, bathe, comb t h e i r h a i r , shave, dress, eat, go t o the bathroom o r d i a l the telephone ( E b e r s o l e & Hess, 1985). Since the i n s t i t u t i o n a l i z e d e l d e r l y s u f f e r from many l o s s e s and changes i t i s easy t o see why " r e a c t i v e d e p r e s s i o n s r e s u l t i n g from v a r i o u s l o s s e s are among the most common emotional d i s o r d e r s found i n o l d people" (Matteson and Munsat, 1982, P. 178). In f a c t the i n c i d e n c e of d e p r e s s i o n i s s a i d t o be as h i g h as 50% (Hawranik & Kandratuk, 1986, p. 26). Because of a l l the changes t h a t have o c c u r r e d due t o h o s p i t a l i z a t i o n , these i n d i v i d u a l s may d i s p l a y rage and anger and be v e r y d i f f i c u l t t o nurse ( E b e r s o l e , 1976, p. 1305). A l s o w h i l e w a i t i n g f o r placement, i t i s not uncommon f o r the c l i e n t t o experience the death of another p a t i e n t on the ward. These i n s t i t u t i o n a l i z e d e l d e r l y w i t h decreased s e l f -esteem and f e e l i n g s of d e p r e s s i o n are i n an environment t h a t t r i g g e r s r e m i n i s c i n g because death and change o r t h r e a t t o a body and change i n l i f e d i r e c t i o n are s t r o n g t r i g g e r s (Matteson & Munsat, 1982; Romaniuk & Romaniuk, 1981). The e l d e r l y c l i e n t s are i n a new environment w i t h many l o s s e s and need h e l p t o " r e a d j u s t , r e s o l v e , r e o r g a n i z e , and r e i n t e g r a t e " (Schnase, 1982, p. 16). B u t l e r (1963) might suggest t h a t these i n d i v i d u a l s need t o p a r t i c i p a t e i n l i f e r eview t o s u c c e s s f u l l y r e o r g a n i z e t h e i r p a s t l i f e i n order t o 31 accomplish E r i k s o n ' s e i g h t h l i f e stage of ego i n t e g r i t y versus d e s p a i r . Summary Reminiscence, a major concept, has been d e f i n e d as the a c t of r e c a l l . A subset of reminiscence, l i f e review, has been d e f i n e d as the a c t of p u r p o s e f u l r e c a l l . S t u d i e s s u p p o r t i n g b e n e f i t s of l i f e review such as a decrease i n d e p r e s s i o n and i s o l a t i o n , and an i n c r e a s e i n s e l f - e s t e e m and i n a c t i v i t i e s of d a i l y l i v i n g have been c i t e d . The l i t e r a t u r e on the adap t i v e and maladaptive s i g n i f i c a n c e of l i f e review and reminiscence has been reviewed i n d i c a t i n g the b i a s toward ada p t i v e s i g n i f i c a n c e . T r i g g e r s have been d e f i n e d as anything t h a t promotes r e c a l l . Both group technique and i n d i v i d u a l technique have been presented as being b e n e f i c i a l , but group technique i s s a i d t o be more c o s t e f f e c t i v e and a l s o has the added element of s o c i a l i z a t i o n . The p s y c h o s o c i a l environment of the i n s t i t u t i o n a l i z e d e l d e r l y has been d e s c r i b e d t o show t h a t the e l d e r l y may b e n e f i t from a l i f e review program. 32 CHAPTER III METHODOLOGY A. quasi-experimental research design was chosen f o r t h i s study (Campbell & Stanley, 1963). A pre- and post-test design was selected to study the influence of l i f e review on the i n s t i t u t i o n a l i z e d e l d e r l y . This chapter discusses the sample and setting used i n this.study; the instruments used to measure independence, integrated functioning, depression, and group process; the data gathering procedures; the independent-dependent variables used; and e t h i c a l consideration. Sample and Setting This study took place i n the long term care u n i t of a community based family practice oriented h o s p i t a l i n Vancouver, B r i t i s h Columbia. A convenience volunteer sample of t h i r t y - f i v e e l d e r l y patients from one unit i n the hospital was used. The el d e r l y (aged 60 and older) on t h i s u n i t were i n a state of t r a n s i t i o n . These e l d e r l y were moved to t h i s p a r t i c u l a r 20 bed un i t from other medical and su r g i c a l units i n the hospital when they were not able to recover from t h e i r admission diagnosis or function with the help of t h e i r support system and or homecare help at home. These patients stay on t h i s u n i t u n t i l they can be placed i n an appropriate care f a c i l i t y . Placement may take up to one year. Thus the uni t i s c a l l e d a transfer unit. P a t i e n t s were s e l e c t e d from a u n i t which was s t a f f e d by 3.5 s t a f f on days, 2.5 on evenings and 2 on n i g h t s . The s t a f f mix c o n s i s t e d of r e g i s t e r e d nurses and p a t i e n t care aides. There was only one r e g i s t e r e d nurse on each s h i f t . On day s h i f t , the u n i t a l s o shared one nursing coordinator and c l i n i c a l nurse educator w i t h a 75 bed u n i t . On evening and n i g h t s h i f t s there was a h o s p i t a l nursing c o o r d i n a t o r a v a i l a b l e t o deal w i t h emergencies. There was no r e h a b i l i t a t i o n therapy coverage on t h i s u n i t . P a t i e n t s could be v i s i t e d by s o c i a l s e r v i c e s and p a s t o r a l care department members i f r e f e r r a l s were made f o r these s e r v i c e s by any member of the s t a f f . There were no r e g u l a r i l y planned a c t i v i t i e s f o r p a t i e n t s on t h i s u n i t . Sometimes a f t e r the p a t i e n t s have been on t h i s u n i t f o r a long time, they were allowed to go on bus t r i p s w i t h the p a t i e n t s from the extended care u n i t . The area of the c i t y served by the chosen h o s p i t a l was a p r i m a r i l y middle t o upper c l a s s area. There was a v a r i e t y of et h n i c groups who r e s i d e d i n t h i s area but almost everyone who was i n the study was Caucasian. At the time of the study, the u n i t had mainly Caucasian p a t i e n t s . There were two O r i e n t a l p a t i e n t s on the u n i t of which one was inc l u d e d i n the study. Only one O r i e n t a l p a t i e n t was i n c l u d e d because only one p a t i e n t f i t the s e l e c t i o n c r i t e r i a . In order to achieve some measure of homogeneity the sample was l i m i t e d to p a t i e n t s who met the f o l l o w i n g c r i t e r i a : 1) They were able to communicate i n E n g l i s h . (The p a t i e n t was c o n s i d e r e d to have adequate E n g l i s h s k i l l s i f he o r she c o u l d comprehend the t a l k on the purpose of the study and c a r r y on a comrehensible c o n v e r s a t i o n w i t h the r e s e a r c h e r i n E n g l i s h . ) 2) The s t a f f b e l i e v e d the p a t i e n t c o u l d t o l e r a t e an a c t i v i t y f o r f o r t y - f i v e minutes. (The person was b e l i e v e d t o have the a b i l i t y t o p a r t i c i p a t e i n a f o r t y - f i v e minute a c t i v i t y i f he or she was judged as being able to p a r t i c i p a t e without d i s r u p t i n g the group and without bowel or b l a d d e r i n c o n t i n e n c e by the r e g i s t e r e d nurse on the u n i t or i f the nurses notes on the p a t i e n t ' s c h a r t s t a t e d t h a t the person had not been i n c o n t i n e n t more f r e q u e n t l y than every two hours and t h e r e was no r e c o r d of d i s r u p t i v e behaviour.) 3) They were not c l i n i c a l l y diagnosed w i t h d e p r e s s i o n . (The i n d i v i d u a l was assumed to be not c l i n i c a l l y depressed u n l e s s a d i a g n o s i s of d e p r e s s i o n was c h a r t e d i n the medical h i s t o r y o r progress notes.) Instruments Four d i f f e r e n t measurement instruments were used. 1) The G e r i a t r i c R a t i n g S c a l e (GRS); f i r s t developed by P l u t c h i k e t a l , 1976; was used t o measure the p a t i e n t ' s a b i l i t y t o f u n c t i o n i n an i n t e g r a t e d manner (see Appendix A). I t c o n s i s t s of 31 items r e l a t e d t o p a t i e n t behaviour t h a t are scored from 0 to 2. The higher the score, the higher the degree of f u n c t i o n a l dependence. The scores are added to o b t a i n a GRS score. The instrument was administered by the researcher i n about 10 minutes. I t s i n t e r r a t e r r e l i a b i l i t y i s about .87 ( P l u t c h i k e t a l , 1976). " I t s v a l i d i t y has been e s t a b l i s h e d by P l u t c h i k et a l (1976) and Smith e t A l (1977) and i t can a l s o be i n f e r r e d from i t s c l o s e approximation of the Stockton G e r i a t r i c Rating Scale" ( P l u t c h i k e t a l , 1976). The o r i g i n a l sample f o r the GDS was 220 h o s p i t a l i z e d g e r i a t r i c p a t i e n t s . For t h i s sample the Hoyt estimate of r e l i a b i l i t y i s 0.87 w i t h a standard e r r o r (SE) of 3.20 f o r the p r e t e s t and 0.86 w i t h a SE of 3.25 f o r the p o s t t e s t . This r e s u l t i s c o n s i s t e n t w i t h the l i t e r a t u r e . 2) The A c t i v i t i e s of D a i l y L i v i n g E v a l u a t i o n Form (ADD i s a s i x item instrument t h a t was used to measure the f u n c t i o n a l independence or dependence of p a t i e n t s w i t h regard t o bathing, d r e s s i n g , going to t o i l e t , t r a n s f e r r i n g , continence and feeding (Appendix B). I t i s r a t e d A to G. "A" being independent i n a l l s i x f u n c t i o n s and "G" being dependent i n a l l s i x f u n c t i o n s . I t was f i r s t designed by Katz et a l (1963) as a measure of f u n c t i o n t h a t could be used i n o b j e c t i v e e v a l u a t i o n on c h r o n i c a l l y i l l and aging p o p u l a t i o n . The ADL was converted t o the A-G s c a l e i n 1970. No v a l i d i t y or r e l i a b i l i t y measures could be found f o r the s c a l e . The s c a l e has "been used to assess need f o r care, e f f e c t i v e n e s s of treatment and as a teaching a i d i n r e h a b i l i t a t i o n " (Katz e t a l , 1970, p. 914). The ADL can be e a s i l y a d m i n i s t e r e d by n u r s i n g s t a f f working w i t h the p a t i e n t s i n about two minutes. In t h i s study, the r e g i s t e r e d nurses on the u n i t completed the ADL. From t h i s study the Hoyt estimate of r e l i a b i l i t y was c a l c u l a t e d t o be 0.75 w i t h a SE of 1.07 f o r the p r e - t e s t and 0.8 5 w i t h a SE of 1.02 f o r the p o s t - t e s t . 3) The G e r i a t r i c D e p r ession S c a l e (GDS) i s a 30 item instrument t h a t was used t o measure d e p r e s s i o n (Appendix C). I t c o n s i s t s of dichotomous (yes/no) q u e s t i o n s . Twenty qu e s t i o n s i n d i c a t e d e p r e s s i o n when answered "yes" and t e n quest i o n s i n d i c a t e d e p r e s s i o n when answered "no". I t can be s e l f - a d m i n i s t e r e d . In t h i s study the i n v e s t i g a t o r r e a d the quest i o n s t o the s u b j e c t s and r e c o r d e d the responses. B r i n k e t a l (1982) developed the s e l f - r a t i n g GDS s c a l e . They found i t t o have a s e n s i t i v i t y of .90 and a s p e c i f i c i t y of .80. They compared i t w i t h the Zung and Hamilton S c a l e s and got a c o r r e l a t i o n of .82. In t h i s study item a n a l y s i s was done. The Hoyt estimate of r e l i a b i l i t y f o r the s c a l e was c a l c u l a t e d as 0.84 w i t h a SE of 2.23 f o r the p r e t e s t and 0.89 w i t h a SE of 2.12 f o r the p o s t t e s t . The instrument has been e x t e n s i v e l y c i t e d i n the l i t e r a t u r e . 4) The Group Process O b s e r v a t i o n a l C h e c k l i s t (GPOC) has been developed by the r e s e a r c h e r t o determine what behaviors occur i n the group (Appendix D). I t i s a 13 item c h e c k l i s t t h a t i n c l u d e s b e h a v i o r a l and v e r b a l o b s e r v a t i o n s (Appendix E ) . T h e 13 i t e m s o n t h e c h e c k l i s t (GPOC) a r e d e r i v e d f r o m B a l e ' s G r o u p P r o c e s s C a t e g o r i e s ( A p p e n d i x F ) . I n B a l e ' s G r o u p P r o c e s s i n s t r u m e n t t h e r e a r e t h r e e c a t e g o r i e s t h a t a r e c o n s i d e r e d p o s i t i v e : s h o w s s o l i d a r i t y , s h o w s t e n s i o n r e l e a s e , a n d a g r e e s ; a n d t h e r e a r e t h r e e n e g a t i v e c a t e g o r i e s : d i s a g r e e s , s h o w s t e n s i o n a n d s h o w s a n t a g o n i s m ( B a l e s , 1 9 8 5 ) . T h e GPOC i s b e l i e v e d t o h a v e v a l i d i t y b e c a u s e i t i s a c h e c k l i s t o f o b s e r v a t i o n s t h a t a r e d i s p l a y e d i n a g r o u p a n d a l s o b e c a u s e i t i s d i r e c t l y d e r i v e d f r o m B a l e ' s g r o u p p r o c e s s c a t e g o r i e s t h a t h a v e b e e n e x t e n s i v e l y u s e d f o r n u m e r o u s y e a r s w i t h g r o u p s , m a i n l y c h i l d r e n i n s c h o o l s . T o t e s t i t s r e l i a b i l i t y , t h e r e s e a r c h e r a n d a n o t h e r n u r s e e d u c a t o r w e n t t o a l o n g t e r m c a r e u n i t a n d a t t e n d e d g r o u p m e e t i n g s . T h e y b o t h o b s e r v e d a n d r e c o r d e d t w o s e s s i o n s . A n i n t e r r a t e r r e l i a b i l i t y o f a t l e a s t . 7 w a s n e e d e d . T h e r e c o r d i n g s o f t h e t w o o b s e r v e r s w e r e i d e n t i c a l , h o w e v e r , i t c a n n o t b e a s s u m e d t h a t t h e i n t e r r a t e r r e l i a b i l i t y w o u l d b e 1 . 0 . T h i s w a s a s p e c i a l c a s e b e c a u s e b o t h o b s e r v e r s w e r e p r o f e s s i o n a l c o l l e a g u e s a n d h a d a v e r y s i m i l a r e d u c a t i o n a l b a c k g r o u n d . A l s o b e f o r e t h e s e s s i o n s t h e y d i s c u s s e d how t h e y w o u l d c l a s s i f y e a c h b e h a v i o r . T h o u g h o n e c a n n o t a s s u m e a r e l i a b i l i t y o f 1 . 0 , o n e c a n s a f e l y s a y t h e r e l i a b i l i t y o f t h e GPOC i s v e r y h i g h . 38 Data C o l l e c t i o n A f t e r c o n s u l t a t i o n w i t h the r e g i s t e r e d nurse on the u n i t , p a t i e n t s who met the c r i t e r i a f o r acceptance i n the study were c o n t a c t e d on the u n i t by the r e s e a r c h e r . Each p o t e n t i a l s u b j e c t was g i v e n an e x p l a n a t i o n of the purpose and d e t a i l s of the study. A l l p a t i e n t s were informed t h a t t h e i r p a r t i c i p a t i o n i n the study was v o l u n t a r y and t h a t i t would i n v o l v e a 20 minute i n t e r v i e w i n the next week and again i n f o u r weeks time (Appendix G). I t was emphasized t h a t the p a t i e n t s c o u l d withdraw a t any time without a f f e c t i n g t h e i r p r e s e n t and f u t u r e medical and n u r s i n g care. A consent form w i t h the same i n f o r m a t i o n was l e f t w i t h the p a t i e n t t o be p i c k e d up l a t e r by the r e s e a r c h e r (Appendix H). T h i s way the p a t i e n t c o u l d d i s c u s s the study w i t h h i s or her f a m i l y p r i o r t o c o n s e n t i n g . In two cases, the r e s e a r c h e r e x p l a i n e d the study t o the f a m i l y a t the p a t i e n t ' s r e q u e s t . I f the p a t i e n t agreed t o p a r t i c i p a t e he or she sig n e d the consent form and kept a copy. Consent was o b t a i n e d from the r e s p e c t i v e p h y s i c i a n s a l l o w i n g t h e i r p a t i e n t s t o partake i n the study (Appendix I ) . The p a t i e n t s who had consented were randomly a s s i g n e d t o the c o n t r o l o r experimental group. Those a s s i g n e d t o the experimental group were approached by the r e s e a r c h e r i n the same manner to s i g n another consent form t o p a r t i c i p a t e i n the e i g h t l i f e review s e s s i o n s (Appendix J ) . These s u b j e c t s were t o l d about the l i f e review s e s s i o n s which would be h e l d twice a week f o r f o u r weeks on the u n i t and about the t o p i c s t h a t were going t o be d i s c u s s e d (Appendix K ) . Again the consent form was l e f t w i t h the p a t i e n t . The r e s e a r c h e r l a t e r r e t u r n e d to p i c k up the completed consent form. I f consent c o u l d not be o b t a i n e d from a l l p a t i e n t s , o t hers were randomly a s s i g n e d to the experimental group u n t i l consent was o b t a i n e d from h a l f the group. There were e i g h t d i f f e r e n t groups i n t o t a l , f o u r experimental and f o u r c o n t r o l . Each group was t o have s i x s u b j e c t s because Bass and Norton (1951) suggest t h a t i t i s d i f f i c u l t t o observe and keep t r a c k of i n t e r a c t i o n s beyond the s i z e of seven. A l s o the time a v a i l a b l e per i n d i v i d u a l t o i n t e r a c t decreases as s i z e i n c r e a s e s . I t i s a l s o more d i f f i c u l t f o r the l e a d e r t o c o o r d i n a t e a c t i v i t y as the group s i z e i n c r e a s e s , and as group s i z e i n c r e a s e s members f e e l more t h r e a t e n e d or i n h i b i t e d t o speak. Thus i n t e r a c t i o n time can be dominated by a few i n d i v i d u a l s i n groups l a r g e r than seven. The p l a n had been t o s e l e c t 12 s u b j e c t s a t a time t h a t met the s e l e c t i o n c r i t e r i a f o r each of the 4 groups and then a s s i g n s i x of them t o the experimental subgroup and s i x t o the c o n t r o l subgroup ( F i g u r e 1). In r e a l i t y t h i s was i m p o s s i b l e . Twelve s u b j e c t s were s e l e c t e d f o r the f i r s t group but they c o u l d not be randomly a s s i g n e d f o r o n l y 6 of them wanted t o be i n the experimental group. When i t was time to s e l e c t the second group, o n l y 6 new s u b j e c t s were 40 Figure 1. Diagrammatic Representation of Study. S i x Subjects i n Con t r o l Group Pre-test-] j j j Control group-carries on w i t h the usual a c t i v i t i e s of the u n i t P o s t - t e s t UNIT - s e l e c t 12 subjects - o b t a i n consent -randomly a s s i g n experimental or c o n t r o l group to C o l l e c t data using the Group Observational C h e c k l i s t I I P r e - t e s t Process -Post-test S i x Subjects i n Experimental Group Weeks 0 Repeat above procedure 3 more times a v a i l a b l e , "the u n i t had had a very low t u r n over r a t e t h a t month. The researcher was not sure whether to a s s i g n three subjects t o the experimental subgroup and three t o the c o n t r o l or t o a s s i g n a l l of them t o the experimental group and use the s i x subjects from the previous group as the c o n t r o l f o r the second group. A f t e r c o n s u l t a t i o n w i t h the other committee members, i t was decided t o a s s i g n a l l of these subjects to the experimental group. This was not p o s s i b l e . One subject d i d not want t o be i n the experimental group so was assigned t o the c o n t r o l . She d i d not want t o be i n the experimental group because she d i d not want to commit to attending e i g h t l i f e review sessions. L a t e r the committee decided t h a t using the same c o n t r o l group again would confound the data. Therefore, t h a t s e t of data as deleted from the r e s u l t s . For the t h i r d group only e i g h t new subjects f i t t i n g the s e l e c t i o n c r i t e r i a were a v a i l a b l e . Of these f o u r were randomly assigned to the experimental subgroup and f o u r t o the c o n t r o l . For the f o u r t h group, 11 new subjects were a v a i l a b l e . Of these f i v e were randomly assigned t o the experimental group and s i x to the c o n t r o l . There were a t o t a l of 3 5 s u b j e c t s . Eighteen i n the experimental groups and 17 i n the c o n t r o l groups. The researcher took the three s c a l e s : the GRS, ADL and GDS, t o the u n i t , before the f i r s t l i f e review s e s s i o n and a f t e r the l a s t . The researcher read the items on the GDS sc a l e t o the su b j e c t and marked the subject's response. The researcher had the f u l l time r e g i s t e r e d nurse on the u n i t complete the GRS, and ADL. Demographic data was c o l l e c t e d from the c l i e n t ' s charts and from the c l i e n t using a s t r u c t u r e d i n t e r v i e w schedule (Appendix G). Data about the p a t i e n t ' s response to the l i f e review sessions was a l s o c o l l e c t e d . Data was c o l l e c t e d d a i l y through observations, j o u r n a l e n t r i e s and s t a f f and f a m i l y i n t e r v i e w s . I t was hoped t h a t t h i s k i n d of data would help i l l u m i n a t e some of the q u a n t i t a t i v e f i n d i n g s and account f o r the l i f e review process. Each experimental subgroup attended e i g h t l i f e review sessions co-lead by two r e g i s t e r e d nurses, one being the researcher. The sessions took place i n the u n i t ' s d i n i n g room. Each s e s s i o n was audiotaped and later- analyzed f o r frequency of v e r b a l response, time l e n g t h of speaking, number of l i f e events and type of i n t e r a c t i o n responses. A b e h a v i o r a l c h e c k l i s t was completed f o r each s e s s i o n . Tea and cookies were served a t each l i f e review s e s s i o n t o increase s o c i a l i z a t i o n . The c o n t r o l group c a r r i e d on w i t h the usual a c t i v i t i e s of the u n i t . A f t e r the e i g h t h l i f e review s e s s i o n , the GRS, ADL and GDS were readministered to experimental and c o n t r o l group p a t i e n t s who d i d not drop out. 43 Hypotheses Data were analyzed i n order t o t e s t the f o l l o w i n g hypotheses: 1] There w i l l be a decrease on t e s t scores of i n t e g r a t e d f u n c t i o n i n g , independence and d e p r e s s i o n a f t e r e i g h t l i f e review s e s s i o n s . 2] The v a r i a b l e s frequency of speech, time l e n g t h of speech, p o s i t i v e b e h a v i o r s , and number of major l i f e events c i t e d w i l l p o s i t i v e l y c o r r e l a t e w i t h each other. 3 ] The v a r i a b l e s frequency of speech, time l e n g t h of speech, p o s i t i v e b e h a v i o r s , and number of major l i f e events c i t e d , w i l l p o s i t i v e l y c o r r e l a t e w i t h i n t e g r a t e d f u n c t i o n i n g , independence l e v e l of f u n c t i o n i n g , and n e g a t i v e l y c o r r e l a t e w i t h d e p r e s s i o n . 4 ] The v a r i a b l e s i n t e g r a t e d f u n c t i o n i n g and independence l e v e l o f f u n c t i o n i n g w i l l be p o s i t i v e l y c o r r e l a t e d w i t h each o t h e r and n e g a t i v e l y c o r r e l a t e d w i t h d e p r e s s i o n . Independent-Dependent V a r i a b l e s The independent v a r i a b l e o r the treatment v a r i a b l e was the l i f e review group p r o c e s s . The treatment c o n s i s t e d of e i g h t l i f e review s e s s i o n s over a f o u r week p e r i o d . Two s e s s i o n s were h e l d weekly one on Tuesday and one on Thursday l a s t i n g about 4 5 minutes each. The s e s s i o n s were c o - l e a d by the r e s e a r c h e r and another r e g i s t e r e d nurse. Each l i f e review s e s s i o n s had a s e t t o p i c but otherwise 44 were not s t r u c t u r e d . The t o p i c s were as f o l l o w s : S e s s i o n 1 -- I n t r o d u c t i o n , F i r s t Move of P a t i e n t S e s s i o n 2 -- School Days S e s s i o n 3 • - Marriage S e s s i o n 4 -- F i r s t C h i l d S e s s i o n 5 -- F i r s t H o s p i t a l i z a t i o n S e s s i o n 6 • - Death of S i g n i f i c a n t Other S e s s i o n 7 -- Move t o Care F a c i l i t y S e s s i o n 8 • - Closure/Good-bye The independent v a r i a b l e , the group process, was analyzed i n terms of the Group Process O b s e r v a t i o n a l C h e c k l i s t (GPOC). A l l group s e s s i o n s were audio recorded. These tapes were analyzed f o r time l e n g t h of speaking, number of times spoken and number of major l i f e events t a l k e d about. The dependent v a r i a b l e s were: 1) I n t e g r a t e d f u n c t i o n i n g was measured by a score on the G e r i a t r i c R a t i n g S c a l e (GRS). 2) Independence i n a c t i v i t i e s of d a i l y l i v i n g was measured by the A c t i v i t y of D a i l y L i v i n g E v a l u a t i o n Form (ADL). 3) I n d i v i d u a l ' s d e p r e s s i o n l e v e l was measured by the score on the G e r i a t r i c Depression S c a l e (GDS). E t h i c a l C o n s i d e r a t i o n The r e s e a r c h p r o p o s a l was submitted t o the U n i v e r s i t y of B r i t i s h Columbia B e h a v i o r a l Sciences Screening Committee and approval obtained. P e r m i s s i o n t o conduct the study was o b t a i n e d from the Nursing Research Committee of the h o s p i t a l . Nursing s t a f f a s s i s t e d i n the s e l e c t i o n of p o t e n t i a l s u b j e c t s a c c o r d i n g t o the sample c r i t e r i a . P h y s i c i a n consents were obta i n e d . Each p o t e n t i a l s u b j e c t was approached i n d i v i d u a l l y by the r e s e a r c h e r . The s u b j e c t s were t o l d t h a t p a r t i c i p a t i o n or n o n - p a r t i c i p a t i o n i n the study would not a f f e c t p r e s e n t and f u t u r e m e d i c a l and n u r s i n g care. They were a l s o t o l d t h a t they c o u l d withdraw from the study a t any time i f they so d e s i r e d without j e o p a r d i z i n g t h e i r care. To p r o t e c t c o n f i d e n t i a l i t y , the s u b j e c t s were g i v e n pseudo names. 46 CHAPTER IV RESULTS The data from the instruments were analyzed t o determine any s i g n i f i c a n t d i f f e r e n c e s i n the independence l e v e l of f u n c t i o n i n g , i n t e g r a t e d f u n c t i o n i n g , and d e p r e s s i o n between the c o n t r o l and experimental groups. Frequency counts of group process behaviors were a l s o determined and c o r r e l a t e d w i t h the scores on the t h r e e instruments: A c t i v i t i e s of D a i l y L i v i n g E v a l u a t i o n Form, G e r i a t r i c R a t i n g S c a l e and the G e r i a t r i c Depression S c a l e . T h i s chapter i s d i v i d e d i n t o two s e c t i o n s . The f i r s t p a r t r e p o r t s the data r e g a r d i n g the s p e c i f i c demographic c h a r a c t e r i s t i c s of the sample. The second s e c t i o n d e s c r i b e s the data r e l a t e d t o the f o u r hypotheses of the study. Demo graph i c s The study c o n s i s t e d of 3 5 p a t i e n t s d i v i d e d between the experimental and c o n t r o l groups. There were 18 p a t i e n t s i n the experimental groups and 17 i n the c o n t r o l groups (Appendix L & M). Of the 18 i n the experimental group 14 were female and 4 were male. In the c o n t r o l group, 13 were female and 4 were male. The average age i n the experimental group was 82.61 years w i t h a range of 66 t o 95 y e a r s . The average age i n the c o n t r o l group was 81.53 years w i t h a range of 66 t o 103 y e a r s . They a l l had some k i n d of medical c o n d i t i o n v a r y i n g from a r t h r i t i s t o a s t r o k e . The p a t i e n t s 47 i n the experimental group had an average of 6.94 l i v i n g f a m i l y members w i t h a range of 0 t o 20 and the c o n t r o l group had an average of 10.06 l i v i n g f a m i l y members w i t h a range of 0 t o 28. Of the l i v i n g f a m i l y members i n the experimental group an average of 3.5 per p a t i e n t l i v e d i n the Vancouver area w i t h a range of 0 t o 15, of the c o n t r o l group an average of 5.18 l i v e d i n Vancouver w i t h a range of 0 t o 26. On average the p a t i e n t s belonged t o 0.55 o r g a n i z a t i o n s w i t h a range of 0 t o 2 i n the experimental group and 0.88 w i t h a range of 0 t o 4 i n the c o n t r o l . They a l l came to the long term care u n i t from an acute care u n i t i n the h o s p i t a l . Of the 18 p a t i e n t s i n the experimental group 15 of them l i v e d alone p r i o r t o h o s p i t a l i z a t i o n and t h r e e of them l i v e d w i t h t h e i r spouse. Of the c o n t r o l group nine p a t i e n t s l i v e d alone and e i g h t l i v e d w i t h t h e i r r e l a t i v e s . Out of the e i g h t , f o u r p a t i e n t s l i v e d w i t h t h e i r spouse, t h r e e w i t h t h e i r s i b l i n g s and one w i t h a c h i l d . T h e i r occupations v a r i e d from homemaker t o p r o f e s s i o n a l . R e s u l t s Since the study was e x p l o r a t o r y , and the groups were small an alpha v a l u e of .10 was used. More s i g n i f i c a n t r e s u l t s were i d e n t i f i e d where they occured. The f i n d i n g s of the study are o r g a n i z e d i n terms of the f o u r hypotheses. 48 Hypothesis Number One: There w i l l be a decrease on t e s t scores of integrated functioning, independence and depression a f t e r eight l i f e review sessions. To t e s t t h i s hypothesis, " t " tests were done of the experimental and control group's pre- and post-test scores on the the G e r i a t r i c Depression Scale (GDS), the A c t i v i t i e s of Daily Living Evaluation Form (ADL), and the G e r i a t r i c Rating Scale (GRS). The scores on the GDS varied from 31 to 53 with a mean of 39.86 and a standard deviation (SD) of 6.38 (Appendix N, 0). The mean pre-test score f o r the experimental group was 39.222 with a SD of 5.537, and 40.765 for the control group with a SD of 5.729. The mean post-test score f o r the experimental group was 36.167 with a SD of 4.668 and 43.765 fo r the control with a SD of 5.629. Using the Multivariate Mixed-Model Manova, the differences i n scores of the experimental and control group was .000 (p<.05) (Figure 2). The l e v e l of depression decreased for the experimental group of patients and increased f o r the control group. The significance between the pre-test scores of the experimental and control groups was not calculated using a s t a t i s t i c a l t e s t because the difference i n the means of the two groups i s less than 1/5 of a standard deviation. Thus, the pretest scores of the experimental and control groups are considered to be s i m i l a r . Therefore, t h i s part of the hypothesis , there w i l l be a decrease on t e s t scores of depression a f t e r Figure 2. Mean Sample Scores of the G e r i a t r i c Depression Scale P r e - t e s t P o s t - t e s t Score Score Note. A low score i s b e t t e r . The d i f f e r e n c e i n scores of the c o n t r o l and experimental groups i s .000 ((p<.05). C= Control Group E= Experimental Group e i g h t l i f e review s e s s i o n s , was supported. The ADL [ A c t i v i t i e s of D a i l y L i v i n g E v a l u a t i o n Form measuring the independence l e v e l of the p a t i e n t s ] was f i l l e d out by the s t a f f on the u n i t . The range of scores f o r the ADL was 6.00 t o 18.00 w i t h a mean of 13.11 and a SD of 2.92 (Appendix N, 0 ) . The mean p r e - t e s t scores f o r the experimental group were 12.944 w i t h a standard d e v i a t i o n of 2.7 75 and f o r the c o n t r o l group the mean was 14.23 5 w i t h an SD of 1.602. The mean p o s t - t e s t scores were 11.889 w i t h a SD of 3.359 f o r the experimental group and 14.412 w i t h a SD of 1.622 f o r the c o n t r o l group. Using the M u l t i v a r i a t e Mixed-Model Manova, the d i f f e r e n c e i n scores of the experimental and c o n t r o l group was 0.113 (Figure 3). The s i g n i f i c a n c e between the p r e - t e s t scores of the experimental and c o n t r o l group were not c a l c u l a t e d using a s t a t i s t i c a l t e s t because the d i f f e r e n c e i n the means of the two groups i s l e s s than 1/3 of a standard d e v i a t i o n . This p a r t of the hypothesis was not supported s t a t i s t i c a l l y . The data suggests the change toward independence (12.944 t o 11.889) was not as much as expected (p=.113) although the change was i n the r i g h t d i r e c t i o n . Since t h i s was a p h y s i c a l a b i l i t y t h a t was being assessed, i t i s not s u r p r i s i n g t h a t there was no s i g n i f i c a n t improvement i n the four short weeks during which the study was conducted. The GRS [ G e r i a t r i c Rating Scale, measuring i n t e g r a t e d f u n c t i o n i n g ] was f i l l e d out by the s t a f f on the u n i t . The p r e - t e s t scores v a r i e d from 38 to 69 w i t h a mean F i g u r e 3 . M e a n S a m p l e S c o r e s o f t h e A c t i v i t i e s o f D a i l y L i v i n g E v a l u a t i o n F o r m 15 14 ( C , 1 4 . 4 1 2 ) ( C , 1 4 . 2 3 5 ) 13 ( E , 1 2 . 9 4 4 12 ( E , 1 1 . 8 8 9 ) 11 10 P r e - t e s t P o s t - t e s t S c o r e S c o r e N o t e . A l o w s c o r e i s b e t t e r . T h e d i f f e r e n c e i n t h e e x p e r i m e n t a l a n d c o n t r o l g r o u p s i s . 113 . C= C o n t r o l G r o u p E= E x p e r i m e n t a l G r o u p of 53.31 and a SD of 8.89 (Appendix N, 0 ) . The mean p r e - t e s t score was 55.389 w i t h a SD of 8.846 f o r the experimental group, and 55.059 w i t h a SD of 9.371 f o r the c o n t r o l group. The mean p o s t - t e s t score was 50.944 w i t h a SD of 8.033 f o r the experimental group, and 55.8 24 w i t h a SD of 9.302 f o r the c o n t r o l . Using the M u l t i v a r i a t e Mixed-Model Manova the d i f f e r e n c e s i n scores of the experimental and c o n t r o l groups was 0.014 (p<.05) (F i g u r e 4). The s i g n i f i c a n c e between the p r e t e s t scores of the experimental and c o n t r o l group were not c a l c u l a t e d u s i n g a s t a t i s t i c a l t e s t because the d i f f e r e n c e i n the means of the two groups i s l e s s than 1/25 of a standard d e v i a t i o n . Thus, the p r e - t e s t scores are b e l i e v e d to be s i m i l i a r . The data supports t h i s p a r t of the h y p o t h e s i s t h a t t h e r e i s a decrease on t e s t s cores of i n t e g r a t e d f u n c t i o n i n g a f t e r e i g h t l i f e review s e s s i o n s . Hypothesis Number Two: The v a r i a b l e s frequency of speech, time l e n g t h of speech, p o s i t i v e b e h a v i o r s and number of major l i f e events c i t e d w i l l p o s i t i v e l y c o r r e l a t e w i t h each o t h e r . A d j u s t e d average scores were o b t a i n e d f o r the 12 behaviors on the Group Process O b s e r v a t i o n a l C h e c k l i s t (GPOC) and each b e h a v i o r was c o r r e l a t e d w i t h the r e s t . The t h i r t e e n t h behavior, p h y s i c a l l y a t t a c k s , was removed from the Group Process O b s e r v a t i o n a l C h e c k l i s t because not a s i n g l e p a t i e n t a t t a c k e d another p a t i e n t . The scores needed to be a d j u s t e d because every p a t i e n t d i d not a t t e n d every s e s s i o n (Appendix Q). Pearson c o r r e l a t i o n c o e f f i c i e n t s were F i g u r e 4. Mean Sample Scores of the G e r i a t r i c R a t i n g S c a l e 56 55 54 53 52 51 50 49 (E, 55.389 (C, 55.059) (C, 55.824) (E, 50.944) P r e - t e s t Score P o s t - t e s t Score Note, A low score i s b e t t e r , The d i f f e r e n c e s of the c o n t r o l and experimental groups .014 (p<.05) . C= C o n t r o l Group E= Experimental Group o b t a i n e d . C o r r e l a t i o n s among t h e f o l l o w i n g b e h a v i o r s w e r e s i g n i f i c a n t ( p < . 1 0 ) . P < .10 w a s u s e d b e c a u s e t h i s w a s t h e f i r s t t i m e t h a t t h e GPOC w a s u s e d i n a l i f e r e v i e w g r o u p . S m i l e s w a s p o s i t i v e l y c o r r e l a t e d w i t h : n o d s i n a g r e e m e n t ( . 4 4 ) , l a u g h s ( . 8 4 ) , v e r b a l i z e s a g r e e m e n t ( . 4 9 ) , a n d o f f e r s v e r b a l e n c o u r a g e m e n t ( . 4 0 ) ( T a b l e 1 ) . N o d s i n a g r e e m e n t w a s p o s i t i v e l y c o r r e l a t e d w i t h : l a u g h s ( . 6 6 ) , j o k e s t o r e l e a s e t e n s i o n ( . 5 6 ) , v e r b a l i z e s a g r e e m e n t ( . 7 6 ) , o f f e r s v e r b a l e n c o u r a g e m e n t ( . 7 1 ) , a n d n e g a t i v e l y c o r r e l a t e d w i t h d i s p l a y s w i t h d r a w l ( . 3 3 ) , a n d p h y s i c a l l y d i s r u p t s ( . 3 4 ) . L a u g h s w a s p o s i t i v e l y c o r r e l a t e d w i t h : j o k e s t o r e l e a s e t e n s i o n ( . 4 6 ) , v e r b a l i z e s a g r e e m e n t ( . 5 6 ) a n d o f f e r s v e r b a l e n c o u r a g e m e n t ( . 5 4 ) . J o k e s t o r e l e a s e t e n s i o n w a s p o s i t i v e l y c o r r e l a t e d w i t h o f f e r s v e r b a l e n c o u r a g e m e n t ( . 4 2 ) . V e r b a l i z e s a g r e e m e n t w a s p o s i t i v e l y c o r r e l a t e d w i t h o f f e r s v e r b a l e n c o u r a g e m e n t ( . 8 3 ) . D i s p l a y s w i t h d r a w l w a s p o s i t i v e l y c o r r e l a t e d w i t h : p h y s i c a l l y d i s r u p t s ( . 5 8 ) , a n d v e r b a l l y d i m i n i s h e s ( . 7 9 ) . V e r b a l i z e s w i t h d r a w l w a s p o s i t i v e l y c o r r e l a t e d w i t h p h y s i c a l l y d i s r u p t s ( . 3 5 ) . V e r b a l i z e s h o s t i l i t y w a s p o s i t i v e l y c o r r e l a t e d w i t h v e r b a l l y i n t e r r u p t s ( . 6 9 ) . P h y s i c a l l y d i s r u p t s w a s p o s i t i v e l y c o r r e l a t e d w i t h : v e r b a l l y i n t e r r u p t s ( . 4 7 ) , a n d v e r b a l l y d i m i n i s h e s ( . 5 3 ) . F o r t h i s p a r t o f t h e h y p o t h e s i s , t h a t t h e p o s i t i v e b e h a v i o r s w i l l c o r r e l a t e p o s i t i v e l y w i t h e a c h o t h e r , t h e r e i s s u p p o r t . H o w e v e r , t h e r e w a s o n e p o s i t i v e b e h a v i o r , n o d s i n a g r e e m e n t , t h a t c o r r e l a t e d s i g n i f i c a n t l y ( p < . 1 0 ) w i t h t h e T a b l e 1 P e a r s o n C o r r e l a t i o n C o e f f i c i e n t s Among t h e B e h a v i o r s o n t h e G r o u p P r o c e s s O b s e r v a t i o n a l C h e c k l i s t S m i l e s N o d s i n L a u g h s J o k e s t o V e r b a l i z e s O f f e r s V e r b a l B e h a v i o r A g r e e m e n t R e l e a s e A g r e e m e n t E n c o u r a g e m e n t T e n s i o n S m i l e s 1 . 0 0 . 4 4 * . 8 4 * * . 0 0 . 4 9 * . 4 0 * N o d s i n A g r e e m e n t . 4 4 * 1 . 0 0 . 6 6 * * . 5 6 * * . 7 6 * * . 7 1 * * L a u g h s . 8 4 * * . 6 6 * * 1 . 0 0 . 4 6 * . 5 6 * * . 5 4 * * J o k e s t o R e l e a s e T e n s i o n . 0 0 . 5 6 * * . 4 6 * 1 . 0 0 . 2 1 . 4 2 * V e r b a l i z e s A g r e e m e n t . 4 9 * . 7 6 * * . 5 6 * * . 2 1 1 . 0 0 . 8 3 * * O f f e r s V e r b a l E n c o u r a g e m e n t . 4 0 * . 7 1 * * . 5 4 * * . 4 2 * . 8 3 * * 1 . 0 0 #p< .10 . * p < . 0 5 . * * p < . 0 1 . T a b l e 1 C o n t i n u e d P e a r s o n C o r r e l a t i o n C o e f f i c i e n t s Among t h e B e h a v i o r s o n t h e G r o u p P r o c e s s  O b s e r v a t i o n a l C h e c k l i s t D i s p l a y s V e r b a l i z e s V e r b a l i z e s P h y s i c a l l y V e r b a l l y V e r b a l l y B e h a v i o r W i t h d r a w l W i t h d r a w l H o s t i l i t y D i s r u p t s I n t e r r u p t s D i m i n i s h e s S m i l e s - . 0 6 N o d s i n A g r e e m e n t - . 3 3 # L a u g h s - . 2 8 J o k e s t o R e l e a s e T e n s i o n - . 2 8 V e r b a l i z e s A g r e e m e n t - . 2 9 O f f e r s V e r b a l E n c o u r a g e m e n t - . 2 7 . 0 6 . 20 . 16 . 0 2 . 0 8 . 02 - . 0 1 - . 2 4 - . 0 2 - . 1 4 . 1 2 . 1 4 0 1 35# 25 16 25 16 16 31 21 . 11 0 1 07 . 14 - . 22 - . 0 7 - . 21 . 22 #p< .10 . * p < . 0 5 . * * p < . 0 1 . T a b l e 1 C o n t i n u e d P e a r s o n C o r r e l a t i o n C o e f f i c i e n t s Among t h e B e h a v i o r s o n t h e G r o u p P r o c e s s O b s e r v a t i o n a l C h e c k l i s t D i s p l a y s V e r b a l i z e s V e r b a l i z e s P h y s i c a l l y V e r b a l l y V e r b a l l y B e h a v i o r W i t h d r a w l W i t h r a w l H o s t i l i t y D i s r u p t s I n t e r r u p t s D i m i n i s h e s D i s p l a y s W i t h d r a w l 1 . 0 0 . 1 4 - . 0 4 . 5 8 * * . 0 8 . 7 9 * * V e r b a l i z e s W i t h d r a w l . 1 4 1 . 0 0 .10 . 3 5# . 1 7 . 10 V e r b a l i z e s H o s t i l i t y - . 0 4 .10 1 . 0 0 - . 0 1 . 6 9 * * . 0 4 P h y s i c a l l y D i s r u p t s . 5 8 * * .35# - . 0 1 1 . 0 0 . 4 7 * . 5 3 * * V e r b a l l y I n t e r r u p t s . 0 8 . 1 7 . 6 9 * * . 4 7 * 1 . 0 0 . 0 5 V e r b a l l y D i m i n i s h e s . 7 9 * * .10 . 0 4 . 5 3 * * . 0 5 1 . 0 0 # p < . 1 0 . * p < . 0 5 . * * p < . 0 1 . 58 n e g a t i v e b e h a v i o r s o f d i s p l a y s w i t h d r a w l ( - . 3 3 ) a n d p h y s i c a l l y d i s r u p t s ( - . 3 5 ) . N e x t t h e v a r i a b l e s f r e q u e n c y o f s p e e c h [ F R S ] , t i m e l e n g t h o f s p e e c h [ T L S ] a n d n u m b e r o f m a j o r l i f e e v e n t s [ L E ] w e r e c o r r e l a t e d w i t h e a c h o t h e r . F R S , T L S , a n d L E w e r e a l l s i g n i f i c a n t l y c o r r e l a t e d w i t h e a c h o t h e r a s p r e d i c t e d ( p < . 0 1 ) ( T a b l e 2 ) . N e x t t h e v a r i a b l e s f r e q u e n c y o f s p e e c h , t i m e l e n g t h o f s p e e c h a n d n u m b e r o f m a j o r l i f e e v e n t s w e r e c o r r e l a t e d w i t h e a c h o t h e r a n d t h e 12 b e h a v i o r s o n t h e G P O C . T h e f o l l o w i n g s i g n i f i c a n t c o r r e l a t i o n s w e r e f o u n d b e t w e e n t h e f r e q u e n c y o f s p e e c h , t i m e l e n g t h o f s p e e c h , a n d n u m b e r o f m a j o r l i f e e v e n t s ( p < . 1 0 ) . F r e q u e n c y o f s p e e c h c o r r e l a t e d p o s i t i v e l y w i t h : n o d s i n a g r e e m e n t ( . 3 2 ) , l a u g h s ( . 4 4 ) , j o k e s t o r e l e a s e t e n s i o n ( . 4 7 ) , v e r b a l i z e s a g r e e m e n t ( . 3 4 ) , o f f e r s v e r b a l e n c o u r a g e m e n t ( . 6 5 ) , v e r b a l i z e s h o s t i l i t y ( . 3 9 ) a n d v e r b a l l y i n t e r r u p t s ( . 3 3 ) a n d n e g a t i v e l y c o r r e l a t e d w i t h d i s p a l y s w i t h d r a w l ( - . 3 9 ) . T i m e l e n g t h o f s p e e c h p o s i t i v e l y c o r r e l a t e d w i t h n o d s i n a g r e e m e n t ( . 3 9 ) , l a u g h s ( . 3 3 ) , j o k e s t o r e l e a s e t e n s i o n ( . 6 7 ) a n d o f f e r s v e r b a l e n c o u r a g e m e n t ( . 4 1 ) . N u m b e r o f m a j o r l i f e e v e n t s c o r r e l a t e d p o s i t i v e l y w i t h : s m i l e s ( . 3 6 ) , n o d s i n a g r e e m e n t ( . 4 9 ) , l a u g h s ( . 5 0 ) , j o k e s t o r e l a e a s e t e n s i o n ( . 5 4 ) , v e r b a l i z e s a g r e e m e n t ( . 3 4 ) , a n d o f f e r s v e r b a l e n c o u r a g e m e n t ( . 5 6 ) ; a n d n e g a t i v e l y c o r r e l a t e d w i t h d i s p l a y s w i t h d r a w l ( - . 3 4 ) . T h i s p a r t o f t h e h y p o t h e s i s t h a t t h e p o s i t i v e b e h a v i o r s w o u l d c o r r e l a t e p o s i t i v e l y w i t h f r e q u e n c y o f s p e e c h [ F R S ] , t i m e l e n g t h o f T a b l e 2 P e a r s o n C o r r e l a t i o n C o e f f i c i e n t s Among F r e q u e n c y o f S p e e c h . T i m e L e n g t h o f S p e a k i n g a n d N u m b e r o f M a j o r L i f e E v e n t s G r o u p P r o c e s s F r e q u e c n y T i m e L e n g t h N o . o f M a j o r V a r i a b l e s o f S p e e c h o f S p e a k i n g L i f e E v e n t s F r e q u e n c y o f S p e e c h 1 . 0 0 . 7 0 * * . 7 6 * * T i m e L e n g t h o f S p e a k i n g . 7 0 * * 1 . 0 0 . 9 2 * * N o . o f M a j o r L i f e E v e n t s . 7 6 * * . 9 2 * * 1 . 0 0 * * p < . 0 1 60 speech [TLS] and number of major l i f e events [LE] was supported. At l e a s t f i v e of the s i x p o s i t i v e b e h a v i o r s c o r r e l a t e d w i t h each item, FRS, TLS, and LE (Table 3). Hypothesis Number Three: The v a r i a b l e s frequency of speech, time l e n g t h of speech, number of major l i f e events c i t e d , and p o s i t i v e b e h a v i o r s w i l l p o s i t i v e l y c o r r e l a t e w i t h i n t e g r a t e d f u n c t i o n i n g , independence l e v e l of f u n c t i o n i n g , and n e g a t i v e l y c o r r e l a t e w i t h d e p r e s s i o n . To t e s t the p a r t of the h y p o t h e s i s t h a t s t a t e s ; the p o s i t i v e b e h a v i o r s w i l l p o s i t i v e l y c o r r e l a t e w i t h i n t e g r a t e d f u n c t i o n i n g , indpendence l e v e l of f u n c t i o n i n g , and n e g a t i v e l y c o r r e l a t e w i t h d e p r e s s i o n ; the G e r i a t r i c Depression S c a l e (GDS), A c t i v i t i e s of D a i l y L i v i n g E v a l u a t i o n Form (ADL), and the G e r i a t r i c R a t i n g S c a l e (GRS) were c o r r e l a t e d w i t h the behaviors on the Group Process O b s e r v a t i o n a l C h e c k l i s t . Pearson c o r r e l a t i o n c o e f f i c i e n t s were c a l c u l a t e d . The f o l l o w i n g were the s i g n i f i c a n t c o r r e l a t i o n s (p<.10). The GDS c o r r e l a t e d p o s i t i v e l y w i t h n e g a t i v e b e h a v i o r s : d i s p l a y s withdrawl (.49), p h y s i c a l l y d i s r u p t s (.61), and v e r b a l l y d i s r u p t s (.45). The ADL p o s i t i v e l y c o r r e l a t e d w i t h d i s p l a y s withdrawl (.36). The GRS c o r r e l a t e d p o s i t i v e l y w i t h the n e g a t i v e b e h a v i o r : d i s p l a y s withdrawl (.32), v e r b a l l y withdraws (.37), v e r b a l i z e s h o s t i l i t y (.57) and v e r b a l l y i n t e r r u p t s (.67). I t n e g a t i v e l y c o r r e l a t e d w i t h nods i n agreement (-.40). The c o r r e l a t i o n a l r e s u l t s of the GDS w i t h the GPOC were i n the p r e d i c t e d d i r e c t i o n , and i n support of the h y p o t h e s i s . T a b l e 3 P e a r s o n C o r r e l a t i o n C o e f f i c i e n t s o f t h e G r o u p P r o c e s s B e h a v i o r s w i t h  F r e q u e n c y o f S p e e c h . T i m e L e n g t h o f S p e a k i n g . N u m b e r o f M a j o r L i f e E v e n t s .  G e r i a t r i c D e p r e s s i o n S c a l e , a c t i v i t i e s o f D a i l y L i v i n g E v a l u a t i o n F o r m a n d  t h e G e r i a t r i c R a t i n g S c a l e F r e q u e n c y T i m e L e n g t h N o . o f G e r i a t r i c A c t i v i t i e s G e r i a t r i c o f S p e e c h o f S p e a k i n g M a j o r L i f e D e p r e s s i o n o f D a i l y R a t i n g E v e n t s S c a l e L i v i n g E v a l u a t i o n S c a l e B e h a v i o r F o r m S m i l e s 24 . 13 .36# - . 23 - . 1 0 . 0 4 N o d s i n A g r e e m e n t 32# • 39# . 4 9 * - . 2 1 - . 15 - . 4 0 * L a u g h s 4 4 * • 33# . 5 0 * - . 2 9 - . 13 - . 14 J o k e s t o R e l e a s e T e n s i o n 4 7 * . 6 7 * * . 54** - . 0 8 . 0 0 - . 29 V e r b a l i z e s A g r e e m e n t 34# . 14 .34# - . 2 8 - . 2 1 - . 19 O f f e r s V e r b a l E n c o u r a g e m e n t . 6 5 * * . 4 1 * . 5 6 * * - . 0 8 - . 0 5 - . 25 # p < . 1 0 . * p < . 0 5 , * * p < . 0 1 , cr> i Table 3 Continued Pearson C o r r e l a t i o n C o e f f i c i e n t s of the Group Process Behaviors w i t h  Frequency of Speech. Time Length of Speaking. Number of Major L i f e Events.  G e r i a t r i c Depression S c a l e . A c t i v i t i e s of D a i l y L i v i n g E v a l u a t i o n Form and  the G e r i a t r i c Rating Scale Frequency Time Length No. of G e r i a t r i c A c t i v i t i e s G e r i a t r i of Speech of Speaking Major L i f e D e p r e ssion of D a i l y R a t i n g Events S c a l e L i v i n g E v a l u a t i o n S c a l e Behavior Form D i s p l a y s Withdrawl 39# -. 16 -.34# .49* .36# .32# V e r b a l i z e s Withdrawl 10 - . 16 -.16 -.17 .25 .37# V e r b a l i z e s H o s t i l i t y 39# -.0 - .03 .02 .24 . 57** P h y s i c a l l y D i s r u p t s 09 - .09 -.17 . 61** . 21 . 25 V e r b a l l y I n t e r r u p t s 33# -.05 .03 .30# .31* . 67** V e r b a l l y Diminishes 17 -.01 - . 11 .45* . 18 - . 11 #p<.10. *p<.05. **p<.01. The GDS was c o r r e l a t e d p o s i t i v e l y w i t h three of the s i x negative behaviors; and the c o r r e l a t i o n s w i t h the p o s i t i v e behaviors were a l l i n the negative d i r e c t i o n . The ADL c o r r e l a t e d s i g n i f i c a n t l y w i t h only one negative behavior. This i m p l i e s t h a t i f an i n d i v i d u a l was p h y s i c a l l y independent, he or she d i s p l a y e d withdrawl i n the group. This r e s u l t was d i f f i c u l t to e x p l a i n . The GRS was n e g a t i v e l y c o r r e l a t e d w i t h one p o s i t i v e behavior and p o s i t i v e l y c o r r e l a t e d w i t h f o u r negative behaviors. This c o n t r a d i c t s the hypothesis. Perhaps those i n d i v i d u a l s t h a t have hig h scores on i n t e g r a t e d f u n c t i o n i n g are s e l f centred. They do not want t o l i s t e n to those who are not as i n t e g r a t e d as them and perhaps do not have patience f o r others w i t h l i m i t e d a b i l i t y . There i s very l i m i t e d support f o r t h i s p a r t of the hypothesis t h a t the p o s i t i v e behaviors w i l l p o s i t i v e l y c o r r e l a t e w i t h i n t e g r a t e d f u n c t i o n i n g , independence l e v e l of f u n c t i o n i n g , and n e g a t i v e l y c o r r e l a t e w i t h depression. To t e s t the p a r t of the hypothesis t h a t s t a t e ; the v a r i a b l e s frequency of speech, time length of speech, and number of major l i f e events c i t e d w i l l p o s i t i v e l y c o r r e l a t e w i t h i n t e g r a t e d f u n c t i o n i n g , independence l e v e l of f u n c t i o n i n g , and n e g a t i v e l y c o r r e l a t e w i t h depression; the v a r i a b l e s frequency of speech [FRS], time l e n g t h of speech [TLS] and number of major l i f e events [LE] were c o r r e l a t e d w i t h the G e r i a t r i c Rating Scale [GRS], the A c t i v i t i e s of D a i l y L i v i n g E v a l u a t i o n Form [ADL], and the G e r i a t r i c 64 D epression S c a l e [GDS]. Pearson c o r r e l a t i o n c o e f f e c i e n t s were c a l c u l a t e d . There were no s i g n i f i c a n t c o r r e l a t i o n s (p<.10) ( Table 4). In f a c t none of the c o r r e l a t i o n s were i n the p r e d i c t e d d i r e c t i o n . The GDS c o r r e l a t e d n e g a t i v e l y w i t h FRS (-.06) and LE (-.04) as p r e d i c t e d , but i t c o r r e l a t e d p o s i t i v e l y w i t h TLS (.05). T h i s may be because the i n d i v i d u a l who was depressed tended t o focus on one event and keeps t a l k i n g about i t i n hopes of r e s o l v i n g the p a s t c o n f l i c t concerning t h a t p a r t i c u l a r event. The ADL c o r r e l a t e d p o s i t i v e l y w i t h FRS (.20) and TLS (.00) (Table 4). p r e d i c t e d but i t c o r r e l a t e d n e g a t i v e l y w i t h LE (-.13). T h i s would mean t h a t those who were more independent t a l k e d about fewer major l i f e events. T h i s may be because those who were more independent were a l s o c o g n i t i v e l y more aware thus may have r e c a l l e d more d e t a i l s about the events they chose to share w i t h the group. The GRS c o r r e l a t e d p o s i t i v e l y w i t h FRS as p r e d i c t e d but c o r r e l a t e d n e g a t i v e l y w i t h TLS and LE. T h i s means t h a t i f an i n d i v i d u a l i s g e n e r a l l y w e l l [ f u n c t i o n a l l y i n t e g r a t e d ] , then he o r she may t a l k l e s s about fewer major l i f e events. These r e s u l t s would f i t B u t l e r ' s work. I f the i n d i v i d u a l i s i n t e g r a t e d , presumably he or she has r e s o l v e d h i s or h e r p a s t c o n f l i c t s and may a l r e a d y be i n E r i c k s o n ' s f i n a l stage of e g o - i n t e g r i t y . T h e r e f o r e , the i n d i v i d u a l would not have many events to t a l k about and may not spend much time t a l k i n g because he i s a t peace w i t h h i s s i t u a t i o n . 6 5 Table 4 Pearson C o r r e l a t i o n C o e f f i c i e r r t s of Frequency of Speech. Time  Length of Speaking, and Number of Major L i f e Events w i t h the  G e r i a t r i c Depression Scale. A c t i v i t i e s of L i v i n g E v a l u a t i o n  Form, and the G e r i a t r i c Rating Scale Scale G e r i a t r i c Depression Scale A c t i v i t i e s of D a i l y L i v i n g E v a l u a t i o n Form Frequency of Speech - .06 . 20 Time Length of Speaking Number of Major L i f e Events 05 04 00 13 - . 21 28 G e r i a t r i c Rating Scale .02 66 Hypothesis Number Four; The v a r i a b l e s i n t e g r a t e d f u n c t i o n i n g and independence l e v e l o f f u n c t i o n i n g w i l l be p o s i t i v e l y c o r r e l a t e d w i t h each o t h e r and n e g a t i v e l y c o r r e l a t e d w i t h d e p r e s s i o n . C o r r e l a t i o n s of the t h r e e s c a l e s , GDS, ADL, and GRS, were done w i t h each other. Pearson c o r r e l a t i o n c o e f f i c i e n t s were c a l c u l a t e d between the GDS and ADL as 0.40, between the GDS and GRS as 0.3 7 and between the GRS and the ADL i s 0.67 (Table 5). The GDS was s i g n i f i c a n t l y c o r r e l a t e d w i t h ADL us i n g (p<.05). The GDS was s i g n i f i c a n t l y c o r r e l a t e d w i t h ADL and GRS (p<.10). The GRS was s i g n i f i c a n t l y c o r r e l a t e d w i t h ADL (p<.05). The GDS was not n e g a t i v e l y c o r r e l a t e d w i t h ADL and GRS as p r e d i c t e d . T h i s means i f an i n d i v i d u a l ' s independence l e v e l i s hig h then h i s or her score on i n t e g r a t e d f u n c t i o n i n g i s h i g h . Only a p a r t of the hy p o t h e s i s t h a t s t a t e d i n t e g r a t e d f u n c t i o n i n g and independence l e v e l of f u n c t i o n i n g w i l l p o s i t i v e l y c o r r e l a t e w i t h each o t h e r i s supported. T a b l e 5 P e a r s o n C o r r e l a t i o n C o e f f e c i e n t s Among t h e G e r i a t r i c D e p r e s s s i o n S c a l e . A c t i v i t i e s o f D a i l y L i v i n g E v a l u a t i o n F o r m , a n d t h e G e r i a t r i c R a t i n g S c a l e G e r i a t r i c D e p r e s s i o n S c a l e A c t i v i t i e s o f D a i l y L i v i n g E v a l u a t i o n F o r m G e r i a t r i c R a t i n g S c a l e G e r i a t r i c D e p r e s s s i o n S c a l e 1 . 0 0 . 4 0 * .37# A c t i v i t i e s o f D a i l y L i v i n g E v a l u a t i o n F o r m . 4 0 * 1 . 0 0 . 6 7 * * G e r i a t r i c R a t i n g S c a l e .37# . 6 7 * 1 . 0 0 # p < . 1 0 . * p < . 0 5 . * * p < . 0 1 . 68 CHAPTER 5 DISCUSSION, CONCLUSIONS, AND RECOMMENDATIONS It i s generally believed that people of a l l ages reminisce about t h e i r past. The e l d e r l y are believed to reminisce more. This raises many questions. If the e l d e r l y are led to discuss t h e i r past l i f e i n a group setting, does that contribute to t h e i r q u a l i t y of t h e i r l i f e ? If the answer to the f i r s t question i s yes, what i s i t about the group process that contributes to the general well being of the i n d i v i d u a l . The purpose of t h i s research was to study the influence of l i f e review sessions with the i n s t i t u t i o n a l i z e d e l d e r l y . There were four hypothesis that were tested i n t h i s study: 1] There w i l l be a decrease on t e s t scores of integrated functioning, independece and depression a f t e r eight l i f e review sessions. 2] The variables frequency of speech, time length of speech, p o s i t i v e behaviors, and number of major l i f e events c i t e d w i l l p o s i t i v e l y correlate with each other. 3 ] The variables frequency of speech, time length of speech, p o s i t i v e behaviors, and number of major-l i f e events cite d , w i l l p o s i t i v e l y correlate with integrated functioning, independence l e v e l of functioning, and negatively correlate with depresssion. 4] The variables integrated functioning and independence l e v e l of functioning w i l l be p o s i t i v e l y cox-related with each other and negatively correaltaed with depression. This chapter i s organized into three sections. In the f i r s t section the findings are discussed, i n part two the conclusions from the study are drawn. This i s followed with recommendations. D i s c u s s i o n The r e s u l t s c l e a r l y i n d i c a t e t h a t l i f e review sessions are b e n e f i c i a l t o the e l d e r l y . The f i n d i n g s from t h i s study show t h a t a f t e r e i g h t l i f e review sessions, the p a t i e n t s were l e s s depressed, more independent and more i n t e g r a t e d . This statement i s supported by both s t a t i s t i c a l and n a r r a t i v e data. The d i f f e r e n c e i n the l e v e l of depression, measured by the G e r i a t r i c Depression Sca l e , between the experimental and c o n t r o l group was found t o be s t a t i s t i c a l l y s i g n i f i c a n t . This means t h a t the l e v e l of depression i n the experimental group decreased i n comparison t o the c o n t r o l group. This i s c o n s i s t e n t w i t h the n a r r a t i v e f i n d i n g s . N a r r a t i v e data was c o l l e c t e d about the p a t i e n t s by observation and d i s c u s s i o n w i t h the p a t i e n t ' s nurses and f a m i l i e s . Ms. H. and Ms. J . became more a t t e n t i v e t o t h e i r appearance, and Ms. B., Ms. F., Mr. R. and Mr. P. became more a l e r t and o r i e n t e d as the group sessions progressed. A few of the p a t i e n t s s t a r t e d to s o c i a l i z e i n and outside the group sessions. Ms. D., Ms. F., Ms. G., Ms. H., Ms. J . , Ms. K., Ms. L., Mr. Q., and Mr. R., helped pass out t e a and cookies i n the group sessions. Ms. C. made f r i e n d s outside the group, Ms H. and Mr. K. i n i t i a t e d conversations w i t h others outside of the group ses s i o n s , Ms, M. s t a r t e d t o eat i n the d i n i n g room, Ms. P. encouraged others i n the group to speak, Mr. R. and Mr. Q. became f r i e n d s , Ms. S. s t a r t e d t o converse more w i t h p a t i e n t s and 70 s t a f f and Mr. T. became l e s s drowsy i n the s e s i o n s (Appendix P). A l s o the groups s t a t e d they enjoyed the l i f e review s e s s i o n s . The above r e s u l t s are c o n s i s t e n t w i t h e a r l i e r f i n d i n g s of McMahon and Rhudick (1964), K i e r n a t (1979), F r y (1983) and Parsons (1986). The r e s u l t s of t h i s study c o n t r a d i c t the f i n d i n g s of P e r o t t a and Meacham (1981) who found t h a t t h e r e was no change i n the l e v e l of d e p r e s s i o n a f t e r l i f e review s e s s i o n s . T h i s study a l s o showed t h a t p a t i e n t s were more i n t e g r a t e d , g e n e r a l l y f e l t and f u n c t i o n e d b e t t e r , a f t e r e i g h t l i f e review s e s s i o n s . Scores on i n t e g r a t e d f u n c t i o n i n g as measured by the G e r i a t r i c R a t i n g S c a l e were s t a t i s t i c a l l y s i g n i f i c a n t between the c o n t r o l and experimental groups. Items on the G e r i a t r i c R a t i n g S c a l e i n c l u d e a p a t i e n t ' s p h y s i c a l a b i l i t y , h i s or her communication s k i l l s and h i s or her s o c i a l i z a t i o n on the ward. I t b a s i c a l l y measures the p a t i e n t ' s g e n e r a l w e l l being. T h i s means t h a t i n d i v i d u a l s i n the experimental group were more i n t e g r a t e d than those i n the the c o n t r o l group. A l s o i n support of t h i s h y p o t h e s i s q u a l i t a t i v e data was c o l l e c t e d through o b s e r v a t i o n and c o n v e r s a t i o n w i t h the s t a f f on the u n i t and the p a t i e n t s ' f a m i l i e s . In g e n e r a l the p a t i e n t s i n the experimental group became more s o c i a b l e , more o r i e n t e d , were more concerned about t h e i r appearance, had b e t t e r r e c a l l , became more a t t e n t i v e i n the group and c o u l d p h y s i c a l l y do more i n the group than o u t s i d e the group s e s s i o n . A l s o some p a t i e n t s wanted t o discuss death and dying w i t h s t a f f a f t e r the group sessions (Appendix P ) . Ms. B. and Ms. D. both wanted to t a l k about death and dying. They were both r e f e r r e d to the p a s t o r a l care department. Ms. D. died three weeks a f t e r the group f i n i s h e d i t s sessions. The D i r e c t o r of P a s t o r a l Care s t a t e s she d i e d a t t h i s time because both the group and the s i s t e r from p a s t o r a l care gave her permission t o d i e . S i s t e r R. from p a a s t o r a l care b e l i e v e s "she f i n a l l y completed her business." Ms. C. who normally had a poor memory remembered to come t o the group meeting on her own. Mr. Q. wandered o f f the ward l e s s f r e q u e n t l y as the group progressed. These f i n d i n g s f u l l y support B u t l e r ' s theory t h a t l i f e review serves an a d a p t a t i o n a l purpose because both Ms. C. and Mr. Q. appeared t o ad j u s t t o t h e i r surroundings. The independence l e v e l of f u n c t i o n i n g was measured by the A c t i v i t i e s of D a i l y L i v i n g E v a l u a t i o n Form. The scores between the experimental and c o n t r o l groups were found not to be s t a t i s t i c a l l y s i g n i f i c a n t . Though the s t a t i s t i c a l r e s u l t s were not s i g n i f i c a n t , there was n a r r a t i v e data i n support of increased independence. The n a r r a t i v e data suggests there was improvement i n the p a t i e n t ' s independence l e v e l of f u n c t i o n i n g . Ms. E. and Mr. T. who normally r e q u i r e d help feeding, fed themselves i n the group sessions. Ms. H. attempted to move her wheelchair on her own and Ms. S. s t a r t e d t o m o b i l i z e h e r s e l f more. Ms. J . s t a r t e d t o dress b e t t e r and pay more a t e n t i o n t o her appearance, Ms. K. s t a r t e d t o have her h a i r done on a r e g u l a r b a s i s (Appendix P) . The f i n d i n g s of t h i s study suggest t h a t independence was i n c r e a s e d . The reason t h e r e was no s t a t i s t i c a l l y s i g n i f i c a n t change c o u l d be due t o the f a c t t h a t t h i s i s a p h y s i c a l a b i l i t y . To improve a p h y s i c a l a b i l i t y of an i n d i v i d u a l w i t h c h r o n i c i l l n e s s e s r e q u i r e s more than j u s t f o u r weeks. A l l t h r e e s c a l e s , GDS, ADL, and GRS, were p o s i t i v e l y c o r r e l a t e d w i t h one another. T h i s means t h a t no s c a l e was t o t a l l y independent of the o t h e r s . In o t h e r words, the s c a l e s o v e r l a p i n the items of measurement. The G e r i a t r i c R a t i n g S c a l e was p o s i t i v e l y c o r r e l a t e d w i t h the A c t i v i t i e s of D a i l y L i v i n g E v a l u a t i o n Form (.67, p<.01). The G e r i a t r i c R a t i n g S c a l e a l s o has q u e s t i o n s on p h y s i c a l as w e l l as p s y c h o l o g i c a l a b i l i t y . T h i s suggests t h a t perhaps the A c t i v i t i e s of D a i l y L i v i n g E v a l u a t i o n Form was not a r e l i a b l e measure. Yet on the Hoyt estimate of r e l i a b i l i t y done by the r e s e a r c h e r , the s c a l e showed t o be v e r y r e l i a b l e . The p a t i e n t s d i d improve i n t h e i r l e v e l of d e p r e s s i o n , i n t e g r a t e d f u n c t i o n i n g and independence. T h e r e f o r e , l i f e review i s found to be b e n e f i c i a l . T h i s i s c o n s i s t e n t w i t h the f i n d i n g s of K l e i n , Le Shan and Furman (1965), K i e r n a t (1979), McMahon and Rhudick (1964), Parsons (1986) P o u l t o n and S t r a s s b e r g (1986), Sherman (1987) and T a f t and Nehrke (1990). The o n l y study the f i n d i n g s do not support i s t h a t of Tobin (1972) i n which the e l d e r l y s t a t e d they t r i e d not to reminisce because they d i d not want to burden other people. In Tobin's study the e l d e r l y f e l t those around them viewed t h e i r r e m i n i s c i n g behavior n e g a t i v e l y , so they f e l t g u i l t y when they reminisced. I t can be i n f e r r e d from Gurm (1990) t h a t l i f e review sessions w i t h the i n s t i t u t i o n a l i z e d e l d e r l y over a long p e r i o d of time, could improve t h e i r w e l l - b e i n g . I f l i f e review sessions enhance i n t e g r a t e d f u n c t i o n i n g and independence and decrease depression, what aspects of the l i f e review process enhance i t ? The three s c a l e s : A c t i v i t i e s of D a i l y L i v i n g E v a l u a t i o n Form (ADL), G e r i a t r i c Rating Scale (GRS), and the G e r i a t r i c Depression Scale (GDS) were c o r r e l a t e d w i t h the Group Process Observational C h e c k l i s t (GPOC) and frequency of speech (FRS), time length of speaking (TLS), and major l i f e events (LE) and each other (Table 3). There were no s i g n i f i c a n t c o r r e l a t i o n s between the p o s i t i v e behaviors of the GPOC and the GDS, ADL, and GRS. Fi v e out of the s i x behaviors of the GPOC were p o s i t i v e l y c o r r e l a t e d w i t h FRS, TLS and LE. This means t h a t no conclusions can be drawn from the study t o i n d i c a t e what v a r i a b l e s i n the l i f e review process c o n t r i b u t e t o the p o s i t i v e changes on the three s c a l e s . Many of the behaviors on the Group Process Observational C h e c k l i s t were p o s i t i v e l y c o r r e l a t e d w i t h each other, but some were not (Table 1). There were s i g n i f i c a n t c o r r e l a t i o n s between FRS, TLS and LE. There are no st u d i e s i n the l i t e r a t u r e to c o n t r a d i c t or support these r e s u l t s . This could p o s s i b l y mean t h a t the 74 group process can not be broken down i n t o components to be analyzed. The whole i s greater than the sum of i t ' s p a r t s because the data s t a t e s t h a t the l i f e review process increased the general w e l l - b e i n g of the p a t i e n t s , but e x a c t l y what i n the process was not p i n - p o i n t e d . There were some unexpected r e s u l t s . The data suggested t h a t the negative behavior of p a t i e n t s i n the group process was c o r r e l a t e d p o s i t i v e l y w i t h the three measures. One could speculate t h a t these observed negative behaviors were an expression of past unresolved c o n f l i c t s . Once these i n d i v i d u a l s expressed these negative behaviors, they f e l t b e t t e r . Thus t h e i r scores on the GDS, ADL, and GRS improved. The number of major l i f e l i f e events the i n d i v i d u a l t a l k e d about i n any s e s s i o n d i d not appear to c o n t r i b u t e t o b e t t e r scores on the measures. I n d i v i d u a l s may tend t o concentrate on t h e i r unresolved c o n f l i c t s r a t h e r than s e v e r a l major l i f e events. I f the i n d i v i d u a l s can r e s o l v e the one c o n f l i c t over the l i f e of the group, they may get b e t t e r scores on the GDS, ADL, and GRS. I t can only be s a i d t h a t t h i s study supports the many case s t u d i e s t h a t have been done i n the past s t a t i n g t h a t the process of l i f e review helps. Hypothesis one; there w i l l be a decrease on t e s t scores of i n t e g r a t e d f u n c t i o n i n g , independence, and depression a f t e r e i g h t l i f e review sessions; was supported. Hypothesis two; the v a r i a b l e s frequency of speech, time length of speech, p o s i t i v e behaviors, and number of major l i f e events c i t e d w i l l p o s i t i v e l y c o r r e l a t e w i t h each other; i s supported. Hypothesis three; the v a r i a b l e s frequency of speech, time length of speech, number of major l i f e events c i t e d , and p o s i t i v e behaviors w i l l p o s i t i v e l y c o r r e l a t e w i t h i n t e g r a t e d f u n c t i o n i n g , independence l e v e l of f u n c t i o n i n g , and n e g a t i v e l y c o r r e l a t e w i t h depression; was p a r t i a l l y supported. The G e r i a t r i c Rating Scale, and A c t i v i t i e s of D a i l y L i v i n g E v a l u a t i o n Form d i d not p o s i t i v e l y c o r r e l a t e w i t h the p o s i t i v e behaviors on the Group Process Observational C h e c k l i s t . Hypothesis fou r ; the v a r i a b l e s i n t e g r a t e d f u n c t i o n i n g and indpendence l e v e l of f u n c t i o n i n g w i l l be p o s i t i v e l y c o r r e l a t e d w i t h each other and n e g a t i v e l y c o r r e l a t e d w i t h depression; was p a r t i a l l y supported. The G e r i a t r i c Depression Scale was not n e g a t i v e l y c o r r e l a t e d w i t h the A c t i v i t i e s of D a i l y L i v i n g E v a l u a t i o n Form, and the G e r i a t r i c Rating Scale as p r e d i c t e d . Conclusions In c o n c l u s i o n , t h i s study has attempted to add t o the body of knowledge regarding the process of l i f e review. I t has been shown t h a t the l i f e review process improves the w e l l - b e i n g of the i n s t i t u t i o n a l i z e d e l d e r l y . I n d i v i d u a l s who p a r t i c i p a t e d i n these sessions were found to be l e s s depressed, more i n t e g r a t e d and more independent. The p a t i e n t s i n the experimental group s t a t e d they enjoyed the l i f e review groups. An attempt was made to f i n d out e x a c t l y what i n these s e s s i o n s caused the improvement i n the q u a l i t y of l i f e i n these i n d i v i d u a l s . However, t h i s experiment c o u l d not p i n p o i n t the exact mechanism t h a t produced these improvements i n one's day to day l i f e . F u r t h e r , more d e t a i l e d s t u d i e s are needed t o p i n p o i n t t h i s exact mechanism. Weaknesses t o be Considered There are some i n d i c a t i o n s i n the l i t e r a t u r e t h a t l i f e r eview i s b e n e f i c i a l t o the i n s t i t u t i o n a l i z e d e l d e r l y , but the r e s u l t s were not c o n c l u s i v e . There were no s t u d i e s of the l i f e review group process u s i n g the GPOC and the GDS, GRS, and the ADL found i n the l i t e r a t u r e searched. T h i s was the f i r s t time t h a t the group behaviors i n an e l d e r l y l i f e review group have been s t u d i e d and c o r r e l a t e d w i t h the GDS, GRS and ADL. The sample s i z e was t o be 48 s u b j e c t s , 24 i n the c o n t r o l and 24 i n the experimental group, but each group became small w i t h a t t r i t i o n and l a c k of p a t i e n t t u r n o v e r on the u n i t used i n the study. There were 18 p a t i e n t s i n the experimental group and 17 i n the c o n t r o l group. The i n d i v i d u a l s i n the c o n t r o l group had more l i v i n g f a m i l y members, more f a m i l y members r e s i d i n g i n the Vancouver area and more of the p a t i e n t s l i v e d w i t h someone p r i o r t o h o s p i t a l i z a t i o n (Appendix L, M). The c o n t r o l group had more s o c i a l support, i n i t i a l l y , than the experimental group. T h i s may have p l a y e d a f a c t o r i n the observed r e s u l t s . The l i f e review may have 77 become the s o c i a l support f o r the experimental group and t h i s may have c o n t r i b u t e d t o the p o s i t i v e r e s u l t s on the ADL, GDS and GRS. I t s p o s s i b l e , but u n l i k e l y because the measures on the ADL, GDS, and GRS were s i m i l a r p r i o r t o the l i f e review s e s s s i o n s . This was a quasi-experimental research design i n which a l l the p a t i e n t s could not be t o t a l l y randomized (Campbell & Stanley, 1963). A l s o , involvement i n t h i s study was v o l u n t a r y . Because volunteers f i t t i n g c e r t a i n c r i t e r i a were used, the f i n d i n g s are not g e n e r a l i z a b l e nor c o n c l u s i v e . G e n e r a l i z a t i o n s from t h i s study are l i m i t e d t o the g e r i a t r i c p o p u l a t i o n of the u n i t being s t u d i e d . A l s o , a f o u r week p e r i o d d i d not appear to to be long enough to see changes i n p h y s i c a l a b i l i t i e s as measured by the A c t i v i t i e s of D a i l y L i v i n g E v a l u a t i o n Form. Recommendations This study supported the c o n c l u s i o n t h a t the educational process of l i f e review i s very b e n e f i c i a l t o the i n s t i t u t i o n a l i z e d e l d e r l y . A r i s i n g from t h i s there are four major recommendations. F i r s t , e l d e r l y p a t i e n t s i n longterm care s e t t i n g s who are not diagnosed w i t h depression and are able t o communicate v e r b a l l y i n E n g l i s h should be given the opportunity to p a r t i c i p a t e i n the process of l i f e review. This process should be f a c i l i t a t e d by a p r o f e s s i o n a l w i t h some p s y c h i a t r i c 78 t r a i n i n g who has gone through the process. This i s necessary because i n d i v i d u a l s may focus on unresolved c o n f l i c t s of the past and become depressed. The h e a l t h p r o f e s s i o n a l must be able t o determine i f the p a t i e n t i s becoming c l i n i c a l l y depressed and r e f e r him or her t o the appropriate p r o f e s s i o n a l f o r c o u n s e l l i n g . The p o s s i b l e appropriate p r o f e s s i o n a l s f o r t h i s r o l e are: h e a l t h educators, s o c i a l workers, doctors, p a s t o r a l care workers, and r e g i s t e r e d nurses w i t h bachelor degrees. There should always be a group operating i n the h e a l t h f a c i l i t y to keep the p a t i e n t ' s minds working. Each group should be a minimum of four weeks, but p r e f e r a b l y longer. The reason i t should be longer i s because four weeks i s not enough time t o o b t a i n the f u l l b e n e f i t s of i n c r e a s i n g the independence l e v e l of the p a t i e n t s i n the group. The time length of the study should be increased t o perhaps a maximum of twelve weeks. The reason the maximum of twelve weeks i s presented i s because twelve c r i t i c a l l i f e events are more than enough t o help i n d i v i d u a l s r e s o l v e t h e i r unresolved c o n f l i c t s . The reason t h a t a longer p e r i o d i s not suggested f o r the process i s because there should be a t l e a s t f o u r d i f f e r e n t groups i n a year so there i s opportunity f o r twenty-four p a t i e n t s t o p a r t i c i p a t e i n a year. The turnover r a t e on these type of u n i t s i s one year. Each group should have no more than s i x p a t i e n t s because i f the s e s s i o n i s an hour long i t gives each p a t i e n t enough time t o t a l k about the t o p i c . Secondly, r e p l i c a t i o n of the data regarding the b e n e f i t s of the l i f e review process are necessary to v a l i d a t e these f i n d i n g s . The s c a l e s used i n t h i s study are v a l i d and r e l i a b l e and should be used again. I f l i f e review processes are done f o r a p e r i o d longer than f o u r weeks to p o t e n t i a l l y assess the proces can enhance an i n d i v i d u a l ' s independence l e v e l s i g n i f i c a n t l y . T h i r d l y , s i n c e the study could not p i n p o i n t the mechanism i n the l i f e review process t h a t c o n t r i b u t e s t o the p o s i t i v e r e s u l t s , perhaps the Group Process Observational C h e c k l i s t should not be used i n i t s present form. Maybe the behaviors should only be c a t a g o r i z e d as p o s i t i v e and negative and not broken down f u r t h e r . F i n a l l y , the number of groups should be increased t o as la r g e of a number as p o s s s i b l e i n va r i o u s h e a l t h f a c i l i t i e s so t h a t g e n e r a l i z a t i o n s can be made about the b e n e f i t s of the l i f e review process. 80 BIBLIOGRAPHY Babb de Ramon, P. (1983). The f i n a l task l i f e review f o r the dying p a t i e n t . Nursing '83. 13(2), 44-49. Baker, N.J. (1985). Reminiscing i n group therapy f o r s e l f -worth . J o u r n a l of G e r o n t o l o g i c a l Nursing, i l ( 7 ) , 21-24. Bales, R.F. (1950). I n t e r a c t i o n process a n a l y s i s . A method  f o r the study of small groups. Chicago: The U n i v e r s i t y of Chicago Press. Bass, B.M. & Norton W. (1951). Group s i z e and l e a d e r l e s s d i s c u s s i o n . J o u r n a l of A p p l i e d Psychology. 35., 397-400. Beadleson-Baird, M. and Lara L. L. (1988). Reminiscing: Nursing A c t i o n s f o r the Ac u t e l y 111 G e r i a t r i c P a t i e n t . Issues i n Mental Health Nursing. 9. 83-94. Beaton, S.R. (1980). Reminiscence i n o l d age, Nursing. Forum. 19(3), 271-283. Berghorn, F. J . and Schafer D. E. (1987). Reminiscence I n t e r v e n t i o n i n Nursing Homes: What and who Changes?*. I n t e r n a t i o n a l J o u r n a l of Aging and Human Development. 24. 113-127. Boden, D., & B i e l b y , D.D. (1983). The past as resource: A co n v e r s a t i o n a l a n a l y s i s of e l d e r l y t a l k . Human  Development. 26(6), 308-319. B o y l i n , W., Gordon, S.K., & Nehrke, M.F. (1976). Reminiscing and ego i n t e g r i t y i n i n s t i t u t i o n a l i z e d e l d e r l y males. The G e r o n t o l o g i s t . 16.(2), 118-124. Bramwell, L. (1984). Use of the l i f e h i s t o r y i n p a t t e r n i d e n t i f i c a t i o n and h e a l t h promotion. Advances i n Nursing Sciences. Z(l), 37-44. Br i n k , T.L., Yeasavage, J.A., Heesema, P.H., Adey, M., & Terrence, L.R. (1982). Screening t e s t s f o r g e r i a t r i c depression. C l i n i c a l G e r o n t o l o g i s t . 1, 37-43. Buechel, H. (1986). Reminiscence: A review and prospectus. P h y s i c a l and Occupational Therapy i n G e r i a t r i c s . 5(2), 25-37. B u t l e r , S. (1987). A d u l t education 580. (Lecture. Nov.). Vancouver, B.C.: The U n i v e r s i t y of B r i t i s h Columbia. 81 B u t l e r , Sidney J . (1987). W r i t i n g f o r P o s t e r i t y . (Class handout, a d u l t education 580). Vancouver, B.C.: The U n i v e r s i t y of B r i t i s h Columbia. B u t l e r , R.N. (1963). The l i f e review: An i n t e r p r e t a t i o n of reminiscence i n the aged. P s y c h i a t r y . 26. 65-7 6. B u t l e r , R.N. (1974). S u c c e s s f u l aging and the r o l e of the l i f e review. J o u r n a l of the American G e r i a t r i c s  S o c i e t y . 22(12), 529-535. Campbell, D.T. & Stanley, J.C. (1963). Experimental and  Quasi-experimental Designs f o r Research. Chicago: Rand, McNally & Co. Coleman, P.G. (1974). Measuring r e m i n i s c i n g requirements. I n t e r n a t i o n a l J o u r n a l of Aging and Human Development. 5 (3), 281-294. David, D. (1990). Reminiscence, Adaptation, and S o c i a l Context i n Old Age. I n t e r n a t i o n a l J o u r n a l of Aging and  Human Development. 30(3). 175-188. Donahue, E.M. (1982). P r e s e r v i n g h i s t o r y through o r a l h i s t o r y r e f l e c t i o n . J o u r n a l of Gerontology Nursing. 8(5), 272-278. Ebersole, P. (1976). Reminiscing. American J o u r n a l of  Nursing. 8., 1304-1305. Ebersole, P. (1976). Problems of group r e m i n i s c i n g w i t h the i n s t i t u t i o n a l i z e d aged. J o u r n a l of Gerontology  Nursing. 2(6), 23-27. Ebersole, P. (1978). A t h e o r e t i c a l approach t o the use of reminiscence. In I. Burnside (Ed.), Working w i t h the e l d e r l y : Group process and technique. Massachusetts: Dunsbury Press. Ebersole, P., & Hess, P. (1985). Toward Healthy Aging Human  Needs and Nursing Response. Toronto: The C.V. Mosby Company. E l l i s o n , K.B. (1981). Working w i t h the e l d e r l y i n l i f e review group. J o u r n a l of G e r o n t o l o g i c a l Nursing. 2 ( 9 ) , 537- 541. Er i k s o n , E.H. (1968). I d e n t i t y : Youth and C r i s i s . New York: W.W. Norton. 82 Eson, M.E., & G r e e n f i e l d , N. (1962). L i f e space: I t s content and temporal dimensions. J o u r n a l of Genetic  Psychology. 100, 113-120. F a l l o t , R.D. (1979-1980). The impact on mood of v e r b a l r e m i n i s c i n g i n l a t e r adulthood. I n t e r n a t i o n a l J o u r n a l  of Aging and Human Development. 10(4), 385-400. F r o e h l i c h , N., & Nelson, D. (1986). A f f e c t i v e meaning of l i f e review through a c t i v i t i e s and d i s c u s s i o n . American  J o u r n a l of O c c u p a t i o n a l Therapy. 4_0,(1)» 27-33 . Fry, P.S. (1983). S t r u c t u r e d and u n s t r u c t u r e d reminiscence t r a i n i n g and d e p r e s s i o n among the e l d e r l y , C l i n i c a l  G e r o n t o l o g i s t . 1(3), 15-37. Funch, D.P., & M a r s h a l l , J.R. (1984). Measuring l i f e s t r e s s : F a c t o r s a f f e c t i n g f a l l - o f f i n the r e p o r t i n g of l i f e events. J o u r n a l of H e a l t h and S o c i a l Behaviour. 25(k), 453- 464. Fuhriman, A., & Packard, T. (1986). Group Process Instruments: T h e r a p e u t i c Themes and Issues, I n t e r n a t i o n a l J o u r n a l of Group Psychotherapy. 36(3), 399-425. Garland, J . , (1985). A d a p t a t i o n s k i l l s i n the e l d e r l y , t h e i r s upporters and c a r e e r s . B r i t i s h J o u r n a l of  M e d i c a l Psychology. 58, 267-274. Greene, R.R. (1982). L i f e Review: A technique f o r c l a r i f y i n g f a m i l y r o l e s i n adulthood. C l i n i c a l  G e r o n t o l o g i s t . 1(2), 59-67. Gunn, J.V. (1982). Autobiography: Towards a P o e t i c E xperience. P h i l a d e l p h i a : U n i v e r s i t y of P e n s l y l v a n i a P r e s s . Hare, A. P. (1962). Handbook of Small Group Research. New York: The Free P r e s s . Harpscates, S.K., Randolph D.L., Gutsch K.U., & Knight, H.V. (1985). I n t e r n a t i o n a l J o u r n a l of Aging and Human  Development. 22(2), 141-146. Havighurst, R., & G l a s s e r , R. (1972). An e x p l o r a t o r y study of r e m i n i s c e n c e . J o u r n a l of Gerontology. .27.(2), 245-253 . Hawranik, P., & Kandratuk, B. (1986). Depression i n the e l d e r l y . Canadian Nurse. October, 25-29. 83 Hughston, G.A. , & Merriam, S.B. (1982). Reminiscence: A nonformal technique f o r improving c o g n i t i v e f u n c t i o n i n g i n the aged. I n t e r n a t i o n a l J o u r n a l of Aging and Human Development. .15(2), 139-149. Job, E.M. (1983). R e t r o s p e c t i v e l i f e - s p a n a n a l y s i s : A method f o r studying extreme o l d age. Jo u r n a l of  Gerontology. 3 8 ( 3 ) , 369-374. Jones, G.V., & Z i e s s , E. (1984). Encouraging r e m i n i s c i n g i n the i n s t i t u t i o n a l i z e d s e t t i n g . P e r s p e c t i v e s . 8.(4), 6-7. Kaminsky, M. (1978). P i c t u r e s from the past: The use of reminiscence i n casework w i t h the e l d e r l y . J o u r n a l of  G e r o n t o l o g i c a l S o c i a l Work. 1 ( 1 ) , 19-32. Karras, B. (1987). Music and Reminiscence: For Groups and I n d i v i d u a l s . Music i n Nursing Homes. (1987 ) . 24. 79-91. Kastenbaum, R. (1982). Time course and time p e r s p e c t i v e i n l a t e r l i f e . In C. E i s d o r f e r (ed.), Annual Review of  Gerontology. 3., New York: Springer. Katz, S., Downs, T.D., Cash, H.R., & Grota, R.C. (1970). Progress i n Development of the Index of ADL. The  Ge r o n t o l o g i s t . 1 0 ( 1 ) , 20-30. Katz, S., Ford, A.B., Moskowitz, R. W., Jackson,B.A., & J a f f e , J.W. (1963). Studies of i l l n e s s i n the aged: The index of ADL, a standardized measure of b i o l o g i c a l and p s y c h o s o c i a l f u n c t i o n , J o u r n a l of the American  Medical A s s o c i a t i o n . 185. 914-919. K i e r n a t , J.M. (1979). The use of l i f e review a c t i v i t y w i t h confused nursing home r e s i d e n t s . American J o u r n a l of  Occupational Therapy. 33.(5), 306-310. King, K.S. (1982). Reminiscing psychotherapy w i t h aging people. J o u r n a l of Ps y c h o s o c i a l Nurse Mental Health  S e r v i c e . 20.(2), 21-25. K l e i n , W.H., Le Shan, E.J. & Furman, S.S. (1965). Promoting  mental h e a l t h of o l d e r people through group methods. A  p r a c t i c a l guide. New York: Mental Health M a t e r i a l s Centre. Lappe, J.M. (1987). Reminiscing: The l i f e review therapy. Jo u r n a l of G e r o n t o l o g i c a l Nursing. JL3.(4), 12-16. Lesser, J . , Lazarus, L.W., F r a n k e l , R., & Havasy, S. (1981). Reminiscence group therapy w i t h p s y c h o t i c g e r i a t r i c i n p a t i e n t s . G e r o n t o l o g i s t . ,21(3), 291-296. 84 Lewis, C.N. (1971). Reminiscing and self-concept i n old age. Journal of Gerontology. 26(2), 240-243. Lewis, C.N. (1973). The adaptive value of reminiscing i n old age. Journal of G e r i a t r i c Psychiatry. 1(1), 117-121. Lewis, C.N. (1980). Memory adaptation to psychological trauma. American Journal of Psychoanalysis , 40.( 4 ) , 319-323. Lewis, M.J., & Butler, R.N. L i f e review therapy. Putting memories to work i n in d i v i d u a l and group psychotherapy. G e r i a t r i c s . 29., 115-173. Lieberman, M.A. & Falk, J.M. (1970). The remembered past as a source of data f o r research on the l i f e cycle. Human  Development. 14, 132-141. Lo Gerfo, M. (1980). Three ways of reminiscence i n theory and practice. International Journal of Aging and Human  Development. .12(1), 39-47. MacRae, I. (1982). Growth and development - fo r elders: Reminiscence, an underused nursing resource. Nurse  Paper. 4(1), 48-56. McCloskey, L.J. (1985). Music and the f r a i l e l d e r l y . A c t i v i t i e s . Adaptation and Aging. 1(2), 73-75. McMahon, A.W., & Rhudick, P.J. (1964). Reminiscing: Adaptational significance i n the aged. Archives of  General Psychiatry. 10, 292-298. Mangen, D.J., & Peterson, W.A. (1984). Research Instruments i n Social Gerontology Volume 3 Health.  Program Evaluation, and Demography. Minneapolis: University of Minnesota Press. Matteson, M.S., & Munsat, E.M. (1982). Group reminiscing therapy with e l d e r l y c l i e n t s . Issues i n Mental Health  Nursing. 4(3), 177-189. Meacham, J. (1977). A t r a n s i t i o n a l model of remembering i n N. Datan and H. Reese (eds.). Life-Span developmental  psychology: D i a l e c t i c a l perspectives. New York: Academic Press. Merriam, S. (1980). The concept and function of reminiscence: A review of the research. The  Gerontologist. 20.(5), 604-608. \ 85 M o l i n a r i , V. & R e i c h l i n , R.E. (1985). L i f e review reminiscence i n the e l d e r l y : A review of the 1 i t e r a t u r e . I n t e r n a t i o n a l J o u r n a l of Aging and Human  Development. 20(2) . 81-92. Nelson, L.R. (1974). Guide t o Lertap Use and I n t e r p r e t a t i o n . Dunedin, New Zealand: Department of Education, U n i v e r s i t y of Otago. N o r r i s , A.D. & Abu, E.M.T. (1982). Reminiscing groups. Nursing Times. 7_8(32), 1268-1269. N o r r i s , A.D. & Abu, E.M.T. (1982). Reminiscing - A therapy f o r both e l d e r l y p a t i e n t s and t h e i r s t a f f . Nursing. Times. 78(32). 1368-1369. N o r r i s , J.T., Gallagher, D., Wilson, A., & Winograd, C. (1987). Assessment of depression i n g e r i a t r i c medical o u t p a t i e n t s : The v a l i d i t y of two screening measures. Jo u r n a l of American G e r i a t r i c s S o c i e t y . .35( 11), 989-995. Parsons, C L . (1986). Group reminiscence therapy and l e v e l s of depression i n the e l d e r l y . Nurse  P r a c t i t i o n e r . 11(3), March, 68, 70, 75-76. P e r o t t a , P., & Meacham, J.A. (1981). Can a r e m i n i s c i n g i n t e r v e n t i o n a l t e r depression and self-esteem? I n t e r n a t i o n a l J o u r n a l of Aging and Human Development. 14(1), 23-30. Perschbacher, Ruth. (1984). An a p p l i c a t i o n of reminiscence i n an a c t i v i t y s e t t i n g . The G e r o n t o l o g i s t . .24(4), 343-345. Pincus, A. (1970). Reminiscence on aging and i t s i m p l i c a t i o n f o r s o c i a l work p r a c t i c e . S o c i a l Work. 15(3), 47-53. P l u t c h i k , R., Conte, H., Lieberman, M., Bakur, M., Grossman, J . , & Lehrman, N. (1970). R e l i a b i l i t y and v a l i d i t y of a s c a l e f o r assessing the f u n c t i o n i n g of g e r i a t r i c p a t i e n t s . J o u r n a l of the American G e r i a t r i c s S o c i e t y . 18, 491-500. P o l l a c k , G.H. (1981). Reminiscence and i n s i g h t . P s y c h o a n a l y t i c Study and the C h i l d . 36, 279-287. Poulton, J.L., and Strassberg, D.S. (1986). The th e r a p e u t i c use of reminiscence. I n t e r n a t i o n a l J o u r n a l  of Group Psychotherapy. 16(3), J u l y , 381-397. 86 P u b l i c a t i o n Manual of the American P s y c h o l o g i c a l A s s o c i a t i o n  3rd ed. (1982). Washington, D.C: Author. Revere, V., & Tobin, S.S. (1980). Myth and r e a l i t y : The o l d e r person's r e l a t i o n s h i p t o h i s past. I n t e r n a t i o n a l  J o u r n a l of Aging and Human Development. 21(1), 15-26. Romaniuk, M. (1981). Review. Reminiscence and the second h a l f of l i f e . Experimental Aging Research. 2 ( 3 ) , 315-336. Romaniuk, M., & Romaniuk, J.G. (1981). Looking back: An a n a l y s i s of reminiscence f u n c t i o n s and t r i g g e r s . Experimental Aging Research. 1 ( 4 ) , 477-489. Rosenthal, T.T. (1982). Implementing reminiscent d i s c u s s i o n groups, VA Nurse. 50(2), 57-60. Ryden, M.B. (1981). Nursing i n t e r v e n t i o n i n support of reminiscence. J o u r n a l of G e r o n t o l o g i c a l Nursing. 7.(8), 61-463. Schnase, R.C. (1982). Therapeutic reminiscence i n e l d e r l y p a t i e n t s . J o u r n a l of Nursing Care. .15(2), 15-17 . Sherman, E. (1987). Reminiscence groups f o r community e l d e r l y . The G e r o n t o l o g i s t . 15(5), 569-572. Smith, J . , B r i g h t , B., & McCloskey, J . (1977). Factor A n a l y t i c Composition of the G e r i a t r i c Rating Scale (GRS). J o u r n a l of Gerontology. 32. 58-62. SPSS Incorporated. (1988). SPSSX User's Guide T h i r d  E d i t i o n . Chicago, I l l i n o i s : SPSS Incorporated. T a f t , L. B. (1990). Reminiscence, L i f e Review, and Ego I n t e g r i t y i n Nursing Home Residents. I n t e r n a t i o n a l  J o u r n a l of Aging and Human Development. 30.(3), 189-196. Tarman, V. I. (1988). Autobiography: The N e g o t i a t i o n of a L i f e t i m e . I n t e r n a t i o n a l J o u r n a l of Aging and Human  Developmment. 27. 171-191. Taylo r , S., Jones, G., & Z e i s s , E. (1983). F i r s t n a t i o n a l conference on g e r o n t o l o g i c a l nursing. June 7-10. Proceedings Volume I I . V i c t o r i a , B.C.: U n i v e r s i t y of V i c t o r i a , School of Nursing. 87 Thornton, S., & B r o t c h i e , J . (1987). Reminiscence: A c r i t i c a l review of the e m p i r i c a l l i t e r a t u r e . B r i t i s h  J o u r n a l of C l i n i c a l Psychology. 26. 92-111. Tobin, S.S. (1972). The e a r l i e s t memory as data f o r research i n aging, In: D.P. Kent, R. Kaustenbaum, & S. Sherwood (Eds.). Research of Planning and A c t i o n f o r  the E l d e r l y : The Power and P o t e n t i a l of S o c i a l Science. New York: B e h a v i o r a l P u b l i c a t i o n s . Webster, J . D. and Yound R. A. (1988). Process V a r i a b l e s of the L i f e Review: C o u n s e l l i n g I m p l i c a t i o n s . I n t e r n a t i o n a l J o u r n a l of Aging and Human Development . 2_6, 315-323. Webster's new c o l l e g i a t e d i c t i o n a r y (8th ed.). (1984). S p r i n g f i e l d , MA: Merriam-Webster. Wysocki, M.R. (1983). L i f e review f o r the e l d e r l y p a t i e n t . Nursing '83. 47-48. Yeasavage, J.A., & B r i n k , T.J. (1983). Development and v a l i d a t i o n of a g e r i a t r i c depression screening s c a l e : A p r e l i m i n a r y r e p o r t . J o u r n a l of P s y c h i a t r i c Research. 17(1), 37-49 88 APPENDIX A GERIATRIC RATING SCALE (GRS) Items of the G e r i a t r i c Rating Scale C i r c l e s only the number which applies 1. When eating, the patient requires: No assistance (feeds s e l f ) 0 A l i t t l e assistance (needs encouragement) 1 Considerable assistance (spoon feeding, etc.) 2 2 . The patients i s incontinent: Never 0 Sometimes (once or twice per week) 1 Often (three times per week or more) 2 3 . When bathing or dressing, the patient needs: No assistance 0 Some assistance 1 Maximum assistance 2 4. The patient w i l l f a l l from his bed or chair unless protected by side r a i l s : Never 0 Sometimes 1 Often 2 5 . With regard to walking, the patient: Has no d i f f i c u l t y 0 Needs assistance i n walking 1 Does not walk 2 6. The patient's v i s i o n , with or without glasses, i s : Apparently normal 0 Somewhat impaired 1 Extremely poor 2 7. The patient's hearing i s : Apparently normal 0 Somewhat impaired 1 Extremely poor 2 89 C i r c l e o n l y the number which a p p l i e s 8. With r e g a r d t o s l e e p , the p a t i e n t : Sleeps most of the n i g h t 0 Is sometimes awake 1 Is o f t e n awake 2 9. During the day, the p a t i e n t s l e e p s : Sometimes 0 Often 1 Most of the day 2 10. With r e g a r d t o r e s t l e s s behaviour a t n i g h t , the p a t i e n t i s : Seldom r e s t l e s s 0 Sometimes r e s t l e s s 1 Ofte n r e s t l e s s 2 11. The p a t i e n t ' s behaviour i s worse a t n i g h t than i n the daytime: Never 0 Sometimes 1 Ofte n 2 12. When not help e d by ot h e r people, the p a t i e n t ' s appearance i s : Almost never sloppy 0 Sometimes sloppy 1 Almost always sloppy 2 13. The p a t i e n t masturbates o r exposes h i m s e l f p u b l i c l y : Never 0 Sometimes 1 Often 2 14. The p a t i e n t i s confused (unable t o f i n d h i s way around the ward, l o s e s p o s s e s s i o n s , e t c . ) : Almost never 0 Sometimes 1 Of t e n 2 90 C i r c l e o n l y "the number which a p p l i e s 15. The p a t i e n t knows the names o f : More than one member of the s t a f f 0 Only one member of the s t a f f None of the s t a f f 16. The p a t i e n t communicates i n any manner (by speaking, w r i t i n g , o r g e s t u r i n g ) w e l l enough t o make h i m s e l f e a s i l y understood: Almost always 0 Sometimes Almost never 17. The p a t i e n t r e a c t s t o h i s own name: Almost always 0 Sometimes Almost never 18. The p a t i e n t p l a y s games, has hobbies, e t c . : Ofte n 0 Sometimes Almost never 19. The p a t i e n t reads books or magazines on the ward: Oft e n 0 Sometimes Almost never 20. The p a t i e n t w i l l b e g i n c o n v e r s a t i o n w i t h o t h e r s : O f t e n 0 Sometimes Almost never 21. The p a t i e n t i s w i l l i n g t o do t h i n g s asked of him: Ofte n 0 Sometimes Almost never 91 C i r c l e o n l y t h e number w h i c h a p p l i e s 22. The p a t i e n t h e l p s w i t h c h o r e s on t h e ward: O f t e n 0 Sometimes 1 Al m o s t n e v e r 2 23. W i t h o u t b e i n g asked, t h e p a t i e n t p h y s i c a l l y h e l p s o t h e r p a t i e n t s : O f t e n 0 Sometimes 1 Al m o s t n e v e r 2 24. W i t h r e g a r d t o f r i e n d s on t h e ward, t h e p a t i e n t : Has s e v e r a l f r i e n d s 0 Has j u s t one f r i e n d 1 Has no f r i e n d s 2 25. The p a t i e n t t a l k s w i t h o t h e r p e o p l e on t h e ward: O f t e n 0 Sometimes 1 A l m o s t n e v e r 2 26. The p a t i e n t has a r e g u l a r work assignment: Away from t h e ward 0 On t h e ward 1 No r e g u l a r assignment 2 27. The p a t i e n t i s d e s t r u c t i v e o f m a t e r i a l s around him (b r e a k s f u r n i t u r e , t e a r s magazines, e t c . ) : Never 0 Sometimes 1 O f t e n 2 28. The p a t i e n t d i s t u r b s o t h e r p a t i e n t s o r s t a f f by s h o u t i n g o r y e l l i n g : Never 0 Sometimes 1 O f t e n 2 92 C i r c l e s o n l y the number which a p p l i e s 29. The p a t i e n t s t e a l s from o t h e r p a t i e n t s o r s t a f f members: Never 0 Sometimes 1 Ofte n 2 30. The p a t i e n t VERBALLY t h r e a t e n s t o harm o t h e r p a t i e n t s o r s t a f f members: Never 0 Sometimes 1 Ofte n 2 Note: from Research Instruments i n S o c i a l Gerontology Volume  3 H e a l t h . Program E v a l u a t i o n , and Demography by D.J. Mangen & W.A. Peter s o n (1984). M i n n e a p o l i s : U n i v e r s i t y of Minnesota P r e s s . APPENDIX B ACTIVITIES OF DAILY LIVING (ADL) EVALUATION FORM Name Date of E v a l u a t i o n For each area of f u n c t i o n i n g l i s t e d below, check the d e s c r i p t i o n t h a t a p p l i e s . (The word " a s s i s t a n c e " means s u p e r v i s i o n , d i r e c t i o n of p e r s o n a l a s s i s t a n c e ) . 1. BATHING--either sponge bath, tub bath, or shower. ( ) Receives no a s s i s t a n c e (gets i n and out of tub by s e l f i f tub i s u s u a l means of b a t h i n g ) . ( ) Receives a s s i s t a n c e i n b a t h i n g o n l y one p a r t of the body (such as back or l e g or g e t t i n g i n and out of the t u b ) . ( ) Receives a s s i s t a n c e i n b a t h i n g more than one p a r t of the body (or not b a t h i n g ) . 2. DRESSING--gets c l o t h e s from c l o s e t s and drawers, i n c l u d i n g u n d e r c l o t h e s , o u t e r garments and u s i n g f a s t e n e r s ( i n c l u d i n g braces, i f worn). ( ) Gets c l o t h e s and gets completely dressed without a s s i s t a n c e . ( ) Gets c l o t h e s and gets dressed without a s s i s t a n c e , except f o r a s s i s t a n c e i n t y i n g shoes. ( ) Receives a s s i s t a n c e i n g e t t i n g c l o t h e s or i n g e t t i n g dressed, or s t a y s p a r t l y or completely undressed. 3. TOILETING--going to the " t o i l e t room" f o r bowel and u r i n e e l i m i n a t i o n ; c l e a n i n g s e l f a f t e r e l i m i n a t i o n , and a r r a n g i n g c l o t h e s . ( ) Goes t o t o i l e t room, cl e a n s s e l f and arranges c l o t h e s w ithout a s s i s t a n c e (may use o b j e c t f o r support such as cane, walker or w h e e l c h a i r , and may manage n i g h t bedpan or commode, emptying same i n morning). ( ) Receives a s s i s t a n c e i n going to t o i l e t room or i n c l e a n i n g s e l f o r i n a r r a n g i n g c l o t h e s a f t e r e l i m i n a t i o n or i n use of bedpan (night) or commode. ( ) Doesn't go t o room termed " t o i l e t " f o r the e l i m i n a t i o n p r o c e s s . 4. TRANSFER ( ) Moves i n and out of bed as w e l l as i n and out of c h a i r w i thout a s s i s t a n c e (may be u s i n g o b j e c t f o r support such as cane or w a l k e r ) . ( ) Moves i n or out of bed or c h a i r w i t h a s s i s t a n c e . ( ) Doesn't get out of bed. 94 5 . C O N T I N E N C E ( ) C o n t r o l s u r i n a t i o n a n d b o w e l m o v e m e n t c o m p l e t e l y b y s e l f . ( ) H a s o c c a s i o n a l " a c c i d e n t s . " ( ) S u p e r v i s i o n h e l p s k e e p u r i n e o r b o w e l c o n t r o l ; c a t h e t e r i s u s e d , o r i s i n c o n t i n e n t . 6 . F E E D I N G ( ) F e e d s s e l f w i t h o u t a s s i s t a n c e . ( ) F e e d s s e l f e x c e p t f o r g e t t i n g a s s i s t a n c e i n c u t t i n g m e a t , b u t t e r i n g b r e a d o r o p e n i n g c o n t a i n e r s . ( ) R e c e i v e s a s s i s t a n c e i n f e e d i n g o r i s f e d p a r t l y o r c o m p l e t e l y b y u s i n g t u b e s o r i n t r a v e n o u s f l u i d s . N o t e : I n S t u d i e s o f I l l n e s s i n t h e a g e d : T h e I n d e x o f A D L , a S t a n d a r d i z e d M e a s u r e o f B i o l o g i c a l a n d P s y c h c o s o c i a l F u n c t i o n i n J o u r n a l o f t h e A m e r i c a n M e d i c a l A s s o c i a t i o n . 1 8 5 . 9 1 4 - 9 1 9 b y S . K a t z e t a l . 95 A P P E N D I X C G E R I A T R I C D E P R E S S I O N S C A L E (GDS) 1 . A r e y o u b a s i c a l l y s a t i s f i e d w i t h y o u r l i f e ? y e s / n o 2 . H a v e y o u d r o p p e d many o f y o u r a c t i v i t i e s a n d i n t e r e s t s ? y e s / n o 3 . Do y o u f e e l t h a t y o u r l i f e i s e m p t y ? y e s / n o 4 . Do y o u o f t e n g e t b o r e d ? y e s / n o 5 . A r e y o u h o p e f u l a b o u t t h e f u t u r e ? y e s / n o 6 . A r e y o u b o t h e r e d b y t h o u g h t s y o u c a n ' t g e t o u t o f y o u r h e a d ? y e s / n o 7 . A r e y o u i n g o o d s p i r i t s m o s t o f t h e t i m e ? y e s / n o 8 . A r e y o u a f r a i d t h a t s o m e t h i n g b a d i s g o i n g t o h a p p e n t o y o u ? y e s / n o 9 . Do y o u f e e l h a p p y m o s t o f t h e t i m e ? y e s / n o 1 0 . Do y o u o f t e n f e e l h e l p l e s s ? y e s / n o 1 1 . Do y o u o f t e n g e t r e s t l e s s a n d f i d g e t y ? y e s / n o 1 2 . Do y o u p r e f e r t o s t a y a t h o m e , r a t h e r t h a n g o i n g o u t a n d d o i n g new t h i n g s ? y e s / n o 1 3 . Do y o u f r e q u e n t l y w o r r y a b o u t t h e f u t u r e ? y e s / n o 1 4 . Do y o u f e e l y o u h a v e m o r e p r o b l e m s w i t h m e m o r y t h a n m o s t ? y e s / n o 1 5 . Do y o u t h i n k i t i s w o n d e r f u l t o b e a l i v e now? y e s / n o 1 6 . Do y o u o f t e n f e e l d o w n h e a r t e d a n d b l u e ? y e s / n o 1 7 . Do y o u f e e l p r e t t y w o r t h l e s s t h e w a y y o u a r e now? y e s / n o 1 8 . Do y o u w o r r y a l o t a b o u t t h e p a s t ? y e s / n o 1 9 . Do y o u f i n d l i f e v e r y e x c i t i n g ? y e s / n o 2 0 . I s i t h a r d f o r y o u t o g e t s t a r t e d o n new p r o j e c t s ? y e s / n o 96 A P P E N D I X C CONTINUED 2 1 . Do y o u f e e l f u l l o f e n e r g y ? y e s / n o 2 2 . Do y o u f e e l t h a t y o u r s i t u a t i o n i s h o p e l e s s ? y e s / n o 23 . Do y o u t h i n k t h a t m o s t p e o p l e a r e b e t t e r o f f t h a n y o u a r e ? y e s / n o 2 4 . Do y o u f r e q u e n t l y g e t u p s e t o v e r l i t t l e t h i n g s ? y e s / n o 2 5 . Do y o u f r e q u e n t l y f e e l l i k e c r y i n g ? y e s / n o 2 6 . Do y o u h a v e t r o u b l e c o n c e n t r a t i n g ? y e s / n o 2 7 . Do y o u e n j o y g e t t i n g u p i n t h e m o r n i n g ? y e s / n o 2 8 . Do y o u p r e f e r t o a v o i d s o c i a l g a t h e r i n g s ? y e s / n o 2 9 . I s i t e a s y f o r y o u t o make d e c i s i o n s ? y e s / n o 3 0 . I s y o u r m i n d a s c l e a r a s i t u s e d t o b e ? y e s / n o N o t e : f r o m D e v e l o p m e n t a n d V a l i d a t i o n o f a G e r i a t r i c D e p r e s s i o n S c a l e : A p r e l i m i n a r y r e p o r t . B y J . A . Y e a s a v a g e & T . J . B r i n k i n J o u r n a l o f P s y c h i a t r i c R e s e a r c h 17 ( 1 ) 3 7 - 4 9 . 97 APPENDIX D GROUP PROCESS OBSERVATIONAL CHECKLIST S u b j e c t s 1 2 3 4 5 6 t o t a l P o s i t i v e B e h a v i o r s t o t a l s m i l e s n o d s i n a g r e e m e n t l a u g h s j o k e s t o r e l e a s e t e n s i o n v e r b a l i z e s - a g r e e m e n t o f f e r s v e r b a l e n c o u r a g e m e n t N e g a t i v e B e h a v i o r s t o t a l d i s p l a y s w i t h d r a w l v e r b a l i z e s w i t h d r a w l p h y s i c a l l y a t t a c k s v e r b a l i z e s h o s t i l i t y p h y s i c a l l y d i s r u p t i v e v e r b a l l y i n t e r r u p t s v e r b a l l y d i m i n i s h e s 98 APPENDIX E DEFINITIONS OF BEHAVIORS Smile- a f a c i a l expression to express amusement or pleasure. Nods i n Agreement- head movement up and down in d i c a t i n g mutual understanding. Laugh- a show of joy with a smile and chuckle or explosive sound. Jokes to Release Tension- a comment made to provoke laughter. Verbalizes Agreement- a spoken statement indicating "yes", a mutual understanding. Offers Verbal Encouragement- a spoken fostering statement ( i . e . yes, t e l l us more). Displays Withdrawal- a detached and unresponsive look ( i . e . stares at w a l l ) . Verbalizes Withdrawal- a statement indicating detachment ( i . e . I don't want to t a l k about that). P h y s i c a l l y Attacks- a movement of the body or parts to s t r i k e an object or person ( i . e . bangs hand against wheelchair). Verbalizes H o s t i l i t y - an unfriendly statement ( i . e . This i s rediculous). P h y s i c a l l y Disruptive- interrupts group a c t i v i t i e s by removing s e l f or inappropriate body language. Verbally Interrupts- a statement made to i n t e r f e r e with group a c t i v i t y ( i . e . c a l l s a person walking by). Verbally Diminishes- a statement made to b e l i t t l e group members ( i . e . that's not correct). APPENDIX F BALES GROUP PROCESS CATEGORIES 99 1. Shows s o l i d a r i t y , r a i s e s o t h e r ' s s t a t u s , g i v e s h e l p , reward: 2. Shows t e n s i o n r e l e a s e , jokes, laughs, shows s a t i s f a c t i o n : 3. Agrees. shows p a s s i v e acceptance, understands, concurs, complies: 4. Gives s u g g e s t i o n , d i r e c t i o n , i m p l y i n g autonomy f o r oth e r : 5. Gives o p i n i o n , e v a l u a t i o n , a n a l y s i s , expresses f e e l i n g , w i t h : 6. Gives o r i e n t a t i o n , informaion, r e p e a t s , c l a r i f i e s , c o n f i r m s : 7. Asks f o r o r i e n t a t i o n , i n f o r m a t i o n , r e p e t i t i o n , conf i r m a t i o n : 8. Asks f o r o p i n i o n , e v a l u a t i o n , a n a l y s i s , e x p r e s s i o n f o f e e l i n g : 9. Asks f o r suggestion, d i r e c t i o n , p o s s i b l e ways of a c t i o n : 10. D i s a g r e e s . shows p a s s i v e r e f e c t i o n , f o r m a l i t y , w i t h h o l d s h e l p : 11. Shows t e n s i o n , asks f o r h e l p , withdraws out of f i e l d : 12. Shows antagonism, d e f l a t e s o t h e r ' s s t a t u s , defends or a s s e r t s s e l f : 1-3 are p o s i t i v e 4-9 are n e u t r a l 10-12 are n e g a t i v e Note: from I n t e r a c t i o n Process A n a l y s i s . A Method f o r the  Study of Small Groups, by R.F. Ba l e s , 198 5. Chicago: The U n i v e r s i t y of Chicago P r e s s . APPENDIX G DEMOGRAPHIC DATA SHEET Name Occupation. Age. Me d i c a l C o n d i t i o n - Alzeihmers/CardiacDisease/CVA/ Diabetes/Hip Surgery/Hypertension/Other: Do you have any l i v i n g f a m i l y members ? Do they l i v e i n Van? Husband C h i l d r e n G r a n d c h i l d r e n Yes/No S i b l i n g s Yes/No Neice/Nephew Yes/No Aunt/Uncle Yes/No Cousin Yes/No Yes/No Yes/No How many. Yes/No Yes/No How many. Yes/No Yes/No Yes/No Yes/No Yes/No Do you belong t o any o r g a n i z a t i o n s ? Church Clubs Community_ Other You came t o t h i s ward from: An acute care h o s p i t a l / a care f a c i l i t y / home/ other_ D i d you l i v e alone? Yes/No Who d i d you l i v e with? hus b a n d / c h i l d r e n / g r a n d c h i l d r e n / s i b l i n g /niece/nephew. 104 APPENDIX K QUESTIONS FOR LIFE REVIEW SESSIONS Session 1 - Introduction. T e l l us your name and something about yourself you would l i k e to share with the group? T e l l us about the f i r s t time you moved? What was i t li k e ? How did you feel? Session 2- School Days. T e l l us about your school days? Can you r e c a l l any s p e c i f i c incidents? Session 3 - Marriage. T e l l us about your wedding day? What do you remember best? (If not married, can you remember a wedding that you attended? What made i t memorable?) Session 4 - F i r s t Child. Recall the b i r t h of your f i r s t c h i l d (or a child)? What was i t like ? Session 5 - F i r s t H o s p i t a l i z a t i o n . What was i t l i k e being i n a hospital f o r the very f i r s t time? Share something about your f i r s t day i n the hospital? Session 6 - Death. Recall the death of your husband or a special friend? Describe how you f e l t ? T e l l us about your experience with death? Session 7 - Move to Care F a c i l i t y . Describe your feelings about going to a care f a c i l i t y ? What does the move mean to you? Session 8 - Closure/Good-bye. Did you enjoy the group? How did you f e e l about coming to the group? Were you comfortable with the topics discussed? How do you f e e l about the group ending? Is i t d i f f i c u l t to say good-bye? 105 APPENDIX L DEMOGRAPHICS OF PATIENTS IN CONTROL GROUP P a t i e n t 1 2 3 4 5 6 7 8 9 Sex F M M M F F F M F Age 8 2 79 65 83 84 75 103 89 83 Occupation HM CA TK JNL SS LW ST ST SC Medical C o n d i t i o n HC CVA CVA B/P CA HC HC CVA CVA L i v i n g Family Members (No.) 18 4 5 3 21 26 1 15 5 L i v i n g Family Members i n Van. (No.) 2 3 2 3 14 26 1 13 0 Membership i n Org. Number 1 1 0 3 1 1 0 0 0 Liv e d alone P r i o r t o H o s p i t a l -i z a t i o n Y N N N N Y Y N N L i v e d w i t h Whom P r i o r to H o s p i t a l -i z a t i o n - Sp Sib S i b S i b - - Sp Sp Legend f o r Demographics of P a t i e n t s i n Study TAble Medical C o n d t i o n s l : HC=Heart Co n d i t i o n , CVA=Stroke, A T H - A r t h r i t i s , B/P=Hypertension, ALZ=Alzeihmer's Disease, and CA=Cancer. Occupations: HM=Homemaker, ST=School teacher, CA=Chartered Accountant, TK=Timekeeper, JNL=Journalist, SS=Seamstress, LW-Laundry worker, SC=store c l e r k , DOA=Dental O f f i c e a s s i s t a n t , BNK=Banker, FR=Farmer, IW- Iron worker, CS=car Salersperson. R e l a t i o n s : Sp=Spouse, Ch=Child, S i b = S i b l i n g Y=yes N=no APPENDIX L CONTINUED DEMOGRAPHICS OF PATIENTS IN CONTROL GROUP CONTINUED P a t i e n t 10 11 12 13 14 15 16 17 Sex F F F F F F F F Age 7 5 76 93 75 83 77 74 90 Occupation HM AD CA HM HM SC CK ST M e d i c a l C o n d i t i o n ALZ ATH CVA HC CVA HC B/P HC L i v i n g Family Members 1 12 5 5 10 12 28 0 L i v i n g Family Members i n Van. (No.) 1 6 3 3 3 0 6 0 Membership i n Organi-z a t i o n s (No.) 0 4 0 1 1 1 0 0 L i v e d alone P r i o r t o H o s p i t a l -i z a t i o n Y N Y N Y Y Y Y L i v e d w i t h Whom P r i o r t o H o s p i t a l -i z a t i o n CH SP Legend f o r Demographics of P a t i e n t s i n Study TAble M e d i c a l C o n d i t i o n s : HC=Heart Condtion, CVA=Stroke, A T H = A r t h r i t i s , B/P=Hypertension, ALZ=Alzeihmer's Disease, and CA=Cancer. Occupations: HM=Homemaker, ST=School teacher, CA=Chartered accountant, TK=Timekeeper, J N L = j o u r n a l i s t , SS=Seamstress, LW=Laundry worker, SC=Store c l e r k , DOA=Dental o f f i c e a s s i s t a n t , BNK=Banker, FR=Farmer, IW=Iron worker, CS=Car s a l e s p e r s o n . R e l a t i o n s : Sp=Spouse, Ch=Child, S i b = S i b l i n g Y=yes N=no APPENDIX M DEMOGRAPHICS OF PATIENTS IN EXPERIMENTAL GROUP P a t i e n t 18 19 20 21 22 23 24 25 26 27 Sex F F F F F M M M F M Age 76 88 92 90 66 72 78 81 95 69 Occupation ST DOA Bnk HM HM FR IW SC SC CS M e d i c a l C o n d i t i o n HC HC CVA CA HC HC HC HC HC CVA L i v i n g Family Members (No.) 20 L i v i n g Family Members i n Van. No.) 2 Membership i n Organi-z a t i o n s (No.) 0 L i v e d alone P r i o r t o H o s p i t a l -i z a t i o n Y L i v e d w i t h Whom P r i o r t o H o s p i t a l -i z a i t o n Legend f o r Demographics of P a t i e n t s i n Study Table M e d i c a l C o n d i t i o n s : HC=Heart C o n d i t i o n , CVA=Stroke. A T H = A r t h r i t i s , B/P=Hypertension, ALZ=Alzeihmer*s Disease, and CA=Cancer. Occupations: HM=Homemaker, ST=School teacher, CA=Chartered Accountant, TK=Timekeeper, J N L = - J o u r n a l i s t , SS=Seamstress, LW=Laundry worker, SC=Store c l e r k , DOA=Dental o f f i c e a s s i s t a n t , BNK=Banker, FR=Farmer, IW=Iron worker, SC=Car s a l e s p e r s o n . 7 20 3 16 0 7 8 2 5 7 15 1 2 0 7 0 2 5 0 0 4 1 0 0 1 1 0 Y Y Y N Y Y N Y N R e l a t i o n s : Sp=Spouse, Ch=Child, S i b = S i b l i n g 108 APPENDIX M CONTINUED DEMOGRAPHICS OF PATIENTS IN EXPERIMENTAL GROUP P a t i e n t 28 29 30 31 32 33 34 35 S e x F F F F F F F F A g e 90 84 92 84 92 72 84 82 O c c u p a t i o n T HM ST T HM SC ST HM M e d i c a l C o n d i t i o n CA CA HC CA A T H HC HC CVA L i v i n g F a m i l y M e m b e r s ( N o . ) 1 0 7 0 7 2 6 14 L i v i n g F a m i l y M e m b e r s i n V a n . ( N o . ) 0 0 5 0 7 2 2 6 M e m b e r s h i p I n O r g a n i -z a t i o n s ( N o . ) 1 1 1 1 0 0 0 2 L i v e d a l o n e P r i o r t o H o s p i t a l -i z a t i o n Y Y Y Y Y Y Y N L i v e d w i t h Whom P r i o r t o H o s p i t a l -i z a t i o n - - - _ - - Sp L e g e n d f o r D e m o g r a p h i c s o f P a t i e n t s i n S t u d y T a b l e M e d i c a l C o n d i t i o n s : H C = H e a r t C o n d i t i o n , C V A = S t r o k e , A T H = A r t h r i t i s , B / P = H y p e r t e n s i o n , A L Z = A l z e i h m e r ' s D i s e a s e , a n d C A = C a n c e r . O c c u p a t i o n s : HM=Homemaker , S T = S c h o o l t e a c h e r , C A = C h a r t e r e d A c c o u n t a n t , T K = T i m e k e e p e r , J N L = J o u r n a l i s t , S S = S e a m s t r e s s , L W = L a u n d r y w o r k e r , S C = S t o r e c l e r k , D O A = D e n t a l o f f i c e a s s i s t a n t , B N K = B a n k e r , F R = F a r m e r , I W = I r o n w o r k e r , C S = C a r S a l e s p e r s o n . R e l a t i o n s : S p = S p o u s e , C h = C h i l d , S i b = S i b l i n g N=no Y = y e s 109 APPENDIX N SUMMARY OF PRE- AND POST-TEST SCORES OF THE GERIATRIC DEPRESSION SCALE (GDS), ACTIVITIES OF DAILY LIVING EVALUATION FORM (ADL), AND THE GERIATRIC RATING SCALE (GRS) FOR THE CONTROL GROUP GDS A D L GRS P r e - P o s t P r e - P o s t P r e - P o s t S u b j e c t S c o r e s S c o r e s S c o r e s 1 35 40 15 14 46 46 2 46 49 15 15 66 66 3 50 53 15 14 57 53 4 40 41 15 15 55 56 5 30 38 12 15 49 54 6 38 44 14 16 61 66 7 43 45 16 14 69 68 8 44 52 14 14 46 52 9 46 46 14 14 53 50 10 38 41 15 15 62 61 11 35 38 17 13 53 44 12 44 47 15 18 48 62 13 40 39 15 15 63 61 14 37 39 10 10 37 38 15 33 34 13 13 43 44 16 49 52 14 15 69 69 17 45 46 15 15 59 59 On a l l s c a l e s , a l o w s c o r e i s b e t t e r S c a l e P r e - t e s t M e a n a n d SD GDS 4 0 . 7 6 5 5 . 7 2 9 A D L 1 4 . 2 3 5 1 . 6 0 2 GRS 5 5 . 0 5 9 9 . 3 7 1 P o s t - t e s t M e a n a n d SD 4 3 . 7 6 5 5 . 6 2 9 1 4 . 4 1 2 1 . 6 2 2 5 5 . 8 2 4 9 . 3 0 2 S c a l e GDS A D L GRS R a n g e 3 3 - 5 3 1 0 - 1 7 3 7 - 6 9 110 APPENDIX O SUMMARY OF PRE- AND POST-TEST SCORES OF THE GERIATRIC DEPRESSION SCALE (GDS), ACTIVITIES OF DAILY LIVING EVALUATION FORM (ADL), AND THE GERIATRIC RATING SCALE (GRS) FOR THE EXPERIMENTAL GROUP GDS ADL GRS Pre -Post Pre-Post Pre-Post S u b j e c t Scores Scores Scores 18 43 38 9 8 41 39 19 36 36 15 14 65 57 20 41 38 11 13 57 66 21 35 32 7 6 51 43 22 34 31 14 13 47 50 23 32 31 12 12 52 51 24 38 34 13 13 69 52 25 38 34 11 7 57 48 26 35 42 13 13 54 53 27 47 41 16 15 59 51 28 41 37 11 9 41 40 29 44 36 17 6 54 46 30 34 34 11 11 49 39 31 54 50 15 13 62 50 32 44 35 11 13 44 52 33 36 37 17 17 61 53 34 37 32 15 16 67 62 35 37 33 15 15 67 65 A low score i s b e t t e r S c a l e P r e - t e s t Mean and SD P o s t - t e s t Mean and SD GDS 39.222 5. 537 36.167 4. 668 ADL 12.944 2.775 11.889 3 . 359 GRS 55.389 8.846 50.944 8.033 S c a l e Range GDS 31-54 ADL 6-17 GRS 39-69 I l l APPENDIX P NARRATIVE DATA Group 1 Ms. B. i n t e r r u p t e d the group q u i t e o f t e n w i t h s a r c a s t i c comments. She d i d not say much when we discussed death and dying. A f t e r the group ended she kept demanding s t a f f time, the s t a f f pointed out t o me. She wanted anyone to come and t a l k t o her about death and a f t e r l i f e . I r e f e r r e d her t o the p a s t o r a l care team. She was and i s s t i l l seen by p a s t o r a l care. They have been h e l p i n g her s o r t out her f e e l i n g s about dying and a f t e r l i f e . Ms. C. seemed to be drowsy and c l o s e her eyes i n the f i r s t few s e s s i o n s . L a t e r she became very a l e r t . The nurses, the recorder and the group leader a l l n o t i c e d how the group meetings j u s t seemed to perk her up. Also f o r the l a s t h a l f of the group meetings she d i d not need to be reminded to come to the group, she remembered on her own. As one nurse commented, "that i s p r e t t y good f o r someone w i t h a poor memory". She a l s o became good f r i e n d s w i t h Ms. E.. She already knew Ms. E., who was her roommate. She made a p o i n t of mentioning to the group how she helped Ms. E. - "she would be l o s t without me. I c a l l the nurse f o r her and get help when she needs i t " . Ms. C. s t a t e d how much she enjoyed the group and why d i d i t have to come to an end. As the new groups s t a r t e d she always came to the group leader and asked "why can't I be i n the group, I ' l l s i t q u i e t l y i n a corner-". She knew t h i s was a study but she could not understand how the r e s u l t s would d i f f e r i f she j u s t sat q u i e t l y i n a corner and observed the group. Ms. D. helped other members i n the group. She q u i t e o f t e n helped pass out cookies. She a l s o asked prompting questions to other subjects t o a s s i s t them to t a l k . According t o the nurses Ms. D. asked them to spend a l o t of time w i t h her t o t a l k about death and a f t e r l i f e . She was a l s o r e f e r r e d to p a s t o r a l care. P a s t o r a l care v i s i t e d her r e g u l a r i l y . About 3 weeks l a t e r she d i e d . A member of p a s t o r a l care and I discussed t h i s case. We conluded t h a t she d i e d at t h i s p a r t i c u l a r time because she had been given permission t o die by both the group and the c o u n s e l l i n g by p a s t o r a l care. Also she may have f i n a l l y completed her "business" t h a t she needed to before death. Ms.' E. had q u i t e a poor memory. She q u i t e o f t e n i n t e r r u p t e d the group by moaning. Both the recorder and leader thought t h i s was a t t e n t i o n - s e e k i n g behavior. While she was t a l k i n g she f e l t great. According t o the nurses, she r e q u i r e d help w i t h feeding. In the group she drank her d r i n k and ate her-cookies without a s s i s t a n c e . 112 APPENDIX P CONTINUED In general, a l l subjects s t a t e d they enjoyed the group very much and would l i k e i t t o continue. They a l l s t a t e d the t o p i c s were r e l e v a n t and should be discussed again. Group I I Ms. F. had a very d i f f i c u l t time remembering past events a c c u a r a t e l y according t o the s t a f f . She was very s o c i a b l e i n the group, she passes out t e a and cookie and smiles a great d e a l . Ms. G., according t o the nurses, t a l k e d more to other people s i n c e she had been p a r t i c i p a t i n g i n the group. Before the group s t a r t e d the leader was up on the u n i t , Ms. G. s a i d how she was l o o k i n g forward t o the group. Also the nurses s t a t e , her memory seemed to have improved since she had been p a r t i c i p a t i n g i n the group. Ms. H. was a very t a l k a t i v e person t h a t sometimes wandered from the t o p i c or monopolized the conversation. She was o f t e n reminded by the leader of the t o p i c or t o give others a chance to t a l k . According t o her daughter, the p a t i e n t s i n c e j o i n i n g the group attempted to move her wheelchair w i t h her f e e t , "she had never t r i e d t h a t before" s t a t e d her daughter. A l s o the daughter s t a t e d the s u b j e c t i n i t i a t e d conversation w i t h strangers i n the h a l l and c a f e t a r i a . Ms. J . was a very c l o s e d person i n the beginning and would not say very much. As time went on she volunteered i n f o r m a t i o n . She a l s o had her daughter bake goodies f o r the group on 2 occasions. She dressed b e t t e r l a t e r and became more a t t e n t i v e t o her appearance as the group progressed. Ms. K. was very sleepy i n the f i r s t few sessions of the group. Near the end she was s t a y i n g awake during the whole se s s i o n . Also she p a i d more a t t e n t i o n t o her appearance. She had her h a i r done on a r e g u l a r b a s i s and one day as the group leader wheelled her to the group she asked " i s my h a i r a l r i g h t ? " The group i n general was very s o c i a b l e . They t a l k e d between themselves before and a f t e r the sessions. They a l l helped pass out cookies and t e a and one time or another. They a l l s t a t e d they enjoyed the group very much and wished t h a t i t would be continued on a r e g u l a r b a s i s . They thought the t o p i c s discussed were appropriate and could not t h i n k of any d i f f e r e n t ones. 113 APPENDIX P CONTINUED Group I I I Ms. L. was a t times confused and i n t e r r u p t e d others. She was t o l d by the leader on many occasions "Lets l i s t e n to t a l k , she i s not f i n i s h e d y e t " . Twice she was removed from the group because she i n t e r r u p t e d others very i n a p p r o p r i a t e l y . She helped pass the goodies to others many times. Near the end of the group meetings she s t a r t e d conversation w i t h other p a t i e n t s on the u n i t . Somedays her memory and appropriateness were b e t t e r than other days. At times when she d i d remember the s t a f f s t a t e she looked forward t o the group meetings. Ms. M. was someone who kept very much to h e r s e l f according t o the s t a f f . A f t e r mid way through the group sessions she ate i n the d i n i n g room and s o c i a l i z e d w i t h other p a t i e n t s . She became f r i e n d s w i t h Ms. N. Ms. N. a f t e r the i n i t i a l few s e s s i o n s , remembered what the t o p i c of the day was. She came to the s e s s i o n on her own and was q u i t e o f t e n prepared to speak on the t o p i c . She became f r i e n d s w i t h Ms. M. and s t a t e d how the group was a good idea i n terms of g i v i n g people a chance to speak about the t o p i c s but a l s o to meet others on the ward. At one s e s s i o n when Ms. M. s t a r t e d t o c r y she o f f e r e d her a kleenex and s t a t e d t h a t i t was good to c r y "my doctor says c r y , i f you need to c r y , don't h o l d i t i n " she t o l d Ms. M. Ms. P. a f t e r the f i r s t few group sessions was very good at encouraging others to speak. She h e r s e l f had a very d i f f i c u l t time remembering her past. Sometimes she j u s t got q u i t e t e a r f u l t r y i n g t o remember. She became f r i e n d s w i t h Ms. N. A l s o she i n i t i a t e d conversation w i t h most p a t i e n t s on the ward on her own. In general the group was very s o c i a b l e i n handing out cookies and t e a . They a l l s t a t e d they enjoyed the group very much and thought the t o p i c s were appropriate. Group IV Mr. Q. was d i s o r i e n t e d around the ward before the group sessions s t a r t e d . Near the end he was o r i e n t e d t o the ward. He was very s o c i a b l e from day one, handing out cookies and pouring t e a . He became f r i e n d s w i t h Mr. R. whom he hadn't t a l k e d t o before even though they shared a room. The nurses n o t i c e d t h a t he d i d n ' t go wandering o f f the ward as the group sessions continued. The nurses a l s o s t a t e d t h a t the p a t i e n t became more cooperative as the group progressed. 114 APPENDIX P CONTINUED Mr R. ws d i s o r i e n t e d around the ward b e f o r e the group s t a r t e d and became more o r i e n t e d as the group went on. A l s o the s t a f f s t a t e he became a more " c o o p e r a t i v e p a t i e n t " . He a l s o h e l p e d hand out cookies and t e a a t every s e s s i o n . He became f r i e n d s w i t h Mr. Q. In one group s e s s i o n he mentioned t h a t he used t o p l a y the piano i n a band. On one of the wards i n the h o s p i t a l , t h e r e i s a piano. He was taken to i t by a s t a f f member and he p l a y e d v e r y w e l l . He s t a t e d he hadn't p l a y e d f o r 8 y e a r s . He v e r y much enjoyed the experience as d i d those p a t i e n t s t h a t l i s t e n e d t o him p l a y . Ms. S. d i d not t a l k much t o o t h e r people b e f o r e the group s e s i o n s . A c c o r d i n g t o the group she s t a r t e d t o converse more wi t h o t h e r p a t i e n t s and s t a f f . A l s o she s t a r t e d t o m o b i l i z e h e r s e l f more. A v i s i t o r of hers s t a t e d t o the s t a f f t h a t the s u b j e c t t o l d her about the group and how much she enjoyed. She a l s o d i s c u s s e d w i t h the v i s i t o r the t o p i c s t a l k e d about i n the group. Mr. T. was v e r y dependent on s t a f f f o r f e e d i n g . In the group he f e d h i m s e l f the cookies and d r i n k s the t e a on h i s own. At the b e g i n n i n g he was v e r y drowsy i n the group, h a l f c l o s i n g h i s eyes. In l a t e r s e s s i o n s he stayed more awake. Ms. V. was confused on and o f f . In one s e s s i o n she and Mr. R pretended to be husband and w i f e . Ms. V. had never been married. Anyways, she became f r i e n d s w i t h Mr. R. but nothing ever developed. She t a l k e d w i t h most people she saw i n the hallways a f t e r the group s e s s i o n s s t a r t e d a c c o r d i n g to the s t a f f . Her v i s i t o r t o l d the s t a f f t h a t the s u b j e c t t a l k e d to her about the group. The v i s i t o r thought the group was a good i d e a . In g e n e r a l the group was v e r y s o c i a b l e . They s t a t e d they enjoyed the s e s s i o n s and thought i t would be a good i d e a to continue them. They had no suggestions f o r d i f f e r e n t t o p i c s t h a t c o u l d be d i s c u s s e d . 115 APPENDIX Q NUMBER OF GROUP SESSSIONS ATTENDED BY SUBJECT 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 G r o u p 1 G r o u p 2 G r o u p 3 G r o u p 4 N o t e : 18 t o t a l s u b j e c t s R a n g e = 4 - 8 M e a n = 7 . 2 

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
http://iiif.library.ubc.ca/presentation/dsp.831.1-0055837/manifest

Comment

Related Items