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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 University, 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 thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA September 1990 (d) Josephine Steckler, 1990 In p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t of the requirements f o r an advanced degree at the U n i v e r s i t y of B r i t i s h Columbia, I agree t h a t the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and study. I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e copying of t h i s t h e s i s f o r s c h o l a r l y purposes may be granted by the Head of my department or by h i s or her r e p r e s e n t a t i v e s . I t i s understood t h a t copying or p u b l i c a t i o n of t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not be allowed without my w r i t t e n p e r m i s s i o n . The U n i v e r s i t y of B r i t i s h Columbia Vancouver, Canada, V6T 1W5 Abstract The purpose of t h i s study was to investigate whether elderly c l i e n t s i n an acute care setting perceived themselves as being treated with dignity and respect, and whether c l i e n t s with a higher socioeconomic status are more l i k e l y than c l i e n t s with a lower socioeconomic status to be treated with dignity and respect. Sixty-two el d e r l y c l i e n t s who had been i n hospital at le a s t f i v e days, were a l e r t and oriented during th e i r h o s p i t a l i z a t i o n , and could speak English were selected for the study. Using a convenience sampling technique, the c l i e n t s were selected from medical and s u r g i c a l units of two major teaching hospitals. They were interviewed within three days afte r discharge to respond to items on a questionnaire selected from the Medicus Quality Assurance Tool. The r e s u l t s of the study show that e l d e r l y c l i e n t s may not perceive that they are consistently treated with dignity and respect. Older c l i e n t s (75+ years) are l e s s l i k e l y than younger older c l i e n t s (65-74) to be treated with dignity and respect, and el d e r l y c l i e n t s with a lower socioeconomic status and women, are le s s l i k e l y to be treated with dignity and respect. i i i Table of Contents Page Abstract i i Table of Contents i i i L i s t of Tables v i Acknowledgements v i i CHAPTER 1. Introduction to the Study 1 Background to the Study 7 Problem Statement 10 Purpose of the Study . 11 Theoretical Framework 12 D e f i n i t i o n of Terms 18 Assumptions 19 Limitations 20 Summary . 20 CHAPTER 2. Review of Selected Literature 21 Growth of the Elderly Population . . . . . . . . 21 Basic Human Needs and the Elder l y Population . . 24 The Hospitalized Elderly . . 28 Aging and Self-Esteem 30 Et h i c a l Considerations i n the Nursing Care of the Elderly Client 33 Attitudes of Nurses toward the Elderly 37 The Elderly's Perception of t h e i r Nursing Care . . 42 Summary 43 i v 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 Rights Protection 49 Data Analysis 49 Summary . . . . . . . . . 50 CHAPTER 4. Presentation and Discussion of the Results 51 Introduction 51 Characteristics of the Sample 51 Research Findings and Discussion 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 Letter 95 B: Consent Form 96 C: Letter for Agency Entry 97 D: Research Tool 98 E: Results of Items from Questionnaire Related to Dignity and Respect 100 F: Results of Items from Questionnaire Related to Level of Education and Dignity and Respect 104 v i L i s t of Tables Page Table 1. O r i e n t a t i o n t o u n i t r e l a t e d t o age group d i f f e r e n c e s . . . . . 55 Table 2. Age group d i f f e r e n c e s r e l a t e d t o i n t r o d u c t i o n t o roommate 55 v i i Acknowledgements I would l i k e t o g r a t e f u l l y acknowledge the p r o f e s s o r s who were the members of my t h e s i s committee, Helen Shore (chairperson) and Ray Thompson, f o r the optimal l e a r n i n g atmosphere t h a t supported me through the process of my r e s e a r c h : t h e i r e x p e r t i s e , t h e i r encouragement, and t h e i r guidance. I would a l s o l i k e t o thank C h r i s Bradley and A l i c e Jope f o r t h e i r a s s i s t a n c e i n g a i n i n g e n t r y i n t o s e t t i n g s where I c o u l d do my r e s e a r c h . For a l l o w i n g me i n t o t h e i r homes to i n t e r v i e w them, I would l i k e t o express my thanks t o the sixty-two o l d e r a d u l t s who p a r t i c i p a t e d i n my study. F i n a l l y , I wish t o thank my husband Robert and our e i g h t wonderful c h i l d r e n f o r t h e i r support, encouragement, and continued i n t e r e s t i n my work. 1 CHAPTER 1 Introduction to the Study Nurses' attitudes toward elderly c l i e n t s have received increasing attention i n recent years. There are three reasons for t h i s i n t e r e s t . F i r s t , there i s an increase i n the number of e l d e r l y c l i e n t s who require nursing services since health service usage r i s e s dramatically with age and there i s an increase i n the absolute numbers of aged (Gutman, Gee, Bojanowski, & Mottet, 1986; Roos, Shapiro, & Roos, 1984; Stone & Fletcher, 1986). While acute care hospital usage has f a l l e n i n B r i t i s h Columbia, t h i s decline i s not seen among the e l d e r l y (Gutman et a l . , 1986). Approximately 10% to 15% of a l l beds i n acute care hospitals are occupied by e l d e r l y people waiting for 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, studies show that registered nurses l e a s t prefer working with the elderly (Campbell, 1971; Smith, Jepson, & P e r l o f f , 1982). While 74% of registered nurses work in acute care hospitals, they do not l i k e to nurse older people (Mantle, 1988b). Third, registered nurses who hold negative attitudes toward the e l d e r l y may engage i n behaviors which w i l l not be therapeutic or may be detrimental to the best i n t e r e s t s of the e l d e r l y c l i e n t (Brower, 1981). The e l d e r l y are not a homogenous group but d i f f e r widely i n t h e i r physical and psychosocial status. Moreover, 2 old age i s not necessarily i n d i c a t i v e of decline. Even though obvious physical changes occur, aging need not be equated with i l l n e s s or disease. As a group, however, older persons are more l i k e l y to experience multiple chronic and disabling conditions (Bossenmaier, 1982; Chappell, Strain, & Blandford, 1986). The r i s k with these chronic conditions and a c t i v i t y l i m i t a t i o n s i s for further decline i n function and acute exacerbation of disease (Bossenmaier, 1982; G i o i e l l a & B e v i l , 1985). The age-related physiologic and psychosocial changes that occur also predispose the older c l i e n t to r i s k , 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 example, changes i n v i s i o n , hearing, and other sensory modalities can a f f e c t cognitive function and predispose the e l d e r l y c l i e n t to a state of confusion (Burnside, 1988; Chodil & Williams, 1970; Worrell, 1977). According to these authors, the in d i v i d u a l imputes meaning to the environment through sensory i n t e r a c t i o n . Use of color, l i g h t , and texture, attention to a c t i v i t y and sounds, placement of equipment, furnishings, and mobility aids as well as caregiver i n t e r a c t i o n can promote or hinder meaningful environmental exchange. If the hospital does not promote meaningful environmental in t e r a c t i o n , a frequent outcome i s an acute confusional state. Confusional states i n the e l d e r l y person increase the p o s s i b i l i t y for f a l l s , incontinence, sleep disturbances and mobility, n u t r i t i o n a l , and skin problems. 3 As a r e s u l t , dependency and the requirement for nursing care increases. Old age i s also characterized by l o s s . Many hospitalized older c l i e n t s have already experienced a loss of job, income, possessions, r e l a t i v e s , friends, and even a spouse or home. The circumstances necessitating h o s p i t a l i z a t i o n may mean further losses, functional a b i l i t y , or independence (Burnside, 1988; Ebersole & Hess, 1985). Together with the normal age-related changes and the multiple health problems already present, the older hospitalized c l i e n t i s highly vulnerable. Diminished physiologic reserves and a decreased capacity to adapt to unfamiliar surroundings are additional c h a r a c t e r i s t i c s which further render the hospi t a l i z e d older c l i e n t at ris 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 , safe l i v i n g environment to the strange, unfamiliar hospital setting that requires interacting with unfamiliar people threatens 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 (Burnside, 1988; Ebersole & Hess, 1985; Gunter, 1983). These authors point out that every nurse i s personally responsible and accountable for nursing practice delivered to c l i e n t s , and that includes e l d e r l y c l i e n t s . Nursing practice guided by models provide a certa i n frame of reference for nurses, t e l l i n g them what to look at and to speculate about (Fawcett, 1984). Each conceptual 4 model has u t i l i t y for professional nursing because of the organization i t provides for thinking, observing, and interpreting i n the use of the nursing process (Leddy & Pepper, 1985). Models also provide the nurse with a way i n which to view the c l i e n t , and the role and function of nursing. One such model, the UBC Model for Nursing (Campbell, 1987) i s a behavioral system model made up of nine subsystems that are i n t e r r e l a t i n g and interdependent. Each subsystem i s responsible for the s a t i s f a c t i o n of a basic human need. The nine needs related to each of the subsystems include the need for (1) balance between production 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) intake of food and f l u i d s , nourishment; (4) intake of oxygen; (5) love, belongingness, and dependence; (6) mastery; (7) respect of s e l f by s e l f and others; (8) safety and security; and (9) stimulation of the system's senses (hearing, v i s i o n , smell, touch, and ta s t e ) . The c l i e n t uses coping behaviors to s a t i s f y each basic human need. Forces (as defined i n the UBC Model for Nursing) determine movement toward or away from goal achievement. Goal achievement means need s a t i s f a c t i o n . I t i s important to recognize that a force (personal, impersonal, or sociocultural) may act p o s i t i v e l y toward one need and negatively toward another, and that a coping behavior which i s suitable to s a t i s f y one need may act as a 5 ne g a t i v e f o r c e i n s a t i s f y i n g another. A f o r c e which may a c t n e g a t i v e l y toward one subsystem, may a l s o a c t as a neg a t i v e f o r c e toward other subsystems. T h i s n o t i o n i s of p a r t i c u l a r importance when using the model t o p l a n care f o r the e l d e r l y c l i e n t . For example, f a i l i n g t o o r i e n t a t e an e l d e r l y c l i e n t to h i s surrounding and i n t r o d u c e him t o h i s roommates may act as a neg a t i v e f o r c e not only on the A c h i e v i n g subsystem, but the E g o - v a l u a t i v e and P r o t e c t i v e subsystems as w e l l . The UBC Model f o r Nursing d e f i n e s n u r s i n g ' s unique 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 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 i n the l i f e c y c l e so t h a t they may develop and use a range of coping behaviors t h a t permit them t o s a t i s f y t h e i r b a s i c human needs, t o achieve s t a b i l i t y and to reach optimal h e a l t h " (p. 10). A c r i t i c a l p e r i o d , a c c o r d i n g t o t h i s model, i s an event 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 t h a t r e q u i r e s the i n d i v i d u a l t o develop and use s u i t a b l e coping behaviors t o s a t i s f y h i s b a s i c human needs. These c r i t i c a l p e r i o d s i n c l u d e m a t u r a t i o n a l and u n p r e d i c t a b l e events. M a t u r a t i o n a l events a re those changes which occur with some p r e d i c t a b i l i t y d u r i n g an i n d i v i d u a l ' s l i f e . A c c o r d i n g to the UBC Model f o r Nursing, these events i n c l u d e body changes (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 ) , g e o g r a p h i c a l change (move to a d i f f e r e n t c i t y or neighbourhood), i n t r a f a m i l i a l change (change w i t h i n the f a m i l y w i t h r e s p e c t t o number, membership, or l o c a t i o n of f a m i l y members), r o l e change, s o c i a l i n t e r a c t i o n changes 6 (change i n human rel a t i o n s h i p s ) , or work career change. Unpredictable events are those changes which occur with l i t t l e or no warning. Categories of these events may include aberrant c e l l 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 disorders, degenerative processes, immunologic disorders, infectious processes, trauma, and separation (physical disconnection of an ind 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 to practice nursing i n such a way as to a s s i s t the el d e r l y c l i e n t who i s experiencing a c r i t i c a l period (unpredictable or maturational) to achieve optimal health within a collaborative and caring rela t i o n s h i p (Burnside, 1988; Ebersole & Hess, 1985; Gunter, 1983; Lueckenotte, 1987). According to these authors, negative and nonsupporting attitudes of nurses contribute to the v u l n e r a b i l i t y of the aged and a f f e c t the qu a l i t y of care they receive. Although there have been several studies that investigate the quality of nursing care the elderly receive, there has been l i t t l e attention given to el d e r l y c l i e n t s ' perceptions of t h e i r care. More recently, however, elderly hospitalized c l i e n t s report a threat to the i r self-esteem when nurses' behaviors toward them indicate a lack of dignity and respect (Mclnnes, 1987). Self-esteem i s an inner assurance of personal worth 7 based on feelings of being valued, useful, and competent (Ebersole & Hess, 1985). It i s the evaluative component of the self-concept. Roy (1976) defined self-concept as a combination of the feelings and b e l i e f s one holds i n regards to oneself. According to Maslow (1970), people have basic human needs and a l l persons "have a need or desire for a stable, f i r m l y based, usually high evaluation of themselves, for self-respect or self-esteem, and for the esteem of others" (p. 90). Maslow i d e n t i f i e d two subsets of esteem needs: self-esteem needs (strength, achievement, mastery and competence, confidence i n the face of the world, independence, and freedom), and respect needs or the need for esteem from others (status, dominance, recognition, attention, importance, and appreciation). The el d e r l y person may have a s o l i d foundation i n a l l these areas based on past achievements, present success, or personal i n t e g r i t y . Self-esteem, however, may be threatenend during a c r i t i c a l period when the elde r l y c l i e n t i s unable to develop suitable coping behaviors to meet his basic human needs for mastery (feeling of accomplishment), for love, belongingness and independence, and for respect of s e l f by s e l f and others (Campbell, 1987). Background to the Study As a r e s u l t of demographic changes, the proportion of health care resources committed to the care of the e l d e r l y w i l l continue to increase. When today's nursing students 8 reach the prime of t h e i r careers, they w i l l l i k e l y spend 75% of t h e i r practice time with the e l d e r l y (Butler, 1980). Evidence indicates that attitudes nurses hold about the aged influence the q u a l i t y of services they provide (Hatton, 1977; Wolk & Wolk, 1971). Certain perceptions held by nurses adversely influence the nursing care the eld e r l y receive. The eld e r l y are generally perceived by younger people as phy s i c a l l y and mentally on the decline, s o c i a l l y withdrawn and unproductive i n society (Schonfield, 1982). Certain physical or behavioral c h a r a c t e r i s t i c s of elderly c l i e n t s can a f f e c t the attitudes of nursing personnel who provide t h e i r care ( E l l i o t t & Hyberton, 1982). El d e r l y c l i e n t s may also respond behaviorally to the attitudes and behaviors of nurses. The elderly may be forced into patterns of behavior by the behavior of nurses toward them (White, 1977). According to t h i s author, the elderly c l i e n t may lack the strength or w i l l to r e s i s t the patterning and expectations put on them by persons i n t h e i r environment. The e l d e r l y are the most stereotyped of any age group ( G i o i e l l a & B e v i l , 1985). These authors state that b e l i e f s influence attitudes which influence feelings, and that negative presentation of the eld 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 contribute to negative b e l i e f s and attitudes toward the e l d e r l y . 9 There have been many studies by s o c i a l s c i e n t i s t s on attitudes toward aging and the aged. Many have revealed negative attitudes toward the aged ( S t e f f i , 1984a). Authors such as Burnside (1988), Dolinsky (1984), and E l l i o t t and Hyberton (1982) state that negative attitudes and attr i b u t i o n s on the part of nursing personnel result i n les s than adequate care for the el d e r l y . Negative att r i b u t i o n s may be in t e r n a l i z e d by an elde r l y person, and may subsequently influence h i s or her b e l i e f s , behaviors, and self-concept (Cherry, 1981). The value a person places upon himself i s a r e s u l t of the s o c i a l interplay which occurs between himself and those i n his environment. Cooley (1922) coined the term, the "looking glass s e l f " . According to Cooley, when a person observes himself i n a mirror, he does not see himself as merely a mechanical r e f l e c t i o n . He imagines what e f f e c t h is r e f l e c t i o n would have upon another person and what would be the other's responses and judgment. As he imagines what t h i s would be* he adopts i t and so views himself as he imagines the other person would. The person's sense of s e l f i s derived from his d e f i n i t i o n of a l l his various roles, values, and goals which have been conveyed to him by others since b i r t h (Cherry, 1981). Hospitalized el d e r l y c l i e n t s derive ideas about themselves according to what they "read" into the behaviors of the nurse, either d i r e c t l y or i n d i r e c t l y (through p o l i c i e s and r u l e s ) . For example/ r a i s i n g the s i d e r a i l s of a l l older c l i e n t s because 10 of t h e i r age rather than on the individual's a b i l i t y fosters dependent behaviors and threatens the c l i e n t s ' self-esteem. This has serious implications for nursing practice since the achievement of independent performance of functional l i v i n g s k i l l s i s greatly influenced by self-esteem. According to Gunter (1983) and Burnside (1988), nurses need to become aware of the importance of t h e i r own behavior i n the care of e l d e r l y c l i e n t s , and that treating older c l i e n t s with dignity and respect maintains or restores t h e i r self-esteem. Eld e r l y c l i e n t s , however, report that nurses' behaviours toward them indicate a lack of dignity and respect (Mclnnes, 1987). Although there are several studies which investigate the q u a l i t y of care the el d e r l y receive, there has been very l i t t l e attention given to the e l d e r l y c l i e n t ' s perceptions 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 relates to dignity and respect. This 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 hospital perceived they were treated with dignity and respect and whether some el d e r l y c l i e n t s were more l i k e l y than others to be treated with dignity and respect. Problem Statement The effectiveness and quality of nursing care administered to the el d e r l y i s greatly influenced by nurses' attitudes toward t h i s group of people (Alford, 1982; Brower, 11 1981; Burnside, 1988; Hatton, 1977; S t o r l i c , 1982; Wolk & Wolkf 1971). Recently, the el d e r l y have begun to speak out on the q u a l i t y of nursing care they receive. More s p e c i f i c a l l y , the el d e r l y report they are not treated with dignity and respect and are made to f e e l l i k e second-class c i t i z e n s (Mclnnes, 1987). According to the Code of Ethics for Nursing (Canadian Nurses Association, 1985), a c l i e n t ' s right to be treated i n a d i g n i f i e d fashion must be r e f l e c t e d i n the nurse's own behavior. The Code contains values concerned with the r e s p o n s i b i l i t y of the nurse's behavior to treat c l i e n t s with dignity and respect. Two of these values are: (1) "A nurse i s obliged to treat c l i e n t s with respect for t h e i r i n d i v i d u a l needs and values" (Canadian Nurses Association, 1985, p. 4), and (2) "the nurse has an obligation to be guided by consideration f o r the dignity of c l i e n t s " (Canadian Nurses Association, 1985, p. 7). Although there are studies which examine the q u a l i t y of nursing care the el d e r l y receive, there has been very l i t t l e attention given to the el d e r l y c l i e n t s * perceptions 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 relates to dignity and respect. Purpose of the Study The purpose of t h i s study was to explore whether elde r l y c l i e n t s i n an acute care hospital perceived they were treated with dignity and respect and whether eld e r l y 12 c l i e n t s with a h i g h e r socioeconomic s t a t u s were more l i k e l y than o t h e r s t o 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 r e s p e c t . Whether e l d e r l y 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 was determined by e l i c i t i n g v e r b a l responses to items on a q u e s t i o n n a i r e . The 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 t o answer were: 1. Do e l d e r l y c l i e n t s i n acute care h o s p i t a l s p e r c e i v e 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 ? 2. Are e l d e r l y c l i e n t s w i t h i n a hig h e r socioeconomic s t a t u s more l i k e l y t o 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 r e s p e c t than c l i e n t s with a lower socioeconomic s t a t u s ? The f o l l o w i n g s e c t i o n e x p l a i n s the t h e o r e t i c a l framework used t o guide the i n v e s t i g a t i o n . T h e o r e t i c a l Framework Symbolic i n t e r a c t i o n i s m was chosen t o serve as the t h e o r e t i c a l framework f o r t h i s study. T h i s theory i s adaptable t o i n v e s t i g a t i n g how we may develop a t t i t u d e s 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 of o t h e r s towards us. From the p e r s p e c t i v e of symbolic i n t e r a c t i o n i s m , s o c i a l r e a l i t y i s seen t o be c o n s t r u c t e d through a process of i n t e r a c t i o n between i n d i v i d u a l s (Blumer, 1969; S t r y k e r , 1980). Through t h i s i n t e r a c t i o n , i n d i v i d u a l s g i v e meaning to o b j e c t s and s i t u a t i o n s they encounter and experience. 13 These objects or situations have no inherent meaning for an i n d i v i d u a l since the meaning emanates from the way the object i s defined by those with whom the i n d i v i d u a l interacts (Blumer, 1969; Meltzer, Petras, & Reynolds, 1977). How we interact with others involves interpreting the meaning of the action of others and our own previous experience (Blumer, 1969). This interpreted meaning then acts as a basis for action that r e f l e c t s our own intended meaning. Since i n t e r a c t i o n involves r e c i p r o c a l l y influenced behavior, s o c i a l i n t e r a c t i o n i s considered to be the determiner or reactor of behavior, not merely a form of i t s expression (Blumer, 1969; Meltzer et a l . , 1977). Charles H. Cooley (1922) and George Herbert Mead (1934) are two of the founders of the symbolic i n t e r a c t i o n i s t approach (Meltzer et a l . , 1977). They noted that a person's self-concept i s a s o c i a l phenomenon. It develops as a r e s u l t of the variety of roles taken on by the person i n s o c i a l i n t e r a c t i o n . In t h i s approach the i n d i v i d u a l i s considered to be an active participant i n a s p e c i f i c s o c i a l s i t u a t i o n or setting. During t h i s process the i n d i v i d u a l defines and interprets a s p e c i f i c s e t t i n g , i n personal terms, because of in t e r a c t i n g with others who are of significance to him verbally or symbolically (through dress, language, gestures and mannerisms). In t h i s way, s o c i a l meaning i s attributed to the symbols and behaviors, and thus shared meanings of the s i t u a t i o n or setting are derived 14 according to the meaning the s i t u a t i o n has for each i n d i v i d u a l . Symbolic interactionism involves three processes that culminate i n s p e c i f i c meanings and therefore i n cognitive or behavioral acts. F i r s t , the individual defines the s o c i a l s i t u a t i o n i n terms of how i t operates and what i t means for him/her (Blumer, 1969; Thomas, 1934). Second, according to Cooley (1922), individuals observe and interact with others i n order to analyze and arrive at a d e f i n i t i o n of the " s e l f " . In t h i s way, we as individuals consider how others see us and how others evaluate what they see i n us. As a r e s u l t of t h i s evaluation and interpretation, which i s ongoing and continuous, we ar r i v e at a view of ourselves and the s i t u a t i o n , and behave accordingly. The t h i r d process involves what Goffman (1959) c a l l s "the presentation of s e l f " . Individuals define the s i t u a t i o n and setting and then decide how they w i l l present themselves to others i n terms of dress, manner, and content of i n t e r a c t i o n and behaviors. According to t h i s author, the type of dress, speech, and behavior pattern i s selected i n order to present a s e l f which i s appropriate to the s p e c i f i c s i t u a t i o n . Symbolic interactionism represents an examination or analysis 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 that occurs i n everyday l i f e . The emphasis, then r i s on s o c i a l i n t e r a c t i o n as a process, and the various meanings and interpretations each pa r t i c i p a n t brings to that i n t e r a c t i o n . 15 Its main concern i s with how each individual interprets and assigns meaning to a s p e c i f i c s i t u a t i o n , behavior, or event. This meaning emphasizes the importance of feedback from s i g n i f i c a n t others i n the development of "the s e l f " . According to Jourard (1974), people's views of themselves are strongly influenced by others' d e f i n i t i o n of them; we continually i n s t r u c t others as to how they should perceive us. This author points out that t h i s v u l n e r a b i l i t y to another's influence may be a l i a b i l i t y or an asset. If others project a negative a t t r i b u t e on another person, t h i s a t t r i b u t e may be i n t e r n a l i z e d by the person, making the v u l n e r a b i l i t y a d e f i n i t e 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 asset, however, i f a s i g n i f i c a n t other projects an att r i b u t e of worthiness and strength to a person. In t h i s way, the person's self-concept i s maintained or enhanced. The term "self-concept" refers to the attitude and evaluation an in d i v i d u a l has concerning himself or the way the s e l f i s evaluated. In f a c t , we may develop attitudes about ourselves on the basis of attitudes toward us i n given settings. According to Cooley (1922) and Mead (1934), an indi v i d u a l ' s self-concept i s a s o c i a l phenomenon. It develops as a res u l t of the variety of roles taken on by the ind i v i d u a l i n s o c i a l i n t e r a c t i o n . That i s , the s e l f r e f l e c t s the responses of others toward the i n d i v i d u a l , as perceived by the individual's own a b i l i t y i n understanding how others see him or her. 16 According to Mead (1934), one's self-concept i s never gained nor maintained once and for a l l and i s quite open to change and development over time. It i s highly i n t e r r e l a t e d with other people's perception of us. Proponents of a symbolic i n t e r a c t i o n i s t view maintain that aging outcomes r e f l e c t the reciprocal relationship between the individual and his or her s o c i a l environment; the ind i v i d u a l simultaneously externalizes his own being into the s o c i a l world and in t e r n a l i z e s i t as an objective r e a l i t y (Cherry, 1981). According to thi s author, fee l i n g s of self-worth and l i f e s a t i s f a c t i o n are maximized when there i s congruence between the individual's self-concept, his inter p r e t a t i o n of the behavior and the behavior of others i n r e l a t i o n to him. In r e l a t i o n to the hospital s e t t i n g , the el d e r l y c l i e n t ' s self-concept during a c r i t i c a l period may be maintained or enhanced i f h i s basic human needs for accomplishment (mastery), love, belongingness and dependence, and respect of s e l f by s e l f and others ( s e l f -esteem) are met. These needs are l a r g e l y met through s o c i a l i n t e r a c t i o n by the c l i e n t developing those coping behaviors capable of maintaining need s a t i s f a c t i o n and goal achievement. That i s to say, the el d e r l y c l i e n t ' s coping behaviors are influenced by the meanings he/she attaches to the behavior of nurses toward him or her (Blumer, 1969; Jourard, 1974). When nurses introduce the c l i e n t to t h e i r surroundings, provide them with information, address them 17 appropriately, insure t h e i r need for privacy, explain procedures before they are done, and provide an opportunity for c l i e n t s to express t h e i r fears and concerns, they are treating c l i e n t s with dignity and respect. The meaning those nursing actions have for elderly c l i e n t s maintain or enhance t h e i r self-concept. Conversely, the e l d e r l y c l i e n t ' s self-concept w i l l be threatened during a c r i t i c a l period i f nursing interventions do not a s s i s t him to develop suitable coping behaviors to meet his needs for mastery, love, belonginess and dependence, and self-esteem. Meanings are modified and dealt with through an in t e r p r e t a t i v e process used by persons i n dealing with those things they encounter (Blumer, 1969). The e l d e r l y c l i e n t ' s self-concept i s not diminished and may be enhanced i f there i s congruence between what the c l i e n t s believe about themselves, and the interpretation of the action of others i n r e l a t i o n to them. Through a process of 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 c l i e n t s ' perceptions and actions may be influenced by how care-givers (registered nurses) view e l d e r l y people. If the actions and behaviors of the care-givers are incongruent with el d e r l y c l i e n t ' s p o s i t i v e perceptions of themselves, the s e l f -concept i s undermined (Kuypers & Bengston, 1973). These authors argue that the e l d e r l y i n t e r n a l i z e these external evaluations and begin to behave as expected (the s e l f -f u l f i l l i n g prophecy). Davis (1968) asserts that older people tend to adopt whatever role i s expected of them. According to Cherry (1981), negative at 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 influence her b e l i e f s , behaviors, and self-concept. Given t h i s framework, the focus of t h i s study was to explore whether eld e r l y c l i e n t s (in an acute care setting) perceived the actions and behaviors of nurses towards them were congruent with th e i r perceptions of themselves (their self-concept). This information was obtained by determining (using a structured interview format) whether e l d e r l y c l i e n t s who received nursing care i n an acute care setting perceived they were treated with dignity and respect. D e f i n i t i o n of Terms Attitudes: absolute i n c l i n a t i o n s or mental readiness which consistently exert influence on evaluative responses that are directed toward some person, group, or subjects (Zimbardo & Ebbesen, 1969). Dignity: being worthy of honor or respect (Allen, 1984). El d e r l y : a person 65 years of age and above. Perception: thoughts, feelings and attitudes of individuals about objects or events as related verbally. Respect: def e r e n t i a l esteem f e l t or shown towards person; avoid i n t e r f e r i n g with or harming, treat with consideration; r e f r a i n from offending person or fee l i n g s (Allen, 1984). 19 Socioeconomic status; defined i n terms of a standard s o c i o l o g i c a l paradigm consisting of three components; education, occupation, and income (George & Bearon, 1980). The l e v e l of education was selected as an i n d i c a t i o n of socioeconomic status for t h i s study since education i s considered to be a determinant of socioeconomic status throughout l i f e . For the purpose of t h i s study, those with a secondary l e v e l of education w i l l be regarded as having a higher socioeconomic status and those with an elementary l e v e l of education a lower socioeconomic status. Assumptions 1. Individuals ( c l i e n t s and nurses) act purposefully and these actions are influenced by the individual's i n t e r p r e t a t i o n of the se t t i n g , s i t u a t i o n or behavior of individuals i n the se 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 elderly c l i e n t s for the study was dependent upon t h e i r a c t i v i t i e s and willingness to communicate perceptions verbally. 3. Attitudes of nurses a f f e c t t h e i r behaviors, and t h e i r behavior influences the nursing care they administer to the e l d e r l y . 4. The questions that have been selected from the Medicus Quality Assurance t o o l are those that w i l l e l i c i t information on whether i d e n t i f i e d aspects of nursing care were perceived by the c l i e n t to meet his/her needs for dignity and respect. 20 Limitations No methodology existed which measured the c l i e n t ' s perception of nursing care with complete adequacy. Moreover, any rel a t i o n s h i p between the attitudes of nurses and the q u a l i t y of nursing care i n t h i s study can only be inferred, since the attitude of nurses i n t h i s sample was not observed or measured. With convenience sampling, and the omission of those c l i e n t s who were not a l e r t and oriented, the available subjects might not be t y p i c a l of the population with regard to the variables being measured. G e n e r a l i z a b i l i t y of the findings may be l i m i t e d . Summary This introductory chapter described the nursing context of the research problem and explained the rationale and purpose of the study. The t h e o r e t i c a l framework, the research questions, the assumptions and l i m i t a t i o n s of the study were addressed. The next chapter provides a review of l i t e r a t u r e pertinent to the investigation. 21 CHAPTER 2 Review of Selected Literature This chapter reviews pertinent t h e o r e t i c a l perspectives and research studies. The l i t e r a t u r e reviewed was selected on the basis of a symbolic i n t e r a c t i o n i s t view of how elderly c l i e n t s view t h e i r nursing care, and t h e i r care-givers (registered nurses) as r e c i p r o c a l l y influencing elements of t h e i r hospital experience. From t h i s perspective, the review of the l i t e r a t u r e i s organized into seven main parts: (1) growth of the e l d e r l y population, (2) basic human needs and the e l d e r l y population, (3) the hos p i t a l i z e d e l d e r l y , (4) aging and self-esteem, (5) e t h i c a l considerations i n the care of the elderly c l i e n t , (6) attitudes of nurses towards the e l d e r l y , and (7) the older person's perception of t h e i r nursing care. Growth of the E l d e r l y Population The number of people over 65 years of age i s s t e a d i l y increasing. It was i n i t i a l l y projected that i n t h i s country by year 2001, t h i s group would comprise about 11% of the population ( S t a t i s t i c s Canada, 1980). But with recent improvements i n survival rates i n the older population and a major decrease i n b i r t h rate, the percentage of people over 65 has been revised upwards (Stone & Fletcher, 1986). Quoting S t a t i s t i c s Canada data, these analysts project that 22 by year 2001, 14% of the population w i l l be over 65 years and by year 2031 t h i s figure w i l l increase to approximately 25%. These findings w i l l be r e f l e c t e d i n an increased number of people over the age of 65 requiring nursing services. The d i s t r i b u t i o n of the population indicates that registered nurses, the single largest group of health care workers i n Canada, are encountering the elderly more frequently i n t h e i r practice. They provide nursing care to the e l d e r l y i n long term and chronic care i n s t i t u t i o n s , i n the community, and i n acute care hospitals. In B r i t i s h Columbia, for example, the number of admissions to acute and r e h a b i l i t a t i o n hospitals and hospital days used, increase dramatically after age 55. In 1982-83, the number of admissions per thousand people age 70-74 was almost four-and one-half times larger than that for the aged 55-59 group; among those age 85 and over, i t was more than f i v e times larger (Gutman et a l . , 1986). While hospital usage in B r i t i s h Columbia generally f e l l between 1971 and 1982-83 as a r e s u l t of e f f o r t s to reduce hospital bed capacity, t h i s o v e r a l l decline did not occur among the e l d e r l y . Gutman points out that admission rates per capita during t h i s period increased for a l l age groups of men over the age of 65 and women over the age of 70. Although the public perception i s that the e l d e r l y make great demands on the hospital system, only 20% of those over 65 are admitted to hospital i n any given year. Out of t h i s group, however, 5% 23 consume 60% of the hospital days; of that high-use group, about half are i n th e i r l a s t year of l i f e or are waiting for a bed i n a nursing home (Silversides, 1987). To c l a r i f y health p o l i c y , the federal government defined f i v e l e v e l s of i n s t i t u t i o n a l care: r e s i d e n t i a l , extended care, chronic 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 are considered long term care. In B r i t i s h Columbia, f i v e l e v e l s of long term care are defined as Personal Care, Intermediate Care I, Intermediate Care I I , Intermediate Care I I I , and Extended Care (Forbes, Jackson, & Kraus, 1987). Long term care services and programs are required by those individuals who have some degree of functional impairment because of physical and/or mental f r a i l t y or d i s a b i l i t y (Mantle, 1988a). According to Mantle, the development of community support services has enabled the e l d e r l y to l i v e within the community for longer periods of time. Eld e r l y residents are now much older before they enter a f a c i l i t y and have much greater degrees of physical and mental d i s a b i l i t y . Gutman et a l . (1986) point out that while l e v e l of care cannot be predicted by age alone, the p r o b a b i l i t y that some l e v e l of service w i l l be required increases dramatically with age. In 1984, 55% of the population aged 85 and over were receiving long term care services. This figure compares with 21% i n the age group 75-84 and only 6% i n the age group 65-74. The proportion of persons receiving 24 c o n t i n u i n g c a r e i n f a c i l i t i e s a l s o r i s e s w i t h i n c r e a s i n g age. Of t h o s e aged 85 and over i n c a r e , about t w o - t h i r d s were i n f a c i l i t i e s . W h i l e a p p r o x i m a t e l y 80% o f p e o p l e over the age of 65 i n Canada ( H e a l t h and W e l f a r e Canada, 1982) are c a p a b l e of l i v i n g i n d e p e n d e n t l y and c a r i n g f o r themselves ( i n s p i t e of t h e f a c t t h a t 75% of o l d e r p e o p l e s u f f e r f r o m a t l e a s t one c h r o n i c h e a l t h p r o b l e m ) , t h e r e i s a r e l a t i o n s h i p between b e i n g o l d e r and r e q u i r i n g more care and b e i n g i n a f a c i l i t y . 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 In t h e UBC Model f o r N u r s i n g ( C a m p b e l l , 1987) , a b e h a v i o r a l system m o d e l , t h e i n d i v i d u a l i s assumed t o have n i n e b a s i c human needs which p e r s i s t t h r o u g h o u t l i f e . The 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 , l o v e , b e l o n g i n g n e s s , and dependence ; r e s p e c t of s e l f by s e l f and o t h e r s ; c o l l e c t i o n and removal of accumulated w a s t e s ; i n t a k e of f o o d and f l u i d ; n o u r i s h m e n t ; s a f e t y and s e c u r i t y ; b a l a n c e between p r o d u c t i o n and u t i l i z a t i o n of e n e r g y ; i n t a k e of oxygen; and s t i m u l a t i o n of t h e s e n s e s . The i n d i v i d u a l c o n s t a n t l y s t r i v e s t o s a t i s f y each b a s i c human need by u s i n g a range of i n n a t e and a c q u i r e d c o p i n g b e h a v i o r s . B e h a v i o r 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 a re i n f l u e n c e d by the s u i t a b i l i t y of t h e c o p i n g b e h a v i o r s he uses and the ways h i s b a s i c human needs a r e met. B a s i c human needs p e r s i s t t h r o u g h o u t l i f e . They a re fundamental r e q u i r e m e n t s f o r s u r v i v a l and growth of the b e h a v i o r a l system ( C a m p b e l l , 1987) . 25 Conceptualizing a h i e r a r c h i c a l framework of basic human needs, Maslow (1968) viewed growth as "a continued, more or less steady upward or forward development" (p. 33). Beginning at the lower end (the most basic part) of the hierarchy are physiologic needs that are important for su r v i v a l . These needs include food, water, a i r , sleep, and sex. Next are the needs for safety, which include security, protection, freedom from anxiety, and some degree of routine 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 physiologic and safety needs have been met, belonging and love i n a caring rel a t i o n s h i p assumes importance. Meeting t h i s need i s an essen t i a l prerequisite to meeting esteem needs, which include reputation, status, prestige, and a f e e l i n g of s e l f -esteem b u i l t on ind i v i d u a l self-worth. When physiologic and safety needs, belonging, love, and esteem needs are met i n sat i s f a c t o r y succession, the person can focus on tasks for s e l f - a c t u a l i z a t i o n . Maslow believed that i n the process of growth, a person has to s a t i s f y basic needs before 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 the person i s capable of becoming). S t e f f i (1984b) points out there are many misconceptions about where older people are expending t h e i r energies. We may expect old people to 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 and they are devoting a l l t h e i r energy to ensuring that t h e i r physiological needs are met. 26 A c c o r d i n g t o the UBC Model of N u r s i n g b a s i c human needs are not h i e r a r c h i a l i n s t r u c t u r e ; a l l n i n e needs must be met r e g u l a r l y i n o r d e r 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 need does not take precedence over another human need ( C a m p b e l l , 1987) . E r i c h Promm (1955) d e s c r i b e s i d e n t i t y , r o o t e d n e s s , r e l a t e d n e s s , t r a n s c e n d e n c e , and a frame of r e f e r e n c e as u n i v e r s a l b a s i c human n e e d s . He s t a t e s t h a t everyone has a need t o have an i d e n t i t y , have a p l a c e i n t ime and space ( r e r o o t i n g i s d i f f i c u l t f o r o l d e r p e o p l e ) , and our s o c i e t y depends on r e l a t e d n e s s t o someone or s o m e t h i n g . Man, a c c o r d i n g t o Fromm, i s the o n l y a n i m a l t h a t has an awareness of 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 about i t , has a need to l e a v e something b e h i n d , and needs a s e t of b e l i e f s ( r e l i g i o u s or non r e l i g i o u s ) t o f a l l back o n . T h r e e b a s i c s o c i a l - p s y c h o l o g i c a l needs of 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 Bengston (1978) a re i d e n t i t y , c o n n e c t e d n e s s , and e f f e c t e n c e . The most i m p o r t a n t p a r t of i d e n t i t y i s who one i s (surname, t i t l e , r o l e ) . Connectedness i s d e f i n e d i n terms of t h e s o c i a l s i t u a t i o n i n which we a l l l i v e and d i e . E f f e c t e n c e means h a v i n g some s o r t of i n f l u e n c e on your environment and b e i n g a b l e t o e f f e c t change (Bengston, 1978) . Communication and i n t e r a c t i o n w i t h o t h e r human b e i n g s are b a s i c human needs which a re v i t a l f o r the e l d e r l y p e r s o n m a i n t a i n i n g a " l i f e l i n e " . I n t e r a c t i o n w i t h o t h e r p e o p l e 27 becomes more d i f f i c u l t i n old age when family and friends die (Burnside, 1988; Ebersole & Hess, 1985). Personal space, t e r r i t o r i a l domain, and s p a t i a l arrangements are important elements i n basic human needs ( G i o i e l l a & B e v i l , 1985; Pastalan, 1970). Personal space refers to the distance individuals maintain between themselves and others. It may be viewed as a bubble surrounding the person - a buffer zone between oneself and the environment. That i s , they need i n d i v i d u a l l y determined s p a t i a l distances for conversation and s o c i a l i n t e r a c t i o n . T e r r i t o r i a l i t y i s defined as a delimited space used by individuals or groups, involves psychological i d e n t i f i c a t i o n with the area, and i s symbolized by attitudes of possessiveness and arrangement of objects (Pastalan, 1970). This author explains that i n d i v i d u a l t e r r i t o r y i s physical or geographical and i s v i s i b l e i n nature, whereas personal space i s more psychological because i t i s carried around with the i n d i v i d u a l and i s not v i s i b l e . A person w i l l i d e n t i f y the boundaries of his t e r r i t o r y with a var i e t y of environmental props, both stationary and mobile, so they can be seen by others. The boundaries of personal space are i n v i s i b l e though they may be inferred from f a c i a l expressions, body movements, gestures, p i t c h or tone of one's voice and v i s u a l contact. When hospi t a l i z e d (Stillman, 1978), individuals usually experience a loss of privacy and control over t h e i r bodies 28 and surrounding area. They are denied t h e i r own f a m i l i a r t e r r i t o r y . Possession of t e r r i t o r y helps meet a need for security and i d e n t i t y , while loss of i t can i n t e r f e r e with psychological homeostasis. The Hospitalized Elderly The e l d e r l y are a heterogeneous group, with wide differences i n t h e i r physical and psychosocial status. Yet, the tendency i s to deal with a l l persons over the age of 65 as though they are a l l developmentally the same (Burnside, 1988; Ebersole & Hess, 1985). As a group, older persons are more l i k e l y to experience multiple chronic and disabling conditions. With these chronic problems, the r i s k i s for further decline i n function and acute exacerbation of the disease (Bossenmaier, 1982; G i o i e l l a & B e v i l , 1985). The normal age-related physiological and psychosocial changes that occur place the older person at r i s k during h o s p i t a l i z a t i o n . For example, al t e r a t i o n s i n v i s i o n , hearing, and other sensory modalities can a f f e c t cognitive function (Chodil & Williams, 1970; Worrell, 1977). According to these authors the in d i v i d u a l maintains contact with the environment and experiences r e a l i t y through reception and perception of sensory i n t e r a c t i o n . Use of color, l i g h t , texture, attention to a c t i v i t y and noise, furnishings, placement of equipment, mobility aids and care giver routine can promote or impede recovery. When the 29 hospital does not meet the el d e r l y person's need for meaningful environmental i n t e r a c t i o n , acute confusion may re s u l t . The presence of confusion predisposes the eld e r l y c l i e n t to a p o s s i b i l i t y f or f a l l s , incontinence, sleep disturbances, mobility and skin problems, and dependency increases (Burnside, 1988; Ebersole & Hess, 1985; Worrell, 1977). The circumstances requiring h o s p i t a l i z a t i o n may mean a loss of health, functional a b i l i t y , independence, or potential l o s s of s e l f through death. Anxiety and depression are common responses to h o s p i t a l i z a t i o n and older c l i e n t s who are mentally a l e r t can be expected to react 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). Additional c h a r a c t e r i s t i c s that put the acutely i l l , h o s p i t a l i z e d aged at r i s k are diminished physiological reserves and decreased capacity to adapt to unfamiliar surroundings (Bossenmaier, 1982; Rowe, 1985). The da i l y coping behaviors required to deal with multiple chronic and acute health problems, decreasing independence, impending l i f e - s t y l e changes, a l l i n the presence of declining resources, are seriously threatened when an unpredictable 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). Relocating from a f a m i l i a r , safe l i v i n g environment to an unfamiliar hospital environment that requires interacting 30 with unknown persons i n the absence of r e l i a b l e support systems and f a m i l i a r routines contributes to the older person's v u l n e r a b i l i t y (Ebersole & Hess, 1985). This s i t u a t i o n predisposes the older person to experience helplessness, dependency, and loss of control. Even when the older adult i s capable of u t i l i z i n g suitable coping behaviors to meet some of t h e i r basic human needs, s t a f f members may believe i t i s f a s t e r or easier to do things for them, thus reinfo r c i n g the older person's dependent pos i t i o n . These losses weaken the older c l i e n t ' s feelings of self-confidence, mastery, and sense of self-esteem ( G i o i e l l a & B e v i l , 1985). Aaina and Self-Esteem According to the UBC Model for Nursing (Campbell, 1987), man has basic human needs for safety and security, c o l l e c t i o n and removal of accumulated wastes, balance between production and u t i l i z a t i o n of energy, intake of oxygen, intake of food and f l u i d , stimulation of the senses, for love, belongingness and dependence, mastery, and for respect of s e l f by s e l f and others (self-esteem). An e s s e n t i a l factor for successful aging i s to meet the need for self-esteem or a p o s i t i v e self-concept (Burnside, 1988; G i o i e l l a & B e v i l , 1985). These authors state that to meet the need for self-esteem, the older i n d i v i d u a l must be aware of h i s own i d e n t i t y , must have control over his own l i f e , must have a sense of self-worth, and must have 31 a f f i l i a t i o n s with others* Butler and Lewis (1977) argue that for individuals with low self-esteem, l i f e becomes meaningless and feelings of hopelessness and helplessnes pervade t h e i r l i v e s . H o s p i t a l i z a t i o n emphasizes the older person's physical deterioration and loss of health, mobility, and independence. This lo s s of independence weakens the older person's feelings of self-confidence and sense of s e l f -esteem (Burnside, 1988; G i o i e l l a & B e v i l , 1985). The older person's self-esteem may be further damaged by the depersonalization that occurs with 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 i n hospital gowns and t h e i r personal possessions and jewelry are removed. They are deprived of privacy to carry out the most basic bodily functions or maintain intimate or family relationships (Kemp, 1978). Maslow (1970) indicated that control i s a c r i t i c a l v a riable influencing self-esteem. This control includes making decisions about one's s e l f . Reid, Hass, and Hawkins (1977) reported a p o s i t i v e r e l a t i o n s h i p between low s e l f -control and negative self-concept and described those who had a negative self-concept as tending to have l e s s l i f e s a t i s f a c t i o n . Bower and Bevis (1979) observed that health promotion and s e l f - c a r e promotion are major generative functions that must be performed by the e l d e r l y i n order for th e i r self-esteem needs to be met. Anger, indecisiveness, 32 and depression are signs that these self-esteem needs remain u n f u l f i l l e d . According to Ebersole and Hess (1985), the c r i t i c a l factor i n the older person's response i s perception. The impact of an event on one's self-esteem and sense of ca 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 of the event. These authors have i d e n t i f i e d productivity and problem-solving a b i l i t y as essential to the maintenance of self-esteem i n the eld e r l y and have suggested that the nurse's role i s to a s s i s t i n development of these coping a b i l i t i e s . According to the UBC Model for Nursing (Campbell, 1987)/ nursing interventions focus on coping behaviors related to goal achievement. Interventions are aimed at discouraging or eliminating coping behaviors associated with lack of goal achievement and potential lack of goal achievement, and encouraging and developing those behaviors capable of maintaining and promoting goal achievement. Change with respect to a c l i e n t ' s coping behaviors can be effected by reduction of negative forces, maintenance and strengthening of p o s i t i v e forces, and fostering of the development of a b i l i t i e s . To practice nursing i n such a way as to a s s i s t e l d e r l y c l i e n t s to develop and use coping behaviors to meet the need for respect of s e l f by s e l f and others, and a t t a i n the goal of self-esteem 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 the Elderly C l i e n t As viewed i n the UBC Model for Nursing (Campbell, 1987), nursing's unique function i s to nurture individuals experiencing c r i t i c a l periods so that they may develop and use a range of coping behaviors that w i l l allow them to s a t i s f y t h e i r basic human needs and to reach optimal health. Nursing's role i n nurturing individuals i s to fost e r , protect, sustain, and teach. According to the Canadian Nurses Association (1985) nursing practice can be defined generally as a "dynamic, caring, helping 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 to achieve and maintain optimal health" (p. 6). By entering the profession, the nurse i s committed to i t s professional ethics and assumes a professional commitment to the health and well-being of c l i e n t s . As such, nursing encompasses moral a c t i v i t i e s . Ethics, a branch of philosophy, promotes moral conduct based on p r i n c i p l e s of behavior that promote the goodness of the human being (Bahr, 1987). This dignity and respect to be afforded the in d i v i d u a l regardless of age brings a focus of equality for that i n d i v i d u a l . This equality, based on the value of the human being as a worthwhile i n d i v i d u a l , i d e n t i f i e s a value system needed to preserve the dignity of the person, young or old. According to the Canadian Nurses' Association Code of Ethics for Nursing (1985), "a c l i e n t ' s right to be treated i n a d i g n i f i e d fashion must be re f l e c t e d 34 i n the nurse's own behavior towards the c l i e n t and i n attempts to influence the actions of other members of the health care team" (p. 3). The way i n which nurses are involved i n situations which give r i s e to e t h i c a l c o n f l i c t i s frequently related to i n s t i t u t i o n a l p o l i c y , the place of the nurse i n the organizational hierarchy and the professional d i v i s i o n of labor. According to Storch (1988), the uniqueness of nursing's e t h i c a l dilemmas can be a function of being there, having multiple obligations, and experiencing the d a i l y ceaseless dilemmas of care. Because nurses are generally the health care professionals who are with the c l i e n t on a more constant basis than other health care providers, they are present to witness the c l i e n t ' s loss of autonomy and submission to health care ministrations (Storch, 1988). When these ministrations are not i n the c l i e n t ' s i n t e r e s t or contrary to the c l i e n t ' s wishes, the nurse i s present to act for the c l i e n t or remain a s i l e n t observer of a wrong. Because obedience and silence are no longer considered appropriate behaviors for the nurse (Coburn, 1981), many nurses experience c o n f l i c t i n f u l f i l l i n g t h e i r e t h i c a l r e s p o n s i b i l i t i e s . And because the nurse i s present, the e t h i c a l and moral dilemmas of practice become even more serious when the nurse i s excluded from the process of decision-making on matters of treatment. This exclusion places 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 decisions even when they disagree with them. A second r e a l i t y of nursing practice related to nursing ethics i s that nurses have multiple obligations (Storch, 1988). Nurses have professional obligations to c l i e n t s , to fam i l i e s , to physicians, to colleagues, and to i n s t i t u t i o n s where they are employed. Early nursing education cautioned against questioning the physician's decisions. Since the 1970s, however, the p r i o r i t y of the nurse's obligation to the c l i e n t has been c l e a r l y stated i n Codes of Ethics and Standards for Nursing Care (Canadian Nurses Association, 1985; Registered Nurses Association of B r i t i s h Columbia, 1984). According to Storch (1988), the problem of multiple obligations for nurses who work i n i n s t i t u t i o n a l settings continues to be a source of role c o n f l i c t for nurses. C i t i n g several authors, Storch (1988) points out that the work place can influence the moral judgment of nurses; " l o y a l t y to the organization, physician, and colleagues competes with l o y a l t y to patient and family" (p. 213). Nurses experience a range and variety of e t h i c a l dilemmas every day (Storch, 1988). There are issues which involve l i f e and death decisions and the l e s s spectacular issues 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 invasion of privacy. And there are the ethics of caring by which nurses t r y to determine the needs of t h e i r c l i e n t s for 36 whom they care. These d a i l y obligations demand an e t h i c a l responsiveness on the part of nurses with a professional r e s p o n s i b i l i t y to act i n the c l i e n t ' s best i n t e r e s t . Curtin and Flaherty (1982) state that i t i s not l i k e l y that nurses w i l l d e l i b e rately transgress the rights of c l i e n t s , but: It i s i n our ordinary day to day contact with patients or c l i e n t s that we are most l i k e l y to f a i l to respect them as human beings. We are too busy or too caught up in the "important" t e c h n i c a l i t i e s to take the time to discover and respect the humanity of each i n d i v i d u a l , (p. 15) Commenting on the central e t h i c a l issues for nurses, Storch (1988) points out that maintaining the patients' or c l i e n t s ' i n t e r e s t as top p r i o r i t y means that nurses must recognize and cope with "being a patient's advocate; dealing with unethical disagreement, incompetence, or unprofessional practice; and being a competent p r a c t i t i o n e r " (p. 214). Advocating the in t e r e s t s of the c l i e n t includes assistance i n achieving access to qual i t y health care. For example, by providing information to c l i e n t s , the nurse enables them to s a t i s f y t h e i r rights to health care. Although the nurse has always functioned as the c l i e n t ' s advocate to 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 with advocacy for the i n s t i t u t i o n or physician (Storch, 1988). This author points out that some degree of 37 c o n f l i c t i s inevitable when dealing with other groups i n matters of health care. Nurses are accountable, however, for the well-being of patients and they must take action when treatment orders seem inappropriate. Moreover, they must ascertain the facts of 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 reporting channels when dealing with matters of c l i n i c a l incompetence and professional misconduct. An obligation of equal importance i s that nurses maintain t h e i r own competence as p r a c t i t i o n e r s . Storch (1988) points out that nurses must take advantage of formal and informal opportunities for continuing education, read and study professional journals, recognize t h e i r own l i m i t a t i o n s , and s t r i v e to provide a high qu a l i t y of patient care. Recognizing one's professional 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 or c l i e n t advocacy, dealing with c o n f l i c t , and ensuring competence can make a s i g n i f i c a n t difference i n the l i v e s of c l i e n t s which may cover the whole range of human l i f e from b i r t h to death. Attitudes of Nurses toward the Elderly Studies show that nurses l e a s t prefer working with the eld e r l y and that nurses who hold negative attitudes toward them w i l l engage i n behaviors which may not be therapeutic or may be detrimental to the best 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, Ludenia, & Mead, 1984). Goebel (1984) states that 38 a t t i t u d e s a re a p o t e n t i a l i n f l u e n c e on i n t e r p e r s o n a l b e h a v i o r s i n s i t u a t i o n s where c l i e n t s of a l l ages a re dependent on c a r e t a k e r s . N e g a t i v e a t t i t u d e s among n u r s e s , t h e r e f o r e , have s e r i o u s i m p l i c a t i o n s f o r t h i s r a p i d l y i n c r e a s i n g c l i e n t p o p u l a t i o n . A l t h o u g h i n t e r e s t and c o n c e r n f o r t h e e l d e r l y has been growing i n r e c e n t y e a r s , many e l d e r l y c l i e n t s i n h e a l t h c a r e f a c i l i t i e s c o n t i n u e t o r e c e i v e i n a d e q u a t e poor q u a l i t y c a r e which i s not i n d i v i d u a l i z e d 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 , 1971; H e a l t h and W e l f a r e Canada, 1982; P o d n i e k s , 1983) . A c c o r d i n g to E b e r s o l e and Hess (1985), t h e myths dangerous t o t h e o l d e r p e r s o n i n our s o c i e t y a r e t h o s e t h a t p e r p e t u a t e the i d e a t h a t t h e aged a r e dependent and t h e young a r e i n d e p e n d e n t . These a u t h o r s say t h a t a t t i t u d e s of n u r s e s toward a g i n g 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 . S t a n l e y and B u r g g r a f (1986) s t a t e t h a t t h i s i s s i g n i f i c a n t because of t h e dependency t h a t i s c r e a t e d by t h e m u l t i p l e c h r o n i c c o n d i t i o n s a f f e c t i n g t h e e l d e r l y . S e v e r a l s t u d i e s have i n v e s t i g a t e d a t t i t u d e s of n u r s e s towards the e l d e r l y . Some s t u d i e s r e v e a l t h a t n u r s e s ' a t t i t u d e s towards the e l d e r l y a re c h a r a c t e r i z e d by s t e r e o t y p i n g , n e g a t i v i s m , and d e f e a t i s m ( C a m p b e l l , 1971; N e l s o n , 1973) . O t h e r s (Kogan, 1979; S c h o n f i e l d , 1982) p o i n t out t h a t t h e e l d e r l y a r e g e n e r a l l y p e r c e i v e d by younger p e o p l e as p h y s i c a l l y and m e n t a l l y on t h e d e c l i n e , s o c i a l l y 39 withdrawn and unproductive i n society. These stereotypes, they say, can adversely influence interactions with the eld e r l y and influence the care nurses provide. Nelson (1973) reported on a study done by Stockwell to investigate i f nursing care d i f f e r e d between "most l i k e d " and "least l i k e d " c l i e n t s . Stockwell found that e l d e r l y c l i e n t s were most l i k e l y to 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 to receive negative responses from nurses. Negative responses were ref l e c t e d by the amount of time taken to answer c a l l b e l l s , amount of time the nurse spent i n verbal communication with c l i e n t s , and the number of in j e c t i o n s nurses were w i l l i n g to give c l i e n t s to r e l i e v e pain. Not a l l studies on nurses* attitudes towards the eld e r l y indicate negative attitudes. Taylor and Harned (1978) found that attitudes of registered nurses were a l l p o s i t i v e or neutral and that nurses who worked i n acute care hospitals had more po s i t i v e attitudes than t h e i r counterpart i n long term care. Brower (1981) reported that nurses employed i n nursing homes had s i g n i f i c a n t l y more negative attitudes toward the el d e r l y i n general than did nurses who worked as v i s i t i n g nurses or i n a h o s p i t a l . This author found that the major reason for more negative attitudes among the nursing home nurses was at l e a s t i n part due to caring for a number of e l d e r l y c l i e n t s who have multiple physical and emotional problems. A study by Wolk and Wolk 40 (1971) found that younger nurses had more negative attitudes toward the e l d e r l y than did older nurses. These authors believe i t i s because younger nurses had le s s d i r e c t experience with e l d e r l y c l i e n t s . A t t i t u d i n a l studies by F u t r e l l and Jones (1977) found that older, better educated and more experienced registered nurses tended to have the most p o s i t i v e attitudes. Other studies suggest that factors associated with in d i v i d u a l c l i e n t s , other than age, are more powerful determinants of the attitude and behavior of nurses. For exampe, nurses prefer c l i e n t s who are neat, appreciative, conforming, s o c i a l l y active and communicative and do not value c l i e n t s who place extra demands on the system by being uncooperative, disruptive, or s o i l i n g the environment (Penner et a l . , 1984; White, 1977). These q u a l i t i e s are associated with lower s e l f - c a r e a b i l i t y rather than age or diagnosis. According to a study by Brown (1969), nurses were observed to give extra care to dying c l i e n t s who are " s o c i a l l y valued", who occupy high status, or who are highly prized by v i r t u e of age, rela t i o n s h i p to another, or productivity. Henretta and Campbell (1976) reported that the higher the individual's s o c i a l class, the greater the l i k e l i h o o d of maintaining status for a longer time; they have resources that give them power i n s o c i a l relationships, thereby enabling them to remain independent. White (1977) found that c l i e n t s who scored lower with 41 respect to 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 received from nursing fewer i n d i v i d u a l i z i n g behaviors such as screening for privacy during care, conversation, and explanations of what was going on during process of care. According to E l l i o t t and Hyberton (1982), c l i e n t s who e l i c i t favorable reactions i n a nursing s t a f f are more apt to receive adequate attention to t h e i r needs than c l i e n t s who exhibit disturbing and troublesome behavior. Those c l i e n t s , she states, who e l i c i t unfavorable reactions are not as l i k e l y to receive the same l e v e l of nursing care. Two authors (Grouse, 1982; Natkins, 1982) address derogatory descriptors used toward the el d e r l y . They both emphasize the importance of a person's name and portray instances which c l e a r l y denigrate c l i e n t s . Grouse discusses the l e g i t i m i z a t i o n of derogatory terms such as "crock", "turkey", "gomer", " d i r t b a l l " , and "spos". Burnside (1988) succinctly points out that 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 to be c a l l e d , or c a l l them "granny" or "gramps", "dearie" or "honey" are threatening the c l i e n t s ' dignity and s e l f respect. Dolinsky (1984) points out that nurses i n f a n t a l i z e the eld e r l y by treating them as children who are incapable of caring for themselves. Gresham (1976) describes various ways that demonstrate how older people are treated i n nursing homes, acute care hospitals, and extended care 42 f a c i l i t i e s . Some of these include addressing the elderly by t h e i r f i r s t name whether or not they request i t f patting the el d e r l y on the head, patronizing the aged, and not including the aged i n decisions about th e i r own care. Butler (1980) states that addressing the e l d e r l y by t h e i r f i r s t or "pet" names should be avoided as that implies loss of dignity and i n f a n t a l i z a t i o n . The Elderly's Perception of t h e i r Nursing Care There have been few studies which look at how the e l d e r l y perceive t h e i r nursing care. Although a l i m i t e d number of studies look at patient s a t i s f a c t i o n , t h e i r purpose i s to discover 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). One study (Elbeck, 1986) which did investigate the ways i n which c l i e n t s describe and evaluate nursing practice does not i d e n t i f y the age group of the c l i e n t population. There are, however, reports i n the media of the elderly's d i s s a t i s f a c t i o n with the q u a l i t y of care they receive. Panel members from a Consumer Advisory Panel on Seniors Health Issues (Mclnnes, 1987) report that the e l d e r l y are made to f e e l l i k e second-class c l i e n t s i n hospitals; they are "treated l i k e infants, or automatically assumed to have some form of Alzheimer's disease". The report states that many health care professionals are observed to c a l l e l d e r l y 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 well as being treated l i k e children, they are not 43 informed about t h e i r condition or treatment. Other incidents, the report states, include nurses r e f e r r i n g to c l i e n t s as "bed-blockers" or "GOMERS", which stands for "get out of my emergency room", within hearing distance of the c l i e n t . This behavior, the e l d e r l y report, deprives them of th e i r dignity and self-respect. Since attitude i s one of the elements that a f f e c t s the performance of the registered nurse, i t i s assumed that t h i s performance i s r e f l e c t e d i n the kind of care the e l d e r l y c l i e n t receives; one area of nursing care which i s questioned by t h i s researcher i s whether the e l d e r l y c l i e n t i s treated with dignity and respect. In conclusion, t h i s l i t e r a t u r e review indicates the following: an increase i n the e l d e r l y population resulting i n an increased need for nursing services; attitudes nurses hold about the aged influence the q u a l i t y of services they provide; and, there i s a s c a r c i t y of studies which explore the e l d e r l y ' s perception of t h e i r nursing care, p a r t i c u l a r l y as i t relates to whether they were treated with dignity and respect. Summary This chapter reviewed the l i t e r a t u r e i n r e l a t i o n to the eld e r l y ' s increased needs for nursing care due to demographic changes, attitudes of nurses toward the e l d e r l y , the implications of these attitudes for the e l d e r l y and b r i e f l y (due to l i m i t e d studies), and the elderly's 44 perception of t h e i r nursing care p a r t i c u l a r l y as i t relates to t h e i r need to be treated with dignity and respect. The next chapter describes the process of t h i s investigation to address the research question. 45 CHAPTER 3 Methodology Research Design This study used a descriptive and c o r r e l a t i o n a l research design* According to P o l i t and Hungler (1983), descriptive research i s designed to summarize the status of some phenomenon of i n t e r e s t as i t presently i s thought to e x i s t . Its main objective i s the portrayal of the c h a r a c t e r i s t i c s of persons, situations or groups and the frequency with which cert a i n phenomenon occur. Correlational studies are research investigations designed to examine the r e l a t i o n s h i p among variables. Descriptive c o r r e l a t i o n a l studies are l e s s concerned with determining cause-and-effect relationships than with a description of how one phenomenon i s related to another (Weldon, 1986). A structured interview with "fixed a l t e r n a t i v e " questions was u t i l i z e d to obtain the data. This type of questioning offers respondents a number of a l t e r n a t i v e r e p l i e s ; the subjects were asked to choose the one that most closely approximated the " r i g h t " answer. The number of responses to each alt e r n a t i v e was tabulated and analyzed i n order to obtain some understanding of what the sample as a whole thought about each question. 46 Sample The required sample consisted of 62 subjects who were 65 years old or over. This research study u t i l i z e d an accidental sampling technique. This technique e n t a i l s the use of the most readil y available persons for use as subjects i n the study ( P o l i t & Hungler, 1983). For example, a l l subjects who met the study c r i t e r i a and were being discharged from hospital during the study period were included i n the sample. The c r i t e r i a for i n c l u s i o n as subjects of the sample were: 65 years of age and over; hosp i t a l i z e d for no le s s than 5 days i n a Medical or Surgical Unit; able to respond ver b a l l y i n English; a l e r t and oriented to time, place, and person during th e i r h o s p i t a l i z a t i o n ; and interviewed within 3 days afte r they l e f t h o s p i t a l . i n s t r u m e n t A review of the l i t e r a t u r e to discover an existing tool was not successful i n finding an instrument useful for the purpose of t h i s study. The l i t e r a t u r e review, however, did uncover a t o o l that had been developed to monitor the qu a l i t y of nursing care (Hegyvary & Haussmann, 1975). The tool (Medicus Quality Assurance Tool), a s e l f - r e p o r t i n g questionnaire contains several items dealing with the provision of nursing care demonstrating regard for dignity and respect. The s e l e c t i o n of items from the Medicus Quality Assurance Tool related to dignity and respect was 47 determined by defining and developing an operational d e f i n i t i o n of the terms. Information to operationalize the terms "dignity and respect", was obtained from items i n the master indicator l i s t of the Medicus Quality Assurance Tool and review of selected l i t e r a t u r e (Chapter 2). These items were: orienting the c l i e n t to the f a c i l i t y , providing c l i e n t s with privacy, seeking t h e i r permission before performing procedures, providing them with information, addressing them by t h e i r proper name unless otherwise requested, and providing an opportunity for them to discuss t h e i r concerns. A copy of selected items from the Medicus Quality Assurance Tool i s found i n Appendix D. Since only part of the tool was relevant to t h i s study i t was necessary to determine what e f f e c t using only selected portions would have on r e l i a b i l i t y and v a l i d i t y . It was found that using selected portions of the Quality Assurance Tool 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 since each item, although i n t e r r e l a t e d with others, has been tested independently (Sue Hegyvary, personal communication, 1988). In order to determine i f there i s a rel a t i o n s h i p between ce 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 perceived they were treated with dignity and respect, other data such as: age of the c l i e n t , sex (male or female), number of days spent i n hospi t a l , type of unit (medical or s u r g i c a l ) , and highest l e v e l of education obtained (to determine socioeconomic status) were e l i c i t e d . 48 Socioeconomic status i s defined i n terms of a standard s o c i o l o g i c a l paradigm consisting of three components; education, occupation, and income (George & Bearon, 1980). The l e v e l of education was selected as an i n d i c a t i o n of socioeconomic status for t h i s study, since education i s considered to be a determinant of socioeconomic status throughout l i f e . Occupation and income, according to George and Bearon (1980), may not be s i g n i f i c a n t for older people since a majority of them are r e t i r e d and some occupational benefits are l o s t . Moreover, retirement d r a s t i c a l l y reduces the earnings of many older people. Data C o l l e c t i o n Procedure The investigator contacted the Directors of Nursing of two large metropolitan teaching hospitals. These two acute care hospitals (A and B) were selected because of the need for samples of subjects who had nursing care provided primarily by registered nurses. A plan to seek consent from the prospective subjects before they l e f t hospital was developed by meeting with the head nurses of f i v e medical and f i v e s u r g i c a l units from both hospitals. Their support was enl i s t e d i n informing the investigator of subjects who met the study c r i t e r i a and were being discharged from h o s p i t a l . Before leaving the hospit a l , the prospective subject was approached by the investigator and provided with a verbal and written explanation of the study. Those subjects 49 who consented were provided with a form to sign in d i c a t i n g t h e i r willingness to p a r t i c i p a t e . Arrangements were made by telephone to interview the consenting subjects at home within three days of discharge from h o s p i t a l . A l l subjects who par t i c i p a t e d were interviewed within a five-week period. Human Rights Protection Approval for t h i s study was provided by the UBC Behavioral Sciences Screening Committee for Research. Subjects i n the study were provided with information (see Appendix A) regarding d e t a i l s of the study with respect to why the study was being conducted, where, how much of th e i r time was required, and that p a r t i c i p a t i o n was voluntary. A l l subjects selected for the study were informed that signing the consent form (see Appendix B) was taken as a consent to p a r t i c i p a t e i n the study. They were informed that refusal to take part or withdrawal from the study would not jeopardize any future treatment, medical care, or h o s p i t a l i z a t i o n . No personal information that could res u l t i n i d e n t i f i c a t i o n of the person and the i r data was requested. Data would be shared only with the two professors on the Thesis Committee. C o n f i d e n t i a l i t y was emphasized and the subjects were assured that a l l data would be destroyed after the investigator had completed her Master's Thesis. Data Analysis The process of analysis included coding the interview responses and tabulating the data. Descriptive s t a t i s t i c s 50 were used to analyze the c h a r a c t e r i s t i c s of the sample and the responses to the questionnaire. In addition, P-values from the Chi-square test are given for the f i r s t three (3) items on the questionnaire. The remainder of the items (questions 4-10) are analyzed to determine the frequency with which selected responses occurred. Because of the nature of the responses and small sample, these questions were not amenable to sign i f i c a n c e t e s t i n g . Summary This chapter discussed the processes undertaken to apply quantitative methods to determine i f e l d e r l y c l i e n t s i n an acute care hospital perceived they were treated with dignity and respect and whether t h i s was related to t h e i r socioeconomic status. A discussion on the sel e c t i o n of the sample, instrument, and procedure for c o l l e c t i n g and analyzing the data was included. Attention to the protection of human rights was provided. Discussion and sig n i f i c a n c e of findings follow i n subsequent chapters. 51 CHAPTER FOUR Presentation and Discussion of Results Introduction The results of t h i s study are organized into the following areas: c h a r a c t e r i s t i c s of the sample, findings related to research purposes, and discussion 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 subjects was obtained from medical and surgical units of 2 university a f f i l i a t e d teaching hospitals located i n Vancouver, BC. Each hospital contains approximately 1,000 beds and i s a major r e f e r r a l center. Data were analysed according to: (1) sex, (2) length of stay [LOS], (3) age, (4) type of unit (medical or s u r g i c a l ) , and (5) l e v e l of education (measure of socioeconomic status). Sex The sample of 62 subjects was composed of 39 males and 23 females. Length of Stay (LPS) The subjects were i n hospital from a minimum of 5 to a maximum of 66 days with a mean stay of 17 days and a median stay of 14 days. Using the median to subdivide the group with respect to LOS, 35 subjects were i n the "short stay" (5-14 days) and 27 i n the "long stay" group (15+ days). 52 Age The s u b j e c t s ranged i n age from 65 to 91 years w i t h a mean of 76 y e a r s and a mode of 76 y e a r s ; 25 of the s u b j e c t s were from 65 t o 74 y e a r s of age (younger old) and 37 were 75 y e a r s of age and over ( o l d e r o l d ) . Type of U n i t The data i n d i c a t e t h a t 34 s u b j e c t s were from medical u n i t s and 28 from s u r g i c a l u n i t s . L e v e l of Educa t i o n 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 ) showed t h a t 27 of the s u b j e c t s had an elementary s c h o o l e d u c a t i o n , 27 had a hi g h s c h o o l e d u c a t i o n (secondary e d u c a t i o n ) , and 8 had a post-secondary e d u c a t i o n ranging from 2 years of c o l l e g e or u n i v e r s i t y t o completion of d o c t o r a l s t u d i e s . Since those s u b j e c t s with p o s t -secondary e d u c a t i o n were small i n number (n = 8 ) , t h i s group was added to the group w i t h secondary e d u c a t i o n (n = 3 5 ) . Research F i n d i n g s and D i s c u s s i o n The f i n d i n g s of t h i s study are presented i n r e l a t i o n t o the two r e s e a r c h purposes: (1) t o determine 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 they are 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 (2) to determine whether e l d e r l y c l i e n t s with a higher (secondary) l e v e l of e d u c a t i o n (as a measure of 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 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 (elementary) l e v e l of e d u c a t i o n . 53 Data were co l l e c t e d to determine whether length of stay, type of unit (medical or s u r g i c a l ) * or sex (male or female) made a difference as to whether eld e r l y c l i e n t s were treated with dignity and respect. The items on the questionnaire were selected from the Master Indicator L i s t of the Medicus Quality Assurance Tool by developing an operational d e f i n i t i o n of dignity and respect. These are behaviors which convey to the c l i e n t that he/she i s worthy of honor, esteem, and i s treated with consideration. The questions (see Appendix D) are: Were elder l y c l i e n t s i n an acute care setting provided with information (Items 1, 2* 3, and 4 of the questionnaire); were they addressed appropriately (Items 5, 6, and 7 of the questionnaire); were t h e i r needs for privacy attended to (Items 8 and 9 of the questionnaire); and was the c l i e n t given an opportunity to discuss his/her feelings 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 ) . F i n d i n g s R e l a t e d to the Research Questions The responses and discussion related to the research questions w i l l be organized according to the questions generated by the operational d e f i n i t i o n i n order to f a c i l i t a t e a comprehensive presentation. Research Question #1: Do Elder l y C l i e n t s i n an Acute Care S e t t i n g Perceive They are Treated with D i g n i t y and Respect. Were el d e r l y c l i e n t s provided with i n f o r m a t i o n ? The results from Items 1, 2, 3, and 4 of the questionnaire provide data to determine whether e l d e r l y c l i e n t s perceived 54 they were being treated with dignity and respect by being provided with information. Chi-square computations were performed on the f i r s t three (3) items of the questionnaire. The remainder of the items (Items 4-10) w i l l be analyzed by considering the frequency of responses. Due to the small sample and nature of the responses, Items 4-10 were not amenable to si g n i f i c a n c e t e s t i n g . The response to Item 1 (Table 1) reveals that 71% of the t o t a l group were oriented to the unit and 26% were not. Looking at the differences between the two groups, more of the "younger old" (88%) were shown around the unit when they arrived i n h o s p i t a l . If the c l i e n t s ' condition (physical, mental, or both) on admission to the unit was not amenable to being oriented to the unit the response was coded as not applicable [NA]. For t h i s reason, 3% of the c l i e n t s were omitted due to t h e i r own condition. The difference between the two groups ("younger old" and "older old") i s s t a t i s t i c a l l y s i g n i f i c a n t (Chi-square = 6.875; p = .009). The responses to Item 2 (Table 2) of the questionnaire related to introduction to roommates by age differences reveals that 31% of the t o t a l group were introduced to t h e i r roommate while 55% were not. (For 14% of the respondents the item was not applicable because the c l i e n t was either i n a private room or his/her condition or the condition of other c l i e n t s were not amenable to introduction.) Examining differences between the two groups shows that 44% of the "younger old" were introduced to th e i r roommates, while 22% 55 o f " o l d e r o l d " were . The d i f f e r e n c e between t h e two groups i s s t a t i s t i c a l l y s i g n i f i c a n t ( C h i - s q u a r e = 5 .123 ; p = . 0 2 4 ) . T a b l e 1. O r i e n t a t i o n t o u n i t 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 Age 65-74 Age 75+ n = 62(%) n = 25(%) n = 37(%) No 16 (26) 2 (8) 14 (38) Yes 44 (71) 22 (88) 22 (59) NA 2 (3) 1 (4) 1 (3) T a b l e 2. Age group d i f f e r e n c e s r e l a t e d t o i n t r o d u c t i o n t o roommate. Code T o t a l Group Age 65-74 Age 75+ n = 62(%) n = 25(%) n = 37(%) No 34 (55) 9 (36) 25 (67) Yes 19 (31) 11 (44) 8 (22) NA 9 (14) 5 (20) 4 (11) Whether e l d e r l y c l i e n t s were i n f o r m e d of a v a i l a b i l i t y of c o u n s e l o r s and f a c i l i t i e s (Item 3, Appendix D) r e v e a l s t h a t 13% of t h e t o t a l group r e c e i v e d t h i s i n f o r m a t i o n . I t was noted t h a t 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 t h e two groups on whether they were i n f o r m e d of t h e 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 and f a c i l i t i e s ( C h i - s q u a r e = 0 .351 ; p = . 5 5 3 ) . 56 The responses from the t o t a l group on whether tests or procedures were explained to them before they were done (Item 4, Appendix D) indicate that 47% had them explained "some of the time", 14% "most of the time", and 23% " a l l of the time". In comparing the "younger o l d " with the "older old", 92% of the "younger old" and "78% of the "older old" had procedures explained. While 78% of the "older old" had the i r procedures explained, 51% had them explained only "some of the time", 13% "most of the time", and 13% " a l l of the time". The 7 subjects who replied "no" (test and procedures were not explained), were over 74 years of age. The data related to whether el d e r l y c l i e n t s i n t h i s study were provided with information has been presented. According to the data, there were some el d e r l y c l i e n t s who were not oriented to t h e i r unit, introduced to t h e i r roommates, informed of the a v a i l a b i l i t y of counselors or had tests and procedures explained before they were done. There were age-related differences; the "older old" (age 75+) were le s s l i k e l y than the "younger o l d " (65-74) to be oriented to the unit or introduced to t h e i r roommates. There were no age-related differences, however, as to whether they were informed of the a v a i l a b i l i t y of counselors or f a c i l i t i e s . The current l i t e r a t u r e , however l i m i t e d , supports the findings that e l d e r l y patients may not be provided with information. Panel members from a Consumer Advisory Panel on Seniors Health Issues (Mclnnes, 1987) reported that as well as being treated l i k e children they are not provided 57 information about t h e i r condition or treatment. Dolinsky (1984) points out that nurses i n f a n t a l i z e the elde r l y by treating them as i f they are incapable of caring for themselves and do not include them i n decisions about their own care. In providing older c l i e n t s with information regarding orientation to the f a c i l i t y and tests and procedures, the nurse i s treating the c l i e n t with dignity and respect. Providing e l d e r l y c l i e n t s with information a s s i s t s them to meet t h e i r basic human needs fo r mastery, self-esteem, and love, belongingness, and dependence. Were e l d e r l y c l i e n t s addressed appropriately? Data from Items 5, 6, and 7 of the questionnaire (see Appendix E) provides information to determine whether elderly c l i e n t s i n the sample were treated with dignity and respect by being addressed appropriately. The responses to Item 5 indicate that a l l the nurses introduced themselves to t h e i r c l i e n t s either "some of the time", "most of the time", or " a l l the time". There were no noticeable differences between the "younger old" and "older old". Information from Item 6 of the questionnaire reveals that 50% of the t o t a l group r e p l i e d that nurses did not c a l l them by t h e i r f i r s t name without t h e i r permission. Of the remaining 50% who re p l i e d that nurses did c a l l them by th 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 old" and 59% were the "older o l d " . The response to Item 7 indicates that 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 that t h i s behavior occurred only "some of the time". It i s noted, however, that 20% of the "younger old", and 46% of the "older old" were addressed by names other than Miss, Mr., or Mrs. "some of the time". The major finding related to whether eld e r l y c l i e n t s i n an acute care setting are addressed appropriately* indicates that nurses introduce themselves to t h e i r c l i e n t s at 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 age-related differences; the older 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 findings support the view of Burnside (1988), Butler (1977), Dolinsky (1984), Gresham (1976), Grouse (1982), and the e l d e r l y themselves (Mclnnes, 1987). These authors describe the various ways i n which older people are treated as children i n hospitals. Some of these include: addressing the el d e r l y by t h e i r f i r s t name whether or not they request i t , c a l l e d by names such as "dear", "good g i r l " , and patting the el d e r l y on the head. Were el d e r l y c l i e n t s needs for privacy attended to? Data from Item 8 and 9 (see Appendix E) provide information 59 on whether t h e s u b j e c t s p e r c e i v e d t h a t t h e i r needs f o r p r i v a c y were met. The r e s p o n s e s t o Item 8 r e v e a l t h a t a l l of the r e s p o n d e n t s i n d i c a t e d t h a t t h e i r p r i v a c y was e n s u r e d by the c u r t a i n b e i n g drawn a n d / o r door c l o s e d d u r i n g e x a m i n a t i o n or t r e a t m e n t " a l l t h e t i m e " (81%) or "most of t h e t i m e " (13%). There were no n o t i c e a b l e a g e - r e l a t e d d i f f e r e n c e s . Data f rom Item 9 i n d i c a t e s t h a t 82% of the t o t a l group d i d f e e l i n a p p r o p r i a t e l y exposed d u r i n g a b a t h , exam, or p r o c e d u r e . There were no a g e - r e l a t e d d i f f e r e n c e s . The major f i n d i n g s a re t h a t t h e r e were some r e s p o n d e n t s who d i d not have t h e i r needs f o r p r i v a c y met . There were, however, no a g e - r e l a t e d d i f f e r e n c e s . The c u r r e n t l i t e r a t u r e s u p p o r t s the f i n d i n g s . A c c o r d i n g t o S t e f f i (1984a), p r o f e s s i o n a l c a r e g i v e r s are o f t e n n e g l i g e n t i n u s i n g bed s c r e e n s , c l o s i n g d o o r s , and a l l o w i n g some p e r s o n a l s p a c e . S t i l l m a n (1978) s t a t e s t h a t h o s p i t a l i z e d i n d i v i d u a l s u s u a l l y e x p e r i e n c e a l o s s o f p r i v a c y and c o n t r o l over t h e i r b o d i e s and the s u r r o u n d i n g a r e a . They a r e d e p r i v e d of p r i v a c y t o p e r f o r m t h e most b a s i c b o d i l y f u n c t i o n s (Kemp, 1978) . Were e l d e r l y c l i e n t s 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 f e e l i n g s and concerns w i t h a n u r s e ? Item 10 of the q u e s t i o n n a i r e (see Appendix E) i n d i c a t e s t h a t 40% o f t h e t o t a l group of 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 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 and concerns w i t h a nurse. A g r e a t e r percentage (49%) of the " o l d e r o l d " than the "younger o l d " (28%) were not p r o v i d e d w i t h the o p p o r t u n i t y . The c u r r e n t l i t e r a t u r e supports the f i n d i n g s t h a t nurses do not p r o v i d e e l d e r l y c l i e n t s w i t h the o p p o r t u n i t y to d i s c u s s t h e i r f e e l i n g s and concerns. S e v e r a l authors (Burnside, 1988; E b e r s o l e & Hess/ 1985; Jackson, 1984) note t h a t , i n acute care u n i t s , o l d e r c l i e n t s are g i v e n i n s u f f i c i e n t time to ask q u e s t i o n s and are g i v e n l i t t l e o p p o r t u n i t y to p a r t i c i p a t e i n any decision-making. G i o i e l l a and B e v i l (1985) argue t h a t the nurse should communicate r e g u l a r l y w i t h c l i e n t s about t h e i r p r o g r e s s , r e a s s u r e them about t h e i r c o n d i t i o n , and g e n e r a l l y p r o v i d e the time f o r the p a t i e n t t o v e r b a l i z e t h e i r w o r r i e s or concerns. Because an i n c r e a s e d l e v e l of a n x i e t y i n t e r f e r e s with the c l i e n t ' s a b i l i t y t o p e r c e i v e and i n t e r p r e t the experiences of h o s p i t a l i z a t i o n c o r r e c t l y , the nurse should make r e g u l a r assessments of the e l d e r l y c l i e n t s ' a n x i e t y l e v e l (Burnside, 1988; E b e r s o l e & Hess, 1985; G i o i e l l a & B e v i l , 1985). To f a c i l i t a t e communication, a l l o l d e r people should be greeted i n a warm, f r i e n d l y manner and the nurse should be p a t i e n t and s u p p o r t i v e . Research Question #2; Are E l d e r l y C l i e n t s with a Higher Socioeconomic Status 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 Respect Were e l d e r l y c l i e n t s p r o v i d e d with 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 (see 61 Appendix F) provide data to determine whether there were differences related to the l e v e l of education attained (used as a measure of socioeconomic status) and whether elderly c l i e n t s were provided with information. The responses to Item 1 of the questionnaire shows that there are no noticeable differences between the two groups (elementary and secondary education completion) i n whether the c l i e n t was oriented to the unit. Respondents who had an elementary school education (67%) were l e s s l i k e l y than those with a secondary school education (46%) to be introduced to t h e i r roommates (Item 2 of the questionnaire). The r e s u l t s , however, were not s t a t i s t i c a l l y s i g n i f i c a n t (Chi-square = 1.268; p = .260). Responses to Item 3 of the questionnaire showed that 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 counselors 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 differences between the two groups (Chi-square = 0.721; p = .396). The data for Item 4 of the questionnaire show that c l i e n t s with a secondary education may be more l i k e l y to have had procedures explained to them before they were done, while 67% of the subjects with an elementary school education had tests explained to them "some of the time", only 32% of those with secondary education did. But, 34% of those with a secondary education had procedures explained " a l l the time", while only 7% of those with an elementary education did. 62 Although, i n some instances, differences between d i f f e r e n t l e v e l s of education (elementary or secondary) were small, the data showed that a greater 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 to be introduced to t h e i r roommates, be informed of available services and f a c i l i t i e s , and be more l i k e l y to have tests and procedures explained to them before they were done. These findings are i n keeping with the l i t e r a t u r e review (Chapter 2). Henretta and Campbell (1976) point out that the higher the individual's socioeconomic cl a s s , the greater the l i k e l i h o o d of maintaining status for a longer time because they have resources that given them power i n s o c i a l r elationships. It may be argued that c l i e n t s with a higher l e v e l of education, because of t h e i r perceived power in s o c i a l r elationships, obtain the information by requesting i t . Were e l d e r l y c l i e n t s addressed appropriately? Data from Items 5, 6, and 7 of the questionnaire (see Appendix F) provide information to determine i f e l d e r l y c l i e n t s i n the sample were being treated with dignity and respect by being addressed appropriately. The responses to Item 5 revealed that nurses usually introduced themselves to t h e i r e l d e r l y c l i e n t s , except they introduced themselves more frequently to those with a secondary education. The data from Item 6 indicate 66% of the elementary group and 80% of the secondary group were c a l l e d by t h e i r 63 f i r s t name w i t h o u t t h e i r p e r m i s s i o n . B e f o r e c o l l a p s i n g t h e secondary and p o s t - s e c o n d a r y g r o u p , however, i t i s n o t e d t h a t o n l y 12% of t h o s e r e s p o n d e n t s w i t h a p o s t - s e c o n d a r y e d u c a t i o n were c a l l e d by t h e i r f i r s t name; 88% of t h e r e s p o n d e n t s i n d i c a t e d t h a t they were not a d d r e s s e d by t h e i r f i r s t name w i t h o u t t h e i r p e r m i s s i o n w h i l e 33% of t h e e l e m e n t a r y group were (see Item 6a , Appendix F ) . The r e s u l t s of Item 7 s u g g e s t t h a t c l i e n t s w i t h a lower l e v e l of e d u c a t i o n may be more l i k e l y t h a n t h o s e w i t h secondary or p o s t - s e c o n d a r y 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 by names o t h e r t h a n M i s s , 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 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 a c u t e c a r e s e t t i n g a re a d d r e s s e d a p p r o p r i a t e l y , i n d i c a t e s t h a t n u r s e s 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 t h e t i m e . N u r s e s d o , 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 a d d r e s s them by names o t h e r t h a n M i s s , M r . , or M r s . The d a t a suggest t h a t the h i g h e r t h e c l i e n t ' s s o c i o e c o n o m i c s t a t u s (as d e t e r m i n e d by l e v e l of e d u c a t i o n ) / t h e more l i k e l y they w i l l be a d d r e s s e d a p p r o p r i a t e l y . S t u d i e s which examine the e l d e r l y c l i e n t s ' s o c i o e c o n o m i c s t a t u s and how e l d e r l y c l i e n t s a re a d d r e s s e d 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 . The r e s u l t s f o u n d i n t h i s s t u d y , however, can be s u p p o r t e d by H e n r e t t a and Campbel l (1976), and B u t l e r (1977) on the b a s i s of s o c i a l c l a s s (mentioned e a r l i e r ) . 64 Were elderly c l i e n t s ' needs for privacy attended to? The results of Item 8 and 9 of the questionnaire (see Appendix F) provide data to determine i f the older person's need for privacy was attended to. The re s u l t s of Item 8 reveal that there i s only a 10% difference between the elementary and secondary educated group; 81% of the elementary school group and 91% of the secondary school group indicated that the curtain was drawn and/or the door closed during an examination or treatment. Data for Item 9 indicate that a greater percentage of those with a secondary school education (91%) than elementary education (74%) f e l t they were inappropriately exposed. Only 9% of the secondary group compared with 26% of the elementary group f e l t inappropriately exposed ("some of the time", "most of the time", or " a l l the time") during a bath, exam, or procedure. The major findings related to whether the e l d e r l y c l i e n t ' s need for privacy i s attended to, reveal that there were some differences to show that some of the respondents did not have t h e i r needs for privacy met. The current l i t e r a t u r e supports t h i s finding. Clients with a higher socioeconomic status were shown to be more l i k e l y to have t h e i r needs for privacy met than c l i e n t s of a lower socioeconomic status* Brown (1969) reported that c l i e n t s who are s o c i a l l y valued were observed to receive extra care from nurses. Henretta and Campbell (1976) found 65 (as mentioned e a r l i e r ) that c l i e n t s with a higher socioeconomic status have resources that give them power i n s o c i a l r e l a t i o n s h i p s . Were el d e r l y c l i e n t s given an opportunity to discuss feelings and concerns with a nurse? The data from Item 10 of the questionnaire (see Appendix F) showed that a greater proportion of c l i e n t s with a secondary school education (23%) than elementary school education (15%) were given an opportunity to discuss t h e i r feelings "most of the time" or " a l l the time". The difference i s small, however, but could be explained by studies c i t e d i n previous paragraph. Other Findings Differences related to length of stay and type of unit (medical or surgical) could not be determined since the information was confounded. Confounding factors are unwanted group differences between comparison groups that occur i n surveys (Weldon, 1986). Comparisons i n t h i s group are "confounded" because the group was not s i m i l a r i n a l l relevant aspects. For example, the "older old" group was larger (n = 37) than the "younger old" (n = 25). While there was a similar number of males and females i n the "older o l d " group, the "younger old" group contained more men. The number of subjects by gender and length of stay were also related; although the "long stay" group had an equal number of males and females, the "short stay" group contained more men. 66 Group differences were not ascertained since sample sizes were too small to look at interactions between variables (age, gender, education, LOS, and u n i t ) . Therefore, each factor was examined separately and no attempt was made to adjust for multiple s i g n i f i c a n c e t e s t s . Therefore, these re s u l t s must be regarded as descriptive only. Gender differences. Nurses tended to address women by names other than Miss or Mrs. more frequently than they addressed men other than Mr. Procedures were explained more frequently to men than women and men reported more responses ind i c a t i n g "treatment with dignity and respect" on Items 4 to 10. Length of stay. There were no noticeable differences between length of stay groups, though people who stayed longer tended to be older. More responses indicating "treatment with dignity and respect" were reported by the "short stay" subjects. Type of unit. Differences between type of unit (medical or surgical) were minimal. C l i e n t s i n s u r g i c a l units reported more responses indicating "treatment with dignity and respect" on 6/7 items (there were more men i n surgical units than women). In examining group differences, a s i g n i f i c a n t finding i s that fewer females reported responses in d i c a t i n g "treatment with dignity and respect" than men. Though 67 l i t e r a t u r e addressing gender differences i n caring for hospi t a l i z e d c l i e n t s i s scarce, one study by Forgan Morle (1984) found that nurses provided explanations more frequently to elde r l y men than they did to elde r l y women. L'Esperance (1979) reported that physicians and nurses often respond negatively to women's questions, provide inadequate information, and lecture t h e i r c l i e n t s instead of encouraging them to p a r t i c i p a t e i n health care decisions. In conclusion, the findings i n t h i s study show that the "younger old" who were male and attained a higher l e v e l of education were more l i k e l y to be treated with dignity and respect. The e l d e r l y c l i e n t ' s perception of his/her nursing care i n t h i s study supports other reports and studies which investigate the qu a l i t y of care the el d e r l y receive (Campbell, 1971; Mclnnes, 1987; Health and Welfare Canada, 1982; Podnieks, 1983). These authors say that the negative attitude of nurses toward aging and the el d e r l y i s one of the factors that contributes to an i n f e r i o r q u a l i t y of nursing care; nurses who hold negative attudies toward the eld e r l y w i l l engage i n behaviors which may not be therapeutic or may be detrimental to the best 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 et a l . , 1984). Negative a t t r i b u t i o n s may be in t e r n a l i z e d by an el d e r l y person, and may subsequently influence his or her b e l i e f s and 68 s e l f - c o n c e p t ( C h e r r y , 1981; Kuypers & B e n g s t o n , 1973) . In o t h e r words , t h e e l d e r l y d e v e l o p p e r c e p t i o n s about t h e m s e l v e s on the b a s i s of a t t i t u d e s of o t h e r s toward them. I t i s g e n e r a l l y h e l d t h a t a t t i t u d e s a r e d e r i v e d , a t l e a s t p a r t i a l l y , f rom t h e p r e v a l e n c e of c u l t u r a l s t e r e o t y p e s (Kogan, 1979; L e v i n & L e v i n , 1980) . N e g a t i v e s t e r e o t y p e s about a g i n g and growing o l d are i n c u l c a t e d t h r o u g h t h e s o c i a l i z a t o n p r o c e s s . In t u r n , t h e s e s t e r e o t y p e s r e p r e s e n t i n c o r r e c t a s s u m p t i o n s , f a u l t y r e a s o n i n g , and m i s p e r c e p t i o n s . I f a c c e p t e d as f a c t , they i n f l u e n c e our b e h a v i o r and a t t i t u d e toward the e l d e r l y . 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 lower the s t a t u s of o l d e r p e o p l e and d e c r e a s e the f r e q u e n c y and q u a l i t y of s o c i a l i n t e r a c t i o n w i t h them. Some e l d e r l y , however, p o s s e s s s t a t u s c h a r a c t e r i s t i c s t h a t e n a b l e them t o r e t a i n power ( H e n r e t t a & C a m p b e l l , 1976) . T h i s r e l e a s e s them from some of t h e c o n s t r a i n t s of a g i n g imposed on o t h e r s by v i r t u e of age . These a u t h o r s r e p o r t e d t h a t t h e h i g h e r 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 t h e 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 p e r i o d of t i m e . These o b s e r v a t i o n s s u p p o r t the f i n d i n g s i n t h i s s t u d y which f o u n d t h a t n u r s e s may p r e s e n t themselves d i f f e r e n t l y t o c l i e n t s w i t h a h i g h e r s o c i o e c o n o m i c s t a t u s . I t seems r e a s o n a b l e t o suggest t h e n t h a t women i n t h i s s t u d y were l e s s 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 r e s p e c t t h a n men because of s t a t u s . The g r e a t e s t number of o l d e r p e o p l e a re women and many of t h e s e women are e c o n o m i c a l l y dependent . 69 Women's s o c i a l status declines with age (Dulude, 1981) i n contrast to that of men, who grow i n "character". This means that as a population ages, i t becomes more and more characterized by old, poor women with low s o c i a l status. The symbolic i n t e r a c t i o n i s t view suggests that d i f f e r e n t dress, speech, and behavior patterns are selected i n order to present a s e l f considered appropriate to the s p e c i f i c s i t u a t i o n . I t may be that e l d e r l y women may be le s s l i k e l y to be treated with dignity and respect because they are perceived to have a lower status. L i l l a r d (1982) points out that el d e r l y women may be affected negatively by the double bias of ageism and sexism. In addition to the negative attitudes and practices that discriminate against the aged (ageism) e l d e r l y women are stereotyped i n ways that are d i r e c t l y related to sexism; they are economically disadvantaged, poorly insured, and s o c i a l l y i s o l a t e d . There i s no l i t e r a t u r e which addresses the combined impact of ageism and sexism on the nursing care of aged women ( L i l l a r d , 1982). Since both biases are present i n the culture and are known to af f e c t health care as separate e n t i t i e s , t h i s author asserts that i t i s reasonable to speculate about the sig n i f i c a n c e of the two factors operating simultaneously. The implication for aged women i s that they may be the l e a s t valued and most underserved patient group. 70 N u r s i n g approaches and a c t i o n s a re shaped by i n p u t from many f a c e t s of s o c i e t y : c u l t u r a l v a l u e s f i l t e r t h r o u g h s o c i a l and p o l i t i c a l systems t o a f f e c t n u r s i n g e d u c a t i o n , p r a c t i c e and care d e l i v e r y ( G i o i e l l a & B e v i l , 1985; L i l l a r d , 1982) . A c c o r d i n g t o t h e s e a u t h o r s , n u r s i n g programs f r e q u e n t l y i g n o r e h e a l t h needs of the e l d e r l y . T o o , the 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 v a l u e s even b e f o r e they are f i l t e r e d t h r o u g h o r g a n i z e d i n s t i t u t i o n s . W i e s s t e i n (1971) s t a t e s t h a t t h e s o c i a l c o n t e x t i s t h e major d e t r i m e n t t o b e h a v i o r ; p e o p l e w i l l a c t as they a r e e x p e c t e d t o even i f t h o s e e x p e c t a t i o n s a r e t r a n s m i t t e d i n d i r e c t l y . In s p i t e of p r e s s u r e s on n u r s e s t o a c t autonomously based on c l i e n t w e l l - b e i n g a l o n e , i f t h e n u r s e ' s c u l t u r a l group i s p r e d o m i n a n t l y s e x i s t , t h e r e i s a l i k e l i h o o d t h a t some of t h e n u r s i n g c a r e w i l l r e f l e c t ( c o n s c i o u s l y or u n c o n s c i o u s l y ) t h o s e s e x i s t v a l u e s . A c c o r d i n g to J o u r a r d (1974), p e o p l e ' s views of t h e m s e l v e s a r e 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. I f n u r s e s 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 t h e e l d e r l y c l i e n t , the a t t r i b u t e may be i n t e r n a l i z e d ; c o n v e r s e l y , i f the n u r s e p r o j e c t s an a t t r i b u t e of d i g n i t y and r e s p e c t , 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 m a i n t a i n e d or enhanced . Summary T h i s c h a p t e r has p r e s e n t e d the d a t a w h i c h were o b t a i n e d t o d e t e r m i n e whether t h e r e a r e d i f f e r e n c e s i n p e r c e p t i o n s r e l a t e d to age and s o c i o e c o n o m i c s t a t u s . Other f a c t o r s such 71 as length of stay, sex, and type of unit (medical or surgical) were also described. The results indicate that the "younger old" males and those with a higher l e v e l of education (socioeconomic status) were more l i k e l y to be treated with dignity and respect. 72 CHAPTER 5 Summary, Conclusions, Implications, and Recommendations Summary and Conclusions This study was designed to investigate whether eld e r l y c l i e n t s i n an acute care setting perceived they were treated with dignity and respect, and to i d e n t i f y whether e l d e r l y c l i e n t s with a higher socioeconomic status were more l i k e l y to be treated with dignity and respect than those with a lower socioeconomic status. After the data were co l l e c t e d the investigator proceeded to i d e n t i f y group-related differences (age, sex, education, length of stay, and type of unit) and whether there were any differences i n r e l a t i o n to dignity and respect. The impetus for t h i s study emanated from empirical findings and information i n the l i t e r a t u r e . Sixty-two subjects who were between 65 and 91 years of age were selected from medical and surgical units of two major teaching hospitals using a convenience sampling technique. These subjects were i n hospital at l e a s t f i v e days and were a l e r t and oriented during t h e i r h o s p i t a l i z a t i o n . They were asked to answer "fixed-a l t e r n a t i v e " questions on a questionnaire (Appendix D) i n an interview i n the i r home within three days after they were discharged from the ho s p i t a l . 73 The f o l l o w i n g a r e major f i n d i n g s and c o n c l u s i o n s of the s t u d y : 1. R e g i s t e r e d n u r s e s f rom acute c a r e s e t t i n g s do not c o n s i s t e n t l y o r i e n t t h e e l d e r l y c l i e n t t o t h e i r u n i t , i n t r o d u c e them t o t h e i r roommates, or i n f o r m them o f t h e a v a i l a b i l i t y of c o u n s e l o r s or f a c i l i t i e s . The e l d e r l y over 75 y e a r s of age were l e s s l i k e l y t h a n t h e younger group (65-74) to be o r i e n t e d t o t h e u n i t or i n t r o d u c e d t o t h e i r roommates. There were no a g e - r e l a t e d d i f f e r e n c e s on whether 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 o f c o u n s e l o r s or f a c i l i t i e s . 2. Those r e s p o n d e n t s who had a h i g h e r 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 i n t r o d u c e d to t h e i r roommates and i n f o r m e d by n u r s e s of a v a i l a b l e s e r v i c e s and f a c i l i t i e s . 3. A l l t h e r e s p o n d e n t s i n d i c a t e d t h a t the n u r s e s i n t r o d u c e d t h e m s e l v e s "some of t h e t i m e " , "most of t h e t i m e " , or " a l l the t i m e " , a l t h o u g h more f r e q u e n t l y t o c l i e n t s w i t h h i g h e r s o c i o e c o n o m i c s t a t u s . H a l f of t h e r e s p o n d e n t s r e v e a l e d t h a t n u r s e s c a l l e d them by t h e i r f i r s t name w i t h o u t t h e i r p e r m i s s i o n "some of t h e t i m e " , "most of the t i m e " , or " a l l t h e t i m e " , and the o l d e r group was more l i k e l y t h a n the younger group and those w i t h a lower s o c i o e c o n o m i c s t a t u s t o be c a l l e d by t h e i r f i r s t name. Nurses were f o u n d t o a d d r e s s t h e i r c l i e n t s by o t h e r t h a n 74 Miss, Mr., or Mrs., but t h i s behavior occurred more frequently i n the "older old" and those with a lower socioeconomic status. 4. A l l of the respondents revealed that the curtains were drawn or the door was closed during an examination or treatment "most of the time" or " a l l the time"; there were no differences between the older and younger group or socioeconomic status. The nurses explained tests and procedures to the 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 of the time" but with greater l i k e l i h o o d i n the "younger old" and those with a higher socioeconomic status. Although some respondents f e l t inappropriately exposed during a bath, exam, or procedure; there were no s i g n i f i c a n t differences between the "older old" and "younger old"" group. There was some in d i c a t i o n , however, that people with a higher socioeconomic status are les s l i k e l y to be inappropriately exposed than those with a lower socioeconomic status. 5. The respondents revealed that they were provided with an opportunity to discuss t h e i r f e e l i n g s or concerns with the nurse "some of the time", "most of the time", or " a l l the time". The "younger old" and those with a higher socioeconomic status were more l i k e l y to be provided with t h i s opportunity. The evidence i n t h i s study suggests that the el d e r l y c l i e n t i n an acute care setting may not be treated with 75 dignity and respect. The evidence i s made more convincing by examining the younger and older groups of the el d e r l y population sample and finding that the older c l i e n t i s less l i k e l y than the younger c l i e n t to be treated with dignity and respect. Moreover, females were le s s l i k e l y than males to be treated with dignity and respect. Some differences existed between the c l i e n t ' s socioeconomic status (as determined by l e v e l of education) and the degree to which the c l i e n t i s treated with dignity and respect. Although there were no s i g n i f i c a n t differences on whether c l i e n t s were provided with information, those c l i e n t s who had a higher socioeconomic status were more l i k e l y to be treated with dignity and respect than those with a lower socioeconomic status on Items 4-10 of the questionnaire. This study suggests that a s i g n i f i c a n t number of eld e r l y c l i e n t s perceive they are not treated with dignity and respect. The investigator w i l l discuss these findings with reference to t h e i r implications for nursing. Implications It has been estimated that by year 2031 about 25% of the population i n Canada w i l l be 65 years or older. The increase i n the proportion of el d e r l y w i l l have fa r reaching demands upon those who provide nursing services. When today's nursing students reach the prime of th e i r careers, 75% of t h e i r nursing practice time w i l l be spent with the 76 e l d e r l y . Because of the demographic trend, the findings of t h i s study have s i g n i f i c a n t implications f o r nursing practice* nursing education, and nursing research. Nursing Practice Several factors 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 poten t i a l to adversely a f f e c t e l d e r l y c l i e n t s i n an acute care environment. The attitudes of caregivers, the normal aging process, chronic disease, being i l l i n a strange environment, and acute i l l n e s s are some of the conditions inte r a c t i n g to 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. Such people may not only be i l l , but tend also to be l a r g e l y i s o l a t e d from family, friends, and f a m i l i a r surroundings. Nurses who work i n acute care hospitals are responsible for planning, implementing, and evaluating nursing care for th e i r c l i e n t s , young or old. As i s apparent from the l i t e r a t u r e addressing nursing ethics, one c r u c i a l r e s p o n s i b i l i t y of nursing i s that of maintaining the dignity and respect and i n d i v i d u a l i t y of hospi t a l i z e d old people. The results of t h i s study indicate, however, that some eld e r l y c l i e n t s ( p a r t i c u l a r l y those of lower status and women) often are not provided with information, addressed appropriately, do not have t h e i r needs f o r privacy attended to, or are not provided with an opportunity to discuss t h e i r fears or concerns. These findings suggest that the nursing management of 77 acutely i l l older adults i n the hospital setting i s a matter of serious ethicolegal consideration. According to the Canadian Nurses Association Code of Ethics (1985), the nurse i s obliged to encourage c l i e n t autonomy, include the c l i e n t i n the decision-making process, and c u l t i v a t e respectful and d i g n i f i e d treatment of the c l i e n t . Negative attitudes and perceptions of the aged and aging held by nurses can have detrimental e f f e c t s on e l d e r l y c l i e n t s . A number of studies have documented the presence of negative attitudes by nurses with some evidence suggesting attitude influences treatment of the e l d e r l y c l i e n t . 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 that perpetuate the idea that the aged are dependent and the young are independent. Cl i e n t s subjected to care practices which defy gerontological care p r i n c i p l e s may regress and become increasingly dependent. If the e l d e r l y are to survive acute h o s p i t a l i z a t i o n and receive humane and therapeutic care, very s p e c i f i c nursing interventions are required. Burnside (1988) asserts that the nurse's role i s to support the older person's a b i l i t y to become informed about the acute care s e t t i n g , organize the information, and a s s i s t the older person's a b i l i t y to adapt to the new environment i n a manner that enables the older person to recover from the acute i l l n e s s . Ebersole and Hess (1985) have i d e n t i f i e d the generative functions of 78 productivity and problem-solving a b i l i t y as essential to the maintenance of self-esteem i n the el d e r l y and have suggested that the nurse's role i s to a s s i s t i n development of these a b i l i t i e s . Providing the older adult with information allows and encourages p a r t i c i p a t i o n i n one's own health care and helps to strengthen feelings of control and autonomy. According to Burnside (1988) some elderly become i l l i n ways which are secondary to nontherapeutic care. 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 for the e l d e r l y . Selected studies show how l i m i t e d knowledge, s k i l l s and attitudes 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 for el d e r l y c l i e n t s (Bossenmaier, 1982; Gunter, 1983; Lueckenotte, 1987). According to 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 and loss of health, mobility, and independence* Even when they are capable of s e l f - c a r e , nurses may believe i t i s faster to do things for them, thus reinfor c i n g the c l i e n t ' s dependent p o s i t i o n . These losses weaken the el d e r l y c l i e n t ' s feelings of self-confidence, sense of self-esteem, and loss of control over t h e i r l i f e -s t y l e (Burnside, 1988; G i o i e l l a & B e v i l , 1985). According to these authors, helping the e l d e r l y c l i e n t begins with the admission procedure. As soon as possible, the nurse should provide the c l i e n t with a thorough orientation to the physical s e t t i n g , routines, roommates, and personnel. Older c l i e n t s should know the locations of t h e i r bed, bathroom, and lounge. 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 a c c u r a t e l y p e r c e i v i n g e v e n t s because o f v a r i o u s s e n s o r y l o s s e s ( C h o d i l & W i l l i a m s , 1970; W o r r e l l , 1977) . Because of p r e v i o u s e x p e r i e n c e s as w e l l 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 and a g i t a t e d . S e v e r a l a u t h o r s (Bossenmaier , 1982; G i o i e l l a & B e v i l , 1985; Forgan M o r l e , 1984) p o i n t out t h a t e x p l a n a t i o n s b e f o r e p r o c e d u r e s b e i n g performed are seldom g i v e n . A c c o r d i n g t o t h e s e a u t h o r s , to reduce t h e a n x i e t y a s s o c i a t e d w i t h d i a g n o s t i c t e s t s , o l d e r c l i e n t s r e q u i r e c l e a r e x p l a n a t i o n s of t h e i r p u r p o s e , the p r e p a r a t i o n r e q u i r e d , and how they can a s s i s t d u r i n g t h e t e s t or p r o c e d u r e . There i s a r e c i p r o c a l r e l a t i o n s h i p between c l i e n t and t h e a t t i t u d e s of n u r s e s ( L i l l a r d , 1982; W h i t e , 1977) . For example, c l i e n t s who cannot c a r e f o r themselves or a r e v iewed as h a v i n g fewer p o s i t i v e a t t r i b u t e s may not be v a l u e d by t h e n u r s e . A c c o r d i n g t o W h i t e (1977) c l i e n t s d e r i v e i d e a s about t h e m s e l v e s a c c o r d i n g t o how they i n t e r p r e t the b e h a v i o r of t h e n u r s e ; t h u s , t h e i r a t t i t u d e s about t h e m s e l v e s a r e r e l a t e d t o d i g n i t y , r e s p e c t and esteem shown by t h e n u r s e e i t h e r d i r e c t l y o r i n d i r e c t l y t h r o u g h t h e i r a c t i o n s . S t u d i e s suggest t h a t t h o s e c l i e n t s who are l e s s s o c i a l l y 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 a r e more l i k e l y t o r e c e i v e p o o r e r c a r e ( B u r n s i d e , 1988; G i o i e l l a & B e v i l , 1985; W h i t e , 1977) . A c c o r d i n g t o W h i t e (1977) we 80 need 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 which n e g a t i v e a t t i t u d e s a r e conveyed t o c l i e n t s and f o r t h e e x t e n t t o which p o s i t i v e a t t i t u d e s a r e not e x p r e s s e d a p p r o p r i a t e l y , or a p p r o p r i a t e b e h a v i o r s do not o c c u r . A l t h o u g h n u r s i n g l i t e r a t u r e r e c o g n i z e s ageism as a r e a l t h r e a t t o the c a r e o f t h e aged , the r e c e n t l i t e r a t u r e does not d i s c u s s sex ism among n u r s e s or i t s r e l a t i o n s h i p t o c l i e n t c a r e ( L i l l a r d , 1982) . The i m p l i c a t i o n f o r aged women, she s t a t e s , i s t h a t they a r e the l e a s t v a l u e d and most u n d e r s e r v e d c l i e n t p o p u l a t i o n . A c c o r d i n g to L i l l a r d , o p t i o n s f o r f u n d i n g r e s e a r c h , e d u c a t i o n and change p r o j e c t s f o c u s e d on i m p r o v i n g the h e a l t h c a r e of e l d e r l y women needs t o become paramount. Every n u r s e 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 f o r t h e 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 a g i n g c l i e n t s . I t i s a l s o the r e s p o n s i b i l i t y of e v e r y n u r s e t o p r o v i d e n u r s i n g c a r e based on a s o u n d , s c i e n t i f i c knowledge b a s e . Nursing Education P o s i t i v e a t t i t u d e s toward the e l d e r l y a r e r e q u i r e d t o a c h i e v e o p t i m a l c a r e f o r the e l d e r l y which meets t h e i r need f o r d i g n i t y and r e s p e c t . A l t h o u g h f i n d i n g s have been m i x e d , t h e r e a re s t u d i e s w h i c h show t h a t nurses who have t a k e n a c o u r s e of s t u d y i n G e r o n t o l o g i c a l N u r s i n g demonstrate more p o s i t i v e a t t i t u d e s toward the e l d e r l y (Gomez, O t t o , B l a t t s t e i n , & Gomez, 1985; S t a n l e y & B u r g g r a f , 1986; W i l h i t e & J o h n s o n , 1976) . T h e r e f o r e , c o n t i n u i n g e d u c a t i o n ( i n 81 general or s p e c i f i c areas) i n u n i v e r s i t i e s , colleges, and health care i n s t i t u t i o n s should be one of the strategies used to maintain or increase p o s i t i v e attitudes about aging. The lack of emphasis i n nursing education on knowledge and application of gerontological nursing p r i n c i p l e s i d e n t i f i e s a need for in-service education. A nursing s t a f f development program must include education i n theories of aging, normal aging (physiologic and psychosocial) changes, s e n s i t i v i t y to stereotypes, and to develop strategies to a s s i s t nurses to incorporate new knowledge into nursing pract i c e . Educational programs for gerontological nursing s t a f f must address the dynamics of the nurse-client interactions. For example, nursing s t a f f could be taught how to reduce dependent behaviors on the part of c l i e n t s . Nursing s t a f f also could be made aware of how the meaning of t h e i r attitudes and behavior i s interpreted by the c l i e n t . A d d i t i o n a l l y , the organizations for which nursing s t a f f work must consider how t h e i r p o l i c i e s and practices may be contributing toward t h e i r s t a f f ' s attitudes toward and perceptions of t h e i r e l d e r l y c l i e n t s . Nursing practice administrators can play a major role i n maintaining and increasing p o s i t i v e attitudes toward the e l d e r l y and promoting the q u a l i t y of care of the aging c l i e n t . This can be achieved by a l l o c a t i n g resources for s t a f f education (including orientation programs), 82 establishing standards of nursing care, and believing that increased knowledge i s paramount to the delivery of quality care. Strategies should be developed to enhance the image of the nurse whose practice includes el d e r l y c l i e n t s . Primary nursing and provision of c l i n i c a l nurse s p e c i a l i s t s whose expertise i s i n gerontological nursing should be promoted. These nurses would function as c l i n i c a l nurse p r a c t i t i o n e r s , consultants, educators, and researchers i n addition to providing leadership and acting as role models for other nurses. Moreover, human dignity and respect of older adults must become our immediate agenda for consideration within schools of nursing and curriculum planning. Nursing Research Nursing research provides a firm foundation for a l l areas of nursing. Unfortunately, nursing research regarding the e l d e r l y c l i e n t ' s perception of his/her nursing care i s very l i m i t e d . Further research would be useful i n substantiating the findings discussed i n t h i s t h e s i s . F i r s t , 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 sampling technique. The problem of an accidental sampling technique (nonprobability sampling) i s that available subjects might not be representative of the population with regard to the c r i t i c a l variables being measured ( P o l i t & Hungler, 1983). The second recommendation relates to the measurement of 83 dignity and respect. Further investigation to describe perception of dignity and respect would be of value. This researcher examined a group of a l e r t and oriented e l d e r l y c l i e n t s . Other el d e r l y c l i e n t s , who are not a l e r t , need to be investigated as to whether t h e i r nursing care ensured t h e i r dignity and respect. This study assumed that personality dimensions are highly dependent on s o c i a l learning and in t e r a c t i o n , and when losses or changes occur i n these areas, older persons, l i k e younger persons, begin to question t h e i r worth and competence. This i n turn can lower th e i r l e v e l of s e l f -esteem or change t h e i r self-concept, thereby leading to changes i n behavior. Research should be conducted to determine the relationship between nursing care which does or does not meet the el d e r l y c l i e n t ' s need to be treated with dignity and respect and i t s e f f e c t on self-concept. This study found males were more l i k e l y to be treated with dignity and respect than women. Studies which examine gender differences i n the qu a l i t y of care are scarce. The fac t that the greatest number of older people are women and are more commonly found i n the ranks of the poor or those on welfare (Dulude, 1981) stimulates the following research questions. To determine: (1) Whether there i s a rela t i o n s h i p between t h e i r lower socioeconomic status and the degree to which el d e r l y women are treated with dignity and respect, and (2) whether nurses' attitudes are more 84 favorable toward e l d e r l y male than el d e r l y female c l i e n t s . Furthermore, what nursing actions 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 female) perception of being treated with dignity and respect. 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(1980). S y m b o l i c i n t e r a c t i o n i s m : A s o c i a l s t r u c t u r a l v e r s i o n . L o n d o n : Benjamin/Cummings. T a y l o r , H . , St H a r n e d , T . L . (1978). A t t i t u d e s toward o l d p e o p l e : A s t u d y of n u r s e s who c a r e f o r t h e e l d e r l y . J o u r n a l of G e r o n t o l o g i c a l N u r s i n g . 4 (5 ) , 43-47. Thomas, W. (1934). The d e f i n i t i o n of the s i t u a t i o n . In W. Thomas (Ed.), The unadjusted g i r l . Boston: L i t t l e , Brown. Weisstein, N. (1971). Psychology constructs the female. In V. Gornick & B. Moran (Eds.), Women i n sexist society. New York: Basic Books. Weldon, K. L. (1986). S t a t i s t i c s : A conceptual approach. New Jersey: Prentice-Hall. White, C. M. (1977). The nurse-patient encounter. Attitude and behaviors i n action. Journal of Gerontological Nursing. 1, 16-21. Wilhite, M. J . , & Johnson, D. M. (1976). Changes i n nursing students' stereotypic attitudes towards old people. Nursing Research. 2JL (6), 62-66. Wolk, R. L., & Wolk, R. B. (1971). Professional workers attitudes toward the aged. Journal of the American G e r i a t r i c s Society. L9_, 624-639. Worrell, J . D. (1977). Nursing implications i n the care of the patient experiencing sensory deprivation. In K i n t z e l , L. D. (Ed.), Advanced concepts i n c l i n i c a l nursing. Philadelphia: Lippincott. Zimbardo, P. G., & Ebbesen, E. B. (1969). Influencing attitudes and chancing behavior. Reading, MA: Addison & Wesley. 95 APPENDIX A Information Letter I am Josephine Steckler, a registered nurse i n the Masters of Nursing program at the University of B r i t i s h Columbia. I am interested i n learning more about how older adults view some aspects of the i r nursing care. It i s believed that the findings of t h i s study w i l l help nurses provide better nursing care for older people. I would l i k e your permission to interview you about the nursing care you received during your stay i n the hos p i t a l . The interview w i l l take about 20 minutes and w i l l take place i n your own home, at your convenience within three (3) days after you leave h o s p i t a l . A l l information w i l l be co n f i d e n t i a l . You w i l l be free to interrupt the interview at any time, to ask questions, rest, or to stop the interview e n t i r e l y . If you are w i l l i n g to take part i n the study you w i l l be asked to sign a consent form and I w i l l contact you to arrange a time for the interview. The questionnaire that I f i l l out during the interview w i l l be shared with my two professors only. After my research report i s written, the completed questionnaire w i l l be destroyed. Although your p a r t i c i p a t i o n would be of great value, you should understand that you may withdraw from the study at any time or choose not to take part without prejudicing the care of yourself or your family member now or i n the future. If you have any questions concerning t h i s study, please f e e l free to ask. You may reach me by leaving a message at the university at. and I w i l l return your c a l l . Thank you Josephine Steckler, R.N., B.A. 96 APPENDIX B Consent Form I agree to p a r t i c i p a t e i n the research study conducted by Josephine Steckler, a graduate student i n Nursing at the University of B r i t i s h Columbia. I have read the information l e t t e r explaining the study and understand that: 1. I w i l l be asked questions about the nursing care I received while I was hospitalized. 2. The interview w i l l be recorded on a questionnaire and w i l l l a s t about 20 minutes. 3. The questionnaire w i l l be available only to Josephine and her two professors and w i l l be destroyed aft e r the thesis has been accepted. 4. The information obtained w i l l be c o n f i d e n t i a l . 5. My refusal to p a r t i c i p a t e or my desire to withdraw from the study at any time w i l l be respected and w i l l not a f f e c t any medical or nursing care I may require i n the future. A l l the questions about the study have been answered by Josephine Steckler. I have received a copy of the information l e t t e r and consent form and I agree to p a r t i c i p a t e i n the study. Signed Date 97 APPENDIX C Letter to Medical and Surgical Nursing Directors for Approval to Conduct Nursing Research My name i s Josephine Steckler. I am a graduate student i n nursing at the University of B r i t i s h Columbia carrying out a research study f o r a Master's Thesis. The study i s designed to determine whether eld e r l y c l i e n t s i n an acute care hospital perceive they were treated with dignity and respect. The information from the selected 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 leave the h o s p i t a l . They w i l l be at l e a s t 65 years of age, have been i n hospital 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 oriented to time, place and person during th e i r e n t i r e h o s p i t a l i z a t i o n . Prior to leaving hospital the c l i e n t s who meet the established c r i t e r i a w i l l be approached and provided with a written and verbal explanation of the study and consenting c l i e n t s w i l l be asked to sign the consent form at t h i s time. A plan to seek consent from prospective c l i e n t s before they leave the hospital w i l l be developed according to the established research protocol of the h o s p i t a l . The investigator w i l l meet with the head nurses to e n l i s t t h e i r support i n se 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 discharged from h o s p i t a l . Thank you for your cooperation i n a s s i s t i n g me to accomplish t h i s research study. Yours t r u l y Josephine Steckler 98 APPENDIX D Research Tool Age of c l i e n t Highest l e v e l of education obtained Number of days i n hospital Nursing unit - Medical / Surgical Sex To the following items code (a) no (b) yes (c) not applicable 1. "Were you shown around the unit when you arrived?" Note: Examples of orientation include showing l o c a t i o n of bathroom, way to c a l l nurse, place to put personal belongings. 2. "When you were admitted to the unit did someone introduce you to your roommate?" Note: Code NA i f patient i n private room. 3. "Have you been 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 counselor and f a c i l i t i e s ? " If yes, ask patient: "Was t h i s Information provided to you by a nurse?" Note: Code NA i f information was given by clerk or hospital brochure. Nursing Process Quality Monitoring Instrument (Medicus Canada). Used with permission (Sue Hegyvary, personal communication, September 12, 1988). 99 To the following items code (a) no (b) yes some of the time (c) yes most of the time (d) yes a l l of the time (e) not applicable 4. "Have you had any tests or procedures while you've been i n t h i s hospital?" If yes, ask: "Were they explained to you by your nurse before they were done?" 5. "Have your nurses introduced themselves to you?" 6. "Have your nurses c a l l e d you by your f i r s t name without your permission?" 7. "Have your nurses addressed you by names other than Miss, Mr., or Mrs.?" Note: Other names include granny, grampa, dear, etc. 8. "When you had an examination or treatment and a nurse was i n the room, were the curtains drawn around you or was the door closed?" 9. "Have you f e l t inappropriately exposed during a bath, exam, or procedure while on t h i s unit?" 10. "While you were i n the ho s p i t a l , were you given an opportunity to discuss your feelings or concerns with your nurse?" 100 APPENDIX E R e s u l t s of Items from Q u e s t i o n n a i r e f o r T o t a l Group (age 65 -91 ) , "Younger O l d " (age 65 -74) , " O l d e r O l d " (age 75 -91) , R e l a t e d t o D i g n i t y and Respect Item 1. O r i e n t a t i o n t o u n i t 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 Age 65-74 Age 75+ n = 62(%) n = 25(%) n = 37(%) No 16 (26) 2 (8) 14 (38) Yes 44 (71) 22 (88) 22 (59) NA 2 (3) 1 (4) 1 (3) Item 2. Acre a rouo d i f f e r e n c e s r e l a t e d t o i n t r o d u c t i o n t o roommate. Code T o t a l Group Age 65-74 Age 75+ n = 62(%) n = 25(%) n = 37(%) No 34 (55) 9 (36) 25 (67) Yes 19 (31) 11 (44) 8 (22) NA 9 (14) 5 (20) 4 (11) 101 Item 3. Knowledge about 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 l o r s and 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 Age 65-74 Age 75+ n = 62(%) n = 25(%) n = 37(%) No 37 (60) 10 (40) 27 (74) Yes 8 (13) 3 (12) 5 (13) NA 17 (27) 12 (48) 5 (13) Item 4. E x p l a n a t i o n of t e s t p r o c e d u r 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 Age 65-74 Age 75+ n = 62(%) n = 25(%) n = 37(%) No 7 (11) 0 (0) 7 (19) Y e s , some of t h e t ime 29 (47) 10 (40) 19 (51) Y e s , most of t h e t ime 9 (14) 4 (16) 5 (13) Y e s , a l l t h e t ime 14 (23) 9 (36) 5 (13) NA 3 (5) 2 (8) 1 (3) Item 5. F requency w i t h which n u r s e s i n t r o d u c e themselves 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 Age 65-74 Age 75+ n = 62(%) n = 25(%) n = 37(%) No 0 (0) 0 (0) 0 (0) Y e s , some of t h e t ime 14 (23) 3 (12) 11 (30) Y e s , most of t h e t ime 21 (34) 11 (44) 10 (27) Y e s , a l l t h e t i m e 27 (43) 11 (44) 16 (43) 102 Item 6. Frequency of nurses addressing patient by t h e i r f i r s t name without permission. Code Total Group n = 62(%) Age 65-74 n = 25(%) Age 75+ n = 37(%) No 31 (50) Yes, some of the time 9 (15) Yes, most of the time 13 (21) Yes, a l l the time 9 (14) 16 (64) 2 (8) 3 (12) 4 (16) 15 (41) 7 (19) 10 (27) 5 (13) Item 7. Frequency of nurses addressing patients other than Miss, Mr., or Mrs. Code Total Group n = 62(%) Age n = 65-74 25(%) Age n = 75+ 37(%) NO 37 (60) 18 (72) 19 (51) Yes, some of the time 32 (35) 5 (20) 17 (46) Yes, most of the time 3 (5) 2 (8) 1 (3) Yes, a l l the time 0 (0) 0 (0) 0 (0) Item 8. Provision of privacy during examination or treatments. Code Total Group Age 65-74 Age 75+ n = 62(%) n = 25(%) n = 37(%) NO 0 (0) 0 (0) 0 (0) Yes, some of the time 0 (0) 0 (0) 0 (0) Yes, most of the time 8 (13) 4 (16) 4 (11) Yes, a l l the time 54 (87) 21 (84) 33 (89) 103 Item 9. Age related differences and inappropriate exposure during bathing* examination, or procedure. Code Total Group n = 62(%) Age 65-74 n = 25(%) Age 75+ n = 37(%) No Yes, some of Yes, most of Yes, a l l the the time the time time 51 (82) 7 (11) 1 (2) 3 (5) 21 (84) 3 (12) 0 (0) 1 (4) 30 (81) 4 (11) 1 (3) 2 (5) Item 10. Age related differences and opportunity to discuss fee l i n g s and concerns with the nurse. Code Total Group Age 65-74 Age 75+ n = 62(%) n = 25(%) n = 37(%) No 25 (40) 7 (28) 18 (49) Yes, some of the time 25 (39) 12 (48) 12 (32) Yes, most of the time 10 (16) 4 (16) 6 (16) Yes, a l l the time 3 (5) 2 (8) 1 (3) 104 APPENDIX F Results from Items on Questionnaire Related to Level of Education (Socioeconomic Status ) and Dignity and Respect Item 1. Orientation to the unit related to 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. Introduction to roommates related to 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) Item 3. Knowledge a v a i l a b i l i t y related to l e v e l of education. 105 Elementary Secondary Code Education Education n = 27(%) n = 35(%) No 17 (63) 20 (57) Yes 5 (19) 3 (9) NA 5 (18) 12 (34) Item 4. Explanation of procedures related to l e v e l of education. Elementary Secondary Code Education Education n = 27(%) n = 35(%) No 4 (15) 4 (11) Yes, some of the time 18 (67) 11 (32) Yes, most of the time 3 (11) 6 (17) Yes, a l l the time 11 (7) 12 (34) NA 0 (0) 2 ( 0) Item 5. Nurses introducing themselves related to l e v e l of education. Elementary Secondary Code Education Education n = 27(%) n = 35(%) No 0 (0) 0 (0) Yes, some of the time 10 (37) 5 (14) Yes, most of the time 8 (30) 13 (37) Yes, a l l the time 9 (33) 17 (49) 106 Item 6. Addressing patients by th e i r f i r s t name related to l e v e l of education. Code Elementary Education n = 27(%) Secondary Education n = 35(%) No Yes, some of the time Yes* most of the time Yes, a l l the time 9 (33) 6 (22) 9 (33) 3 (11) 7 (20) 5 (15) 11 (31) 12 (34) Item 6a. Code Elementary n = 27(%) Secondary n = 27(%) Post-Secondary n = 8(%) No 9 (33) 0 (0) 7 (88) Yes, some of the time 6 (22) 4 (15) 1 (12) Yes, most of the time 9 (33) 11 (41) 0 (0) Yes, a l l the time 3 ( I D 12 (44) 0 (0) Item 7. Addressing patients by names other than Miss, Mr., or Mrs. related to l e v e l of education. Code Elementary Education n = 27(%) Secondary Education n = 35(%) No Yes, some of the time Yes, most of the time Yes, a l l the time 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 d u r i n g e x a m i n a t i o n r e l a t e d t o l e v e l of e d u c a t i o n . E lementary Secondary Code E d u c a t i o n E d u c a t i o n n = 27(%) n = 35(%) No Y e s , some of t h e t ime Y e s , most of t h e t ime Y e s , a l l t h e t ime 0 (0) 0 (0) 0 (0) 0 (0) 5 (19) 3 (9) 22 (81) 32 (91) Item 9. I n a p p r o p r i a t e exposure d u r i n g b a t h , exam, or p r o c e d u r e r e l a t e d t o l e v e l of e d u c a t i o n . E l e m e n t a r y Secondary Code E d u c a t i o n E d u c a t i o n n = 27(%) n = 35(%) No Y e s , some of t h e t ime Y e s , most of t h e t i m e Y e s , a l l t h e t ime 20 (74) 32 (91) 5 (18) 3 (9) 1 (4) 0 (0) 1 (4) 0 (0) Item 10. 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 w i t h n u r s e r e l a t e d to l e v e l of e d u c a t i o n . E l e m e n t a r y Secondary Code E d u c a t i o n E d u c a t i o n n = 27(%) n = 35(%) No Y e s , some of t h e t ime Y e s , most of t h e t ime Y e s , a l l t h e t ime 11 (41) 12 (44) 3 (11) 1 (4) 14 (40) 13 (37) 7 (20) 1 (3) 

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