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UBC Theses and Dissertations

Do elderly clients in an acute care hospital perceive they are treated with dignity and respect Steckler, Josephine 1990

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DO ELDERLY CLIENTS IN AN ACUTE CARE HOSPITAL PERCEIVE THEY ARE TREATED WITH DIGNITY AND RESPECT by JOSEPHINE STECKLER B.A.,' Queen's U n i v e r s i t y , 1979  A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in THE FACULTY OF GRADUATE STUDIES School of Nursing  We accept t h i s t h e s i s as conforming t o the r e q u i r e d  standard  THE UNIVERSITY OF BRITISH COLUMBIA September 1990  (d)  Josephine S t e c k l e r , 1990  In p r e s e n t i n g  this  thesis  r e q u i r e m e n t s f o r an British freely that  Columbia,  in partial  advanced degree a t the  I agree that  available for  reference  department or  by  understood that financial  gain  be  h i s or  c o p y i n g or shall  not  and  study.  I further  of B r i t i s h  V a n c o u v e r , Canada, V6T  1W5  of the  this  of  this  a l l o w e d w i t h o u t my  Columbia  thesis  Head o f  representatives.  permission.  University  of  s h a l l make i t  publication  be  University  Library  g r a n t e d by  her  the  the  permission f o r extensive copying  s c h o l a r l y p u r p o s e s may  The  f u l f i l m e n t of  agree for  my  It i s thesis written  for  Abstract  The purpose  of t h i s study was  t o i n v e s t i g a t e whether  e l d e r l y c l i e n t s i n an acute care s e t t i n g p e r c e i v e d themselves  as being t r e a t e d w i t h d i g n i t y and r e s p e c t , and  whether c l i e n t s w i t h a h i g h e r socioeconomic likely  s t a t u s are more  than c l i e n t s with a lower socioeconomic  s t a t u s t o be  t r e a t e d w i t h d i g n i t y and r e s p e c t . Sixty-two e l d e r l y c l i e n t s who  had been i n h o s p i t a l a t  l e a s t f i v e days, were a l e r t and o r i e n t e d d u r i n g t h e i r h o s p i t a l i z a t i o n , and c o u l d speak E n g l i s h were s e l e c t e d f o r the study.  Using a convenience  sampling technique, the  c l i e n t s were s e l e c t e d from medical and s u r g i c a l u n i t s of major t e a c h i n g h o s p i t a l s .  two  They were i n t e r v i e w e d w i t h i n  t h r e e days a f t e r d i s c h a r g e t o respond t o items on a q u e s t i o n n a i r e s e l e c t e d from the Medicus Q u a l i t y  Assurance  Tool. The r e s u l t s of the study show t h a t e l d e r l y c l i e n t s  may  not p e r c e i v e t h a t they are c o n s i s t e n t l y t r e a t e d with d i g n i t y and r e s p e c t .  Older c l i e n t s  younger o l d e r c l i e n t s  (75+ years) are l e s s l i k e l y  (65-74) t o be t r e a t e d w i t h d i g n i t y  r e s p e c t , and e l d e r l y c l i e n t s w i t h a lower s t a t u s and women, are l e s s l i k e l y and r e s p e c t .  than and  socioeconomic  t o be t r e a t e d w i t h d i g n i t y  iii  Table of Contents Page Abstract  i i  Table of Contents  i i i  L i s t of Tables  vi  Acknowledgements CHAPTER 1.  v i i  I n t r o d u c t i o n t o the Study  1  Background t o the Study  7  Problem Statement  10  Purpose of the Study Theoretical  .  11  Framework  12  D e f i n i t i o n of Terms  18  Assumptions  19  Limitations  20  Summary CHAPTER 2.  . Review of S e l e c t e d L i t e r a t u r e  Growth o f the E l d e r l y P o p u l a t i o n  The H o s p i t a l i z e d  Elderly  21  . . . . . . . .  B a s i c Human Needs and the E l d e r l y P o p u l a t i o n  20  . .  . .  Aging and Self-Esteem  21 24 28 30  E t h i c a l C o n s i d e r a t i o n s i n the Nursing Care of the E l d e r l y C l i e n t  33  Attitudes  37  of Nurses toward the E l d e r l y  The E l d e r l y ' s Summary  P e r c e p t i o n of t h e i r Nursing Care . .  42 43  iv  Page CHAPTER 3.  Methodology  .  45  Research Design  45  Sample  46  Instrument  46  Data C o l l e c t i o n Procedure . . . . .  48  Human R i g h t s P r o t e c t i o n  49  Data A n a l y s i s  49  Summary . . . . . . . . CHAPTER 4.  .  50  P r e s e n t a t i o n and D i s c u s s i o n  of the R e s u l t s  51  Introduction  51  C h a r a c t e r i s t i c s of the Sample  51  Research F i n d i n g s and D i s c u s s i o n  52  Summary  70  CHAPTER 5.  Summary, Conclusions,  Implications,  and Recommendations  72  Summary and Conclusions  72  Implications  75  Nursing  Practice  76  Nursing  Education  80  Nursing  Research  82  References  85  V  Page  APPENDIXES A:  Information L e t t e r  95  B:  Consent Form  96  C:  L e t t e r f o r Agency Entry  97  D:  Research Tool  98  E:  R e s u l t s of Items from  Questionnaire  R e l a t e d t o D i g n i t y and Respect F:  R e s u l t s of Items from  100  Questionnaire  R e l a t e d to L e v e l of E d u c a t i o n and D i g n i t y and Respect  104  vi  List  of  Tables Page  Table  Table  1.  2.  Orientation  to unit  differences  . . . . .  Age  related  group d i f f e r e n c e s  introduction  t o age  group 55  related  t o roommate  to 55  vii  Acknowledgements  I would l i k e  to gratefully  acknowledge t h e p r o f e s s o r s  who were t h e members o f my t h e s i s c o m m i t t e e , H e l e n (chairperson)  and Ray Thompson,  f o r the optimal  Shore  learning  a t m o s p h e r e t h a t s u p p o r t e d me t h r o u g h t h e p r o c e s s  o f my  research:  their  and t h e i r  guidance.  I would a l s o l i k e  Alice  expertise,  Jope f o r t h e i r  homes t o i n t e r v i e w  thanks t o t h e sixty-two study.  Finally,  eight wonderful and  do my  continued  encouragement,  t o thank C h r i s B r a d l e y  assistance  s e t t i n g s where I c o u l d their  their  i n gaining  research.  into  F o r a l l o w i n g me  them, I would l i k e older  entry  and  into  t o e x p r e s s my  a d u l t s who p a r t i c i p a t e d i n my  I w i s h t o t h a n k my h u s b a n d R o b e r t a n d o u r children f o r their  i n t e r e s t i n my  work.  support,  encouragement,  1  CHAPTER 1 I n t r o d u c t i o n t o the Study  Nurses' a t t i t u d e s toward e l d e r l y c l i e n t s have r e c e i v e d i n c r e a s i n g a t t e n t i o n i n recent y e a r s . reasons f o r t h i s i n t e r e s t .  There are  three  F i r s t , t h e r e i s an i n c r e a s e i n  the number of e l d e r l y c l i e n t s who  require nursing  services  s i n c e h e a l t h s e r v i c e usage r i s e s d r a m a t i c a l l y with age  and  there i s an i n c r e a s e i n the a b s o l u t e numbers of aged (Gutman, Gee, Roos, 1984;  Bojanowski, & Mottet, 1986;  Stone & F l e t c h e r , 1986).  Roos, Shapiro,  &  While acute care  h o s p i t a l usage has f a l l e n i n B r i t i s h Columbia, t h i s d e c l i n e i s not seen among the e l d e r l y (Gutman et a l . , 1986). Approximately 10% are occupied  to 15%  of a l l beds i n acute care h o s p i t a l s  by e l d e r l y people w a i t i n g f o r placement i n long  term care f a c i l i t i e s  ( S i l v e r s i d e s , 1987).  Second, s t u d i e s  show t h a t r e g i s t e r e d nurses l e a s t p r e f e r working with elderly  (Campbell, 1971;  While 74%  Smith, Jepson, & P e r l o f f , 1982).  of r e g i s t e r e d nurses work i n acute care h o s p i t a l s ,  they do not l i k e to nurse o l d e r people (Mantle, T h i r d , r e g i s t e r e d nurses who the e l d e r l y may  h o l d negative  engage i n behaviors  t h e r a p e u t i c or may  be d e t r i m e n t a l  the e l d e r l y c l i e n t  (Brower, 1981).  The widely  the  1988b).  a t t i t u d e s toward  which w i l l not  be  to the best i n t e r e s t s of  e l d e r l y are not a homogenous group but  i n t h e i r p h y s i c a l and p s y c h o s o c i a l  differ  status.  Moreover,  2 o l d age  i s not n e c e s s a r i l y i n d i c a t i v e of d e c l i n e .  though obvious p h y s i c a l changes occur, equated w i t h i l l n e s s or d i s e a s e .  Blandford, and  1986).  aging need not  multiple chronic  (Bossenmaier, 1982;  The  be  As a group, however, o l d e r  persons are more l i k e l y to experience disabling conditions  Even  Chappell,  r i s k with these c h r o n i c  and  Strain, &  conditions  a c t i v i t y limitations i s for further decline in function  and acute e x a c e r b a t i o n Gioiella & Bevil, The  of d i s e a s e  (Bossenmaier,  1982;  1985).  a g e - r e l a t e d p h y s i o l o g i c and p s y c h o s o c i a l  t h a t occur  a l s o predispose  the o l d e r c l i e n t to  risk,  p a r t i c u l a r l y at the time of h o s p i t a l i z a t i o n . For changes i n v i s i o n , h e a r i n g ,  and  a f f e c t c o g n i t i v e f u n c t i o n and to a s t a t e of c o n f u s i o n 1970;  W o r r e l l , 1977).  example,  other sensory m o d a l i t i e s  predispose  (Burnside, According  changes  1988;  can  the e l d e r l y c l i e n t Chodil & Williams,  to these authors,  the  i n d i v i d u a l imputes meaning t o the environment through sensory i n t e r a c t i o n .  Use  a t t e n t i o n to a c t i v i t y and  of c o l o r , l i g h t , and  texture,  sounds, placement of equipment,  f u r n i s h i n g s , and m o b i l i t y a i d s as w e l l as  caregiver  i n t e r a c t i o n can promote or hinder meaningful environmental exchange.  I f the h o s p i t a l does not promote meaningful  environmental i n t e r a c t i o n , a frequent confusional state.  Confusional  acute  s t a t e s i n the e l d e r l y person  i n c r e a s e the p o s s i b i l i t y f o r f a l l s , disturbances  outcome i s an  incontinence,  and m o b i l i t y , n u t r i t i o n a l , and  sleep  s k i n problems.  3 As a r e s u l t , dependency and the requirement  f o r n u r s i n g care  increases. Old age i s a l s o c h a r a c t e r i z e d by l o s s .  Many  h o s p i t a l i z e d o l d e r c l i e n t s have a l r e a d y experienced a l o s s of job, income, p o s s e s s i o n s , r e l a t i v e s , f r i e n d s , and even a spouse or home.  The circumstances n e c e s s i t a t i n g  h o s p i t a l i z a t i o n may mean f u r t h e r l o s s e s , f u n c t i o n a l  ability,  or independence (Burnside, 1988; E b e r s o l e & Hess, 1985). Together  w i t h t h e normal a g e - r e l a t e d changes and the  m u l t i p l e h e a l t h problems a l r e a d y p r e s e n t , t h e o l d e r hospitalized c l i e n t i s highly vulnerable. p h y s i o l o g i c r e s e r v e s and a decreased u n f a m i l i a r surroundings  Diminished  c a p a c i t y t o adapt t o  a r e a d d i t i o n a l c h a r a c t e r i s t i c s which  f u r t h e r render t h e h o s p i t a l i z e d o l d e r c l i e n t a t r i s k (Bossenmaier, 1982; G i o i e l l a & B e v i l , 1985).  Relocating  from a f a m i l i a r , s a f e l i v i n g environment t o the strange, unfamiliar hospital setting that requires interacting u n f a m i l i a r people t h r e a t e n s the aged person's  a b i l i t y to  cope when h o s p i t a l i z a t i o n i s sudden and unplanned 1988;  E b e r s o l e & Hess, 1985; Gunter, 1983).  with  (Burnside,  These authors  p o i n t out t h a t every nurse i s p e r s o n a l l y r e s p o n s i b l e and accountable  f o r n u r s i n g p r a c t i c e d e l i v e r e d t o c l i e n t s , and  that includes e l d e r l y  clients.  Nursing p r a c t i c e guided by models p r o v i d e a c e r t a i n frame of r e f e r e n c e f o r nurses, t e l l i n g them what t o look a t and t o s p e c u l a t e about (Fawcett,  1984).  Each conceptual  4 model has u t i l i t y f o r p r o f e s s i o n a l n u r s i n g because of the o r g a n i z a t i o n i t p r o v i d e s f o r t h i n k i n g , o b s e r v i n g , and i n t e r p r e t i n g i n the use of t h e n u r s i n g process (Leddy & Pepper, 1985).  Models a l s o p r o v i d e the nurse w i t h a way i n  which t o view the c l i e n t , and the r o l e and f u n c t i o n of nursing.  One such model, the UBC Model f o r Nursing  (Campbell, 1987) i s a b e h a v i o r a l system model made up of nine subsystems t h a t a r e i n t e r r e l a t i n g and interdependent. Each subsystem i s r e s p o n s i b l e f o r the s a t i s f a c t i o n of a b a s i c human need. The n i n e needs r e l a t e d t o each of the subsystems i n c l u d e the need f o r (1) balance between p r o d u c t i o n and u t i l i z a t i o n of energy; (2) c o l l e c t i o n and removal of accumulated wastes;  (3) i n t a k e of food and f l u i d s ,  nourishment; (4) i n t a k e of oxygen; and dependence; others;  (6) mastery;  (5) l o v e , belongingness,  (7) r e s p e c t of s e l f by s e l f and  (8) s a f e t y and s e c u r i t y ; and (9) s t i m u l a t i o n of the  system's senses (hearing, v i s i o n , s m e l l , touch, and t a s t e ) . The c l i e n t uses coping b e h a v i o r s t o s a t i s f y each b a s i c human need.  Forces (as d e f i n e d i n the UBC Model f o r  Nursing) determine movement toward or away from goal achievement.  Goal achievement means need  satisfaction.  I t i s important t o r e c o g n i z e t h a t a f o r c e  (personal,  impersonal, or s o c i o c u l t u r a l ) may a c t p o s i t i v e l y toward one need and n e g a t i v e l y toward another, and t h a t a coping behavior which i s s u i t a b l e t o s a t i s f y one need may a c t as a  5 negative  force i n satisfying  negatively force  subsystems.  i m p o r t a n c e when u s i n g  to  h i s surrounding  act  as a n e g a t i v e  but  the Ego-valuative  This notion  f o r c e n o t o n l y on t h e A c h i e v i n g  i n the l i f e  defines nursing's  that permit  A critical  m o d e l , i s an e v e n t  periods  events  and t o r e a c h  period, according  during  their optimal  to this that  and u s e s u i t a b l e c o p i n g These  and u n p r e d i c t a b l e  a r e those  critical  events.  changes which o c c u r  an i n d i v i d u a l ' s l i f e .  t h e UBC Model f o r N u r s i n g ,  changes  and use a  them t o s a t i s f y  stability  t o develop  include maturational  some p r e d i c t a b i l i t y to  critical  may d e v e l o p  t o s a t i s f y h i s b a s i c human n e e d s .  Maturational  unique  o c c u r r i n g i n an i n d i v i d u a l ' s l i f e  requires the individual behaviors  experiencing  c y c l e so t h a t they  behaviors  (p. 1 0 ) .  subsystem,  and P r o t e c t i v e s u b s y s t e m s a s w e l l .  b a s i c human n e e d s , t o a c h i e v e health"  client  and i n t r o d u c e h i m t o h i s roommates may  UBC Model f o r N u r s i n g  range o f c o p i n g  f o r the elderly  t o o r i e n t a t e an e l d e r l y  f u n c t i o n as " n u r t u r i n g i n d i v i d u a l s periods  negative  i s of p a r t i c u l a r  t h e model t o p l a n c a r e  F o r example, f a i l i n g  The  A f o r c e w h i c h may a c t  t o w a r d one s u b s y s t e m , may a l s o a c t a s a  toward other  client.  another.  these  events  with  According  i n c l u d e body  (change i n p h y s i c a l s t r u c t u r e and f u n c t i o n ) ,  geographical  change  neighbourhood), family with  (move t o a d i f f e r e n t  intrafamilial  change  c i t y or  (change w i t h i n t h e  r e s p e c t t o number, membership, o r l o c a t i o n o f  f a m i l y members), r o l e  change, s o c i a l  interaction  changes  6 (change i n human r e l a t i o n s h i p s ) , or work career change. U n p r e d i c t a b l e events a r e those changes which occur little  or no warning.  i n c l u d e aberrant c e l l  with  C a t e g o r i e s of these events may growth (deviant development of c e l l s  occurring after b i r t h ) /  congenital disorders, c i r c u l a t o r y  d i s o r d e r s , degenerative  processes,  immunologic d i s o r d e r s ,  i n f e c t i o u s processes, trauma, and s e p a r a t i o n ( p h y s i c a l d i s c o n n e c t i o n of an i n d i v i d u a l from s i g n i f i c a n t persons or objects). It  i s an e t h i c a l duty t o p r a c t i c e n u r s i n g i n such a way  as t o a s s i s t the e l d e r l y c l i e n t who i s e x p e r i e n c i n g a c r i t i c a l p e r i o d ( u n p r e d i c t a b l e or maturational)  t o achieve  optimal h e a l t h w i t h i n a c o l l a b o r a t i v e and c a r i n g relationship 1983;  (Burnside, 1988; E b e r s o l e & Hess, 1985; Gunter,  Lueckenotte,  1987).  n e g a t i v e and nonsupporting  According  t o these  a t t i t u d e s o f nurses  authors, contribute to  the v u l n e r a b i l i t y of t h e aged and a f f e c t t h e q u a l i t y of care they r e c e i v e . Although  t h e r e have been s e v e r a l s t u d i e s t h a t  i n v e s t i g a t e t h e q u a l i t y of n u r s i n g care t h e e l d e r l y r e c e i v e , t h e r e has been l i t t l e  a t t e n t i o n given t o e l d e r l y  p e r c e p t i o n s of t h e i r c a r e .  clients'  More r e c e n t l y , however, e l d e r l y  h o s p i t a l i z e d c l i e n t s report a threat to t h e i r  self-esteem  when nurses' behaviors toward them i n d i c a t e a l a c k of d i g n i t y and r e s p e c t Self-esteem  (Mclnnes, 1987).  i s an inner assurance  of p e r s o n a l worth  7 based on f e e l i n g s of being v a l u e d , u s e f u l , and competent (Ebersole & Hess, 1985). the s e l f - c o n c e p t . combination to o n e s e l f .  I t i s the e v a l u a t i v e component of  Roy (1976) d e f i n e d s e l f - c o n c e p t as a  of t h e f e e l i n g s and b e l i e f s one holds i n regards According t o Maslow (1970), people have b a s i c  human needs and a l l persons  "have a need or d e s i r e f o r a  s t a b l e , f i r m l y based, u s u a l l y high e v a l u a t i o n of themselves, f o r s e l f - r e s p e c t or s e l f - e s t e e m , and f o r t h e esteem of others"  (p. 90). Maslow i d e n t i f i e d two subsets o f esteem  needs:  s e l f - e s t e e m needs ( s t r e n g t h , achievement, mastery  and competence, c o n f i d e n c e i n the f a c e of t h e world, independence, and freedom),  and r e s p e c t needs or t h e need  f o r esteem from others  ( s t a t u s , dominance, r e c o g n i t i o n ,  a t t e n t i o n , importance,  and a p p r e c i a t i o n ) .  The e l d e r l y person may have a s o l i d f o u n d a t i o n i n a l l these areas based on p a s t achievements, personal i n t e g r i t y .  present success, or  Self-esteem, however, may be  threatenend d u r i n g a c r i t i c a l p e r i o d when the e l d e r l y  client  i s unable t o develop s u i t a b l e coping behaviors t o meet h i s b a s i c human needs f o r mastery  ( f e e l i n g of  accomplishment),  f o r l o v e , belongingness  and independence, and f o r r e s p e c t of  s e l f by s e l f and others  (Campbell,  1987).  Background t o the Study As a r e s u l t of demographic changes, t h e p r o p o r t i o n of h e a l t h care resources committed t o the c a r e of t h e e l d e r l y w i l l continue t o i n c r e a s e .  When today's n u r s i n g students  8 reach the prime of t h e i r c a r e e r s ,  they w i l l l i k e l y spend 75%  of t h e i r p r a c t i c e time with the e l d e r l y ( B u t l e r , 1980). Evidence i n d i c a t e s t h a t a t t i t u d e s nurses h o l d about the aged i n f l u e n c e the q u a l i t y of s e r v i c e s they p r o v i d e 1977;  (Hatton,  Wolk & Wolk, 1971). Certain perceptions  the n u r s i n g  h e l d by nurses a d v e r s e l y  care the e l d e r l y r e c e i v e .  generally perceived  influence  The e l d e r l y a r e  by younger people as p h y s i c a l l y and  m e n t a l l y on the d e c l i n e , s o c i a l l y withdrawn and unproductive in society  ( S c h o n f i e l d , 1982).  behavioral  c h a r a c t e r i s t i c s of e l d e r l y c l i e n t s can a f f e c t the  a t t i t u d e s of n u r s i n g  C e r t a i n p h y s i c a l or  personnel who p r o v i d e t h e i r care  ( E l l i o t t & Hyberton, 1982). E l d e r l y c l i e n t s may a l s o respond b e h a v i o r a l l y t o the a t t i t u d e s and behaviors of nurses. forced into patterns  of behavior by the behavior of nurses  toward them (White, 1977).  According t o t h i s author, the  e l d e r l y c l i e n t may l a c k the s t r e n g t h patterning  The e l d e r l y may be  and e x p e c t a t i o n s  or w i l l t o r e s i s t the  put on them by persons i n t h e i r  environment. The  e l d e r l y a r e the most stereotyped  ( G i o i e l l a & B e v i l , 1985).  of any age group  These authors s t a t e t h a t b e l i e f s  i n f l u e n c e a t t i t u d e s which i n f l u e n c e f e e l i n g s , and t h a t negative p r e s e n t a t i o n  of the e l d e r l y i n l i t e r a t u r e , on  t e l e v i s i o n , and i n jobs a l l c o n t r i b u t e t o n e g a t i v e b e l i e f s and  a t t i t u d e s toward the e l d e r l y .  9 There have been many s t u d i e s by s o c i a l s c i e n t i s t s on a t t i t u d e s toward aging and the aged.  Many have r e v e a l e d  n e g a t i v e a t t i t u d e s toward the aged ( S t e f f i , 1984a). such as Burnside Hyberton  Authors  (1988), D o l i n s k y (1984), and E l l i o t t and  (1982) s t a t e t h a t n e g a t i v e a t t i t u d e s and  attributions than adequate  on the p a r t of n u r s i n g personnel r e s u l t care f o r the e l d e r l y .  may be i n t e r n a l i z e d  by an e l d e r l y  Negative  i n less  attributions  person, and may  subsequently i n f l u e n c e h i s or her b e l i e f s , b e h a v i o r s , and self-concept  (Cherry, 1981).  The v a l u e a person p l a c e s upon  h i m s e l f i s a r e s u l t of t h e s o c i a l i n t e r p l a y  which occurs  between h i m s e l f and those i n h i s environment. coined the term, the " l o o k i n g g l a s s s e l f " .  Cooley  (1922)  According t o  Cooley, when a person observes h i m s e l f i n a m i r r o r , he does not see h i m s e l f as merely a mechanical r e f l e c t i o n .  He  imagines what e f f e c t h i s r e f l e c t i o n would have upon another person and what would be the o t h e r ' s responses and judgment. As he imagines what t h i s would be* he adopts i t and so views h i m s e l f as he imagines the other person would.  The person's  sense of s e l f i s d e r i v e d from h i s d e f i n i t i o n of a l l h i s v a r i o u s r o l e s , v a l u e s , and g o a l s which have been conveyed t o him by o t h e r s s i n c e b i r t h elderly  (Cherry, 1981).  Hospitalized  c l i e n t s d e r i v e ideas about themselves a c c o r d i n g t o  what they "read" i n t o the behaviors of the nurse, d i r e c t l y or i n d i r e c t l y  either  (through p o l i c i e s and r u l e s ) .  example/ r a i s i n g the s i d e r a i l s of a l l o l d e r c l i e n t s  For because  10 of t h e i r age r a t h e r than on the i n d i v i d u a l ' s a b i l i t y dependent behaviors and t h r e a t e n s the c l i e n t s '  fosters  self-esteem.  T h i s has s e r i o u s i m p l i c a t i o n s f o r n u r s i n g p r a c t i c e s i n c e the achievement of independent performance of f u n c t i o n a l s k i l l s i s g r e a t l y i n f l u e n c e d by A c c o r d i n g to Gunter  living  self-esteem.  (1983) and Burnside  (1988),  need to become aware of the importance of t h e i r own  nurses behavior  i n the care of e l d e r l y c l i e n t s , and t h a t t r e a t i n g o l d e r c l i e n t s w i t h d i g n i t y and r e s p e c t maintains or r e s t o r e s t h e i r self-esteem. behaviours respect  E l d e r l y c l i e n t s , however, r e p o r t t h a t nurses'  toward them i n d i c a t e a l a c k of d i g n i t y  (Mclnnes,  Although  and  1987).  there are s e v e r a l s t u d i e s which i n v e s t i g a t e  the q u a l i t y of care the e l d e r l y r e c e i v e , t h e r e has been very l i t t l e a t t e n t i o n g i v e n to the e l d e r l y c l i e n t ' s p e r c e p t i o n s of the q u a l i t y of t h e i r care, p a r t i c u l a r l y as i t r e l a t e s to d i g n i t y and  respect.  T h i s study was  designed  to determine whether e l d e r l y  c l i e n t s i n an acute care h o s p i t a l p e r c e i v e d they were t r e a t e d with d i g n i t y and  r e s p e c t and whether some e l d e r l y  c l i e n t s were more l i k e l y than others to be t r e a t e d with d i g n i t y and  respect. Problem Statement  The e f f e c t i v e n e s s and q u a l i t y of n u r s i n g care administered t o the e l d e r l y i s g r e a t l y i n f l u e n c e d by  nurses'  a t t i t u d e s toward t h i s group of people  Brower,  ( A l f o r d , 1982;  11 1981;  B u r n s i d e , 1988;  Wolk  1971).  f  Hatton, 1977;  S t o r l i c , 1982;  Wolk &  Recently, the e l d e r l y have begun t o speak out  on the q u a l i t y of n u r s i n g care they r e c e i v e .  More  s p e c i f i c a l l y , the e l d e r l y r e p o r t they are not t r e a t e d w i t h d i g n i t y and r e s p e c t and are made t o f e e l l i k e citizens  (Mclnnes,  second-class  1987).  A c c o r d i n g t o the Code of E t h i c s f o r Nursing  (Canadian  Nurses A s s o c i a t i o n , 1985), a c l i e n t ' s r i g h t t o be t r e a t e d i n a d i g n i f i e d f a s h i o n must be r e f l e c t e d i n the nurse's behavior.  The Code c o n t a i n s v a l u e s concerned  own  w i t h the  r e s p o n s i b i l i t y of the nurse's behavior t o t r e a t c l i e n t s w i t h d i g n i t y and r e s p e c t .  Two  of these v a l u e s a r e :  (1) "A  nurse  i s o b l i g e d t o t r e a t c l i e n t s with r e s p e c t f o r t h e i r i n d i v i d u a l needs and v a l u e s " (Canadian Nurses A s s o c i a t i o n , 1985,  p. 4 ) , and  (2) "the nurse has an o b l i g a t i o n t o be  guided by c o n s i d e r a t i o n f o r the d i g n i t y of c l i e n t s " (Canadian Nurses A s s o c i a t i o n , 1985,  p. 7 ) .  Although t h e r e are s t u d i e s which examine the q u a l i t y of n u r s i n g care the e l d e r l y r e c e i v e , there has been very a t t e n t i o n g i v e n to the e l d e r l y c l i e n t s *  little  p e r c e p t i o n s of the  q u a l i t y of t h e i r c a r e , p a r t i c u l a r l y as i t r e l a t e s t o d i g n i t y and r e s p e c t . Purpose of the Study The purpose of t h i s study was  t o e x p l o r e whether  e l d e r l y c l i e n t s i n an acute care h o s p i t a l p e r c e i v e d they were t r e a t e d w i t h d i g n i t y and r e s p e c t and whether e l d e r l y  12 c l i e n t s with a higher socioeconomic  s t a t u s were more  likely  t h a n o t h e r s t o p e r c e i v e t h e y were t r e a t e d w i t h d i g n i t y respect.  Whether e l d e r l y  treated with dignity verbal  responses  The  c l i e n t s p e r c e i v e d they  a n d r e s p e c t was d e t e r m i n e d  t o items  and  were by  eliciting  on a q u e s t i o n n a i r e .  r e s e a r c h q u e s t i o n s the i n v e s t i g a t o r proposed  to  answer were: 1.  Do e l d e r l y  clients  i n acute care h o s p i t a l s p e r c e i v e  t h e y were t r e a t e d w i t h d i g n i t y 2.  Are e l d e r l y  s t a t u s more l i k e l y dignity  and r e s p e c t ?  c l i e n t s within a higher  socioeconomic  t o p e r c e i v e t h e y were t r e a t e d  and r e s p e c t t h a n  c l i e n t s w i t h a lower  with  socioeconomic  status? The  following  framework u s e d  section  explains the t h e o r e t i c a l  t o guide the i n v e s t i g a t i o n . Theoretical  Symbolic theoretical adaptable  Framework  i n t e r a c t i o n i s m was c h o s e n t o s e r v e a s t h e  framework f o r t h i s  to investigating  study.  how we may  This theory i s develop  a b o u t o u r s e l v e s on t h e b a s i s o f a t t i t u d e s  attitudes  of others  towards  us. From t h e p e r s p e c t i v e o f s y m b o l i c reality  i s seen  t o be c o n s t r u c t e d t h r o u g h  i n t e r a c t i o n between i n d i v i d u a l s 1980). to  interactionism,  Through t h i s  o b j e c t s and s i t u a t i o n s  a process of  (Blumer, 1969;  interaction,  individuals  they encounter  social  Stryker, g i v e meaning  and e x p e r i e n c e .  13 These o b j e c t s or s i t u a t i o n s have no individual since  i n h e r e n t meaning f o r  the meaning emanates from the way  o b j e c t i s d e f i n e d by those with whom the interacts How  (Blumer, 1969; we  experience  meaning.  M e l t z e r , P e t r a s , & Reynolds, 1977).  a c t i o n of o t h e r s and  (Blumer, 1969).  a c t s as a b a s i s  our  interpreting  own  This interpreted  for action that  r e f l e c t s our  Since i n t e r a c t i o n i n v o l v e s  expression  meaning then own  intended  reciprocally  are  two  of the  the  Cooley  Meltzer et a l . , 1977).  (1922) and  founders of the  George Herbert Mead (1934)  symbolic i n t e r a c t i o n i s t  approach (Meltzer et a l . , 1977). self-concept  influenced  of behavior, not merely a form of i t s  (Blumer, 1969;  C h a r l e s H.  the  previous  behavior, s o c i a l i n t e r a c t i o n i s c o n s i d e r e d to be determiner or r e a c t o r  the  individual  i n t e r a c t w i t h others i n v o l v e s  meaning of the  an  They noted t h a t  i s a s o c i a l phenomenon.  a person's  I t develops as  a  r e s u l t of the v a r i e t y of r o l e s taken on by the person i n social interaction.  In t h i s approach the  c o n s i d e r e d to be an a c t i v e p a r t i c i p a n t s i t u a t i o n or s e t t i n g . d e f i n e s and  individual i s  in a specific social  During t h i s p r o c e s s the  individual  interprets a s p e c i f i c s e t t i n g , i n personal  terms, because of i n t e r a c t i n g with o t h e r s who s i g n i f i c a n c e t o him  verbally  language, gestures and meaning i s a t t r i b u t e d shared meanings of the  or s y m b o l i c a l l y  mannerisms). to the  are  (through d r e s s ,  In t h i s way,  symbols and  of  social  b e h a v i o r s , and  s i t u a t i o n or s e t t i n g are  derived  thus  14 a c c o r d i n g t o the meaning the s i t u a t i o n has f o r each individual. Symbolic  i n t e r a c t i o n i s m i n v o l v e s three processes t h a t  culminate i n s p e c i f i c meanings and t h e r e f o r e i n c o g n i t i v e or behavioral acts.  First,  the i n d i v i d u a l d e f i n e s the s o c i a l  s i t u a t i o n i n terms of how him/her Cooley  (Blumer, 1969;  i t operates and what i t means f o r  Thomas, 1934).  Second, a c c o r d i n g to  (1922), i n d i v i d u a l s observe and i n t e r a c t w i t h o t h e r s  i n order t o analyze and a r r i v e at a d e f i n i t i o n of the "self".  In t h i s way,  see us and how  we as i n d i v i d u a l s c o n s i d e r how  others  others e v a l u a t e what they see i n us.  As a  r e s u l t of t h i s e v a l u a t i o n and i n t e r p r e t a t i o n , which i s ongoing  and continuous, we  a r r i v e at a view of o u r s e l v e s and  the s i t u a t i o n , and behave a c c o r d i n g l y .  The t h i r d  process  i n v o l v e s what Goffman (1959) c a l l s "the p r e s e n t a t i o n of self".  I n d i v i d u a l s d e f i n e the s i t u a t i o n and s e t t i n g  then decide how  they w i l l p r e s e n t themselves  to others i n  terms of d r e s s , manner, and content of i n t e r a c t i o n behaviors. speech,  and  and  A c c o r d i n g t o t h i s author, the type of d r e s s ,  and behavior p a t t e r n i s s e l e c t e d i n order t o present  a s e l f which i s a p p r o p r i a t e t o the s p e c i f i c Symbolic  situation.  i n t e r a c t i o n i s m r e p r e s e n t s an examination  or  a n a l y s i s of a s p e c i f i c s o c i a l process or s i t u a t i o n t h a t occurs i n everyday  life.  The emphasis, t h e n  r  i s on  social  i n t e r a c t i o n as a p r o c e s s , and the v a r i o u s meanings and i n t e r p r e t a t i o n s each p a r t i c i p a n t b r i n g s t o t h a t i n t e r a c t i o n .  15 Its  main concern i s with how  each i n d i v i d u a l i n t e r p r e t s  and  a s s i g n s meaning t o a s p e c i f i c s i t u a t i o n , behavior, or event. T h i s meaning emphasizes the importance of feedback  from  s i g n i f i c a n t o t h e r s i n the development of "the s e l f " . A c c o r d i n g to J o u r a r d (1974), people's views of are  s t r o n g l y i n f l u e n c e d by o t h e r s ' d e f i n i t i o n of them; we  c o n t i n u a l l y i n s t r u c t o t h e r s as t o how us.  themselves  they should p e r c e i v e  T h i s author p o i n t s out t h a t t h i s v u l n e r a b i l i t y t o  another's i n f l u e n c e may  be a l i a b i l i t y  or an a s s e t .  If  others p r o j e c t a n e g a t i v e a t t r i b u t e on another person, a t t r i b u t e may  this  be i n t e r n a l i z e d by the person, making the  vulnerability a definite l i a b i l i t y .  The v u l n e r a b i l i t y  may  be an a s s e t , however, i f a s i g n i f i c a n t other p r o j e c t s an a t t r i b u t e of worthiness and s t r e n g t h t o a person. way,  In t h i s  the person's s e l f - c o n c e p t i s maintained or enhanced. The term " s e l f - c o n c e p t " r e f e r s t o the a t t i t u d e and  e v a l u a t i o n an i n d i v i d u a l has concerning h i m s e l f or the the s e l f i s e v a l u a t e d .  In f a c t , we may  develop  attitudes  about o u r s e l v e s on the b a s i s of a t t i t u d e s toward settings.  A c c o r d i n g to Cooley  way  us i n g i v e n  (1922) and Mead (1934), an  i n d i v i d u a l ' s s e l f - c o n c e p t i s a s o c i a l phenomenon.  It  develops as a r e s u l t of the v a r i e t y of r o l e s taken on by the individual in social interaction.  That i s , the s e l f  r e f l e c t s the responses of o t h e r s toward the i n d i v i d u a l , p e r c e i v e d by the i n d i v i d u a l ' s own how  o t h e r s see him or her.  as  a b i l i t y i n understanding  16 According t o Mead (1934), one's s e l f - c o n c e p t i s never gained nor maintained  once and f o r a l l and i s q u i t e open t o  change and development over time.  I t i s highly interrelated  with other people's p e r c e p t i o n of us. symbolic  Proponents of a  i n t e r a c t i o n i s t view maintain t h a t aging outcomes  r e f l e c t t h e r e c i p r o c a l r e l a t i o n s h i p between the i n d i v i d u a l and h i s or her s o c i a l environment; t h e i n d i v i d u a l s i m u l t a n e o u s l y e x t e r n a l i z e s h i s own being i n t o t h e s o c i a l world and i n t e r n a l i z e s i t as an o b j e c t i v e r e a l i t y 1981).  (Cherry,  According t o t h i s author, f e e l i n g s of s e l f - w o r t h and  l i f e s a t i s f a c t i o n a r e maximized when t h e r e i s congruence between the i n d i v i d u a l ' s s e l f - c o n c e p t , h i s i n t e r p r e t a t i o n of the behavior and t h e behavior of o t h e r s i n r e l a t i o n t o him. In r e l a t i o n t o the h o s p i t a l s e t t i n g , the e l d e r l y c l i e n t ' s s e l f - c o n c e p t during a c r i t i c a l p e r i o d may be maintained  or enhanced i f h i s b a s i c human needs f o r  accomplishment  (mastery), l o v e , belongingness and  dependence, and r e s p e c t of s e l f by s e l f and o t h e r s esteem) a r e met.  (self-  These needs a r e l a r g e l y met through  i n t e r a c t i o n by t h e c l i e n t d e v e l o p i n g those coping  social  behaviors  capable of m a i n t a i n i n g need s a t i s f a c t i o n and goal achievement.  That i s t o say, the e l d e r l y c l i e n t ' s coping  behaviors a r e i n f l u e n c e d by t h e meanings he/she a t t a c h e s t o the behavior of nurses toward him or her (Blumer, 1969; Jourard, 1974).  When nurses i n t r o d u c e t h e c l i e n t t o t h e i r  surroundings, p r o v i d e them w i t h i n f o r m a t i o n , address them  17 a p p r o p r i a t e l y , i n s u r e t h e i r need f o r p r i v a c y , e x p l a i n procedures b e f o r e they are done, and p r o v i d e an o p p o r t u n i t y for  c l i e n t s t o express t h e i r f e a r s and concerns, they are  t r e a t i n g c l i e n t s with d i g n i t y and r e s p e c t .  The meaning  those n u r s i n g a c t i o n s have f o r e l d e r l y c l i e n t s m a i n t a i n or enhance t h e i r s e l f - c o n c e p t .  Conversely, the e l d e r l y  c l i e n t ' s s e l f - c o n c e p t w i l l be threatened d u r i n g a c r i t i c a l p e r i o d i f n u r s i n g i n t e r v e n t i o n s do not a s s i s t him t o develop s u i t a b l e coping behaviors t o meet h i s needs f o r mastery, l o v e , b e l o n g i n e s s and dependence, and s e l f - e s t e e m . are m o d i f i e d and d e a l t w i t h through an  Meanings  interpretative  process used by persons i n d e a l i n g with those t h i n g s they encounter  (Blumer,  1969).  The e l d e r l y c l i e n t ' s s e l f - c o n c e p t i s not d i m i n i s h e d and may  be enhanced i f t h e r e i s congruence between what the  c l i e n t s b e l i e v e about themselves,  and the i n t e r p r e t a t i o n of  the a c t i o n of others i n r e l a t i o n t o them.  Through a process  of  clients'  i n t e r p r e t a t i o n and i n t e r a c t i o n , e l d e r l y  p e r c e p t i o n s and a c t i o n s may  be i n f l u e n c e d by how c a r e - g i v e r s  ( r e g i s t e r e d nurses) view e l d e r l y people.  I f the a c t i o n s and  behaviors of the c a r e - g i v e r s are incongruent w i t h e l d e r l y c l i e n t ' s p o s i t i v e p e r c e p t i o n s of themselves, concept i s undermined  (Kuypers & Bengston,  the  1973).  selfThese  authors argue t h a t the e l d e r l y i n t e r n a l i z e these e x t e r n a l e v a l u a t i o n s and begin t o behave as expected f u l f i l l i n g prophecy).  Davis  (the s e l f -  (1968) a s s e r t s t h a t o l d e r  people tend to adopt whatever r o l e i s expected of them. According t o Cherry  (1981), n e g a t i v e a t t r i b u t i o n s may  i n t e r n a l i z e d by an e l d e r l y person, and may  be  subsequently  i n f l u e n c e her b e l i e f s , b e h a v i o r s , and s e l f - c o n c e p t . Given t h i s framework, the focus of t h i s study was e x p l o r e whether e l d e r l y c l i e n t s  to  ( i n an acute care s e t t i n g )  p e r c e i v e d the a c t i o n s and b e h a v i o r s of nurses towards them were congruent w i t h t h e i r p e r c e p t i o n s of themselves self-concept).  T h i s i n f o r m a t i o n was  (their  o b t a i n e d by determining  (using a s t r u c t u r e d i n t e r v i e w format) whether e l d e r l y c l i e n t s who  r e c e i v e d n u r s i n g care i n an acute c a r e s e t t i n g  p e r c e i v e d they were t r e a t e d w i t h d i g n i t y and r e s p e c t . D e f i n i t i o n of Terms Attitudes:  a b s o l u t e i n c l i n a t i o n s or mental  readiness  which c o n s i s t e n t l y e x e r t i n f l u e n c e on e v a l u a t i v e responses t h a t are d i r e c t e d toward (Zimbardo  some person, group, or s u b j e c t s  & Ebbesen, 1969).  Dignity:  being worthy of honor or r e s p e c t  (Allen,  1984). Elderly:  a person 65 y e a r s of age and above.  Perception:  thoughts, f e e l i n g s and a t t i t u d e s of  i n d i v i d u a l s about o b j e c t s or events as r e l a t e d v e r b a l l y . Respect:  d e f e r e n t i a l esteem f e l t or shown towards  person; a v o i d i n t e r f e r i n g with or harming, t r e a t w i t h c o n s i d e r a t i o n ; r e f r a i n from o f f e n d i n g person or f e e l i n g s ( A l l e n , 1984).  19 Socioeconomic  status;  d e f i n e d i n terms of a standard  s o c i o l o g i c a l paradigm c o n s i s t i n g of t h r e e components; e d u c a t i o n , o c c u p a t i o n , and income (George & Bearon, 1980). The l e v e l of e d u c a t i o n was socioeconomic  s e l e c t e d as an i n d i c a t i o n of  s t a t u s f o r t h i s study s i n c e education i s  c o n s i d e r e d t o be a determinant throughout a secondary  life.  of socioeconomic  status  For the purpose of t h i s study, those w i t h  l e v e l of e d u c a t i o n w i l l be regarded as having a  h i g h e r socioeconomic  s t a t u s and those with an  l e v e l of e d u c a t i o n a lower socioeconomic  elementary  status.  Assumptions 1.  I n d i v i d u a l s ( c l i e n t s and nurses) a c t p u r p o s e f u l l y  and these a c t i o n s are i n f l u e n c e d by the  individual's  i n t e r p r e t a t i o n of the s e t t i n g , s i t u a t i o n or behavior of i n d i v i d u a l s i n the s e t t i n g or s i t u a t i o n . 2.  The s e l e c t i o n of e l d e r l y c l i e n t s f o r the study  was  dependent upon t h e i r a c t i v i t i e s and w i l l i n g n e s s t o communicate p e r c e p t i o n s v e r b a l l y . 3.  A t t i t u d e s of nurses a f f e c t t h e i r b e h a v i o r s ,  and  t h e i r behavior i n f l u e n c e s the n u r s i n g care they administer to the 4.  elderly. The q u e s t i o n s t h a t have been s e l e c t e d from  Medicus Q u a l i t y Assurance  t o o l are those t h a t w i l l  the elicit  i n f o r m a t i o n on whether i d e n t i f i e d aspects of n u r s i n g care were p e r c e i v e d by the c l i e n t t o meet h i s / h e r needs f o r d i g n i t y and r e s p e c t .  20 Limitations No methodology e x i s t e d which measured the  client's  p e r c e p t i o n of n u r s i n g care with complete adequacy. Moreover, any  r e l a t i o n s h i p between the a t t i t u d e s of nurses  and the q u a l i t y of n u r s i n g care i n t h i s study can only be i n f e r r e d , s i n c e the a t t i t u d e of nurses i n t h i s sample  was  not observed  and  or measured.  With convenience  the omission of those c l i e n t s who  sampling,  were not a l e r t  and  o r i e n t e d , the a v a i l a b l e s u b j e c t s might not be t y p i c a l of the p o p u l a t i o n w i t h regard t o the v a r i a b l e s being measured. G e n e r a l i z a b i l i t y of the f i n d i n g s may  be  limited.  Summary T h i s i n t r o d u c t o r y chapter d e s c r i b e d the n u r s i n g context of the r e s e a r c h problem and e x p l a i n e d the r a t i o n a l e purpose of the study.  and  The t h e o r e t i c a l framework, the  r e s e a r c h q u e s t i o n s , the assumptions and l i m i t a t i o n s of the study were addressed.  The next chapter p r o v i d e s a review of  l i t e r a t u r e p e r t i n e n t t o the  investigation.  21  CHAPTER 2 Review of S e l e c t e d L i t e r a t u r e  T h i s chapter and  reviews p e r t i n e n t t h e o r e t i c a l p e r s p e c t i v e s  research studies.  The  on the b a s i s of a symbolic  l i t e r a t u r e reviewed was  selected  i n t e r a c t i o n i s t view of  how  e l d e r l y c l i e n t s view t h e i r n u r s i n g care, and t h e i r givers  care-  ( r e g i s t e r e d nurses) as r e c i p r o c a l l y i n f l u e n c i n g  elements of t h e i r h o s p i t a l experience.  From t h i s  p e r s p e c t i v e , the review of the l i t e r a t u r e i s organized seven main p a r t s :  (1) growth of the e l d e r l y p o p u l a t i o n ,  b a s i c human needs and  the e l d e r l y p o p u l a t i o n ,  h o s p i t a l i z e d e l d e r l y , (4) aging  and  (3)  self-esteem,  a t t i t u d e s of nurses towards the e l d e r l y , and of t h e i r n u r s i n g  (2)  the (5)  c o n s i d e r a t i o n s i n the care of the e l d e r l y c l i e n t ,  person's p e r c e p t i o n  into  ethical  (6)  (7) the o l d e r  care.  Growth of the E l d e r l y P o p u l a t i o n The  number of people over 65 years of age  increasing.  I t was  by year 2001, population  i s steadily  i n i t i a l l y projected that i n t h i s  t h i s group would comprise about 11%  ( S t a t i s t i c s Canada, 1980).  But w i t h  of  country the  recent  improvements i n s u r v i v a l r a t e s i n the o l d e r p o p u l a t i o n and major decrease i n b i r t h r a t e , the percentage of people over 65 has been r e v i s e d upwards (Stone & F l e t c h e r , 1986). Quoting S t a t i s t i c s Canada data, these a n a l y s t s p r o j e c t t h a t  a  22 by year 2001,  14% of the p o p u l a t i o n w i l l be over 65 years  and by year 2031 25%.  this figure w i l l  i n c r e a s e t o approximately  These f i n d i n g s w i l l be r e f l e c t e d i n an i n c r e a s e d  number of people over the age of 65 r e q u i r i n g n u r s i n g services.  The d i s t r i b u t i o n of the p o p u l a t i o n i n d i c a t e s t h a t  r e g i s t e r e d nurses, the s i n g l e l a r g e s t group of h e a l t h care workers i n Canada, are encountering the e l d e r l y more frequently i n their practice.  They p r o v i d e n u r s i n g care t o  the e l d e r l y i n l o n g term and c h r o n i c c a r e i n s t i t u t i o n s , i n the community, and i n acute c a r e h o s p i t a l s . Columbia,  In B r i t i s h  f o r example, the number of admissions t o acute and  r e h a b i l i t a t i o n h o s p i t a l s and h o s p i t a l days used, i n c r e a s e d r a m a t i c a l l y a f t e r age 55.  In 1982-83, the number of  admissions per thousand people age 70-74 was  almost  four-  and one-half times l a r g e r than t h a t f o r the aged 55-59 group; among those age 85 and over, i t was more than f i v e times l a r g e r  (Gutman e t a l . , 1986).  B r i t i s h Columbia  generally f e l l  While h o s p i t a l usage i n  between 1971  and 1982-83 as  a r e s u l t of e f f o r t s t o reduce h o s p i t a l bed c a p a c i t y , o v e r a l l d e c l i n e d i d not occur among the e l d e r l y .  this  Gutman  p o i n t s out t h a t admission r a t e s per c a p i t a d u r i n g t h i s p e r i o d i n c r e a s e d f o r a l l age groups of men 65 and women over the age of 70.  over the age of  Although the p u b l i c  p e r c e p t i o n i s t h a t the e l d e r l y make g r e a t demands on the h o s p i t a l system, only 20% of those over 65 are admitted to h o s p i t a l i n any g i v e n y e a r .  Out of t h i s group, however, 5%  23 consume 60% of the h o s p i t a l days; of t h a t high-use group, about h a l f a r e i n t h e i r l a s t year of l i f e or a r e w a i t i n g f o r a bed i n a n u r s i n g home ( S i l v e r s i d e s , 1987). To c l a r i f y h e a l t h p o l i c y , the f e d e r a l government d e f i n e d f i v e l e v e l s of i n s t i t u t i o n a l c a r e :  residential,  extended c a r e , c h r o n i c h o s p i t a l , r e h a b i l i t a t i o n , and acute h o s p i t a l ; the f i r s t three a r e considered  long term c a r e .  In  B r i t i s h Columbia, f i v e l e v e l s of l o n g term care are d e f i n e d as Personal  Care, Intermediate  Intermediate  Care I, Intermediate  Care I I ,  Care I I I , and Extended Care (Forbes, Jackson, &  Kraus, 1987).  Long term care s e r v i c e s and programs a r e  r e q u i r e d by those  i n d i v i d u a l s who have some degree of  f u n c t i o n a l impairment because of p h y s i c a l and/or mental f r a i l t y or d i s a b i l i t y  (Mantle,  1988a).  the development of community support  According  t o Mantle,  s e r v i c e s has enabled  the e l d e r l y t o l i v e w i t h i n the community f o r longer of time.  periods  E l d e r l y r e s i d e n t s a r e now much o l d e r before  they  enter a f a c i l i t y and have much g r e a t e r degrees of p h y s i c a l and mental  disability.  Gutman e t a l . (1986) p o i n t out t h a t w h i l e l e v e l of care cannot be p r e d i c t e d by age alone, the p r o b a b i l i t y t h a t some l e v e l of s e r v i c e w i l l be r e q u i r e d i n c r e a s e s d r a m a t i c a l l y with age.  In 1984, 55% of t h e p o p u l a t i o n aged 85 and over  were r e c e i v i n g l o n g term care s e r v i c e s .  This f i g u r e  compares with 21% i n the age group 75-84 and only 6% i n the age  group 65-74.  The p r o p o r t i o n of persons r e c e i v i n g  24 continuing age.  care i n f a c i l i t i e s  Of t h o s e  were  also  aged 85 a n d o v e r  in facilities.  rises  i n care,  While approximately  with increasing about  two-thirds  80% o f p e o p l e  the  age o f 65 i n Canada ( H e a l t h and W e l f a r e C a n a d a ,  are  capable of l i v i n g  themselves suffer  (in spite  from at l e a s t  over  1982)  i n d e p e n d e n t l y and c a r i n g f o r of the f a c t that  75% o f o l d e r  one c h r o n i c h e a l t h p r o b l e m ) ,  people there i s a  r e l a t i o n s h i p b e t w e e n b e i n g o l d e r a n d r e q u i r i n g more c a r e a n d being  in a facility. Basic  Human Needs a n d t h e E l d e r l y P o p u l a t i o n  I n t h e UBC Model f o r N u r s i n g  (Campbell, 1987),  behavioral  system model, t h e i n d i v i d u a l  nine basic  human n e e d s w h i c h p e r s i s t  n i n e needs  i n c l u d e t h e need f o r m a s t e r y ,  belongingness, others;  and dependence;  i s assumed t o  throughout l i f e .  respect  of s e l f  nourishment;  safety  by s e l f a n d  and s e c u r i t y ;  and s t i m u l a t i o n o f t h e s e n s e s .  constantly  strives  of innate  to s a t i s f y  each b a s i c  suitability  Basic fundamental behavioral  human n e e d by u s i n g Behavior  a r e i n f l u e n c e d by t h e a n d t h e ways h i s  a r e met.  human n e e d s p e r s i s t requirements system  balance  The i n d i v i d u a l  o f t h e c o p i n g b e h a v i o r s he u s e s  human needs  intake  i n t a k e of  and a c q u i r e d c o p i n g b e h a v i o r s .  and p e r s o n a l i t y c h a r a c t e r i s t i c s  basic  The  love,  between p r o d u c t i o n a n d u t i l i z a t i o n o f e n e r g y ;  a range  have  c o l l e c t i o n and removal of accumulated w a s t e s ;  of f o o d and f l u i d ;  oxygen;  a  throughout l i f e .  They a r e  f o r s u r v i v a l and growth o f t h e  (Campbell,  1987).  25 Conceptualizing  a h i e r a r c h i c a l framework of b a s i c human  needs, Maslow (1968) viewed growth as "a continued,  more or  l e s s steady upward or forward development" (p. 3 3 ) . Beginning a t the lower end (the most b a s i c part)  of t h e  h i e r a r c h y a r e p h y s i o l o g i c needs t h a t a r e important f o r survival. sex.  These needs i n c l u d e food, water, a i r , s l e e p , and  Next a r e t h e needs f o r s a f e t y , which i n c l u d e s e c u r i t y ,  p r o t e c t i o n , freedom from a n x i e t y ,  and some degree of r o u t i n e  and p r e d i c t a b i l i t y i n d a i l y l i v i n g .  When p h y s i o l o g i c and  s a f e t y needs have been met, belonging r e l a t i o n s h i p assumes importance.  and l o v e i n a c a r i n g  Meeting t h i s need i s an  e s s e n t i a l p r e r e q u i s i t e t o meeting esteem needs, which i n c l u d e r e p u t a t i o n , s t a t u s , p r e s t i g e , and a f e e l i n g of s e l f esteem b u i l t on i n d i v i d u a l s e l f - w o r t h .  When p h y s i o l o g i c and  s a f e t y needs, belonging,  l o v e , and esteem needs a r e met i n  s a t i s f a c t o r y succession,  t h e person can focus on tasks f o r  self-actualization.  Maslow b e l i e v e d t h a t i n t h e process of  growth, a person has t o s a t i s f y b a s i c needs b e f o r e the person can be motivated toward s e l f a c t u a l i z a t i o n (becoming a l l t h e person i s capable of becoming). Steffi  (1984b) p o i n t s out there a r e many misconceptions  about where o l d e r people a r e expending t h e i r e n e r g i e s .  We  may expect o l d people t o be s e l f - a c t u a l i z i n g when, i n f a c t , t h e i r self-esteem  i s being  threatened  a l l t h e i r energy t o ensuring are met.  and they a r e devoting  t h a t t h e i r p h y s i o l o g i c a l needs  26 According are  t o t h e UBC Model o f N u r s i n g  not h i e r a r c h i a l i n structure;  regularly  i n order  b a s i c human n e e d s  a l l n i n e n e e d s must be met  t o a c h i e v e b e h a v i o r a l system s t a b i l i t y  and one human n e e d does n o t t a k e p r e c e d e n c e human n e e d  (Campbell,  Erich  universal  describes  transcendence,  identity,  He s t a t e s  need t o h a v e a n i d e n t i t y , h a v e a p l a c e is difficult  depends on r e l a t e d n e s s according  i n time and space and our s o c i e t y  to f a l l  and e f f e c t e n c e .  i s who one i s  i n terms  and d i e .  (1978)  are i d e n t i t y ,  The most i m p o r t a n t p a r t  (surname,  Connectedness i s d e f i n e d w h i c h we a l l l i v e  back o n .  s o c i a l - p s y c h o l o g i c a l needs o f e l d e r l y  i n d i v i d u a l s d e s c r i b e d by B e n g s t o n connectedness,  about i t , has a need t o  and needs a s e t o f b e l i e f s  o r non r e l i g i o u s )  Three b a s i c  title,  change  (Bengston,  of the s o c i a l  a "lifeline".  some  able to  1978).  b a s i c human n e e d s w h i c h a r e v i t a l  maintaining  situation i n  E f f e c t e n c e means h a v i n g  C o m m u n i c a t i o n and i n t e r a c t i o n w i t h o t h e r are  of  role).  o f i n f l u e n c e on your environment and b e i n g  effect  Man,  t o Fromm, i s t h e o n l y a n i m a l t h a t h a s an a w a r e n e s s  (religious  sort  as  everyone has a  t o someone o r s o m e t h i n g .  something b e h i n d ,  identity  that  for older people),  o f h i s own f i n i t e n e s s and s p e c u l a t e s leave  rootedness,  and a f r a m e o f r e f e r e n c e  b a s i c human n e e d s .  (rerooting  another  1987).  Promm (1955)  relatedness,  over  Interaction  human b e i n g s  f o r the e l d e r l y person with other  people  27 becomes more d i f f i c u l t die  (Burnside, 1988;  i n o l d age when f a m i l y and f r i e n d s  E b e r s o l e & Hess,  1985).  Personal space, t e r r i t o r i a l domain, and arrangements  spatial  are important elements i n b a s i c human needs  ( G i o i e l l a & B e v i l , 1985;  P a s t a l a n , 1970).  P e r s o n a l space  r e f e r s t o the d i s t a n c e i n d i v i d u a l s m a i n t a i n between themselves and o t h e r s .  I t may  be viewed as a bubble  surrounding the person - a b u f f e r zone between o n e s e l f and the environment.  That i s , they need i n d i v i d u a l l y  s p a t i a l d i s t a n c e s f o r c o n v e r s a t i o n and s o c i a l Territoriality  determined  interaction.  i s d e f i n e d as a d e l i m i t e d space used by  i n d i v i d u a l s or groups, i n v o l v e s p s y c h o l o g i c a l  identification  w i t h the a r e a , and i s symbolized by a t t i t u d e s of p o s s e s s i v e n e s s and arrangement  of o b j e c t s  (Pastalan,  1970).  T h i s author e x p l a i n s t h a t i n d i v i d u a l t e r r i t o r y i s p h y s i c a l or g e o g r a p h i c a l and i s v i s i b l e i n nature, whereas p e r s o n a l space i s more p s y c h o l o g i c a l because i t i s c a r r i e d w i t h the i n d i v i d u a l and i s not v i s i b l e .  around  A person w i l l  i d e n t i f y the boundaries of h i s t e r r i t o r y w i t h a v a r i e t y of environmental props, both s t a t i o n a r y and mobile, so they can be seen by o t h e r s .  The boundaries of p e r s o n a l space are  i n v i s i b l e though they may  be i n f e r r e d from  facial  e x p r e s s i o n s , body movements, g e s t u r e s , p i t c h or tone of one's v o i c e and v i s u a l When h o s p i t a l i z e d  contact. ( S t i l l m a n , 1978), i n d i v i d u a l s  usually  experience a l o s s of p r i v a c y and c o n t r o l over t h e i r bodies  28 and surrounding area. territory.  They are denied t h e i r own  familiar  P o s s e s s i o n of t e r r i t o r y h e l p s meet a need f o r  s e c u r i t y and i d e n t i t y , w h i l e l o s s of i t can i n t e r f e r e w i t h psychological  homeostasis. The H o s p i t a l i z e d  Elderly  The e l d e r l y are a heterogeneous  group, w i t h wide  d i f f e r e n c e s i n t h e i r p h y s i c a l and p s y c h o s o c i a l s t a t u s . the tendency  Yet,  i s t o d e a l w i t h a l l persons over the age of 65  as though they are a l l developmentally the same (Burnside, 1988;  E b e r s o l e & Hess, 1985). As a group,  o l d e r persons are more l i k e l y t o experience  m u l t i p l e c h r o n i c and d i s a b l i n g c o n d i t i o n s . c h r o n i c problems,  With these  the r i s k i s f o r f u r t h e r d e c l i n e i n  f u n c t i o n and acute e x a c e r b a t i o n of the d i s e a s e 1982;  Gioiella & Bevil,  (Bossenmaier,  1985).  The normal a g e - r e l a t e d p h y s i o l o g i c a l and p s y c h o s o c i a l changes t h a t occur p l a c e the o l d e r person at r i s k d u r i n g hospitalization.  For example, a l t e r a t i o n s i n v i s i o n ,  h e a r i n g , and other sensory m o d a l i t i e s can a f f e c t function  (Chodil & W i l l i a m s , 1970;  cognitive  W o r r e l l , 1977).  According t o these authors the i n d i v i d u a l maintains c o n t a c t with the environment  and e x p e r i e n c e s r e a l i t y  through  r e c e p t i o n and p e r c e p t i o n of sensory i n t e r a c t i o n .  Use of  c o l o r , l i g h t , t e x t u r e , a t t e n t i o n t o a c t i v i t y and n o i s e , f u r n i s h i n g s , placement  of equipment, m o b i l i t y a i d s and care  g i v e r r o u t i n e can promote or impede r e c o v e r y .  When the  29 h o s p i t a l does not meet t h e e l d e r l y person's need f o r meaningful environmental i n t e r a c t i o n , acute c o n f u s i o n may result.  The presence of c o n f u s i o n p r e d i s p o s e s  client to a p o s s i b i l i t y f o r f a l l s , disturbances, increases  the e l d e r l y  incontinence,  sleep  m o b i l i t y and s k i n problems, and dependency  (Burnside,  1988; Ebersole  & Hess, 1985; W o r r e l l ,  1977). The  circumstances r e q u i r i n g h o s p i t a l i z a t i o n may mean a  l o s s of h e a l t h , f u n c t i o n a l a b i l i t y ,  independence, or  p o t e n t i a l l o s s o f s e l f through death. depression  A n x i e t y and  a r e common responses t o h o s p i t a l i z a t i o n and o l d e r  c l i e n t s who a r e mentally  a l e r t can be expected t o r e a c t  with  heightened l e v e l s of these emotions ( G i o i e l l a & B e v i l , 1985; Rossman, 1979). A d d i t i o n a l c h a r a c t e r i s t i c s t h a t put t h e a c u t e l y  ill,  h o s p i t a l i z e d aged a t r i s k a r e diminished p h y s i o l o g i c a l r e s e r v e s and decreased c a p a c i t y t o adapt t o u n f a m i l i a r surroundings coping  (Bossenmaier, 1982; Rowe, 1985).  behaviors  The d a i l y  r e q u i r e d t o d e a l with m u l t i p l e c h r o n i c and  acute h e a l t h problems, d e c r e a s i n g  independence, impending  l i f e - s t y l e changes, a l l i n the presence of d e c l i n i n g resources,  a r e s e r i o u s l y threatened  when an u n p r e d i c t a b l e  event such as h o s p i t a l i z a t i o n i s sudden and unplanned (Burnside,  1988; G i o i e l l a & B e v i l , 1985).  R e l o c a t i n g from a f a m i l i a r , s a f e l i v i n g environment t o an u n f a m i l i a r h o s p i t a l environment t h a t r e q u i r e s i n t e r a c t i n g  30 with unknown persons i n the absence of r e l i a b l e systems and  f a m i l i a r r o u t i n e s c o n t r i b u t e s to the o l d e r  person's v u l n e r a b i l i t y s i t u a t i o n predisposes  (Ebersole & Hess, 1985). the o l d e r person t o  h e l p l e s s n e s s , dependency, and  This  experience  l o s s of c o n t r o l .  the o l d e r a d u l t i s capable of u t i l i z i n g behaviors  support  Even when  s u i t a b l e coping  to meet some of t h e i r b a s i c human needs, s t a f f  members may  b e l i e v e i t i s f a s t e r or e a s i e r to do t h i n g s f o r  them, thus r e i n f o r c i n g the o l d e r person's dependent position.  These l o s s e s weaken the o l d e r c l i e n t ' s f e e l i n g s  of s e l f - c o n f i d e n c e , mastery, and (Gioiella & Bevil,  1987), man  self-esteem  1985). Aaina and  According  sense of  to the UBC  Self-Esteem  Model f o r Nursing  (Campbell,  has b a s i c human needs f o r s a f e t y and s e c u r i t y ,  c o l l e c t i o n and  removal of accumulated wastes, balance  between p r o d u c t i o n  and  u t i l i z a t i o n of energy, i n t a k e of  oxygen, i n t a k e of food and f l u i d ,  s t i m u l a t i o n of the  f o r l o v e , belongingness and  dependence, mastery, and  r e s p e c t of s e l f by s e l f and  others  1988;  meet the need f o r s e l f - e s t e e m , aware of h i s own  i s t o meet the  or a p o s i t i v e s e l f - c o n c e p t  G i o i e l l a & B e v i l , 1985).  for  (self-esteem).  An e s s e n t i a l f a c t o r f o r s u c c e s s f u l aging need f o r s e l f - e s t e e m  senses,  (Burnside,  These authors s t a t e t h a t to the o l d e r i n d i v i d u a l must be  i d e n t i t y , must have c o n t r o l over h i s  l i f e , must have a sense of s e l f - w o r t h , and must have  own  31 a f f i l i a t i o n s w i t h others*  B u t l e r and  t h a t f o r i n d i v i d u a l s w i t h low meaningless and pervade t h e i r  Lewis (1977) argue  self-esteem,  l i f e becomes  f e e l i n g s of hopelessness and  helplessnes  lives.  H o s p i t a l i z a t i o n emphasizes the o l d e r person's p h y s i c a l d e t e r i o r a t i o n and independence.  l o s s of h e a l t h , m o b i l i t y ,  T h i s l o s s of independence weakens the  person's f e e l i n g s of s e l f - c o n f i d e n c e and esteem (Burnside, The  1988;  by the d e p e r s o n a l i z a t i o n  may  older  self-  1985).  be f u r t h e r damaged  t h a t occurs w i t h h o s p i t a l i z a t i o n .  Upon admission c l i e n t s are dressed t h e i r personal  sense of  Gioiella & Bevil,  o l d e r person's s e l f - e s t e e m  are d e p r i v e d  and  possessions  and  i n h o s p i t a l gowns and  jewelry  are removed.  They  of p r i v a c y to c a r r y out the most b a s i c b o d i l y  f u n c t i o n s or m a i n t a i n i n t i m a t e or f a m i l y r e l a t i o n s h i p s (Kemp, 1978). Maslow (1970) i n d i c a t e d t h a t c o n t r o l i s a v a r i a b l e i n f l u e n c i n g self-esteem. making d e c i s i o n s about one's s e l f . (1977) r e p o r t e d c o n t r o l and had  satisfaction. promotion and  includes  Reid, Hass, and  a p o s i t i v e r e l a t i o n s h i p between low  negative  a negative  This control  critical  s e l f - c o n c e p t and  self-concept  as tending  Bower and B e v i s  described  Hawkins self-  those  who  t o have l e s s l i f e  (1979) observed t h a t  s e l f - c a r e promotion are major  health  generative  f u n c t i o n s t h a t must be performed by the e l d e r l y i n order t h e i r self-esteem  needs to be met.  for  Anger, i n d e c i s i v e n e s s ,  32 and d e p r e s s i o n a r e s i g n s t h a t these s e l f - e s t e e m needs remain unfulfilled. According  t o E b e r s o l e and Hess (1985), the c r i t i c a l  f a c t o r i n the o l d e r person's response i s p e r c e p t i o n .  The  impact of an event on one's s e l f - e s t e e m and sense o f c a p a b i l i t y w i l l a f f e c t the degree of response more than the magnitude o f the event.  These authors have i d e n t i f i e d  p r o d u c t i v i t y and p r o b l e m - s o l v i n g  a b i l i t y as e s s e n t i a l t o t h e  maintenance o f s e l f - e s t e e m i n the e l d e r l y and have t h a t the nurse's coping  suggested  r o l e i s t o a s s i s t i n development o f these  abilities.  According  t o the UBC Model f o r Nursing  1987)/ n u r s i n g i n t e r v e n t i o n s focus on coping r e l a t e d t o g o a l achievement.  (Campbell, behaviors  I n t e r v e n t i o n s are aimed a t  d i s c o u r a g i n g or e l i m i n a t i n g coping behaviors a s s o c i a t e d with l a c k of goal achievement and p o t e n t i a l l a c k of goal achievement, and encouraging capable of m a i n t a i n i n g  and developing those  behaviors  and promoting goal achievement.  Change with r e s p e c t t o a c l i e n t ' s coping b e h a v i o r s  can be  e f f e c t e d by r e d u c t i o n of negative f o r c e s , maintenance and s t r e n g t h e n i n g of p o s i t i v e f o r c e s , and f o s t e r i n g o f t h e development of a b i l i t i e s . To p r a c t i c e n u r s i n g i n such a way as t o a s s i s t  elderly  c l i e n t s t o develop and use coping behaviors t o meet the need f o r r e s p e c t of s e l f by s e l f and o t h e r s , and a t t a i n the goal of s e l f - e s t e e m i s an e t h i c a l  duty.  33 E t h i c a l C o n s i d e r a t i o n s i n the N u r s i n g Care of t h e E l d e r l y  Client  As viewed i n the UBC Model f o r Nursing  (Campbell,  1987), n u r s i n g ' s unique f u n c t i o n i s t o n u r t u r e  individuals  e x p e r i e n c i n g c r i t i c a l p e r i o d s so t h a t they may develop and use a range of coping behaviors t h a t w i l l a l l o w them t o s a t i s f y t h e i r b a s i c human needs and t o reach o p t i m a l h e a l t h . Nursing's  role i n nurturing individuals i s to foster,  p r o t e c t , s u s t a i n , and t e a c h .  According t o t h e Canadian  Nurses A s s o c i a t i o n (1985) n u r s i n g p r a c t i c e can be d e f i n e d g e n e r a l l y as a "dynamic, c a r i n g , h e l p i n g r e l a t i o n s h i p i n which the nurse a s s i s t s the c l i e n t t o achieve and m a i n t a i n optimal h e a l t h " (p. 6 ) . By e n t e r i n g t h e p r o f e s s i o n , t h e nurse i s committed t o i t s p r o f e s s i o n a l e t h i c s and assumes a p r o f e s s i o n a l commitment t o t h e h e a l t h and w e l l - b e i n g of clients.  As such, n u r s i n g encompasses moral a c t i v i t i e s .  E t h i c s , a branch of p h i l o s o p h y , promotes moral based  conduct  on p r i n c i p l e s of behavior t h a t promote t h e goodness of  the human being  (Bahr, 1987).  T h i s d i g n i t y and r e s p e c t t o  be a f f o r d e d the i n d i v i d u a l r e g a r d l e s s o f age b r i n g s a focus of e q u a l i t y f o r t h a t i n d i v i d u a l .  T h i s e q u a l i t y , based on  the v a l u e of t h e human being as a worthwhile  individual,  i d e n t i f i e s a v a l u e system needed t o p r e s e r v e t h e d i g n i t y of the person, young or o l d .  According t o the Canadian  A s s o c i a t i o n Code of E t h i c s f o r Nursing  (1985),  Nurses'  "a c l i e n t ' s  r i g h t t o be t r e a t e d i n a d i g n i f i e d f a s h i o n must be r e f l e c t e d  34 i n the nurse's own attempts  behavior towards the c l i e n t and i n  t o i n f l u e n c e the a c t i o n s of other members of the  h e a l t h care team" (p. 3 ) . The way  i n which nurses are i n v o l v e d i n s i t u a t i o n s  which g i v e r i s e to e t h i c a l c o n f l i c t i s f r e q u e n t l y r e l a t e d to i n s t i t u t i o n a l p o l i c y , the p l a c e of the nurse i n the o r g a n i z a t i o n a l h i e r a r c h y and the p r o f e s s i o n a l d i v i s i o n of labor.  A c c o r d i n g t o S t o r c h (1988), the uniqueness  of  n u r s i n g ' s e t h i c a l dilemmas can be a f u n c t i o n of being t h e r e , having m u l t i p l e o b l i g a t i o n s , and e x p e r i e n c i n g the d a i l y c e a s e l e s s dilemmas of c a r e . Because nurses are g e n e r a l l y the h e a l t h care p r o f e s s i o n a l s who  are w i t h the c l i e n t on a more constant  b a s i s than other h e a l t h care p r o v i d e r s , they are p r e s e n t t o witness the c l i e n t ' s l o s s of autonomy and submission h e a l t h care m i n i s t r a t i o n s (Storch, 1988).  to  When these  m i n i s t r a t i o n s are not i n the c l i e n t ' s i n t e r e s t or c o n t r a r y t o the c l i e n t ' s wishes,  the nurse i s p r e s e n t t o a c t f o r the  c l i e n t or remain a s i l e n t observer of a wrong. obedience  Because  and s i l e n c e are no l o n g e r c o n s i d e r e d a p p r o p r i a t e  behaviors f o r the nurse  (Coburn,  experience c o n f l i c t i n f u l f i l l i n g responsibilities.  1981), many nurses their  ethical  And because the nurse i s p r e s e n t , the  e t h i c a l and moral dilemmas of p r a c t i c e become even more s e r i o u s when the nurse i s excluded from the process of decision-making  on matters of treatment.  This exclusion  p l a c e s nurses i n a d i f f i c u l t p o s i t i o n when they must implement the d e c i s i o n s even when they d i s a g r e e  w i t h them.  A second r e a l i t y of n u r s i n g p r a c t i c e r e l a t e d t o n u r s i n g e t h i c s i s t h a t nurses have m u l t i p l e o b l i g a t i o n s 1988).  (Storch,  Nurses have p r o f e s s i o n a l o b l i g a t i o n s t o c l i e n t s , t o  f a m i l i e s , to physicians, to colleagues,  and t o i n s t i t u t i o n s  where they a r e employed.  education  against questioning  E a r l y nursing  the p h y s i c i a n ' s  decisions.  cautioned  Since the  1970s, however, the p r i o r i t y of the nurse's o b l i g a t i o n t o the c l i e n t has been c l e a r l y s t a t e d i n Codes of E t h i c s and Standards f o r Nursing Care (Canadian Nurses A s s o c i a t i o n , 1985;  Registered  Nurses A s s o c i a t i o n of B r i t i s h  Columbia,  1984). According  to Storch  (1988), the problem of m u l t i p l e  o b l i g a t i o n s f o r nurses who work i n i n s t i t u t i o n a l s e t t i n g s continues  t o be a source of r o l e c o n f l i c t f o r nurses.  C i t i n g s e v e r a l authors, Storch  (1988) p o i n t s out t h a t the  work p l a c e can i n f l u e n c e the moral judgment of nurses; " l o y a l t y t o the o r g a n i z a t i o n , p h y s i c i a n , and c o l l e a g u e s competes w i t h l o y a l t y t o p a t i e n t and f a m i l y "  (p. 213).  Nurses experience a range and v a r i e t y of e t h i c a l dilemmas every day (Storch, 1988).  There a r e i s s u e s which  i n v o l v e l i f e and death d e c i s i o n s and the l e s s  spectacular  i s s u e s such as breaches of c l i e n t c o n f i d e n t i a l i t y and i n v a s i o n of p r i v a c y .  And there a r e the e t h i c s of c a r i n g by  which nurses t r y t o determine the needs of t h e i r c l i e n t s f o r  36 whom they c a r e .  These d a i l y o b l i g a t i o n s demand an e t h i c a l  responsiveness on the p a r t of nurses w i t h a p r o f e s s i o n a l r e s p o n s i b i l i t y t o a c t i n the c l i e n t ' s b e s t i n t e r e s t . C u r t i n and F l a h e r t y  (1982) s t a t e t h a t i t i s not l i k e l y  t h a t nurses w i l l d e l i b e r a t e l y t r a n s g r e s s  the r i g h t s of  c l i e n t s , but: I t i s i n our o r d i n a r y day t o day c o n t a c t w i t h p a t i e n t s or c l i e n t s t h a t we a r e most l i k e l y t o f a i l them as human b e i n g s .  t o respect  We a r e too busy or t o o caught up  i n t h e "important" t e c h n i c a l i t i e s t o take t h e time t o d i s c o v e r and r e s p e c t the humanity o f each i n d i v i d u a l , (p. 15) Commenting on t h e c e n t r a l e t h i c a l i s s u e s f o r nurses, Storch  (1988) p o i n t s out t h a t m a i n t a i n i n g  the p a t i e n t s ' or  c l i e n t s ' i n t e r e s t as t o p p r i o r i t y means t h a t nurses must recognize  and cope w i t h "being  a p a t i e n t ' s advocate; d e a l i n g  w i t h u n e t h i c a l disagreement, incompetence, or u n p r o f e s s i o n a l p r a c t i c e ; and being  a competent p r a c t i t i o n e r " (p. 214).  Advocating the i n t e r e s t s of t h e c l i e n t i n c l u d e s in achieving providing  access t o q u a l i t y h e a l t h c a r e .  information  For example, by  t o c l i e n t s , the nurse enables them t o  s a t i s f y t h e i r r i g h t s t o health care. always f u n c t i o n e d  assistance  Although t h e nurse has  as the c l i e n t ' s advocate t o some degree,  the p r i o r i t y of c l i e n t advocacy has sometimes been i n c o n f l i c t w i t h advocacy f o r the i n s t i t u t i o n or p h y s i c i a n (Storch, 1988).  T h i s author p o i n t s out t h a t some degree of  37 c o n f l i c t i s i n e v i t a b l e when d e a l i n g w i t h other groups i n matters of h e a l t h c a r e .  Nurses a r e accountable, however,  f o r the w e l l - b e i n g of p a t i e n t s and they must take when treatment  orders seem i n a p p r o p r i a t e .  action  Moreover, they  must a s c e r t a i n the f a c t s o f the s i t u a t i o n and use i n s t i t u t i o n a l r e p o r t i n g channels when d e a l i n g w i t h of c l i n i c a l  incompetence and p r o f e s s i o n a l  An o b l i g a t i o n of equal importance  matters  misconduct.  i s t h a t nurses  m a i n t a i n t h e i r own competence as p r a c t i t i o n e r s .  Storch  (1988) p o i n t s out t h a t nurses must take advantage of formal and i n f o r m a l o p p o r t u n i t i e s f o r c o n t i n u i n g e d u c a t i o n , read and study p r o f e s s i o n a l j o u r n a l s , r e c o g n i z e t h e i r own l i m i t a t i o n s , and s t r i v e t o p r o v i d e a high q u a l i t y of p a t i e n t care. Recognizing one's p r o f e s s i o n a l and e t h i c a l r e s p o n s i b i l i t i e s f o r c l i e n t advocacy, d e a l i n g w i t h  conflict,  and e n s u r i n g competence can make a s i g n i f i c a n t d i f f e r e n c e i n the l i v e s of c l i e n t s which may cover t h e whole range of human l i f e from b i r t h t o death. A t t i t u d e s of Nurses toward the E l d e r l y S t u d i e s show t h a t nurses l e a s t p r e f e r working w i t h the e l d e r l y and t h a t nurses who h o l d negative a t t i t u d e s toward them w i l l engage i n behaviors which may not be t h e r a p e u t i c or may be d e t r i m e n t a l t o the b e s t i n t e r e s t of the e l d e r l y client  (Brower, 1981; Campbell,  Penner, Ludenia, & Mead, 1984).  1971; Lueckenotte, 1987; Goebel  (1984) s t a t e s t h a t  38 attitudes  are a p o t e n t i a l  behaviors  i n situations  i n f l u e n c e on i n t e r p e r s o n a l  where c l i e n t s  d e p e n d e n t on c a r e t a k e r s .  Negative attitudes  therefore,  have s e r i o u s  increasing  client population.  Although i n t e r e s t growing  continue  many e l d e r l y c l i e n t s  to receive  to the  inadequate  to Ebersole  i n health  poor q u a l i t y  and Hess  These authors  Podnieks,  1983).  (1985),  t h e myths  dangerous  are those that  perpetuate  say t h a t  attitudes  of  nurses  t o w a r d a g i n g a n d t h e e l d e r l y i s one o f t h e f a c t o r s  (1986)  state that this  of t h e dependency t h a t conditions affecting Several towards  studies  towards  stereotyping, Nelson, out t h a t  1973).  is significant  i s c r e a t e d by t h e m u l t i p l e  Stanley because  chronic  the e l d e r l y . have  the e l d e r l y .  attitudes  that  t o an i n f e r i o r q u a l i t y o f n u r s i n g c a r e .  and B u r g g r a f  care  t h e aged a r e d e p e n d e n t a n d t h e y o u n g a r e  independent.  contributes  care  1982;  the o l d e r person i n our s o c i e t y idea that  rapidly  and i s d e p e r s o n a l i z e d ( C a m p b e l l ,  H e a l t h and W e l f a r e Canada,  According  nurses,  and c o n c e r n f o r t h e e l d e r l y has been  which i s n o t i n d i v i d u a l i z e d 1971;  among  implications for this  i n recent years,  facilities  o f a l l ages a r e  investigated  Some s t u d i e s  attitudes  reveal  that  the e l d e r l y are characterized  negativism, Others  and d e f e a t i s m  (Kogan,  1979;  the e l d e r l y are generally  of  nurses  nurses' by  (Campbell, 1971;  S c h o n f i e l d , 1982)  point  p e r c e i v e d by y o u n g e r  p e o p l e a s p h y s i c a l l y a n d m e n t a l l y on t h e d e c l i n e ,  socially  39 withdrawn and unproductive i n s o c i e t y .  These s t e r e o t y p e s ,  they say, can a d v e r s e l y i n f l u e n c e i n t e r a c t i o n s w i t h the e l d e r l y and i n f l u e n c e the c a r e nurses p r o v i d e .  Nelson  (1973) r e p o r t e d on a study done by S t o c k w e l l t o i n v e s t i g a t e i f n u r s i n g care d i f f e r e d between "most l i k e d " and liked" clients.  "least  S t o c k w e l l found t h a t e l d e r l y c l i e n t s were  most l i k e l y t o f i t  the c h a r a c t e r i s t i c s of c l i e n t s which  nurses " l e a s t l i k e d " and were more l i k e l y t o r e c e i v e n e g a t i v e responses from nurses.  Negative responses were  r e f l e c t e d by the amount of time taken t o answer c a l l  bells,  amount of time the nurse spent i n v e r b a l communication w i t h c l i e n t s , and the number of i n j e c t i o n s nurses were w i l l i n g t o give c l i e n t s to r e l i e v e pain. Not a l l s t u d i e s on nurses* a t t i t u d e s towards the e l d e r l y i n d i c a t e negative a t t i t u d e s .  T a y l o r and Harned  (1978) found t h a t a t t i t u d e s of r e g i s t e r e d nurses were a l l p o s i t i v e or n e u t r a l and t h a t nurses who  worked i n acute care  h o s p i t a l s had more p o s i t i v e a t t i t u d e s than t h e i r c o u n t e r p a r t i n long term c a r e .  Brower  (1981) r e p o r t e d t h a t nurses  employed i n n u r s i n g homes had s i g n i f i c a n t l y more n e g a t i v e a t t i t u d e s toward the e l d e r l y i n g e n e r a l than d i d nurses worked as v i s i t i n g nurses or i n a h o s p i t a l .  who  T h i s author  found t h a t the major reason f o r more n e g a t i v e a t t i t u d e s among the n u r s i n g home nurses was  at l e a s t i n p a r t due t o  c a r i n g f o r a number of e l d e r l y c l i e n t s who p h y s i c a l and emotional problems.  have m u l t i p l e  A study by Wolk and Wolk  40 (1971) found t h a t younger nurses had more n e g a t i v e a t t i t u d e s toward  the e l d e r l y than d i d o l d e r nurses.  These authors  b e l i e v e i t i s because younger nurses had l e s s experience w i t h e l d e r l y c l i e n t s . F u t r e l l and Jones  direct  A t t i t u d i n a l s t u d i e s by  (1977) found t h a t o l d e r , b e t t e r  educated  and more experienced r e g i s t e r e d nurses tended to have the most p o s i t i v e  attitudes.  Other s t u d i e s suggest t h a t f a c t o r s a s s o c i a t e d w i t h i n d i v i d u a l c l i e n t s , other than age, are more powerful determinants of the a t t i t u d e and behavior of nurses. exampe, nurses p r e f e r c l i e n t s who  are neat, a p p r e c i a t i v e ,  conforming, s o c i a l l y a c t i v e and communicative v a l u e c l i e n t s who  and do not  p l a c e e x t r a demands on the system  being uncooperative, d i s r u p t i v e , or s o i l i n g environment  (Penner et a l . ,  1984;  For  by  the  White, 1977).  These  q u a l i t i e s are a s s o c i a t e d w i t h lower s e l f - c a r e a b i l i t y than age or d i a g n o s i s .  rather  According to a study by Brown  (1969), nurses were observed t o g i v e e x t r a care t o dying c l i e n t s who or who  are " s o c i a l l y v a l u e d " , who  occupy h i g h s t a t u s ,  are h i g h l y p r i z e d by v i r t u e of age,  another, or p r o d u c t i v i t y .  r e l a t i o n s h i p to  H e n r e t t a and Campbell  (1976)  r e p o r t e d t h a t the higher the i n d i v i d u a l ' s s o c i a l c l a s s ,  the  g r e a t e r the l i k e l i h o o d of m a i n t a i n i n g s t a t u s f o r a l o n g e r time; they have r e s o u r c e s t h a t g i v e them power i n s o c i a l r e l a t i o n s h i p s , thereby e n a b l i n g them to remain White (1977) found t h a t c l i e n t s who  independent.  scored lower w i t h  41 r e s p e c t t o a c t i v i t i e s of d a i l y l i v i n g and s o c i a l p a r t i c i p a t i o n r e c e i v e d from n u r s i n g fewer behaviors  such as s c r e e n i n g f o r p r i v a c y d u r i n g  c o n v e r s a t i o n , and e x p l a n a t i o n s process  individualizing  o f care.  According  care,  of what was going on d u r i n g  t o E l l i o t t and Hyberton  c l i e n t s who e l i c i t f a v o r a b l e r e a c t i o n s i n a n u r s i n g  (1982), staff  are more apt t o r e c e i v e adequate a t t e n t i o n t o t h e i r needs than c l i e n t s who e x h i b i t d i s t u r b i n g and troublesome behavior.  Those c l i e n t s , she s t a t e s , who e l i c i t  unfavorable  r e a c t i o n s are not as l i k e l y t o r e c e i v e t h e same l e v e l of nursing  care.  Two authors derogatory  (Grouse, 1982; Natkins,  1982) address  d e s c r i p t o r s used toward t h e e l d e r l y .  They both  emphasize the importance of a person's name and p o r t r a y i n s t a n c e s which c l e a r l y d e n i g r a t e c l i e n t s . the l e g i t i m i z a t i o n of derogatory "turkey",  Grouse d i s c u s s e s  terms such as "crock",  "gomer", " d i r t b a l l " , and "spos".  Burnside  (1988)  s u c c i n c t l y p o i n t s out t h a t nurses who c a l l c l i e n t s by t h e i r f i r s t name without  asking what they want t o be c a l l e d , or  c a l l them "granny" or "gramps", " d e a r i e " or "honey" a r e t h r e a t e n i n g t h e c l i e n t s ' d i g n i t y and s e l f Dolinsky  respect.  (1984) p o i n t s out t h a t nurses i n f a n t a l i z e the  e l d e r l y by t r e a t i n g them as c h i l d r e n who a r e i n c a p a b l e o f c a r i n g f o r themselves.  Gresham (1976) d e s c r i b e s v a r i o u s  ways t h a t demonstrate how o l d e r people a r e t r e a t e d i n n u r s i n g homes, acute care h o s p i t a l s , and extended  care  42 facilities.  Some of these i n c l u d e addressing  t h e i r f i r s t name whether or not they request  the e l d e r l y by i t  e l d e r l y on the head, p a t r o n i z i n g the aged, and the aged i n d e c i s i o n s about t h e i r own s t a t e s t h a t addressing names should  care.  patting  f  not  including  Butler  the e l d e r l y by t h e i r f i r s t  the  (1980)  or  "pet"  be avoided as t h a t i m p l i e s l o s s of d i g n i t y  and  infantalization. The  E l d e r l y ' s Perception  There have been few  of t h e i r Nursing Care  s t u d i e s which look  e l d e r l y perceive t h e i r nursing  care.  at how  the  Although a l i m i t e d  number of s t u d i e s look at p a t i e n t s a t i s f a c t i o n ,  their  purpose i s t o d i s c o v e r how  s a t i s f i e d e l d e r l y c l i e n t s were  with a p a r t i c u l a r f a c i l i t y  (Forgan Morle, 1984).  (Elbeck,  1986)  One  study  which d i d i n v e s t i g a t e the ways i n which  c l i e n t s d e s c r i b e and i d e n t i f y the age  evaluate  nursing  p r a c t i c e does not  group of the c l i e n t p o p u l a t i o n .  There are,  however, r e p o r t s i n the media of the e l d e r l y ' s d i s s a t i s f a c t i o n w i t h the q u a l i t y of care they r e c e i v e . Panel members from a Consumer Advisory Health  Issues (Mclnnes, 1987)  made t o f e e l l i k e second-class  Panel on  Seniors  r e p o r t t h a t the e l d e r l y are c l i e n t s i n h o s p i t a l s ; they  are " t r e a t e d l i k e i n f a n t s , or a u t o m a t i c a l l y some form of Alzheimer's d i s e a s e " .  The  assumed to have  report states  many h e a l t h care p r o f e s s i o n a l s are observed to c a l l  that  elderly  c l i e n t s "dear" or use t h e i r f i r s t names on f i r s t meeting. As w e l l as being  t r e a t e d l i k e c h i l d r e n , they are  not  43 informed about t h e i r c o n d i t i o n or treatment.  Other  i n c i d e n t s , the r e p o r t s t a t e s , i n c l u d e nurses r e f e r r i n g c l i e n t s as "bed-blockers" out of my client.  or "GOMERS", which stands f o r  emergency room", w i t h i n hearing T h i s behavior,  to  d i s t a n c e of  "get  the  the e l d e r l y r e p o r t , d e p r i v e s them of  t h e i r d i g n i t y and s e l f - r e s p e c t . Since a t t i t u d e i s one  of the elements t h a t a f f e c t s the  performance of the r e g i s t e r e d nurse, i t i s assumed t h a t  this  performance i s r e f l e c t e d i n the k i n d of care the e l d e r l y c l i e n t r e c e i v e s ; one questioned  area of n u r s i n g care which i s  by t h i s researcher  i s t r e a t e d w i t h d i g n i t y and  i s whether the e l d e r l y c l i e n t  respect.  In c o n c l u s i o n , t h i s l i t e r a t u r e review i n d i c a t e s the following:  an i n c r e a s e i n the e l d e r l y p o p u l a t i o n r e s u l t i n g  i n an i n c r e a s e d need f o r n u r s i n g  s e r v i c e s ; a t t i t u d e s nurses  h o l d about the aged i n f l u e n c e the q u a l i t y of s e r v i c e s they provide;  and,  there i s a s c a r c i t y of s t u d i e s which  the e l d e r l y ' s p e r c e p t i o n of t h e i r n u r s i n g c a r e ,  explore  particularly  as i t r e l a t e s to whether they were t r e a t e d with d i g n i t y and respect. Summary T h i s chapter  reviewed the l i t e r a t u r e i n r e l a t i o n to  e l d e r l y ' s i n c r e a s e d needs f o r n u r s i n g care due  the  to  demographic changes, a t t i t u d e s of nurses toward the e l d e r l y , the i m p l i c a t i o n s of these a t t i t u d e s f o r the e l d e r l y and briefly  (due to l i m i t e d s t u d i e s ) , and  the e l d e r l y ' s  44 p e r c e p t i o n of t h e i r n u r s i n g care p a r t i c u l a r l y to t h e i r need to be t r e a t e d with d i g n i t y  and  as i t r e l a t e s respect.  next chapter d e s c r i b e s the process of t h i s i n v e s t i g a t i o n address the r e s e a r c h q u e s t i o n .  The to  45  CHAPTER 3 Methodology  Research Design T h i s study used a d e s c r i p t i v e and r e s e a r c h design*  correlational  A c c o r d i n g to P o l i t and  Hungler  (1983),  d e s c r i p t i v e r e s e a r c h i s designed to summarize the s t a t u s some phenomenon of i n t e r e s t as i t p r e s e n t l y  i s thought t o  exist.  of  I t s main o b j e c t i v e  i s the p o r t r a y a l  of  the  c h a r a c t e r i s t i c s of persons, s i t u a t i o n s or groups and  the  frequency with which c e r t a i n phenomenon occur. Correlational studies to examine the  are  research i n v e s t i g a t i o n s  r e l a t i o n s h i p among v a r i a b l e s .  c o r r e l a t i o n a l studies  designed  Descriptive  are l e s s concerned w i t h determining  c a u s e - a n d - e f f e c t r e l a t i o n s h i p s than with a d e s c r i p t i o n how  one  phenomenon i s r e l a t e d t o another  A structured q u e s t i o n s was  interview  (Weldon, 1986).  with " f i x e d a l t e r n a t i v e "  u t i l i z e d to o b t a i n  the data.  T h i s type of  q u e s t i o n i n g o f f e r s respondents a number of r e p l i e s ; the  alternative  s u b j e c t s were asked t o choose the one  c l o s e l y approximated the  " r i g h t " answer.  responses to each a l t e r n a t i v e was order to o b t a i n  of  The  tabulated  t h a t most  number of  and  analyzed i n  some understanding of what the sample as  whole thought about each q u e s t i o n .  a  46 Sample The r e q u i r e d sample c o n s i s t e d of 62 s u b j e c t s who  were  65 y e a r s o l d or over. T h i s r e s e a r c h study u t i l i z e d an a c c i d e n t a l technique.  sampling  T h i s technique e n t a i l s the use of the most  r e a d i l y a v a i l a b l e persons f o r use as s u b j e c t s i n the study ( P o l i t & Hungler, 1983).  For example, a l l s u b j e c t s who  met  the study c r i t e r i a and were being d i s c h a r g e d from h o s p i t a l d u r i n g the study p e r i o d were i n c l u d e d i n the sample. The c r i t e r i a f o r i n c l u s i o n as s u b j e c t s of the sample were:  65 y e a r s of age and over; h o s p i t a l i z e d f o r no  less  than 5 days i n a Medical or S u r g i c a l U n i t ; a b l e t o respond v e r b a l l y i n E n g l i s h ; a l e r t and o r i e n t e d to time, p l a c e , and person d u r i n g t h e i r h o s p i t a l i z a t i o n ; and i n t e r v i e w e d w i t h i n 3 days a f t e r they l e f t  hospital. instrument  A review of the l i t e r a t u r e t o d i s c o v e r an e x i s t i n g was  not s u c c e s s f u l i n f i n d i n g an instrument u s e f u l f o r the  purpose of t h i s study.  The l i t e r a t u r e review, however, d i d  uncover a t o o l t h a t had been developed t o monitor q u a l i t y of n u r s i n g care (Hegyvary tool  tool  the  & Haussmann, 1975).  The  (Medicus Q u a l i t y Assurance T o o l ) , a s e l f - r e p o r t i n g  q u e s t i o n n a i r e c o n t a i n s s e v e r a l items d e a l i n g with the p r o v i s i o n of n u r s i n g care demonstrating regard f o r d i g n i t y and r e s p e c t .  The s e l e c t i o n of items from the Medicus  Q u a l i t y Assurance Tool r e l a t e d t o d i g n i t y and r e s p e c t was  47 determined  by d e f i n i n g and d e v e l o p i n g an o p e r a t i o n a l  d e f i n i t i o n of the terms.  Information t o o p e r a t i o n a l i z e the  terms " d i g n i t y and r e s p e c t " , was  obtained from items i n the  master i n d i c a t o r l i s t of the Medicus Q u a l i t y Assurance and review of s e l e c t e d l i t e r a t u r e were:  (Chapter 2 ) .  Tool  These items  o r i e n t i n g the c l i e n t t o the f a c i l i t y , p r o v i d i n g  c l i e n t s with p r i v a c y , seeking t h e i r p e r m i s s i o n b e f o r e performing procedures, p r o v i d i n g them w i t h i n f o r m a t i o n , a d d r e s s i n g them by t h e i r proper name u n l e s s  otherwise  requested, and p r o v i d i n g an o p p o r t u n i t y f o r them t o d i s c u s s t h e i r concerns.  A copy of s e l e c t e d items from the Medicus  Q u a l i t y Assurance  Tool i s found i n Appendix  S i n c e o n l y p a r t of the t o o l was i t was  necessary t o determine  r e l e v a n t to t h i s  study  what e f f e c t u s i n g o n l y  s e l e c t e d p o r t i o n s would have on r e l i a b i l i t y I t was  D.  and  validity.  found t h a t using s e l e c t e d p o r t i o n s of the Q u a l i t y  Assurance  T o o l would not a f f e c t r e l i a b i l i t y  or v a l i d i t y  s i n c e each item, although i n t e r r e l a t e d w i t h o t h e r s , has been t e s t e d independently  (Sue Hegyvary, p e r s o n a l communication,  1988). In  order t o determine  i f there i s a r e l a t i o n s h i p  between c e r t a i n c l i e n t c h a r a c t e r i s t i c s and whether c l i e n t s p e r c e i v e d they were t r e a t e d w i t h d i g n i t y and r e s p e c t , other data such as:  age of the c l i e n t , sex  (male or female),  number of days spent i n h o s p i t a l , type of u n i t  (medical or  s u r g i c a l ) , and h i g h e s t l e v e l of e d u c a t i o n o b t a i n e d (to determine  socioeconomic  s t a t u s ) were e l i c i t e d .  48 Socioeconomic s t a t u s i s d e f i n e d i n terms of a standard s o c i o l o g i c a l paradigm c o n s i s t i n g of t h r e e components; e d u c a t i o n , o c c u p a t i o n , and income (George & Bearon, 1980). The l e v e l of e d u c a t i o n was s e l e c t e d as an i n d i c a t i o n of socioeconomic  s t a t u s f o r t h i s study, s i n c e education i s  c o n s i d e r e d t o be a determinant throughout  life.  Occupation  of socioeconomic  status  and income, a c c o r d i n g t o George  and Bearon (1980), may not be s i g n i f i c a n t f o r o l d e r people s i n c e a m a j o r i t y of them a r e r e t i r e d and some o c c u p a t i o n a l benefits are l o s t .  Moreover, r e t i r e m e n t d r a s t i c a l l y  reduces  the earnings of many o l d e r people. Data C o l l e c t i o n The two  Procedure  i n v e s t i g a t o r contacted the D i r e c t o r s of Nursing of  large metropolitan teaching h o s p i t a l s .  These two acute  care h o s p i t a l s (A and B) were s e l e c t e d because of the need f o r samples of s u b j e c t s who had n u r s i n g care p r o v i d e d p r i m a r i l y by r e g i s t e r e d  nurses.  A p l a n t o seek consent  from the p r o s p e c t i v e s u b j e c t s  b e f o r e they l e f t h o s p i t a l was developed  by meeting w i t h the  head nurses of f i v e medical and f i v e s u r g i c a l u n i t s from both h o s p i t a l s .  T h e i r support was e n l i s t e d i n i n f o r m i n g the  i n v e s t i g a t o r of s u b j e c t s who met the study c r i t e r i a and were being d i s c h a r g e d from h o s p i t a l . Before l e a v i n g the h o s p i t a l , the p r o s p e c t i v e s u b j e c t was approached by the i n v e s t i g a t o r and p r o v i d e d w i t h a v e r b a l and w r i t t e n e x p l a n a t i o n of the study.  Those s u b j e c t s  49 who consented  were p r o v i d e d w i t h a form t o s i g n i n d i c a t i n g  their willingness to participate. telephone  Arrangements were made by  t o i n t e r v i e w t h e consenting s u b j e c t s a t home  w i t h i n t h r e e days of d i s c h a r g e from h o s p i t a l .  A l l subjects  who p a r t i c i p a t e d were i n t e r v i e w e d w i t h i n a five-week  period.  Human Rights P r o t e c t i o n Approval  f o r t h i s study was p r o v i d e d by t h e UBC  B e h a v i o r a l Sciences Screening Committee f o r  Research.  S u b j e c t s i n t h e study were p r o v i d e d w i t h i n f o r m a t i o n (see Appendix A) r e g a r d i n g d e t a i l s of t h e study w i t h r e s p e c t t o why the study was being conducted,  where, how much of t h e i r  time was r e q u i r e d , and t h a t p a r t i c i p a t i o n was v o l u n t a r y . A l l s u b j e c t s s e l e c t e d f o r t h e study were informed s i g n i n g t h e consent consent  form  (see Appendix B) was taken as a  t o p a r t i c i p a t e i n the study.  They were  t h a t r e f u s a l t o take p a r t or withdrawal not j e o p a r d i z e any f u t u r e treatment, hospitalization.  that  informed  from t h e study would  medical  care, or  No p e r s o n a l i n f o r m a t i o n t h a t c o u l d r e s u l t  i n i d e n t i f i c a t i o n of t h e person and t h e i r data was requested.  Data would be shared only w i t h t h e two  p r o f e s s o r s on the T h e s i s Committee.  C o n f i d e n t i a l i t y was  emphasized and t h e s u b j e c t s were assured t h a t a l l data would be destroyed a f t e r t h e i n v e s t i g a t o r had completed her Master's T h e s i s .  Data A n a l y s i s The process of a n a l y s i s i n c l u d e d coding the i n t e r v i e w responses  and t a b u l a t i n g the d a t a .  Descriptive s t a t i s t i c s  50 were used t o analyze t h e c h a r a c t e r i s t i c s of t h e sample and the responses t o the q u e s t i o n n a i r e .  In a d d i t i o n ,  P-values  from t h e Chi-square t e s t a r e given f o r t h e f i r s t t h r e e (3) items on the q u e s t i o n n a i r e .  The remainder  o f t h e items  (questions 4-10) a r e analyzed t o determine t h e frequency w i t h which s e l e c t e d responses o c c u r r e d .  Because of t h e  nature of the responses and small sample, these q u e s t i o n s were n o t amenable t o s i g n i f i c a n c e  testing.  Summary T h i s chapter d i s c u s s e d the processes undertaken t o apply q u a n t i t a t i v e methods t o determine  i f elderly  clients  i n an acute care h o s p i t a l p e r c e i v e d they were t r e a t e d w i t h d i g n i t y and r e s p e c t and whether t h i s was r e l a t e d t o t h e i r socioeconomic  status.  A d i s c u s s i o n on t h e s e l e c t i o n of the  sample, instrument, and procedure f o r c o l l e c t i n g and a n a l y z i n g t h e data was i n c l u d e d .  A t t e n t i o n to the  p r o t e c t i o n of human r i g h t s was p r o v i d e d . D i s c u s s i o n and s i g n i f i c a n c e o f f i n d i n g s f o l l o w i n subsequent c h a p t e r s .  51  CHAPTER FOUR P r e s e n t a t i o n and D i s c u s s i o n of R e s u l t s  Introduction The  r e s u l t s of t h i s study a r e organized  f o l l o w i n g areas:  i n t o the  c h a r a c t e r i s t i c s of the sample, f i n d i n g s  r e l a t e d t o r e s e a r c h purposes, and d i s c u s s i o n of the r e s u l t s . C h a r a c t e r i s t i c s of the Sample The  sample of 62 s u b j e c t s was obtained  from medical and  s u r g i c a l u n i t s of 2 u n i v e r s i t y a f f i l i a t e d t e a c h i n g h o s p i t a l s l o c a t e d i n Vancouver, BC. approximately  1,000 beds and i s a major r e f e r r a l  Data were analysed stay and  [LOS],  Each h o s p i t a l c o n t a i n s  according  to:  center.  (1) sex, (2) l e n g t h of  (3) age, (4) type of u n i t (medical or s u r g i c a l ) ,  (5) l e v e l of e d u c a t i o n  (measure of socioeconomic  status). Sex The 23  sample of 62 s u b j e c t s was composed of 39 males and  females.  Length of Stay (LPS) The  s u b j e c t s were i n h o s p i t a l from a minimum of 5 t o a  maximum of 66 days with a mean s t a y of 17 days and a median stay of 14 days.  Using  the median t o s u b d i v i d e the group  with r e s p e c t t o LOS, 35 s u b j e c t s were i n the " s h o r t s t a y " (5-14  days) and 27 i n the "long s t a y " group (15+ days).  52 Age The  s u b j e c t s ranged  mean o f 76  years  y e a r s and a mode o f 76 65  were f r o m  i n age f r o m  t o 74  y e a r s o f age  o f age and o v e r  65  t o 91 y e a r s w i t h a  y e a r s ; 25  (younger  of the subjects  o l d ) and 37  were  75  (older o l d ) .  Type o f U n i t The  data  u n i t s and 28  t h a t 34  indicate from  surgical  s u b j e c t s were f r o m  medical  units.  Level of Education The  level  socioeconomic  o f e d u c a t i o n a t t a i n e d (used as a measure of s t a t u s ) showed t h a t 27 27  o f t h e s u b j e c t s h a d an  elementary  school education,  (secondary  e d u c a t i o n ) , and 8 h a d a p o s t - s e c o n d a r y  ranging  from  2 years  of c o l l e g e or u n i v e r s i t y  of d o c t o r a l s t u d i e s . secondary was  had a h i g h s c h o o l  Since those  added t o t h e g r o u p w i t h s e c o n d a r y  The  f i n d i n g s of t h i s  i n an a c u t e  with dignity elderly  study  care s e t t i n g  and r e s p e c t , and  (as a m e a s u r e o f s o c i o e c o n o m i c be t r e a t e d w i t h d i g n i t y level  are presented  (1) t o d e t e r m i n e  c l i e n t s with a higher  (elementary)  this (n =  group 35).  F i n d i n g s and D i s c u s s i o n  t h e two r e s e a r c h p u r p o s e s : clients  post-  (n = 8 ) ,  education  education completion  subjects with  e d u c a t i o n were s m a l l i n number  Research  to  education  (2)  i n relation to whether e l d e r l y  perceive they t o determine  (secondary)  level  are treated whether of education  s t a t u s ) were more l i k e l y  and r e s p e c t t h a n  of education.  those with a  to  lower  53 Data were c o l l e c t e d t o determine whether l e n g t h of s t a y , type of u n i t (medical or s u r g i c a l ) *  or sex (male or  female) made a d i f f e r e n c e as t o whether e l d e r l y c l i e n t s were t r e a t e d w i t h d i g n i t y and r e s p e c t . The  items on the q u e s t i o n n a i r e were s e l e c t e d from the  Master I n d i c a t o r L i s t of t h e Medicus Q u a l i t y Assurance T o o l by developing respect.  an o p e r a t i o n a l d e f i n i t i o n of d i g n i t y and  These a r e behaviors  which convey t o the c l i e n t  t h a t he/she i s worthy of honor, esteem, and i s t r e a t e d with consideration.  The q u e s t i o n s  e l d e r l y c l i e n t s i n an acute information  (see Appendix D) a r e : Were  care s e t t i n g p r o v i d e d  with  (Items 1, 2* 3, and 4 of the q u e s t i o n n a i r e ) ;  were they addressed a p p r o p r i a t e l y (Items 5, 6, and 7 of the q u e s t i o n n a i r e ) ; were t h e i r needs f o r p r i v a c y attended t o (Items 8 and 9 of the q u e s t i o n n a i r e ) ; and was the c l i e n t given an o p p o r t u n i t y  t o d i s c u s s h i s / h e r f e e l i n g s and  concerns w i t h the nurse (Item 10 of the q u e s t i o n n a i r e ) . Findings  The  Related  t o the Research Q u e s t i o n s  responses and d i s c u s s i o n r e l a t e d t o the r e s e a r c h  q u e s t i o n s w i l l be organized  according  t o the q u e s t i o n s  generated by the o p e r a t i o n a l d e f i n i t i o n i n order t o f a c i l i t a t e a comprehensive p r e s e n t a t i o n . Research Q u e s t i o n #1:  Do E l d e r l y C l i e n t s i n an Acute Care  S e t t i n g P e r c e i v e They a r e Treated w i t h D i g n i t y and Respect. Were e l d e r l y c l i e n t s p r o v i d e d w i t h i n f o r m a t i o n ?  The  r e s u l t s from Items 1, 2, 3, and 4 of the q u e s t i o n n a i r e p r o v i d e data t o determine whether e l d e r l y c l i e n t s  perceived  54 they were being t r e a t e d w i t h d i g n i t y and r e s p e c t provided  with information.  Chi-square computations were  performed on the f i r s t t h r e e The  by being  (3) items of the q u e s t i o n n a i r e .  remainder of the items (Items 4-10) w i l l be analyzed by  considering  the frequency of responses.  Due t o t h e small  sample and nature of t h e responses, Items 4-10 were not amenable t o s i g n i f i c a n c e t e s t i n g . The  response t o Item 1 (Table 1) r e v e a l s t h a t 71% of  the t o t a l group were o r i e n t e d t o the u n i t and 26% were n o t . Looking a t the d i f f e r e n c e s between the two groups, more of the  "younger o l d "  (88%) were shown around the u n i t when they  arrived i n hospital.  I f the c l i e n t s ' c o n d i t i o n  (physical,  mental, or both) on admission t o the u n i t was not amenable to being o r i e n t e d  t o the u n i t the response was coded as not  applicable  For t h i s reason, 3% of the c l i e n t s were  [NA].  omitted due t o t h e i r own c o n d i t i o n .  The d i f f e r e n c e between  the two groups ("younger o l d " and " o l d e r old") i s statistically The  s i g n i f i c a n t (Chi-square = 6.875; p = .009).  responses t o Item 2 (Table 2) of the q u e s t i o n n a i r e  r e l a t e d t o i n t r o d u c t i o n t o roommates by age d i f f e r e n c e s r e v e a l s t h a t 31% of the t o t a l group were i n t r o d u c e d roommate w h i l e 55% were not.  to t h e i r  (For 14% of the respondents  the item was not a p p l i c a b l e because the c l i e n t was e i t h e r i n a p r i v a t e room or h i s / h e r  c o n d i t i o n or the c o n d i t i o n of  other c l i e n t s were not amenable t o i n t r o d u c t i o n . )  Examining  d i f f e r e n c e s between the two groups shows t h a t 44% of the "younger o l d " were i n t r o d u c e d  t o t h e i r roommates, w h i l e 22%  55 of  "older  is  statistically  T a b l e 1.  o l d " were.  The d i f f e r e n c e  significant  between t h e two g r o u p s  (Chi-square = 5.123;  Orientation to unit  related  p =  .024).  t o age g r o u p  differences. Code  Age 65-74  Age  n =  n = 25(%)  n = 37(%)  62(%)  75+  No  16  (26)  2  (8)  14  (38)  Yes  44  (71)  22  (88)  22  (59)  2  (3)  1  (4)  1  (3)  NA Table  T o t a l Group  2.  Age g r o u p d i f f e r e n c e s  related  to introduction  to  roommate. Code  T o t a l Group  Age 65-74  Age  75+  n =  n = 25(%)  n =  37(%)  62(%)  No  34  (55)  9  (36)  25  (67)  Yes  19  (31)  11  (44)  8  (22)  9  (14)  5  (20)  4  (11)  NA  Whether  elderly clients  counselors  were i n f o r m e d o f a v a i l a b i l i t y o f  and f a c i l i t i e s  13% o f t h e t o t a l  (Item 3,  group r e c e i v e d  A p p e n d i x D) r e v e a l s  this  noted t h a t  t h e r e were no s i g n i f i c a n t  two g r o u p s  on whether  of p =  differences  I t was between t h e  t h e y were i n f o r m e d o f t h e a v a i l a b i l i t y  r e l i g i o u s counselors .553).  information.  that  and f a c i l i t i e s  (Chi-square  =  0.351;  56  The responses from the t o t a l group on whether t e s t s or procedures were e x p l a i n e d t o them b e f o r e they were done (Item 4, Appendix D) i n d i c a t e t h a t 47% had them e x p l a i n e d "some of t h e time", 14% "most of the time", and 23% " a l l of the time". old",  In comparing the "younger o l d " with the "older  92% of the "younger o l d " and "78% of the " o l d e r o l d "  had procedures e x p l a i n e d .  While 78% of t h e " o l d e r o l d " had  t h e i r procedures e x p l a i n e d , 51% had them e x p l a i n e d only "some o f t h e time", 13% "most of the time", and 13% " a l l of the time".  The 7 s u b j e c t s who r e p l i e d "no" ( t e s t and  procedures were not e x p l a i n e d ) , were over 74 y e a r s of age. The d a t a r e l a t e d t o whether e l d e r l y c l i e n t s i n t h i s study were p r o v i d e d w i t h i n f o r m a t i o n has been p r e s e n t e d . According t o the d a t a , t h e r e were some e l d e r l y c l i e n t s who were not o r i e n t e d t o t h e i r u n i t , i n t r o d u c e d t o t h e i r roommates, informed of the a v a i l a b i l i t y o f c o u n s e l o r s or had t e s t s and procedures e x p l a i n e d b e f o r e they were done. were a g e - r e l a t e d d i f f e r e n c e s ; the " o l d e r o l d " (age 75+) l e s s l i k e l y than t h e "younger o l d " (65-74) the u n i t o r i n t r o d u c e d t o t h e i r roommates.  There were  t o be o r i e n t e d t o There were no  a g e - r e l a t e d d i f f e r e n c e s , however, as t o whether they were informed of the a v a i l a b i l i t y o f c o u n s e l o r s or f a c i l i t i e s . The c u r r e n t l i t e r a t u r e , however l i m i t e d , supports the f i n d i n g s t h a t e l d e r l y p a t i e n t s may not be p r o v i d e d w i t h information.  Panel members from a Consumer A d v i s o r y Panel  on S e n i o r s Health Issues (Mclnnes, 1987)  r e p o r t e d t h a t as  w e l l as being t r e a t e d l i k e c h i l d r e n they a r e not p r o v i d e d  57 i n f o r m a t i o n about t h e i r c o n d i t i o n or treatment.  Dolinsky  (1984) p o i n t s out t h a t nurses i n f a n t a l i z e the e l d e r l y by t r e a t i n g them as i f they a r e i n c a p a b l e o f c a r i n g f o r themselves and do not i n c l u d e them i n d e c i s i o n s about t h e i r own care. In p r o v i d i n g o l d e r c l i e n t s with i n f o r m a t i o n o r i e n t a t i o n t o the f a c i l i t y  regarding  and t e s t s and procedures, the  nurse i s t r e a t i n g t h e c l i e n t with d i g n i t y and r e s p e c t . P r o v i d i n g e l d e r l y c l i e n t s with i n f o r m a t i o n a s s i s t s them t o meet t h e i r b a s i c human needs f o r mastery, s e l f - e s t e e m , and l o v e , belongingness,  and dependence.  Were e l d e r l y c l i e n t s addressed a p p r o p r i a t e l y ? from Items 5, 6, and 7 of the q u e s t i o n n a i r e  Data  (see Appendix E)  p r o v i d e s i n f o r m a t i o n t o determine whether e l d e r l y c l i e n t s i n the sample were t r e a t e d with d i g n i t y and r e s p e c t by being addressed a p p r o p r i a t e l y . The  responses t o Item 5 i n d i c a t e t h a t a l l t h e nurses  i n t r o d u c e d themselves t o t h e i r c l i e n t s e i t h e r "some of t h e time", "most of the time", or " a l l the time".  There were no  n o t i c e a b l e d i f f e r e n c e s between t h e "younger o l d " and " o l d e r old". Information  from Item 6 of t h e q u e s t i o n n a i r e  reveals  t h a t 50% o f t h e t o t a l group r e p l i e d t h a t nurses d i d not c a l l them by t h e i r f i r s t name without remaining  t h e i r permission.  Of t h e  50% who r e p l i e d t h a t nurses d i d c a l l them by t h e i r  f i r s t name without  t h e i r permission,  "some of the time",  58 "most of the time", or " a l l the time", 36% were the "younger o l d " and 59% were the " o l d e r o l d " . The response t o Item 7 i n d i c a t e s t h a t 40% of the t o t a l group were addressed by names other than Miss, Mr.,  or  Mrs.;  35% r e p l i e d t h a t t h i s behavior o c c u r r e d o n l y "some of the time".  I t i s noted, however, t h a t 20% of the "younger o l d " ,  and 46% of the " o l d e r o l d " were addressed by names other than Miss, Mr.,  or Mrs.  "some of the time".  The major f i n d i n g r e l a t e d t o whether e l d e r l y c l i e n t s i n an acute c a r e s e t t i n g are addressed a p p r o p r i a t e l y *  indicates  t h a t nurses i n t r o d u c e themselves t o t h e i r c l i e n t s a t l e a s t some of the time.  Nurses do, however, c a l l t h e i r c l i e n t s by  t h e i r f i r s t name and address them by names other than Miss, Mr.,  or Mrs.  Moreover, the data show a g e - r e l a t e d  d i f f e r e n c e s ; the o l d e r the c l i e n t , the more l i k e l y they w i l l not be addressed  appropriately.  These f i n d i n g s support the view of Burnside Butler  (1988),  (1977), D o l i n s k y (1984), Gresham (1976), Grouse  (1982), and the e l d e r l y themselves  (Mclnnes, 1987).  These  authors d e s c r i b e the v a r i o u s ways i n which o l d e r people are t r e a t e d as c h i l d r e n i n h o s p i t a l s .  Some of these i n c l u d e :  a d d r e s s i n g the e l d e r l y by t h e i r f i r s t name whether or not they request i t , girl",  c a l l e d by names such as "dear", "good  and p a t t i n g the e l d e r l y on the head.  Were e l d e r l y c l i e n t s needs f o r p r i v a c y attended to? Data from Item 8 and 9 (see Appendix E) p r o v i d e i n f o r m a t i o n  59 on  whether  the subjects perceived  that t h e i r  needs f o r  p r i v a c y were m e t . The  responses  respondents curtain  t o Item 8 r e v e a l  indicated that their  b e i n g drawn a n d / o r  treatment  " a l l the time"  door  (81%)  T h e r e were no n o t i c e a b l e  feel  The  age-related  major  The According  current  t h e r e were some  supports  space.  over  functions  feelings  questionnaire  respondents  There  were,  care givers  are  c l o s i n g d o o r s , and  Stillman  their  (Kemp,  clients  and concerns  or  the f i n d i n g s .  professional  (1978)  states  a loss  that  of  b o d i e s and t h e s u r r o u n d i n g  They a r e d e p r i v e d o f p r i v a c y bodily  exam,  group  differences.  i n d i v i d u a l s u s u a l l y experience  Were e l d e r l y  total  during a bath,  i n u s i n g bed s c r e e n s ,  p r i v a c y and c o n t r o l  basic  82% o f t h e t o t a l  f o r p r i v a c y met.  (1984a),  some p e r s o n a l  (13%).  differences.  literature  to S t e f f i  hospitalized  area.  needs  no a g e - r e l a t e d  often negligent allowing  that  f i n d i n g s are that  of the time"  t o p e r f o r m t h e most  1978).  given  an o p p o r t u n i t y  with a nurse?  to discuss  Item 10 o f t h e  ( s e e A p p e n d i x E) i n d i c a t e s  that  40% o f t h e  g r o u p o f s u b j e c t s were n o t p r o v i d e d w i t h an  opportunity  to discuss  their  or  differences.  T h e r e were no a g e - r e l a t e d  who d i d n o t h a v e t h e i r however,  p r i v a c y was e n s u r e d by t h e  o r "most  i n a p p r o p r i a t e l y exposed  procedure.  a l l of the  closed during examination  D a t a f r o m Item 9 i n d i c a t e s did  that  feelings  and concerns  with a  nurse. the  A greater percentage  "younger o l d " (28%)  (49%)  of the  "older old"  were n o t p r o v i d e d  with  than  the  opportunity. The nurses  current l i t e r a t u r e  do  not  provide  supports  elderly  c l i e n t s with  to discuss t h e i r  feelings  (Burnside,  E b e r s o l e & Hess/  that,  1988;  i n acute  insufficient opportunity and  Bevil  and  care u n i t s ,  time  t o ask  concerns.  about t h e i r  clients  c o n d i t i o n , and  B e c a u s e an client's  experiences  Bevil,  1985).  To  1988;  greeted  s h o u l d be  p a t i e n t and  Research Question  little  communicate reassure  them for  concerns.  interpret  correctly, elderly  the nurse  clients'  communication,  with  the should  anxiety  Gioiella a l l older  i n a warm, f r i e n d l y manner and  #2;  Gioiella  of anxiety i n t e r f e r e s  the  & people  nurse  supportive. Are  Elderly  S o c i o e c o n o m i c S t a t u s More L i k e l y and  or  E b e r s o l e & H e s s , 1985;  facilitate  s h o u l d be  progress,  t o p e r c e i v e and  of h o s p i t a l i z a t i o n  (Burnside,  should  note  given  are given  worries  make r e g u l a r a s s e s s m e n t s o f t h e level  are  1984)  g e n e r a l l y p r o v i d e the time  increased level  ability  authors  decision-making.  about t h e i r  the p a t i e n t to v e r b a l i z e t h e i r  the  and  (1985) a r g u e t h a t t h e n u r s e  regularly with  opportunity  Jackson,  older clients  i n any  the  Several  1985;  questions  to p a r t i c i p a t e  the f i n d i n g s t h a t  C l i e n t s with  t o be  a  Higher  Treated with Dignity  Respect Were e l d e r l y  results  c l i e n t s provided with  f r o m Items 1,  2,  3/  and  information?  4 of the q u e s t i o n n a i r e  The (see  61 Appendix F) p r o v i d e data t o determine  whether t h e r e were  d i f f e r e n c e s r e l a t e d t o the l e v e l of e d u c a t i o n a t t a i n e d (used as a measure of socioeconomic  s t a t u s ) and whether e l d e r l y  c l i e n t s were p r o v i d e d with i n f o r m a t i o n . The  responses  t o Item 1 of the q u e s t i o n n a i r e shows t h a t  t h e r e are no n o t i c e a b l e d i f f e r e n c e s between the two (elementary  and secondary  the c l i e n t was  e d u c a t i o n completion)  i n whether  o r i e n t e d to the u n i t .  Respondents who  had an elementary  school education  (67%) were l e s s l i k e l y than those with a secondary education of  groups  school  (46%) t o be i n t r o d u c e d to t h e i r roommates (Item 2  the q u e s t i o n n a i r e ) .  The  statistically significant  r e s u l t s , however, were not  (Chi-square = 1.268; p =  .260).  Responses t o Item 3 of the q u e s t i o n n a i r e showed t h a t many c l i e n t s were not informed of the a v a i l a b i l i t y of r e l i g i o u s c o u n s e l o r s or f a c i l i t i e s .  There were* however, no  s i g n i f i c a n t d i f f e r e n c e s between the two 0.721; p =  groups (Chi-square =  .396).  The d a t a f o r Item 4 of the q u e s t i o n n a i r e show t h a t c l i e n t s w i t h a secondary have had procedures while 67%  e d u c a t i o n may  be more l i k e l y  e x p l a i n e d t o them b e f o r e they were done,  of the s u b j e c t s w i t h an elementary  school  education had t e s t s e x p l a i n e d t o them "some of the only 32% of those w i t h secondary those w i t h a secondary  education d i d .  e d u c a t i o n had procedures  " a l l the time", w h i l e o n l y 7% of those w i t h an education d i d .  to  time",  But, 34% explained elementary  of  62 Although, i n some i n s t a n c e s , d i f f e r e n c e s between d i f f e r e n t l e v e l s of education  (elementary  or secondary) were  s m a l l , the data showed t h a t a g r e a t e r percentage of  elderly  c l i e n t s with a higher l e v e l of education were more l i k e l y be i n t r o d u c e d to t h e i r roommates, be informed s e r v i c e s and  facilities,  and be more l i k e l y  to  of a v a i l a b l e  to have t e s t s  and procedures e x p l a i n e d to them before they were done. These f i n d i n g s are i n keeping w i t h the l i t e r a t u r e (Chapter  2).  Henretta  and Campbell  review  (1976) p o i n t out t h a t  the higher the i n d i v i d u a l ' s socioeconomic c l a s s , the the l i k e l i h o o d of m a i n t a i n i n g  s t a t u s f o r a longer  time because they have resources social relationships.  I t may  h i g h e r l e v e l of education,  greater  t h a t g i v e n them power i n  be argued t h a t c l i e n t s with a  because of t h e i r p e r c e i v e d power  i n s o c i a l r e l a t i o n s h i p s , o b t a i n the i n f o r m a t i o n  by  requesting i t . Were e l d e r l y c l i e n t s addressed a p p r o p r i a t e l y ? from Items 5, 6, and  7 of the q u e s t i o n n a i r e  Data  (see Appendix F)  p r o v i d e i n f o r m a t i o n t o determine i f e l d e r l y c l i e n t s i n the sample were being t r e a t e d with d i g n i t y and  r e s p e c t by  being  addressed a p p r o p r i a t e l y . The  responses to Item 5 r e v e a l e d t h a t nurses u s u a l l y  i n t r o d u c e d themselves to t h e i r e l d e r l y c l i e n t s , except  they  i n t r o d u c e d themselves more f r e q u e n t l y t o those with a secondary The group and  education. data from Item 6 i n d i c a t e 66% 80%  of the elementary  of the secondary group were c a l l e d by  their  63 first  name w i t h o u t t h e i r  permission.  secondary  and p o s t - s e c o n d a r y  that  12% o f t h o s e r e s p o n d e n t s w i t h a  only  group,  Before c o l l a p s i n g the  e d u c a t i o n were c a l l e d by t h e i r respondents first  g r o u p were  The r e s u l t s level  first  post-secondary  name;  88% o f t h e  p e r m i s s i o n w h i l e 33% o f t h e  ( s e e Item  6a, Appendix F ) .  o f Item 7 s u g g e s t  that  o f e d u c a t i o n may be more l i k e l y  secondary  i t i s noted  i n d i c a t e d t h a t t h e y were n o t a d d r e s s e d by t h e i r  name w i t h o u t t h e i r  elementary  however,  or post-secondary  by names o t h e r  than M i s s ,  clients  w i t h a lower  than those with  s c h o o l e d u c a t i o n t o be a d d r e s s e d  M r . , and M r s . , b u t t h e d i f f e r e n c e s  seem m i n i m a l . The m a j o r  finding  an a c u t e c a r e s e t t i n g that nurses  Mr.,  first  t o whether  socioeconomic  The d a t a status  t h e more l i k e l y  to their  Nurses d o , however,  name a n d a d d r e s s  or M r s .  suggest  that  study,  Campbell class  call  be a d d r e s s e d  (1976),  (mentioned  least  c l i e n t s by than  Miss,  client's  education)/  appropriately. clients'  s t a t u s a n d how e l d e r l y c l i e n t s  however,  at  their  (as d e t e r m i n e d by l e v e l o f  they w i l l  indicates  the higher the  w i t h any s p e c i f i c i t y a r e n o n - e x i s t e n t . this  clients  them by names o t h e r  S t u d i e s w h i c h examine t h e e l d e r l y socioeconomic  elderly clients in  are addressed a p p r o p r i a t e l y ,  introduce themselves  some o f t h e t i m e . their  related  are  addressed  The r e s u l t s  found i n  c a n be s u p p o r t e d by H e n r e t t a and  and B u t l e r earlier).  (1977)  on t h e b a s i s  of s o c i a l  64 Were e l d e r l y c l i e n t s ' needs f o r p r i v a c y attended to? The r e s u l t s of Item 8 and 9 of the q u e s t i o n n a i r e (see Appendix  F) p r o v i d e d a t a t o determine i f the o l d e r person's  need f o r p r i v a c y was  attended t o .  The r e s u l t s of Item 8 r e v e a l t h a t t h e r e i s o n l y a 10% d i f f e r e n c e between the elementary and secondary  educated  group; 81% of the elementary s c h o o l group and 91% of the secondary s c h o o l group i n d i c a t e d t h a t the c u r t a i n was  drawn  and/or the door c l o s e d d u r i n g an examination or treatment. Data f o r Item 9 i n d i c a t e t h a t a g r e a t e r percentage of those w i t h a secondary s c h o o l e d u c a t i o n (91%) than elementary education  (74%) f e l t  they were i n a p p r o p r i a t e l y  exposed.  Only 9% of the secondary group compared w i t h 26% of the elementary group f e l t  i n a p p r o p r i a t e l y exposed  ("some of the  time", "most of the time", or " a l l the time") d u r i n g a bath, exam, or procedure. The major f i n d i n g s r e l a t e d t o whether the e l d e r l y c l i e n t ' s need f o r p r i v a c y i s attended t o , r e v e a l t h a t t h e r e were some d i f f e r e n c e s to show t h a t some of the respondents did  not have t h e i r needs f o r p r i v a c y  met.  The c u r r e n t l i t e r a t u r e supports t h i s f i n d i n g .  Clients  w i t h a h i g h e r socioeconomic s t a t u s were shown t o be more l i k e l y t o have t h e i r needs f o r p r i v a c y met lower socioeconomic s t a t u s * c l i e n t s who  than c l i e n t s of a  Brown (1969) r e p o r t e d t h a t  are s o c i a l l y v a l u e d were observed t o r e c e i v e  e x t r a care from n u r s e s .  H e n r e t t a and Campbell  (1976) found  65 (as mentioned e a r l i e r ) t h a t c l i e n t s with a higher socioeconomic s t a t u s have resources  t h a t g i v e them power i n  social relationships. Were e l d e r l y c l i e n t s given an o p p o r t u n i t y t o d i s c u s s f e e l i n g s and  concerns with a nurse?  of the q u e s t i o n n a i r e  The  data from Item 10  (see Appendix F) showed t h a t a g r e a t e r  p r o p o r t i o n of c l i e n t s with a secondary s c h o o l (23%)  than elementary school education  opportunity  education  (15%) were g i v e n  an  t o d i s c u s s t h e i r f e e l i n g s "most of the time" or  " a l l the time".  The  d i f f e r e n c e i s s m a l l , however, but  be e x p l a i n e d by s t u d i e s c i t e d i n p r e v i o u s  could  paragraph.  Other F i n d i n g s D i f f e r e n c e s r e l a t e d to l e n g t h of s t a y and type of u n i t (medical or s u r g i c a l ) could not be determined s i n c e the i n f o r m a t i o n was  confounded.  Confounding f a c t o r s are  unwanted group d i f f e r e n c e s between comparison groups t h a t occur  i n surveys  (Weldon, 1986).  Comparisons i n t h i s group  are "confounded" because the group was relevant aspects. larger  (n = 37)  there was  not s i m i l a r i n a l l  For example, the " o l d e r o l d " group  than the "younger o l d " (n = 25).  a s i m i l a r number of males and  was  While  females i n the  " o l d e r o l d " group, the "younger o l d " group c o n t a i n e d more men.  The  number of s u b j e c t s by gender and l e n g t h of stay  were a l s o r e l a t e d ; although  the "long s t a y " group had  equal number of males and females, contained more  men.  an  the " s h o r t s t a y " group  66 Group d i f f e r e n c e s were not a s c e r t a i n e d s i n c e sample s i z e s were t o o s m a l l t o look a t i n t e r a c t i o n s between variables  (age, gender, e d u c a t i o n , LOS, and u n i t ) .  T h e r e f o r e , each f a c t o r was examined s e p a r a t e l y and no attempt was made t o a d j u s t f o r m u l t i p l e s i g n i f i c a n c e t e s t s . T h e r e f o r e , these r e s u l t s must be regarded as d e s c r i p t i v e only. Gender d i f f e r e n c e s .  Nurses tended t o address women by  names other than Miss or Mrs. more f r e q u e n t l y than they addressed men other than Mr.  Procedures were e x p l a i n e d more  f r e q u e n t l y t o men than women and men r e p o r t e d more responses i n d i c a t i n g "treatment with d i g n i t y and r e s p e c t " on Items 4 to 10. Length of s t a y .  There were no n o t i c e a b l e d i f f e r e n c e s  between l e n g t h of s t a y groups, though people who s t a y e d l o n g e r tended t o be o l d e r .  More responses i n d i c a t i n g  "treatment w i t h d i g n i t y and r e s p e c t " were r e p o r t e d by the "short stay"  subjects.  Type of u n i t .  D i f f e r e n c e s between type of u n i t  (medical or s u r g i c a l ) were minimal.  Clients i n surgical  u n i t s r e p o r t e d more responses i n d i c a t i n g "treatment with d i g n i t y and r e s p e c t " on 6/7 items (there were more men i n s u r g i c a l u n i t s than women). In examining group d i f f e r e n c e s , a s i g n i f i c a n t i s t h a t fewer females r e p o r t e d responses  finding  indicating  "treatment w i t h d i g n i t y and r e s p e c t " than men.  Though  67 l i t e r a t u r e a d d r e s s i n g gender d i f f e r e n c e s i n c a r i n g f o r h o s p i t a l i z e d c l i e n t s i s s c a r c e , one study by Forgan  Morle  (1984) found t h a t nurses p r o v i d e d e x p l a n a t i o n s more f r e q u e n t l y t o e l d e r l y men than they d i d t o e l d e r l y women. L'Esperance  (1979) r e p o r t e d t h a t p h y s i c i a n s and nurses o f t e n  respond n e g a t i v e l y t o women's q u e s t i o n s , p r o v i d e inadequate i n f o r m a t i o n , and l e c t u r e t h e i r c l i e n t s i n s t e a d of encouraging them t o p a r t i c i p a t e i n h e a l t h c a r e d e c i s i o n s . In c o n c l u s i o n , t h e f i n d i n g s i n t h i s study show t h a t the "younger o l d " who were male and a t t a i n e d a higher l e v e l of e d u c a t i o n were more l i k e l y t o be t r e a t e d w i t h d i g n i t y and respect. The e l d e r l y c l i e n t ' s p e r c e p t i o n of h i s / h e r n u r s i n g care i n t h i s study supports other r e p o r t s and s t u d i e s which i n v e s t i g a t e t h e q u a l i t y of care t h e e l d e r l y (Campbell, 1971; Mclnnes, 1982;  Podnieks, 1983).  receive  1987; H e a l t h and Welfare Canada,  These authors say t h a t t h e n e g a t i v e  a t t i t u d e o f nurses toward  aging and the e l d e r l y i s one of  the f a c t o r s t h a t c o n t r i b u t e s t o an i n f e r i o r q u a l i t y of n u r s i n g c a r e ; nurses who h o l d n e g a t i v e a t t u d i e s toward the e l d e r l y w i l l engage i n b e h a v i o r s which may not be t h e r a p e u t i c or may be d e t r i m e n t a l t o t h e b e s t i n t e r e s t of the e l d e r l y c l i e n t  (Brower,  1981; Campbell, 1971;  Lueckenotte, 1987; Penner e t a l . ,  1984).  Negative  a t t r i b u t i o n s may be i n t e r n a l i z e d by an e l d e r l y person, and may subsequently i n f l u e n c e h i s or her b e l i e f s and  68 self-concept  (Cherry,  other  the e l d e r l y develop perceptions  words,  themselves It least  on t h e b a s i s  i s generally  partially,  (Kogan, about  1979;  incorrect  attitude  from the prevalence  Levin & Levin,  process.  are derived,  of c u l t u r a l Negative  however,  releases  Negative  greater  the l i k e l i h o o d  It  respect  power  (Henretta  toward the  w i t h them. characteristics & Campbell,  of age.  These  the i n d i v i d u a l ' s  social  likely  support  authors class,  the  longer  themselves  socioeconomic  status.  t o s u g g e s t t h e n t h a t women i n t h i s  t o be t r e a t e d w i t h d i g n i t y a n d The g r e a t e s t number o f  a r e women and many o f t h e s e women a r e dependent.  of  the f i n d i n g s i n  may p r e s e n t  with a higher  t h a n men b e c a u s e o f s t a t u s .  economically  attitudes  of m a i n t a i n i n g s t a t u s f o r a  seems r e a s o n a b l e  people  represent  and m i s p e r c e p t i o n s .  possess status  These o b s e r v a t i o n s  to clients  s t u d y were l e s s  stereotypes  through the  interaction  study which found t h a t nurses  differently  stereotypes  them f r o m some o f t h e c o n s t r a i n t s  the higher  period of time.  at  people and d e c r e a s e the  i m p o s e d on o t h e r s by v i r t u e that  them.  i n f l u e n c e our b e h a v i o r and  them t o r e t a i n  This  In  about  of o t h e r s toward  reasoning,  and q u a l i t y o f s o c i a l  enable  reported  older  they  1973).  these stereotypes  the s t a t u s of o l d e r  Some e l d e r l y ,  1976).  faulty  toward the e l d e r l y .  frequency  this  1980).  In t u r n ,  assumptions,  e l d e r l y lower  aging  of a t t i t u d e s  held that attitudes  a c c e p t e d as f a c t ,  that  Kuypers & Bengston,  a g i n g and growing o l d a r e i n c u l c a t e d  socializaton  If  1981;  69 Women's s o c i a l s t a t u s d e c l i n e s with age (Dulude, 1981) i n c o n t r a s t t o t h a t of men, who grow i n " c h a r a c t e r " .  This  means t h a t as a p o p u l a t i o n ages, i t becomes more and more c h a r a c t e r i z e d by o l d , poor women with low s o c i a l s t a t u s . The  symbolic  i n t e r a c t i o n i s t view suggests t h a t d i f f e r e n t  d r e s s , speech, and behavior t o present  p a t t e r n s a r e s e l e c t e d i n order  a s e l f considered  situation.  appropriate to the s p e c i f i c  I t may be t h a t e l d e r l y women may be l e s s  likely  t o be t r e a t e d with d i g n i t y and r e s p e c t because they a r e p e r c e i v e d t o have a lower s t a t u s . Lillard  (1982) p o i n t s out t h a t e l d e r l y women may be  a f f e c t e d n e g a t i v e l y by t h e double b i a s of ageism and sexism. In a d d i t i o n t o t h e n e g a t i v e  a t t i t u d e s and p r a c t i c e s t h a t  d i s c r i m i n a t e a g a i n s t t h e aged stereotyped  i n ways t h a t a r e d i r e c t l y r e l a t e d t o sexism;  they a r e economically socially  (ageism) e l d e r l y women a r e  disadvantaged, p o o r l y i n s u r e d , and  isolated.  There i s no l i t e r a t u r e which addresses the combined impact of ageism and sexism on t h e n u r s i n g care of aged women ( L i l l a r d , 1982).  Since both b i a s e s a r e present  i n the  c u l t u r e and a r e known t o a f f e c t h e a l t h care as separate e n t i t i e s , t h i s author a s s e r t s t h a t i t i s reasonable t o s p e c u l a t e about the s i g n i f i c a n c e o f the two f a c t o r s operating simultaneously.  The i m p l i c a t i o n f o r aged women i s  t h a t they may be the l e a s t v a l u e d p a t i e n t group.  and most underserved  70 Nursing many f a c e t s social  approaches  and a c t i o n s  of s o c i e t y :  c u l t u r a l values  and p o l i t i c a l s y s t e m s  practice 1982).  a r e s h a p e d by i n p u t f r o m  and care d e l i v e r y  to affect  (Gioiella  According to these authors,  frequently  i g n o r e h e a l t h needs  to  states  behavior;  those  that the s o c i a l people w i l l  expectations  pressures  of the e l d e r l y .  well-being  alone,  predominantly nursing those  sexist  themselves them.  even b e f o r e Wiesstein  i s t h e major  indirectly.  detriment t o even i f  In s p i t e of  c u l t u r a l group i s  there i s a l i k e l i h o o d  reflect  to Jourard  are strongly project  the a t t r i b u t e  nurse p r o j e c t s  elderly  they  that  some o f t h e  (consciously or unconsciously)  values.  If nurses  client,  Too, the  a c t as they a r e e x p e c t e d  i f the nurse's  care w i l l  Lillard,  t o a c t a u t o n o m o u s l y b a s e d on c l i e n t  sexist,  According  the  values  context  are transmitted  on n u r s e s  1985;  n u r s i n g programs  f i l t e r e d through organized i n s t i t u t i o n s .  (1971)  through  nursing education,  &Bevil,  n u r s e may be i n f l u e n c e d by s o c i e t y ' s are  filter  client's  (1974),  p e o p l e ' s views of  i n f l u e n c e d by o t h e r ' s a negative  attribute  d e f i n i t i o n of on t h e e l d e r l y  may be i n t e r n a l i z e d ; c o n v e r s e l y ,  an a t t r i b u t e  self-concept  if  o f d i g n i t y and r e s p e c t ,  the  i s maintained or enhanced.  Summary This to  chapter  has presented  d e t e r m i n e whether  related  t h e d a t a w h i c h were  there are differences  t o age and s o c i o e c o n o m i c  status.  obtained  i n perceptions Other f a c t o r s  such  71 as l e n g t h of s t a y , sex, and type of u n i t (medical or s u r g i c a l ) were a l s o d e s c r i b e d .  The r e s u l t s i n d i c a t e t h a t  the "younger o l d " males and those with a higher l e v e l of education  (socioeconomic  s t a t u s ) were more l i k e l y t o be  t r e a t e d with d i g n i t y and r e s p e c t .  72  CHAPTER 5 Summary, C o n c l u s i o n s ,  Implications,  and Recommendations  Summary and Conclusions T h i s study was designed  t o i n v e s t i g a t e whether e l d e r l y  c l i e n t s i n an acute care s e t t i n g p e r c e i v e d they were t r e a t e d w i t h d i g n i t y and r e s p e c t , and t o i d e n t i f y whether e l d e r l y c l i e n t s w i t h a higher socioeconomic  s t a t u s were more l i k e l y  to be t r e a t e d with d i g n i t y and r e s p e c t than those w i t h a lower socioeconomic  status.  A f t e r the data were c o l l e c t e d  the i n v e s t i g a t o r proceeded t o i d e n t i f y differences  group-related  (age, sex, education, l e n g t h of s t a y , and type  of u n i t ) and whether t h e r e were any d i f f e r e n c e s i n r e l a t i o n t o d i g n i t y and r e s p e c t .  The impetus f o r t h i s study emanated  from e m p i r i c a l f i n d i n g s and i n f o r m a t i o n i n the l i t e r a t u r e . Sixty-two  s u b j e c t s who were between 65 and 91 years of  age were s e l e c t e d from medical  and s u r g i c a l u n i t s of two  major t e a c h i n g h o s p i t a l s using a convenience technique.  sampling  These s u b j e c t s were i n h o s p i t a l a t l e a s t  days and were a l e r t and o r i e n t e d during hospitalization.  five  their  They were asked t o answer " f i x e d -  a l t e r n a t i v e " q u e s t i o n s on a q u e s t i o n n a i r e  (Appendix D) i n an  i n t e r v i e w i n t h e i r home w i t h i n t h r e e days a f t e r they were discharged from the h o s p i t a l .  73  The f o l l o w i n g  are  major  findings  and c o n c l u s i o n s o f  the  study: 1.  Registered  consistently  orient  i n t r o d u c e them t o availability 75 y e a r s o f 74)  to  nurses the  their  roommates. t h e y were  elderly client roommates,  of counselors age were l e s s  be o r i e n t e d t o  the  T h e r e were informed of  from acute c a r e s e t t i n g s  or  or  their  likely  unit,  i n f o r m them o f  facilities.  the  The e l d e r l y  over  than the younger group  u n i t or  introduced to  no a g e - r e l a t e d the  to  do n o t  their  differences  a v a i l a b i l i t y of  (65-  on w h e t h e r  counselors  or  facilities. 2.  Those respondents  e d u c a t i o n were more l i k e l y roommates  who had a h i g h e r l e v e l to  be i n t r o d u c e d t o  and i n f o r m e d by n u r s e s  of  their  of a v a i l a b l e s e r v i c e s  and  facilities. 3.  A l l the  respondents  introduced themselves time", clients  or  " a l l the  respondents  the  time",  likely  or  that nurses  N u r s e s were  "most  status.  " a l l the  status to  found to  nurses of  the  time",  Half  to  of  the  c a l l e d them by t h e i r  p e r m i s s i o n "some o f t h e  than the younger  socioeconomic  time",  the  a l t h o u g h more f r e q u e n t l y  socioeconomic  revealed  name w i t h o u t t h e i r  "some o f t h e  time",  with higher  indicated that  and t h e  older  time",  first  "most  g r o u p was  more  g r o u p and t h o s e w i t h a l o w e r be c a l l e d by t h e i r  address  their  clients  first  name.  by o t h e r  of  than  74 Miss, Mr., or Mrs., but t h i s behavior o c c u r r e d more f r e q u e n t l y i n the " o l d e r o l d " and those w i t h a lower socioeconomic 4.  status.  A l l of the respondents  r e v e a l e d t h a t the c u r t a i n s  were drawn or the door was c l o s e d d u r i n g an examination or treatment "most of t h e time" or " a l l t h e time"; t h e r e were no d i f f e r e n c e s between the o l d e r and younger group or socioeconomic s t a t u s .  The nurses e x p l a i n e d t e s t s and  procedures t o t h e i r e l d e r l y c l i e n t s "some of the time", " a l l the time", or "most o f the time" but w i t h g r e a t e r l i k e l i h o o d i n the "younger o l d " and those w i t h a h i g h e r socioeconomic status.  Although some respondents f e l t  inappropriately  exposed d u r i n g a bath, exam, or procedure; t h e r e were no s i g n i f i c a n t d i f f e r e n c e s between the " o l d e r o l d " and "younger o l d " " group.  There was some i n d i c a t i o n , however, t h a t  people w i t h a higher socioeconomic s t a t u s a r e l e s s l i k e l y t o be i n a p p r o p r i a t e l y exposed than those w i t h a lower socioeconomic 5.  status.  The respondents r e v e a l e d that they were p r o v i d e d  w i t h an o p p o r t u n i t y t o d i s c u s s t h e i r f e e l i n g s or concerns w i t h the nurse "some o f the time", "most of the time", or " a l l the time".  The "younger o l d " and t h o s e with a higher  socioeconomic s t a t u s were more l i k e l y t o be p r o v i d e d w i t h t h i s opportunity. The evidence i n t h i s study suggests t h a t the e l d e r l y c l i e n t i n an acute c a r e s e t t i n g may not be t r e a t e d w i t h  75 d i g n i t y and r e s p e c t .  The evidence i s made more c o n v i n c i n g  by examining the younger and o l d e r groups of t h e e l d e r l y population likely and  sample and f i n d i n g t h a t the o l d e r c l i e n t  i sless  than the younger c l i e n t t o be t r e a t e d with d i g n i t y  respect.  Moreover, females were l e s s l i k e l y  than males  t o be t r e a t e d with d i g n i t y and r e s p e c t . Some d i f f e r e n c e s e x i s t e d between t h e c l i e n t ' s socioeconomic s t a t u s  (as determined by l e v e l of education)  and  the degree t o which t h e c l i e n t i s t r e a t e d with d i g n i t y  and  respect.  Although there were no s i g n i f i c a n t d i f f e r e n c e s  on whether c l i e n t s were provided c l i e n t s who had a higher likely  with i n f o r m a t i o n ,  those  socioeconomic s t a t u s were more  t o be t r e a t e d w i t h d i g n i t y and r e s p e c t than those  w i t h a lower socioeconomic s t a t u s on Items 4-10 of t h e questionnaire. T h i s study suggests t h a t a s i g n i f i c a n t number o f e l d e r l y c l i e n t s p e r c e i v e they a r e not t r e a t e d with d i g n i t y and  respect.  The i n v e s t i g a t o r w i l l d i s c u s s these f i n d i n g s  with reference to t h e i r i m p l i c a t i o n s f o r nursing. Implications I t has been estimated the p o p u l a t i o n  t h a t by year 2031 about 25% of  i n Canada w i l l be 65 years  or o l d e r .  i n c r e a s e i n t h e p r o p o r t i o n of e l d e r l y w i l l have f a r  The reaching  demands upon those who p r o v i d e n u r s i n g s e r v i c e s .  When  today's n u r s i n g  careers,  75%  students  reach t h e prime o f t h e i r  of t h e i r nursing p r a c t i c e time w i l l be spent with t h e  76  elderly.  Because of t h e demographic t r e n d , the f i n d i n g s of  t h i s study have s i g n i f i c a n t i m p l i c a t i o n s f o r n u r s i n g p r a c t i c e * n u r s i n g education, Nursing  and n u r s i n g  research.  Practice  S e v e r a l f a c t o r s have been i d e n t i f i e d i n the l i t e r a t u r e (Chapter  2) as having  the p o t e n t i a l t o a d v e r s e l y  e l d e r l y c l i e n t s i n an acute care environment. of c a r e g i v e r s , the normal aging process, being  ill  i n a strange  affect  The a t t i t u d e s  chronic disease,  environment, and acute i l l n e s s a r e  some of t h e c o n d i t i o n s i n t e r a c t i n g t o make h o s p i t a l i z a t i o n a p o t e n t i a l l y harmful experience. ill,  Such people may n o t only be  but tend a l s o t o be l a r g e l y i s o l a t e d from f a m i l y ,  f r i e n d s , and f a m i l i a r  surroundings.  Nurses who work i n acute for planning,  care h o s p i t a l s a r e r e s p o n s i b l e  implementing, and e v a l u a t i n g n u r s i n g care f o r  t h e i r c l i e n t s , young or o l d . l i t e r a t u r e addressing  As i s apparent from the  n u r s i n g e t h i c s , one c r u c i a l  r e s p o n s i b i l i t y of n u r s i n g i s t h a t of m a i n t a i n i n g  the d i g n i t y  and  r e s p e c t and i n d i v i d u a l i t y o f h o s p i t a l i z e d o l d people.  The  r e s u l t s of t h i s study  elderly clients  i n d i c a t e , however, t h a t some  ( p a r t i c u l a r l y those o f lower s t a t u s and  women) o f t e n a r e not p r o v i d e d with i n f o r m a t i o n , addressed a p p r o p r i a t e l y , do not have t h e i r needs f o r p r i v a c y t o , or a r e not p r o v i d e d with an o p p o r t u n i t y  attended  to discuss their  f e a r s or concerns. These f i n d i n g s suggest t h a t the n u r s i n g management of  77 acutely i l l  o l d e r a d u l t s i n the h o s p i t a l s e t t i n g i s a matter  of s e r i o u s e t h i c o l e g a l c o n s i d e r a t i o n .  According  Canadian Nurses A s s o c i a t i o n Code of E t h i c s  to  the  (1985), the nurse  i s o b l i g e d to encourage c l i e n t autonomy, i n c l u d e the i n the decision-making process, d i g n i f i e d treatment of the  and  cultivate respectful  of the aged  h e l d by nurses can have d e t r i m e n t a l  clients.  and  e f f e c t s on e l d e r l y  A number of s t u d i e s have documented the presence  of negative suggesting client.  and  client.  Negative a t t i t u d e s and p e r c e p t i o n s aging  client  a t t i t u d e s by nurses w i t h some evidence a t t i t u d e i n f l u e n c e s treatment of the e l d e r l y  According  to Ebersole  and  Hess (1985), the myths  dangerous to the e l d e r l y c l i e n t are those t h a t p e r p e t u a t e the i d e a t h a t the aged are dependent and independent.  C l i e n t s subjected  the young  are  to care p r a c t i c e s which defy  g e r o n t o l o g i c a l care p r i n c i p l e s may  r e g r e s s and become  i n c r e a s i n g l y dependent. I f the e l d e r l y are to s u r v i v e acute h o s p i t a l i z a t i o n and r e c e i v e humane and  therapeutic  i n t e r v e n t i o n s are r e q u i r e d .  care, very  specific  nursing  B u r n s i d e (1988) a s s e r t s t h a t  the nurse's r o l e i s t o support the o l d e r person's a b i l i t y become informed about the acute care s e t t i n g , organize information, t o the new  and  the  a s s i s t the o l d e r person's a b i l i t y to adapt  environment i n a manner t h a t enables the  person to recover  to  from the acute i l l n e s s .  (1985) have i d e n t i f i e d the g e n e r a t i v e  Ebersole  functions  of  older and  Hess  78 productivity  and p r o b l e m - s o l v i n g a b i l i t y as e s s e n t i a l to the  maintenance of s e l f - e s t e e m i n the e l d e r l y and have  suggested  t h a t the nurse's r o l e i s t o a s s i s t i n development of these abilities.  P r o v i d i n g the o l d e r  adult with information  a l l o w s and encourages p a r t i c i p a t i o n i n one's own and helps t o strengthen f e e l i n g s of c o n t r o l According t o Burnside which are secondary  health  care  and autonomy.  (1988) some e l d e r l y become i l l  t o nontherapeutic c a r e .  i n ways  Nurses must be  aware of the r i s k s of h o s p i t a l i z a t i o n f o r the e l d e r l y . Selected studies attitudes  show how  l i m i t e d knowledge, s k i l l s  of nurses make h o s p i t a l i z a t i o n a p o t e n t i a l l y  harmful experience f o r e l d e r l y c l i e n t s (Bossenmaier, Gunter,  and  1983;  Lueckenotte,  1987).  1982;  According t o these  authors, h o s p i t a l i z a t i o n emphasizes the e l d e r l y c l i e n t ' s physical  deterioration  independence* nurses may  and l o s s of h e a l t h ,  mobility,  Even when they are capable of s e l f - c a r e ,  believe  i t i s f a s t e r t o do t h i n g s f o r them, thus  r e i n f o r c i n g the c l i e n t ' s dependent p o s i t i o n . weaken the e l d e r l y c l i e n t ' s f e e l i n g s of  (Burnside, 1988;  These  losses  self-confidence,  sense of s e l f - e s t e e m , and l o s s of c o n t r o l style  and  over t h e i r  G i o i e l l a & B e v i l , 1985).  life-  According  to these authors, h e l p i n g the e l d e r l y c l i e n t begins w i t h the admission procedure.  As soon as p o s s i b l e ,  p r o v i d e the c l i e n t w i t h a thorough physical  setting, routines,  lounge.  orientation  of t h e i r bed,  should  t o the  roommates, and p e r s o n n e l .  c l i e n t s should know the l o c a t i o n s and  the nurse  Older  bathroom,  79 O l d e r p e o p l e o f t e n have d i f f i c u l t y perceiving  events  accurately  because of v a r i o u s sensory l o s s e s  & Williams,  1970; W o r r e l l ,  experiences  as w e l l  1977).  Because  1984)  1982; G i o i e l l a  p o i n t out t h a t  &Bevil,  clients  test  1985;  authors  Forgan  Morle, being  to these authors,  with diagnostic tests,  explanations  of t h e i r  to  older  purpose, the  r e q u i r e d , and how t h e y c a n a s s i s t  during the  or procedure. There i s a r e c i p r o c a l  the  According  associated  require clear  preparation  Several  explanations before procedures  performed a r e seldom g i v e n . reduce the anxiety  of previous  as i n s u f f i c i e n t i n f o r m a t i o n , o l d e r  c l i e n t s may become a n x i o u s a n d a g i t a t e d . (Bossenmaier,  (Chodil  attitudes  example,  of nurses  by t h e n u r s e .  According  of the nurse;  themselves  1982; W h i t e , 1 9 7 7 ) .  care f o r themselves  fewer p o s i t i v e a t t r i b u t e s  about themselves  behavior  (Lillard,  c l i e n t s who c a n n o t  viewed as h a v i n g  ideas  r e l a t i o n s h i p between c l i e n t a n d  are related  by t h e n u r s e e i t h e r  to White  (1977)  For  or are  may n o t be v a l u e d  clients  derive  a c c o r d i n g t o how t h e y  i n t e r p r e t the  thus,  about  their  to dignity,  attitudes respect  and e s t e e m shown  d i r e c t l y or i n d i r e c t l y through  their  actions. Studies socially  suggest  that those  c l i e n t s who a r e  less  v a l u e d or have fewer p o s i t i v e a t t r i b u t e s  likely  to receive  poorer  care  Bevil,  1985; W h i t e , 1977).  (Burnside,  According  a r e more  1988; G i o i e l l a &  to White  (1977) we  80 n e e d t o be c o n c e r n e d b o t h f o r t h e e x t e n t t o w h i c h attitudes  a r e conveyed t o c l i e n t s  which p o s i t i v e a t t i t u d e s appropriate  behaviors  negative  and f o r t h e e x t e n t  are not expressed  to  appropriately,  do n o t o c c u r .  Although nursing l i t e r a t u r e  recognizes  ageism as a  t h r e a t to the care of the aged,  the recent l i t e r a t u r e  not  or i t s r e l a t i o n s h i p  discuss  s e x i s m among n u r s e s  client  care  women,  she s t a t e s ,  most  (Lillard,  1982).  i s that  underserved c l i e n t  options  f o r funding  they  become  nursing practice responsibility a sound,  education  of every  nurse  projects  c a r e o f e l d e r l y women n e e d s  attitudes  f o r the  It  i s also  to provide nursing care  knowledge  based  base.  Education  o p t i m a l c a r e f o r t h e e l d e r l y w h i c h meets t h e i r  there are studies  attitudes  Blattstein,  w h i c h show t h a t  nurses  & Johnson,  toward the e l d e r l y  & Gomez, 1 9 8 5 ; 1976).  need  A l t h o u g h f i n d i n g s have b e e n m i x e d ,  of study i n G e r o n t o l o g i c a l Nursing  positive  the  toward t h e e l d e r l y a r e r e q u i r e d t o  d i g n i t y and r e s p e c t .  course  Lillard,  a n d change  d e l i v e r e d to aging c l i e n t s .  scientific  Positive  for  According to  i s r e s p o n s i b l e and a c c o u n t a b l e  Nursing  achieve  to  paramount.  Every nurse  on  does  a r e t h e l e a s t v a l u e d and  population.  research,  real  The i m p l i c a t i o n f o r aged  f o c u s e d on i m p r o v i n g t h e h e a l t h to  or  Stanley  Therefore,  who h a v e t a k e n demonstrate  (Gomez,  & Burggraf,  a  more  Otto, 1986;  continuing education  Wilhite  (in  81 g e n e r a l or s p e c i f i c areas) i n u n i v e r s i t i e s , c o l l e g e s , and h e a l t h care i n s t i t u t i o n s should be one of the s t r a t e g i e s used to m a i n t a i n  or i n c r e a s e p o s i t i v e a t t i t u d e s about  The l a c k of emphasis i n n u r s i n g education and  a p p l i c a t i o n of g e r o n t o l o g i c a l n u r s i n g  on knowledge  principles  i d e n t i f i e s a need f o r i n - s e r v i c e e d u c a t i o n . development program must i n c l u d e education aging, normal aging  aging.  A nursing  staff  i n t h e o r i e s of  ( p h y s i o l o g i c and p s y c h o s o c i a l )  changes,  s e n s i t i v i t y to s t e r e o t y p e s , and  t o develop s t r a t e g i e s to  a s s i s t nurses to i n c o r p o r a t e new  knowledge i n t o n u r s i n g  practice. E d u c a t i o n a l programs f o r g e r o n t o l o g i c a l n u r s i n g  staff  must address the dynamics of the n u r s e - c l i e n t i n t e r a c t i o n s . For example, n u r s i n g s t a f f c o u l d be taught dependent behaviors  how  on the p a r t of c l i e n t s .  a l s o c o u l d be made aware of how a t t i t u d e s and behavior  to reduce  Nursing  staff  the meaning of t h e i r  i s i n t e r p r e t e d by the  client.  A d d i t i o n a l l y , the o r g a n i z a t i o n s f o r which n u r s i n g s t a f f work must c o n s i d e r how  t h e i r p o l i c i e s and p r a c t i c e s may  be  c o n t r i b u t i n g toward t h e i r s t a f f ' s a t t i t u d e s toward perceptions Nursing  of t h e i r e l d e r l y  client.  clients.  p r a c t i c e a d m i n i s t r a t o r s can p l a y a major r o l e  i n maintaining e l d e r l y and  and  and  i n c r e a s i n g p o s i t i v e a t t i t u d e s toward the  promoting the q u a l i t y of care of the  aging  T h i s can be achieved by a l l o c a t i n g resources  s t a f f education  ( i n c l u d i n g o r i e n t a t i o n programs),  for  82 e s t a b l i s h i n g standards  of n u r s i n g care, and b e l i e v i n g t h a t  i n c r e a s e d knowledge i s paramount to the d e l i v e r y of q u a l i t y care. S t r a t e g i e s should be developed  to enhance the image of  the nurse whose p r a c t i c e i n c l u d e s e l d e r l y c l i e n t s .  Primary  n u r s i n g and p r o v i s i o n of c l i n i c a l nurse s p e c i a l i s t s whose e x p e r t i s e i s i n g e r o n t o l o g i c a l n u r s i n g should be promoted. These nurses would f u n c t i o n as c l i n i c a l nurse p r a c t i t i o n e r s , c o n s u l t a n t s , educators,  and r e s e a r c h e r s i n a d d i t i o n to  p r o v i d i n g l e a d e r s h i p and a c t i n g as r o l e models f o r other nurses.  Moreover, human d i g n i t y and  r e s p e c t of o l d e r a d u l t s  must become our immediate agenda f o r c o n s i d e r a t i o n w i t h i n s c h o o l s of n u r s i n g and c u r r i c u l u m p l a n n i n g . Nursing Nursing  Research  research provides a f i r m foundation f o r a l l  areas of n u r s i n g .  Unfortunately, nursing research  regarding  the e l d e r l y c l i e n t ' s p e r c e p t i o n of h i s / h e r n u r s i n g care i s very  limited. F u r t h e r r e s e a r c h would be u s e f u l i n s u b s t a n t i a t i n g the  findings discussed i n t h i s t h e s i s .  First,  r e p l i c a t i o n of  t h i s study i s recommended using a p r o b a b i l i t y technique.  sampling  The problem of an a c c i d e n t a l sampling  technique  ( n o n p r o b a b i l i t y sampling) i s t h a t a v a i l a b l e s u b j e c t s might not be r e p r e s e n t a t i v e of the p o p u l a t i o n w i t h regard to the c r i t i c a l v a r i a b l e s being measured ( P o l i t & Hungler, 1983). The  second recommendation r e l a t e s to the measurement of  83 d i g n i t y and r e s p e c t .  Further  i n v e s t i g a t i o n to describe  p e r c e p t i o n of d i g n i t y and r e s p e c t would be of v a l u e . T h i s researcher elderly clients.  examined a group of a l e r t and o r i e n t e d  Other e l d e r l y c l i e n t s , who a r e n o t a l e r t ,  need t o be i n v e s t i g a t e d as t o whether t h e i r nursing  care  ensured t h e i r d i g n i t y and r e s p e c t . T h i s study assumed t h a t p e r s o n a l i t y dimensions a r e h i g h l y dependent on s o c i a l l e a r n i n g and i n t e r a c t i o n , and when l o s s e s or changes occur  i n these areas,  l i k e younger persons, begin t o q u e s t i o n competence.  o l d e r persons,  t h e i r worth and  T h i s i n t u r n can lower t h e i r l e v e l o f s e l f -  esteem o r change t h e i r s e l f - c o n c e p t , thereby l e a d i n g t o changes i n behavior.  Research should be conducted t o  determine t h e r e l a t i o n s h i p between n u r s i n g  care which does  or does not meet the e l d e r l y c l i e n t ' s need t o be t r e a t e d with d i g n i t y and r e s p e c t and i t s e f f e c t on s e l f - c o n c e p t . T h i s study found males were more l i k e l y t o be t r e a t e d with d i g n i t y and r e s p e c t than women.  S t u d i e s which examine  gender d i f f e r e n c e s i n the q u a l i t y of care a r e s c a r c e .  The  f a c t t h a t t h e g r e a t e s t number o f o l d e r people a r e women and are more commonly found i n the ranks of t h e poor o r those on welfare  (Dulude, 1981) s t i m u l a t e s the f o l l o w i n g  questions.  To determine:  research  (1) Whether t h e r e i s a  r e l a t i o n s h i p between t h e i r lower socioeconomic s t a t u s and the degree t o which e l d e r l y women a r e t r e a t e d with d i g n i t y and  r e s p e c t , and (2) whether nurses'  a t t i t u d e s are more  84 f a v o r a b l e toward e l d e r l y male than e l d e r l y female c l i e n t s . Furthermore, what n u r s i n g a c t i o n s would be most e f f e c t i v e i n heightening  the c l i e n t s '  (male and  being t r e a t e d with d i g n i t y and  female) p e r c e p t i o n of  respect.  As p r e v i o u s l y s t a t e d , the p r o p o r t i o n of e l d e r l y people i s i n c r e a s i n g ; by year  2031,  an estimated  p o p u l a t i o n w i l l be over 65 years of age.  24% This  of the has  i m p l i c a t i o n s f o r a l l areas of n u r s i n g p r a c t i c e , education, and  research.  E d u c a t i o n a l l y , nurses must be w e l l  for this responsibility.  Nursing  should be based on sound  research.  p r a c t i c e and  prepared  education  85  REFERENCES  A l f o r d , D . M.,  (1982).  Tips f o r teaching 60-63.  L i f e . 2,  Nursing  A l l e n , R. E. (Ed.).  (1984).  current enqlish.  The Oxford d i c t i o n a r y o f  Great B r i t a i n : Cox & Wyman L t d .  (1987).  Bahr, R. T.  Adding t o the e d u c a t i o n a l  J o u r n a l of G e r o n t o l o g i c a l Nursing. (1978).  Bengston, V. L.  older adults.  t h e i r s o c i a l needs. needs o f the aged;  agenda.  1_ ( 3 ) ,  6-11.  The i n s t i t u t i o n a l i z e d aged and In E. Seymour  (Ed.),  Psychosocial  A h e a l t h care p e r s p e c t i v e .  Angeles: U n i v e r s i t y of Southern C a l i f o r n i a (1969).  Blumer, H.  and method.  (1982).  Perspective  The h o s p i t a l i z e d e l d e r l y :  g e r i a t r i c N u r s i n g , 1 (4),  Bower, F., & B e v i s , E. practice;  Press.  New J e r s e y : P r e n t i c e - H a l l .  Bossenmaier, M. look,  Symbolic i n t e r a c t i o n i s m ;  Los  (1979).  A first  253-256  Fundamentals of n u r s i n g  Concepts, r o l e s and f u n c t i o n s .  St. Louis:  Mosby, 1979. (1981).  Brower, H. T.  S o c i a l o r g a n i z a t i o n and nurses  a t t i t u d e s toward o l d e r persons. G e r o n t o l o g i c a l Nursing. Brown, M. I .  (1969).  1 (5),  J o u r n a l of 293-298.  Patient variables associated  preferences  among e l d e r l y p a t i e n t s .  ANA Nursing  Research Conference.  with  Paper presented a t  B u r n s i d e , I . M. approach.  New  B u t l e r , R. N. New  (1988). York:  (1980).  York: Harper &  B u t l e r , R.,  N u r s i n g and the aged:  & Lewis, M.  McGraw-Hill.  Whv  survive?  (1977).  (1987).  Aging and mental  health:  S t . L o u i s : Mosby.  The UBC model f o r n u r s i n g :  Directions for practice. British  Being o l d i n America.  Row.  Routine p s y c h o s o c i a l approaches. Campbell, M. A.  A self-care  Vancouver,  BC: U n i v e r s i t y of  Columbia.  Campbell, M. E.  (1971).  Study of the a t t i t u d e s of n u r s i n g  p e r s o n n e l toward g e r i a t r i c p a t i e n t s .  Nursing Research.  2£ (2), 147-151. Canadian Nurses A s s o c i a t i o n . nursing.  Ottawa:  (1985).  Code of e t h i c s f o r  Author.  Chappel, N. L., S t r a i n , L. A., Aging and h e a l t h c a r e :  & B l a n d f o r d , A. A.  (1986).  A social perspective.  Canada:  H o l t , R i n e h a r t & Winston. Cherry, R.  (1981).  The aoing e x p e r i e n c e .  Singapore N a t i o n a l  Printers.  C h o d i l , J . , & W i l l i a m s , B. deprivation.  Singapore:  (1970).  The concept of sensory  Nursing C l i n i c s of North America. (5),  453-465. Coburn, J .  (1981).  of n u r s i n g . Torrance  I see and I am s i l e n t :  A short  In D. Coburn, C. D'Archy, P. New,  (Eds.), H e a l t h and Canadian s o c i e t y .  Fitzhenry & Whiteside.  history & G. Toronto:  (1922).  Cooley, C. H.  Human nature  and t h e s o c i a l o r d e r .  New York: S c r i b n e r . C u r t i n , L., & F l a h e r t y , M. J . Theories  and pragmatics. (1968).  Davis, R. W. nursing.  (1982).  Nursing  ethics:  Bowie, MD: Robert Brady.  P s y c h o l o g i c a l a s p e c t s of g e r i a t r i c  Ame r i c a n J o u r n a l of Nursing.  6.8 ( 4 ) ,  802-  804.  (1984).  D o l i n s k y , E. H.  I n f a n t a l i z a t i o n of the e l d e r l y :  An area f o r n u r s i n g r e s e a r c h . G e r o n t o l o g i c a l Nursing. Dulude, L.  (1981).  Pension  Ottawa: Advisory  J o u r n a l of  1 £ (9),  12-19.  reform with women i n mind.  C o u n c i l on the Status of Women. (1985).  E b e r s o l e , P., & Hess, P.  Toward healthy  Human needs and n u r s i n g response. (1986).  Elbeck, M. A. practice.  Nursing  Papers. 18 ( 2 ) ,  e l d e r l y that e l i c i t s  conceptual  (1982).  a negative  G e r o n t o l o g i c a l Nursing. (1984).  S t . L o u i s : Mosby.  C l i e n t perception of nursing  E l l i o t t , B., & Hyberton, D.  Fawcett, J .  aoino:  8 (10),  17-23.  What i s about t h e response?  J o u r n a l of  568-571.  A n a l y s i s and e v a l u a t i o n of  models of n u r s i n g .  Philadelphia:  Davis. Forbes, W. F., Jackson, J . A., & Kraus, A. S.  (1987).  I n s t i t u t i o n a l i z a t i o n of t h e e l d e r l y i n Canada. Toronto:  Butterworths.  Forgan Morle, K. M. the e l d e r l y .  (1984).  P a t i e n t s a t i s f a c t i o n : Care of  J o u r n a l of Advanced Nursing.  9_, 7 1 - 7 6 .  Fromm, E.  (1955).  The sane s o c i e t y .  F u t r e l l , M., & Jones, W.  (1977).  New York: Rhinehart.  A t t i t u d e s of p h y s i c i a n s ,  nurses and s o c i a l workers toward the e l d e r l y and h e a l t h maintenance s e r v i c e s f o r the e l d e r l y : h e a l t h manpower p o l i c y .  Implications f o r  Journal of Gerontological  Nursing, 1 (3), 41-46. George, L., & Bearon, L. persons:  (1980).  Q u a l i t y of l i f e i n o l d e r  Meaning and measurement.  New York: Human  Sciences Press. G i o i e l l a , E. C., & B e v i l , C. W. the aging c l i e n t :  (1985).  Nursing care o f  Promoting h e a l t h y a d a p t a t i o n .  Norwalk, CT: A p p l e t o n - C e n t u r y - C r o f t s . Goebel, B. L.  (1984).  nurses. Goffman, E. life.  Age s t e r e o t y p e s h e l d by student  J o u r n a l of Psychology. (1959).  H6_  (2), 249-250.  The p r e s e n t a t i o n of s e l f i n everyday  New York: Doubleday.  Gomez, G. E., Otto, D., B l a t t s t e i n , A., & Gomez, A.  (1985).  Beginning n u r s i n g students can change a t t i t u d e s about the aged. Gresham, M. L.  J o u r n a l of G e r o n t o l o g i c a l N u r s i n g . L i (1). (1976).  The i n f a n t a l i z a t i o n of t h e e l d e r l y :  A developing concept.  Nursing Forum. 15 (196), 195-  210. Grouse, L.  (1982).  Dirtball.  J o u r n a l of t h e American  Medical A s s o c i a t i o n . 2A1 (22), 2059-3060. Gunter, L. J .  (1983).  E t h i c a l consideratins f o r nursing  care of o l d e r p a t i e n t s i n t h e acute care s e t t i n g . Nursing C l i n i c s of North America. 18 (2), 411-421.  The  (1986).  Gutman, G., Gee, E., Bojanowski, B., & Mottet, D. Fact book on aging i n B r i t i s h Columbia. Simon F r a s e r U n i v e r s i t y , Gerontology (1977).  Hatton, J .  Burnaby, BC:  Research Center.  Nurses a t t i t u d e toward the aged:  Relationship to nursing care.  Journal of  G e r o n t o l o g i c a l Nursing. 1 ( 3 ) , 2 1 - 2 6 . (1982).  H e a l t h and Welfare Canada. r e p o r t on aging.  Ottawa:  Canadian government  Author. (1975).  Hegyvary, S., & Haussmann, R.  Monitoring nursing  J o u r n a l o f Nursing A d m i n i s t r a t i o n ?  care q u a l i t y .  (6),  17-26.  (1976).  Henretta, J . , & Campbell, R. s t a t u s maintenance: age.  S t a t u s attainment and  A study of s t r a t f i c a t i o n i n o l d  American S o c i o l o g i c a l Review. 4JL ( 6 ) , (1984).  Jackson, M.  981-992.  G e r i a t r i c r e h a b i l i t a t i o n on an acute  care medical u n i t .  J o u r n a l o f Advanced Nursing.  (9),  441-448.  J o u r a r d , S. M.  (1974).  Healthy p e r s o n a l i t y .  New York:  Macmillan. Kemp, J .  (1978).  21 ( 5 ) ,  Kogan, N.  Planning h o s p i t a l c a r e .  Nursing  Times.  198-201.  (1979).  o l d people:  B e l i e f s , a t t i t u d e s and s t e r e o t y p e s about A new look a t some o l d i s s u e s .  Research  on Aging. L, 1 7 - 3 6 . Kuypers, J . , & Bengston, B. competence:  (1973).  S o c i a l breakdown and  A model o f normal aging.  Development. 1 6 , 1 8 1 - 2 0 1 .  Human  Leddy, S.  f  & Pepper, J . M.  (1985).  professional nursing. L e v i n , J . S.,  & L e v i n , W.  Conceptual bases of  Philadelphia: (1980).  Lippincott.  P r e j u d i c e and  d i s c r i m i n a t i o n a g a i n s t the e l d e r l y .  California:  Wadsworth. Lillard, J.  (1982).  sexism.  A double-edged  sword:  Ageism and  J o u r n a l of G e r o n t o l o g i c a l N u r s i n g . 8_(11),  630-  634. L'Esperance, C. M. aggression?  (1979).  Home b i r t h - a m a n i f e s t a t i o n of  J o u r n a l of O b s t e t r i c s and G y n e c o l o g i c a l  N u r s i n g . 8, 227-230. Lueckenotte, A. settings.  (1987).  Sharpen  skills  i n hospital  J o u r n a l of G e r o n t o l o g i c a l N u r s i n g .  H,  12-19. Mantle, J .  (1988a).  agencies.  Nursing p r a c t i c e i n long-term care  In A. Baumgart & J . L a r s e n (Eds.),  n u r s i n g f a c e s the f u t u r e :  Canadian  Development and chance.  St.  L o u i s : Mosby. Mantle, J .  (1988b, A p r i l ) .  gerontological nursing. of  The s t a t e of the a r t of Paper presented at the meeting  the B r i t i s h Columbia G e r o n t o l o g i c a l Nurses Group,  Vancouver, Maslow, A. H. York: Van Maslow, A. H.  BC. (1968).  Toward a psychology of b e i n g .  New  Nostrand. (1970).  York: Harper &  Row.  M o t i v a t i o n and p e r s o n a l i t y .  New  91 Mclnnes, C.  (1987  f  December 2 ) .  T r e a t us w i t h d i g n i t y ,  don't c a l l us "dear", e l d e r l y demand.  Globe and M a i l ,  pp. A16. Mead, G. H.  (1934).  Mind, s e l f and s o c i e t y .  Chicago:  U n i v e r s i t y of Chicago P r e s s . M e l t z e r , B. N., P e t r a s , J . W., Symbolic i n t e r a c t i o n i s m : criticism. N a t k i n s , L.  & Reynolds, L. T.  (1977).  Genesis, v a r i e t i e s and  Boston: Routledge & Kegan P a u l .  (1982).  "Hi L u c i l l e , t h i s i s Dr. G o l d " .  J o u r n a l of American  Medical A s s o c i a t i o n . 2A1 (17),  2415.  Nelson, B. K.  (1973).  Study i n d i c a t e s which p a t i e n t s  nurses don't l i k e . P a s t a l a n , L.  (1970).  Modern H o s p i t a l . 8, 70-72. S p a t i a l behavior of o l d e r people.  Ann Arbor: U n i v e r s i t y of Michigan. Penner, L., Ludenia, K., & Mead, G. attitudes:  Image or r e a l i t y ?  (1984).  Staff  J o u r n a l of  G e r o n t o l o g i c a l N u r s i n g . 1Q_ ( 3 ) , 110-117. Podnieks, E.  (1983).  Abuse o f the e l d e r l y .  The Canadian  Nurse. 7_9_ (5), 34-35. P o l i t , D., & Hungler, B.  (1983).  P r i n c i p l e s and methods.  Nursing r e s e a r c h :  Philadelphia:  Lippincott.  R e g i s t e r e d Nurses' A s s o c i a t i o n of B r i t i s h Columbia. Standards f o r n u r s i n g p r a c t i c e i n B r i t i s h Vancouver:  Author.  (1984).  Columbia.  R e i d , D.,  Hass, G.  & Hawkins, D.  f  (1977).  Focus of d e s i r e d  c o n t r o l and p o s i t i v e s e l f - c o n c e p t of the e l d e r l y . J o u r n a l of Gerontology. 3 1 , Roos, N.,  441-450.  S h a p i r o , E., & Roos, L.  demand f o r h e a l t h s e r v i c e s : demand? Rossman, D.  (1984).  Which aged and whose  The G e r o n t o l o g i s t . 24 (1979).  Aging and the  (1), 31-36.  Clinical geriatrics.  Philadelphia:  Lippincott. Rowe, J . w.  (1985).  H e a l t h care of the e l d e r l y .  England J o u r n a l of Medicine. __1 Roy,  C.  (1976).  model.  New  S c h o n f i e l d , D.  (13), 827-835.  I n t r o d u c t i o n t o nursing;  An a d a p t a t i o n  Jersey: Prentice-Hall. (1982).  Who  The G e r o n t o l o g i s t . 2 2 , S i l v e r s i d e s , A.  i s s t e r e o t y p i n g whom and why? 267-272.  (1987, A p r i l 27).  Aging s o c i e t y ' s  on c o s t of h e a l t h care i s c a l l e d exaggerated. and M a i l , pp. Smith, S. P.,  New  impact Globe  A16.  Jepson, V.,  & P e r l o f f , E.  (1982).  of n u r s i n g care p r o v i d e r s toward e l d e r l y  Attitudes  patients.  Nursing and H e a l t h Care. 3_, 93-98. S t a n l e y , M.,  & Burggraf, V.  shaping the f u t u r e .  (1986).  The path of the p a s t  J o u r n a l of G e r o n t o l o g i c a l N u r s i n g .  12 ( 7 ) , 30-34. S t a t i s t i c s Canada.  (1980).  Population projection f o r  Canada and the P r o v i n c e s . 1976-2001.  Ottawa: Author.  Steffi,  B . M.  (1984a).  gerontological  Attitudes  nursing.  Steffi,  a g i n g and  I n B . M. S t e f f i  Handbook o f G e r o n t o l o g i c a l York:  toward  Nursing  (Ed.),  (pp. 17-24).  New  Van Nostrand R e i n h o l d .  B . M.  (1984b).  tasks of aging. gerontological  Basic  human n e e d s a n d d e v e l o p m e n t a l  In B . M. S t e f f i nursing  (Ed.),  (pp. 39-49).  Handbook o f  New Y o r k : V a n  Nostrand R e i n h o l d . Stillman,  M.  (1978).  Territoriality  American Journal Stone,  0.,  better  S.  increases  health.  Division.  space.  o f N u r s i n g . 1Q_, 1 6 7 0 - 1 6 7 2 .  & Fletcher,  Dramatic  and p e r s o n a l  (1986).  The s e n i o r s  i n longevity  Statistics  Ottawa:  boom:  and p r o s p e c t s f o r  Canada -  Population  Studies  M i n i s t e r o f Supply and S e r v i c e s  Canada. Storch,  J.  L.  (1988).  Baumgart & J . Development Storlic,  F. J .  Larsen  (1982).  S.  structural Taylor,  H . , St H a r n e d ,  old people: elderly. 43-47.  A study  Journal  St. Louis:  future:  Mosby.  of the o l d .  Journal  8 , 555.  Symbolic i n t e r a c t i o n i s m :  version.  In A .  Nursing faces the  The r e s h a p i n g  Nursing.  (1980).  i n nursing p r a c t i c e .  (Eds.),  and c h a n g e .  Gerontological Stryker,  Ethics  London: T. L.  A social  Benjamin/Cummings.  (1978).  Attitudes  toward  o f n u r s e s who c a r e f o r t h e  of Gerontological  Nursing. 4  (5),  Thomas, W. W.  (1934).  The d e f i n i t i o n of the s i t u a t i o n .  Thomas (Ed.), The unadjusted g i r l .  Boston:  In  Little,  Brown. W e i s s t e i n , N.  (1971).  Psychology c o n s t r u c t s the female.  In V. Gornick & B. Moran (Eds.), Women i n s e x i s t society.  New  Weldon, K. L. New White,  York: B a s i c Books.  (1986).  Statistics:  A conceptual approach.  Jersey: Prentice-Hall.  C. M.  (1977).  The n u r s e - p a t i e n t encounter.  A t t i t u d e and b e h a v i o r s i n a c t i o n . G e r o n t o l o g i c a l N u r s i n g . 1,  J o u r n a l of  16-21.  W i l h i t e , M. J . , & Johnson, D. M.  (1976).  Changes i n  n u r s i n g s t u d e n t s ' s t e r e o t y p i c a t t i t u d e s towards o l d people.  Nursing Research. 2JL (6), 62-66.  Wolk, R. L., & Wolk, R. B.  (1971).  a t t i t u d e s toward the aged.  Professional  J o u r n a l of the  workers  American  G e r i a t r i c s S o c i e t y . L9_, 624-639. W o r r e l l , J . D. the  (1977).  p a t i e n t e x p e r i e n c i n g sensory d e p r i v a t i o n .  K i n t z e l , L. D. nursing. Zimbardo,  Nursing i m p l i c a t i o n s i n the care of  (Ed.), Advanced concepts i n c l i n i c a l  Philadelphia: Lippincott.  P. G.,  & Ebbesen,  E. B.  (1969).  a t t i t u d e s and chancing b e h a v i o r . & Wesley.  In  Influencing  Reading, MA:  Addison  95  APPENDIX A Information  Letter  I am Josephine S t e c k l e r , a r e g i s t e r e d nurse i n the Masters of Nursing program a t the U n i v e r s i t y of B r i t i s h Columbia. I am i n t e r e s t e d i n l e a r n i n g more about how o l d e r a d u l t s view some aspects of t h e i r n u r s i n g care. It i s b e l i e v e d t h a t t h e f i n d i n g s of t h i s study w i l l h e l p nurses p r o v i d e b e t t e r n u r s i n g care f o r o l d e r people. I would l i k e your p e r m i s s i o n t o i n t e r v i e w you about the n u r s i n g care you r e c e i v e d during your s t a y i n the h o s p i t a l . The i n t e r v i e w w i l l take about 20 minutes and w i l l take p l a c e i n your own home, a t your convenience w i t h i n three (3) days a f t e r you l e a v e h o s p i t a l . A l l i n f o r m a t i o n w i l l be confidential. You w i l l be f r e e t o i n t e r r u p t the i n t e r v i e w at any time, t o ask q u e s t i o n s , r e s t , or t o stop the interview e n t i r e l y . I f you are w i l l i n g t o take p a r t i n t h e study you w i l l be asked t o s i g n a consent form and I w i l l c o n t a c t you t o arrange a time f o r t h e i n t e r v i e w . The q u e s t i o n n a i r e t h a t I f i l l out d u r i n g the i n t e r v i e w w i l l be shared with my two p r o f e s s o r s o n l y . A f t e r my r e s e a r c h r e p o r t i s w r i t t e n , the completed q u e s t i o n n a i r e w i l l be destroyed. Although your p a r t i c i p a t i o n would be o f g r e a t v a l u e , you should understand t h a t you may withdraw from t h e study at any time or choose not t o take p a r t without p r e j u d i c i n g the care of y o u r s e l f or your f a m i l y member now or i n t h e future. I f you have any q u e s t i o n s concerning t h i s study, p l e a s e f e e l f r e e t o ask. You may reach me by l e a v i n g a message a t the u n i v e r s i t y a t . and I w i l l r e t u r n your c a l l . Thank you  Josephine S t e c k l e r , R.N., B.A.  96  APPENDIX B Consent Form I agree t o p a r t i c i p a t e i n the r e s e a r c h study by Josephine S t e c k l e r , a graduate U n i v e r s i t y of B r i t i s h  student i n Nursing at the  Columbia.  I have read the i n f o r m a t i o n l e t t e r and understand 1.  I w i l l be asked q u e s t i o n s about the n u r s i n g care I  The  hospitalized.  i n t e r v i e w w i l l be recorded on a q u e s t i o n n a i r e  and w i l l l a s t 3.  e x p l a i n i n g the study  that:  r e c e i v e d w h i l e I was 2.  conducted  about 20  minutes.  The q u e s t i o n n a i r e w i l l be a v a i l a b l e only t o  Josephine and her two p r o f e s s o r s and w i l l be destroyed  after  the t h e s i s has been accepted. 4.  The  5.  My  i n f o r m a t i o n obtained w i l l be r e f u s a l t o p a r t i c i p a t e or my  confidential. d e s i r e t o withdraw  from the study a t any time w i l l be r e s p e c t e d and w i l l a f f e c t any medical or n u r s i n g care I may  not  r e q u i r e i n the  future. A l l the q u e s t i o n s about the study have been answered by Josephine S t e c k l e r . information l e t t e r  I have r e c e i v e d a copy of the and consent form and  I agree t o  p a r t i c i p a t e i n the study. Signed Date  97  APPENDIX C L e t t e r t o Medical and S u r g i c a l Nursing D i r e c t o r s f o r Approval to Conduct Nursing  Research  My name i s Josephine S t e c k l e r . I am a graduate student i n n u r s i n g a t the U n i v e r s i t y of B r i t i s h Columbia c a r r y i n g out a r e s e a r c h study f o r a Master's T h e s i s . The study i s designed t o determine whether e l d e r l y c l i e n t s i n an acute care h o s p i t a l p e r c e i v e they were t r e a t e d w i t h d i g n i t y and respect. The i n f o r m a t i o n from the s e l e c t e d c l i e n t s w i l l be e l i c i t e d a f t e r they l e a v e the h o s p i t a l . They w i l l be at l e a s t 65 y e a r s of age, have been i n h o s p i t a l no l e s s than f i v e (5) days and w i l l have been a l e r t and o r i e n t e d t o time, p l a c e and person d u r i n g t h e i r e n t i r e h o s p i t a l i z a t i o n . P r i o r t o l e a v i n g h o s p i t a l the c l i e n t s who meet the e s t a b l i s h e d c r i t e r i a w i l l be approached and p r o v i d e d w i t h a w r i t t e n and v e r b a l e x p l a n a t i o n of the study and c o n s e n t i n g c l i e n t s w i l l be asked t o s i g n the consent form a t t h i s time. A p l a n t o seek consent from p r o s p e c t i v e c l i e n t s b e f o r e they l e a v e the h o s p i t a l w i l l be developed a c c o r d i n g t o the e s t a b l i s h e d r e s e a r c h p r o t o c o l of the h o s p i t a l . The i n v e s t i g a t o r w i l l meet w i t h the head nurses to e n l i s t t h e i r support i n s e l e c t i n g c l i e n t s who meet the c r i t e r i a and are being d i s c h a r g e d from h o s p i t a l . Thank you f o r your c o o p e r a t i o n i n a s s i s t i n g me accomplish t h i s r e s e a r c h study. Yours  truly  Josephine S t e c k l e r  to  98  APPENDIX D Research Tool  Age of c l i e n t Highest l e v e l of e d u c a t i o n o b t a i n e d Number of days i n h o s p i t a l Nursing u n i t - Medical / S u r g i c a l Sex To the f o l l o w i n g items code (a) (b) (c) 1.  no yes not a p p l i c a b l e  "Were you shown around the u n i t when you a r r i v e d ? " Note: Examples of o r i e n t a t i o n i n c l u d e showing l o c a t i o n of bathroom, way t o c a l l nurse, p l a c e t o put p e r s o n a l belongings.  2.  "When you were admitted t o the u n i t d i d someone i n t r o d u c e you t o your roommate?" Note:  3.  Code NA i f p a t i e n t i n p r i v a t e room.  "Have you been informed o f the a v a i l a b i l i t y of r e l i g i o u s counselor and f a c i l i t i e s ? " I f y e s , ask p a t i e n t : "Was t h i s Information p r o v i d e d t o you by a nurse?" Note: Code NA i f i n f o r m a t i o n was g i v e n by c l e r k or h o s p i t a l brochure.  Nursing Process Q u a l i t y M o n i t o r i n g Instrument (Medicus Canada). Used w i t h p e r m i s s i o n (Sue Hegyvary, p e r s o n a l communication, September 12, 1988).  99  To the f o l l o w i n g items code (a) (b) (c) (d) (e) 4.  no yes yes yes not  some of the time most of the time a l l of t h e time applicable  "Have you had any t e s t s or procedures w h i l e you've been in this hospital?" I f y e s , ask: "Were they e x p l a i n e d t o you by your nurse b e f o r e they were done?"  5.  "Have your nurses i n t r o d u c e d themselves t o you?"  6.  "Have your nurses c a l l e d you by your f i r s t name without your p e r m i s s i o n ? "  7.  "Have your nurses addressed you by names other than Miss, Mr., or Mrs.?" Note:  Other names i n c l u d e granny, grampa, dear, e t c .  8.  "When you had an examination or treatment and a nurse was i n the room, were the c u r t a i n s drawn around you or was the door c l o s e d ? "  9.  "Have you f e l t i n a p p r o p r i a t e l y exposed d u r i n g a bath, exam, or procedure w h i l e on t h i s u n i t ? "  10.  "While you were i n the h o s p i t a l , were you g i v e n an o p p o r t u n i t y t o d i s c u s s your f e e l i n g s or concerns w i t h your nurse?"  100  APPENDIX E R e s u l t s o f Items f r o m Q u e s t i o n n a i r e f o r T o t a l G r o u p (age 6 5 - 9 1 ) , " Y o u n g e r O l d " (age 6 5 - 7 4 ) , " O l d e r O l d " (age 7 5 - 9 1 ) , R e l a t e d t o D i g n i t y a n d R e s p e c t  Item 1 .  Orientation to unit related differences.  t o age g r o u p  Code  T o t a l Group n = 62(%)  Age 65-74 n = 25(%)  Age 75+ n = 37(%)  No Yes NA  16 44 2  2 22 1  14 22 1  Item 2 .  (26) (71) (3)  Acre a r o u o d i f f e r e n c e s roommate.  related  (8) (88) (4)  to introduction  (38) (59) (3)  to  Code  T o t a l Group n = 62(%)  Age 65-74 n = 25(%)  Age 75+ n = 37(%)  No Yes NA  34 19 9  9 11 5  25 8 4  (55) (31) (14)  (36) (44) (20)  (67) (22) (11)  101 Item 3 .  Knowledge a b o u t a v a i l a b i l i t y o f r e l i g i o u s c o u n s e l l o r s a n d f a c i l i t i e s r e l a t e d t o age group d i f f e r e n c e s .  Code  T o t a l Group n = 62(%)  Age 65-74 n = 25(%)  Age 75+ n = 37(%)  No Yes NA  37 8 17  10 3 12  27 5 5  Item 4.  E x p l a n a t i o n of t e s t procedures differences.  Code  No Yes, Yes, Yes, NA  some o f t h e t i m e most o f t h e t i m e a l l the time  Item 5.  some o f t h e t i m e most o f t h e t i m e a l l the time  (40) (12) (48)  (74) (13) (13)  r e l a t e d t o age g r o u p  T o t a l Group n = 62(%)  Age 65-74 n = 25(%)  Age 75+ n = 37(%)  7 29 9 14 3  0 10 4 9 2  7 19 5 5 1  (11) (47) (14) (23) (5)  Frequency w i t h which r e l a t e d t o age g r o u p  Code  No Yes, Yes, Yes,  (60) (13) (27)  (0) (40) (16) (36) (8)  nurses introduce differences.  (19) (51) (13) (13) (3)  themselves  T o t a l Group n = 62(%)  Age 65-74 n = 25(%)  Age 75+ n = 37(%)  0 14 21 27  0 3 11 11  0 11 10 16  (0) (23) (34) (43)  (0) (12) (44) (44)  (0) (30) (27) (43)  102 Item 6.  Frequency of nurses a d d r e s s i n g p a t i e n t by t h e i r f i r s t name without p e r m i s s i o n .  Code  No Yes, some of the time Yes, most o f the time Yes, a l l t h e time  Item 7.  Age 65-74 n = 25(%)  Age 75+ n = 37(%)  31 9 13 9  16 (64) 2 (8) 3 (12) 4 (16)  15 7 10 5  (50) (15) (21) (14)  (41) (19) (27) (13)  Frequency of nurses a d d r e s s i n g p a t i e n t s other than Miss, Mr., or Mrs.  Code  NO Yes, some of the time Yes, most of the time Yes, a l l t h e time  Item 8.  T o t a l Group n = 62(%)  T o t a l Group n = 62(%)  Age 65-74 n = 25(%)  Age 75+ n = 37(%)  37 (60) 32 (35) 3 (5) 0 (0)  18 (72) 5 (20) 2 (8) 0 (0)  19 (51) 17 (46) 1 (3) 0 (0)  P r o v i s i o n of p r i v a c y d u r i n g examination or treatments.  Code  NO Yes, some o f the time Yes, most of the time Yes, a l l the time  T o t a l Group n = 62(%)  Age 65-74 n = 25(%)  Age 75+ n = 37(%)  0 (0) 0 (0) 8 (13) 54 (87)  0 (0) 0 (0) 4 (16) 21 (84)  0 (0) 0 (0) 4 (11) 33 (89)  103 Item 9.  Age r e l a t e d d i f f e r e n c e s and i n a p p r o p r i a t e exposure d u r i n g bathing* examination, or procedure.  Code  No Yes, some of the time Yes, most of the time Yes, a l l the time  Item 10.  T o t a l Group n = 62(%)  Age 65-74 n = 25(%)  Age 75+ n = 37(%)  51 (82) 7 (11) 1 (2) 3 (5)  21 (84) 3 (12) 0 (0) 1 (4)  30 (81) 4 (11) 1 (3) 2 (5)  Age r e l a t e d d i f f e r e n c e s and o p p o r t u n i t y t o d i s c u s s f e e l i n g s and concerns w i t h the nurse.  Code  No Yes, some of the time Yes, most of the time Yes, a l l the time  T o t a l Group n = 62(%)  Age 65-74 n = 25(%)  Age 75+ n = 37(%)  25 (40) 25 (39) 10 (16) 3 (5)  7 (28) 12 (48) 4 (16) 2 (8)  18 (49) 12 (32) 6 (16) 1 (3)  104  APPENDIX F R e s u l t s from Items on Q u e s t i o n n a i r e R e l a t e d to L e v e l of E d u c a t i o n (Socioeconomic S t a t u s ) and D i g n i t y and Respect  Item 1.  O r i e n t a t i o n t o t h e u n i t r e l a t e d t o l e v e l of education.  Code  Elementary Education n = 27(%)  Secondary Education n = 35(%)  No Yes NA  7 (26) 20 (74) 0 (0)  9 (26) 25 (71) 1 (3)  Item 2.  I n t r o d u c t i o n t o roommates r e l a t e d t o l e v e l of education.  Code  Elementary Education n = 27(%)  Secondary Education n = 35(%)  No Yes NA  15 (67) 7 (26) 2 (7)  16 (46) 12 (34) 7 (20)  105 Item 3.  Knowledge a v a i l a b i l i t y education.  r e l a t e d t o l e v e l of  Code  Elementary Education n = 27(%)  Secondary Education n = 35(%)  No Yes NA  17 (63) 5 (19) 5 (18)  20 (57) 3 (9) 12 (34)  Item 4.  E x p l a n a t i o n of procedures r e l a t e d t o l e v e l of education.  Code  No Yes, some of t h e time Yes, most of t h e time Yes, a l l t h e time NA  Item 5.  Elementary Education n = 27(%)  Secondary Education n = 35(%)  4 (15) 18 (67) 3 (11) 11 (7) 0 (0)  4 11 6 12 2  Nurses i n t r o d u c i n g themselves education.  Code  No Yes, some of t h e time Yes, most of t h e time Yes, a l l the time  (11) (32) (17) (34) ( 0)  r e l a t e d to l e v e l of  Elementary Education n = 27(%)  Secondary Education n = 35(%)  0 (0) 10 (37) 8 (30) 9 (33)  0 (0) 5 (14) 13 (37) 17 (49)  106 Item 6.  Addressing p a t i e n t s by t h e i r to l e v e l o f e d u c a t i o n .  f i r s t name  Elementary Education n = 27(%)  Code  No Yes, some of t h e time Yes* most of the time Yes, a l l the time  9 6 9 3  (33) (22) (33) (11)  related  Secondary Education n = 35(%) 7 5 11 12  (20) (15) (31) (34)  Item 6a.  Code  Elementary n = 27(%)  No Yes, some o f the time Yes, most of the time Yes, a l l the time  Item 7.  9 6 9 3  (33) (22) (33) (ID  Secondary n = 27(%) 0 (0) 4 (15) 11 (41) 12 (44)  PostSecondary n = 8(%) 7 (88) 1 (12) 0 (0) 0 (0)  Addressing p a t i e n t s by names other than Miss, Mr., or Mrs. r e l a t e d t o l e v e l of e d u c a t i o n .  Code  No Yes, some o f t h e time Yes, most of the time Yes, a l l t h e time  Elementary Education n = 27(%)  Secondary Education n = 35(%)  15 (56) 12 (44) 0 (0) 0 (0)  22 (63) 10 (28) 3 (9) 0 (0)  107 Item 8.  Drawing c u r t a i n s around p a t i e n t r e l a t e d to l e v e l of e d u c a t i o n .  Code  No Yes, Yes, Yes,  some o f t h e t i m e most o f t h e t i m e a l l the time  Item 9.  some o f t h e t i m e most o f t h e t i m e a l l the time  Item 1 0 .  No Yes, Yes, Yes,  examination  Elementary Education n = 27(%)  Secondary Education n = 35(%)  0 0 5 22  0 0 3 32  (0) (0) (19) (81)  I n a p p r o p r i a t e e x p o s u r e d u r i n g b a t h , exam, procedure r e l a t e d to l e v e l of e d u c a t i o n .  Code  No Yes, Yes, Yes,  during  (0) (0) (9) (91)  or  Elementary Education n = 27(%)  Secondary Education n = 35(%)  20 5 1 1  32 3 0 0  (74) (18) (4) (4)  (91) (9) (0) (0)  O p p o r t u n i t y t o d i s c u s s f e e l i n g s and c o n c e r n s nurse r e l a t e d to l e v e l of e d u c a t i o n .  with  Code  Elementary Education n = 27(%)  Secondary Education n = 35(%)  some o f t h e t i m e most o f t h e t i m e a l l the time  11 12 3 1  14 13 7 1  (41) (44) (11) (4)  (40) (37) (20) (3)  

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