Open Collections

UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

Fear of falling : the experience of elderly individuals who have previously fallen Convey, Marilynne G. 1993

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

Item Metadata


831-ubc_1993_spring_convey_marilynne.pdf [ 3.72MB ]
JSON: 831-1.0086086.json
JSON-LD: 831-1.0086086-ld.json
RDF/XML (Pretty): 831-1.0086086-rdf.xml
RDF/JSON: 831-1.0086086-rdf.json
Turtle: 831-1.0086086-turtle.txt
N-Triples: 831-1.0086086-rdf-ntriples.txt
Original Record: 831-1.0086086-source.json
Full Text

Full Text

FEAR OF FALLING: THE EXPERIENCE OF ELDERLYINDIVIDUALS WHO HAVE PREVIOUSLY FALLENByMARILYNNE G. CONVEYB.S.N., University of Victoria, 1987A THESIS SUBMITTED IN PARTIAL FULFILLMENT OFTHE REQUIREMENTS FOR THE DEGREE OFMASTER OF SCIENCE IN NURSINGinTHE FACULTY OF GRADUATE STUDIESThe School of NursingWe accept this thesis as conformingTHE UNIVERSITY OF BRITISH COLUMBIAApril, 1993Marilynne G. Convey, 1993In presenting this thesis in partial fulfilment of the requirements for an advanceddegree at the University of British Columbia, I agree that the Library shall make itfreely available for reference and study. I further agree that permission for extensivecopying of this thesis for scholarly purposes may be granted by the head of mydepartment or by his or her representatives. It is understood that copying orpublication of this thesis for financial gain shall not be allowed without my writtenpermission.e?Department ofThe University of British ColumbiaVancouver, CanadaDate DE-6 (2/88)iiAbstractFear of Falling: The Experience of ElderlyIndividuals Who Have Previously FallenFear of falling resulting from a previous fall hasserious health implications for elderly individuals wholive in the community. This fear has been linked toactivity restriction, poor physical health, increaseddependence, and lifestyle changes. Previous researchon fear of falling has described it in relation toother outcomes of a fall and not as a discrete entity.None of the studies included the individual'sperspective. Therefore, the purpose of this study wasto describe the meaning of the experience of fear offalling from the perspective's of elderly individualswho have previously fallen.The phenomenological method was used to gain anunderstanding of the subjective experience of the nineelderly community-dwelling individuals who participatedin the study. All of the participants had fallen morethan once and all had sustained an injury from a fall.In the course of two or three interviews, eachparticipant and the researcher constructed an accountof the participant's experience of the fear of falling.iiiUsing content analysis the data was conceptualized intothemes and concepts reflective of the participants'perspectives. The presentation of this descriptivedata was organized into two major themes whichrepresented a process of adjustment: making meaning ofthe experience of the fear of falling and integratingthe meaning of the experience into daily living.The findings revealed that fear of fallingthreatened the individual's physical and psychologicalsurvival. In response a process of adjustment wasinitiated in which the individual used behavioural andcognitive activities that sought to maintain controland were self-enhancing.The participants' accounts of their fear offalling highlight the importance of determining theclient's perspective in order to understand and workwith elderly individuals who fall and are afraid offalling again. In light of the research findingsimplications for nursing practice, nursing education,and nursing research are discussed.ivTABLE OF CONTENTSAbstract^Table of Contents^ ivAcknowledgements viCHAPTER ONE: INTRODUCTION^ 1Introduction and Background to the Problem^ 1The Framework^ 5Statement of the Problem^ 10Purpose of the Study 11Research Question 11Definition of Terms 11Significance for Nursing^ 11Introduction to the Methodology 13Methodological Issues 14Assumptions^ 16Limitations 17Summary 17CHAPTER TWO: LITERATURE REVIEW^ 18Introduction^ 18Fear^ 18Related Phenomena 24Fear of Falling 28Summary 35CHAPTER THREE: METHODOLOGY^ 37Introduction^ 37Procedure 37Selection Criteria^ 37Selection and Recruitment^ 39Data Collection^ 41Data Analysis 43Ethical Considerations^ 45Summary^ 46CHAPTER FOUR: CHARACTERISTICS OF THE PARTICIPANTSAND THEIR ACCOUNTS^ 47Introduction^ 47Characteristics of the Participants 49The Accounts of the Participants^ 51Making Meaning of the Experience^ 51Linking Fearfulness to Falling 52Recognizing Other Fears 55Appraising Self ^ 60Integrating the Meaning of the Experience^ 63Reordering Behaviour  64Preserving Identity  78Summary^  86CHAPTER FIVE: DISCUSSION OF RESEARCH FINDINGS^ 89Introduction^ 89Maintaining Control^ 90Self-enhancement 96Summary 102CHAPTER SIX: SUMMARY AND IMPLICATIONS FOR NURSING.. .104Summary^ImplicationsNursingNursingNursing104for Nursing^ 106Practice 106Education 114Research 116REFERENCES^ 120APPENDICESAppendix A: Letter of InformationAppendix B: Consent FormAppendix C: Trigger Questions133^ 133^ 135136viAcknowledgements I would like to thank the people who have assistedme in the completion of this thesis. To the members ofmy Thesis Committee, Angela Henderson (Chairperson),Tess Orlando, Dr. Marilyn Willman, and Dr. CarolJillings for your support, encouragement, and guidance.I want to thank my peers and co-workers in the CapitalRegional District Care programs for your patience andunderstanding. Your comments and interest throughouthelped to encourage my forward progress. Ongoingsupport came from my two friends, Rosemary Williams andSharon Galloway who were always only a phone call awayand helped to put things into perspective. Thank youto the nurses in the Home Care Program and Long TermCare Program who helped obtain the participants forthis study. I gratefully acknowledge the contributionof the participants in sharing their thoughts,feelings, and opinions about their experience of livingwith their fear.A special thank-you to my family who experiencedmy many ups and downs, but especially to my longtimecompanion and husband Paul who knew I could do it andwouldn't let me quit.1CHAPTER ONEIntroductionIntroduction and Background to the ProblemIn Canada, approximately 11% of the population isover the age of 65; and, of these, 95% choose to livein their own homes (Mackus & Millette, 1987). Theprojection is that those over 65 years of age willrepresent approximately 20% of the total population bythe year 2001 (Stats Canada, 1988). This demographicchange will have an impact on the services thatcommunity nurses provide for individuals living in thecommunity.In the community-dwelling elderly population,falls are a common problem and can have seriousconsequences for the individual. It is estimated that1/3 of this population will experience one or morefalls a year (Campbell, Reinken, & Allan, 1981; Perry,1982; Prudham & Evans, 1981; Sorock, 1988).Approximately 5 to 15% will sustain a serious injurywhich requires health care intervention (Tinetti,Richman, & Powell, 1990). Many researchers report thatphysical trauma can lead to loss of mobility andfunction (Brummel-Smith, 1989; Sorock 1988; Tinetti,2Speechley, & Ginter, 1988; Tinetti et al., 1990). Itis also reported that some individuals may restricttheir activities as a way of coping (Speechley &Tinetti, 1990). Lack of activity can lead to decreasedstrength and independence and may result in anincreased risk for falling (Brummel-Smith, 1989).The literature also describes "psychologicaltrauma" (Tinetti et al., 1990, p. 239) occurring as aresult of a fall in the elderly individual who lives athome. Over 50% of the studies on the community-basedelderly which were reviewed included comments by theresearchers about fear of falling. Fear of falling waslinked to activity restriction (Speechley & Tinetti,1989), poor physical health, reduced mobility,increased dependence (Downton & Andrews, 1990; Prudham& Evans, 1981; Vellas, Cayla, Bocquet, de Pemille, &Alvarede, 1987; Walker & Howland, 1990), lifestylechanges (Prudham & Evans, 1981), and feelings ofboredom and depression (Vellas et al., 1987). Thesepose serious health problems for the elderly and maythreaten their ability to function independently intheir own homes.In most of the studies using the community3dwelling elderly as the sample, the association betweenfear of falling, function, mobility, and independencehas been found retrospectively; and, therefore, noassumption can be made about whether the fear precededor followed the fall event. In addition, those studieswhich were prospective in nature did not consistentlydefine fear of falling or utilize a standard method ofassessing the fear. Methods of sampling were poorlydescribed in some of the studies (Tideiksaar &Silverton, 1989; Walker & Howland, 1990). In others,small sample size and lack of randomization preventedthe generalizability of the results to other targetpopulations (Tideiksaar & Silverton, 1989; Tinetti etal., 1988). Nonetheless, the range of reportedestimates of fear of falling in these studies indicatedthat this phenomenon is a health problem that warrantsfurther research (Downton & Andrews, 1990; Tideiksaar &Silverton, 1989; Walker & Howland, 1990).The literature on falls in the elderly populationhas identified that fear of falling has seriousconsequences for the individual. The fear thatindividuals feel following a fall has been linked tochanges in their ability to cope with activities of4daily living (Brummel-Smith, 1989). Some investigatorshave suggested that fear of falling contributed to aloss of confidence and self esteem (Brummel-Smith,1989; Tinetti et al., 1990). Restriction of activitiesand social isolation have been described by researchersin association with fear of falling (Downton & Andrews,1990). Coping with the fear of falling by decreasingfunction has the potential to compromise anindividual's ability to maintain an independentlifestyle in the community.As increasing numbers of elderly individualschoose to remain in their own homes as they grow older,it seems likely that falls and fear of falling willpose significant health concerns for this population.Community health nurses will be required to assistthese individuals towards maintaining their self careand independent lifestyle. To do this will requirethat nurses have a broad knowledge base that considersthe client's experience from the client's perspective.An individualized care plan that has the greatestpotential for success is one in which the nurse'sperspective is congruent with that of the client.Therefore, it is important for community nurses, in5order to provide effective care, to understand themeaning of fear of falling as experienced by theindividual who has previously fallen. Very littleresearch has been done that describes fear of fallingand no research has been done that examines thesubjective experience of this fear from the perspectiveof an individual who has previously fallen. In order toprovide nurses with insight about the experience offear of falling, the proposed research has relevance.The FrameworkThe framework for a research study provides theresearcher with a perspective from which to view theproblem (Woods & Catanzaro, 1988). The frameworkchosen for this study is the life-span construct modelas described by Whitbourne (1985). This model is theresult of a re-evaluation of three traditional modelsof adaptation: the life events model (Hultsch &Plemons, 1979), the cognitive appraisal model (Lazarus,1966), and the subjective well-being model (Campbell,1980). Each of the these models is concerned withresearching individuals at varying ages across thelife-span and each emphasizes specific features of theadaptation process. However, all concur that the6fundamental focus of adaptation is the preservation ofthe physical and psychological well-being of theindividual and that this outcome can function as amotivational force to facilitate adaptation(Whitbourne, 1985).The basic assumption of the life events model ofadaptation (Hultsch & Plemons, 1979) is that any typeof change brought about by a life event disrupts thenormal state or homeostasis of an individual. Thismodel discounts human behaviour that seeksdisequilibrium and change. The weaknesses of thismodel include the lack of consideration for thesubjective meaning an individual attaches to an eventand the negative connotations attached to change. Themajor contribution of this model is that itdimensionalizes the qualities of events that createstress (Holmes & Rahe, 1967) and the characteristics ofthe individuals that mediate the stress (George, 1980;Hinkle, 1974). The cognitive appraisal model (Lazarus,1966) incorporates the individual's interpretation ofan event and the appropriateness of the coping strategyin terms of that interpretation (Whitbourne, 1985). Aweakness of this model is the lack of clarity in7differentiating between the differences andsimilarities of the various coping mechanisms inresponse to positive or negative emotional experiences.The subjective well-being model supports thepremise that the evaluation of a situation is asubjective judgemental process (Whitbourne, 1985).Andrews and Whithey (1976) found evidence of thisprocess in the feedback loop which was created by aninitial evaluation of a situation, to the copingbehaviour, and to a re-evaluation of the situation. Asimilar feedback mechanism has been proposed in thecognitive appraisal model (Lazarus, 1966). Theweakness of this model is the lack of consideration forchanges that may occur in the characteristics of theindividual or the environment as a means of coping.The life-span construct model draws on thestrengths of each of the above models. Its underlyingpremise is that the individual's cognitive andemotional construction of the life-span determines howthe individual develops through a lifetime ofexperiences. This model offers an integrated approachto understanding an individual's ability to adapt tochange. It focuses on the ways in which physical,8psychological, and social functioning over anindividual's life course influence adaptation tostressful life events and activities of daily living(Whitbourne, 1985).The primary source and content of the life-spanconstruct is identity which defines the individual'ssense of self. It is shaped by the individual'sphysical, psychological, and social qualities. Otherinfluences include the individual's value system as itrelates to family, work, self development, age norms,and involvement in the social welfare of the community(Whitbourne, 1985). Within the life-span construct,there are two structural components: the scenario andthe life story. The scenario consists of expectationsabout the future which have been identified by identityas important, and the life story is an incorporation ofpast events into an organized sequence which provides asense of continuity.The life-span construct model of adaptationproposes that coping strategies can vary depending onwhether an event is consistent or inconsistent with anindividual's scenario. An individual's perception ofthe environment may change or the individual may9directly change the environment. Perceiving theenvironment in a different way is a mechanism toprotect the self-esteem and requires an appraisalprocess. Protection of the self-esteem may involve arestructuring of identity which involves changing theestimation of one's capacities to be congruent withactual abilities. It may also involve distorting themeaning of the event.The life-span construct model proposed byWhitbourne (1985) provides a way of viewing theindividual from a broad perspective. It incorporatesthe subjective appraisal process with the individuals'perceptions about past, present, and future events.The model recognizes the influence of physical, social,and psychological qualities on an individual's uniqueconception of the life course. Therefore, the life-span construct model would seem to be a usefulframework for understanding the meaning of the fear offalling from the elderly individual's perspective. Itwould direct one to consider a variety of copingstrategies and would facilitate an understanding of thethinking, feeling, and behaviours of those who livewith a fear of falling. In addition, this framework10will direct nurses to collect and examine data from abroad perspective when planning care for individualswho have a fear of falling.The goal of community nursing is to promote selfcare and independence. This goal assumes thatindividuals are active participants in their care andhave the potential for growth and development. This isconsistent with the basic premise of the life-spanconstruct model which proposes that the potential forchange exists only within the individual; and,therefore, it is an appropriate model to guide thisstudy.Statement of the ProblemFalls have been documented as a common problem inthe elderly population living in the community. Fearof subsequent falling may have serious consequences forthe individual and may contribute to restrictions inactivity and lifestyle changes. These consequences maycompromise an individual's ability to functionindependently. Little is known about the experience ofthe fear of falling from the individual's perspectiveand the resultant changes in behaviour and lifestyle.Understanding the meaning of this experience will1 1enhance the community nurse's ability to plan andprovide care that meets the individual's needs.Purpose of the StudyThe purpose of this study is to describe themeaning of fear of falling and its impact on theactivities of daily living from the perspective of anelderly individual living in the community who haspreviously fallen.Research QuestionWhat is the meaning of the experience of the fearof falling for the elderly individual living in thecommunity who has previously fallen?Definition of TermsFall: An untoward event in which the individualcomes to rest unintentionally on the ground (Morris &Issacs, 1980).Fear: A normal response to active or imaginedthreats, comprised of an outer behavioral experience,an inner feeling, and accompanying physiologicalchanges (Bhala, O'Donnell, & Thoppil, 1982).Significance for NursingNursing's goal is to understand clients in orderto know how to care for them more effectively. This12study has practical significance for nurses caring forelderly clients who are afraid of falling. It is anattempt to describe the phenomenon and the humanexperience of living it. Nurses who have a fullerawareness of the interpretation of this experience fromthe perspective of the individual will be able toprovide care that better meets his/her needs.Understanding the perceptions of the fear of fallingwill enable the nurse to assist individuals in copingwith these feelings.The notion that clients and health careprofessionals may not share the same perspective inregard to the fall event has significant implicationsfor health care. The focus of this study is theclient, however it is hoped that a better understandingof the client's perspective will assist nurses inplanning care. It is important for nurses to attend totheir clients' interpretations so that care can beplanned that is congruent with the individuals' needs.As the number of elderly people who live in theirown homes continues to grow, community nurses willassume more expanded roles as primary care givers.There is a greater need for them to understand the13clients' perspectives and the impact of theseperspectives on the determination of patientbehaviour.Introduction to the MethodologyPhenomenology is the research design selected forthis study. Phenomenology is the appropriate approachwhen the goal of the research is to understand humanexperience from the individual's perspective (Knaack,1984). This method attempts to describe the humanexperience as it is lived (Oiler, 1982). The perceivedworld is examined in order to describe the livedexperience. The researcher becomes immersed in thephenomenon and enters the world of the participants.The researcher must bracket or set aside any thoughtsor biases previously formulated in order to accuratelydescribe the perceived world (Oiler, 1982).Elaboration of the perceived world enhances ourunderstanding of the experience under investigation(Oiler, 1986). This method is well suited to thisstudy as the purpose is to understand the meaning offear of falling from the perspective of the individual.Phenomenology is appropriate when little is knownabout the phenomenon (Oiler, 1986). The inductive and14descriptive methods used in this approach impart anunderstanding of the phenomenon.Additional support for using this approach is itsrelationship to the nursing profession which bases itscare on a holistic perspective (Oiler, 1982). A goalof nursing is to understand the experience of theindividual and to provide care which takes it intoaccount. Nursing values the individual and encouragesindividuals to participate in their care. This studywill provide a holistic view of individuals who have afear of falling and their care needs; and, as a result,nurses will be better able to support and nurture them.Methodological Issues Phenomenology is the qualitative research methodused for this study. Qualitative research assumes thatthere is value in understanding the inner experienceand outer behaviour of a subject as a way to enhancethe comprehension of human behaviour (Rist, 1979).This is in sharp contrast to the quantitative methodwhich applies an empirical standard to socialphenomena. Therefore, the criteria for evaluating aqualitative study are different than those used for aquantitative study. To ensure scientific rigor in a15qualitative study, Guba and Lincoln (1981) haveproposed four criteria against which a study ismeasured. These include the "truth value,applicability, consistency, and neutrality" (p. 103-104).The truth value of a qualitative study is "in thediscovery of human phenomena or experiences as they arelived and perceived by subjects" (Sandelowski, 1986, p.30). Credibility is the criterion against which thetruth value is evaluated. Credibility exists when thedescriptions and interpretations of the data arerecognizable by those having had the experience as wellas those who read the study. The truth valuerepresents the internal validity in a qualitative study(Sandelowski, 1986).Applicability in a qualitative study refers to thecriterion of "fittingness" (Sandelowski, 1986, p. 32).This criterion is met when the findings fit intocontexts outside the research situation and when theaudience views the findings as meaningful andapplicable in terms of their own experiences(Sandelowski, 1986). In a quantitative study,applicability is analogous to external validity.16Consistency is the criterion which determines astudy's reliability (Sandelowski, 1986). Inqualitative research the concept of auditabilityrelates to the consistency of the findings and ispresent when another researcher after examining thedata, reaches the same conclusions as the investigatorsof the study. Guba and Lincoln (1981) refer to this asthe decision trail.The fourth criterion is neutrality which refers tothe "freedom from bias in the research process andproduct" (Sandelowski, 1986, p. 33). In qualitativeresearch, confirmability is the criterion ofneutrality; and, in quantitative research, it isobjectivity. Confirmability is achieved whenauditability, truth value, and applicability areestablished.Assumptions 1. Fear of falling is a significant experience inthe life of an elderly individual who has alreadyexperienced a fall.2. Individuals who participate in this study willhave fallen and be able to recount and articulate theirfeelings about their fear of falling again.173. Understanding the participants' subjectiveexperience of fear of falling enables a greater depthof comprehension of human behaviour.Limitations Only the perspectives of the individualparticipants in this study were included; and,therefore, the findings are not generalizable to othergroups; however, knowledge of individual experienceadds to our understanding of human behaviour.SummaryFear of falling has serious implications forelderly individuals, but little information existswhich describes the experience of this phenomenon fromthe individual's perspective. This chapter hasdescribed the problem which provides the rationale forthe study. It has outlined the framework, methodology,assumptions and limitations. Chapter Two presents areview of the literature relevant to this study.Chapter Three describes the methodology and ChapterFour presents the findings and their interpretation.Chapter Five presents a discussion of the findings inrelation to relevant literature. The summary andimplications for nursing are presented in Chapter Six.18CHAPTER TWOLiterature ReviewIntroductionThe purpose of a review of the literature is toprovide a description and analysis of the current stateof knowledge about the subject under investigation. Togain a broad perspective about the subject, theliterature review selected includes information on fearand specifically fear of falling. It is organized intothree sections: (1) fear, (2) related phenomena, and(3) fear of falling.FearA clear scientific definition of fear has not beenidentified in the literature, but rather a variety ofdefinitions have been found relating to specificfearful stimuli (Bamber, 1974; Key, 1986; Wolpe & Lang,1964). There is consensus, however, among theresearchers that fear is an emotional response to atangible stimulus (Rachman, 1978), concrete or clearlyin-focus objects (Key, 1986), and specific stimuli(Geer, 1965).Izard (1972) has described fear as one of thefundamental emotions that can be experienced as a19discrete entity. Three components characterize thefundamental emotions and distinguish them from othercomplex emotions. These include an innate nervoussystem function, a distinct neuromuscular-expressivepattern, and a distinct subjective quality. Rachman(1978) has described the components of fear similarlyand describes them as the subjective experience ofapprehension, associated psychophysiological changes,and attempts to avoid or escape from certainsituations. Fear has been further differentiated intoacute and chronic fear by Rachman (1978) and Gellhorn(1965). They describe acute fear as more intense andsudden in onset and associate chronic fear withanxiety.Izard (1971) believes that, almost immediately,the initial emotion of fear elicits other emotions thatinteract with it. The combination of fear with otheremotions does not change its essential components, butthe observable behaviour of the combinations maydiffer. For example, fear in combination with guiltyields only avoidance or withdrawal. Fear incombination with interest yields alternating approachand avoidance behaviours (Izard, 1972).20Difficulties often arise in studying fear becausethere is a lack of correspondence between the threemain components (Rachman, 1978). For example, anelderly individual who is intensely apprehensive aboutfalling may express a fear of falling, experiencephysiological symptoms of anxiety, but may not make anyattempt to avoid the situation causing the fear.Rachman (1978) believes that although the threecomponents may not correspond they do exist. Thereforeit is helpful in fear research, to specify whichcomponent is being reported.The importance of fear in any person's lifedepends to a large extent on its intensity, duration,and frequency. The subjective component is essentialto any conception of fear (Rachman, 1978). Therefore,it seems reasonable that in order to understand fear asubjective description by the individual is required.Several researchers have linked the experience offear to an individual's ability to control the outcomeof the situation. Rachman (1972) posited that theability to control a potentially threatening situationdecreases the possibility of fear. Bandura's theory(1986) of behaviourial change suggests that fear is21mediated by changes in the perceived self-efficacywhich equates to an individual's sense ofcontrollability. The greater the perception ofcontrol, the less likely that the individual willexperience fear. This concept is also prominent inSeligman's theory (1975) of personal helplessness.Seligman (1975) states that the expectation ofuncontrollability "produces fear for as long as thesubject is uncertain of the uncontrollability of theoutcome" (p. 56). The sense of controllability isrelated to predictability, and according to thistheory, individuals prefer predictable events. Both ofthese theories have implications for nurses caring forindividuals who have a fear of falling. The moreinformation that an individual has about a fearfulsituation, the warning signs, and the probable outcome,the greater the likelihood of finding ways to preventit or of reducing its consequences.Concern about ways to modify fear has promptedresearchers to develop scales for describing andmeasuring the range and intensity of fears. Moststudies have been conducted on children, adolescents,college students, and psychiatric patients (Bamber,221974; Geer, 1965; Wolpe & Lang, 1964).Kirkpatrick (1984) conducted a study on a sampleof 545 men and women between the ages of 15 and 89years for the purpose of determining the presence ofcommon intense fears among adults. Subjects completeda 133-item self-administered questionnaire. Fear ofdeath of a loved one was the overall highest fear amongboth men and women. Kirkpatrick's (1984) concludingremarks are relevant for the study reported here. Hestated that the findings showed that over the lifespanchildhood fears mostly diminished by adulthood througha process of adaptation. A possible explanation foradaptation may be that an individual's identity hasbeen restructured in response to the stressful event.Kirkpatrick (1984) also found that cultural andenvironmental factors have a significant value inexplaining adult fears. In the life-span constructmodel, these factors are considered to influence and bean intregal part of an individual's adaptation.Croake, Myers, and Singh (1988) utilized a life-span approach to study the fears expressed by elderlymen and women. A total of 66 elderly adults completeda 121-item scale. The results indicated that older23women expressed greater fearfulness than men, thegreatest fears of both men and women were aging andsickness, and that these fears intensified over thelifespan. The researchers indicated the need forfurther research on patterns of adult fears with largersamples in order to generalize the results.In summary, fear is a complex phenomenon andstudies to date have been fraught with methodologicalissues. These include lack of clear definition,instruments which have not been adequately tested toestablish reliability and validity, and lack of a cleartheoretical framework to guide the studies (Key, 1986).Use of checklists to assess fear is common, but someresearchers feel they are an inadequate way to describethe experience of fear (Key, 1986; Rachman, 1972).Several researchers have concluded that the subjectivecomponent is essential to any conception of fear(Kercher et al., 1988; Key, 1986; Rachman, 1972). Key(1986) suggests that, because the study of fear is at apreliminary stage, "soft" techniques of open-endedquestionnaires and unstructured interviews are the mostsuitable techniques. He also recommends that it may beuseful to identify those fears that are unique to the24population being studied.Related Phenomena Phenomena which are closely linked to fear includeworry, concern, anxiety, helplessness, and phobias.Within the literature these terms are used frequently,interchangeably, and without precise definition.Anxiety has been investigated extensively. Someresearchers have concerned themselves with definingthis concept in order to measure it. According toIzard (1971), anxiety includes fear and two or more ofthe fundamental emotions of distress, anger, shame, andthe positive emotion of interest-excitement. Sarason's(1966) analysis of anxiety concluded that the anxietyexperience involves the fundamental emotions of fear,shame or guilt, distress, and anger. Other researchershave described anxiety as complex and incorporatingfear (Epstein, 1972; Levitt, 1967; Spielberger, 1972).Clearly, there is consensus that anxiety is notunipolar, unidimensional, or unifactoral in nature(Izard, 1971).May (1950) defined anxiety as diffuseapprehension, differing from fear in its vagueness andobjectlessness. He further described it as a state25associated with feelings of helplessness and a threatto an individual's self-concept. This definition wouldseem to involve a cognitive component.Covington (1986) equated anxiety to despair andhelplessness which relates to a realization that theindividual is personally incompetent to alter theevents. This position supports the notion that it isthe lack of controllability that causes anxiety.An individual's sense of worth is threatened when thereis a loss of control.Seligman's theory (1975) of personal helplessnessis compatible with this interpretation. Individualsperceive themselves as unable to complete a task evenwhere the event is controllable. This perception mayproduce both anxiety and depression.Carver and Scheier (1986) proposed that anxietyarose when individuals had some reason for beingconcerned about their well-being. They found thatconcern is based on an individual's perception andcognitive processing of information that eitherphysical or psychological harm is possible.Garber, Miller, and Abramson (1980) distinguishedbetween neurotic and realistic anxiety. Realistic26anxiety or fear is caused by the perception of real oranticipated danger while neurotic anxiety is influencedby hereditary factors. A view which stresses theimportance of environmental influences in thedevelopment of anxiety derives from the Neo-Freudianschool. This view posits that anxiety is sociallyproduced and, when present, reduces the efficiency ofthe individual in meeting basic needs, disturbsinterpersonal relations, and produces confusion inthinking (Garber, Miller, & Abramson, 1980).Janis (1982) postulated that worrying begins assoon as an individual perceives signs of impendingpersonal danger. Anticipation of the stressful eventand the accompanying period of worrying decreases theintensity of fear. Lack of preparation for thestressful event can cause feelings of helplessness(Janis, 1982). Miller (1979) linked worries andbrooding together as a reaction by an individual who isnot in any physical danger but who cognitivelyperceives an unrealistic fear. In his analysis ofpsychological well-being, Bradburn (1969) relatedpersonal worries to an individual's assessment ofbodily symptoms associated with psychological27difficulties and anxiety.Phobias are a special kind of fear (Bhala,O'Donnell & Thoppil, 1982) and are out of proportion tothe demands of the situation, cannot be explained orreasoned away, are beyond voluntary control, and canlead to avoidance of the feared situation (Marks,1969). Phobias may be a result of classicalconditioning processes through association (Bhala,O'Donnell, & Thoppil, 1982).There is agreement among the researchers thatanxiety arises from stimuli that are less concrete thanthe stimuli that elicit fear. Key (1986) stated thatanxiety is "an emotional reaction when the object orsituation is vague or not clearly in focus" (p. 54-55).Geer (1965) considered anxiety to be a "response to amore general or pervasive stimulus" (p. 45). Croake,Myers, and Singh (1988) believed anxiety to be aresponse to a menacing stimulus not specificallydelineated.Anxiety, worry, concern, and helplessness arecombinations of interacting fundamental emotions(Izard, 1972). The emotional processes are influencedby innate and sociocultural factors, learning, and28individualized experiences. Izard (1972) furtherstated that these emotional processes direct and affectthe cognition and behaviour of an individual. However,among the theorists there is ongoing debate about therelationship between emotion and behaviour, andcognition and behaviour. The literature is unclearabout whether emotion or cognition has the greaterinfluence on our thoughts and actions.From a review of the literature it is evident thatdistinguishing between fear and other emotions isdifficult. How these emotions affect an individual'sbehaviour has not been clearly described. In addition,descriptions of the related phenomena from theperspective of the individual are absent from theliterature. Further study is needed based onsubjective interpretation of fear in order todifferentiate it from the various related phenomena.Fear of FallingA review of the literature on falls revealed apaucity of information specific to fear of falling.Many studies implied that fear of falling was aconsequence of a fall, but few were directly concernedwith its description or measurement (Nelson & Amin,291990; Sattin, Lambert Huber, DeVito, Rodriguez, Ros,Bacchelli, Stevens, & Waxweiller, 1990; Tideiksaar,1986; Vellas et al., 1987).Nelson and Amin (1990) reviewed eight hospital andcommunity-based studies. Common throughout thesestudies were the references to the psychologicalconsequences of the fall event. The consequences weredescribed as fear of falling which resulted inrestricted mobility and inactivity which led to furthersocial isolation and physical decline. Thesereferences to the psychological consequences of a fallare supported by two recent studies. Galloway (1991)in a study of community-dwelling elderly women who werehospitalized for a fall, found that fear and worryabout falling again altered their lifestyle. They weremore cautious, more dependent on others, and lessactive. Ursic (1991) studied elderly women who hadfractured a hip as a result of a fall. Her findingssupported the notion that fear of falling again and theloss of energy and stamina contributed to alteredperceptions of self. These women were unable initiallyto return to their pre-hip fracture activity level, andthey were plagued with anxiety about the future. Both3 0of these researchers (Galloway, 1991; Ursic, 1991)identified the psychological trauma of the fall asdiminishing the women's sense of control.No institution-based studies were identified inthe literature that specifically sought to investigatethe fear of falling. A few community-based studiesattempted to quantify and describe fear of falling.Tinetti et al. (1988) conducted a one yearprospective study with a sample of 336 persons 75 yearsof age or older who were living at home. The purposeof this study was to identify risk factors for falling.As part of the assessment process, subjects were "askedabout falls occurring during the previous two years,recent mobility, fear of falling, dizziness,unsteadiness, and musculoskeletal symptoms" (Tinetti etal., 1988, p. 1702). The results indicated that, ofthe 108 subjects who fell, 48% said they were afraid offalling and, of those, 26% avoided activities becauseof their fear of falling. The method for assessing thefear was unclear and no standardized tool wasdescribed. No definition of fear was included. Fearof falling was not studied as a discrete entity but asone of the intrinsic factors. How fear of falling31related to the other factors including age, sex,health, postural hypotension, depression, and livingsituation was not described.A study by Tideiksaar and Silverton (1989) soughtto determine the presence of psychologicalcharacteristics that may place a person who has fallenat continued risk. Twenty-two individuals over the ageof 65 who had fallen and were living in the communitywere assessed for their fall under-reporting, denial offunctional limitations, and fear of falling. Theresearchers reported that fear of falling or"fallaphobia" was found in 55% of the sample(Tideiksaar & Silverton, 1989, p. 82). The subjectsdescribed the fear as panic attacks, accompanied bysudden intense apprehension, coupled with dizziness orheart palpitations, and found that the intensity oftheir feelings related to the length of time that theylay on the ground following the fall. The limitationsof this study include the small poorly-defined sampleand the retrospective nature of the study.In a sample of 115 subjects aged 62 years of ageor older who were living in a seniors' apartmentcomplex, fear of falling (25%) was found to be the32greatest fear when compared with other common fearsincluding fear of robbery, fear of forgetting animportant appointment, fear of financial difficulties,and fear of losing a cherished item (Walker & Howland,1990). The results of this study showed that falls arefrequent and fear of falling prevalent among thissample. The researchers suggest that interventionsintended to increase knowledge about falls and promotebehaviourial change should focus on the individual'ssense of personal control in order for theinterventions to be more successful (Walker & Howland,1990). It might be assumed that the type of livingsituation described in this study would provide asense of security; and, therefore, the fear of robberyand losing a cherished item would have less importancefor those individuals in the study. As well, it isdifficult to compare fear of falling, which theresearchers found was associated with limited mobility,reduced social interaction, and compromised quality oflife, to fear of financial difficulties.Downton and Andrews (1990) carried out aretrospective study of 203 fallers and non-fallers over75 years of age for the purpose of describing factors3 3associated with falls. They assessed dependency,depression, cognitive function, anxiety, and drug usewith a variety of standardized questionnaires. Fear offalling was assessed by asking the question: Do youlimit your activity because of fear of falling? Theresults indicated that over half of those who hadfallen in the previous 12 months and a third of thosewho had not fallen limited their activity due to a fearof falling (Downton & Andrews, 1990). The results alsoshowed that subjective dizziness and fear of fallingwere associated with higher dependency, an increasednumber of physical symptoms, greater drug consumption,and higher scores for anxiety and depression. Theresearchers subdivided the sample several waysincluding inside fallers and outside fallers but foundthat all groups were equally anxious and depressed.They concluded that "fear of falling is itself asubstantial problem for elderly people" (Downton &Andrews, 1990, p. 97).One study was reported in the literature thatdescribed the development of a tool to measure fear offalling and its effect on functional decline. Tinettiet al. (1990) developed the Falls Efficacy Scale (FES)34based on the operational definition of this fear as"low perceived self-efficacy at avoiding falls duringessential, non-hazardous activities of daily living"(p. 239). The self-efficacy concept is based onBandura's (1986) theoretical assumption that cognitionprocesses underlie emotions. The article describingTinetti et al's. (1990) work reports on preliminarypsychometric data associated with the development ofthe FES.Although the study by Tinetti et al. (1990) isquantitative and the tool has had insufficient testing,some of the early results are relevant for the researchreported here. The FES score was associated withdifficulty getting up after a fall, anxiety trait,general fear, and balance and gait. The researchersfurther stated that self-efficacy was shown to beinfluenced not only by relevant skills, but also bypast experience, vicarious learning, and socialcontact. As well, the association between the FES andanxiety trait suggests the influence of hereditaryfactors. While this study did address fear of falling,there is still a lack of information from theperspectives of individuals who live with this fear on35a daily basis.To date the experience of fear of falling has notbeen examined from the individual's perspective. Nostudies have been found that confirm and describe thefear associated with falling.SummaryIn this chapter the literature was reviewed thatwas relevant to the study and included research onfear, related phenomena, and fear of falling. Theresearch on fear and related phenomena focused on theidentification of the stimuli causing the fear and thephysiological response to this fear. The researchersacknowledged that a subjective component was essentialto the conception of fear, and they referred to arelationship between fear, cognition, and behaviour;however, there was a dearth of information on theserelationships. In the research on falls, fear offalling has been identified as a serious problem forthe elderly; however, the research has been limited toattempts to demonstrate a relationship betweenfunctional ability and fear. Missing from the researchis a description of the experience of fear of fallingfrom the individual's perspective, the meaning the36phenomenon has for the individual, and the effect ithas on cognition and behaviour. The following chapterdescribes the methodology which guided this study.37CHAPTER THREEMethodologyIntroductionThe phenomenological method was used for thisstudy to gain an understanding of the experience offear of falling from the perspectives of elderlyindividuals who had previously fallen. This chapterdescribes how the research data were obtained and ispresented under the following topics: the selection ofparticipants, data collection, data analysis, andethical considerations.ProcedureSelection Criteria The selection criteria were purposefully developedin order to ensure that the sample was knowledgeableabout the experience under investigation and able toprovide descriptions that would increase theresearcher's understanding. The following is adescription of the selection criteria, the procedurefor recruitment, and the characteristics of theparticipants.The criteria for inclusion described eachindividual in the following way:3 81. Seventy-five years of age or older.2. Lives independently in a non-institutional setting.3. Resides in the Capital Regional District.4. Has fallen at least once within the last sixmonths.5. Has the ability to recount and describe his/herfear of falling.6. Is English speaking.The rationale for these criteria will be discussedbriefly. The age specification was set to ensure thatthe descriptions were obtained from an elderlypopulation. The purpose of this study was tounderstand the experience under investigation from theperspective of those living in the community;therefore, the institutionalized elderly were excluded.Because the researcher resided in the CRD, theresidence requirement was set to ensure ease of accessto the participants by the researcher. To ensure vividrecall of the fall event and the subsequent fear offalling again, it was specified that at least one fallhad occurred within the last six months. The abilityto recount and describe fear of falling was specifiedin order to exclude those individuals whose memory or3 9mental status would make it difficult to obtainaccurate descriptions of the event. Because theresearcher was fluent in English only, it was necessarythat the participants were able to converse in thislanguage to ensure and facilitate understanding betweenthem.Selection and RecruitmentThis study was concerned with understanding thefear of falling experienced by an elderly individualfollowing a fall. Participants in a qualitative studyare selected because they are knowledgeable about thephenomenon under investigation and can engage incooperative dialogue with the researcher (Rnaack,1984). A planned procedure for the recruitment of theparticipants was followed. Initially, approval for theresearch in terms of protection of human rights wasobtained from the University of British ColumbiaBehaviourial Sciences Screening Committee for Researchand Other Subjects Involving Human Subjects.Permission to recruit participants through Long TermCare (LTC) and Home Nursing Care (HNC) was obtained inwriting from the Capital Regional District's CarePrograms (CRD).40Participants were identified from the caseloads ofcommunity health nurses working in the LTC and HNCdivisions of the CRD's Care Programs. A verbalexplanation of the study and selection criteria weregiven to the nurses. Potential participants who metthe selection criteria were approached by the nurses todetermine their interest in the study. The communityhealth nurses reviewed the letter of information(Appendix A) with the potential participants.Participants who acknowledged that they had a fear offalling and were willing to take part in the study gavepermission to the community health nurses for theresearcher to contact them. Names of these individualswere given to the researcher. Initial contact by theresearcher and further explanation was done bytelephone. A home visit for the first interview wasarranged with those individuals who agreed toparticipate. A consent form was signed at this time.(Appendix B)As is typical in a qualitative design, subjectselection is complete when the phenomena being studiedcannot be illuminated any further. Therefore samplesize is not predetermined (Sandelowski, 1986). In this41study several individuals were approached by theresearcher and declined to participate. The initialsample size was eight, but was enlarged by one when thequality of the data was determined to be inadequate.The sample included six women and three men whose agesranged from 75 to 91. Their mean age was 84. All ofthe participants had fallen more than once, and all hadsustained some kind of injury as a result of a fall. Amore complete description of the participants will bepresented in Chapter Four.Data collectionIn a qualitative study, knowledge andunderstanding are developed through experiences thatare shared and understood by the participant and theresearcher (Rist, 1979). To facilitate anunderstanding of the experience from the individual'sperspective, the researcher uses the technique of"bracketing" which involves consciously setting asideany preconceptions about the phenomenon under study(Knaack, 1984, p. 111). Using the strategy of in-depthinterviewing, the researcher actively engages in theinteractive process and enters into the world of theindividuals whose experiences are under study (Oiler,421982). This method of data collection allows theresearcher to get close to the data and be immersed inthe phenomena before attempting to interpret them. Inaddition, the researcher actively listens for key wordsand statements and verbally reflects them to theparticipants in order to facilitate furtherdescriptions (Omery, 1983; Knaack, 1984). The accuracyof the description is enhanced by verification of themeaning with the participant.A set of trigger questions (Appendix C) was usedby the researcher to guide the initial interviews andas a means of eliciting rich descriptions of the humanexperience without telling the participants what to say(Knaack, 1984). In addition, the researcher askedquestions based on the experiences described by theparticipants. In this way "the researcher 'takes onthe role of the other..' and seeks to understand 'thedefinition of the situation' from within the frameworkof the participants" (Rist, 1979, p. 20). Subsequentinterviews with the participants were based onquestions which arose from the analysis of the initialinterviews.All interviews were conducted by the researcher in43the participants' homes. They were each 50 to 90minutes long, tape recorded, and transcribed verbatim.Written notes were made to record conversations nottape recorded, phone calls, and descriptions of theparticipants' non-verbal communication. Eachparticipant was interviewed once and six wereinterviewed twice. Second interviews were unable to becompleted with two of the women because they diedduring the study and the third woman moved to a LongTerm Care facility. Two of the participants wereinterviewed a third time for purposes of validation ofthe data.Data Analysis The process of data analysis occurred concurrentlywith data collection which allowed validation ofemerging themes and concepts with the participants. Inaddition, data reduction during the collection stageassisted in decreasing the quantity of the data beinggenerated.Giorgi's (1985) method of analyzing data in aphenomenological investigation guided this process.Each transcript was read in its entirety "to get asense of the whole" (ornery, 1983. p. 57). The44transcript was read slowly a second time for thepurpose of identifying common statements or ideas andidentifying "meaning units" (Giorgi, 1985).Identification of patterns of meaning or themes wasachieved through constant analysis which involvedinferring, questioning, and modifying the data. Theemerging themes were compared by relating them to eachother and to the whole.The third step was the transformation of theparticipant's everyday language into language orconcepts of science. This step was facilitated by aprocess of reflection and imaginative variation.Integration and synthesizing of the participants'perceptions comprised the total description.Throughout the data collection and analysis theresearcher validated and clarified the themes throughongoing review and reflection of the data. To ensurethat the descriptions were recognizable by theparticipants as representative of their experience, theresearcher sought confirmation with each participant.Sandelowski (1986) has stated that the credibility of astudy is established when the descriptions of theexperience are immediately recognized by those who have45had the experience.Auditability of this study was established bythe researcher through the clear articulation of the"decision trail" (Sandelowski, 1986, p. 33). A cleardecision trail describes and justifies what was doneand why. For this study, the analysis and conclusionswere reviewed by the researcher and thesis committee onan ongoing basis to verify the progression of events ofthe study and their logic (Sandelowski, 1986).Ethical Considerations The approval of the UBC Behaviourial SciencesScreening Committee for Research and Other StudiesInvolving Human Subjects was obtained prior to datacollection. The standards as approved by the Committeewere followed throughout the study.Participation in this study was voluntary. Allparticipants were given both a verbal and writtenexplanation of the purpose of the study, the timecommitment required, and the nature of theirinvolvement. (Appendix A) A written consent wasobtained prior to the first interview. (Appendix B)The participants were given a copy of the consent formwhich advised them of their right to decline to46participate or to withdraw from the study, andidentified that the study would not pose any threat totheir present or future health care needs.Confidentiality was ensured through coding of thetranscripts and the participants' identification wasknown only to the researcher. No personalidentification of the participants was included in thethesis. The data on the tapes was known only to theresearcher, thesis committee, and typist. All recordedinformation on the tapes was destroyed at thecompletion of the study.A brief summary of the findings of the researchwas made available to participants at their request.SummaryIn this chapter the design and methodology of thestudy were outlined and included a discussion of theselection of the participants, data collection, dataanalysis, and ethical considerations. Theparticipants' accounts of their fear of falling andtheir explanations for their behaviours will bepresented in the following chapter.47CHAPTER FOURCharacteristics of the Participants and Their AccountsIntroductionThis chapter presents the characteristics of theparticipants and their accounts related to their fearof falling again. These accounts were generated fromquestions which reflected the framework of the study:the lifespan perspective. During the interviewprocess, meanings were formulated from theparticipants' accounts. The meanings were thenclustered into emerging themes through the process ofconstant comparative analysis of individualexplanations. Together the themes represent theessential structure of the phenomena of fear of fallingagain.Out of these themes there were two underlyingconcepts which recurred and were evident throughout theparticipants' accounts: control and self-enhancement.The importance of these two concepts will be discussedin the following chapter in relation to the presentfindings and current research.The findings are presented as two major inter-related themes. Each theme arises from the48participant's fear of falling and represents a processof adjustment. The first theme, making meaning of theexperience, describes the way participants made senseof their fearfulness. This theme is comprised of threeelements: linking fearfulness to falling, recognizingother fears, and appraising self. Together theserepresent the ways in which the participants sought tounderstand and interpret their fear of another fall.The second major theme, integrating the meaning of theexperience into daily living, describes the way theparticipants sought to restore balance into theirlives. There were two elements within this theme. Thefirst, reordering behaviour, includes the behaviouralcoping strategies which the participants implemented inorder to control their risk of falling again: alteringmobility, changing activities, following routines, andaccepting help. The second, preserving identity,represents the participants' efforts at maintaining aconsistent sense of self. Two introspective processesare described: favourable comparison to others andsolitary reflecting. The individual's identity wasalso influenced by the reordered behaviours.4 9Characteristics of the Participants The individuals in this study represented thefrail community-dwelling elderly. They all had one ormore chronic health problems including osteoporosis,osteoarthritis, Parkinson's disease, hypothyroidism,cataracts, diabetes, cancer, and peripheral vasculardisease. Two of the men had suffered a cerebralvascular accident and all of the participantsexperienced decreased visual acuity and hearing.The participants exhibited varying degrees ofmobility. Two individuals used a cane, three requireda walker, one depended on human assistance at alltimes, one needed human assistance only when outside,and one was confined to a wheelchair. One of the mendid not use any walking aides, and as a result he oftenfell; however, he still drove his car occasionally.Socially the participants were isolated. Onewoman had not been outside her apartment for over ayear and several of the other women had been out onlythree or four times in the last year for doctor'sappointments or special family affairs. Only oneparticipant regularly left his home to engage in asocial activity. The other two men left their homes50several times monthly for grocery shopping and doingsmall errands. One of the men was always accompaniedby a neighbour.The living arrangements of the participantsvaried: seven lived alone either in an apartment ortheir own home, and two shared a home with an adultchild who was absent from the home during the day. Allof the participants were widowed. Eight had homemakerassistance which ranged from once every two weeks to 24hour care. They received help with cleaning, laundry,personal care, and meal preparation. All had help withgrocery shopping which indicated their difficulty inmobilizing outside the home. Seven of the participantshad raised children, and for them the family providedanother avenue of support. Three used a medic-alertsystem.Falling was a recent event for most of theparticipants. Three had experienced their first fallwithin the last four years, and six began fallingwithin the last two years. All participants reportedfalling at least once within the last six months. Theparticipants all had fallen frequently: six had fallenthree times, two had fallen twice, and one reported51falling many times. Of the nine participants in thisstudy four described near falls, stumbles, and tripswhich they had not perceived as falls because they hadnot landed on the ground. A variety of physicalinjuries resulted from their falls. Six participantssuffered fractures ranging from a fractured hip to"cracked" ribs. The other participants sustainedbruising and lacerations. Six required hospitalizationand rehabilitation before returning home. All of theparticipants suffered the psychological consequence offear of falling which they attributed directly to theirfalls.The Accounts of the Participants The participants' accounts of their fear offalling again are presented in this chapter. Theverbatim comments made by the participants are includedand help to illustrate the researcher's interpretationand conceptualization of these accounts.Making Meaning of the ExperienceThe first major theme, making meaning of theexperience, represents the efforts of the participantsto make sense of their feelings about fear of fallingagain.^Making meaning is a highly individual process;52and, therefore, the participants' interpretationsreflected differing perspectives. The data arepresented in relation to the three elements whichcomprise the theme of making meaning: linkingfearfulness to falling, recognizing other fears, andappraising self.Linking Fearfulness to Falling. The interviewdiscussions began with the participants telling theirstories about their falls which they described indetail. Emerging from these discussions were thereasons why the participants felt afraid. In recallingtheir falls the participants denied feeling afraid atthe time of the fall and attributed this to theunexpectedness and suddenness of the event:Well, that is just the way it is, somethinghappens, you don't know what to do or how to stopit or anything, you just, it didn't last long. Itwas only less than a second. During that time Ilost all tension in my muscles and so I just fell.That's all, I wasn't afraid at the time.The onset of the fear of falling varied among theparticipants and was attributed to the severity oftheir injuries and the number of falls they had53experienced. Some of the participants related theirfear of falling to problems associated with theirchronic illnesses. They were worried about theirphysical health and this seemed to accelerate theirfear of falling. One man described the change in hisfeelings about falling following a recent stroke whichhad left him with marked weakness on one side:Recently I have been more concerned. I wasn'tconcerned at most of my earlier falls of a year ortwo ago, but now, I am cautious and consciousabout it. I know if I fall, I'm going to gethurt. There is not much doubt about it, so I giveit much more serious consideration since mystroke.For some of the participants feeling afraid ofanother fall related to their feelings of helplessnessfollowing the fall. These feelings were confirmed ifthey were unable to help themselves up or if theyneeded hospitalization. Help was often required fromfamily, friends, neighbours, and even strangers "andah.. the milkman had to come and lift me up", "yes, Ididn't move at all and they came", and "Bob came overand the woman downstairs heard it."54For all of the participants, the worry aboutbecoming a burden to others exaggerated their fearabout falling again. Relying on others confirmed theirdeclining abilities and was in sharp contrast to theirself-image:I've always been able to do for myself. It seemslike I've lost the ability to deal with myself.Because it's not that I hate, I shouldn't saythat, I don't like to put people out of their way.Falling had an impact on the way they felt aboutmobilizing. Their fearfulness ranged from feeling"terrified" to feeling "anxious." As a result theymoved with a foreboding sense of caution. One womandescribed the tenseness she felt:I get panicky. That's why I say, that you got to,don't tense up. If you tense yourself up you'vegot more danger going down than if you just relaxand go the other direction. Getting tensed up andafraid, uh, is one sure way of going down and..that's me.Some of the factors which had an impact on the feelingsof two of the participants were the expectation thatfalling was common to growing older and the influence55of a lifelong pattern of falling:You know, sure you stumble a bit at times,especially when you get older.I've been falling all my life. They were nothingin my life. I didn't expect to be injured in anyway and I never was really. It's the same nowexcept I am conscious of falling again.For these two participants, a fall confirmed theirexpectation and adapting to their fearfulness was lessdifficult.In making sense of their fear of falling again,the participants were afraid of another fall becausethey feared its consequences, "You can't stop it andyou know what the possibilities are." Thinking aboutfalling again triggered thoughts about their otherfears.Recognizing Other Fears. The participantsdescribed other fears related to the consequences whichthey perceived would result from another fall: fear offracturing a hip, fear of hospitalization andplacement, and fear of mental deterioration. Togetherthese were believed to be the reasons for feeling56afraid of another fall.Breaking a hip was their greatest fear and wasbelieved to be an event from which there might not beany recovery. It was perceived as an event which washighly probable should they fall again. They alsobelieved that it would confirm their decline:I would be scared to death I would break my hipand I'd be back in the hospital and, uh I don'tthink I could take it. I think that would be thelast thing I could take. That would be the finalof me because I just couldn't take it. I couldn'tfight it.The fear of fracturing a hip was reinforced byphysicians, nurses, and friends:I hear if from everybody. Nurses at the hospital,you know, you are lucky you didn't break a hip.You are lucky you didn't break a hip. Really, I'mscared stiff.The participants acknowledged that a fracturewould mean hospitalization. The meaning ofhospitalization for the participants was based on theirpast and present experiences with hospitals. Theyrecalled being "looked after", "the lack of privacy",57and the "impersonal care." Hospitalization meant theywere dependent on others and less able to control theirlives. A loss of identity was a concern for several ofthe participants:The trouble with the hospital as far as I amconcerned right now, is the nurses generallyspeaking don't know you because they're only thereone day and you never see them again.Many of the participants had been cared for in units orrooms where other patients were disoriented andconfused and this contributed to their negativefeelings about hospitals. This exposure alsocontributed to their fear that their own mentaldeterioration would accompany another fall, and thisincreased their fear of falling again. They perceivedthat being confused would make them dependent andpowerless. One woman had cared for her confusedhusband, and she worried that she might be similar:If I wasn't here to care for him, you know, it wasa handful. He didn't know anybody. I know whathe was like and I know what my brother was like,so God help me if I'm in the same position theyare. So, uh, I'm very careful not to fall again.58The participants believed that being hospitalizedfor a fall would ultimately result in permanentplacement, and they worried about the loss of theirhome. "Home" symbolized who they were; they had morecontrol, independence, and privacy in their home:It's mine. It's my front door. It's mine. Idon't have to answer to anybody. If youunderstand what I mean. That's important to me.I don't have to answer to anybody.Placement would mean that the participants' activitieswould be regulated by others, and this would mean aloss of decision-making. They perceived that theywould have less control over their lives. Thinkingabout permanent placement caused them to worry moreabout falling again.Other individuals worried about being abandoned byfamily and friends if they lived in a facility. Theyfeared the loss of meaningful relationships andimagined an uncertain future. Anxiety about fallingagain increased for some of the participants whenfamily members threatened to institutionalize them ifthey fell:"You know mother if you have another accident and59have to go to the hospital you won't be cominghome when you come out of the hospital." Ithought that was a little bit rough.The participants also worried that their identitywould be lost in the institution. One woman'snegative experience with a friend increased heranxiety:She [her friend] opened her purse one day thereand showed it to me, I said, "Don't you know whatshe is showing you?" That they took everythingfrom her, her identity card. She has nothing inthere. I would be like that. They would come andtry to get my purse, they would have a fight! Isaid, "That is your privacy. That is youridentity."In making meaning of the experience of the fear offalling again, the participants were afraid because ofthe perceived consequences of another fall. Theyperceived that another fall could result in a fracture,hospitalization, placement, and mental deterioration.These were significant concerns for them and threatenednot only their physical survival but also theirperception of themselves. Through a process of60appraisal, the participants thought about themselves asthey tried to find meaning in their fear of fallingagain.Appraising Self. Falling and the fear of fallingagain represented a threat to the participants' self-perceptions because it altered how they felt aboutthemselves. It triggered a process of self-appraisalas a way of making meaning of their fear:But when I started falling, and I couldn't giveyou a good reason for falling. I had to turnaround and look at myself. Look at thingsdifferently. Yes I feel differently.When the participants were asked to describe theeffect of their fearfulness on their lives, they allrecalled images of themselves as independent,competent, and confident individuals. Since fallingthey viewed themselves as more dependent and less ableto carry out their daily activities independently. Themost common feeling expressed by the participants as aresult of their falls was the loss of confidence inmobilizing. The loss of confidence increased theirfear of falling again:61Well I think the main loss of confidence was inthe actual physical side of the thing, you know.That's what I'm not confident about anymore. Idon't feel confident that I cannot fall sometime.Feelings of uselessness and unreliability were alsodescribed by the participants. Declining abilities andthe reliance on others had an impact on their self-image:It hurts yourself. It hurts your self-image. Itdoesn't physically hurt you, you know what I mean.It's a mental state. It's sort of you are no darngood.One man related his fearfulness to the feeling thatfalling meant he was losing the ability to control hisactivities:I suppose I was losing control. I can never go outanymore up to the park.The fear of another fall seemed to expose theirfeelings of vulnerability, and they reflected ongrowing older. Aging and the associated losses ofstrength and stamina were a focus of their attentionsince falling:62Before those falls I used to be able to go, go,go, but now I can't. I must be old. Too tired togo.Thoughts about the future were triggered by theirthoughts of what might happen should they fall againand this increased their fear:I'd never thought what I would be like, because Inever thought I'd live this long, for one thing.And I've often said, "I hope I don't live to beold and crippled." But I did. You don't have anysay.This woman had been confined to her apartment foralmost a year because of her fear of falling again.Fear of falling again represented a threat to theparticipants, both physically and psychologically. Inresponse to this threat, a process of adjustmentoccurred. The participants attempted to make sense ofthe meaning of their fear within the context of thefall event, their other fears, and their self-perceptions. The way in which the participants madesense of their fearfulness represented the first themeof the adjustment process, making meaning. Makingmeaning was a way for the participants to understand,63predict, and control their situation. Finding meaningin their experience initiated efforts at planning forthe future as a means of control. In an attempt tointegrate the meaning of the experience of fear offalling again, they developed adaptive strategies.Integrating the Meaning of the Experience The second major theme is integrating the meaningof the experience of fear of falling into daily living.It represents the efforts of the participants to adaptto their fearfulness. Because the fear of fallingthreatened the physical and psychological survival ofthe participants, they dealt with their fear on twolevels: behaviourally and cognitively. They reorderedtheir behaviour in order to decrease the risk offalling again and as a way to attend to the problemsassociated with living daily with the fear of fallingagain. The reordered behaviours centred around theirability to gain control over their fear of fallingagain and over their lives. The changes they made totheir behaviours also influenced their perceptions ofthemselves: the changes helped to enhance theiridentity. Preserving their identity was a cognitive,introspective process which was aided by self-enhancing64efforts and the reordered behaviours.Reordering Behaviour. Reordered behaviours werethe observable changes that the participants made inorder to cope with their fear of falling again. Thesechanges included altering mobility, changingactivities, following routines, and accepting help.Their primary purpose was to limit the threat ofanother fall and to maintain control over theirindependent lifestyle. All of the participantsacknowledged that they needed to make changes in theiractivities:You have to accept that. If you accept that, youcan never, I know I can't go on. I can't do whatI was doing before.Fear of falling was a pervasive feeling whichaffected all aspects of the participants' lives andaltering mobility was the most common strategy used bythe participants as a way to reduce their fear. Theway they mobilized since falling reflected a consciousawareness of the need to be cautious and careful.Their movements lacked spontaneity and instead weredeliberate and calculated:65I'm awfully careful now, how I walk over things.I'm always conscious you know. Don't forget for amoment.That's with me, I'm not automatic anymore.But I do consider, think all the time of notfalling again.The participants changed the way they walked in orderto prevent another fall:I don't walk the way I used to walk at all, yes,well they [referring to her legs] are stiffbecause I walk like that, not because my legs arestiff. There's nothing wrong with my legs. I walkand I, uh, if I'm going to make it or if I'm goingto fall, because specially I'm more scared sincethe last fall because it happened so fast.Another participant gave this account of how he walkedin order to be as safe as possible when he was outside.He ignored the risks associated with walking in thisway:I walk with my head down looking for obstructionson the pavement. That's the one thing that keeps66me out of trouble. I don't like walking bent downlike this, but this is the only way to go.Verbal reminders, visual cuing, and mentallyrehearsing their planned movements were ways in whichthe participants felt more secure in mobilizing. Usingwalking aides, including canes and walkers, to assisttheir mobility also increased their sense of security.Since falling and becoming afraid of another fall,seven of the participants used a walking aide; theothers steadied themselves on furniture and the wallsof their home:Oh yes, yes, because you walk in there and it'smore, it's on wheels, you see and you feel moresecure.Accepting the need for a walking aide was moredifficult for two of the men because it wasinconsistent with their self-image. For these twoparticipants, the importance of their image wasstronger than the issue of personal safety. Both menfell frequently and were at high risk for a seriousinjury.Six of the nine participants were afraid offalling and being alone if they fell. They felt unable67to go out of their homes unless accompanied by familyor friend. Being with someone helped them to feel safeand secure, but also made them feel less independent.As a result they altered their mobility pattern:I'm afraid that if I go out by myself, I mightdrop on the street. So I usually wait for mydaughter and my granddaughter or this lady that,this lady I don't know. I don't go out veryoften.The participants believed that the freedom toremain in their own homes depended on their ability tosafely mobilize. This was a strong motivator becausethe loss of their home was perceived to be the ultimateloss which would signal the end of their independentlife. One woman who used a walker and was crippledwith osteoporosis struggled to walk safely to thewashroom. Maintaining control over her bodilyfunctions gave her a feeling of independence and sheinterpreted it as evidence that she was able to remainat home:I keep saying, please God, you know, let me getaround properly in this [walker]. Please God letme be able to go to the bathroom, and every time I68go in that bathroom now it's almost like I hategoing in because I've fallen in there so much, yousee.This woman was afraid of falling each time shemobilized, but her desire to be independent and in herown home motivated her to ambulate very cautiously,slowly, and with her walker.Thus, to reduce their fear of falling again theparticipants altered their pattern of mobility byincreasing the care and caution with which they moved.Changing their mobility helped to increase theirfeelings of security and independence, and gave them asense of control over their activities.Changing their activities was the second mostcommon strategy employed by the participants as a wayto reduce their fear of falling. Because of their lackof confidence in mobilizing, the participants chose torestrict their activities outside the home:I put it off and put it off [going uptown]. So Ihaven't gone yet.Activities outside their homes were perceived to bemore unpredictable and more difficult to control.Thus, the participants felt safer ambulating within69their homes in familiar surroundings.For some of the participants restricting theiractivities represented significant losses to them, andthey had difficulty reconciling the need to be safewith the need to accomplish meaningful activities. Onewoman remained positive about the changes even thoughshe was saddened by them:I feel different because I can't do nothing[without help]. But before I used to doeverything for myself. My own washing, and, butnow, that is the difference in me. I can't be thesame. I, uh, but I, I'm still happy the way I am,except I would like to be able to move about more.Restricting their activities to their own homeshelped to reduce their fear of falling again but alsoisolated them from family and friends. The loss ofcontact with friends was more difficult for thosewithout children. For one woman this loss reinforcedher own aging and she expressed a feeling ofhopelessness:Uh, I'm alone too much. My friends come, but theylive away out and they've got other things to do,and they get sick. I have one friend that I'm70very close to and now she has had her breast offand then a bad shake, so she can't come any more.You see, my friends are getting old along with meand they are wearied out the same as I am.To cope with the social isolation, the participantskept in contact with friends and family by phone. Theyalso spent long hours occupied in solitary activitieslike reading, watching television, listening to theradio, and contemplation.The participants planned daily activities thatwere within their capabilities. Successful completionof simple tasks like getting dressed gave them a senseof control and independence over their lives. Thesefeelings helped to reduce the lack of confidence onewoman felt:It gives you confidence in yourself. Yourconfidence gets destroyed when you continually tryto do stuff and continually fail, well you reallythink you are a failure. Where if you dosomething, and you do it, you feel a little bit,maybe it's silly, but you feel a sense of pride.Feeling more confident also had an impact on theirfeelings about themselves.71Falling and feeling afraid of another fall seemedto accelerate the process of narrowing their interests.The participants concentrated on activities that weresimple, attainable, and that would meet their basicneeds:No, I live from day to day. I think that's thebest way to be for me. You know, I don't, I knowthere's no future to speak of and so I just dowhat is necessary every day.The participants restricted their activities toreduce their fear of falling again. The activitiesthat they selected were ones which helped them meettheir basic needs, presented the least risk of falling,and gave them a sense of control. They were able tomake choices about their activities. Making decisionshelped to maintain their feelings of self-worth.Another strategy used by the participants was toritualize their daily routines. Routines wererepetitive patterns of behaviour that helped to ensurepredictability and increased their sense of safety andsecurity. In this way routines helped to decreasetheir fear of falling again.The degree of rigidity in their routines varied72among the participants and was related to theirprevious patterns of behaviour. For those whoseprevious patterns of daily activities had beenunstructured and spontaneous the fear of falling againprompted them to develop predictable patterns ofactivities. For those who had always relied onpredictability their routines became very rigid:Oh, I've always followed a routine since my wifedied, but now I am very conscious of doing thesame thing every day. It's better that way andI'm not so likely to fall.Another factor which influenced the rigidity oftheir routines was the participants belief in the valueof routines. One man felt that his daily routine of"keeping house" gave him a purpose:Yes, I think if you are going to be interested inlife at all, you have to have a routine. Youknow, it's really better for you. To do somethingwhether it is interesting or not, if it isworthwhile. I think that's, I think it'sworthwhile to keep the house clean.Following familiar routines helped to reduce thelack of confidence they felt because they were afraid73of falling again. The participants felt a sense ofreassurance when they were able to accomplish theirdaily routines. Routines also helped them to cope withtheir limited energy and stamina. They were theeasiest way to get things done and conserved theirlimited energy resources:My whole day is a series of routines. Sort ofthose practice kinds of events. Well, uh, myroutine, even if you have your full faculties, yougo through a routine, you may not be thinking ofit, but it is a routine, and you go through thatbecause it is the easiest way to get things done.Unexpected interruptions to their daily routinescaused the participants to feel anxious and less ableto cope. As a result their fear of falling againescalated. One woman gave this account of how companycaused a disruption to her usual routine:And of course, when there is more than one personthat comes, I get a little tense. More than oneperson at a time with me, is too much, and theyhad gone and I was going to go out to the kitchenand I didn't have my walker, I always have mywalker, and I fell on my back.74Living by a series of routines was a way for theparticipants to maintain a sense of control andpredictability over their lives. Being able toaccomplish familiar tasks gave them a sense ofcompetence. Worrying about falling again was reducedby the regularity of their behaviour. These behavioursalso assisted the participants in striving toward apositive sense of self.The fear of falling again resulted in theparticipants limiting their activities. Restrictedactivities threatened their ability to liveindependently. In order to further reduce their fearof falling and maintain control over theirindependence, the participants accepted help with someof the tasks of daily living.All of the participants struggled with their needfor assistance and their desire to remain independent.Accepting help was perceived as a way for them tocontinue to live in their own homes:You have to, you have to accept things. That'sall there is to it. There are a lot of thingsamong other things, just like you have to acceptbeing helped. When you've been a person that's75been independent as blazes and all of a sudden youhave to ask everybody for help, it hurts. But,uh, finally you get to accept it that they have tohelp you and you shut up and take it, you know,and be glad that people are as kind as they are.Factors which affected their ability to accepthelp were their self-image and their health. Of thenine participants, the men had the greatest difficultyaccepting help. They had the least amount of help andlived at the greatest risk for falling again. One manresisted suggestions from his family to have increasedhomemaker help:I don't discount their suggestions that I have thehelp, but, uh, I suppose that I, I suppose if Iwere really honest about it, I feel that it is,uh, uh, false pride.Reconciling the need for help was easier for someof the participants because they were able to find newchallenges in their changed lifestyle. Teaching herhomemaker new skills was a way for one woman to manageher household tasks but also enhanced her selfperceptions:Oh yes, I have to, I have to more or less teach76her what to do because she's not used to our ways.She's not used to our cooking. I have to show herwhat to do in the cooking. I guess I still havemy brains in spite of all.Accepting help meant that the participants had tochange their previous practices. Some of theparticipants found they had to lower their standardsand others found they had to give up activities whichthey enjoyed. Fear of falling again and unsteadinessmeant that many of the participants needed help withpersonal care:I have to have help bathing and I like to have abath more than a shower and so instead of a bathI. .soaking, soak out the aches and pains. Now Ihave a shower, but I have help with that.Accepting formal help on a regular basis becamepart of the daily routine for some of the participantsand provided a measure of security for them. Fear offalling and the consequences of another fall werereduced because the homemakers were able to do taskswhich the participants were unable to do. Their fearof falling was also reduced because they knew thattheir homemakers would help them if they fell:77I was helpless on both my knees. I've gotarthritis in this knee, but anyhow, I thought wellit can't be very far from 9 o'clock. So that'swhat I had to do, just wait until she [homemaker]came, and she got me up you see into a chair. Shehelped me and I got over it. I would have been inworse shape to wait for my son.Family and friends also provided some assistance,but the participants felt less able to direct andcontrol this type of help. They accepted as littlehelp as possible to avoid being a burden.Accepting help was a strategy the participantsused in varying amounts to assist with their activitiesof daily living. Only those tasks which provided thegreatest risk of falling and which were unmanageablefor the participants were the ones relinquished tosomeone else. Being able to make decisions about thekind of assistance which was accepted helped them tofeel control over their lives.Reordering behaviour was one way that theparticipants integrated the meaning of the experienceof fear of falling into their daily lives. Makingbehavioural changes to their mobility and activities78were efforts directed toward their physical survival.These changes decreased the risk of falling again andhelped the participants manage the problems of livingwith the fear of falling. The reordered behavioursalso affected their perceptions and feelings aboutthemselves. They felt a greater sense of control overtheir independence, and in this way the behaviourshelped to maintain their psychological survival.Preserving Identity. The second strategy that theparticipants used to integrate the meaning of theexperience of fear of falling into their daily liveswas through a process of cognitive adaptation. Feelingafraid of falling again created a stressful environmentfor the participants and threatened their selfperceptions. In response they used strategies whichwould preserve their identity and enhance their senseof self in terms of their altered circumstances. Thetwo major strategies they used to help them in thisprocess were comparing themselves to others andsolitary reflecting.Feeling afraid of falling again conjured upfeelings of loss of confidence and self-worth. Thesefeelings affected the participants identity: they79threatened the maintenance of an integrated sense ofself. Comparing themselves to others was a consciouscognitive process to foster feelings of value andworth.All of the participants had either direct orindirect knowledge of others who had sustainedfractures, been hospitalized, or permanently placed inlong term care institutions as a result of a fall.They described reasons why they felt lucky as theyappraised their present situations in comparison toother individuals.Falling and fracturing a bone was something thatthe participants feared. Having survived a fallwithout sustaining a serious injury helped one womanfeel positive:I feel fortunate about the strength of my bones,more than anything because the falls I have had,some of them have been quite severe, and yet Ihaven't hurt my bones at all.For those who had sustained a fracture, they felt luckybecause they had been able to recover and continueliving in their own home. They credited their recoveryto positive personal lifestyle choices, for example80eating well and keeping active.Comparing themselves to those in poor health wascommon. It was a strategy which allowed theparticipants to view themselves favourably and in thisway they enhanced their sense of identity:Well I know lots of people in worse shape, so Ithink I'm doing pretty good. I must be doingsomething right and that helps, helps you, uh,your feelings.The participants also compared themselves withothers in the same age group. Although their socialidentity had changed with aging and their presentcircumstances, they were able to view their longevityas unequivocal evidence of their personal strengths:I have been really lucky. Next month I'll be 88.I'm 87, so I thought my God you're not too bad foran old woman. But I was always careful and keptactive. That kept me going not like some of them.One gentleman compared himself to his good friend.He admired her ability to get around, even though shewas older and had poor vision:I admire her determination. She came up here, shestayed at the Admiral, and she walked way over81here and she would walk right over here and go upto the park for coffee with me. I can't walk asfar as her but I try. She's so damn independent,but then so am I.For this gentleman comparing himself to his friendencouraged him to try and be as active.The strategy of comparing themselves to those inless favourable situations allowed the participants toreaffirm their own positive personal qualities.Feeling positive helped them to deal with the lack ofconfidence they felt in relation to their fear offalling.Solitary reflecting was another strategy which theparticipants used to enhance their self perceptions.It was a cognitive process that all of the participantspractised in varying amounts and in various ways.Memories of the past, thoughts about the future, andpresent circumstances were contemplated.All participants reflected on their past. Onewoman reflected on the past because she found thepresent and future held little hope for her since herfall. Finding comfort and predictability in the pasthelped her to maintain her sense of value and worth:82I have no future. I can't get out. My friendscan't come. I can't plan, it's too uncertain so Ilive in the past. I like it.Another woman who was housebound because of her fear offalling dwelt on the past as a way of denying herpresent circumstances. She reflected on her earlierlife because it had been meaningful. Reconciling therealities of her life into her identity was a struggle:And everybody says you're left here for a purposeand I say, "What kind of a purpose? I'm no goodto myself, I'm no good to anybody else. So whatpurpose am I left for?" It' hard to find meaningin this [life]. So I just live with it and thinkof the past, the past, yes, the past.Solitary reflecting helped several of theparticipants put their present circumstances intoperspective. Acceptance of their present circumstanceswas less difficult for those participants who were ableto resolve past regrets. Feeling satisfaction with thepast helped some of the participants view themselvesfavourably:It's really amazing that, uh, later on thatsomething I didn't like a long time ago, and I83think, gosh, that's sixty years ago. Why should Iworry about something that happened that far ago.I've made changes in my life and now, as far asliving, I don't, I have no ambition to live biggerthan this.Reflecting on the future and spending timeplanning each day enabled some of the participants tofeel control over their lives. A sense of control gavethem a feeling of confidence and improved their selfperception:When I go to bed at night. I think of it all, amI going up to the coffee shop up there tomorrow orwill I go down to the Thrifty's. Decisions,decisions and I still make them.Another outcome of solitary reflecting was therecreation of one's lifestory in order to feel positiveabout oneself. This was particularly evident with oneof the women who had struggled in a difficult marriage.She had raised her children without much support fromher husband and felt proud of her will-power and selfdetermination. Since falling and being afraid ofanother fall, she had recreated her story so that thesevirtues were an intregal part of her perceived success84at coping:I fell but I recovered. You see, if you didn'thave will-power, you won't keep your independenceat all, but uh, and you have to fight. You can'tthink it's going to come unless you try.Persevere and try, and that's with me.This woman rarely got outside and used a walker withinher home.Imagining that their physical abilities wouldimprove gave the participants a feeling of hope andfostered a feeling of control. For some of theparticipants solitary reflecting enabled them to denytheir fear and mentally wish it away:I think will I get better enough to walk by myselfto town and that, I don't know. Not the way I wasat 30 years old, but the way I was before I fell,before I was so scared. I hope for, but I don'tknow if I ever will. No it's just a dream.Wishful thinking as the saying goes.Fear of falling again affected the participants'feelings about themselves. They felt less confident,less independent and less able to control their lives.These feelings had an impact on their perception of85themselves. They engaged in solitary reflection in aneffort to preserve and reinforce their self-identity.Thinking about the past, the present, and the futuregenerated self-referent knowledge which assisted theparticipants to maintain feelings of self worth.Solitary reflection provided a validation mechanismwhich the participants used to reaffirm and preservetheir identity.The fear of falling again stimulated feelings ofloss of confidence and control, and undermined theparticipants self-identity. Thus, to integrate thesepsychological consequences into their daily living theparticipants sought ways to preserve their identity.They compared themselves to others and used solitaryreflection to regain a sense of confidence and controlover their lives. Identifying themselves on the basisof favourable comparison to those less fortunate wascomforting and promoted positive feelings. Ignoringthe present, denial of their feelings, planning thefuture, altering the lifestory, and putting things intoperspective were techniques used in the process ofsolitary reflection to promote self worth.86SummaryThis chapter has presented the characteristics ofthe participants and their accounts related to theirfear of falling again. The accounts were organizedwithin a framework developed from the themes arisingfrom the data and reflected the influence of thelifespan perspective which guided this research. Themeanings of the participants' interpretations wereviewed from a broad perspective and were conceptualizedinto two major themes of adaptation.Making meaning of the experience of their fear offalling was one of the major themes of theparticipant's adjustment process and represented theirefforts at understanding their fear. As a result offalling they developed feelings of fearfulness and theybegan to seek meaning for these feelings. The processof making meaning acted as the catalytic agent for thereordered behaviours and activities to preserve theiridentity. However, there was evidence that this was anongoing process as evidenced by the continual effortsof the participants to understand and interpret theirfeelings about their fear. Within this theme the wayin which they made sense of their fearfulness was87presented as three elements: linking fearfulness tofalling, recognizing other fears, and appraising self.The second major theme, integrating the meaning ofthe experience of fear of falling into daily livingdescribed the way the participants coped with thedisruption caused by their fear. This disruptionthreatened their physical and psychological survivaland as a result the process of adjustment occurred atthe behaviourial and cognitive levels. Within thistheme there were two elements: reordering behaviour andpreserving identity. The reordered behaviours were thefunctional changes the participants made in order todecrease the risk of falling again and to maintaintheir independent lifestyle. These included alteringmobility, changing activities, following routines, andaccepting help. These behaviours also influenced theway the participants felt about themselves. Preservingidentity involved two cognitive processes: favourablecomparison to others and solitary reflection. Theirpurpose was to elicit positive feelings of value andself-worth as the participants dealt with the loss ofconfidence, independence, and control which resultedfrom their fear of falling again. Both of these88strategies provided validating experiences which helpedto preserve their identity.The findings of this study have been presented inthis chapter. Many important issues were identified;however, two underlying concepts, control and self-enhancement recurred throughout the participants'accounts. Because of their significance they wil bediscussed in the following chapter in relation to theliterature.89CHAPTER FIVEDiscussion of Research FindingsIntroductionThis chapter will discuss the research findingspresented in Chapter Four. The most significantfindings which emerged from the themes: control andself-enhancement will be reviewed in relation to therelevant literature which is currently available.The data originating from this research identifiedfear of falling as a significant concern for theparticipants. In response to this concern, theparticipants provided rich accounts of how theyinterpreted their fear of falling and how they managedtheir lives in relation to this unrelenting fear.Their accounts were conceptualized into two majorthemes: making meaning of the experience andintegrating the meaning of the experience into theirlives. Both of these themes together represented theway in which the participants sought to adapt to theirfear of falling again. Emerging from these themes weretwo recurring concepts: maintaining control and effortsat self-enhancement, and these will be the focus ofthis chapter.90Maintaining Control The fear of falling again undermined theparticipants' sense of control. They felt less able tocontrol another fall and less able to control theactivities of daily living. Efforts to maintaincontrol were exemplified by actual behaviouralactivities as well as cognitive activities.The participants' initial efforts to maintaincontrol occurred during the process of making meaning.They sought to attribute their fearfulness to eventswhich they could identify, including the fall itselfand its consequences. Being able to identify thesource of their fearfulness was one way theparticipants felt a sense of control. Individuals whoexperience a threatening event will make attributionsin order to understand, predict, and control theirenvironment (Taylor, 1983). Causal explanations ofsome kind were sought by each of the participants inthis study. Thus, the participant's process ofunderstanding and interpreting their fear can beunderstood from this perspective.Another way that the participants sought tomaintain control was by blaming specific circumstances91for their fall and fearfulness. Identifying thesecircumstances reassured the individuals that they couldsomehow avoid a recurrence. Assigning blame representsa desire for control (Walster, 1966). Viewed in thisway laying blame positively benefitted the individualbecause it acted as a self-protective mechanism whichprovided a feeling of control.The findings of this study indicated that theparticipants had varying perceptions of control.Perceived control can be either internal or external(Rotter, 1966). Internal control is contingent uponthe individual's own behaviour while external controlis contingent on others. This helped to explain whysome of the participants felt marginally in control,while others felt a significant amount of control evenwhen they lacked the physical resources to actualizetheir control. This suggested that the perception ofcontrol may be more important than the actualbehavioural control. Taylor (1983) proposed thatillusionary control is beneficial and can motivate anindividual to persist in their behavioural efforts toachieve personal control and self-enhancement. Shedescribed illusionary control as the perception of the92probability of success even though the outcome cannotbe influenced. Not having a strong sense of personalcontrol or perceived control seemed to strengthen thenegative impact of the experience of the fear offalling. Therefore, the participants' perceptions ofcontrol helped to explain their persistent behaviourstoward control and their determination to beindependent even in the face of significant losses.The fear of another fall caused a disruption tothe participants' previous activities. They had lostconfidence in mobilizing; and, as a result, theylimited their activities. Activities within theirhomes were more predictable and gave them a sense ofsecurity and safety. Individuals who feel insecureavoid change and decline to become involved in new orunfamiliar situations (Silverstone and Hyman (1976).It was understandable, therefore, that the participantsrestricted their activities as a way to avoidsituations in which they would have less control.Another way that the participants sought tomaintain control was by following a routine for theirdaily activities. These routines were familiar andrequired the least expenditure of energy. Because of93their familiarity the participants' expectations ofsuccessfully completing them was high. Control stemsfrom the ability to predict and is heightened whenexpectations are met (Rothbaum, Weisz, & Snyder, 1982).This position is similar to Bandura's (1977) self-efficacy theory that defines the efficacy expectationas the "conviction that one can successfully executethe behaviour required to produce the outcome." (pp.193). Therefore, it seemed likely that followingroutines fulfilled several functions: conservation ofenergy, accomplishment of daily activities,reinforcement of their own abilities, and a feeling ofcontrol. All of these had a psychological benefit forthe individual.The participants exhibited ongoing efforts tocontrol and accomplish meaningful activities. Controlwas often thwarted because of a lack of resources. Thetheory of learned helplessness maintains that afterrepeated, unsuccessful attempts at control, theindividual will give up responding (Seligman, 1975).However, most of the participants in this studydemonstrated an amazing persistence to find ways tocontrol those aspects of their lives where control was94possible. They established new goals or functionswhich were within their capabilities. When controlover some aspect of their life was not possible theyshifted to something else that was controllable. Forsome of the participants finding new activities wasmore difficult than for others. This explains thedifferences in the feelings of competence and controlexpressed by the participants.The findings indicated that the ability to makedecisions was an important source of personal controlfor the participants. Having opportunities to be self-determining can be intrinsically motivating and highlyrewarding (Deci, 1975). Therefore, the participants'ability to be self-determining enhanced their sense ofcontrol and their feelings about themselves. However,conflict occurred and their fear escalated whencaregivers tried to usurp their decision-makingability, for example when family members made decisionsabout the need for formal assistance in the home.Being forced to accept help that was perceived to beunnecessary undermined their feelings of competence.The principle of autonomy is an important considerationin view of the importance of the individual's right to95determine his/her own course of existence. Individualswho are capable of rational thought have the right tobe self-determining as long as it does not infringe onthe autonomy of others (Hogstel & Gaul, 1991). Thisprinciple helped to understand not only the importanceof decision-making as an essential component of controlbut also the importance that the participants placed ontheir own cognitive ability.Another dimension of personal control isindependence and is characterized by the ability to acton decisions (Johnson, 1991). For the participants,home symbolized their independence; and, in order tomaintain it, they accepted help. Although notphysically able to act on all of their decisions, theywere able to realize them through the efforts ofothers. They felt a personal sense of control overtheir independence when they were able to hire,organize, direct, and guide their formal caregivers.Personal control was also realized when they were ableto make decisions about which activities theyrelinquished and which activities they struggled toretain.The findings of this study illustrated the96importance of maintaining control for individuals whowere afraid of falling again. Maintaining personalcontrol was related to the meaning one attaches to anevent, predictability of activities, decision-makingability, competence, and independence. Personalcontrol was realized through the participants' directefforts to reduce the threat of another fall and theiraccompanying fear, but also from their perception ofcontrol. The perception of control was illusionarybecause actual control was unattainable. However,because it involved a positive interpretation of asituation it helped the individual avoid disappointmentand maintain hope. Both types of controlpsychologically bolstered the identity of theparticipants.Self-Enhancement Feeling afraid of another fall influenced how theindividuals felt about themselves. Their identity hadbeen altered and they felt less confident, lesscompetent, and questioned their self-worth. To dealwith these feelings, they engaged in cognitive effortsto enhance their sense of self, including socialcomparison and self-reflection. Threatening events97have been found to affect one's self regard even whenthe causal relationship was clear (Bulman & Wortman,1977: Taylor, 1983). Thus, the negative effect of thefear of falling on the individual's self-perceptioncould be understood form this perspective.Comparing themselves to those in less favourablepositions was a strategy which all participants used tosome degree. No matter how debilitated or functionallyunable the participants were, they compared themselvesto someone in a worse situation. As well, theyfabricated comparison persons when none existed throughtheir own experiences. The participants usedcomparison as a means of self-enhancement and as a wayto feel more self-worth. This process also seemed tobe a mechanism of self-protection which reduced thethreat of coping with the fear of falling again.Social comparison theory (Festinger, 1954) was helpfulin the interpretation of the findings of this study;however, contrary to this theory the participantsthought they were doing as well as or better than otherindividuals in similar situations. These resultssuggested that they were making downward comparisons.Individuals when faced with a threat will usually make98comparisons that are self-enhancing and bolster theself-esteem (Wills, 1981). The idea that cognitiveactivity positively influenced the individuals'feelings about themselves helped explain whyconsiderable time was devoted to this activity.Some of the participants used comparison to othersas a motivator for their own behaviour. The successfulcoping of someone perceived to be more disadvantagedthan themselves encouraged them to pattern theirbehaviour similarly. The previous description of theman who tried to emulate his friend's ability tomobilize illustrated how social comparison wasmotivational. Not only was this result a psychologicalbenefit to the individual but it also stimulated thesame coping efforts. Cognitive illusions can havemultiple functions including self-enhancement,instructive, and motivating influences (Taylor, 1983).Thus, social comparison served two needs: it made theindividual appear better off and stimulated successfulcoping behaviours.The participants limited their physical activitybecause of their fear of another fall, and as a resultthey spent long periods of each day in contemplation.99Contemplation and inactivity can have positive benefitsfor the individual (Atchley, 1985). For theparticipants, solitary reflection was perceived to bean activity which was beneficial to them, and they usedthis time to enhance and validate their self-perceptions.The participants used the strategy of reflectingon past accomplishments in order to feel more positive.The literature on life review and reminiscence washelpful in understanding the process and function ofthis activity. Butler (1963) proposed that life reviewis an evaluative process to resolve, reintegrate, orreorganize what is troubling and is triggered byapproaching death. However, in this study life reviewwas used to gain a feeling of satisfaction and wasbeing done even though impending death was not afactor. Self-reflecting for these individuals seemedto occur naturally; and, since falling, the time spentin reflecting had increased. Memories of the pastacted as a repository of information about themselvesthat enabled them to make self-references. Theyselected positive aspects of their lives, and in thisway they were able to view themselves in a better100light. Reminiscence contributes in a fundamental wayto the maintenance and generation of positive self-esteem (Kovach, 1991).Maintenance of the self-concept depends upon therevision of one's life history, and individuals willremember themselves as more successful than they reallywere (Greenwald, 1980; Pearlin & Schooler, 1978).Reconstructing the lifestory as a way to minimizedissatisfaction with the past and focus on one'sperceived positive personal qualities was another waythe participants sought to enhance their feelings aboutthemselves. It follows that their positive sense ofidentity was aided by ignoring what was troublesome andemphasizing what was positive. Thus, the usefulness ofsolitary reflecting in the process of reconstruction asa means of self-enhancement was understood.The findings of this study suggested that somepeople used denial as a self-protective mechanism. Bydenying their present needs, the participants were ableto protect their self-perception and to maintain apositive perspective. This strategy does have thepotential to have a negative outcome if it supports theindividual in refusing to accept appropriate help.101Denial may be a positive adaptation strategy if theindividual does not distort reality, or action isimpossible, or the emotional distress in notpathological (Lazarus, 1981). Another perspective inconsidering an individual's use of denial was theirright to refuse help and their right to live at risk.The cognitive processes that the participants usedin this study were initiated in response to the fear offalling again. Feeling afraid had altered how theyfelt about themselves and challenged their previousidentities. To preserve their identity, they engagedin activities which were self-enhancing, includingcomparison and solitary reflecting.It was clear that the behavioural and cognitiveactivities employed by the participants overlappedfunctionally and met dual needs. The behaviouralactivities that the participants implemented weredirected toward controlling the threat of another falland their fear. By achieving a sense of control theparticipants also enhanced their feelings aboutthemselves. The need to find meaning in the experiencehelped the participants not only find an explanationfor their feelings, but also represented an effort at102controlling the reasons for their fearfulness.Likewise, self-enhancement was achieved throughcomparison and self-reflection, but also by believingin the ability to control events either throughpersonal effort or others.SummaryThis chapter discussed the findings of the studyin relation to other research, assumptions, andtheories found in the literature. The participants'perspectives as developed in this study differed fromsome of the literature, while lending support toothers. The discussion focused on the concepts ofmaintaining control and self-enhancement which emergedfrom the major themes of the study: making meaning ofthe experience and integrating the meaning of theexperience into their lives.The first concept, maintaining control, describedthe efforts of the participants to control not only thethreat of another fall and their fear, but also tocontrol their lives. Attempts to forestall anotherfall was a way to protect their physical survival. Asthey were able to maintain a sense of control, theyfelt more positive about themselves.103The second concept, self-enhancement, describedthe cognitive activities that the participants engagedin to reaffirm and validate their sense of self. Theirpositive self-perceptions were of psychological benefitto them.The adaptations that the participants made towardmaintaining control and self-enhancement were at thebehaviourial and cognitive levels. These adaptationshelped to preserve the individual's identity in theface of living daily with the unrelenting and pervasivefear of falling again.This chapter focused on a discussion of two of themost noteworthy findings which were presented inChapter Four. The summary and implications for nursingwill be presented in the final chapter.104CHAPTER SIXSummary and Implications for NursingSummaryThis study presented a qualitative approach to theunderstanding of elderly individuals who have fallenand have a fear of falling again. Falling in thecommunity-dwelling elderly is a common problem andposes serious problems for them. Previous research hasconcentrated on the identification of risk factors anddiscussions about the impact on the physical well-beingof individuals who have fallen. This study differedfrom previous research by focusing on the individual'sperspective of the fear of falling again and the effectit had on daily living.The importance of this study is also directlyrelated to the increasing numbers of elderly people whochoose to live in their own homes. With increasing agethe risk of falling rises. Both of these factors havean effect on the services which are provided toindividuals living in the community. Thus, to providecare that effectively meets the needs of the elderlyindividual who is afraid of falling again, nurses mustunderstand the meaning of the experience from the105individual's perspective. Nurses must also understandthe relationship between the cognitive adaptations andthe behaviours they observe in order to support theindividual. Greater understanding will facilitate boththe physical and psychological survival of the fearfulindividual.The phenomenological method was selected for thisstudy as it seeks to understand and describe thesubjective meaning of human experience (Knaack,1984).Using interview data generated by each of the nineparticipants in the study, the participant'sperspective was constructed. This perspectivedescribed the meaning of the fear of falling again andthe behaviours that were used in response to the fear.The lifespan construct provided a useful frameworkthat directed the researcher to consider the physical,social, and psychological qualities which influencedthe participants as they dealt with their fear offalling. This framework enabled a broad perspective tobe employed in the collection and conceptualization ofthe data.The participants' constructions wereconceptualized into two major themes: making meaning of106the experience and integrating the meaning of theexperience into daily living. Making meaning waspresented as three elements: linking fearfulness tofalling, recognizing other fears, and appraising self.The second major theme, integrating the meaning of theexperience was presented as two elements: reorderingbehaviours and preserving identity. Two of the mostsignificant findings, maintaining control and self-enhancement, were discussed in relation to currentresearch and literature.The nature of phenomenological research does notlend itself to definitive statements or is it intendedas a method of theory development. However, this studydoes suggest implications for nursing practice,education, and research.Implications for NursingThe findings presented in Chapter Five haveimplications for nursing. They will be discussed asthey apply to nursing practice, education, andresearch.Nursing Practice The importance of maintaining control and self-enhancement are critical to the well-being of everyone.107However, for the elderly individual who has suffered aloss of mobility, function, and feelings of self-worth,they are even more important. Nursing care, to beeffective, should be directed toward optimizing theclients ability to control and to perceive control overtheir situations.^Promoting feelings of control canpositively influence self-perception. Additionally,nurses should encourage the use of cognitive processesthat enhance an individual's self-regard.The finding that the cognitive process of makingmeaning occurred prior to the adaptations whichresulted in feelings of control, directs nurses toaddress this as a first concern in caring for anelderly individual who experiences a threateningsituation. Establishing a mutually respectful rapportwith these individuals by active listening is necessaryin order for the individuals to share theirexperiences. A thorough health assessment whichencourages reflection on the fall event and theirfearfulness will assist in exploring causalexplanations. Identification of the sources of theirfearfulness provides opportunities for the nurse tosupport the attributions or to provide information that108may initiate reassessment of them. Coachingindividuals to interpret their experiences as anopportunity for such positive outcomes as rest,increased safety, and reflection can contribute to anincreased sense of control.The focus of community health care is to assistindividuals toward self-care and this study indicatesthat attention needs to be paid to behaviouralactivities that help them maintain a feeling ofcontrol. During assessment the individuals' abilitiesshould be carefully investigated and a plan developedwhich focuses on the accomplishment of tasks withintheir capabilities such as meal planning, gettingdressed, and taking their medications. These tasksshould be integrated into their daily activities sothat they become part of their familiar routines. Anawareness and respect for the ritualized behaviours,the need for predictability, their limited energyresources, and the scheduling of nursing visitsconvenient to the individual are ways that the nursecan promote personal control. Ongoing reinforcement bythe nurse about the individuals' accomplishments willfacilitate positive feelings of self-worth.109The importance of maintaining control suggeststhat all interventions toward self care should involvecollaboration between the individual and the nurse.This requires that the nurse must be flexible andwilling to work toward goals which are perceived by theclient as desirable and attainable. Nurses who workwith their clients to set mutual goals, choose optionsand activities to meet these goals can facilitate theirclient's decision-making and as a result feelings ofcontrol will be promoted. Feelings of self-worth willbe enhanced when clients can make decisions about thespecific activities they are responsible for in orderto meet the mutual goal.Nurses can assist the individual to overcome thebarriers to control through the advocacy role. Therole of the advocate is to inform individuals byproviding accurate information followed by supportingtheir decisions. For example, giving the clientinformation on the role of the home support worker, thetasks which they can carry out, and the method ofassessing eligibility for this service would facilitatetheir ability to make an informed decision and enhancefeelings of control. Respecting their decisions can110increase feelings of self-worth.The finding that the accomplishment of meaningfulactivities helped give the elderly individual a senseof control suggests that nurses need to identify waysto achieve this. Establishing a network of individualswho are afraid of falling again as a support system foreach other may assist the individual to perceivegreater control through this involvement, maintainsocial contact, and provide an additional feeling ofsecurity.Community nurses are often the liaison between theelderly who desire to remain in their own home andfamily members who wish to institutionalize them or toimpose their own decisions. The nurse can supportindividuals to be as independent as possible byencouraging and setting up resources that increase thesafety of their living arrangements. For example,arranging for a medic-alert system and safety checksystem through the postal service are ways that canalleviate the anxiety of the family and at the sametime allow the individual to remain independent.Counselling family members, allowing them time toverbalize their concerns, and giving them information111on support groups can also alleviate their distress.The finding that the perception of controlenhanced self-worth and promoted persistence inbehaviour toward actual control, directs the nurse tonurture the individuals' illusions of control. Theillusion of control can be facilitated by listening andaccepting the client's need to predict events so as toavoid disappointment, encouraging persistent behaviourin simple, repetitive tasks, supporting their ongoingattempts to understand their situations so as to derivemeaning from them, and recognizing that expectations ofcontrol can potentially enhance efforts at control.Thus, to promote a sense of control in elderlyindividuals who are afraid of falling again ongoingassessment and evaluation should be carried out. Theassessment should determine the personal controldesired, the abilities needed to carry out specificactivities, acknowledge the uncontrollable situationswhich would benefit from interventions or illusionarycontrol, and evaluate the need for a sharing ofcontrol.The importance of self-enhancing cognitions was animportant finding of this study. Nursing interventions112which encourage the use of social comparison, lifereview and reminiscence can help promote positivefeelings in the individual.Nurses need to be sensitive to the expressedcomparisons that their elderly clients make. Askingopen-ended questions that invite further elaborationwill encourage them to focus on their strengths, willvalidate them, and can promote their self-perceptions.Nurses can assist elderly individuals, who do notactively engage in comparing themselves to fabricatecomparison persons. Asking questions that help themimagine another individual who would be worse off mayencourage them to make comparisons and to viewthemselves more favourably.In order for nurses to implement life review andreminiscence as self-enhancing interventions, anassessment must be completed. Determining theindividual's cognitive ability to retrieve storedinformation, to verbally communicate, and to bephysically able to tolerate and participate indiscussion for thirty minutes or more can beaccomplished during an initial head to toe assessment.Further information can be collected through the use of113a mental status tool, for example the Folstein (1975)mini-mental state. A thorough history should becompleted including details about the formative years,schooling, family life, work life, significant lifeevents, hobbies, and interests. Setting regular timeaside which is convenient to the individual forreminiscence validates the importance of their personalmemories and life history. During this interventionthe nurse should use simple prompting questions andsilence to enable individuals to share their memories.The nurse must be sensitive, supportive, and non-judgemental.Caregivers need to be informed of the value ofreminiscence and life review. Teaching them tofacilitate these strategies can help bridge the gap tocommunicating in a more meaningful way with theindividual. These strategies also have the potentialof increasing the individual's sense of belonging andparticipation through the shared memories. Anothercreative way to aide personal reminiscence is throughthe use of a memory book which can include photographs,letters, mementoes, and written details of the pastwhich provides evidence of the individuals' past114accomplishments and past successes at coping with lifestresses.Social comparison, life review, and reminiscenceallow elderly individuals to view themselvespositively. While individuals engage in reflection,they also have the opportunity to restructure theirlife story, find alternate causal attributions fortheir feelings, problem-solve daily activities, andreinterpret their present circumstances based on thepast.Nursing EducationFear of falling created stress for the individualand resulted in multiple losses and efforts to adapt.Nursing education should include loss theory,information on normal age-related losses, coping andadaptation research. Application of this knowledgewithin a supervised setting early in a nurse'seducation would facilitate the learning of thisinformation.The education of nurses in the basic programs hasfocused on diagnosis and interventions in an acute caresetting. Given the trend toward maintaining elderlyindividuals in their homes, early hospital discharge115programs, the projected increase in the population ofindividuals over the age of 65, and the number ofindividuals in this age group who will fall, it isimperative that there be a shift in the content andfocus of nursing education programs. Increasedemphasis on gerontology and community nursing areneeded to meet the needs of elderly individuals livingin the community. Opportunities for clinicalplacements, for example, in Home Nursing Care, LongTerm Care, and Adult Day Care throughout the basiceducation programs would help to prepare nurses forcommunity work.It is recommended that educational institutionsestablish a specialty in community nursing with astrong focus in gerontology in order to adequatelyprepare nurses to practice in this setting. This focusis critical because the elderly constituteapproximately 75% of the community nurse's caseload.As well the community setting requires that the nursehave advanced problem-solving and critical thinkingskills in order to practice effectively withoutsupervision or immediate peer support. Morespecifically and based on the findings of this study,116this level of nursing education should also include asignificant component on cognitive adaptations. As theelderly living in the community become more dependentand housebound, they will spend increased amounts oftime in solitary activities. Community nurses need tobe able to guide and encourage their elderly clientswho are afraid of falling to use their time in waysthat will potentially benefit them. They need tounderstand and support their cognitive illusions,comparisons, and self-reflecting. Having an extensiveclinical practicum with opportunities to integrate andapply the information on loss, stress, and adaptationof the elderly to threatening events in communitysettings will enable the nurse to meet the needs oftheir elderly clients more effectively.Nursing Research Further research is needed on the adaptationselderly individuals make in situations where they feelthreatened. Comparing the themes from new researchwith the study data and the current literature isimportant in developing a strong knowledge base aboutthe reactions of the elderly to threateningexperiences.117The findings of this study indicated thatmaintaining control was an important way that theelderly individual adapts to the fear of falling again.Therefore, research that tests the relationship betweencontrol activities and fearfulness, well-being, andfeelings about self are indicated. Determining theeffectiveness of actual control and the perception ofcontrol as strategies to foster feelings of self-worthwould be useful in the planning of care to meet theneeds of individuals who experience a threateningevent. Exploring the effects of a shared model ofcontrol between the client and nurse will help toidentify the outcome of control on client morale,satisfaction, and fear.The functions that specific cognitions serve andtheir relationship to actual behaviour merits furtherattention. Examination of this relationship with othergroups of elderly individuals who are experiencinglosses and threats to their well-being would increaseour understanding and enhance the planning and deliveryof health care to them.Another line of research that is suggested wouldbe the study of the reactions of individuals to118threatening situations where their efforts at controland self-enhancement are unsuccessful. What happens toan individual's identity when efforts are thwarted?Reminiscence and life review need to be studied todetermine their usefulness as a nursing interventionwith elderly individuals living in the community whoare afraid of falling. What triggers this process?Do they influence adaptation to stress? What are theshort and long term effects on morale, mood, and self-esteem? These are a few of the questions that couldbe studied. In addition, more knowledge about howthese strategies affect the caregiver's relationshipand communication with the elderly would be useful toinclude in the development of courses for formalcaregivers and in the teaching of family members.In conclusion, this study has described themeaning of the experience of fear of falling from theperspectives of elderly individuals who have previouslyfallen. The meaning of the experience centered aroundthe participants' efforts at adaptation bothbehaviourally and cognitively. Based on thesignificance of the findings it is important thatnurses who care for these individuals focus not only on119their physical recuperation but on their mentalrecuperation. Nurses who understand the adaptationsthat the elderly make when they are afraid of fallingagain can improve the elderly individual's ability tofunction and inspire them to find new meaning in life.Thus, nurses will be more effective in meeting theneeds of individuals who are afraid of falling again.120ReferencesAndrews, F. M., & Whithey, S. B. (1976). Social indicators of well-being: American's perceptions of life quality. New York: Plenum.Atchley, R. C. (1985). Social forces and aging: An introduction to social gerontology (4th ed.).Belmont, Ca: Wadsworth.Bamber, J. H. (1974). The fears of adolescents. The Journal of Genetic Psychology, 125, 127-140.Bandura, A. (1977). Self-efficacy: Toward a unifyingtheory of behavioural change. Psychological Bulletin, 84(2), 191-215.Bandura, A. (1986). Social foundations of thought and action. A social cognitive theory. EnglewoodCliffs, New Jersey: Prentice-Hall.Bhala, R. P., O'Donnell, J., & Thoppil, E. (1982).Ptophobia: Phobic fear of falling and its clinicalmanifestations. Physical Therapy, 62(2), 187-190.Bradburn, N. M. (1969). The structure of psychological well-being. Chicago, Illinois: Aldine.Brummel-Smith, K. (1989). Falls in the aged. Primary Care, 16(2), 377-393.Bulman, R. J., & Wortman, C. B. (1977). Attributions121of blame and coping in the "Real World": Severeaccident victims react to their lot. Journal of Personality and Social Psychology, 35(5), 351-363.Campbell, A. (1980). The sense of well-being inAmerica. New York: McGraw-Hill.Butler, R. N. (1963). The life review: Aninterpretation of reminiscence in the aged.Psychiatry, 26, 65-76.Campbell, A. J., Reinken, J., Allan, B.C., & Martinez,G. S. (1981). Falls in old age: A study offrequency and related clinical factors. Age and Aging, 10, 264-270.Carver, C. S., & Scheier, M. F. (1986). Functional anddysfunctional responses to anxiety: The interactionbetween expectancies and self-focused attention. InR. Schwarzer (Ed.), Self-related cognitions inanxiety and motivation (pp. 111-141). Hillsdale, NewJersey: Lawrence Erlbaum Associates.Costa, Jr., P. T., & McCrae, R. R. (1989) Personality,stress, and coping: Some lessons from a decade ofresearch. In K. S. Markides & C. L. Cooper (Eds.),Aging, stress and health (pp. 269-283). New York:John Wiley & Sons.122Covington, M. V. (1986). Anatomy of failure - inducedanxiety: The role of cognitive mediators. In R.Schwarzer (Ed.), Self-related cognitions in anxietyand motivation (pp. 247-263). Hillsdale, New Jersey:Lawrence Erlbaum Associates.Croake, J. W., Myers, K. M., & Singh, A. (1988). Thefears expressed by elderly men and women: Alifespan approach. International Journal of Agingand Human Development, 26(2), 139-146.Deci, E. L. (1975). Intrinsic motivation. New York:Plenum Press.Downton, J. H., & Andrews, K. (1990). Posturaldisturbance and psychological symptoms amongstelderly people living at home. Journal of GeriatricPsychiatry, 5, 93-98.Epstein, S. (1972). The nature of anxiety withemphasis upon its relationship to expectancy. In C.D. Spielberger (Ed.). Anxiety: Current trends in theory and research (Vol. 2). New York: AcademicPress.Festinger, L. (1954). A theory of social comparisonprocesses. Human Relations, 1, 117-140.Folkman, S., & Lazarus, R. S. (1988). Coping as a123mediator of emotion. Journal of Personality andSocial Psychology, 54(3), 466-475.Folstein, M., Folstein, S., & McHugh, P. (1975). Mini-mental state: A practical method for grading thecognitive states for clinicians. Journal of Psychiatric Research, 12, 189-198.Galloway, S. E. (1991). Hospital to home: Perceivedneed for care and support. Unpublished master'sthesis, University of British Columbia, Vancouver,B.C.Garber, J., Miller, S. M., & Abramson, L. Y. (1980).On the distinction between anxiety and depression:Perceived control, certainty, and probability ofgoal attainment. In J. Garber & M. E. P. Seligman(Eds.). Human helplessness: Theory and applications (pp. 131-169). New York: Academic Press.Geer, J. H. (1965). The development of a scale tomeasure fear. Behaviour Research and Therapy, 3,45-53.Gellhorn, E. (1965). The neurophysiological basis ofanxiety: A hypothesis. Perspectives in Biology and Medicine, 8, 488-515.George, L. K. (1980). Role transitions in later life.124Belmont, CA: Wadsworth.Giorgi, A. (1985). Sketch of a psychologicalphenomenological method. In A. Giorgi (Ed.).Phenomenological and psychological research (pp. 8-22). Pittsburgh, Pa: Duquesne University.Greenwald, A. G. (1980). The totalitarian ego:Fabrication and revision of personal history.American Psychologist, 35, 603-618.Guba, E., & Lincoln, Y. (1981). Effective evaluation.San Francisco: Jossey-Bass.Hinkle, L. E. Jr. (1974). The effect of exposure toculture change, social change, and changes ininterpersonal relationships on health. In B.S.Dohrenwend & B.P. Dohrenwend (Eds.). Stressful lifeevents (pp. 9-44). New York: John Wiley & Sons.Hogstel, M. 0., & Gaul, A. L. (1991). Safety orautonomy: An ethical issue for clinicalgerontological nurses. Journal of Gerontological Nursing, 17(3), 6-11.Holmes, T.H., & Rahe, R.H. (1967). The socialreadjustment rating scale. Journal of Psychosomatic Research, 11, 213-218.Hultsch, D. F., & Plemons, J. K. (1979). Life events125and life-span development, In P. B. Baltes & 0. G.Brim (Eds.). Life-span development and behaviour (Vol. 2, pp. 1-35). New York: Academic Press.Izard, C. E. (1971). The face of emotion. New York:Appleton-Century-Crofts.Izard, C. E. (1972). Patterns of emotions: A newanalysis of anxiety and depression. New York:Academic Press.Janis, I. L. (1982). Stress, attitudes and decisions: Selected papers. New York: Praeger Publishers.Johnson, J. L. (1991). Learning to live again: Theprocess of adjustment following a heart attack, InJ. M. Morse & J. L. Johnson (Eds.). The Illness experience: Dimensions of suffering. Newbury Park,Ca: Sage.Kercher, K., Kosloski, K. D., & Normoyle, J. B. (1988).Reconsideration of fear of personal aging andsubjective well-being in later life. Journal of Gerontology, 43(6), 170-172.Key, W. H. (1986). Measurement in research onsociophobics. In D. Scruton (Ed.). Sociophobics: The anthropology of fear (pp. 50-59). London:Westview Press.126Kirkpatrick, D. R. (1984). Age, gender and patterns ofcommon intense fears among adults. Behaviour Research and Therapy, 22(2), 141-150.Knaack, P. (1984). Phenomenological research. WesternJournal of Nursing Research, 6(1), 107-114.Kovach, C. R. (1990). Promise and problem inreminiscence research. Journal of Gerontological Nursing, 16(4), 10-14.Lazarus, R. S. (1966). Psychological stress and the coping process. New York: McGraw-Hill.Lazarus, R. S. (1981). The costs and benefits ofdenial, In B. S. Dohrenwend & B. P. Dohrenwend(Eds.). Stressful life events and their contexts (pp. 131-156). New York: Prodist.Lazarus, R. S. (1981). The stress and coping paradigm,In C. Eisdorfer, D. Cohen, A. Kleinman, & P. Maxim(Eds.). Models for psychopathology (pp. 177-214).New York: Spectrum.Levitt, E. E. (1967). The psychology of emotion.Indianapolis: Bobbs-Merrill.Mackus, M. L., & Millette, J. (1987). SupportingCanadian elderly. Journal of Gerontological Nursing, 13(12), 26-29.127Marks, I. M. (1969). Fears and phobias. New York:Academic Press.May, R. (1950). The meaning of anxiety. New York:Ronald Press.Miller, S. M. (1979). Controllability and humanstress: Method, evidence and theory. Behaviour Research and Therapy, 17, 287-304.Morris, E. V., & Issacs, B. (1981). The prevention offalls in a geriatric hospital. Age and Ageing, 9,1981-1985.Nelson, R.C., & Amin, M. A. (1990). Falls in theelderly. Emergency Medicine Clinics of NorthAmerica, 8(2), 309-324.Oiler, C. J. (1982). The phenomenological approach innursing research. Nursing Research, 31(3), 178-187.Oiler, C. J. (1986). Phenomenology: The method. In P.L. Munhall & C.J. Oiler (Eds.). Nursing research. Aqualitative perspective (pp. 69-84). Norwald, Conn:Appleton-Century-Crofts.Ornery, A. (1983). Phenomenology: A method for nursingresearch. Advances in Nursing Science, 1, 49-63.Pearlin, L. I., & Schooler, C. (1978). The structureof coping. Journal of Health and Social Behaviour,12819, 2-21.Perry, B. C. (1982). Falls among the elderly living inhigh-rise apartments. The Journal of FamilyPractice, 14(6), 1069-1073.Prudham, D., & Evans, J. G. (1981). Factors associatedwith falls in the elderly: A community study. Ageand Ageing, 10, 141-148.Rachman, S. J. (1978). Fear and courage. SanFrancisco: W. H. Freeman and Co.Rist, R. (1979). On the means of knowing: Qualitativeresearch in education. New York UniversityQuarterly, summer, 17-21.Rothbaum, R., Weisz, J. R., & Snyder, S. S. (1982).Changing the world and changing the self: A two-process model of perceived control. Journal ofPersonality and Social Psychology, 42(1), 5-37.Rotter, J. B. (1966). Generalized expectancies forinternal versus external control of reinforcement.Psychological Monographs, 80, 1-28.Sandelowski, M. (1986). The problem of rigor inqualitative research. Advances in Nursing Science,4, 27-37.Sarasin, S. B. (1966). The measurement of anxiety in129children: Some questions and problems. In C. D.Spielberger (Ed.). Anxiety and behaviour (pp. 63-81). New York: Academic Press.Sattin, R. W., Lambert Huber, D. A., DeVito, C. A.,Rodriguez, J. G., Bacchelli, S., Stevens, J. A., &Waxweiller, R.J. (1990). The incidence of fallinjury events among the elderly in a definedpopulation. American Journal of Epidemiology, 131(6), 1028-1037.Seligman, M. E. P. (1975). Helplessness: Ondepression, development and death. San Francisco:Freeman.Silverstone, B., & Hyman, H. K. (1976). You and your aging parent. New York: Pantheon.Sorock, G. S. (1988). Falls among the elderly:Epidemiology and prevention. American Journal of Preventive Medicine, 4(5), 282-288.Speechley, M., & Tinetti, M. (1990). Assessment ofrisk and prevention of falls among elderly persons:Role of the physiotherapist. Physiotherapy Canada,42(2), 75-79.Spielberger, C. D. (1972). Anxiety as an emotionalstate. In C. D. Spielberger (Ed.). Anxiety: Current130trends in theory and research (Vol. 1, pp. 24-46).New York: Academic Press.Statistics Canada. (1988). Canada year book 1988.Ottawa, Ontario: The Bryan Press Ltd.Taylor, S. E. (1983). Adjustment to threatening events:A theory of cognitive adaptation. AmericanPsychologist, 11, 1161-1173.Tideiksaar, R. (1986). Geriatric falls in the home.Home Healthcare Nurse, 4(2), 14-23.Tideiksaar, R., & Silverton, R. (1989). Psychologicalcharacteristics of older people who fall. Clinical Gerontologist, 80-82.Tinetti, M. E., Speechley, M., & Ginter, S. F. (1988).Risk factors for falls among elderly persons livingin the community. The New England Journal of Medicine, 319(26), 1701-1706.Tinetti, M. E., Richman, d., & Powell, L. (1990).Falls efficacy as a measure of fear of falling.Journal of Gerontology, 45(6), 239-243.Ursic, P. A. (1991). The meaning of fracturing a hipfor elderly community-dwelling women. Unpublishedmaster's thesis, University of British Columbia,Vancouver, B. C.131Vellas, B., Cayla, K., Bocquet, H., de Pemille, F., &Alvarede, J. L. (1987). Prospective study ofrestriction of activity in old people after falls.Age and Ageing, 16(3), 189-193.Walker, J. E., & Howland, J. (1990). Falls and fear offalling among elderly persons living in thecommunity: Occupational therapy intervention. TheAmerican Journal of Occupational Therapy, 45(2),119-122.Walster, E. (1966). Assignment of responsibility foran accident. Journal of Personality and Social Psychology, 3, 73-79.Wills, T. A. (1981). Downward comparison principles insocial psychology. Psychological Bulletin, 90, 245-271.Wolpe, J., & Lang, P. (1964). A fear survey schedulefor use in behaviour therapy. Behaviour Researchand Therapy, 2, 27-30.Woods, N. F., & Catanzaro, M. (1988). Nursingresearch: Theory and practice. St. Louis, Missouri:The C. V. Mosby Co.Whitbourne, S. K. (1985). The psychologicalconstruction of the life-span. In J. E. Birren & K.W. Schaie (Eds.). Handbook of the psychology of aging (2nd ed.). (pp. 594-618). New York: VanNostrand Reinhold Co.132133Appendix ALetter of InformationMy name is Marilynne Convey, and I am a RegisteredNurse working on my Master of Science in Nursing degreefrom the University of British Columbia. The topic Iam studying for my thesis is concerned withunderstanding the fear of falling that elderlyindividuals experience following a fall.This letter is to invite you to participate in mystudy. I am interested in understanding what fear offalling means to you and how it affects your dailyliving. Very little is known about this subject, and Ithink it is important for nurses who care for elderlyindividuals to have a better understanding of thisfear.If you are willing to participate in my study, Iwould like to meet with you in your home two or threetimes. Each interview will require 30 to 90 minutes.During the initial interview, I will ask you questionsabout your experience concerning your fear of falling.Follow-up interviews will be a time for us to clarifythe original information and for you to describeadditional thoughts or feelings about your fear. All134interviews will be tape recorded so that I can payclose attention to what you are saying. Theinformation will be confidential; no names will be usedon the tapes or the transcribed notes. Access to thisinformation will be limited to myself, my thesisadvisors, and my typist. At any time during the studyyou may request erasure of the information, and at thecompletion of the study the information on the tapeswill be destroyed.Participation in this study is voluntary, and youare free to withdraw at any time. Withdrawal from thisstudy will not affect your contact or services throughthe CRD Care Programs.If you decide to participate or have otherquestions, please call me at 592-8179. The supervisorfor this project is Angela Henderson and her officenumber is 822-7435. You can also give permission toyour nurse for me to contact you. I look forward tospeaking with you. A summary of the study will besent to interested participants.Sincerely,Marilynne Convey135Appendix BConsent FormTitle of the Study:^Fear of Falling: The Experienceof Elderly Individuals Who Have Previously FallenInvestigator:^Marilynne Convey, R.N., B.S.N.Advisor: Angela Henderson, R.N., M.S.N.^  give myconsent to participate in the study of fear of fallingwhich has been explained to me by Marilynne Convey andis being conducted through the School of Nursing at theUniversity of British Columbia.I understand that this study involves one to threeinterviews of 30 to 90 minutes duration in my home andthat the interviews will be tape-recorded. Iunderstand that: (a) participation in the studyinvolves no risks or discomforts to me; (b) myparticipation is voluntary and that I may withdraw atany time; (c) refusal to participate in the study orwithdrawal from the study will in no way interfere withthe care and services which I will receive; (d) allinformation personally identifying me will remainstrictly confidential, and (e) I may contact MarilynneConvey at 592-8179 or Angela Henderson at 822-7435 if Ihave further questions about the study.I acknowledge receipt of a copy of this consentform.Participant's^ Researcher'sSignature SignatureDate^ Date136Appendix CTrigger Questions1. What is your experience of falling?2. Describe your feelings about falling?3. Describe your fear of falling?4. Describe how your feelings affect you on a dayto day basis?Note: Specific information on the fall event will besolicited from the participants and will include thefollowing:Number of falls.Circumstances of first, subsequent, and last fall.Reaction of family, friends, and neighbours.Risk factors - eg. medications, environment, andhealth.


Citation Scheme:


Citations by CSL (citeproc-js)

Usage Statistics



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"
                            async >
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:


Related Items