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The experience of aging : a qualitative study of well elderly individuals Tomilson, Roxanne Gaye 1992

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THE EXPERIENCE OF AGING: A QUALITATIVE STUDY OF WELL ELDERLY INDIVIDUALS By ROXANNE GAYE TOMILSON B.N., The University of New Brunswick, 1984 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in THE FACULTY OF GRADUATE STUDIES (The School of Nursing) We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA September 1992 ©Roxanne Gaye Tomilson, 1992 In presenting this thesis in partial fulfillment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of NURSING The University of British Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date September 9. 1992 ii Abstract This phenomenological study was designed to explore and describe the perceptions of well elders who are experiencing aging. The study was conducted with a sample of nine elders ranging in age from 65 to 77 years. Data were collected by intensive interviewing usually at the community centre or at the home of the elder. The data were analyzed for common themes. The findings revealed that the elderly participants described their aging experience in terms of control. The concept of control was mentioned in relation to lifestyle, finances, and health. The participants repeatedly emphasized that their degree of control directly related to how positively they viewed the aging experience. In other words, the greater the elder's perceived control over lifestyle, finances, and health, the greater the elder's positive perception of aging. The results of a study such as this can be used to facilitate the individual nurse's development of knowledge and expertise as it provides information that may be used in developing and providing nursing services for the elderly population. iii Table of Contents Page Abstract ii Acknowledgements vi Chapter One Introduction 1 Statement of Problem and Purpose 2 Definition of Terms 3 Conceptual Framework 4 Methodology 6 Assumptions and Limitations 7 Summary 8 Chapter Two Literature Review 9 Experience of Aging 9 Demography 10 Biology 11 Economy 13 Psychology 14 Societal Factors Influencing Aging 18 Role Transitions 20 Stereotypes 24 Summary 26 Chapter Three Methodology 29 Sampling 30 Selection Procedure 30 Description of Respondents 31 Ethical Considerations 32 Data Collection 34 Data Analysis 35 Validity and Reliability 37 Summary 41 iv Page Chapter Four Presentation of Findings 42 Development of an Analytical Framework 42 The Experience of Aging 42 Lifestyle 44 Skill-Related Activities 44 Friendships 48 Retirement 51 Finances 56 Income 57 Social Benefits 58 Home Ownership 60 Health 62 Health Maintenance 63 Preparing for Illness, Dying, and Death 64 Summary 69 Chapter Five Discussion of the Findings 70 The Experience of Aging 70 Lifestyle 71 Skill-Related Activities 71 Friendships 76 Retirement 78 Finances 80 Income 80 Social Benefits 83 Home Ownership 86 Health 88 Health Maintenance 90 Preparing for Illness, Dying, and Death 93 Summary 97 Chapter Six Summary, Conclusions, and Implications for Nursing 98 Summary of the Study 98 Conclusions 102 Implications for Nursing 103 Nursing Practice 103 Nursing Education 106 Nursing Research 108 Summary 109 V Page References jjO Appendices Appendix A Information and Consent Form 120 Appendix B Sample Trigger Questions 121 VI Acknowledgements I would like to extend a special thank you to all the participants who so thoughtfully and candidly shared their personal experiences. I wish to thank my committee members Sally Thorne and Carol Jillings for their support and guidance. I would like to express my appreciation to family and friends who provided "sounding boards" and encouragement. Particularly, I would like to thank Kevin for his proofreading and unfailing support throughout this undertaking. 1 CHAPTER ONE Introduction The "problem" of the elderly has been artificially created, the result too often of planning for old people, without input from them. In many cases, the needs of committees, agencies and administration have taken priority over the needs of old people. In this way, the supposed solutions have become part of the problem (Marshall, 1987, p. 27). Aging and care of elderly people in health and illness are relatively recent areas of investigation, particularly for health professionals. Studies of aging have been influenced by research in the basic sciences and have focused primarily on biological and physiological functioning of body systems. The findings from such studies influence the treatment of elders in traditional medical institutions, such as chronic care units in hospitals. In addition, many noninstitutional services (housing, transportation, and home supports), which have recently emerged in the private sector, function in response to what are perceived as the needs of the elderly and the problems with aging. Often the primary interest of these services lies not with their clientele but rather with economic gain (Marshall, 1987). 2 The market for the various services that address the basic social needs of the elder population is increasing dramatically; in fact, one out of five Canadians will be 65 years of age and over by the year 2021. Approximately 95% of that population will not be institutionalized (Hees, 1987). In addition, several studies have predicted that the elderly population of the future will be healthier and more active in society (Connidis, 1987; Kastenbaum, 1979; Knopf, 1977). Consequently, the number and variety of services will likely increase as well (Chappell, 1988). Canadian society appears, however, to have a prevailing negative stereotype of aging and the elderly. The stereotype of older Canadians depicts them as being frail and sick (Burdman, 1986; Connidis, 1987; Signori, Dorcas, & Kozak, 1977). Often this stereotype leads to a self-fulfilling prophecy for the elderly in that they assume the negative image that society has projected (Cooper & Goethals, 1981). The effects of the stereotyping are twofold: the elderly are less inclined to participate actively in the development of services and programs due to poor self-concept, and those in the business of serving the elderly can more readily take advantage of this population. Statement of Problem and Purpose Although considerable knowledge has been gained in relation to the physical changes throughout the process of aging (for example, the gradual changes in body functions), limited knowledge is available concerning aging from the elder's perspective, as noted in the opening quotation. The need to look at aging through the eyes of the elderly is important in developing an understanding of precisely what the experience of aging entails. Not only would such an understanding assist in the 3 treatment of the elderly in institutional settings that address their physical needs but, more importantly, would allow well elders to have more input into and control over community programs and services. Such input from well elders may ensure that health promotion and community services take precedence over acute care services (Gilbert, 1986; Kastenbaum, 1979) and that community-based services emerge from the needs perceived by well elders rather than by others who may have other interests. Consequently, the purpose of this study is to determine how well elders describe the experience of aging and, from that basis, to consider the implications of their perceptions particularly for the practice of nursing. Definition of Terms The following terms have been defined for the purpose of clarifying their meaning in the text of this thesis. Aging: The natural and continuous process of growing mature or old. Experience: Active participation in events or activities, leading to the accumulation of knowledge or skill (The American Heritage Dictionary of the English Language, 1969). Perception: Direct or intuitive recognition: intelligent discernment (Webster's, 1961, p. 1975). Elder: Individual who has attained or surpassed the age of 65 years. Well: Self-defined good health but may have chronic disease not requiring hospitalization. 4 Conceptual Framework The conceptual framework that will direct this study is Kleinman, Eisenberg, and Good's Explanatory Model (1978). These theorists have constructed a conceptual framework of the health care system that acknowledges the importance of the individual's experience within the broader sociocultural context. The health care system, as a cultural system, involves the articulation of health, illness, and health care aspects of society. Kleinman and colleagues' conceptualization suggests that alterations in health status occur in the context of three different structural domains of the health care system: the professional sector, which includes scientific medicine; the folk sector, which includes non-professional healers; and the popular sector, which includes the individual, the family and the social network. Each structural domain has its own clinical reality that includes beliefs, expectations, roles, and relationships (Kleinman et al., 1978). For the same phenomenon, the different domains would have different explanatory models to describe "what is wrong with the patient and what should be done" (p. 254). Similarly, the phenomenon of aging would have different explanatory models in each domain. When members of different sectors interact, the incongruent explanatory models can lead to conflicting expectations. Although understanding of aging is influenced by personal experience and cultural background, the professional's viewpoint is informed and regulated by a distinct education and training within the framework of the profession. 5 Such a framework is based on a knowledge system that lends the profession a certain influence and power over the general treatment of the elderly. Consequently, the members of the professional sector have explanatory models of aging that may conflict with the perceptions of elders. Furthermore, Kleinman and colleagues indicate that the state of "nonhealth" has three dimensions: disease, illness, and sickness. These are complex phenomena that are formulated according to biological, psychological, and sociological perspectives. In keeping with this view, nonhealth is an alteration in the normative structure of the individual within a physical, psychological, or social context. People's subjective experiences are located within social, cultural, economic, and historical settings that influence their personal experience (Kleinman, 1978). As Kleinman (1978) states: "[Models]...must be able to examine both individual as well as social dimensions of health care beliefs and actions" (p. 89). Aging is also a concept that is located and formulated in biological, psychological, and social contexts that influence how it is perceived by the individual. Analysis of accounts derived from interviews with elders will not only reflect the degree to which these contexts have influenced their perspectives on aging but may also provide valuable insights about their personal experiences with aging. 6 Methodology The accounts from elders that are used for analysis in this study were gathered through indepth interviewing. This method gathers detailed information about the participants' points of view; in this case, the method elicits the elders' perceptions of aging. "Interviewing is both a direct source of information on belief and knowledge systems and a form of vicarious observation to increase case examples of various types of overt behavior" (Pearsall, 1965, p. 346). The accounts may elicit not only the belief and knowledge systems that the elders hold but also their personal experience with aging. This qualitative approach to research entails several theoretical assumptions based on phenomenological philosophy. To begin, the goal of phenomenology lies in describing experiences as they are lived by individuals who determine their own reality (Oiler, 1982). Rist (1979) states that "all knowledge is socially constructed. No information exists outside that produced by individuals within their social and cultural context" (p. 18). When an individual interprets another individual's actions in the context of his own, rather than the other's, perceptions, he lacks accurate knowledge to understand this person's unique viewpoint (Schutz, 1967). Consequently, the role of the researcher in phenomenological research is to be "the major instrument of data collection" (Ragucci, 1972, p. 487). The success of the researcher depends upon the ability to establish rapport and respect with the sample population (Ragucci, 1972) and to conduct each study with an open mind. This prevents the formulation of hypotheses relating to how and why the sample 7 population behaves as it does before the study commences (Oiler, 1982). The researcher's role within this methodology is one of "discovery, of generating an explanation rather than verifying an imposed theory. Such an approach attempts to avoid a preconceived theoretical framework and allows the study to emerge from the words of participants" (Wilson, 1977, p. 106). The entire phenomenological attitude is one of understanding the meaning of the subjects' experiences from their perspective (Oiler, 1982). Secondly, the method does not allow the researcher to assume the meaning of the experience without obtaining clarification and feedback from the individual studied. Once clarification is obtained, the researcher can proceed to analyze the data from the informant's perspective. Within the research context, analysis and interpretation of the data will be credible only if it is intelligible to others and confirmed by others familiar with the research topic (Guba & Lincoln, 1981). Assumptions and Limitations For the purpose of this study, the researcher makes the following assumptions: that elders can articulate their perceptions about aging, that the researcher exerts an influence on the data, and that the phenomenological method is appropriate to exploring the elders' experiences of aging. Due to time constraints, the number of informants interviewed and the number of interviews conducted were limited. Also, due to transportation constraints, informants were selected from one urban area. Consequently, the informants may represent a specialized subgroup of the population. The generalizability of the findings will therefore be limited to the informant population. 8 Summary The goal of this study was to elicit and analyze information from well elders on the topic of aging. This introductory chapter describes the background to the research problem, explains the rationale and purpose of the study, and outlines the conceptual framework for this study. This chapter also indicates the methodological perspective, perceptions, and the assumptions and limitations of the study. The next chapter provides a review of the literature pertinent to this investigation. 9 CHAPTER TWO Literature Review As the North American population of aging individuals grows, the need to explore the phenomenon of aging and what it means to elders is becoming increasingly important for health care professionals and elders themselves. The purpose of this chapter is to examine pertinent literature that is directly or indirectly related to this topic. This study focuses on the well elder's experience of aging, yet little of the literature reviewed relates directly to this topic. Most of the literature pertains to issues related to the biological factors of aging. This literature review organizes the information under two themes: experience of aging and factors influencing aging. The first section divides the experience of aging into four categories: demography, biology, economy, and psychological theories. Section two includes a review of the literature relating to factors influencing aging in two categories: role transitions and stereotypes. A summary of the findings in the literature review concludes this chapter. Experience of Aging Elderly individuals everywhere experience the aging process. The aging process is a "normal" development process in which sociological, biological, and psychological changes interact (Burdman, 1986). This process commences at 10 conception and, according to Lowy (1985), is a continuous process whose cumulative effects manifest themselves at a later stage in the life cycle. According to Comfort (1976), aging is a natural, continuous process of physiological and psychological change. This process is influenced by genetic endowment, environment, and sociogenic factors. Sociogenic factors of aging are defined as "the role which society imposes on people as they reach a certain chronological age" (p. 9). Burdman (1986) states that in order to understand "...the process of aging and the interdependence of the biological, psychological, and social roles, one must bear in mind that, much like the child or young adult, the older adult is always changing and evolving" (p. 20). Aging is a dynamic process experienced by everyone; however, the cumulative effect is more pronounced in the increasing older population. Demography The population of Canadian elders is increasing at a far greater rate than was experienced in the past. According to Hees (1987), 2.7 million Canadians were over 65 years of age in 1986, representing 11% of the population compared to 6% in 1931. By the year 2021, the percentage of elders will rise to 19%~one out of five Canadians. Several factors account for this expanding population, such as decreased birth rate and increased life expectancy (Kaufman, 1986). In addition, the elderly population will have tripled in size due to the "Baby Boom Generation" entering the ranks of the elder population (Marshall, 1987; Stone & Fletcher, 1986). Many 11 of these senior citizens remain healthy. In fact, only 2% of elders between the ages of 65 and 69 live in institutions, compared to 37% of those 70 and over (Hees, 1987). The increasing population of elders who are remaining healthy and enjoying a longer life expectancy necessitates the importance of looking at aging with new eyes. And what better eyes to view aging through than those of the elders themselves? Much of the current research relating to the experience of aging tends to concentrate on the physiological changes that occur. The following section explores the literature related to the biological aspects of aging. Biology The stereotype of older Canadians depicts them as being frail and sick (Burdman, 1986). While it is clear there are declines in the various aspects of health as people age, the later years are not totally devastating for most people (Comfort, 1976). In Canada, approximately 80 percent of elderly people over 65 have some chronic conditions and about 50 percent have some functional disability. However, only about 20 percent have major functional disability (Hees, 1987). Interestingly, individuals' attitudes and subjective perceptions of health do not become more negative with age. Rather, there is some suggestion that the negative attitudes decrease. Individuals assess their current situation against their own expectations and the situations of others to arrive at their own personal adjustment to their situations. The elderly are not a homogenous group, and there is a great variability in their health status (Macione & Hayes, 1976). 12 According to a survey done by the U.S. Health Department (1975), despite the many health problems that develop with increasing age, most individuals over age 65 do not consider themselves to be seriously handicapped in pursuing then-daily activities. Although approximately four out of five persons who are 65 years of age and over suffer from at least one chronic medical condition, less than one in five report that they are unable to carry out major daily activities. Canadian statistics are similar (Chappell, Strain, & Blandford, 1986; Stone & Fletcher, 1986). Chronological age alone does not produce senility, feebleness, or unproductivity. Rather, a combination of specific disease processes, an unhealthy physical and/or psychological environment, and an expected decrease in capacity to adapt to stress are the usual causes for stereotyped characteristics associated with advancing age (Macione & Hayes, 1976). Although there are many theories concerning the nature of biological aging, researchers have had difficulty establishing facts relevant to the specific nature of the changes associated with aging; consequently, much controversy exists over what conclusions can be drawn from research regarding changes due to aging. One major contribution to the confusion has been the difficulty distinguishing between changes caused by aging and those caused by time-related pathological events (e.g., diseases such as osteoarthritis and arteriosclerosis) (Cox, 1984; Macione, 1979; Weg, 1983). 13 Although the older population has a higher rate of chronic conditions than the younger population, it has a relatively low rate of reported acute conditions (Harris, 1981). Chronic conditions associated with aging generally include illnesses such as chronic physical ailments and disabilities, long-term mental illness, decreased visual and auditory acuity, neurological and circulatory disorders, diabetes, cancer, arthritis, and rheumatic diseases. The prevalence of chronic disorders differs among the sexes, with older females displaying higher rates of arthritis and hypertension, slightly higher rates of visual disorders and lower rates of hearing difficulties. Cardiac conditions are similar between sexes. Prevalent rates of all chronic conditions, except ulcers, are higher among the poor (Fales, MacKeracher, & Vigoda, 1981; U.S. Health Department, 1975). In summary, there is a vast body of literature related to the biological aspects of aging. Many of these exhibit themselves as chronic conditions, which studies have shown do not seriously handicap most elders. Economy Another prevalent topic in the literature on aging pertains to the economy of aging and focuses on the financial status of elders. Indications are that many of the elderly have tended to accept the subsistence lifestyle as the best that could be expected in old age. Attitudinal surveys have found, for example, that despite their relatively low economic status, very high proportions of the elderly view their economic situation as satisfactory and not below their expectations (Harris & Associates, 1975). 14 Further, retirement expectations are changing. In part, this has resulted from increases in living standards at all ages. More importantly, the development of pension programs and the continuous improvement in their provisions have given the elderly increasing independence and for the first time placed a comfortable standard of living within the reach of many (Schulz, 1976). In addition, the "no pension generation"-workers too old to achieve regular pension status when the national pension plan or their employer's pension plans were initially established-is quickly disappearing. However, despite these improvements, a large proportion of elders remains below the poverty level (Hees, 1987). Elderly women appear to be the most at risk. Many elderly women at one time were unemployed and lived on their spouses' salaries and pensions; however, upon the death of their spouses, this stipend was reduced. If these elderly women were employed as younger adults, it was often for small wages or for intermittent work periods (between periods of child rearing). Another factor that appears to take its toll on elders living on a fixed income is the inflation rate. Food and housing, in particular, are problematic for those on a fixed income, and often the situation can only worsen. Psychology In addition to the biological and economic aspects of aging, there are many psychological theories related to the concept of successful aging that imply the value judgment that some adjustments are better than others. People accommodate themselves to old age in various ways. According to Neugarten 15 (1974), successful aging is in the eye of the beholder. However, she and her colleagues have constructed a measure of life-satisfaction based upon five components. Individuals are rated positively to the extent that they: (1) take pleasure from whatever round of activities that constitute everyday life, (2) regard life as meaningful and accept responsibility for what life has been, (3) feel success in achieving major life goals, (4) hold a positive self-image and regard themselves as worthwhile people, (5) maintain optimistic attitudes and moods (Neugarten, 1974, p. 13). In addition to Neugarten's framework, researchers frequently cite two psychological theories of successful aging: disengagement and activity (Burbank, 1986; Cottrell, 1974; Fogel & Woods, 1981). The disengagement theory postulates a mutual withdrawal between the elderly person and society. When disengagement is complete, there is an increased sense of freedom, as the individual feels less controlled by norms governing everyday behavior. Cumming and Henry (1961) state that fully disengaged persons have transferred much of their cathexis to then-own inner life; their memories, fantasies, and self-image are those of someone who is something and has accomplished something. According to Morgan (1979), disengagement is a gradual process triggered by a series of role exits such as: unemployment, retirement, widowhood, sickness, or disability. In contrast, activity theory advocates successful aging through continuing the interests, activities, and attitudes of middle age. In essence, the elderly individual who ages optimally is one who stays active and manages to resist the shrinkage of 16 bis or her social world. Morgan (1979) views this process as a denial of the individual's age and associated meaning. Directly related to the above two theories is the individual's self-concept. The self-concept is the image the individual has of himself; it reflects his actual self and the way he interprets this self (Kalish, 1975). According to Morgan (1979), as the individual ages he tends to become more reliant on internal realities and less dependent on external factors. There is a tendency to seek stability within the self at the very time the self is threatened by the capacity to find relatedness and stability. Two important components of self-concept are self-esteem and body image. Each is influenced by the aging process and, in turn, affects the psychosocial aspects of the aging process. Kalish (1975) states that "given the stresses and losses that come with increasing age, given the lack of respect shown the elderly, given their diminishing cognitive capacities, it is only common sense to believe that people's self-esteem should drop, perhaps drastically, as they enter their later years" (p. 57). Some studies, however, have shown that the above viewpoint may not be entirely accurate. Gurin, Veroff, and Feld's (1960) comparative research of young, middle-aged, and old men indicated that self-esteem increases with age. Knight (1986) believes this occurs when the individual is able to maintain or reestablish a means of self-esteem development. Morgan (1979) states that, for persons whose self-worth is contained within the status derived from an occupational role, the loss of that status in retirement can reduce feelings of personal importance. Those who 17 are able to channel their energies into new pursuits or different roles based on past skills are generally more capable of maintaining self-esteem. Leisure activities or volunteer work have traditionally provided this opportunity, but more recently attention has been paid to maintenance of employment opportunities, either full-time or part-time (Morgan, 1979). Kaplan and Pokorny (1970) also studied the interaction between chronological age and other variables that affect an individual's self-esteem. They found that if the older person has a reasonably stable recent history, an achievable standard of living, and no strong fears of being alone, his or her self-esteem rises with age. In a similar vein, Riley and others (1968) compared younger people to older individuals. Their findings were that older people are less likely to admit shortcomings, almost as likely to view their intelligence as being as good as that of others, and more likely to consider themselves as having positive moral values. Kalish (1975) suggests that those elders who are physically well, socially and emotionally stable, and financially secure do not normally come to the attention of agencies and institutions. Thus, the health professionals, who are major molders of public opinion, interact largely with those elderly people whose situations suggest that their self-concept is below average for their age group. As stated earlier, body image is another component of self-concept The body image of older adults and their responses to alterations in their bodies have not been studied extensively. Body image is a composite of psychologic and physiologic factors. Zucker (1961) believes that body image is both conscious and 18 unconscious. It is dependent on both external and internal promptings, reality-bound as well as fantasy-dictated. In addition, Witkin (1965) believes that an individual's body perceptions are formed during the individual's development. Biological, psychological, and sociological changes occur as part of the aging phenomenon and have an impact on body image perception. Among the variables that may influence body image are: culture and environment, physiological disturbances, internal drives, dependency needs, motivational states, religious and ethnic backgrounds, as well as identification with others considered ideal (Esberger, 1978; Janelli, 1986; Murray & Zentner, 1985; Plutchik, Conte, & Weiner, 1971, 1972). These variables help to explain differences in body image that occur in each situation, environment, activity, or interpersonal relationship. Because the attitudes and responses of others help one to define one's body (Schilder, 1950; Selekman, 1983; Wilson & Kneisl, 1979), social interactions are required to form a concept of body image. Society's values are clearly illustrated in the media by the fact that youth is to be valued and preserved and that aging is a battle to be fought. The impact of these values, however, has not been widely researched. Societal Factors Influencing Aging Besides the psychological, biological, and economic factors influencing aging, individuals age in the context of societies. Different societies and cultures hold forth different expectations about the timing and meaning of the transition into old age and about the allocation of societal resources in later life (Atchley, 1971; 19 Kalish, 1975; Maddox, 1985; Marshall, 1980). Such factors as retirement, formal education, cultural groups, and rural-urban differences are becoming sociologically important (Chappell, Strain, & Blandford, 1986). Current statistics support the popular belief that those who are elderly today are, by and large, outside the paid labor force (Stone & Fletcher, 1986). While elderly individuals today tend to have less formal education than younger adults, the elderly population of tomorrow will have more formal education than the present elderly population. Those with more formal education could enter old age with greater expectations of the formal system, with more flexible attitudes towards living arrangements, and with more confidence and ease in managing massive government bureaucracies (Chappell, Strain, & Blandford, 1986; Marshall, 1980). Future cohorts of elderly persons, especially in Canada, may show increased proportions of foreign born individuals (Statistics Canada, 1984). The relevance of culture for the elderly population is an under-researched area in gerontology. The extent to which rural-urban differences are relevant for the provision of care to elderly individuals is another shady area (Chappell, Strain, & Blandford, 1986). Many factors influence the aging experience, but two of the most widely written about factors are role transitions and social stereotypes. 20 Rnlft Transitions Role transitions are a major reason for concern with regard to aging. The roles older people discontinue, those they espouse, and others' attitudes toward them affect their world view~the way they define themselves, the way they feel, and their place in society. The social role of the senior citizen is less clearly defined than the roles assigned to young and middle-aged adults (Marshall, 1980). The term "social role" implies the context of a specific behavior pattern or a particular situation. Since individuals often define themselves in terms of social roles and the roles determine the individual's place in society, social roles are significant. As people pass through the stages of life, the variety of positions for which they are eligible keeps changing. Available roles are more ambiguous in later life and often require major adjustments; hence, many roles have negative connotations. The roles available to the elderly may involve those associated with retirement, widowhood, dependency, disability, sickness, and institutionalization. For the purpose of this study of well elders and their perceptions on aging, the literature review focused on the role transitions of retirement and widowhood, as they have received considerable scholarly attention. Research on the experience of retirement reveals that this is not the traumatic experience it was once believed to be (Atchley, 1971; Cutler, 1977; Kalish, 1975; Lowy, 1985; Marshall, 1980). Indeed, most individuals adjust to retirement, and many consider it a positive experience. More recently, there has been greater popularity for the view that occupational identity is not the central 21 role for many workers; rather, it is one of many significant roles (Atchley, 1976; Palmore, 1981). Palmore, Fillenbaum, and George (1984) argue that retirement is accepted and desired. Indeed, it is viewed by some as an opportunity for continuation of other roles and development of new ones. Retirement is increasingly viewed as an expected life event (Friedmann & Orbach, 1974). A panel study of Iowa males reported an acceptance of retirement as a legitimate stage in the life cycle (Goudy, Powers, Keith, & Reger, 1980). A study of retired men and women in southwestern Ontario found that retirement is not as disruptive and critical as one might anticipate when compared with other life events such as marriage, birth of a child, and death of a spouse (Matthews, Brown, Davis, & Denton, 1982). Prior research reports similar findings (Paraes, 1981; Paraes & Nestel, 1981; Streib & Schneider, 1971). In fact, one study concluded that satisfaction with retirement is expressed by a majority, despite reduced levels of income (Paraes & Nestel, 1981). Palmore and associates (1984) examined the effects of retirement, controlling for differences that existed prior to retirement, in their comparisons of working and retired individuals. Not surprisingly, their results indicate that at least half of the difference in income is caused by retirement However, few, if any, of the health differences are caused by this event In addition, they claim that retirement has little effect on social activity, life satisfaction, or happiness. There is little research on the effects of retirement on women. Szinovacz (1982) points out that research specifically concerned with female retirement was 22 practically unheard of until 1975. Atchley & Corbett (1977) suggest that women may experience greater adjustment if they start their career late and have not reached their career goals at the time of retirement Connidis (1987), focusing especially on the retirement of females, suggests that the interaction between work and familial careers must be considered as well as the meaning attached to them. The experience of widowhood does seem to be a more traumatic event than retirement, particularly in its initial bereavement stage. While there is much variety in individuals' styles of coping, here again most adjust and continue their lives. Matthews and associates (1982) conclude that widowhood is reported as more traumatic than retirement. However, as Ferraro (1984) concludes from his review of the literature, the majority of research shows very few, if any, decrements in social participation immediately upon widowhood. Further, after a few years, interaction with friends and neighbors is likely to increase. Regardless of the adjustment, loneliness is one of the major problems experienced by widows. Harvey and Bahr (1974) suggest that the negative impact on morale associated with widowhood may not be the result of the experience per se but rather from socioeconomic circumstances. Availability of economic resources has been identified as one of the principal factors associated with involvement with family, friends, and neighbors and participation in activities (Arling, 1976; Morgan, 1979). 23 Most research on widowhood has focused on women. Some researchers have examined the differences between widowed males and females and report that widowed females in their sixties tend to have higher social participation than then-male counterparts. However, in the 70 and over age group, this gender difference disappears (Schlossberg, 1984; Veroff, Kulka, & Douvan, 1981). Elwell and Maltbie-Crannell (1981) speculate that, after the initial bereavement period, the adverse effect on social participation occurs only when it places the individual in a position different from that of his or her age and sex peers. In other words, women in their sixties are likely to have female friends who are also widows; men of the same age are not. Elwell and Maltbie-Crannell also suggest that loss is less devastating for women than for men and that financial security may be a more important coping resource for men. Social participation may be more important for mediating stress for men than women. In a similar vein, Watson and Kivett (1976) argue that widowhood may be much worse for men than for women because of a weaker grandparent role, because of an expectation that they will die before their spouse (therefore, they do not rehearse for widowhood), and because of a decline in kin interaction. Both retirement and widowhood are characterized as role exits. Characteristically, men retire and leave the labor force while women are widowed and left alone. In both cases they leave roles that are generally considered as contributory to society. Moreover, researchers writing from the perspective of the 24 political economy of aging, such as Myles (1984) and Guillemard (1984), point out that the conditions of aging in Western society are largely negative: individuals are excluded from paid labor, they live in relative poverty, their major functions of raising a family have come to an end, there are no major roles to replace these, and their health is deteriorating. Yet, according to Myles (1984), the aged adjust and cope very well. Despite the elderly individual's positive response to these role transitions, the stereotypes held by society persist and elders are considered by others and by themselves as having exited the mainstream of society. Stereotypes In addition to role transitions, stereotyping plays a strong role in shaping the experience of aging in society. Society values youth and, as a result, has developed negative stereotypes of aging. The problems that may accompany aging seem to characterize old age itself, thus bolstering the negative stereotypes of old age" (Connidis, 1987, p. 452). Palmore (1980) analyzed over 100 research studies that had used his "Facts On Aging Quiz" to test Americans' attitudes toward aging and the elderly and found that negative attitudes and stereotypes persisted in one-fifth to one-third of the population. Canadian and American national surveys indicate that society has a preponderance of less than favorable images of what it is to be old (Chappell, Strain, & Blandford, 1986; Harris & Associates, 1981). Subjects were asked to respond to a list of potential problems (e.g., fear of crime, poor health, poverty, loneliness, and poor housing) from two perspectives: how serious each was for 25 people aged 65 and over and, also, how serious each was for the subject him or herself. From this, Harris and colleagues (1975) found that public expectations about old age clearly did not match what was reported by older people themselves. Every problem on the list was overestimated by the general public as a problem for older people. Similar findings have been reported by Canadian investigators (Fales, MacKeracher, & Vigoda, 1981; Koyl, 1977). Perhaps a negative consequence of such inaccurate stereotyping is the self-fulfilling prophecy. According to Cooper & Goethals (1981), the self-fulfilling prophecy is a subtle phenomenon with potentially devastating effects for the self-image of the older person. To the extent that stereotypes are believed, social structures tend to guarantee and reinforce these expectations. Consequently, social structures (educational system, legal system, health care system) in turn prompt the behaviors that confirm the stereotypes. There is some evidence that social stereotypes may have a subtle effect on older adults. As stated earlier, the general public interpreted old age substantially more negatively than did respondents aged 65 and over. It is interesting to note, however, that these elders viewed the rest of the elderly population as negatively as did their young cohorts. Seemingly, many were distancing themselves from what they perceived to be as a problem of aging by not admitting to or identifying with such problems. In contrast, studies such as that of Harris and associates (1975), have found that older people are generally more content than people of younger ages. Harris 26 (1981) found that older people are unlikely to feel stress to the degree younger people do and are more likely to feel satisfied with the various domains of their lives. In summary, there appears to be an abundance of research related to the stereotypes of aging. However, a few studies conducted from the elder's vantage point appear to be quite positive. As Kalish (1975) states, "...elderly people's perceptions of their roles (and aging) not only reflect reality to an appreciable extent, but they also create reality" (p. 71). Summary Although the literature review emphasizes the multifaceted nature of studies on aging, it reveals that very little of this research directly and specifically relates to the well elder's experience. Two areas of literature related to the study problem are: the experience of aging and the societal factors influencing aging. The experience of aging was divided into four categories: demography, biology, economy, and psychology. The demographic literature reveals that the Canadian elders population is increasing at a far greater rate than experienced in the past. Furthermore, these elders remain healthy and noninstitutionalized to a later age. The literature related to the biological aspects of the aging process revealed that 80% of elderly Canadians have some chronic conditions. However, only about 20% have major disability. While the older population has a higher incidence of chronic conditions, it has relatively lower rates of acute conditions. Researchers 27 have found that individual attitudes and subjective perceptions of health do not become more negative as people age but, in fact, may become less negative. The discussion of literature related to the economic aspects of aging indicated that, despite the improvements in pension plans and services, many elders are still struggling below the poverty level. The inflation rate appeared to be one of the major contributing factors in this uphill struggle. The psychological literature related to the aging process discussed disengagement and activity theories of aging. Self-concept and its components, self-esteem and body image, were discussed as they related to the above theories. There appear to be conflicting findings with regard to studies conducted on self-esteem in older individuals. Some studies state that self-esteem decreases, and some studies indicate that self-esteem remains the same or increases with age. The concept of body image of older adults and their responses to alterations in their bodies have not been studied extensively. The section pertaining to the factors influencing aging revealed research related to role transitions as well as stereotypes. The major role transitions examined were retirement and widowhood. Most of the retirement literature focused on men, while most of the widowhood literature focused on women. Despite these major role transitions, the literature indicates that, on the whole, elderly Canadians cope very well. The final section discussed stereotypes held in Canadian society. There appears to be an abundance of research related to the negative aspects of aging. 28 However, a few studies conducted from the elder's vantage point appear to be quite positive. The limited amount of nursing research in relation to aging from the well elders' perspective became evident in this review. This lack of research and data prevents health professionals from fully understanding the elders' perspective and, thus, puts such professionals at risk for providing unsuitable, unsupportive, and inconsistent nursing care. This study, then, seeks to interpret the elders' perceptions of aging in order to provide a more accurate portrayal of the reality of aging than does the body of available research-based knowledge. Therefore, collection of first-hand information from well elders would be useful to give direction for improving nursing care for this growing population. It is hoped that this study will contribute to a greater understanding of elders' perceptions on aging and allow these perceptions articulation within this field of study. CHAPTER THREE Methodology As indicated by the literature review, most research that involves well elders tends to center on biological, psychological, and sociological aspects of aging. In most cases, the theoretical frameworks established in these disciplines are applied in a directive manner to the population. Elders become the subjects of studies that allow little or no active participation from the elders themselves. In contrast, this study attempts to gain the elders' perceptions of the experience of aging using phenomenological research methods. Because phenomenology is concerned with understanding human experience as it is lived, data are collected in the natural setting from individuals who can share their firsthand knowledge. Therefore, the researcher must set aside theories and preconceptions in order to understand the perceptions of the person experiencing the phenomenon (Sandelowski, 1986). For the data to be valid, the study participants must actually be experiencing the phenomenon, and they must understand that the researcher is seeking information about the participants' experience as it is truly lived. If they are to be candid in their accounts, study participants must feel that their experience is as important as the experience of others and that their accounts will be treated with respect and confidentiality. Finally, steps must be taken to ensure that interpretations of the data remain grounded in the participants' accounts, so that study results are a valid representation of the phenomenon as it is lived. 30 Sampling When research of this nature is conducted, participants are viewed as knowledgeable informants who discuss their experiences with the researcher, clarifying data and verifying the researcher's ongoing analysis (Diers, 1979). The subject is a participant, who is aware of the intent of the study and who contributes on an equal basis with the researcher. To be valid sources of data, participants must recognize the phenomenon under study and be willing and able to communicate their experiences to the researcher. Study participants are purposely selected for their ability to articulate the experience under study. Accordingly, the selected study participants met the following criteria: 1. Participants aged 65 and over were selected if they identified themselves as well and living independently in the community. 2. Participants had to be able to speak English fluently in order to communicate their thoughts and feelings about their experience of aging to the researcher. 3. Participants had to be accessible to the researcher in the metropolitan Vancouver area. 4. Participants had to choose freely to share their experience. Selection Procedure Potential study participants were recruited from three community centers. The researcher gained access to the three community centers through a community health nurse. An appointment was arranged with each elders' group through the 31 program coordinator. An explanation of the purpose of the study and the methodology was provided to each group by the researcher. Questions from potential participants were answered at this time. Following the verbal presentation, an explanatory letter and consent form were distributed to potential participants (Appendix A). Participants were asked in the letter to phone the researcher if they were interested in taking part in the study. When potential participants contacted the researcher, they were given further information if they requested it. The researcher verified that the respondent met the selection criteria, and set an initial appointment, usually in the participant's home or other convenient location. Many of the interviews were conducted in a private room in the community center. At the first interview, the researcher explained the study and the reason for recording interviews in more detail, answering questions until the participant seemed satisfied. The participant was then asked to read and sign a prepared consent (Appendix A). Description of the Respondents There were nine participants in the study. Two male and seven female participants, ages ranging from 65 to 77 years, consented to participate in this study. At the time of the study, all participants were retired. They had worked at a variety of occupations: social worker, school teachers, carpenter, executive, salesmen, nurse, and retail manager. Al l participants lived independently and owned their own dwellings: six in self-contained homes and three in apartment complexes. 32 Five participants were married and lived with their spouses. Two women were widowed. One male and one female were unmarried. Al l participants had some form of chronic disease, such as arthritis and heart disease, but lived independently and defined themselves as physically and mentally well. Although the participants defined themselves as well, two of them stated that their spouses could not be defined as well. Al l of the participants were involved in volunteer, church, or community activities. Al l but three participants had children who lived away from their parents' homes. Al l participants were Caucasian. Most of the participants gave similar reasons for participating in the study: they were anxious to tell their story and they wanted to hear the stories of others. The size of the study sample in phenomenological research is usually small because of the intensive nature of data collection (Sandelowski, 1986). In addition, this study sample was small because the data elicited were rich and because the researcher's time and resources were limited. Ethical Considerations A study such as this involves face-to-face contact between study participants and the researcher. The data elicited are of a personal nature. One wants to take precautions to ensure that participants do not feel coerced to participate, that they feel free to withdraw, and that they feel unharmed. Accordingly, ethical considerations were addressed through the following provisions: 1. This study met the criteria specified by the University of British Columbia's Behavioural Sciences Screening Committee for Research and Other Studies Involving Human Subjects. 33 2. Participation was voluntary with written consent (Appendix A). 3. AU potential participants were informed in writing (Appendix A) that refusal to participate or withdrawal at any time would in no way jeopardize any treatment they might be receiving. 4. Prior to consenting, participants received a description of the study and an explanation of their role in it. 5. Prior to each interview, the participants were reminded that they were unconditionally free to withdraw at any time or to refuse to answer any question without jeopardy to any treatment they might be receiving. 6. Confidentiality was maintained. Only the interviewer knew the identity of the participants. After all studies of the data are completed, the audiotapes will be erased. Transcriptions were coded with subject identity known only to the researcher. There is no written material that used names in connection with the study. Access to the data is limited to the researcher and her advisory committee. 7. The role of the researcher was explained. 8. The benefits to the participants were the opportunity to contribute to nursing knowledge and the possibly cathartic benefit of telling their stories. 9. Finally, participants were offered a summary of study results if they were interested. 34 Data Collectipp The role of the researcher in phenomenological methodology is to enter the phenomena being studied, recognizing that the researcher's bias becomes part of the interactive process of data collection (Oiler, 1982). However, the researcher must discipline her bias to promote collégial exploration of the participant's aging experience. Data were collected in two intensive interviews. The researcher began each initial interview by asking sensitizing questions formulated to set aside the researcher's bias and leave the participant to be the expert (Appendix B). The researcher then followed the participant's lead in the interview, encouraged free expression of thoughts and feelings, and clarified her perceptions of the points the participant was making. The data were analyzed concurrently with data collection so the researcher could validate her perceptions and pursue analytical hypotheses with the study participants in each subsequent interview. Setting the study participants at ease in each interview involved overcoming some barriers such as having the interview audiotaped and trusting a stranger to hear their thoughts and feelings. After some initial self-consciousness about the tape recorder, study participants settled into the interview without visible discomfort. Participants were reminded at the beginning of each interview that the contents of the interview were confidential and that all references to the data obtained would maintain their anonymity. 35 The interviews were conducted in the participants' homes or in the community center, although the participants were given the option of choosing alternate arrangements if they wished. The interviews each lasted one to one and one half hours. The first interviews were longer, lasting an average of seventy-five minutes and were conducted over a period of three weeks. Field notes were made immediately after each interview, giving some detail about the circumstances of the interview and the researcher's reactions. In this study, all first interviews were concluded before the second round was begun. The second interviews lasted an average of one hour. They were conducted two weeks later over a period of one month. There were three sources of data for this study. Most of the data came from verbatim transcriptions of the audiotaped interviews and from field notes of the researcher's perceptions during the interviews. A small amount of data also came from telephone calls with respondents and participants. In summary, data were collected primarily through intensive interviews. The researcher used various strategies to enhance the validity of the data and to promote the comfort of the study participants. Data Analysfs Phenomenological research aims to understand the subjects' experiences from the data elicited during interviews, both the verbal data supplied by the participants and data supplied by the perceptions of the researcher. The researcher validates her perceptions with the study participants and continually tests her 36 analytical hypotheses against the data obtained. Interpretive understanding is inferred in data analysis by comparing the accounts of the participants (Sandelowski, 1986). Diers (1979) asserts that the essence of the phenomenological method is the subjective construction of meaning within the context of an interpersonal encounter between the researcher and each study participant. Phenomenological research, then, produces an intersubjective description of the phenomenon under study. This section will outline the process of data analysis in this study. The following points will illustrate the point of view from which the researcher was working. This study was conducted because the researcher experienced a need for a greater understanding of how well elderly individuals experienced aging. The researcher, therefore, resolved to study the day-to-day experience of older Canadians encountering a phenomenon common to them al l -aging-in an attempt to understand how these individuals derived meaning from their circumstances. In phenomenological research, analysis is conducted concurrently with data collection. Accordingly, the researcher began analysis immediately after the first interview with the first participant. The researcher transcribed the interviews verbatim. The researcher then examined each account to identify all shifts in the topic of discussion or the perspective from which a topic was discussed (Giorgi, 1975). This type of analysis produced a list of topics or meaning units (Giorgi, 1975) that study participants raised. Many of the topics common to the study 37 participants' descriptions could be grouped into one theme-control. Some topics were not common to all participants' descriptions, but they seemed to describe important facets of aging. Three categories of topics seemed relevant in describing the nature of the aging experience: lifestyles, finances, and health. The second interviews validated the emerging theme and categories. Although the participants reported that they were comfortable and satisfied with the first interview, during the second interview the participants reported and discussed personal issues in much more detail. For example, participants expounded at greater length on family dynamics, personal relationships, and physical health. The second interviews continued to support the category of topics around the theme of control noted in the first interview. During the process of data collection, then, the analytic framework for organizing the information evolved around the theme of control and the supporting topics. This analytic framework related the elements of participants' individual descriptions into a composite description of the experience of aging for well elders while still accounting for variations in the data. Validity and Reliability Every research study must address issues on validity and reliability. For validity, research of this nature must remain grounded in the informants' accounts. For reliability, consumers of this research must be able to understand how the researcher arrived at the conclusions presented. Sandelowski (1986) maintains that, like quantitative methods, qualitative research methods have their own rules about 38 aims, evidence, inference and verification, but there are not clearly established rules for demonstrating rigor. Moreover, quantitative measures of rigor do not apply in qualitative research. Accordingly, Sandelowski advances four concepts through which rigor may be addressed for this type of research: credibility, applicability, auditability, and œnfirmability. Three of the concepts will be discussed in relation to the study at hand. Confirmability is achieved when the others are achieved. In qualitative research, where the findings are the subjective experience as lived, credibility comes from proof that the research is faithful to the subjects' descriptions. In these studies, the researcher describes as accurately as possible the process of data collection and analysis. Two questions that test internal validity or credibihty are: "Would study participants immediately recognize the analyzed research results as true to their story?" and "Would individuals reading the research report be able to recognize the phenomenon solely from having read about it?" (Sandelowski, 1986). Both these questions remain to be answered when the researcher summarizes the study for the participants and presents the results to colleagues. Informal reports from colleagues have been positive. One threat to credibihty is that the researcher runs the risk of becoming too involved to be able to interpret the phenomenon in a meaningful way. The researcher countered this risk by using literature and discussion with her committee and others to expand her views and find outside validation of the issues discussed. 39 In qualitative research every subject of the study population is regarded as a unique source of an equally representative perception of the phenomenon under study. Samples are small because the time is taken to elicit a great depth of detail. Applicability of the study findings derives from the ability of the findings to fit other situations, whether the findings do actually represent the data from which they have come (Sandelowski, 1986). To test the applicability of the study findings, the researcher presented her analytical framework to a community health nurse who facilitated the elders' wellness groups in the community centers. The nurse concurred that the central theme of control divided into topics of lifestyle, finances, and health was an appropriate and effective conceptual framework for describing this population. Sandelowski (1986) identifies two threats to external validity. First, the researcher may obtain rich complete accounts only from the most articulate and accessible participants, possibly missing many dimensions of the phenomenon that other individuals may experience. The researcher found some study participants to be more explicit about the effects of their experiences than others. The researcher was aware that participants expressing strongly negative emotions and strongly positive emotions influenced the direction of analysis. Continual comparison among all accounts about each of the elements identified reduced this tendency. 40 The second threat to external validity is the possibility that the researcher presents the data as a more complete description than it really is. The researcher offset this possibility by encouraging study participants to tell their story from their own points of view, by following their leads in identifying important elements through analysis, and by validating hypotheses and conclusions as much as possible within time constraints. In attempting to account for typical and atypical elements of the data, the researcher felt the study sample was too small to show all the possibilities of aging situations. Further theoretical sampling would have remedied the problem. Consequently, a further study is indicated. The validity of a study is enhanced when another researcher following a similar analytical decision path, obtains similar results. In qualitative research the repeatability of a study is difficult to determine when the method emphasizes the uniqueness of individual situations, emphasizes the intersubjective construction of experience between the respondent and the researcher, and promotes analysis by examining variations of the experience. Therefore, to ensure some possibility of repeatability, the researcher must be open about her biases and describe the basis of her decisions throughout the research process. In this way, the research procedure becomes auditable. This thesis attempts to describe as completely and succinctly as possible the process by which this research was conducted. Chapters Three and Four contain sections explaining decision-making throughout the process of setting the research 41 question, data collection, and data analysis. Chapter Four will present the findings using representative examples from the data itself. Summary Research for this study was conducted using the phenomenological research method. Nine participants were selected from three community centers in Vancouver using the guidelines noted. Background information and current social demographics were documented. The research met the ethical criteria specified by the University of British Columbia's Behavioural Sciences Screening Committee for Research and Other Studies Involving Human Subjects. The researcher collected the data from two audiotaped interviews with each of the participants. Other sources of information included field notes of the researcher's perceptions and telephone calls with participants. These data were analyzed according to Giorgi's analytic method (1975). The conceptual framework for this study was developed and organized in relation to this method and the content of the interviews. Finally, the issues of validity and reliability in relation to this study were discussed. 42 CHAPTER FOUR Presentation of Findings The aim of this study is to understand the subjective experience of aging for the well, elderly individual. Therefore, the study findings describe the participants' collective experience as the researcher understood it. Development of an Analytical Framework The purpose of data collection and analysis was to elicit the perceptions of well elders and to identify patterns among them. Using the phenomenological research method, the researcher developed an understanding from discussing the perceptions of participants according to each individual's unique experience of aging. In consultation with the participants, the researcher then developed a composite descriptive analysis that incorporated the various perceptions of individual study participants into an analytical framework. The Experience of Aging The researcher asked well elders to tell their stories about what it is like to age. In telling their stories, the theme of control appeared throughout as a key factor in their experience of aging. The fact that many of these elders felt that they had some control over a variety of facets of their life was deemed essential to understanding their perceptions of aging. In fact, participants stated that aging had not been a negative experience precisely because they felt they still had some control over various aspects of their lives. During the interviews, words and phrases such as 43 "in control," "force," and "I decided" were used frequently and supported their very conscious effort to express the importance of control. Consequently, careful attention to the language used by the participants supported the development of the analytical framework. For example, one individual told of her decision to move away: "After I'd completely made up my mind and I knew exactly what I wanted to do, then I made the big announcement and that was it. I mean, discussion over." In these two brief sentences, the participant used the first pronoun "I" five times and attached to it very strong verbal constructions: made, knew, wanted, and mean. Thus, the participants defined aging positively for themselves by virtue of then-having maintained control over important areas of their lives. In contrast, they described negative aspects of aging in the context of their commentary on other elderly people (friends and acquaintances) who did not have the same degree of control in their lives. Their description of the negative experiences of others strongly aligned with the North American stereotype of an elderly person (i.e., frail, physically and/or mentally dependent). Participants repeatedly emphasized that they had no intention of falling into this stereotype. However, all seemed to recognize the inevitability that they too would eventually be considered as frail elderly individuals. Several stated that, as a result of this eventuality, they wanted to live life to the fullest and enjoy it now. As one participant emphasized, "I think you realize that as you become 65, your years are becoming measured, no matter how young you feel and how young you are. You know we're getting around to the end of the ball game here, so let's try and enjoy it in a healthy way." 44 Consequently, the researcher was able to appreciate that the notion of aging for these participants was primarily viewed as negative or positive in terms of issues related to control. In their accounts the elders addressed the theme of control in the context of three major components of their experience: lifestyle, finances, and health. From their perspective, a loss of control in any of these areas would be a traumatic event and would have an impact on their present experience and perception of aging. The findings related to the elders' perceptions of aging will therefore be presented in the context of control in these three dimensions. Lifestyle The aspect of control over aging that elicited the most rich and detailed description from these participants centered around their concern for fulfilling basic daily needs and activities. In this context, the participants frequently discussed activities that required a certain amount of physical skill and energy, such as driving, house cleaning, laundry, grocery shopping, gardening, and meal preparation. They reported that their perception of aging depended to a significant degree upon then-ability to maintain these functions and thus maintain a degree of autonomy in pursuing daily routines and interests. In this discussion, their accounts revealed three types of lifestyle issues that they considered important in the aging process: skill-related activities, friendships, and retirement. Skill-related activities. Many participants thought it was important to make their own decisions and set their own limits with regard to skill-related activities; they wanted to demonstrate the fact that they could make their own reasonable decisions 45 rather than have someone else make the decisions for them. Driving a motor vehicle was one of the more pertinent skill-related activities that the participants felt they had to come to terms with: "I no longer drive. I felt that there are enough idiots on the road without somebody that knows perfectly well that she is slowing down a bit and her reflexes aren't as fast." Another participant further stated: I've driven with people the same age and so on and so forth, and ah, they scare me. And I thought, well, if I'm as bad as that, I certainly don't want to drive. And I certainly don't want to wait until I am that bad to stop driving. So I just tore up my license. I really wasn't all that fussy about driving anyway. And moving to the city where there's all kinds of transportation, I thought there's all kinds of cars on the road without an extra one. Others did not dispose of their license altogether but set some personal limits such as driving only around the neighborhood, only in the daylight, or only on the highway accompanied by someone who could read the signs for them. Most elders disliked driving in the city and felt that it was also unnecessary due to the availability of public transportation. These elders demonstrated recognition of their waning abilities yet, at the same time, maintained control over the situation by setting their own guidelines and limitations. Besides driving, the participants repeatedly mentioned that they were now unable to complete tasks or duties as they had done as younger individuals, especially household maintenance activities. However, to maintain some form of control, many 46 found that they would prioritize tasks and/or set longer time frames to complete these tasks. For example, one elderly lady had always cleaned her entire home every Spring, but now she found this same task was beyond her capabilities, so she compromised by doing the rooms most likely to be seen by visitors first Another participant added: I do find I'm slowing down physically. We were talking about this, that it seemed to me that I could take much more in my stride. I could do the garden and the house together, but now I find I haven't even spring cleaned this year yet. I just keep things clean and that's about i t Another participant further stated: It wouldn't occur to me to take down the curtains to wash them and iron them and have them back up all in the same day. I mean you just did that Now I find that maybe it's not as important to get the curtains back up on the window in the same day. It would tire me out to do i t And why should I tire myself out? So you make concessions, so you feel you're not pushing yourself. Many tasks, such as spring cleaning, were no longer as important or held the same sense of urgency as they once did for these elders: You don't attach the same importance to what the neighbors might think. You cannot. I remember being very upset, because I used to mow the lawn every week. I simply cannot mow and trim and everything on the one day anymore. So if my gardener doesn't show up and it's not presentable, then it's too bad. He'll get there. 47 Organizing, prioritizing, and adjusting were all approaches that the participants identified as ways of coping with the effects of physical aging that also allowed them to exert control over their lifestyles. In particular, this meant mamtaining their homes. Ultimately, the participants wanted to make the decision for themselves as to when it would be appropriate to leave their homes. As one elderly lady stated: I'm ready for changes if I have to get out of my home. I still live in my family home. But, ah, I haven't reached that point yet I still feel well. But that's not to say that I'm going to dig my heels in when the time comes. I hope I recognize when the time comes, and, when it does, I think I'll sell it with no qualms, and say O.K. this is inevitable. Another added: I moved last November. I lived in this area for 50 years in the same house that I moved when I got married. Well, it [moving] was something I had to think about seriously. But think about so that I was in charge and that I was making the decision. It wasn't ill health and, ah, not necessarily financial. But the house was old and, ah, although it was very well kept up and had always been kept up, urn, I got to be thinking about the roof and plumbing, and all this kind of thing. I thought do I need this? I simply don't feel that I want the hassle of getting people in to look at this and then making arrangements to have it fixed. And I just felt the time had come. 48 Skill-related activities were identified as being affected by the natural changes associated with aging. This often required the individuals to adjust their activities to cope with such changes. Organizing, prioritizing, and limiting activities were all approaches that the participants used as ways of coping with the effects of physical aging. Friendships. The importance of the home and neighborhood also influenced and affected another important factor that many of the participants felt was a confidence builder-maintaining close friendships. Many of the participants saw then-close friends as a source of comfort and support In spite of all the changes occurring to and around them, their friends were stable and still cared about them as people. They could share and draw from a common history of experiences and accomplishments to combat some of the loneliness and isolation resulting from other losses associated with aging, such as, the death of a spouse. This one little lady, we've known each other since we were 18 years of age. We always lived within a few blocks of each other. Never been, ah, the type of friends that ran in and out of each other's home or anything like that, but always been good friends and played bridge together and that kind of thing. We've shared a lot in all those years. Another stated: I never expected to be a widow and going through this stage of my life alone. Also, I didn't expect to be having to rely on friendships. Friendships take on a whole different meaning when you get older, and that is for shared 49 experiences. I'm sure you have a friend that you grew up with, who is absolutely different from all the rest. You've got a lot of acquaintances, but you've got one special friend. The participants stressed the importance of friendships not only as a source of support for the feelings of isolation and loneliness that accompany aging, but also as a challenge in making new acquaintances and developing new friendships as they had done throughout their lives, although perhaps with not as much ease: I certainly don't think you make friends as easily as you used to. You may make many acquaintances, but I don't think you make good friends when you're older. Maybe it's that your friends have shared experiences. I think you can do; for instance, I have made a very good friend in the last few years. Many elders felt that they took extra time to understand new acquaintances more deeply rather than engaging in superficial socialization: A lot of the friends I had when I was working [pause] they were fun to be with. They were people that I was attracted to. They were funny, a great sense of humour. Now I find that the friendships are different because they are based on something other than just, an, fun and a nice person and good looking or whatever you were attracted to when you were younger. You take a good look at someone who might not be attractive physically to you, but, boy, they sure have depth. 50 On the other hand, one participant stated that she now had more acquaintances than at any time in her life: I don't have any close friends. I've always been in the house, I haven't had a chance to make friends. And I moved a lot and so never developed that kind of friendship. But since I've been working in the exercise deal [teaching aerobics to elders] I've met all kinds of fond acquaintances. For the participants, the process of aging prompted them to make adjustments in the way they developed friendships; they felt that they lost some sense of control over their social lifestyle when friends or family moved away, were institutionalized, or died: "Yeah, you lose a confidante and just someone to talk about 'old times' with." This loss often forced the elders to make new acquaintances, and often these were younger individuals living in the community: "You begin to lose friends-people you have known. They move away or die or go into homes and so on. So, therefore, you are more or less surrounded by younger people. They are friendly enough." One lady humorously described her experiences around younger friends: "They were quite surprised at first when I went out with them and had some opinions on what's going on in the world or what I thought. Because years ago, I think old people sat and crocheted and really never absorbed anything." The elders also found adjusting to younger acquaintances a difficult task because they often came from very dissimilar backgrounds or upbringing: You haven't got the people to kid around with and joke with like you used to. You come into a different generation, you see. A lot of people who haven't 51 had the experience that you've had. A lot of older people grew up as working people like firemen, lumberman, fishermen, or farmers. These are city kids [pause] professional people. This section has discussed the impact of aging on friendships. As the individual ages, friendships take on a heightened importance due to the shared history of experiences and accomplishments. However, many of these cohort friendships are tested by changes incurred through aging (i.e., illness, institutionalization, or even death). Many of the participants in this study described meeting new people as a challenge over which they had some control. Retirement. According to the participants, retirement affected the ability to maintain both skill-related activities and friendships. In addition, retirement challenged the participants with a new set of transitions. The participants identified retirement as having an impact on their lifestyles and their perception of aging; the majority expressed that they had taken aging for granted, or at least had not noticed the differences in their lifestyles until retirement. The elders perceived retirement as something that could have threatened their sense of control over their lifestyles. Employment-related skills and working relationships and friendships suddenly seemed distant. Consequently, they stated that they had to attempt to learn other ways to use their skills and develop relationships in order to maintain their sense of control over their lifestyles: Of course retirement was a big thing. You never have to go back to work, and you are free to do as you like. You miss the work, the routine, the people you 52 work with, and doing the job. It didn't bother me as much because I'm quite happy and self-contained, doing other things [pause]. My activities have changed from work to civics. Another participant stated: I'd been very active. I'd worked for a big company for 40 years, and I took early retirement, and, um, suddenly I was not in the work force, and my husband had died, and so I was hanging on, like grim death, to home and everything that was there. One of the reasons I joined this group [the senior's wellness group] was to get interested in something other than the house. Because of retirement, many participants experienced a short lived loss in a sense of value or self-worth, and turned to other avenues to maintain some control over then-lives. As indicated in the quote above, one elderly man mentioned that he had traded work for civics and had become very active lobbying for a variety of good causes: We were finding the heavy traffic [pause] we were hoping to keep it down. The local rent payers' association were thinking of putting all these mini parks and diverters and things in to discourage the traffic. So I got involved with them, and we went at it hot and heavy for 5 or 6 years and really got into it They got me talking and making speeches up at City Hall. Another participant stated: "I'm active in various organizations, but none of it is essential though I am proud of some small accomplishments with the bus fares for seniors and the Stanley Park bus." Another participant commented: "I fought for the 53 buses and the senior people. I got very upset I went out and stopped all the traffic on Granville bridge because I thought, if we couldn't have our buses, they couldn't run their cars." Alternatively, some of the other participants took up volunteer work and hobbies in retirement As stated earlier, many of the participants became interested in helping organizations or relationships. This voluntary service often helped boost their sense of control, particularly because they were offering a service and not being paid to do so. Some joined language classes, craft groups, or bridge clubs. Others volunteered to sit on committees, supervise at daycares, teach Sunday school, or volunteer at seniors centres: "I volunteer over here (community centre), which I enjoy immensely. But if my husband wasn't ill, I'd get more into volunteering. I'm not interested in the monetary part of it" In addition to volunteer work, social activism and community activities, all the participants interviewed noted an interest in travelling and perceived travelling as another means both to adapt to retirement or cope with the loss of a spouse and to control their lifestyles. As one commented, "This trip is going to be a test for me. If I really like it and find that I manage alright, urn, then I think I would consider selling the house, buying a condo, and travelling more. Perhaps go into this Elderhostel program." Others saw travel as an opportunity to learn: "I was a school teacher and I majored in history at University. So I want to keep learning about places. I love to visit museums and old churches." 54 Some participants commented that travel was a great way to meet others like themselves who were trying out their new-found freedom from responsibility: Last year, when I was climbing the Great Wall, I thought "what am I doing there?" You know it was cold and [pause] and yet there were people there that were older than I was. Not by very many years. There are not that many people older than that. And enjoying it I think travel is a great thing because you do meet people who are not sitting home and worrying about whether they are going to [pause] you know they might have a heart condition or they might have bad legs or bad knees or something. But they're not sitting home saying I'd better not do that because [pause] and they have a great attitude, you know? In the context of these activities (volunteer work, social and community activities, travel), some of the participants indicated feeling more control over their lifestyles now than they did when they were younger. They commented that they no longer had all the responsibilities that they had had as younger individuals and that they only had themselves to look after: I looked after an elderly parent for a while, had a full time job and a home. So you don't have time to worry about yourself too much. When I was part way through my own health problem and just into my treatments, my husband took ill. So once all those problems were [pause] taken away, then I thought "this is my time." 55 Further, many of the participants felt that they had matured in their outlook. They were willing and had the time to examine both sides of an issue. They also felt that they had less to lose if they expressed an opinion or made a move on something. In fact, many stated that they were more apt to accept new risks or challenges than in the past: Being willing to try even if you've never tried it before. I tMnk what the heck give it a whirl. I think you lose some of your inhibitions about what is proper and safe. And, therefore, you think well what the heck I'll give it a shot, and sometimes you do fall flat on your face and sometimes it comes off. Another participant stated: When you're young you make a decision about your career. For instance, well my gosh it could go on for 40 or 50 years, and we ain't got that long to worry about it. I mean so we make a mistake. We're not going to be around very long to worry about it. Similarly, a third participant commented: You have to have both your physical and mental health to give anything a good shot, and so I've been fortunate to try different things that I wouldn't think of trying. And, as I say, some turned out well and some were a bit of a disaster and some I thought, "oh how did I ever get involved in that?" These things are self-limiting, because you're older you get yourself involved in something you feel is too much for yourself. You can always plead old age. 56 A common age-related change for employed individuals is retirement. While many of the participants described the initial feeling of loss, they all expressed a need to control this aspect of their lifestyle through activity. This sense of control was fostered through their new-found freedom from responsibility and commitment The participants addressed many different facets of their daily lives that influenced their perceptions of the aging process. They identified skill-related activities, friendships, and retirement as important factors that had had an impact on their lifestyles and, consequently, their perceptions of aging. Making adjustments, realizing limitations, and undertaking new activities were all key means of employing control. Beyond maintaining a former lifestyle, many participants also engaged in and created for themselves new and challenging lifestyles. Thus, for them, maintaining control over their lifestyle was essential for a positive experience of aging. Finances All the participants identified financial independence as a basic factor in their sense of control over their lifestyles in their advanced years. Their freedom to engage in community and social activities, their ability to maintain friendships, and the impact of retirement on their lives all were dependent on financial circumstances for these participants. Financial security allowed them to view aging as a positive experience. Their descriptions of concerns about income, home ownership, and social benefits illustrate another important way in which a sense of control rendered aging as a positive experience. 57 Income. Al l the participants in this study perceived themselves as financially secure. All were receiving at least two pensions and had managed to accumulate sufficient savings to allow them to maintain their lifestyle as they were accustomed to, if not better: I retired when I was 61. I only did that because financially I could do that. Because the Provincial Government [long pause] you can get your superannuation at 60 and then it reduces when you're 65. But at the same time, in the U.K. where I've worked, as I said to you. [long pause] And I continued paying into the pension part of it when I first came to Canada. Because I only intended to come to Canada for a few years for a visit [long pause]. So of course, last year, 65, it was a big event to get the CPP and the OAS even though my superannuation went down. Also, none of the participants had experienced any recent financial setbacks: Your money will go further because you wouldn't be spending much on clothes. You've got practically eveiything in your home. You're not going out and buying new furniture. Well, actually, our furniture now are antiques and worth more than the new stuff. Despite the fact that all the participants viewed themselves as financially secure, they all were cognizant of elders who were less fortunate, those who were receiving only one pension or who had been forced to retire early due to physical or mental ailments: "So many women have been left with very little money and cannot afford to have a vehicle or use the bus or even cabs. Increases in rent or food have taken its toll on those poor women." 58 Another added: Growing older isn't so bad if you're financially O.K. There are one or two ladies here [community center] who are worried about finances. That must be very wearing too. I mean you don't have to be rich, but as long as you know that you're not going to be financially strapped all the time. It must be pretty bleak thinking you might have 20 years of life left but you really don't know where you're going to live it or how you're going to live it. Generally, the participants in this study identified themselves as unusually fortunate and recognized that the majority of elders experienced some form of financial insecurity. Financial security contributed to the participants' sense of control, thus making aging for them a positive experience. Social benefits. The participants also discussed the abundance of services and discounts that society provides for them in the context of financial security. However, the attitudes towards such benefits varied within the group from a reasonable expectation to a feeling of being patronized. Some elders felt that the benefits offered them could and would be abused by other elders. They felt that many who really did not require the assistance would take advantage of the services simply because they were available. Thus, some participants viewed such assistance programs as fostering a dependency among elders and, paradoxically, depriving them of their autonomy and control. One woman commented that she was surprised at the network of programs and social assistance in place for elders, and she went on to add: "I wonder how many people take advantage of them because they know that 59 they are there, rather than do for themselves for as long as they can and only use them when the going got tough." Another participant stated: I'm sure that the people that run these services must put up some kind of parameters that people have to fit into in order to qualify. But on the other side of the coin, there are people who have gone their whole lives beating the system. And ah, when I saw that booklet of services [Seniors Services Bulletin] I thought "good grief, I bet you there'd be a lot of people who'd make a real study of this and say I can get this for free, or I can get people to come and do this for me." I don't know how good it is to have people come and do for you all the time. As was also evident in their views on housing, most participants in this study showed concern for those less fortunate than themselves with regards to social benefits for elders. Moreover, they could appreciate the usefulness of such benefits in creating a positive experience of aging for other people: Where on earth would you find, ah, a place where seniors can if necessary get all their medical [long pause], glasses, dental [long pause] they never have to really be without. I'm not saying that I particularly want to have it that way, but certainly it's there for you, and nobody has to know the difference. It's such a private way of doing things. You get to keep your dignity. Although control over their lives through financial security was considered central by the participants, they clearly indicated that it must be coupled with a sense 60 of dignity and privacy. Consequently, some of the participants viewed assistance programs and services as their right and privilege, since they had contributed to society all their lives. In fact, one participant stressed the need for elders to assert their right for these privileges: There are a lot of discounts for seniors, and I believe it's due to seniors hard work fighting for these privileges." Thus the participants felt that the social benefits were not necessary for themselves due to their personal financial security. However, many felt that social benefits, if used appropriately, would foster some sense of control for those less fortunate. To summarize, as a basis for maintaining or advancing their lifestyles and as a factor strongly influencing their perceptions of aging, the participants identified financial security as a major issue. Income, home ownership, and social benefits were all key factors. Although all the participants in this study were financially secure, they considered their security on a comparative basis to other elders who were not as fortunate. The participants' insights allowed them to prepare for future circumstances, such as deteriorating health and transitions in lifestyle. Home ownership. In addition to income, and social benefits, the participants also stressed that ownership of their homes or apartments was a key factor influencing their financial security and, therefore, helping them maintain a sense of control over their lifestyle. All of the participants owned their own dwelling, and many felt that this added to their sense of financial security because they were not threatened with such experiences as rent hikes or evictions. Several of the 61 participants expressed their concern for friends or acquaintances who were vulnerable to increases in housing costs: Well, you know what I really feel sorry for, and I've had people in tears on the phone, as soon as they retired or the family was gone, sold their house and moved in and rented an apartment. Now they thought they were set for life [pause]. Then they find that the rents are leaping up. They suddenly found that they couldn't afford i t Then what are they going to do? They don't want to live anywhere else. Where are they going to go? The participants recognized that this housing problem is prevalent among elders and has a significant impact on their sense of control. One participant even identified lack of financial advice for elders as a contributory factor to this housing problem: "But I do think that a lot of people have poor financial advice. People should know better. I'm not a great wizard, but I am careful. This is a big problem with seniors." Although the participants emphasized mamtaining control of their lifestyles through home ownership and financial security, they also addressed the inevitability of having to change their residence with the same kind of practical attitude and thinking that they indicated in their response to a change in lifestyle: I'm ready for changes if I have to get out of my home [long pause]. A lot of people have asked me would I not like to give it up. Get something smaller and easier to maintain. But, ah, I haven't reached that point yet I still feel well. Financially, I can still stay there...I have some friends who are very much afraid of having to give up their home. But I think in time they'll realize that it's for the best and enjoy getting an apartment 62 The participants identified home ownership as key to their financial security. However, many stated that they were able to maintain their home because they were physically and mentally well enough to do so. Al l the participants addressed the possibility of having to choose alternative housing due to age-related changes in physical or mental functioning and expressed a desire to have some control over the choices. Health The participants' consideration of lifestyle and finances as factors influencing their perceptions of aging was dependent upon a broader concern for general well-being, based on physical health. Consequently, these elders identified health as the most important area in which they strived for control over their lives and the area that most influenced their overall perceptions of aging. The interviews indicated that health and health-related issues were of prime concern to these participants and that their state of health affected all other areas of their lives. In describing their concern for well-being, the participants made frequent references to illness and dying and death. Hence, some descriptions of these participants' attitudes towards death and dying have been included in this discussion. This section, then, presents the participants' concern for well-being and the effect this concern has on their perception of aging as it emerges in various areas of their lives: maintenance of health and preparing for illness, dying and death. 63 Health maintenance. The majority of the participants felt that if they wanted to maintain their present state of control over their health they had to work at i t Two key areas they identified as requiring adjustments in this regard were nutrition and exercise. First of all, many felt that they were eating healthier now than as younger individuals; they were more conscious of their diet and the way it affected them physically. The participants were all very aware of their bodies' reactions to certain foods. They attributed this heightened awareness to having more time to listen to their bodies' response. As one elderly gentleman stated: Tve lived with this body for 76 years, so I think I know it fairly well." Another participant explained her change in eating habits as a means to maintaining her present state: "I think when you were younger you'd think nothing of eating Chinese food three nights a week for dinner, but now you kind of back off that a little and go more for the fresh fruits and vegetables. I think if your body is in good shape, you want it to stay that way." The importance of diet was further expressed by other participants: I'm extremely lucky to have health and that is the key to enjoying old age. I think when you are older you have to be very aware of your nutrition and not get out of the habit of making meals and looking at new recipes and trying new recipes. Another participant added: Tve enjoyed my old age because I know what to do with my life and how to eat and how to look after myself." 64 In addition to more careful attention to regular diet, many participants indicated an interest in and use of dietary supplements such as vitamins and various health foods recommended by physicians, friends, or the media: Recently I read that if you find yourself forgetting things, you're not getting enough lecithin [pause] and so I went and bought a jar of lecithin. You are supposed to take two tablespoons a day. The second area in which these participants indicated their attempt to control their health was exercise. Many of the participants were physically active as younger individuals. Several found that, immediately upon retirement, they were not as active. So many took up new hobbies and activities to keep them going. One participant stated that she was more physically fit now than when she was younger: You know, I never had any recreation when I was a kid. I didn't learn how to swim or skate or any of those things. I had to stay home and help my Mom. And so I've always worked all my life. Now I do a lot of going out and teaching a lot of exercise and things like that. Many of the social activities that people described in relation to niamtaining friendships also contribute to physical fitness. Thus, all of the participants believed that proper nutrition and physical activity promoted a healthier being and enabled them to enjoy the aging experience more fully. Preparing for illness, riving, and death. The participants' attempts to control their health through diet and exercise were often influenced by having been ill themselves or by having witnessed the illness of a loved one. For the participants, 65 illness prompted them to take more control over their lifestyles to facilitate more healthy living. As one elderly woman expressed it: Last year I developed high blood pressure and had never had that kind of a problem And so I had to take it seriously, naturally and really worked on i t And then there was a cholesterol problem came up and that was quite serious. But I just did what I was supposed to do and really studied everything I could get my hands on and read everything I could get my hands on. I went to all the right doctors and got all the information I could. An illness event also made participants very aware of the aging process. They often saw themselves falling into the stereotype set by society of a frail aging individual. As one elderly individual put it: 1 never thought about getting older or old until I took sick two years ago. I did a lot of soul searching during my illness and I think that I've come to terms with my life." From his point of view, coming to terms with his life meant that he had readjusted some of his goals and examined his accomplishments. The stereotypic image of aging is a frail, dependent individual who is plagued by chronic and acute illness episodes until death. Many of the participants explained that when they were exposed to illness, this stereotypic picture became more applicable to them personally. Therefore, to maintain their current status, many elders actively pursued control by living healthier lifestyles. Often an illness event invoked thoughts of death and forced the participants to consider their feelings related to death and dying. In addition, many of the 66 participants had to examine their perceptions of death and dying when they were faced with the death of a family member or friend: I've got a man I worked with who was gay, and, of course, eventually he got AIDS. We talked a lot about death as he was beœming more and more ill . He's not afraid of death, but he's afraid of dying. And I agree with this because he's got a horror of going into hospital and then being stuck there and wanting to die, and nobody will do anything about i t And I entirely agree with that I'm not afraid of death, and I only hope that when my time comes that I can be struck down like my father who was found dead in the garden when we had seen him only an hour before alive and well. Now once you're in hospital that [natural death] seems impossible, and this is what he's afraid of, and I agree. I would hate to get to that stage and having no family who could look after me, and, urn, this to me is a real fear. I've spoken to my doctor about this, and I've signed a living will which I gave to her the other day. The majority of elders interviewed had similar feelings about death and dying. Some had different supports they relied upon when considering death; for example, several participants referred to their religious beliefs in the context of considering death and dying: As you get older, and people around you are dying, you realize that the inevitable is coming. If you're spiritually healthy, if you realize that this is a fact of life, and it's just as inevitable as anything else-as the hair going grey 67 and the skin sagging. You're prepared for i t I personally wonder how people who have no belief in anything, how they can cope with any of i t I know it's a source of comfort for me to have some sort of spiritual philosophy. Another participant developed her own belief system in considering death that appeared closer to Eastern beliefs than to Western religion: Well I'm a person who doesn't go along with the orthodox church idea that you are going to heaven or hell. I believe in reincarnation and I believe in this [long pause]. I know it's spiritless teaching, but it makes sense to me. That people go through grades and when you pass away, you go to the grade where you're at. And you are not necessarily going to come back to earth, but if you study and work on the important things in life, you can get to higher grades. And only when you get to grade 9,1 think it is, I'm not sure, you are on the level with Jesus Christ And then you are going to be a teacher for others. I believe in that So I'm not afraid of death myself. Finally, many of the elderly participants articulated and emphasized the importance of practical preparations and considerations for the event of their death that seemed to indicate an attitude of acceptance: When you get a little bit older then you start looking at yourself, looking squarely, yes I could die. So get the will made, that doesn't say that you're going to drop dead because you've made your will. You face up to things and say O.K. I've got to give this some more thought I've got to get prepared. Once you're prepared, then on you just relax and enjoy. Don't worry about it 68 because it all falls in place. You have to be ready to make whatever changes you have to make. Thus, for these participants, aging was associated with eventual death. Many of them sought to maintain control by actively preparing for the inevitability of dying and death. In examining their feelings about death and dying, these elders thought about the practical things associated with the event, such as completing their wills and instructing family members about what should be done. An important factor for the elders interviewed was that they not be seen as a burden to their family. One elderly woman stated that she was glad she had made the decision to move into a townhouse under her own steam instead of having her family say, "What are we going to do with Mom?" Another participant stated: "Well you know the end is approaching and it's got to come and if your health starts to fail [long pause]. I don't mean little physical ailments, but major problems. Then you have to rely on someone else, and I don't want to be a bother to anyone." Another elderly woman stated her fears: I want to wear out not rust out. I'm sure I could enjoy life if I was hobbling around, but I certainly don't want to die if I thought I could enjoy life. But I don't want to get to the stage where life is a burden, for whatever reason. And when it is, I would like for someone to give me something where I could choose. I don't believe in transplanting parents or the elderly to suit the children's lifestyle. I mean they are not able to care for themselves. You 69 learn to resent that old person, and the old person is separated from all her friends. But that is my fear of aging, of living in pain. Thus, like others, this woman described the importance of physical well-being as a factor influencing her perception of the aging process. Like others, she defined such health through reflection on illness, death and dying; in fact, such reflection prompted the elders to take positive action towards controlling their health through nutrition and exercise and, as well, to take measures to ensure that illness and their inevitable death would not adversely affect family members, caregivers, and society. Summary The elders interviewed in this study identified lifestyle, finances, and health as three areas that were important in maintaining control over the aging process and, therefore, three major influences on their perceptions of aging. The participants' accounts of skill-related activities, friendships, and retirement were examined in the context of lifestyles. Their financial security was discussed in relation to their concerns with income, home ownership, and social benefits. Finally, the importance of physical well-being as a factor influencing the aging process was revealed to be a critical area of concern for them. In this regard, their accounts shared their concerns about maintenance of health and preparing for illness, and death and dying. On the basis of these findings, the subsequent chapter will provide an analysis in light of the current literature. 70 CHAPTER FIVE Discussion of the Findings This chapter presents a discussion of the findings of this study. To enrich the discussion, the findings are considered in relation to pertinent literature, which is used to elaborate upon the key themes that were found and to compare the findings of this study with the findings and observations of other researchers and authors. The purpose of this study was to understand the meaning of aging from the well elder's perspective. A major theme that evolved from the interviews in relation to the elders' perceptions of their aging experience was the concept of control in relation to three specific areas: lifestyle, finances, and health. The elders' sense of control over these areas contributed greatly to their perceptions of successful aging. The Experience of Aging The elders in this study explained their positive experience of aging as a result of having control over three main areas of their lives: lifestyle, finances, and health-all of which the elders saw as being interdependent. The elders consistently reiterated that a decrement in one factor would certainly influence their status with regard to the other two factors. For example, a decline in health could affect both lifestyle and finances and, thus, their sense of control and their perception of aging as a positive experience. Because the well elders of this study felt that they had successfully adapted to adverse conditions, they believed they had experienced aging positively. 71 This contrasts greatly with the socially accepted stereotype of the "old" in North America: that elderly individuals do not have any control or power over their lives but are merely frail, dependent, and disabled members of society. Lifestyle Maintaining moderate levels of activities in daily living within their present lifestyle was frequently mentioned by the participants as something that influenced their experience of aging. Control over areas such as skill-related activities, friendships, and retirement were the categories that evolved from the interviews. By being able to maintain control of these three factors, the elders were able to view their personal aging experience as successful. Bandura (1982), and Baron and Rodin (1978) both propose that positive life outcomes evolve when individual elders believe they are generally in control of their lives. It follows then that if the elders in this study believe that they can exert control over skill-related activities, friendships, and retirement, then they will probably view aging as positive or successful. Skill-related activities. All of the elders interviewed in this study recognized that, over time, some of their former capabilities in relation to the performance of certain activities had decreased, primarily as a result of age-related changes. Driving, housework, meal preparation, and gardening had deteriorated as a result of diminished physical abilities, which the elders recognized as a precursor of old age. In fact, many stated that old age would arrive when the kind of physical limitations they were already beginning to experience became serious enough to immobilize 72 them. Many of the elders coped with their waning abilities by giving priority to certain tasks, taking longer periods of time to complete tasks, and setting self-limitations on tasks. By deciding to cope in these ways, the elders felt that they were still in control, able to make adjustments of their own volition. Moreover, because they could maintain such control, many of the elders perceived themselves as being much younger than their chronological age. There are many studies in the literature related to successful aging that mention older adults and their younger age perceptions in correlation with their well-being. Andrews and Withey (1976) point out that people's perceptions of their own well-being ultimately define the quality of their lives. Thus, if elders perceive their well-being as positive, then they will probably view the quality of their life positively as well. Similarly, Montepare and Lachman (1989) also state that younger age perception coincides with greater life satisfaction and self-esteem, until disability and impairment occur. The elders in this study continued to strive for control in relation to skill-related activities by modifying their activities, until they were no longer able to do so. As long as the elders were able to maintain control over skill-related activities, they continued to dissociate themselves from the stereotypic image of the frail, dependent elder and associate themselves with the middle-aged population (and all the perceived capabilities that this population possesses, compared to the perceived diminished capabilities of the old-age population). 73 The respondents in this study demonstrated the ability to maintain control of their lives in two key skill-related areas which are often affected by aging: driving and household maintenance. To compensate for the natural functional changes associated with aging as described in Chapter Two (Chappell, Strain, & Blandford, 1986; Stone & Fletcher, 1986), they utilized many creative methods to help them maintain control. Some set limitations on their driving, such as driving shorter distances, driving only in the daylight, or driving on the highway accompanied by someone who could read the signs for them. Others who had decided to relinquish their driver's licenses opted to find transportation through the public system, family, or friends. Likewise, diminished abilities for household maintenance stimulated the elders to be inventive in coping with their waning abilities. Most stated that they had adapted to their physical limitations by prioritizing household tasks and/or taking longer to complete tasks. The participants were all aware that their ability to modify their behaviors was probably limited, and would become less effective as they progressed in aging, necessitating assistance from others and a subsequent decrease in control. Even at this point, however, the elders expressed a desire to attempt to maintain control by actively problem-solving and making the decision of when and by whom daily tasks would be completed. In fact, a few of the participants stated that they had already acquired help for certain tasks such as lawn mowing and cleaning windows. The elders' perception of themselves as problem-solvers can be seen in the light of the concept of self-efficacy as postulated by Bandura (1982) who suggests that people 74 use cognitive processing of many types, plus various sources of information, to make choices about their actions and to exercise control over their environment. In essence, the elders had effectively altered their environment to suit their needs using means that were available to them. They had assumed an active, problem-solving approach to life which led to coping behaviors that helped them to alter, prepare for, or avoid stressful events that could have an impact on their sense of control and their perception of the aging experience. Diminished ability to drive or move from place to place could create stress on their sense of freedom and control. Also, the elders' inability to maintain their own home could potentially create stress insofar as their ability to remain in familiar surroundings~a place that is key to their identity, continuity, and power to determine daily routines-could be in jeopardy. Another major factor which affected the participants' perceptions of the aging experience was their housing situation. The majority of the participants in this study were living alone in their own homes. To this point, they were able to maintain their homes and had chosen to remain there, but each person emphasized that they hoped they would recognize the necessity for alternative housing arrangements and would be instrumental in making the decision to move when the time came. Although they did not specify what form of alternative housing they would choose, they all assertively stated that it would depend entirely on their financial and physical condition at the time. Only one elderly woman in the study had chosen a smaller, more modern home in exchange for her older home, which potentially would be more costly (both physically and financially) in repairs and upkeep. The move was her choice though, because she did not want "the hassles" of running the older home. 75 All the participants emphatically stated that living with a relative would not be their first choice in alternative living arrangements. They all expressed concern that this alternative would greatly reduce their independence and ability to make decisions with regard to their day to day activities. They were, in fact, extremely adamant about not living with a relative. They repeatedly stated that this arrangement would only happen under circumstances where the elder was physically or financially incapable of providing self care or receiving professional care. Why did the elderly hold this perception? Could it be that they were so inundated with the socially accepted, negative stereotype of the frail, dependent elder, that they were terrified of being a burden on a family caregiver? In moving back to their families for care, the roles of parent (care provider) and child (care receiver) are sometimes reversed and the elder can experience an even greater loss of control by being indebted for the care provided. A professional caregiver, who receives a fee for service from an elder, could possibly preserve the elder's perception of control over the situation. Bandura (1982) relates that people use cognitive processing from many sources in an effort to make choices and exert control over their situation. Thus, the more informed the elders are with regard to alternative housing options, perhaps, the less concerned or out of control they will feel. In addition, because the elders in this study were in good physical and mental health, as well as financially secure, they could distance themselves from the need for decision-making with regard to alternative housing and only predict what they would do in the event of a crisis. This was one stressor that they had not yet experienced in aging. 76 Generally, people have control or power over a situation if they are able to identify their state of affairs, exercise choices and influence and evaluate outcomes. The elders in this study were competent in maintaining control over skill-related activities such as driving, household maintenance, and housing. They exercised control by prioritizing tasks, taking longer periods of time to complete tasks, and setting self-limitations on tasks. As a result of this ability to exert control, the elders experienced their aging as successful. Friendships. The elders interviewed also indicated that friendships were important in shaping their perceptions of aging. By having friends or social supports, they did not have to face alone the changes associated with aging. In spite of all the changes (such as widowhood, retirement, and physical changes) that were occurring in the participants' lives, their friendships were a stabilizing force and were frequently mentioned as contributing to their sense of well-being and comfort. This aspect is also dealt with in the literature (Cohen, Teresi, & Holmes, 1985; Palmore, 1979; Roberto & Scott, 1986; Ward, 1985). Specifically, Palmore (1979) states that although social supports fail to modify the impact of stressful global events, specific dimensions of social support lessen the effects of specific life events on psychological well-being. Similarly, Roberto and Scott (1986) state that friendships are important to an individual's psychological and social well-being. Through friendships, individuals find acceptance, support and companionship, all of which are vital to a sense of personal worth and fulfilment in later life. They add that friendships help people sustain a sense of usefulness and self-esteem more effectively than do filial 77 relationships because the former rest on mutual choice and mutual needs and involve a voluntary exchange of sociability between equals. Older adults, in particular, benefit from the support of friends because they are able to assist the elder in coping with the multitude of stressors, such as physical and mental changes, widowhood, and retirement, which are associated with aging. Participants in this study stated that the friends they had maintained in later life were directly related to their sense of security or control. They valued the acceptance and companionship that these friends provided. Friendships gave the elders a cushion of support when faced with a stressor or crisis. The participants also saw themselves as a source of support for their friends in their time of need. Little research has been conducted with regard to friendships in old age; however, the literature abounds with information about the effects of loneliness and isolation on aging. Given the present healthier, more active population of elders, the present focus of the literature on the effect of loneliness and isolation on aging will undoubtedly change in the future to a focus on the effect of friendships and activity on old age. Many of the elders in this study mentioned that because of family and work commitments they had led relatively limited social lives during their working years, but with the advent of children growing up and of retirement, there was more time for them to seek social opportunities. One means the participants used to attain or maintain friendships with acquaintances was through their choice to be actively involved in social clubs, organizations, or programs designed for the benefit of elders. 78 A key element of this involvement was the regular social contact derived from participation in these groups. Because the elders in this study had the financial and physical means, they could participate in these social activities with very few restrictions. Therefore, they were able to seek new opportunities to maintain or develop friendships and, as a result, enhance their sense of success in aging. The elders in this study also viewed the development of new friendships in old age as a challenge. The long-lasting friendships of earlier years were generally based on many years of shared experiences, while the newfound friendships tended to be based on common interests or similar circumstances. New friendships enhanced the elders' sense of control or experience of success because making friends strengthened the elders' support network. Friends provide elders with the social support, acceptance and companionship that help them to deal with and control potentially stressful events. As a result, friendships contribute to the elders' general sense of personal worth, well-being, and security. The elders' involvement in various social groups enabled them to establish and maintain friendship networks which greatly enhanced their sense of successful aging. Retirement. Because sixty-five years of age has been legislated as the mandatory retirement age in Canada, the time of retirement is one aspect of aging over which elders have little control. Although the option to take early retirement was available to the participants, they all decided to remain employed until age 65. By deciding to work until the mandatory retirement age, the elders were exercising their right to 79 choose and thus, maintaining some control over the timing aspect of retirement. Because retirement changed their routine and structure, the elders had to make minor alterations in their perception of control. It was mentioned that retirement was one concrete example of the fact that the elder was aging or could even be considered old. However, the participants had adjusted very well to this enforced life change and strived to maintain or even gain control in their retirement years. Many of the participants in this study used the time and freedom that their retirement had afforded to travel, become involved in politics or causes, or become active in organizations and social circles. McLeish (1976) gives numerous examples of persons who either launch into totally new careers or areas of creativity during the second half of life and of those who remain "richly productive within the sphere of creativity where he or she had long performed" (p. 17). As Birren (1959) states, in the later years, individuals have met their responsibilities for career, family, and community, and can be free in a new sense to act with impunity. In a similar vein, Ogilvie (1987) states that elders are free to discard undesirable activities and responsibilities and to pursue those that are meaningful, which in turn adds to their perception of life satisfaction. By having this financial, physical, and social freedom in retirement, the elders in this study were now able to "spread their wings" and pursue activities such as involvement in politics, learning new languages and volunteering in organizations that were meaningful to them. Thanks to these opportunities, the elders saw this time in their life as exciting and positive. 80 Finances Many of the participants in this study stated that their financial independence had enhanced their positive outlook on aging. Specifically, the elders' ability to purchase essentials, such as food, shelter, and clothing, as well as non-essential items, such as travel, automobiles, and higher education, greatly influenced their physical, mental, and social well-being and thus, their experience of aging. In the interviews, the elders described their financial status in terms of income, social benefits, and home ownership, and described themselves as financially secure and independent. None of the participants was "financially strapped" and all felt that they would not be as readily susceptible to those financial stressors, such as home repairs and upkeep, that they believed limited the control experienced by the poor elderly. Little research has been done in relation to the poor elderly and control, but if the opinions and perceptions of the well elders of this study are valid, poor elders have less control and because of that may have a less positive view of aging. The participants in this study felt that a substantial decrease in income and social benefits or a loss of their home would deprive them of a sense of control and/or power. They thus suggested that such losses would cause them to have a more negative outlook on aging. Income. The participants in this study were, in their opinion, financially secure and perceived that they had control over their finances. As seen in Fisher's (1984) writings, attitudes about the presence or absence of control may reflect the nature of the life-events and life-history experiences of elders. The life-history experiences of the elders in this study were perceived by them to be positive. They were retired 81 from a variety of white collar occupations, with the exception of one self-employed carpenter, and were receiving income beyond the basic Canada Pension Plan. They had also accumulated savings over the years, which added a margin of comfort to their financial picture. For these elders, it was easy to feel that they had control over their finances because they had a financial cushion for support. This sense of control or security with their financial status permitted them to travel and spend money on other non-essential items, further enhancing their sense of power or accomplishment. According to the current literature, a growing proportion of the elderly population has a positive financial picture during retirement (Harris, 1981, Novak, 1985, Strate & Dubnoff, 1986). The positive financial status of this study population gave them a successful view of aging, which they believed those on marginal incomes would not have. They felt that their aging process had been successful because they owned homes free from mortgages, received incomes from one or more retirement pensions, and enjoyed social benefits under pension and health plans that the poor elderly could not afford. Thus, in repeatedly comparing themselves to the stereotype of the impoverished elder, they suggested to this researcher that financial security was a necessary component of successful aging. For them, a lack of such security meant reduced control over lifestyle and health and, correspondingly, a more negative perception of aging. In addition to the participants' incomes from pensions, all were relatively healthy and active (therefore had few health-related expenses), all had public transportation at their disposal, and all had been employed in professional roles which provided them with the ability to save and invest during their working 82 lives, providing them with substantial income during their retirement. Such financial well-being, they maintained, was key to being an independent elder and experiencing aging positively. Their perceptions, however, may be suspect, for it was not necessarily the level of income but the consistency of income that the elders in this study stressed. As long as their income was stable, they felt little pressure from the possibility that they would lose their lifestyle or be unable to adapt to health care problems. Moreover, in stating that their needs were fewer after retirement, they indicated that their control over finances had increased even though their income levels had decreased. Freed of mortgage commitments, financially dependent children, and the costs of furnishing a home, the elders found that their sense of control over finances had actually increased. Because of this, they felt that they had adapted to the aging process successfully. As Cheal (1983) suggests, income is not the only element in the typical older person's financial picture. Cheal shows that many elders have savings that add to their income. He found, for instance, that while the average total wealth decreased after age 65, liquid assets, like savings, did not Likewise, prior to retirement, the elders in this study were able to enhance their financial status by consulting a financial planner, investing money, or simply placing money in savings accounts. The nine participants all emphasized that they used their pensions for daily living expenses, and used the interest from their savings for special extras, such as travel and entertainment. 83 All the participants, however, recognized how potentially tenuous their financial stability could be. They repeatedly mentioned, in keeping with the social stereotype of the sickly elder, that as they aged, concurrent, large, unexpected expenses such as home repairs and/or health care costs (i.e., homemakers and home renovations for wheelchairs and walkers) could jeopardize their sense of control over finances, and undermine their successful aging experience. In summary, the participants in this study were self-reported as a financially privileged group. They perceived themselves to be in control of a stable financial situation, which gave them freedom, control, and the ability to absorb many incidental expenses. All respondents, however, emphasized that their sense of financial stability could be altered quite drastically by large, unexpected expenses in the areas of health (health care) and lifestyle (home repairs). Social benefits. When speaking of their experience of aging the elders frequently mentioned social benefits, usually in conjunction with income. By utilizing the available social benefits, the elders were left with more disposable income to spend elsewhere. Because of this increased spending power, they felt that they had enhanced control over their financial situation, and this contributed to their overall perception of successful aging. The participants admitted to being overwhelmed by the vast number of discounts, exemptions and resources available to elders in Canada. However, they expressed mixed feelings with regard to elders' utilization of the available social benefits. Some of the respondents felt that they were entitled to these services and resources 84 regardless of their financial status because it was their hard work and contribution in the form of tax dollars which made the services available. The attitude these elders showed towards social benefits is documented in the literature related to the economics of aging (Harris & Associates, 1975; Novak, 1985; Schulz, 1976; Strate & Dubnoff, 1986). Specifically, elders felt that these social benefits were the government's repayment of dollars which were taxed during their pre-retirement years, thereby giving them a privileged status in their older years. These elders, therefore, were more likely to actively seek out and use any social benefits available to them. Conversely, other participants expressed the fear that the use of such privileges could be abused by those who did not currently need them, thus, limiting the resources available for those in need. As reported in the literature, the financial situation of the elderly in Canada is improving, but there are still significant numbers of elderly who live on marginal incomes (Harris, 1981; Novak, 1985; Strate & Dubnoff, 1986), and the participants in this study believed that many of them would undoubtedly benefit from the wide array of social benefits available to elders. Perhaps for some elders, accessing social benefits would move them from a marginal financial status to a more comfortable situation, barring unexpected expenses. Therefore, the participants who believed in the potential for abuse and dependence on social benefits did not actively seek to use the more obscure social benefits such as subsidies for home maintenance or health care even though they were aware of their existence. However, they frequently utilized the more common and less limited social benefits, such as reduced ticket prices for events and reduced bus fares for 85 elders. Being able to choose which social benefits they were going to use further enhanced the elders' perception of their power over finances: they did not need the discounts and exemptions to survive. By under-utilizing social benefits these financially stable elders felt they were contributing aid to the poor elderly. This further enhanced the participants' perception of success in aging. Although many social benefits are available to all elderly regardless of location, the larger metropolitan areas tend to have a greater number and variety of such services (Novak, 1985; Strate & Dubnoff, 1986). The participants in this study all lived in the Greater Vancouver area and did have greater access to resources should they choose to use them. It would also be beneficial to study the availability, need, and utilization of social benefits from the rural elders' perspective. Is there a difference in utilization between rural and urban elders? If there is an imbalance, what can be done to correct it? Since the urban centres tend to have a greater number and variety of social benefits, one would assume that perhaps urban elders utilize these services more than elders in rural areas, who have fewer services offered to them. In summary, the availability of social benefits contributed to the elders' income by offering savings on a variety of services. The participants in this study had mixed feelings when it came to using the resources available to them: some felt that it was their right and viewed it as repayment for years of taxed income. Most of the literature on the economics of aging related to the poor elders' utilization of social benefits reflects the perspective that elders view social benefits as a privilege of being 86 old (Novak, 1985; Schulz, 1976). Other participants felt that social benefits were "great" but worried about the potential for abuse of the services which, in turn, could limit the availability of the benefits for those in need. These elders felt that given their secure financial status they were able to distance themselves from the need for social benefits; thus, they enhanced their perception of successful aging. Home ownership. The final component that contributed to the elders' perceptions of success in aging was the fact that they all owned their own dwellings. Six lived in self-contained homes and three in self-owned condominiums. These participants stressed that ownership of their homes or apartments was a key factor influencing their sense of financial security, which in turn gave them a sense of control over their lives. Torrey (1988) suggests that the aged keep their assets as long as possible to cover themselves in the event of an emergency or to insure their financial independence. Similarly, Lawton (1982) suggests that elders retain control over their financial assets, such as their home, as a way of determining their own affairs. These assets provide security, which significantly contributes to their sense of well-being because, if needed, these assets can be liquidated to provide more spending power. A common assumption might be that elders keep their houses because of sentimental value or family ties, but the participants in this study, while acknowledging these factors, stressed that they retained their homes as financial assets. They assumed that, given the Canadian inflation rate and the current housing situation in Vancouver, the value of their homes would increase proportionately. If the elders were faced with unexpected expenses, such as health-related and lifestyle-related 87 expenditures, that were beyond their immediate financial capability, they felt they could re-mortgage or even sell their homes. Even if an elder was no longer physically or mentally capable of remaining in his or her home, the monies from the sale of that home could help the elder to find suitable alternative housing. One aspect of home ownership that was frequently mentioned by the elders in this study was the freedom from increased rents and threats of evictions often experienced by renters. Stone and MacLean (1979) state that freedom from mortgage and rent indirectly provide the elder with more disposable income, which, in turn, could allow greater financial freedom and control. Because the elders in this study were free of mortgage or rent payments, they were able to use that money for home maintenance or to pursue activities such as travel and higher education. The ability to use this disposable income without affecting their other assets, coupled with the fact that the elders had a home that they could sell or re-mortgage, contributed greatly to their sense of stability and success in aging. When considering their financial status, the participants described three components: income, social benefits, and home ownership. Sufficient assets in all of these components greatly contributed to the elders' sense of control and success in aging. In addition, none of these components could be viewed in isolation, but were interdependent with other facets of the elders' lives. For example, their ability to maintain a home, their penchant for travel, and their healthful habits were directly related to their financial resources (liquid and otherwise). Health The participants stressed health as a major factor in determining their perception of the aging process as successful. Larson's (1978) review of thirty years of research on the subjective well-being of older adults indicates that self-reported well-being is strongly related to positive health status for the general population of elders. Likewise, the elders in this study repeatedly emphasized throughout the interviews that, as long as they were physically and mentally healthy, they were able to control the other facets of their lives and this made aging a successful experience for them. In addition, Okun (1986) states that from the earliest reviews of correlates and conditions of life satisfaction such as health and social involvement, up to recent ones, health has been found to be one of the most powerful predictors of well-being in old age. He adds that, health, as perceived by the person, is considered even more predictive than the medically assessed health status. Similarly, Engle and Graney (1986) suggest that the health of elders has traditionally been viewed from two perspectives: the presence or absence of disease (medical model) and the functional ability of the elder (functional model). They add that careful examination reveals that substantial discrepancies exist between self-assessment and physician assessment of health. In fact, in an earlier study, Graney and Zimmerman (1980) state "it appears that people in general either overrate their health or that older people tend to adjust their health expectations downward relative to physiological-medical standards" (p. 49). While the elders in this study had all been medically diagnosed with one or more chronic conditions, such as arthritis, heart disease, cancer, 89 hypertension, high cholesterol, or asthma, they refused to describe themselves as "unhealthy." They may, however, have overrated their health. Some elders with chronic conditions such as arthritis, which required medications and adjustments in their day-to-day activities, refused to view themselves as unhealthy because they were not handicapped to the extent that they required assistance from others. Other researchers have reported similar findings in relation to elders' ability to adapt to chronic illness. Shanas (1979) suggests that a slow onset of illness may permit the older person to adapt successfully to body changes and maintain self-care in, and control over, daily activities. This gradual adaptation to chronic illness can contribute to an individual's sense of mastery over life-events or life-outcomes. For example, in this study, one woman who had been diagnosed with cancer years before these interviews found that with each successful treatment and additional year she lived, she became stronger and more confident in her ability to live with illness. Another factor influencing health self-assessment is the internalized value judgment that a person places on norms for physical and mental well-being (Patrick, Bush, & Chen, 1973). Age self-concept is one such value judgment. A shift in age self-concept from middle-age to old age can be the result of the internalization of negative stereotypes in relation to old age, such as an emphasis on loss of health, decline in psychological functioning, and decreased mobility (Chappell, Strain, & Blandford, 1986; Kalish, 1975). A self-concept of old age may also be dependent upon a loss of ability to perform previously enjoyed leisure-time activities and social-role activities. To date, the elderly individuals in this study have not experienced this 90 shift in age self-concept. They still tend to view themselves as middle-aged. This lack of "shift" may be due to the participants' internal locus of control, which is defined by Chang (1978) as one's ability to view one's own behavior as responsible for much of what happens in one's life. The elderly participants in this study chose to focus on the positive instead of the negative. Perhaps that is because the negative has not yet become an insurmountable force for them. The well status of many elders is probably due to the active role elders take in maintaining their health. Many authors believe this new enthusiasm for healthy living is a result of their being more educated, having a better financial picture, and the availability of more resources, such as seniors community network centres. The participants in this study repeatedly emphasized that control over health in the two areas of health maintenance and preparing for illness, dying, and death, were integral to their perceptions of successful aging. Health maintenance. Participants in this study described adequate nutrition, exercise, and activity as essential components to maintaining their present good health and their perception of a positive aging experience. In keeping with Chang's (1978) writings on the internal locus of control, these participants were actively pursuing healthy alternatives because they were aware that it was their choice of behavior that affected their health and life outcomes. As Novak (1985) states, people know more today about habits and lifestyles that lead to good health than they did in the past. More people are taking part in active health programs such as the Be-Well Programs in Vancouver. It should be noted that all the participants in this study 91 were contacted through community centres in which they were active in the Be-Well Programs. The elders in this study expressed concern over proper diet and nutrition. They emphasized that they monitored their nutritional intake in order to maintain control over their present state of wellness and enjoyment of life. Again, Chang's (1978) theory is evident in the above findings. In addition, researchers have found a correlation between perceived good health and good food habits in respondents (Lehr, 1967; Shifflett & Mcintosh, 1986). The literature reviewed on nutrition and the elderly was extensive but with varying themes. According to the literature, many elders are prone to restricting their diet to a few foods that are easily prepared and relatively inexpensive (Posner, 1979). Many of the elders in this study stated that only on occasion were they tempted to take the easy, less nutritious route. This was perhaps due to the fact that these elders were proactively health conscious (part of the Be-Well Program consists of aerobic and healthful living classes). The health education and counselling provided by community health nurses and various instructors in programs like the Be-Well Program, assisted and encouraged the elders to adopt more healthful living habits. In addition, peer pressure from other participants in the program could also raise the elders' consciousness about health. Posner (1979) adds that the qualitative aspects of diet are important in health maintenance, and that there is no evidence to suggest that normal aging people require special supplements. In contrast to this view, several of the participants in this study indicated that they did use dietary supplements, such as vitamins and 92 various health foods as recommended by physicians, friends, and the media. Some of the elders believed that these supplements could enhance their current healthy status and this promoted their perception of success in aging to an even greater degree. There is also an abundance of literature relating to activity levels, specifically exercise, and aging. The elders in this study discussed the importance of remaining alert and active. They felt that exercise was one means to attain this goal and maintain control over their health. Their choice to maintain or improve their current health status by exercising is reflected in the literature (George & Landerman, 1984; Paffenbarger, Hyde, Wing, & Hseih, 1986). According to Paffenbarger, Hyde, Wing, and Hseih (1986), a life of physical activity has been correlated with increased health and life expectancy in later years. In addition, George and Landerman (1984) suggest that life long patterns of activity, as well as exercise programs begun late in life, significantly affect the degree and progression of many chronic conditions among elders. Heart disease, hypertension, diabetes, obesity, respiratory diseases, osteoporosis, lower back pain, depression, and colon cancer are a few conditions mentioned by the above authors. Millar (1984) also states that elders who exercise regularly report that they are more energetic, sleep and eat better, have fewer aches and pains, suffer less from stress, smoke less, and drink less alcohol. The participants in this study, by becoming active in the Be-Well Program, recognized the benefit of regular physical activity and made a concerted effort to maintain their participation in the program. Several of the participants emphasized how important regular exercise was to their general perception of well-being and successful aging. Another component of health maintenance described by the participants was the maintenance of adequate activity levels. As stated earlier, the participants were all active in various community organizations and hobbies. For elders, the ability to remain active affects not only health but also the quality of life, as it affects the degree of independence and control they can assume in activities of daily living and the continuing ability to interact socially with family, friends, and community groups. In reviewing the literature, one finds that activity is seen as a positive factor in facilitating the ability of elders to accept certain aging changes more adequately (Borkan & Norris, 1981). A study conducted by Palmore and associates (1984) found that when the subjects participated in a regular monthly activity program their self-esteem scores were higher. Similarly, the participants in this study all exhibited signs of positive self-esteem such as having regular social contacts with family and friends, and a generally positive outlook on life and living. This positive outlook enabled them to pursue activities of interest, such as hobbies, education, and social ventures. In summary, the elders in this study maintained control over their health by pursuing adequate nutrition, regular exercise, and participation in various activities. The elders reported their health as good, and they actively attempted to maintain this good health through healthful living behaviors, such as those listed above. Being in good health and being able to control components that facilitated their good health further enhanced the respondents' perceptions of success in aging. Preparing for illness, dying, and death. As noted earlier, the elders in this study emphasized that preparing for illness, dying, and death was another key area in their perception of a positive aging experience. The study participants all had some form 94 of chronic illness which was not currently disabling or problematic. They all took positive measures such as maintaining their medication regime, eating properly, and getting regular exercise to prevent further progression, and onset of more acute aspects, of the diseases. They attempted to control their illnesses and serve their present "well" self in order to maintain control over health through appropriate nutrition and exercise. As has been discussed, the elders in this study maintained good health through nutrition and exercise. In this study, the elders' experiences with illnesses, the aging process, and the increasing numbers of deaths of family members and friends, encouraged them to reflect upon their own death and dying. Even though the participants emphasized that they were very happy with their lives, they were also very matter of fact about their eventual deaths. Ail were aware that, with advancing age, their time-left-to-live is decreased appreciably with each successive year. With knowledge of the finiteness of life, the elders expressed their desire to maintain control over even this aspect of their lives by developing living wills and making their wishes known. Participants did not view death as an event to be feared. The reduction of fear of death with advancing age, Kalish (1985) postulates, may be due to a variety of factors. He asserts that death becomes more familiar with advancing age because elders generally have more experience with the death of others. In addition, the death of parents makes death more of a reality to individuals since parents generally die before their children. Further, the urgency of staying alive diminishes when individuals no longer have dependent children to care for. Finally, death is expected 95 in the later years so elders are more prepared for and resigned to it (Kalish, 1985). Illness, dying, and death of family and friends made the thought of their own deaths more prominent for the participants. Further, the elders in this study were free from many of their working-life responsibilities. They no longer had dependent children, a mortgage to pay off, or work-related responsibilities; therefore, they felt quite free to accept the inevitability of death. Studies show that religious beliefs and education are stronger influences on death attitudes than is age (Kalish, 1976; Lowenthall, Thurnher & Chiriboza, 1975; Riley, 1968). These authors suggest that the stronger the religious beliefs, the less fear is expressed about death. Many of the participants in this researcher's study emphasized that their spiritual health gave them a great source of strength and comfort in assisting them to accept their eventual deaths. They recognized that death for them was a natural evolution into another life-death was not perceived as an end. In addition, the elders in this study were healthy, and this could have further reduced their fear of death. However, as Butler (1977) points out, even though many elders do not show any obvious fear of death, when confronted with the reality of it, they may react otherwise. Although, the elders in this study denied having a fear of death, they all expressed a fear of dying a prolonged and painful death. Their greatest fears were of becoming a burden to their families and being unable to control the circumstances surrounding their process of dying. The elders feared that with advancing age and a deterioration in their physical and/or mental status they might become dependent on and a burden to their families. Many studies have focused on the negative aspects of the "burden 96 of caregiving" (Aronson, 1985; Brody, 1981; Chappell, 1982; Zarit, Reever & Bach-Peterson, 1980). These studies highlight the many negatives that family caregivers must cope with, such as loss of employment, poverty, exhaustion, social isolation, and disrupted family life while providing care for the elderly family member. The elders in this study were all aware of these potential, negative repercussions on their families and were quite adamant that they would not "burden" their families, if they could avoid it. The elders explained that they would hire in-home help or move to a special care apartment before they would "burden" their families. Participants coped with their second greatest fear, that of being unable to control their deaths and the circumstances leading up to them by preparing for these events. Some of the elders attempted to maintain control by drafting wills, developing living wills, making their wishes known to family and friends, and making appropriate funeral arrangements. The elders' plans for dying and death are reminiscent of Rodin's (1979) writings on control which cites control as the ability to regulate or influence intended outcomes through selective responding. The elders in this study sought to influence their dying process by selectively taking the above measures. The elders felt that by taking the initiative to plan what was to be done in the event of their dying and death, they were relieving themselves and their families of the stresses of decision-making at that time. By making these plans, the elders' sense of success in coping with aging was enhanced. In summary, the participants in this study repeatedly emphasized that their health and well-being was directly related to their sense of control in two areas which greatly contributed to their perception of successful aging: health maintenance and 97 preparing for illness, dying, and death. By actively pursuing healthful living behaviors, such as adequate nutrition, exercise, and activity, the elders felt that they had exerted control over the maintenance of their current good health. In addition, the elders' perceived ability to control the process of dying and death through preparing living wills and wills, as well as making funeral arrangements, further enhanced their general sense of well-being and their perception of successfully adapting to aging. Summary In this chapter, the researcher discusses the major findings of the current study. To accomplish that, the findings arising from the interviews in relation to the well elders' experience of aging are analyzed in light of the literature. The elders identified their personal aging experience as successful. This success in aging was further identified as a product of control over three interdependent areas of their lives: lifestyle, finances, and health. By being able to influence the impact of age-related changes through their own creative coping behaviors, the elders were able to enhance their sense of stability and control. This greatly contributed to their sense of success in aging. In the succeeding chapter, a summary of the study is presented and major conclusions are drawn, followed by suggested implications for nursing practice, education, and research. CHAPTER SIX Summary, Conclusions, and Implications for Nursing 98 This chapter presents a summary of the study and related conclusions about its findings. In addition, this chapter suggests implications of the findings for the nursing profession, implications which relate to nursing practice, nursing education, and nursing research. Summary of the Study This study was designed to explore and describe the experience of aging from the perspective of well elders. While numerous studies have been done on aging and illness, relatively little in the literature focuses on well elders and their experience of aging. The aging population in Canada is growing very rapidly, and the literature predicts that this aging population of tomorrow will be healthier than elders in the past and lead a more active lifestyle. As health care providers, it behooves us to understand the aging experience from the well elders' perspective. Not only would such an understanding assist in planning for the elderly in institutional settings, but, more importantly, it would allow the perspective of well elders to be more influential in the development of community programs and services. All of these factors showed the need for a study that would generate knowledge, and provide direction for the provision of effective health care for this group. 99 The Kleinman, Eisenberg, and Good Explanatory Model (1978), which acknowledges the individual's experience within the broader sociocultural context, provided the conceptual framework for the study. It was believed that this model would have considerable utility for understanding the experience in question, because aging is a concept that is located and formulated in biological, psychological, and social contexts that influence how aging is perceived by elders. The phenomenological method of qualitative research was selected to guide this study. This method was congruent with the conceptual framework and the researcher's aim of obtaining a description of the aging experience from the perspective of well elders. The data were obtained through audio-taped interviews with seven women and two men. A total of eighteen in-depth interviews took place over a seven week period. The audio-tapes of the semi-structured interviews, in which questions which were designed to elicit descriptions of the participants' experience were asked, were transcribed verbatim immediately following their collection so that data collection and analysis occurred concurrently. During data analysis, the interview transcripts were examined for similar and dissimilar themes. Over time, major and minor categories of conceptual themes which were indicators of the essence of the experience evolved. The ongoing process of combined data collection and analysis enabled the researcher to return to the participants in order to have themes validated, refuted, or elaborated upon. The final analysis was performed after completion of data collection and continued during the writing of the final report. 100 Although each participant's experience was unique, it was found that all the elders cited three main components that affected their experience of aging. These components, identified as key to the overall experience, included lifestyle, finances and health, each of which, although distinct, also had an impact on the other two components. The experience of aging is thus a complex dynamic process. The participants provided descriptions of what they meant by lifestyle, finances, and health as well as their reactions to, and their ways of coping with, age-related changes in each of these areas of their experience. The data were therefore organized within each of these three categories. The participants in this study all believed that their experience of aging has been successful or positive, and, the elders emphasized that this success in aging was a product of their ability to exert control in each of the areas of lifestyle, finances, and health. The lifestyle component was characterized by an appraisal of the elders' ability to cope with age-related changes. The key elements within the lifestyle facet which were reported to be essential in maintaining control were: skill-related activities, friendships, and retirement. The participants all identified changes as a result of aging with which they had had to adjust or cope. In fact, the elders in this study utilized a variety of creative coping behaviors and techniques that enabled them to maintain a stable, positive experience of aging. Due to this stability and lack of appreciable impediments as a result of aging, the elders were able to dissociate themselves from the stereotypic image of the aged and maintain a younger age perception. The elders' ability to cope with or control age-related changes, combined 101 with the support and companionship gained from friendships and the freedom gained through retirement all contributed to the elders' perception of aging as a positive experience. Finances were identified as another facet in the elders' lives that greatly influenced their experience of aging. When considering their financial status, the participants emphasized three components: income, social benefits, and home ownership. The elders all discussed their positive financial status in terms of a stabilizing force which provided them with freedom and contributed to their perception of successful aging. The fact that they had the financial resources for extras, such as travel, education, and home renovations, further enhanced the elders' positive outlook on the aging experience. Comparing themselves to those less fortunate financially led the elders to speculate on that group's inability to exert control over the experience of aging due to their lack of financial security. These comparisons further bolstered the elders' self confidence and perception of their successfulness in aging from a financial perspective. The health component was typically appraised as the facet that most influenced the elders' experience of aging. They believed that good health permitted them to have greater success in controlling the other two facets in aging. Health was discussed in terms of maintenance of health and preparation for illness, dying and death. Cognizant of the social stereotype of the frail, disabled, dependent elder, and the increasing numbers of illnesses and deaths among family members and friends, the participants sought to control their health through regular exercise, healthy eating 102 habits and participation in various activities of a social or volunteer nature. Similarly, the participants attempted to control the circumstances surrounding their eventual dying process by drafting wills, making funeral arrangements, and making their wishes known to their family, friends, and physician. The elders believed that by exerting control over these aspects of their lives, they were able to enhance their success in coping with aging. Conclusions The researcher of this study drew a number of conclusions about well elders and their experience of aging. These conclusions may not be representative of all elders in the population as a result of the privileged nature of the nine participants. 1. The experience of aging is viewed by the well elders in this study as successful or positive. 2. Success in aging seems related to the elders' ability to exert control over or cope with age-related changes. 3. The ability of well elders to control significant or valued aspects of their lifestyle seems to be an important factor in determining positive feelings about the aging process. 4. The ability to maintain a stable financial status in retirement is viewed by the well elders as contributing to their positive experience of aging. 5. Being "healthy" is identified by the well elders as a major contributor to their successful aging experience. 103 6. The ability of the well elders to control key aspects of their health, such as adequate nutrition, regular exercise, and participation in activities seems to be an important component in deterrnining positive feelings about the aging experience. 7. The ability to control some of the circumstances surrounding the process of dying and death is viewed by the well elders as contributing to the their positive experience of aging. Implications for Nursing The findings of this study suggest a number of implications for nursing practice, nursing education, and nursing research. The following section presents these implications. Nursing Practice The findings of this study generate many implications for the provision of nursing care to elderly persons and can be used by nurses in each phase of the nursing process. In order to understand the impact of aging on an individual client, a nurse will need to assess the elder's experiences and perceptions of his or her ability to control or maintain stability in aging. The assessment should include an examination of all three facets of the aging experience: lifestyle, finances, and health. Additionally, the nurse should gather information on the effectiveness of various coping strategies in relation to each facet of the experience. When analyzing the data, interrelationships between the three facets must be recognized. A detailed assessment is necessary for the nurse to understand the full impact of the experience of aging from the client's perspective. This assessment should, of course, be validated with the elder. 104 The nurse could encourage a sense of control by focusing on past achievements or accomplishments and exploring the elder's personal available resources. The nurse must also recognize that some physiological or psychological requirements may need addressing before the elderly person can exert control. In planning care and assisting the elder to identify realistic goals and interventions to meet these goals, the nurse must be keenly aware of the elder's need for control and independence. Thus, nursing care for the elderly must be planned so that it is individually acceptable and clinically appropriate and, whenever possible, directed toward maintaining independence, a moderate level of activity, and a continuing, if not renewed, pursuit of interests. In implementing the plan of care, the nurse should continuously support the elder by using appropriate techniques to validate the elder's experience. Nurses can use control enhancing interventions and encourage the individual to make as many decisions about the interventions as he or she is comfortable with. For example, in the institutional setting nurses can enhance the elder's sense of control by encouraging the individual to take responsibility for some of his or her care, such as bathing, grooming, meal choices, and leisure or therapeutic activities. In addition, nurses must encourage elders to make decisions based on information provided and to seek additional information as required. Being informed will enhance the elderly individual's ability to take responsibility for his or her own well-being. 105 By evaluating the elder's response to nursing interventions, the nurse can assist the elder to interpret his or her own abilities and coping behaviors. If the elder demonstrates a need for strengthening in any area, the nurse can return to the assessment phase in order to determine the variables conflicting with the elder's ability to control aspects in the experience of aging. Using the elders' descriptions of what facilitates perceptions of control in aging, nurses should assess factors which could affect their own ability to be a facilitator to the elders. For example, the nurse's ability to be non-judgmental would eliminate the negative impact of the stereotype of elders as frail and dependent. In order to be a successful facilitator in this endeavor, a nurse has to be able to honestly identify any values, beliefs, or personal biases, that might interfere with the ability to collaborate with an elder and ensure that the individual is the recipient of effective and professional nursing care. Further, there are implications for nursing practice in relation to health promotion and illness prevention. Given the greater proportion of healthy elderly and the potential for stress on our health care system as a result of age-related deficits, the need for health promotion and illness prevention becomes paramount. Too often programs and services are designed for the elderly in response to what the program developers perceive as the needs of the elderly; this perception is not always in line with actual needs. To eliminate this problem, articulate, knowledgeable elders should be involved in the planning, implementation, and evaluation of programs designed for the elderly. Their input would help to reduce the risk of the 106 programs and services providing unsuitable, unsupportive, and inconsistent assistance to elders, and ensure more responsiveness to their needs. In addition, nurses should work in collaboration with elders in influencing public health policy and legislation. In this regard, nurses and elders could work to dispel the stereotypical image of the aged and foster a recognition of the contribution and needs of the elderly in the community and in society as a whole. Nursing Education Nurses need to be cognizant of the significance of the phenomenon of aging in relation to caring for older adults as the elders' experiences of aging will ultimately affect their reception of nursing care. The well elders in this study perceived their ability to control aspects of their aging as integral to their positive aging experience. Toward that end, nursing programs should provide students with an opportunity to understand the phenomenon of control in aging as it pertains to a variety of clinical settings. Two widely accepted principles of nursing are that practitioners understand the client's experience and that nurses give thorough individualized care. In order to accomplish these goals with the well elderly, nurses must prepare themselves in such a way that they do indeed understand the individual's experience of aging. Nursing curricula must provide students with a general knowledge of the intricacies of aging and the elderly and specific practical knowledge about adjusting to aging in later life. In addition, nursing curricula need to include content and learning experiences that highlight the importance of soliciting the perspectives of individual elders and of avoiding stereotyping these individuals. It is important to emphasize the positives as 107 well as the negatives associated with aging. Nursing curricula should focus not only on the ill elderly but also on the well elderly. To foster a positive attitude in students, it is important that students also work with elders who are unaffected by disease or illness. This educational approach is particularly important in light of the predominantly negative stereotype of the elderly held within society. Further, in order to ensure effective and non-biased care delivery, educators should provide students with learning experiences which enable them to recognize their own beliefs and values, and to predict the impact of those beliefs and values on their ability to deliver care. Students might also learn holistic assessment skills to appreciate the interplay between physical, psychological, social and spiritual factors in aging. Therefore, nursing education must facilitate students' learning and practice of comprehensive geriatric assessment skills. It is especially important to instill in students the value of eliciting the meaning of the situation from the perspective of the client. Unless the situation can be understood from the client's perspective, it will be impossible to provide effective care which is sensitive to the individual client's needs. In this regard, nursing students should learn communication techniques to assist them to elicit information from elders and to further understand the elders' perceptions. In order to teach nursing students to understand and assist older clients in the process of aging, curriculum designers might ensure that students have a strong background in role theory, developmental theory and, multigenerational dynamics, as well as teaching and learning theory. In the aging process, elders experience 108 numerous changes in their social roles and relationships with others, and they frequently require information to help them to understand and adapt to these changes. For referral purposes, students should be knowledgeable about available community resources and supports. Finally, one of the essential components to include in nursing curricula is working theories of control and loss which would facilitate nurses' understanding of the experience of aging. Moreover, fostering the elders' active participation in teaching and counselling would enhance the effectiveness of the education and counselling as well as the elders' sense of control. Nursing Research The findings of this study, which begin to elucidate the perceptions and the experiences of well elders and their experience of aging, also highlight the need for more studies of this nature. Because the participants in this study were seven female and two male, white, middle-to-upper class Caucasians, there are limitations to this study. Additional studies are necessary in order to address these limitations. Are there differences in gender, ethnicity, socio-economic levels and regionalism which may have an effect on the elders' experience of aging? Studies that individually address these factors will contribute to a greater understanding of the experience of aging. As well, to enhance the knowledge of the aging experience, a separate study on each of the three components, lifestyle, finances, and health, could prove illuminating. Case studies 109 and longitudinal studies would be beneficial in clarifying, for example, the elders' alternative housing choices and the methods employed to exert control over decision-making. In addition, the participants in this study thought that poor or unwell elders would have a less positive or successful aging experience than themselves. Thus, comparative studies could be conducted to evaluate the perceptions of aging between elders from different socio-economic levels or health statuses. 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I am interested in learning about well senior's experience of aging. I hope to gain more information in this area by interviewing seniors like yourself. If you agree to participate in this study, I will arrange to visit you at your home, at your convenience. I would like to interview you twice. The interviews will be tape-recorded and will take approximately one hour per interview. I will transcribe the tapes and your name will not be identified in the transcribed material. Only myself and my thesis advisors will have access to the taped material and transcripts. During the interview, you may refuse to answer any questions or to stop the interview at any time. You may also request to erase any part of the audio-tape if you feel it necessary at any time. I may include excerpts of the interview when I write my report, but again, no names will be identified in the report. The tapes will be erased when my thesis is completed. The purpose of the second interview is to clarify the issues you have raised and to prevent any misunderstanding. Your participation is entirely voluntary and you are free to withdraw at any time. Any decision you make will not jeopardize the treatment or care you receive. I anticipate that this study will benefit me by increasing my knowledge about aging from the senior's perspective. I wish to communicate this knowledge to health professionals involved in working with the elderly. If you have additional questions and would like further information, please feel free to contact me at home 733-3280 or at U.B.C. 228-7561. **************************************************************** I have received a copy of the information and consent form. I understand the nature of this study and consent to participate. Date Signature of Participant c.c. Participant 121 APPENDIX B Sample Trigger Questions 1. What is it like for you to be (age)? 2. What has been your experience with aging? 3. How are you different from the way you were as a younger person? 4. How have you stayed the same? 5. Is aging the way you expected it to be? 

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