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The meaning of fracturing a hip for elderly community-dwelling women Ursic, Pauline Ann 1991

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THE MEANING OF FRACTURING A HIP FOR ELDERLY COMMUNITY-DWELLING WOMEN By PAULINE ANN URSIC B.S.N., The University of B r i t i s h Columbia, 1985 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i n THE FACULTY OF GRADUATE STUDIES The School of Nursing We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA August, 1991 ©Pauline Ann Ursic, 1991 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of The University of British Columbia Vancouver, Canada •ate rvcJ-y i q q | DE-6 (2/88) ABSTRACT This study describes the meaning of fr a c t u r i n g a hip f o r e l d e r l y community-dwelling women. To provide collaborative, i n d i v i d u a l i z e d and meaningful care f o r patients, i t i s imperative that nurses understand what the experience of fr a c t u r i n g a hip i s l i k e f o r the el d e r l y i n d i v i d u a l . Giorgi's phenomenological approach was used to explore the hip fracture experience from the women's perspective. Data were c o l l e c t e d through fourteen unstructured audiotaped interviews with s i x women who had fractured t h e i r hip. Analysis occurred concurrently with data c o l l e c t i o n . The findings indicate that the o v e r a l l experience of f r a c t u r i n g a hip i s characterized by a sense of loss of control. The loss of control threatens the el d e r l y i n d i v i d u a l ' s self-esteem and causes her to reevaluate her self-perceptions, b e l i e f s about aging and expectations f o r the future. The e l d e r l y women used various coping behaviours i n an attempt to es t a b l i s h some control over t h e i r s i t u a t i o n including attempting to make sense of the f a l l event, taking action, thinking p o s i t i v e l y and maintaining a p o s i t i v e attitude. The findings i i i emphasize the need f o r nurses to a s s i s t e l d e r l y i n d i v i d u a l s to develop a v a r i e t y of coping behaviours aimed at regaining elements of control and reaffirming self-esteem. Implications f o r nursing practice, education and research were i d e n t i f i e d and recommendations presented. i v Table of Contents Page Abstract i i Table of Contents i v Acknowledgements... v i i CHAPTER ONE: INTRODUCTION 1 Background and Significance 1 Problem Statement 4 Purpose 4 Conceptualization. 5 D e f i n i t i o n of Terms... 6 Assumptions 7 Limitations 8 Chapter Summary 8 CHAPTER TWO: LITERATURE REVIEW . 10 Epidemiology and Mortality S t a t i s t i c s 10 Prediction of Survival and Rehabi l i t a t i o n 12 Achieving Subsystem 12 A f f e c t i v e Subsystem 15 Ego-valuative Subsystem 18 Chapter Summary. 19 y CHAPTER THREE: METHODOLOGY 21 Overview o f t h e M e t h o d o l o g i c a l Approach 21 M e t h o d o l o g i c a l I s s u e s 23 S a m p l i n g 23 V a l i d i t y and R e l i a b i l i t y . . . . 24 S e l e c t i o n o f P a r t i c i p a n t s 25 C r i t e r i a f o r S e l e c t i o n 26 S e l e c t i o n P r o c e d u r e 27 C h a r a c t e r i s t i c s o f P a r t i c i p a n t s 29 Data C o l l e c t i o n 30 Data A n a l y s i s . 31 E t h i c a l C o n s i d e r a t i o n s 33 C h a p t e r Summary 34 CHAPTER FOUR: PRESENTATION AND DISCUSSION OF FINDINGS 36 A c c o u n t s o f t h e Meaning o f F r a c t u r i n g a H i p 36 The F a l l Event 37 The H o s p i t a l i z a t i o n E x p e r i e n c e 42 The P o s t d i s c h a r g e E x p e r i e n c e 48 C o p i n g w i t h t h e H i p F r a c t u r e E x p e r i e n c e 55 C o p i n g w i t h t h e F a l l Event 55 C o p i n g w i t h t h e H o s p i t a l i z a t i o n E x p e r i e n c e . . 57 C o p i n g w i t h t h e P o s t d i s c h a r g e E x p e r i e n c e . . . 61 v i D i s c u s s i o n o f the F i n d i n g s 70 The U.B.C. Model f o r N u r s i n g 85 Chapter Summary 89 CHAPTER FIVE: SUMMARY, IMPLICATIONS AND RECOMMENDATIONS FOR NURSING 90 Summary 90 I m p l i c a t i o n s and Recommendations f o r N u r s i n g 93 Nu r s i n g P r a c t i c e . . 93 Nu r s i n g E d u c a t i o n . 100 Nu r s i n g Research. . . . 102 Concl u d i n g Remarks 104 REFERENCES 105 APPENDICES I l l A. I n t r o d u c t o r y L e t t e r t o P o t e n t i a l V o l u n t e e r s 112 B. Consent Form 114 C. Sample Questions f o r I n i t i a l I n t e rview... 116 v i i ACKNOWLEDGEMENTS I would l i k e t o acknowledge and thank the women who p a r t i c i p a t e d i n t h i s study f o r s h a r i n g t h e i r p e r s o n a l e xperiences w i t h me. My s i n c e r e a p p r e c i a t i o n i s extended t o Angela Henderson and Tess Orlando f o r t h e i r guidance i n the r e s e a r c h process, s c h o l a r l y c r i t i q u e and e x p r e s s i o n s o f confidence, encouragement and humour. F i n a l l y I would l i k e t o acknowledge my f a m i l y f o r t h e i r unwavering.support and a ve r y s p e c i a l thanks t o my husband Zoran f o r h i s i n c r e d i b l e u nderstanding and p a t i e n c e d u r i n g t h i s c h a l l e n g i n g endeavour. CHAPTER ONE INTRODUCTION Background and Significance Hip fractures are a leading cause of d i s a b i l i t y among the e l d e r l y and one of the acute health events that may lead to permanent changes i n the l e v e l of functioning of the e l d e r l y i n d i v i d u a l (Furstenberg, 1986). Recent national figures f o r Canada, 1987-88, show that approximately 11,770 indi v i d u a l s , s i x t y f i v e years and older had surgery f o r a fracture of the hip, accounting f o r nearly 396,000 hos p i t a l days or an average length of stay of approximately 33.6 days ( S t a t i s t i c s Canada, 1991). Hip fracture cases have doubled i n the l a s t twenty years and with more people l i v i n g longer the number i s predicted to double again by the year 2000. I t i s estimated that one i n three women and one i n six men over the age of ninety, w i l l experience a hip fracture (Kelsey & Hoffman, 1987). Costs to the health care system associated with treatment of hip fractures are substantial and are expected to increase with the "greying" of North America (Auerbach & Gerber, 1976). Increasingly nurses working i n the community, acute, long term and extended care u n i t s w i l l f i n d themselves c a r i n g f o r e l d e r l y i n d i v i d u a l s w i t h h i p f r a c t u r e s . Nurses i n a l l o f these s e t t i n g s w i l l t h e r e f o r e need t o be f a m i l i a r w i t h the r e s e a r c h t h a t has been done i n r e l a t i o n t o h i p f r a c t u r e s and what f u t u r e r e s e a r c h i s r e q u i r e d . T h i s study focuses on the meaning o f f r a c t u r i n g a h i p f o r e l d e r l y community-dwelling women. The study attempts t o f i l l a gap i n the c u r r e n t r e s e a r c h r e v e a l e d d u r i n g a l i t e r a t u r e review, by f o c u s i n g on the meaning o f f r a c t u r i n g a h i p from the p e r s p e c t i v e o f the people who a c t u a l l y e x p e r i e n c e the f r a c t u r e . A review o f the l i t e r a t u r e r e v e a l s t h a t the m a j o r i t y o f s t u d i e s on f r a c t u r i n g a h i p have focu s e d on epidemiology and the s t a t i s t i c a l p r e d i c t i o n o f m o r t a l i t y , s u r v i v a l and the f u n c t i o n a l and s o c i a l r e h a b i l i t a t i o n o f e l d e r l y i n d i v i d u a l s . The purpose o f these s t u d i e s has been t o determine the f a c t o r s c o n t r i b u t i n g t o h i p f r a c t u r e as w e l l as t h e i r p r e v a l e n c e and a s s o c i a t e d p a t i e n t p r o g n o s i s . Research f i n d i n g s t h a t focus on who i s a t r i s k f o r h i p f r a c t u r e s , how they occur and the expected p a t i e n t p r o g n o s i s are extremely r e l e v a n t t o nurses c a r i n g f o r p a t i e n t s w i t h h i p f r a c t u r e s . However, i f nurses are approaching patient care h o l i s t i c a l l y and working c o l l a b o r a t i v e l y with the patient with a hip fracture, then a broader, more comprehensive knowledge base i s required. A comprehensive nursing knowledge base demands that the nurse consider the c l i e n t ' s experience from the c l i e n t ' s own perspective. Provision of meaningful, i n d i v i d u a l i z e d care stems from the nurse's i n s i g h t i n t o the meaning a p a r t i c u l a r experience such as f r a c t u r i n g a hip has f o r the patient. Very l i t t l e research has been done i n terms of determining what the e l d e r l y i n d i v i d u a l s ' subjective experience of f r a c t u r i n g a hip i s l i k e and what meaning the experience has for these patients. In order f o r nurses to be able to a s s i s t e l d e r l y i n d i v i d u a l s to cope with t h i s traumatic event, i t i s es s e n t i a l that they understand what the experience i s l i k e from the e l d e r l y i n d i v i d u a l ' s perspective. As a means of increasing nursing knowledge and ins i g h t into the experience of hip fracture i t seems timely to focus t h i s study on describing the meaning of fr a c t u r i n g a hip f o r e l d e r l y community-dwelling women. The focus on the e l d e r l y women's perspective recognizes the fact that approximately 75% of the people who fracture t h e i r hip are women. Problem Statement A review of the l i t e r a t u r e reveals a dearth of knowledge regarding the meaning of fr a c t u r i n g a hip f o r the e l d e r l y community-dwelling i n d i v i d u a l . To provide collaborative, i n d i v i d u a l i z e d and meaningful care f o r patients, i t i s imperative that the nurse understands what the experience of fra c t u r i n g a hip i s l i k e f o r the el d e r l y i n d i v i d u a l . Purpose The purpose of t h i s study was to answer the question: What i s the meaning of fr a c t u r i n g a hip f o r e l d e r l y community-dwelling women? The s p e c i f i c questions that are answered i n t h i s study are: 1. How do women describe what i t i s l i k e to fracture a hip? 2 . How do women describe t h e i r feelings associated with f r a c t u r i n g a hip? 3 . How do women explain how they cope with f r a c t u r i n g a hip? 4. How do women describe the e f f e c t s of f r a c t u r i n g a hip on t h e i r d a i l y l i v e s and expectations f o r the future? Conceptualization The U.B.C. Model for Nursing (U.B.C. School of Nursing, 1980) provides a conceptual framework f o r viewing i n d i v i d u a l s and understanding nursing's unique function i n caring f o r them. The Model i s used as a means of conceptualizing the i n d i v i d u a l i n t h i s study. In the U.B.C. Model f o r Nursing the i n d i v i d u a l i s viewed as a behavioural system made up of nine subsystems: achieving, a f f e c t i v e , ego-valuative, excretory, ingestive, protective, reparative, respiratory and s a t i a t i v e . Each subsystem has a s p e c i f i c need and goal. Fracturing a hip i s considered an unpredictable event i n the l i f e cycle which a f f e c t s the e n t i r e behavioural system and requires the development of suitable coping behaviours to s a t i s f y basic human needs, achieve s t a b i l i t y and reach optimal health. Each subsystem i s composed of an inner personal region which includes a need and a b i l i t i e s to meet that need as well as a psychological environment which includes forces and a goal. Fracturing a hip i s 6 c o n s i d e r e d a f o r c e t h a t has meaning f o r the p s y c h o l o g i c a l environment o f one o r more subsystems. Each subsystem i s i n t e r a c t i n g and interdependent w i t h every o t h e r subsystem. T h e r e f o r e the meaning t h a t f r a c t u r i n g a h i p has i n one or more subsystems a f f e c t s the e n t i r e b e h a v i o u r a l system. I t i s the r e s e a r c h e r ' s b e l i e f t h a t the meaning o f f r a c t u r i n g a h i p f o r e l d e r l y community-dwelling women can be understood by examining the f o r c e o f a h i p f r a c t u r e i n the p s y c h o l o g i c a l environment o f the i n d i v i d u a l ' s subsystems. D e f i n i t i o n o f Terms The f o l l o w i n g terms are d e f i n e d t o make e x p l i c i t t h e i r use i n the study. F r a c t u r e d Hip: an i n t r a o r e x t r a c a p s u l a r f r a c t u r e o f the femur above the l e v e l o f the l e s s e r t r o c h a n t e r (Lewinnek, Kelsey, White & K r e i g e r , 1980). Meaning: the i n d i v i d u a l ' s i n t e r p r e t a t i o n o f h i s o r her c o g n i t i v e s u b j e c t i v e p e r s p e c t i v e o f the phenomenon o f f r a c t u r i n g a h i p and the e f f e c t o f t h a t p e r s p e c t i v e on the l i v e d experience o r co p i n g behaviours o f t h a t i n d i v i d u a l (Omery, 1983). E l d e r l y community-dwelling woman: for the purposes of t h i s study, a woman over the age of s i x t y - f i v e who p r i o r to and following discharge from h o s p i t a l l i v e s i n a house or apartment which i s not part of a r e s i d e n t i a l care f a c i l i t y . Assumptions Several assumptions underly the researcher's approach to t h i s study. The researcher assumes that \ f r a c t u r i n g a hip i s an unpredictable event i n the l i f e cycle that has meaning f o r the i n d i v i d u a l experiencing i t . I t was also assumed that an understanding of what i t i s l i k e to have a fractured hip can be ascertained through phenomenological research methods. Rieman (1986) states that phenomenological analysis requires researchers to acknowledge and then suspend t h e i r assumptions regarding the phenomenon under inve s t i g a t i o n i n order to f u l l y understand the experience of the subject. In suspending t h e i r preconceptions, researchers avoid imposing an a p r i o r i hypothesis on the experience. I t was therefore assumed that bracketing personal preconceptions regarding the 8 experience of hip fracture was e s s e n t i a l . The researcher also assumed that the in d i v i d u a l s ' accounts provide accurate data with regard to t h e i r experience of f r a c t u r i n g a hip. Limitations The p a r t i c i p a n t s i n t h i s study were l i m i t e d to el d e r l y community-dwelling women. Therefore, t h e i r experience of fr a c t u r i n g a hip cannot be generalized to a l l i n d i v i d u a l s who experience a hip fracture. Chapter Summary This introductory chapter has presented background material relevant to t h i s study which seeks to answer the question: "What i s the meaning of f r a c t u r i n g a hip fo r e l d e r l y community-dwelling women?". Background information demonstrating the lack of research on the meaning of fr a c t u r i n g a hip to e l d e r l y community-dwelling i n d i v i d u a l s was presented and the timeliness of such a study was established. The U.B.C. Model f o r Nursing which was used as a means of conceptualizing the i n d i v i d u a l i n t h i s study; was explained. Terms central to the research study were defined and assumptions and l i m i t a t i o n s of the study were outlined. In the following chapter l i t e r a t u r e relevant to the i d e n t i f i e d research problem i s reviewed. Chapter Three explains the methodology used to guide the study. Presentation and discussion of the findings comprise Chapter Four. The f i f t h and concluding chapter presents a summary of the study and the implications of i t s findings i n r e l a t i o n to recommendations f o r nursing practice, education and research. 10 CHAPTER TWO LITERATURE REVIEW The purpose o f t h i s c h apter i s t o p r e s e n t a d e s c r i p t i o n and a n a l y s i s o f the l i t e r a t u r e r e l a t e d t o h i p f r a c t u r e s . A review o f the l i t e r a t u r e r e v e a l s t h a t the m a j o r i t y o f s t u d i e s on f r a c t u r i n g a h i p have focu s e d on epidemiology and the s t a t i s t i c a l p r e d i c t i o n o f m o r t a l i t y , s u r v i v a l and the f u n c t i o n a l and s o c i a l r e h a b i l i t a t i o n o f e l d e r l y i n d i v i d u a l s . The l i t e r a t u r e review i s p r e s e n t e d i n two major s e c t i o n s . The f i r s t o f these s e c t i o n s d i s c u s s e s l i t e r a t u r e p e r t a i n i n g t o e p i d e m i o l o g i c a l r e s e a r c h and m o r t a l i t y s t a t i s t i c s . The second s e c t i o n examines l i t e r a t u r e r e g a r d i n g the p r e d i c t i o n o f s u r v i v a l and f u n c t i o n a l and s o c i a l r e h a b i l i t a t i o n o f the e l d e r l y i n d i v i d u a l f o l l o w i n g h i p f r a c t u r e . In the second s e c t i o n the r e s e a r c h i s reviewed i n r e l a t i o n t o i t s r e l e v a n c e t o s p e c i f i c subsystems d e s c r i b e d i n the U.B.C. Model f o r Nursing. Epidemiology and M o r t a l i t y S t a t i s t i c s The number o f h i p f r a c t u r e cases has doubled i n the l a s t twenty years and w i t h more people l i v i n g l o n g e r , the number i s p r e d i c t e d t o double a g a i n by the yea r 2000 (Dubrovskis & Wells; Lewinnek e t a l . , 1980). 11 Epidemiological research studies have found that 70-80% of hip fractures occur i n females over the age of s i x t y with the population at highest r i s k being Caucasian females, eighty - f i v e years or older (Johnell, Nilsson, Obrant & Sernbo, 1984; Lewinnek et a l . , 1980; Melton & Riggs, 1983). Studies have estimated that approximately two t h i r d s of e l d e r l y i n d i v i d u a l s who sustain hip fractures l i v e i n the community (Ceder, Thorngren & Wallden, 1980; Reinhard, 1988). Mortality following hip fracture has been estimated to be anywhere between two to f i v e times what i s observed f o r matched samples who have experienced upper limb fractures (Colbert & O'Muircheartaigh, 1976; Dahl, 1980; F i t t s , Lehr, Schor & Roberts, 1959; M i l l e r , 1978; Mossey, Mutran, Knott & Craik, 1989). It i s cl e a r from the epidemiological s t a t i s t i c s that the number of hip fracture cases per year i s r i s i n g dramatically and that the majority of people who experience hip fractures are e l d e r l y women who l i v e i n the community. I t i s also evident that the number of deaths related to hip fracture i s notably higher than the number of deaths re l a t e d to other fractures which e l d e r l y i n d i v i d u a l s sustain as a r e s u l t of a f a l l . 12 P r e d i c t i o n o f S u r v i v a l and R e h a b i l i t a t i o n The U.B.C. Model f o r N u r s i n g d e s c r i b e s nine subsystems; a c h i e v i n g , a f f e c t i v e , e g o - v a l u a t i v e , e x c r e t o r y , i n g e s t i v e , p r o t e c t i v e , r e p a r a t i v e , r e s p i r a t o r y and s a t i a t i v e subsystems. The s t u d i e s r e l a t e d t o h i p f r a c t u r e appear t o have p a r t i c u l a r r e l e v a n c e t o t h r e e o f these subsystems. These subsystems are the a c h i e v i n g , a f f e c t i v e and ego-v a l u a t i v e subsystems. A c h i e v i n g Subsystem In the U.B.C. Model f o r Nursing, the a c h i e v i n g subsystem focuses on the i n d i v i d u a l ' s need f o r mastery. A sense o f mastery i s based on the i n d i v i d u a l ' s behaviour b e i n g c o n s i s t e n t w i t h s e l f - e x p e c t a t i o n s and the e x p e c t a t i o n s o f ot h e r s ( M i l l e r , 1983). I t makes sense t o hy p o t h e s i z e t h a t a p a t i e n t ' s r e s u l t i n g f e e l i n g s about mastery w i l l depend on how r e a l i s t i c t h e i r e x p e c t a t i o n s are about the p r o b a b i l i t y o f rec o v e r y . Thus meeting the g o a l o f t h i s subsystem i s more r e l a t e d t o e x p e c t a t i o n s than t o a c t u a l achievements. 13 The following studies have s i g n i f i c a n t implications i n terms of the i n d i v i d u a l ' s need f o r mastery. I t has been reported that only 12-23% of patients with hip fractures return to pre-fracture ambulatory status and/or functional independence (Cobey, Cobey, Conant, Weil & Greenwald, 1976). Well established predictors of patient prognosis following hip fracture which have been documented i n the l i t e r a t u r e include the patient's age, mental status, functioning p r i o r to hip fracture and presence of other health conditions (Beals, 1972; Ceder et a l . , 1980; Cobey et a l . , 1976; Jensen & Bagger, 1982). Advanced age and the presence of concomitant i l l n e s s , mental impairment or d i s a b i l i t y p r i o r to the fracture have been found to be associated with poor patient outcome (Bauer, Hansson, Lidgren, Stromqvist & Thorngren, 1985; Ceder et a l . , 1980; Katz, Ford, Heiple & Newill, 1964). Ceder and colleagues (1980) found that early ambulation and a b i l i t y to manage dressing and personal hygiene during the f i r s t two post-operative weeks were of prognostic importance. From the findings, Ceder and colleagues predicted that e l d e r l y i n d i v i d u a l s who managed these functions two weeks post surgery could 14 almost be r e h a b i l i t a t e d at home whereas e l d e r l y i n d i v i d u a l s who d i d not manage these functions during t h i s period risked i n s t i t u t i o n a l i z a t i o n . Many of the research studies reviewed speculated on the subjective experience of patients who sustained a fractured hip but few of these speculations were substantiated by s c i e n t i f i c enquiry. Two studies relevant to the achieving subsystem i d e n t i f i e d the expectations about outcome following hip fracture among older people (Dougherty et a l . , 1984; Furstenberg, 1986). During interviews with community-dwelling people, Dougherty and colleagues (1984) found that the majority of people viewed the outcome of hip fracture to be uncertain and fraught with r i s k s such as compromised physical, s o c i a l and psychosocial functioning and possibly death. Furstenberg (1986) interviewed e l d e r l y patients admitted to h o s p i t a l with hip fractures and found that the patient's expectations regarding recovery were s i m i l a r to those i d e n t i f i e d by the people interviewed by Dougherty and colleagues except patients with hip fractures d i d not foresee death as a possible outcome. Furstenberg's study provides some ins i g h t into what the experience of hip 15 fracture i s l i k e from e l d e r l y i n d i v i d u a l ' s perspective but i t does not present the enti r e picture as i t focuses s o l e l y on the patient's expectations regarding recovery. In summary, the hip fracture l i t e r a t u r e relevant to the achieving subsystem can be organized i n t o two groups. The f i r s t , and by f a r the larger of the two groups, focuses on the s t a t i s t i c a l p r e d i c t i o n of functional r e h a b i l i t a t i o n and speculates on what the experience of hip fracture may be l i k e f o r the e l d e r l y i n d i v i d u a l . The second group of studies focus on the el d e r l y i n d i v i d u a l ' s perspective regarding recovery from hip fracture.. I t i s apparent from a review of t h i s l i t e r a t u r e that the "force" of hip fracture has a s i g n i f i c a n t impact upon the i n d i v i d u a l . Further study i s needed to determine what e f f e c t the hip fracture experience has i n r e l a t i o n to the ind i v i d u a l ' s need f o r mastery and f o r feelings of accomplishment and s a t i s f a c t i o n with accomplishment. A f f e c t i v e Subsystem According to the a f f e c t i v e subsystem within the U.B.C. Model fo r Nursing, i n d i v i d u a l s have a need f o r feelings of love, belongingness and dependence. Studies which have sig n i f i c a n c e f o r the a f f e c t i v e subsystem follow. The importance of discharging e l d e r l y patients who come from the community back to t h e i r home as soon as possible has been recognized by a number of researchers (Bauer et a l . , 1985; Ceder et a l . , 1980; Jensen & Bagger, 1982; Sikorski, Davis & Senior, 1985). Jensen and Bagger (1982) found that patients discharged to t h e i r own home were more l i k e l y to maintain t h e i r s o c i a l functioning than patients who were r e h a b i l i t a t e d i n h o s p i t a l . One possible explanation f o r t h i s r e l a t i o n s h i p i s that patients discharged home return to f a m i l i a r environments where they are once again able to re e s t a b l i s h control over t h e i r s o c i a l sphere whereas patients discharged to a r e h a b i l i t a t i o n f a c i l i t y remain s o c i a l l y dependent fo r a prolonged period i n an unfamiliar environment. Sikorsk i and colleagues (1985) believe that i f a patient i s i n hos p i t a l f o r a prolonged period recovering from hip fracture, that the s o c i a l f a b r i c of t h e i r home environment may disintegrate. Friends may forget them or t h e i r family may decide to place them i n an i n s t i t u t i o n . These researchers believe that with a prolonged h o s p i t a l stay e l d e r l y patients may have very 17 l i t t l e to return to i n terms of t h e i r former s o c i a l l i v e s . Investigation into the i n d i v i d u a l ' s perspective may illuminate and c l a r i f y the r e l a t i o n s h i p between early discharge and maintenance of s o c i a l functioning. From a review of the research l i t e r a t u r e , i t appears that the need fo r dependence as i t relates to hip fracture has not been addressed. From the writer's experience, patients with hip fractures are highly dependent i n the immediate post-operative period. A degree of dependence i s not only i n e v i t a b l e but also desirable to f a c i l i t a t e recovery and the integration of new coping s k i l l s . As the patient convalesces the nature of the nurse-patient r e l a t i o n s h i p changes. The expectations of the nurse are f o r the patient to become more independent. One wonders what e f f e c t such expectations have on the patient's need f o r dependence as well as the patient's need fo r mastery as described i n the achieving subsystem. Although i t i s r e a d i l y apparent that the hip fracture experience involves the a f f e c t i v e subsystem p a r t i c u l a r l y i n r e l a t i o n to the need fo r dependence, i t has not been addressed i n the research l i t e r a t u r e nor has i t been studied from the perspective of the patient 18 w i t h a h i p f r a c t u r e . Thus, r e s e a r c h i s needed t o d e s c r i b e t h i s aspect o f the p a t i e n t ' s experience. E g o - v a l u a t i v e Subsystem A c c o r d i n g t o the U.B.C. Model f o r Nursing, the i n d i v i d u a l has a need f o r s e l f - r e s p e c t and f o r r e s p e c t from o t h e r s . The g o a l o f the e g o - v a l u a t i v e subsystem i s f o r s e l f - e s t e e m . The f i n d i n g s o f Cobey and a s s o c i a t e s (1976) and Mossey and a s s o c i a t e s (1989) suggest t h a t s e l f - e s t e e m i n e l d e r l y p a t i e n t s w i t h f r a c t u r e d h i p s p l a y s a s i g n i f i c a n t r o l e i n p a t i e n t outcomes. One o f these outcomes i s d e p r e s s i o n . The development o f d e p r e s s i o n p o s t surgery was found t o be r e l a t e d t o poor recove r y o f both f u n c t i o n a l and p s y c h o s o c i a l s t a t u s (Cobey e t a l . , 1976; Mossey e t a l . , 1989). C o n s i s t e n t a n e c d o t a l r e p o r t s by both l a y people and h e a l t h p r o f e s s i o n a l s d e s c r i b e the unaccountable r a p i d d e c l i n e and sometimes demise o f some h i p f r a c t u r e p a t i e n t s . Authors' d e s c r i p t i o n s o f what they f e e l the experie n c e o f f r a c t u r i n g a h i p may be l i k e f o r e l d e r l y i n d i v i d u a l s can be found i n the theory-based l i t e r a t u r e . These s p e c u l a t i o n s focus p r i m a r i l y upon a d r a s t i c change i n l i f e s t y l e and independence and p o t e n t i a l f o r i n s t i t u t i o n a l i z a t i o n (Brown, 1982; Dubrovskis & Wells, 1988; Gaudine, 1986; Sikorski et a l . , 1985). I f these speculations are well founded i n r e a l i t y then f r a c t u r i n g a hip could p o t e n t i a l l y lead to devastating changes i n the e l d e r l y i n d i v i d u a l ' s l e v e l of independence and self-esteem. I t i s obvious that the i n d i v i d u a l ' s need f o r s e l f -respect and f o r respect from others i s affected by the hip fracture experience. The need fo r respect i s also affected by expectations of s e l f and of s i g n i f i c a n t others. From a review of the relevant l i t e r a t u r e i t i s cl e a r that further research which focuses on the s e l f -esteem of the hip fracture patient from a personal perspective i s required. Chapter Summary It i s c l e a r that the majority of studies on hip fractures have focused on epidemiology and the s t a t i s t i c a l p r e d i c t i o n of mortality, s u r v i v a l and the functional and s o c i a l r e h a b i l i t a t i o n of e l d e r l y i n d i v i d u a l s . Knowledge regarding the experience of f r a c t u r i n g a hip i s primarily l i m i t e d to t h e o r e t i c a l speculation and authors' assumptions. To provide relevant and appropriate nursing care which respects the collaborative nature of the nurse-patient 20 relationship, the nurse requires an understanding of the meaning an unpredictable event such as a hip fracture has for the patient. Excellence i n nursing p r a c t i c e requires that the nurse go beyond providing routine care dictated by standard procedures, to providing nursing care that i s meaningful, i n d i v i d u a l i z e d and demonstrates a respect for, and a valuing of, the patient's perspective. In collaborating with patients the nurse must s t a r t from "where the patient i s " . In other words, the nurse must have an understanding of what the experience i s l i k e from the patient's perspective. C l e a r l y what i s needed i s research into the meaning of the hip fracture experience from the patient's perspective. The following chapter explains the methodology that was used to guide t h i s study. 21 CHAPTER THREE METHODOLOGY In t h i s c h a p t e r the phenomenological r e s e a r c h p r o c e s s i s e x p l a i n e d . The s p e c i f i c sampling procedure and i s s u e s o f r e l i a b i l i t y and v a l i d i t y are reviewed. F o l l o w i n g t h a t , the proc e s s e s o f p a r t i c i p a n t s e l e c t i o n , data c o l l e c t i o n and data a n a l y s i s are d e s c r i b e d . The chapter concludes w i t h a d i s c u s s i o n o f r e l e v a n t e t h i c a l c o n s i d e r a t i o n s . Overview o f the M e t h o d o l o g i c a l Approach The phenomenological r e s e a r c h approach was used i n t h i s study t o enable the r e s e a r c h e r t o understand and d e s c r i b e the meaning o f f r a c t u r i n g a h i p from the p e r s p e c t i v e o f the i n d i v i d u a l . Phenomenology i s a q u a l i t a t i v e r e s e a r c h methodology t h a t enables the r e s e a r c h e r t o study phenomena h o l i s t i c a l l y . Phenomenological methods a l l o w the r e s e a r c h e r t o understand the experience from the p e r s p e c t i v e o f the p a r t i c i p a n t s who have l i v e d i t . Phenomenology has been d e s c r i b e d as a phi l o s o p h y , an approach and a r e s e a r c h method ( F i e l d & Morse, 1985; Knaack, 1984; O i l e r , 1982). H u s s e r l , the 19th cen t u r y p h i l o s o p h e r , i s c o n s i d e r e d t o be the founder o f the 22 phenomenological research movement (Spiegelberg, 1981). Marcel, Sartre, Merleau-Ponty and other e x i s t e n t i a l philosophers have also been a predominant influence (Spiegelberg, 1970). The objective of the movement i s to describe experiences by i d e n t i f y i n g r e l a t e d meanings perceived by the ind i v i d u a l s involved. These descriptions provide i n s i g h t into human behaviour. With t h i s emphasis on understanding human behaviour, phenomenology i s a p a r t i c u l a r l y relevant research methodology i n the f i e l d s of sociology, anthropology and psychology (Oiler, 1986). Within the l a s t t h i r t y years, phenomenology has been embraced by nurse researchers who have r e a l i z e d i t s value as a method which f a c i l i t a t e s the il l u m i n a t i o n and understanding of human experience which i s of prime concern to nursing i n r e l a t i o n to health and i l l n e s s . Phenomenology i s an inductive, descriptive approach to research. Fundamental to i t i s the requirement that the researcher acknowledge and suspend any personal preconceived ideas about the experience (Sandelowski, 1986). The researcher uses open-ended questions to obtain the pa r t i c i p a n t s ' viewpoint without d i r e c t i n g or influencing t h e i r response. I t i s through 23 t h i s process that the meaning of the phenomenon as humanly experienced i s elucidated and described as f a i t h f u l l y as possible. Methodological Issues Sampling The sampling procedure f o r q u a l i t a t i v e research i s d i f f e r e n t from quantitative research. The purpose of quantitative research i s "to examine the d i s t r i b u t i o n of previously known phenomena i n a population" ( F i e l d & Morse, 1985, p. 93). The use of random sampling i s therefore appropriate. The purpose of q u a l i t a t i v e research i s to understand phenomena which may not be evenly d i s t r i b u t e d throughout the population. To understand a p a r t i c u l a r phenomenon, i t i s necessary to seek out the s p e c i f i c population within which i t would be most appropriate to investigate the phenomenon. For phenomenological research a purposeful sample (also known as a t h e o r e t i c a l sample) i s required ( F i e l d & Morse, 1985). The sample of informants i s selected based on t h e i r s p e c i f i c knowledge or c h a r a c t e r i s t i c s e s s e n t i a l to the study. Subjects are selected on the basis of t h e i r a b i l i t y to illuminate the phenomenon 24 being studied. The size of the sample cannot be predicted p r i o r to data c o l l e c t i o n as i t depends upon the q u a l i t y of the data and the time i t takes to es t a b l i s h t y p i c a l or a t y p i c a l behaviours, experiences or events associated with the phenomenon (Sandelowski, 1986). This means that data are c o l l e c t e d u n t i l no new information can be obtained or when saturation occurs ( F i e l d & Morse, 1985). Saturation occurs when themes or major categories are repeated. V a l i d i t y and R e l i a b i l i t y The i n t e r n a l v a l i d i t y of q u a l i t a t i v e research can be evaluated based on the c r e d i b i l i t y of the study (Sandelowski, 1986). Sandelowski (1986) states that "a q u a l i t a t i v e study i s credible when i t presents such f a i t h f u l descriptions or interpretations of a human experience that the people having the experience would immediately recognize i t from those descriptions or interpretations as t h e i r own" (p. 30). Rieman (1986) suggests that themes may be validated by r e f e r r i n g back to the o r i g i n a l interviews and asking the informants i f the themes are accurate. In quantitative research studies the external v a l i d i t y or g e n e r a l i z a b i l i t y of the study r e s u l t s 25 depends upon t h e e x i s t e n c e o f s p e c i f i c c o n d i t i o n s w h i c h a r e s t r i c t l y c o n t r o l l e d . I n q u a l i t a t i v e r e s e a r c h t h e emphasis i s on s t u d y i n g t h e phenomena i n t h e n a t u r a l s e t t i n g w i t h few c o n t r o l l i n g c o n d i t i o n s . T h e r e f o r e t h e r e a r e fewer t h r e a t s t o e x t e r n a l v a l i d i t y i n q u a l i t a t i v e as opposed t o q u a n t i t a t i v e r e s e a r c h . E l i t e b i a s i s a problem i n q u a l i t a t i v e r e s e a r c h because s u b j e c t s who a c t as i n f o r m a n t s a r e f r e q u e n t l y t h e most a r t i c u l a t e , a c c e s s i b l e o r h i g h s t a t u s members o f t h e i r group ( S a n d e l o w s k i , 1986). R e l i a b i l i t y i s a p r e r e q u i s i t e f o r v a l i d i t y . I n q u a n t i t a t i v e r e s e a r c h r e l i a b i l i t y i s t h e a b i l i t y o f t h e s t u d y t o be r e p e a t e d . I n q u a l i t a t i v e terms r e l i a b i l i t y r e f e r s t o t h e a u d i t a b i l i t y o r ease w i t h w h i c h a n o t h e r r e s e a r c h e r can f o l l o w t h e d e c i s i o n t r a i l o u t l i n e d by t h e s t u d y ' s i n v e s t i g a t o r ( S a n d e l o w s k i , 1986). S e l e c t i o n o f P a r t i c i p a n t s I n p h e n o m e n o l o g i c a l r e s e a r c h t h e s u b j e c t i s c o n s i d e r e d a p a r t i c i p a n t who i s knowledgeable and a b l e t o d e s c r i b e t h e e x p e r i e n c e b e i n g s t u d i e d . Random s e l e c t i o n o f s u b j e c t s i s t h e r e f o r e n o t a p p r o p r i a t e as s u b j e c t s randomly s e l e c t e d , may be u n a b l e t o speak t o t h e phenomenon (Anderson, E l f e r t & L a i , 1989). 26 Par t i c i p a n t s e l e c t i o n f o r t h i s study was therefore guided by the p r i n c i p l e s of t h e o r e t i c a l sampling wherein pa r t i c i p a n t s are selected on the basis of t h e i r a b i l i t y to speak to the phenomenon of f r a c t u r i n g a hip. In phenomenological research contact with p a r t i c i p a n t s tends to be intensive and generates a large volume of verbal data to be analyzed (Sandelowski, 1986). Based on t h i s consideration sample sizes tend to be small i n comparison to those used i n quantitative research. Sample si z e i n q u a l i t a t i v e research cannot r e a l i s t i c a l l y be predetermined because i t depends on the q u a l i t y of the data c o l l e c t e d and the point at which saturation i s reached. I t i s evident from a review of numerous q u a l i t a t i v e studies, that a f t e r interviewing an average of six to eight p a r t i c i p a n t s no new information appears to be generated. C r i t e r i a f o r Selection The c r i t e r i a used i n s e l e c t i n g i n d i v i d u a l s f o r p a r t i c i p a t i o n i n t h i s study included a woman who: 1. was 65 years of age or older. 2. l i v e d i n a house or apartment not associated with a r e s i d e n t i a l care f a c i l i t y . 3. had sustained a hip fracture (which had not 27 resulted from malignancy or i t s treatment) and had the fracture s u r g i c a l l y repaired and had not sustained other major immobilizing fractures simultaneously. 4. had the a b i l i t y to r e c a l l and describe the hip fracture experience. 5. had the a b i l i t y to converse f l u e n t l y i n English. 6. was staying within the metropolitan area following discharge from h o s p i t a l . The reason these c r i t e r i a were established i s self-evident, with one possible exception. The c r i t e r i o n that an i n d i v i d u a l ' s hip fracture not be rel a t e d to malignancy i s included due to the researcher's b e l i e f that the meaning an i n d i v i d u a l a t t r i b u t e s to a hip fracture r e s u l t i n g from a metastatic as opposed to traumatic process may be r a d i c a l l y d i f f e r e n t . Selection Procedure Individuals were selected from an acute care h o s p i t a l i n a metropolitan area. The researcher reviewed the l i s t of e l d e r l y patients admitted to the orthopaedic units to e s t a b l i s h the compatibility of patients with the selection c r i t e r i a . 28 When an i n d i v i d u a l had been i d e n t i f i e d as a s u i t a b l e candidate f o r p a r t i c i p a t i o n i n the study, i n i t i a l c o n t a c t was made by the r e s e a r c h e r , who p r o v i d e d i n f o r m a t i o n about the study (See Appendix A) t o the p a t i e n t . I f upon r e a d i n g the i n f o r m a t i o n , the p a t i e n t i n d i c a t e d a w i l l i n g n e s s t o p a r t i c i p a t e , t he r e s e a r c h e r made arrangements t o c o n t a c t the p a t i e n t one t o t h r e e weeks f o l l o w i n g h o s p i t a l d i s c h a r g e t o e s t a b l i s h an i n t e r v i e w time convenient t o the p a t i e n t . P r i o r t o b e g i n n i n g the f i r s t i n t e r v i e w the p a t i e n t was asked t o s i g n the consent form (See Appendix B). The p a r t i c i p a n t s were reminded t h a t they c o u l d choose t o ter m i n a t e t h e i r p a r t i c i p a t i o n a t any time. Each p a r t i c i p a n t was i n t e r v i e w e d a t l e a s t t w i c e but not more than t h r e e times. The s e l e c t i o n process o c c u r r e d over a seven week p e r i o d . During t h i s p e r i o d , the r e s e a r c h e r c o n t a c t e d n i n e p r o s p e c t i v e p a r t i c i p a n t s . A l l o f these i n d i v i d u a l s i n i t i a l l y agreed t o p a r t i c i p a t e . However due t o v a r y i n g circumstances o n l y s i x i n d i v i d u a l s a c t u a l l y became p a r t i c i p a n t s . Of the t h r e e i n d i v i d u a l s who o r i g i n a l l y agreed t o p a r t i c i p a t e but who d i d not end up i n the a c t u a l study sample, two d e c l i n e d t o p a r t i c i p a t e d u r i n g the p o s t d i s c h a r g e telephone c o n t a c t . One o f these i n d i v i d u a l s s t a t e d t h a t she "wished t o f o r g e t t he whole e x p e r i e n c e " and "was not a t a l l i n t e r e s t e d i n the study". The second p o t e n t i a l c a n d i d a t e s t a t e d t h a t she would r a t h e r not p a r t i c i p a t e a t t h a t time. The t h i r d i n d i v i d u a l s t a t e d she would be i n t e r e s t e d i n p a r t i c i p a t i n g i n the study " e s p e c i a l l y i f i t would h e l p o t h e r o l d l a d i e s w i t h h i p f r a c t u r e s " . U n f o r t u n a t e l y t h i s i n d i v i d u a l was d i s c h a r g e d t o an i n t e r m e d i a t e care f a c i l i t y which meant she no l o n g e r met the p a r t i c i p a n t s e l e c t i o n c r i t e r i a . C h a r a c t e r i s t i c s o f the P a r t i c i p a n t s S i x women p a r t i c i p a t e d i n t h i s study. T h e i r ages ranged from 69 t o 84 years (median 78.2). Three o f these women were m a r r i e d and l i v e d w i t h t h e i r spouse. Two i n d i v i d u a l s were widowed. One o f these two i n d i v i d u a l s l i v e d alone and the ot h e r l i v e d w i t h her daughter. The s i x t h p a r t i c i p a n t was not m a r r i e d and l i v e d alone. A l l o f the p a r t i c i p a n t s had f r a c t u r e d a h i p t h a t was subsequently s u r g i c a l l y r e p a i r e d . Two o f the p a r t i c i p a n t s e x p e r i e n c e d a second f a l l and again had t h e i r h i p s u r g i c a l l y r e p a i r e d w i t h i n a p e r i o d o f 30 approximately eight weeks of t h e i r o r i g i n a l fracture. One of these i n d i v i d u a l s was r e c r u i t e d a f t e r she had her hip repaired f o r the second time. The other i n d i v i d u a l experienced her second f a l l between the f i r s t and second interview with the researcher. A l l of the part i c i p a n t s promptly indicated an i n t e r e s t and willingness to p a r t i c i p a t e i n the study, though nearly a l l thought they would have nothing to o f f e r or would not be able to think of anything useful upon which to comment. Data C o l l e c t i o n Data was c o l l e c t e d from the p a r t i c i p a n t s i n intensive audiotaped interview sessions. Open-ended questions were asked to provide a loose structure f o r the i n i t i a l interview (See Appendix C). The interview guide served as a t o o l f o r f a c i l i t a t i n g exploration of the hip fracture experience. The d i r e c t i o n subsequent interviews took depended on analysis of the i n i t i a l interviews and p a r t i c i p a n t cues. Verbatim t r a n s c r i p t i o n of the audiotapes and d e t a i l e d f i e l d notes made a f t e r each interview regarding pertinent environmental and behavioural observations formed the data base for t h i s study. 31 A t o t a l of fourteen interviews were conducted. A l l p a r t i c i p a n t s were interviewed twice, with two of the s i x parti c i p a n t s being interviewed three times. The t h i r d interviews were used as a means of v a l i d a t i n g the researcher's i n t e r p r e t a t i o n of the findings. Between interviews, the researcher read the transcribed tapes and planned f o r the next interview by developing another set of open-ended questions based on the previously c o l l e c t e d and analyzed data. A l l f i r s t time interviews were completed and analyzed before commencing the second ones. Between six to t h i r t e e n weeks elapsed between the f i r s t and second interviews. A l l interviews occurred within a sixteen week period. The interviews ranged i n length from t h i r t y to seventy-f i v e minutes. The time spent i n the pa r t i c i p a n t ' s home was considerably longer. Frequently once the recorder was of f , comments relevant to the study were made. The researcher made f e i l d notes of these comments from memory immediately a f t e r the interview. Data Analysis Data c o l l e c t i o n and analysis do not constitute d i s t i n c t phases of the implementation of 32 phenomenological r e s e a r c h . Data were a n a l y z e d throughout the c o l l e c t i o n phase and i n f l u e n c e d the data c o l l e c t i o n p r o c e s s . The audiotapes were t r a n s c r i b e d by a t y p i s t and the t r a n s c r i p t i o n s checked by the r e s e a r c h e r l i s t e n i n g t o the tapes and r e a d i n g the t e x t s i m u l t a n e o u s l y . Data a n a l y s i s was guided by G i o r g i ' s i n t e r p r e t a t i o n o f the phenomenological method ( G i o r g i , 1985). T h i s means t h a t each t r a n s c r i p t was r e a d t o a c q u i r e a sense o f the whole experience f o r each i n d i v i d u a l . The t r a n s c r i p t was then read a second time t o i d e n t i f y s i g n i f i c a n t statements. A f t e r r e f l e c t i n g on these statements the r e s e a r c h e r i d e n t i f i e d meaning u n i t s . A meaning u n i t i s a l a b e l t h a t can be used t o i d e n t i f y the s m a l l e s t u n i t o f a n a l y s i s . T h i s l a b e l i s congruent w i t h the language o f the p a r t i c i p a n t s . I t i s a way o f c o d i n g the data so t h a t i t i s reduced and workable without s i g n i f i c a n t meanings b e i n g l o s t (Catanzaro, 1988). Using constant comparative a n a l y s i s , the meaning u n i t s o f each i n d i v i d u a l ' s d e s c r i p t i o n was compared w i t h those o f o t h e r s and common themes were i d e n t i f i e d . The r e s e a r c h e r v a l i d a t e d and c l a r i f i e d these themes w i t h the i n d i v i d u a l s i n subsequent i n t e r v i e w s . The emergent 33 themes were developed to describe the meaning of fra c t u r i n g a hip to el d e r l y community-dwelling women. E t h i c a l Considerations Measures were taken to ensure that the rights of the i n d i v i d u a l s who p a r t i c i p a t e d i n t h i s study were protected. Approval to conduct t h i s study was obtained from the University of B r i t i s h Columbia's Behavioural Science Screening Committee and from the Research Committee of the hos p i t a l involved. The rights of the partic i p a n t s were protected i n the following ways. I n i t i a l contact was made by the researcher who explained to each p o t e n t i a l p a r t i c i p a n t the purpose and nature of the study as well as the implications of p a r t i c i p a t i o n . The po t e n t i a l p a r t i c i p a n t was then given an Introductory Letter that r e i t e r a t e d the points the researcher had explained (See Appendix A). Individuals were advised that p a r t i c i p a t i o n was s t r i c t l y voluntary and that non-p a r t i c i p a t i o n i n the study would i n no way a f f e c t the medical or nursing care they received. Participants were also informed that p a r t i c i p a t i o n involved no expected r i s k s . Individuals were reminded p r i o r to the interviews that they could choose to terminate t h e i r 34 p a r t i c i p a t i o n at any time and to refuse to answer any questions. Participants were informed that taped materials would be kept anonymous and c o n f i d e n t i a l and written material i n r e l a t i o n to the study would not use any names or i d e n t i f y i n g factors. Prospective pa r t i c i p a n t s were provided an opportunity to ask any questions regarding the study and to have these questions s a t i s f a c t o r i l y answered p r i o r to giving consent. Before commencing the f i r s t interview, a consent form (See Appendix B) was signed i n duplicate by each par t i c i p a n t , with the p a r t i c i p a n t r e t a i n i n g a copy. Chapter Summary This chapter has described the methodology that guided t h i s study i n i t s exploration of the meaning of f r a c t u r i n g a hip f o r e l d e r l y community-dwelling women. An explanation of the phenomenological research method was presented and the s p e c i f i c sampling procedure and the issues of r e l i a b i l i t y and v a l i d i t y were discussed. Following that, the processes of p a r t i c i p a n t selection, data c o l l e c t i o n and data analysis were described. The chapter concluded with a discussion of the study's e t h i c a l considerations. The next chapter focuses on presentation and discussion of the findings of the study with regard to the meaning of f r a c t u r i n g a hip 36 CHAPTER FOUR PRESENTATION AND DISCUSSION OF FINDINGS In t h i s c h apter the f i n d i n g s o f the study a re f i r s t p r e s e n t e d and then d i s c u s s e d . The f i r s t h a l f o f the c h a p t e r focuses on the women's d e s c r i p t i o n s o f what i t was l i k e t o f r a c t u r e a h i p and how they coped w i t h the experience. Throughout the p r e s e n t a t i o n , the f i n d i n g s are i l l u s t r a t e d w i t h v e r b a t i m e x c e r p t s from the p a r t i c i p a n t s ' accounts. The verb a t i m e x c e r p t s a l l o w the reader t o a u d i t the " f i t " o f the d e s c r i p t i o n w i t h the o r i g i n a l data from which i t was d e r i v e d (Sandelowski, 1986). In the l a t t e r h a l f o f the chapter, the f i n d i n g s are d i s c u s s e d i n r e l a t i o n t o p e r t i n e n t l i t e r a t u r e which h e l p s t o c l a r i f y and i l l u s t r a t e key themes t h a t were found and al l o w s the reader t o compare the f i n d i n g s o f t h i s study w i t h the f i n d i n g s and o b s e r v a t i o n s o f o t h e r r e s e a r c h e r s and authors. The accounts o f the study p a r t i c i p a n t s p r o v i d e d a d e s c r i p t i o n o f the meaning o f f r a c t u r i n g a h i p t o e l d e r l y community-dwelling women. Although each woman's account d e s c r i b e d the unique and p e r s o n a l meaning o f f r a c t u r i n g a h i p , common themes r e p r e s e n t i n g 37 the shared aspects o f the experience were r e a d i l y e v i d e n t . Loss o f c o n t r o l was a common theme t h a t c h a r a c t e r i z e d the o v e r a l l h i p f r a c t u r e e x p e r i e n c e . The l o s s o f c o n t r o l t h r e a t e n e d the e l d e r l y i n d i v i d u a l ' s s e l f - e s t e e m and caused them t o r e e v a l u a t e t h e i r s e l f -p e r c e p t i o n s , b e l i e f s about a g i n g and t h e i r e x p e c t a t i o n s f o r the f u t u r e . Accounts o f the Meaning o f F r a c t u r i n g a Hip In t h i s s e c t i o n the f i n d i n g s w i l l be p r e s e n t e d i n the o r d e r i n which the events occurred, b e g i n n i n g w i t h the f a l l event and p r o g r e s s i n g through t o the h o s p i t a l i z a t i o n and p o s t d i s c h a r g e experience. The F a l l Event When asked about what i t i s l i k e t o f r a c t u r e a hi p , each p a r t i c i p a n t responded w i t h a n a r r a t i v e d e s c r i b i n g the sequence o f events l e a d i n g up t o the a c t u a l f a l l . Each p a r t i c i p a n t o u t l i n e d i n d e t a i l how they came t o be i n t h a t p a r t i c u l a r s e t t i n g a t t h a t p a r t i c u l a r time. They d e s c r i b e d what they were doing, how they were f e e l i n g and what they were t h i n k i n g . W e l l I was f e e l i n g v e r y good t h a t morning. I f e l t l i k e doing a l o t o f t h i n g s . N i c e and b r i g h t and 38 so on. And I de c i d e d t o do the washing..I was j u s t washing some t h i n g s a t the k i t c h e n s i n k . P a r t i c i p a n t were independently i n v o l v e d i n a c t i v i t i e s o f d a i l y l i v i n g . They t y p i c a l l y d e s c r i b e d themselves as f e e l i n g h e a l t h y , e n e r g e t i c and were going about t h e i r t a s k s w i t h a sense o f purpose and competence. They assumed they were engaged i n r o u t i n e , low r i s k a c t i v i t i e s . Nothing i n t h e i r environment l e d them t o suspect otherwise. However, w i t h i n a matter o f seconds t h e i r sense o f c o n t r o l , s e l f - e s t e e m and p e r c e i v e d l e v e l o f competence were completely d i s r u p t e d by t h e i r f a l l . W e l l , t o f a l l and not be a b l e t o get up. I t h i n k t h a t i s the worse experi e n c e I have ever had i n my l i f e . That you are h e l p l e s s . I t was common f o r p a r t i c i p a n t s t o r e f e r t o themselves i n a derogatory manner f o r having f a l l e n and t o express t h e i r shock a t how the a c t o f f a l l i n g was i n c o n s i s t e n t w i t h t h e i r e x p e c t a t i o n s o f s e l f . I j u s t c o u l d n ' t b e l i e v e i t . That's something you know. To be so s t u p i d as t o f a l l l i k e t h a t . 39 I thought, oh gee, how s t u p i d c o u l d I be, and so you know, t o do a t h i n g l i k e t h a t you know. F a l l down. Only two p a r t i c i p a n t s were r e a d i l y a b l e t o i d e n t i f y an obvious reason f o r t h e i r f a l l i n the o r i g i n a l t e l l i n g o f t h e i r s t o r y . And down I went. I t must have been a b i t o f s l u s h or something. There was an e i g h t i n c h drop from t h i s p l a t f o r m down, which I was not aware o f . In both cases the o b j e c t o r substance t h a t p o t e n t i a t e d the f a l l was p h y s i c a l l y e v i d e n t and t h e r e f o r e e a s i l y i d e n t i f i e d . The remaining p a r t i c i p a n t s i n i t i a l l y e xpressed f r u s t r a t i o n and a sense o f bewilderment as they were unable t o i d e n t i f y an obvious cause. And I went down, which I c o u l d not understand. There was n o t h i n g t o t r i p on or anything. At times I t h i n k t o myself, I ' l l be slow. But I am sure I was, I c o u l d n ' t have been slower g e t t i n g up t h a t morning and j u s t w a i t i n g f o r the k e t t l e t o b o i l . 40 However, these same women co n t i n u e d t o r e f l e c t upon the event u n t i l they were a b l e t o f i n d an a c c e p t a b l e e x p l a n a t i o n . There wasn't any reason why I sho u l d f a l l . Except f o r i t , I '11 t e l l you what i t was. I t was proba b l y my s l i p p e r s . Yeah, yeah. I had a p a i r o f bedroom s l i p p e r s on. And I t h i n k t h a t i s what happened. One o f them j u s t s l i p p e d and the ot h e r one stuck on the f l o o r . I t was i n t e r e s t i n g t o note t h a t i t was o n l y d u r i n g the r e s e a r c h i n t e r v i e w t h a t t h i s woman came t o the r e a l i z a t i o n t h a t her s l i p p e r s c o u l d have been the c a u s a l f a c t o r . She was then q u i t e s a t i s f i e d t o have f i n a l l y i d e n t i f i e d a l o g i c a l reason and r e f e r r e d t o i t on numerous o c c a s i o n s . Another woman who was unable t o i d e n t i f y an obvious cause f r e q u e n t l y r e f e r r e d t o a s u s p i c i o n she h e l d r e g a r d i n g the c o n d i t i o n o f her bones. But I j u s t seemed t o go, l i k e i t was, l i k e . . i t seemed t o me l i k e a break t h a t was maybe coming f o r sometime. And I d i d n ' t r e a l l y know t h a t . But I f e l t i t was a d e t e r i o r a t i o n o r something o f 41 the bone or something...cause I have heard of others having done that you see, a break l i k e that. Thus t h i s woman made sense of her f a l l and r e s u l t i n g fracture by i d e n t i f y i n g a p o t e n t i a l l y l o g i c a l , although not p h y s i c a l l y obvious causal factor. I t was common for p a r t i c i p a n t s to describe some way i n which they were ei t h e r d i r e c t l y or i n d i r e c t l y responsible f o r t h e i r circumstances. Individuals described how they should have known better than to be doing what they were doing or they should have taken t h e i r time or been more aware of t h e i r surroundings. And then you can't get over the f a c t that i t was your own f a u l t you see. That you brought a l l t h i s on yourself. I wished I hadn't done what I di d many times. Well I am annoyed with myself f o r being so stupid, to not have.. I don't know what I could have done. I suppose look before I even moved my foot. 42 Thus fo r these women t h e i r f a l l and t h e i r hip fracture were unexpected events that represented losses with respect to t h e i r sense of control, self-esteem and l e v e l of perceived competence. The H o s p i t a l i z a t i o n Experience The f a l l event i t s e l f was perceived as a physical demonstration of incompetence and a loss of control. Loss of control continued to be a theme that predominated i n p a r t i c i p a n t s ' ongoing descriptions of -t h e i r h o s p i t a l i z a t i o n experience. I hadn't been through any of t h i s . I heard people t a l k i n g about i t , but I had no idea what i t was l i k e . . . 1 think you know, somebody might have explained. It was r e a d i l y evident from p a r t i c i p a n t s ' comments that they experienced a fear of the unknown. Not being informed of what was happening or what to expect contributed to the perception of loss of control. I t also posed a threat to p a r t i c i p a n t s ' sense of s e l f -esteem as they f e l t that t h e i r feelings and perceptions were eithe r being ignored or were not considered a p r i o r i t y . When I a r r i v e d i n t h e r e (to the emergency department), I was j u s t another person who came i n and needed a t t e n t i o n . . . u n l e s s I asked them they d i d n ' t e x p l a i n a n ything. I was a l i t t l e i n c l i n e d t o t h i n k they had so many people coming i n t h a t t h e r e i s a l o t o f t h i n g s they take f o r granted, t h a t people would know t h a t t h i s was what they had t o do. P a r t i c i p a n t s ' d e s c r i p t i o n s conveyed t h a t sometimes they f e l t they were b e i n g p r o c e s s e d through the h o s p i t a l m i l l as j u s t another f r a c t u r e d h i p r a t h e r than b e i n g t r e a t e d as an i n d i v i d u a l who happened t o have a h i p f r a c t u r e . R e p r e s e n t a t i v e comments f o l l o w . Even when the d o c t o r came i n . . . n e v e r once, ( d i d he) you know, s o r t o f came up c l o s e t o me. I mean i t makes you f e e l a l i t t l e more c o n f i d e n t , you know. You are l o o k i n g up a t the man. You are t a l k i n g t o him and he i s s a y i n g something t o the o t h e r guy ( r e s i d e n t ) and he s o r t o f loo k s up and says something e l s e . I t h i n k he i s a t e r r i f i c surgeon. I mean by r e p u t a t i o n . But he c e r t a i n l y l a c k e d i n , i n bedside manners, s h a l l we say. You 44 know and I r e s p e c t h i s a b i l i t y but t h e r e wasn't a touch o f warmth or, c a r i n g o r anything. So t h i s was what was v e r y d i f f i c u l t i n h o s p i t a l . There was one nurse and she thought I was s o r t o f a m a l i n g e r e r , t h a t I d i d n ' t want t o get up t o go t o the bathroom. You see the problem was t h a t I had had a s l e e p i n g p i l l and t h e r e f o r e I s l e p t u n t i l about seven o ' c l o c k i n the morning and then when I had t o go, I had t o go. And I c o u l d n ' t get out o f bed you know...they had those t h i n g s , c a l f compression devices) on my l e g s . You see t h a t a l l had t o be taken o f f . . . a n d those beds are h i g h . And by the time, (I got them o f f ) I c o u l d n ' t get t o the bathroom i n time, you know. I thought t h a t she was p r e t t y c r u e l . . . A l l I wanted was a l i t t l e more c o n s i d e r a t i o n from the nurse. In the f i r s t excerpt, the woman i n v o l v e d p e r c e i v e d t h a t t h e r e was a " c l i n i c a l " d i s t a n c e between h e r s e l f and her surgeon. His impersonal manner l e d her t o b e l i e v e t h a t he was more i n t e r e s t e d i n the s u r g i c a l r e p a i r than i n the person who underwent the surgery. In the second e x c e r p t the p a r t i c i p a n t i n t e r p r e t e d the nurse's a c t i o n s 45 as demonstrating a l a c k o f r e s p e c t f o r her as an i n d i v i d u a l . She b e l i e v e d t h a t r e g a r d l e s s o f her i n d i v i d u a l e x t e n u a t i n g circumstances she was expected t o conform t o standar d procedure. The p r e s s u r e t o conform i r r e s p e c t i v e o f i n d i v i d u a l circumstances posed a f u r t h e r t h r e a t t o the p a r t i c i p a n t s ' sense o f s e l f -esteem. A l a c k o f i n d i v i d u a l i z e d treatment was a g a i n emphasized t o p a r t i c i p a n t s when they d i s c o v e r e d t h a t t h e i r d i s c h a r g e p l a n s had been made without t h e i r knowledge o r i n p u t . I had no i d e a , except t h a t e a r l y i n the stay, I t h i n k i t was t e n days a l t o g e t h e r , someone mentioned t h a t p o s s i b l y the next Saturday I would be a b l e t o go home. But they were not sure. On the Thursday, which was approximately seven o r e i g h t days l a t e r , the nurse came i n a t 10:25 p.m. and she s a i d , "Oh I see you are going home tomorrow", which was the F r i d a y . The o n l y day t h a t had ever been mentioned. There had been no ot h e r r e f e r e n c e t o i t . I t would be, p o s s i b l y on t h a t Saturday. And I was very, v e r y upset, because I d i d n ' t have anywhere t o go. And I s a i d , 46 "I don't have anywhere t o go", and I know t h a t sounded strange t o her. But the f a c t o f the matter was, t h a t I l i v e (out o f town). I don't have a maid o r a housekeeper. And i t would mean t h a t my husband would have t o st a y home every minute o f the day w i t h me, f o r I don't know how long . As a r e s u l t o f t h i s l a c k o f c o l l a b o r a t i o n , the di s c h a r g e p l a n s t h a t were developed f r e q u e n t l y d i d not adequately address the needs o f the women i n v o l v e d but c o n t r i b u t e d t o t h e i r f r u s t r a t i o n and p e r c e p t i o n o f l o s s o f c o n t r o l . Thus impersonal i n t e r a c t i o n s , adherence t o standard procedures and l a c k o f c o l l a b o r a t i o n l e d these women t o p e r c e i v e t h a t they were not i n c o n t r o l o f t h e i r circumstances and t h a t c e r t a i n h e a l t h p r o f e s s i o n a l s were more concerned w i t h the completion o f t h e i r t a s k s than w i t h meeting t h e i r p a t i e n t s ' i n d i v i d u a l needs. T h i s l a c k o f a t t e n t i o n t o p a r t i c i p a n t s ' i n d i v i d u a l i t y was a t h r e a t t o t h e i r sense o f s e l f - e s t e e m . P a r t i c i p a n t s c o n s i s t e n t l y d e s c r i b e d one e x c e p t i o n t o t h i s g e n e r a l i z a t i o n . They p e r c e i v e d t h a t p h y s i o t h e r a p i s t s t r e a t e d them as i n d i v i d u a l s and a s s i s t e d them t o achieve t h e i r p e r s o n a l g o a l s . 47 These women d e s c r i b e d the p h y s i o t h e r a p i s t s as a l l i e s who were a v e r y v a l u a b l e source o f encouragement. But I thought they (the p h y s i o t h e r a p i s t s ) were r e a l l y remarkable and s o r t o f encouraging people. G e t t i n g you t o t r y and a l l t h a t . The p h y s i o t h e r a p i s t s they don't l e t you moan about i t , you know. They say, you have got t o do i t . So t h a t i s t h a t . And keep on t r y i n g and you w i l l do i t i n the end. The p o s i t i v e a t t i t u d e s o f the p h y s i o t h e r a p i s t s i n s p i r e d the p a r t i c i p a n t s t o c o n s i s t e n t l y make a c o n c e r t e d e f f o r t toward improving t h e i r l e v e l o f f u n c t i o n i n g . And they (the p h y s i o t h e r a p i s t s ) don't push you, you know. They show you what t o do and I guess they f i g u r e each day you should improve which I d i d . Thus the women p e r c e i v e d t h a t p h y s i o t h e r a p i s t s r e s p e c t e d t h e i r o p i n i o n and t h e i r i n d i v i d u a l l i m i t a t i o n s . They a l s o c o l l a b o r a t e d w i t h them t o mutua l l y i d e n t i f y r e a l i s t i c g o a l s and demonstrated r e s p e c t f o r them by i n d i v i d u a l i z i n g t h e i r approach. 48 The p h y s i o t h e r a p i s t s ' i n t e r v e n t i o n s a s s i s t e d the p a r t i c i p a n t s t o m a i n t a i n t h e i r s e l f - e s t e e m and r e g a i n elements o f c o n t r o l over t h e i r s i t u a t i o n . In summary i t would appear t h a t w h i l e i n h o s p i t a l the i s s u e s o f c o n t r o l and the d e s i r e t o be t r e a t e d as i n d i v i d u a l s were o f primary importance t o these women. I t i s a l s o c l e a r t h a t the i n t e r v e n t i o n s o f h e a l t h p r o f e s s i o n a l s s i g n i f i c a n t l y impacted upon both the p a r t i c i p a n t s ' p e r c e p t i o n s o f c o n t r o l and t h e i r sense o f s e l f - e s t e e m . The Post d i s c h a r g e Experience As p a r t i c i p a n t s began t o f e e l b e t t e r t h e i r d e s i r e f o r c o n t r o l became i n c r e a s i n g l y more important. P a r t i c i p a n t s v e r b a l i z e d t h e i r need t o make t h e i r own d e c i s i o n s and d i c t a t e t h e i r own r o u t i n e s . A c e r t a i n degree o f resentment r e l a t e d t o t h e i r p e r c e i v e d l a c k o f c o n t r o l w h i l e s t i l l i n h o s p i t a l was apparent i n t h e i r d e s c r i p t i o n s . When you are used t o doing t h i n g s on your own and a l l t h a t , you get a l i t t l e t i r e d (laughing) you know, (of people t e l l i n g you what t o do). " I t ' s time now t h a t you know..it w i l l soon be supper time now and you w i l l h u r r y a l o n g now" and t h i s 49 k i n d o f t h i n g . I t was j u s t t h a t I was... I wanted t o go home and be a b l e t o change my own c l o t h e s . Thus p a r t i c i p a n t s regarded t h e i r d i s c h a r g e as an o p p o r t u n i t y f o r them t o r e t u r n t o a f a m i l i a r environment where they b e l i e v e d they would once a g a i n be independent and i n c o n t r o l o f t h e i r s i t u a t i o n . The i n f o r m a t i o n t h a t was p r o v i d e d t o p a r t i c i p a n t s p r i o r t o d i s c h a r g e f a i l e d t o prepare them f o r the r e a l i t y o f the r e c o v e r y p r o c e s s . T h e i r e x p e c t a t i o n s f o r a r a p i d r e c o v e r y and a q u i c k r e t u r n t o t h e i r p r e v i o u s l e v e l o f f u n c t i o n i n g were not r e a l i z e d . Once home the d i s c r e p a n c y between t h e i r e x p e c t a t i o n s and the a c t u a l process o f r e c o v e r y became i n c r e a s i n g l y more apparent. P a r t i c i p a n t s expressed t h e i r s u r p r i s e and dismay a t not b e i n g a b l e t o be as e n e r g e t i c o r as mobile as they had a n t i c i p a t e d . I was v e r y e a s i l y t i r e d a f t e r I got home. I d i d n ' t r e a l l y have any e x t r a energy. I was so s u r p r i s e d because i n the h o s p i t a l , I was a l i t t l e b i t bored...But eh, when I came home I was, I seemed t o t i r e out v e r y e a s i l y . 50 W e l l o f course when I came home f i r s t , I j u s t , I t h i n k I t o l d you b e f o r e , I j u s t c o u l d n ' t b e l i e v e t h a t I would not be mobile, you know. T h i s i n a b i l i t y t o be mobile hampered the p a r t i c i p a n t s ' l e v e l o f independence and made i t e s s e n t i a l t h a t they r e l y upon o t h e r s f o r a s s i s t a n c e . Oh w e l l i t ( f r a c t u r i n g a hip) has changed i t ( l i f e ) completely. Because I am home. I cannot go out and I, I depend on o t h e r people. Whereas I have always been v e r y independent. F r a c t u r i n g a h i p meant t h a t these women who normally p r i d e d themselves on b e i n g independent and i n c o n t r o l o f t h e i r home environment, t e m p o r a r i l y had t o r e l i n q u i s h t h a t c o n t r o l and depend upon o t h e r people t o a s s i s t them t o meet t h e i r needs. T h i s was another unexpected occurrence t h a t posed a t h r e a t t o the women's sense o f s e l f - e s t e e m . F o r some i n d i v i d u a l s not b e i n g a b l e t o make d e c i s i o n s and manage independently r e i n f o r c e d t h e i r f e e l i n g s o f incompetence and p r e c i p i t a t e d r e c u r r e n t episodes o f d e p r e s s i o n . 51 And i t i s depressing. I have gone through awful depression. You see not being able to get out and do things and also not being able to be independent. Not being independent, you have to depend on other people you know. These in d i v i d u a l s also expressed concern that friends and family members not only had to a s s i s t them to meet t h e i r normal a c t i v i t i e s of d a i l y l i v i n g but they also had to assume some of the women's usual r e s p o n s i b i l i t i e s . Well i t does (bother me). Because he has so much on his shoulders. This i s why. Things I should have been doing, he has to do now. This obvious sense of g u i l t over causing family members and friends to disrupt t h e i r usual routine i n order to do something f o r the patient, pervaded a l l p a r t i c i p a n t s ' accounts. I t was as i f the women worried that t h i s temporary disruption would cause t h e i r s i g n i f i c a n t others to begin to resent them and perhaps see them more as a burden rather than the v i t a l active senior they were p r i o r to t h e i r hip fracture. 52 And I was a w f u l l y s o r r y about the f a m i l y cause I mean i t upset them. They had t o come and see me. Every day t r a i p s e over. And then my o t h e r f r i e n d , he w i l l go anytime a t a l l . But as I s a i d , you hate b o t h e r i n g people, you r e a l l y do. Thus i t was apparent t h a t these women's e x p e c t a t i o n s r e g a r d i n g t h e i r l e v e l o f m o b i l i t y and independence were i n c o n s i s t e n t w i t h r e a l i t y . T h e i r i n a b i l i t y t o l i v e up t o t h e i r e x p e c t a t i o n s caused the women t o f e e l somewhat depressed and s h a t t e r e d t h e i r p e r c e p t i o n s o f c o n t r o l . A l l o f the women expressed f r u s t r a t i o n w i t h the slowness o f the re c o v e r y p r o c e s s . I am g e t t i n g too i m p a t i e n t . I f i g u r e t h i n g s s h o u l d be moving al o n g a l i t t l e q u i c k e r t o what they a r e . P a r t i c i p a n t s a l s o expressed v a r y i n g degrees o f u n c e r t a i n t y r e g a r d i n g the ext e n t o f t h e i r r e c o v e r y . I t concerns me because I don't know whether I w i l l have a f u l l r e c o v e r y . And I t h i n k about t h a t o c c a s i o n a l l y . Not b e i n g f a n a t i c a l about i t , y e t . But i t ' s t h e r e , you know. And sometimes when I am o f f and you know dragging, I t h i n k , geez, am I going t o get p a s t t h i s ? Or i s i t ever, o r I am ever going t o walk p r o p e r l y ? You know the way you can (imagine). T h e i r l a c k o f energy a l s o generated concerns about t h e i r r e c o v e r y . That bothered me a b i t . Because I have heard t h a t sometimes people, e s p e c i a l l y people my age, they have something l i k e t h i s happen and then j u s t a k i n d o f a g r a d u a l d r a i n , you see. Because they don't have the stamina t o go on. C l e a r l y the u n c e r t a i n t y a s s o c i a t e d w i t h the ext e n t o f t h e i r r e c o v e r y o f f u n c t i o n was a source o f a n x i e t y t h a t a t times predominated the p a r t i c i p a n t s ' thoughts. P a r t i c i p a n t s a l s o r e c o g n i z e d t h a t the p o t e n t i a l e x i s t e d f o r t h e i r s u r g i c a l r e p a i r t o be d i s r u p t e d through o v e r e x e r t i o n o r another f a l l . When I am l y i n g down t o s l e e p , I t h i n k , I t r y and get my mind o f f some o f these t h i n g s you know, but I have v i s i o n s o f s t e p p i n g out and f a l l i n g you know t h a t k i n d o f t h i n g . I t j u s t seems t o come t o me a l l the time. 54 The experience o f f a l l i n g made these women a c u t e l y aware o f the dangers o f such an event. Another f a l l c o u l d r e s u l t i n a worse outcome w i t h r e s p e c t t o t h e i r l e v e l o f p h y s i c a l f u n c t i o n i n g and g e n e r a l h e a l t h . I don't r e a l l y want t o be a s i s s y s o r t o f t h i n g . But I f e e l , t h a t , i t c o u l d happen a g a i n and I w i l l take p r e c a u t i o n s because I don't want t o l a n d back i n the same p l a c e . And I d i d hear o f a l a d y the o t h e r day and she had broke her h i p l a s t F a l l a f t e r f a l l i n g over something. And she was g e t t i n g a l o n g not too bad. But i f she d i d n ' t break the o t h e r one. So she i s i n a n u r s i n g home. I t i s c l e a r from the women's d e s c r i p t i o n s t h a t the f e a r o f f a l l i n g and the l o s s o f energy and stamina were p e r c e i v e d as major t h r e a t s t h a t had the p o t e n t i a l t o p r e c i p i t a t e a f u r t h e r l o s s o f c o n t r o l . In summary, i t i s apparent t h a t these women exp e r i e n c e d a c e r t a i n amount o f f r u s t r a t i o n and decreased s e l f - e s t e e m as they were unable t o l i v e up t o t h e i r e x p e c t a t i o n s f o l l o w i n g d i s c h a r g e . They ex p e r i e n c e d a number o f f e a r s and concerns r e l a t e d t o t h e i r l e v e l o f dependence, the extent o f t h e i r r e c o v e r y and the p o t e n t i a l f o r another t r a u m a t i c event t o occur. 55 A l l o f these f o r c e s n e g a t i v e l y a f f e c t e d the p a r t i c i p a n t s ' p e r c e p t i o n s o f c o n t r o l and s e l f - e s t e e m . Coping w i t h the Hip F r a c t u r e E x p e rience T h i s s e c t i o n p r e s e n t s a d e s c r i p t i o n o f the cop i n g behaviours t h a t p a r t i c i p a n t s used t o d e a l w i t h t h e i r f a l l , h o s p i t a l i z a t i o n and pos t d i s c h a r g e e x p e r i e n c e s . Copinq w i t h the F a l l Event The f a l l event r e p r e s e n t e d l o s s e s w i t h r e s p e c t t o the e l d e r l y i n d i v i d u a l ' s sense o f c o n t r o l , s e l f - e s t e e m and l e v e l o f p e r c e i v e d competence. F a l l i n g i n p u b l i c i s a v i s i b l e demonstration o f incompetence. I t c a l l s unwanted a t t e n t i o n t o the f a l l v i c t i m . A f t e r the f a l l o ccurs i t i s a n a t u r a l r e a c t i o n t o attempt t o r e g a i n one's c o n t r o l as q u i c k l y as p o s s i b l e . As p a r t i c i p a n t s d e s c r i b e d , they were unable t o q u i c k l y r e e s t a b l i s h t h e i r d e s i r e d l e v e l o f c o n t r o l . [R: What were you t h i n k i n g then when you f e l l ? ] What was I t h i n k i n g ? G e t t i n g up quick. But I co u l d n ' t . P a r t i c i p a n t s attempted t o cope w i t h and make sense o f t h e i r s i t u a t i o n by i d e n t i f y i n g a p l a u s i b l e cause f o r the a c c i d e n t . In some i n s t a n c e s the women devoted a good d e a l o f time and e f f o r t t o t h i s i d e n t i f i c a t i o n 56 p r o c e s s . P a r t i c i p a n t s coped w i t h t h e i r l o s s o f c o n t r o l and decreased sense o f s e l f - e s t e e m by a c c e p t i n g some r e s p o n s i b i l i t y f o r t h e i r a c c i d e n t and t h e i r r e c o v e r y . They a l s o d e a l t w i t h t h e i r s i t u a t i o n by d e s c r i b i n g p r e v e n t a t i v e measures t h a t they c o u l d take t o a v o i d f u t u r e f a l l s . I've c e r t a i n l y h e s i t a t e d t o do t h i n g s . I t c e r t a i n l y s t a y s i n my mind. Yes, I f e e l t h a t I would l i k e t o do i t but pro b a b l y I ' l l s i t down a few minutes f i r s t , you know. But I t h i n k I am going t o have t o wear some proper shoes, when I get back on my f e e t . Something you know. I t i s not a good i d e a wearing bedroom s l i p p e r s so they say. These p r e v e n t a t i v e measures i n c l u d e d a v a r i e t y o f ways i n which p a r t i c i p a n t s c o u l d m a i n t a i n c o n t r o l over t h e i r own a c t i o n s as w e l l over o b j e c t s i n t h e i r environment. C l e a r l y p a r t i c i p a n t s ' coping s t r a t e g i e s r e l a t e d t o the f a l l event were aimed a t r e e s t a b l i s h i n g t h e i r sense o f c o n t r o l and t a k i n g whatever measures they c o u l d t o ensure another f a l l would not occur. 57 But the main t h i n g i s . . . how can I l i v e so t h a t I w i l l cause the l e a s t t e a r and wear because I never want t o go through t h i s a g a i n you see. Copinq w i t h the H o s p i t a l i z a t i o n Experience C e r t a i n events t h a t o c c u r r e d d u r i n g p a r t i c i p a n t s ' h o s p i t a l i z a t i o n p e r i o d f u r t h e r enhanced t h e i r p e r c e p t i o n s o f l o s s o f c o n t r o l and t h r e a t e n e d t h e i r s e l f - e s t e e m . Forces which s i g n i f i c a n t l y i n f l u e n c e d the p a r t i c i p a n t s ' coping behaviours i n c l u d e d t h e i r own s e l f - c o n c e p t and the a c t i o n s o f a number o f d i f f e r e n t h e a l t h p r o f e s s i o n a l s . P a r t i c i p a n t s ' c o p i n g s t r a t e g i e s i n v o l v e d perseverance and s e l f - r e l i a n c e where p o s s i b l e and the acceptance o f support when necessary. P a r t i c i p a n t s ' s e l f - c o n c e p t proved t o be a major f o r c e a f f e c t i n g t h e i r a b i l i t y t o cope and t o m a i n t a i n t h e i r sense o f s e l f - e s t e e m . T h e i r p r i d e i n t h e i r a b i l i t y t o per s e v e r e and be s e l f - r e l i a n t was obvious. I t h i n k (I have coped) a l l r i g h t as f a r as... I mean I am a person who can cope w i t h a n y t h i n g i f I have t o . That's the way I f e e l . But I have always s a i d , I can do an y t h i n g I want t o . I have too, you know. Because I w i l l p e r s e v e r e t o do i t you know. 58 I was strong. My mother didn't believe i n molly coddling. You know, i f anything happened you, you got better yourself as well as you could without doctors. A c t i v e l y p a r t i c i p a t i n g i n physiotherapy was one means by which a l l p a r t i c i p a n t s attempted to regain elements of control and reaffirm t h e i r sense of self-esteem. P a r t i c i p a t i o n i n physiotherapy required that they r e l y upon t h e i r own a b i l i t y to persevere. They devoted a great deal of energy and e f f o r t to t h e i r physiotherapy regimes and r e l i g i o u s l y adhered to the physiotherapists' recommendations. Participants depended upon other people only when they were unable to do i t themselves. The women frequently referred to the assistance they received from t h e i r roommates. One of the young women who went over from the f i r s t h o s p i t a l with me, she only needed a l i t t l e b i t more therapy and so on ' t i l she could go out. So she sort of t r o t t e d around and would do l i t t l e things f o r us. It was common for p a r t i c i p a n t s to express t h e i r 59 f r u s t r a t i o n r e g a r d i n g t h e i r i n t e r a c t i o n s w i t h a number o f h e a l t h p r o f e s s i o n a l s . P a r t i c i p a n t s p e r c e i v e d t h a t they were not always t r e a t e d w i t h the r e s p e c t t h a t they deserved. One p a r t i c i p a n t shared the d e t a i l s o f a p a r t i c u l a r l y u p s e t t i n g n u r s e - p a t i e n t i n t e r a c t i o n . A f t e r d e s c r i b i n g the i n c i d e n t she s a i d : I don't t h i n k t h a t i s n u r s i n g , myself. And I agree they have got a l l kinds t o put up wit h . I agree w i t h t h a t . But i t i s not c a l l e d f o r you know. But I d i d n ' t l i k e t o speak up. I t wasn't my p l a c e . The women chose t o cope w i t h these s i t u a t i o n s by a v o i d i n g c o n f r o n t a t i o n s o r n e g a t i v e i n t e r a c t i o n s . However, the women d i d not permit these i n t e r a c t i o n s t o s h a t t e r t h e i r s e l f - e s t e e m . I n s t e a d they attempted t o t h i n k p o s i t i v e l y by d e l i b e r a t e l y choosing not t o dw e l l on elements o f t h e i r s i t u a t i o n over which they p e r c e i v e d they had no c o n t r o l . They then f o c u s e d t h e i r energy on comparing themselves w i t h o t h e r people who more i n c a p a c i t a t e d than themselves. And I t h i n k too, I t h i n k b e i n g i n h o s p i t a l w i t h those, w i t h o t h e r people. I t h i n k s e e i n g people who r e a l l y are so much worse o f f than myself and 60 were going through an awful l o t o f pain...And then s e e i n g t h i s , you know, j u s t makes me, makes one f e e l . W e l l o f course I am conscious o f t h i s . Everyday I go out and I always seem t o see somebody who i s worse o f f . You know, you see somebody w i t h t h e i r cane or t h e i r walker a whe e l c h a i r you know, t h i s s o r t o f t h i n g . And you t h i n k , you know, how much b e t t e r o f f you are . . . W e l l you know, you j u s t t h i n k t h a t you should j u s t s o r t o f count your b l e s s i n g s . Thus p a r t i c i p a n t s r e l i e d upon the power o f p o s i t i v e t h i n k i n g t o r e s t o r e t h e i r sense o f s e l f - e s t e e m and weaken t h e i r n e g a t i v e thoughts. They d i d t h i s by d e l i b e r a t e l y choosing t o not d w e l l upon elements o f t h e i r s i t u a t i o n over which they p e r c e i v e d they had no c o n t r o l and by comparing themselves w i t h o t h e r people. P a r t i c i p a n t s m aintained t h e i r p o s i t i v e a t t i t u d e by f i n d i n g ways t o g i v e back t o o t h e r s . The women t y p i c a l l y consented t o p a r t i c i p a t i n g i n the r e s e a r c h p r o j e c t i f i t would "help o t h e r o l d l a d i e s l i k e myself". T h e r e f o r e , t h i s coping behaviour s e r v e d a du a l purpose i n t h a t i t a s s i s t e d p a r t i c i p a n t s t o f e e l 61 u s e f u l and he l p e d them t o make sense o f t h e i r h i p f r a c t u r e e x p e r i e n c e . In summary i t was apparent t h a t p a r t i c i p a n t s coped w i t h t h e i r h o s p i t a l i z a t i o n experience by a v o i d i n g c o n f r o n t a t i o n , b e i n g as s e l f - r e l i a n t as p o s s i b l e , t h i n k i n g p o s i t i v e l y and m a i n t a i n i n g a p o s i t i v e a t t i t u d e . Copinq w i t h the Post d i s c h a r g e Experience The women exp e r i e n c e d a c e r t a i n amount o f f r u s t r a t i o n and decreased s e l f - e s t e e m as they were unable t o l i v e up t o t h e i r e x p e c t a t i o n s o f themselves f o l l o w i n g d i s c h a r g e . They a l s o r e f e r r e d t o a number o f f e a r s and concerns t h a t they had r e l a t e d t o t h e i r l e v e l o f dependence, the exte n t o f t h e i r r e c o v e r y and the p o t e n t i a l f o r another t r a u m a t i c event t o occur. These f e a r s and f r u s t r a t i o n s c o n t r i b u t e d t o t h e i r p e r c e p t i o n s o f l o s s o f c o n t r o l . However, p a r t i c i p a n t s d e s c r i b e d a r e p e r t o i r e o f coping behaviours t h a t a s s i s t e d them t o r e g a i n a sense o f c o n t r o l and r e e s t a b l i s h t h e i r s e l f -esteem. The c a t e g o r i e s were s i m i l a r t o the ones used t o d e a l w i t h the women's h o s p i t a l i z a t i o n e x p e r i e n c e w i t h one e x c e p t i o n . The category o f a v o i d i n g c o n f r o n t a t i o n was not f e a t u r e d i n the women's 62 description of coping post discharge. Instead the women focused upon "taking action" while thinking p o s i t i v e l y and maintaining a p o s i t i v e attitude. The repertoire of coping behaviours r e l a t e d to taking action included, planning a timetable f o r resumption of a c t i v i t y , i d e n t i f y i n g progress, performing prescribed exercises and maintaining a balance between s e l f - r e l i a n c e and accepting support from others. Planning a timetable f o r resumption of a c t i v i t i e s was a coping behaviour that a l l p a r t i c i p a n t s engaged i n as a means of reestablishing some control over t h e i r recovery of mobility. But I don't expect to go out for a couple more weeks. Two or three more weeks. In addition to providing part i c i p a n t s with concrete goals and objectives t h i s process allowed the women to f e e l that they retained control over the pace at which they would resume t h e i r a c t i v i t i e s . P articipants also dealt with t h e i r f r u s t r a t i o n s regarding t h e i r l i m i t a t i o n s i n mobility by investing time and energy i n i d e n t i f y i n g as many v i s i b l e signs of progress as possible. 63 I can see an improvement every day...Even j u s t the f a c t t h a t you are bending your l e g a l i t t l e f u r t h e r back each day you know. Things t h a t I can do t h a t I c o u l d n ' t do the f i r s t day t h a t I came home and t r i e d t o do i t . I t h e l p e d me out. So I j u s t d i d i t ( e x e r c i s e s ) b e f o r e l u n c h today. And I can r e s i s t r i g h t up o f f t h i s c r a d l e now you know. I t h u r t s a l i t t l e but I can do i t you know and I can move my toes more and my ankle. So I have graduated t o the cane. And now I have graduated a l i t t l e more. I t was c l e a r l y e v i d e n t t h a t p a r t i c i p a n t s regarded the process o f i d e n t i f y i n g s i g n s o f pro g r e s s as a worthwhile investment o f energy. I d e n t i f y i n g , p r o g r e s s h e l p e d them t o f e e l p o s i t i v e about t h e i r s i t u a t i o n and demonstrated t o them t h a t they were g r a d u a l l y i n c r e a s i n g t h e i r c a p a c i t y f o r a c t i v i t y . A l l p a r t i c i p a n t s r e f e r r e d t o how they c o n t i n u e d t o c o n s i s t e n t l y perform the e x e r c i s e regimes p r e s c r i b e d f o r them by t h e i r p h y s i o t h e r a p i s t a f t e r they were d i s c h a r g e d home. 64 I got i t a l l on a piece of paper, what to do. Different exercises you know. And I do them, every day. Because i t strengthens the muscle then, you see. Then, then i t shouldn't hurt a f t e r a while. And I s t i l l exercise every morning...Well i t keeps you mobile f o r one thing and i t s to b u i l d up the muscles I guess more than anything. They viewed exercise as a means of a c t i v e l y pursuing t h e i r reestablishment of control over t h e i r l e v e l of mobility and independence. Participants emphasized that they viewed themselves as independent people who were used to r e l y i n g upon themselves and t h e i r a b i l i t y to persevere to make things happen. You make more progress when you do things yourself. Than i f somebody else does i t f o r you. You have to do these things. Following discharge when the women were unable to be as independent as they had previously anticipated they made i t cl e a r that they only accepted support from others when i t was absolutely necessary. 65 I am not one t h a t wants t o t r o u b l e anybody t o h e l p me i f I don't need i t . However, when i t became c l e a r t o p a r t i c i p a n t s t h a t i t would be i m p o s s i b l e f o r them t o manage independently a t home they r e c o g n i z e d t h a t they needed t o accept support from o t h e r s . Thus although p a r t i c i p a n t s p r e f e r r e d t o cope w i t h t h e i r s i t u a t i o n independently they r e c o g n i z e d the v a l u e i n a c c e p t i n g support when necessary. They d i d however, m a i n t a i n an element o f s e l f - r e l i a n c e by choosing t o keep thoughts about t h e i r i n j u r y and d i s a b i l i t y t o themselves. T h i s c o p i n g behaviour h e l p e d them t o m a i n t a i n s e l f - r e s p e c t and enhance t h e i r s e l f -esteem. I don't ever whine t o people o r go around b e i n g s u l k y and, and l o o k i n g f o r sympathy. You have got t o be s t r o n g enough. T h i s i s what has happened, i t s p a r t l y my f a u l t o r i t s p a r t l y , i t wasn't my f a u l t . But t h i s i s how i t i s . And you have t o cope w i t h i t and do the b e s t you can. But t h a t i s my a t t i t u d e and t h a t i s what I t r y t o do. They don't want t o be nuisance t o people. I t h i n k you f e e l you w i l l be a nuisance t o your daughter 66 o r your daughter-in-law, l i k e me. You do f e e l l i k e t h a t , when you are g e t t i n g o l d . So you don't always t e l l them e v e r y t h i n g . . . Yes you don't. You keep i t from them, u n l e s s i t i s necessary you see. A l l p a r t i c i p a n t s p e r c e i v e d t h a t p r i o r t o t h e i r f a l l they moved q u i c k l y and t o a c e r t a i n e x t e n t took t h i s a b i l i t y f o r granted. The r e a l i z a t i o n t h a t they had taken t h i s a b i l i t y f o r granted was made c l e a r t o them when they f a i l e d t o meet t h e i r e x p e c t a t i o n s r e g a r d i n g a r a p i d r e c o v e r y . The slower than a n t i c i p a t e d r e c o v e r y heightened t h e i r awareness o f t h e i r i n a b i l i t y t o rebound from a b o d i l y i n j u r y and caused them t o r e c o n s i d e r t h e i r b e l i e f s about aging. So anyway, I thought t h a t I would be walking but I guess w i t h my age they f i g u r e d w e l l , you know I shouldn't be h u r r y i n g t h i n g s up too much. P a r t i c i p a n t s coped w i t h t h e i r disappointment r e g a r d i n g t h e i r i n a b i l i t y t o q u i c k l y resume t h e i r p r e v i o u s l e v e l o f f u n c t i o n i n g by r e c o n s i d e r i n g t h e i r b e l i e f s about the aging p r o c e s s . They were then a b l e t o a t t r i b u t e t h e i r slower than a n t i c i p a t e d r e c o v e r y as b e i n g due the t h e i r advancing age, a f a c t o r they had p r e v i o u s l y not c o n s i d e r e d . 67 Oh I get t i r e d at times but I suppose i t s to be expected as one gets older. The women were very cautious not to overexert themselves, always keeping i n mind that a strong p o t e n t i a l existed that the outcome of another f a l l could be much more devastating. Participants dealt with t h i s uncertainty by seeking advice and adhering to t h e i r surgeon's recommendations regarding prescribed l e v e l of a c t i v i t y and exertion and taking preventative measures. But, I don't know I think,I w i l l have to be considerably more cautious you know. But I am going about with t h i s (cane) s t i l l . I w i l l do so f o r a long time u n t i l i t i s r e a l l y healed. I know what i t i s now to take care of bones. Really you have to l e t them, I had to l e t them r e a l l y set and get r i g h t . At c e r t a i n times part i c i p a n t s focused on negative s t o r i e s they had heard about other people who d i d not f u l l y recover from t h e i r hip fracture. But to p u l l 68 themselves out from these d e p r e s s i v e thoughts they f o r c e d themselves t o t r y and t h i n k p o s i t i v e l y . They d i d t h i s by making p o s i t i v e comparisons, choosing t o focus on the people they knew who had succeeded. People who were back p a r t i c i p a t i n g i n t h e i r normal r o u t i n e s and a c t i v i t i e s o f d a i l y l i v i n g . T h i s h e l p e d them t o r e g a r d t h e i r c u r r e n t s i t u a t i o n as a temporary s e t back t h a t would be r e s o l v e d i n the f u t u r e . [R: Has f r a c t u r i n g your h i p a f f e c t e d your o u t l o o k on l i f e i n anyway?] No, I don't t h i n k so. I guess I don't know what t o expect. I t h i n k I know a number o f o t h e r s who have d i s l o c a t e d h i p s and f r a c t u r e s and they are dancing again. F o r some women l o o k i n g on the b r i g h t s i d e o f t h i n g s a s s i s t e d them t o a v o i d d w e l l i n g on aspects o f t h e i r s i t u a t i o n over which they p e r c e i v e d they had no c o n t r o l . W e l l t h e r e i s n o t h i n g you can do about i t , so ... you have t o look on the b r i g h t s i d e . These women chose t o t h i n k p o s i t i v e l y by emphasizing t h a t t h e i r c u r r e n t s i t u a t i o n was o n l y a temporary s e t back t h a t would be r e s o l v e d i n the f u t u r e . 69 As I say I am coping. And I know i t i s not going to be forever. Ya but I know i t i s gonna, i t i s going to get better. Not worse. For a l l participants, maintaining a p o s i t i v e attitude required that they d e l i b e r a t e l y choose not to think about worrisome aspects of t h e i r s i t u a t i o n . Well I never thought about not getting better. I just t r y to turn myself to something else to think about. There i s no use i n , no use about worrying about something that might never happen. Thus following discharge from hospi t a l , p a r t i c i p a n t s used a va r i e t y of coping strategies which helped them to regain elements of control and to view t h e i r s i t u a t i o n from a p o s i t i v e perspective. Participants attempted to regain control by planning a timetable f o r resumption of a c t i v i t i e s , i d e n t i f y i n g progress, performing prescribed exercises and maintaining a balance between s e l f - r e l i a n c e and accepting support 70 from others. P o s i t i v e thinking was achieved by looking on the bright side, viewing t h e i r lengthy recovery as a temporary set back and not dwelling on aspects of t h e i r s i t u a t i o n over which they perceived they had no control. Maintaining a p o s i t i v e attitude was achieved by keeping thoughts about t h e i r d i s a b i l i t y to themselves, readjusting t h e i r expectations i n an e f f o r t to come to terms with the perceived slowness of recovery and del i b e r a t e l y choosing not to think about worrisome aspects of t h e i r s i t u a t i o n . The presentation w i l l now focus upon a discussion of the general findings i n r e l a t i o n to pertinent l i t e r a t u r e . Discussion of the Findings This section provides a discussion of the research findings. Pertinent l i t e r a t u r e i s presented to help c l a r i f y and i l l u s t r a t e the key themes. The accounts of the study part i c i p a n t s provided a description of the meaningg of fr a c t u r i n g a hip to el d e r l y community-dwelling women. Loss of control was a common theme that characterized the o v e r a l l hip fracture experience. The loss of control threatened the e l d e r l y i n d i v i d u a l ' s self-esteem and caused them to 71 reevaluate t h e i r self-perceptions, b e l i e f s about aging and t h e i r expectations f o r the future. The importance of maintaining control of one's l i f e i s supported by Seligman's (1975) contention that what produces self-esteem and a sense of competence i s not the absolute q u a l i t y of an experience, but the perception that one's own actions control the experience. P r i o r to t h e i r hip fractures these women l e d busy active l i v e s unencumbered by poor health or r e s t r i c t i o n s i n mobility or a c t i v i t y . They made numerous independent decisions, assumed various s o c i a l roles and r e s p o n s i b i l i t i e s and maintained control over t h e i r physical and s o c i a l environment. The act of f a l l i n g was physical evidence of a loss of control. These women described how they viewed the act of f a l l i n g and fr a c t u r i n g t h e i r hip as a demonstration that t h e i r bodies or some aspect of themselves had i n some way f a i l e d them. The women were unable to regain t h e i r sense of control by quickly and independently getting up and being able to casually dismiss the f a l l event as a very b r i e f and uncharacteristic demonstration of physical incompetence. However, 72 p a r t i c i p a n t s coped w i t h t h e i r f a l l by attempting t o i d e n t i f y a c a u s a l f a c t o r . T h i s i d e n t i f i c a t i o n p r o c e s s i s commonly r e f e r r e d t o i n the l i t e r a t u r e as c a u s a l a t t r i b u t i o n ( K e l l e y , 1971; T a y l o r , 1983). F u r s t e n b e r g (1988) suggests t h a t the i d e n t i f i c a t i o n o f a cause f o r the occurrence o f an u n p r e d i c t a b l e event i s a means by which i n d i v i d u a l s r e g a i n a sense o f c o n t r o l over t h e i r s i t u a t i o n . I n d i v i d u a l s who are unable t o i d e n t i f y a cause f o r the event do not cope w i t h t h e i r s i t u a t i o n as e f f e c t i v e l y as those who do (Furstenberg, 1988). T h i s c o u l d e x p l a i n why s e v e r a l o f the women co n t i n u e d t o r e f l e c t upon the u n p r e d i c t a b l e event u n t i l they determined a l o g i c a l cause. In t h i s way they were a b l e t o r e g a i n a sense o f c o n t r o l over t h e i r t r a u m a t i c event w h i l e p r e s e r v i n g t h e i r s e l f - e s t e e m and l e v e l o f p e r c e i v e d competence. P a r t i c i p a n t s a l s o i d e n t i f i e d themselves as b e i n g 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 r e s p o n s i b l e f o r t h e i r f a l l . T h i s d e c l a r a t i o n o f s e l f - r e s p o n s i b i l i t y appears t o be another means by which the women attempted t o master the f a l l event. Wortman (1976) maintains t h a t i n d i v i d u a l s who assume some r e s p o n s i b i l i t y f o r t h e i r s i t u a t i o n o r engage i n se l f - b l a m e do so t o f a c i l i t a t e 73 the b e l i e f that they have control over t h e i r l i v e s . Wortman also believes that i f in d i v i d u a l s perceive they have some control or r e s p o n s i b i l i t y f o r p r e c i p i t a t i n g t h e i r accident that they may also perceive they have control over furthering t h e i r recovery and preventing future accidents. This b e l i e f was supported by the research findings as parti c i p a n t s a c t i v e l y sought to further t h e i r recovery process while ensuring they adhered to preventative practices to decrease the l i k e l i h o o d of another f a l l . Being admitted to the hospital f o r treatment of t h e i r hip fracture meant that f o r an unknown period of time, these women were no longer able to be as active, as independent or as much i n control of t h e i r s i t u a t i o n as they desired. I t i s generally accepted that people who are admitted to acute care f a c i l i t i e s , regardless of t h e i r age, are vulnerable and stressed. Ryan and Robinson-Smith (1990) suggest that f o r the h o s p i t a l i z e d el d e r l y , the l e v e l of stress and v u l n e r a b i l i t y i s increased by a number of i n t e r a c t i n g factors including diminished functioning, sensory decline, unfamiliar surroundings and separation from s i g n i f i c a n t others. These factors contributed to the p a r t i c i p a n t s ' l e v e l of 74 stress and perceptions of loss of control. Not being informed of what was occurring also contributed to part i c i p a n t s perceptions of loss of control. This f i n d i n g i s supported by M i l l e r ' s (1983) observation that factors such as unexplained delays, waiting i n various h o s p i t a l departments and brisk, i n s e n s i t i v e verbal interactions by s t a f f are often the most s i g n i f i c a n t causes of powerlessness and loss of control f o r h o s p i t a l i z e d patients. Participants made numerous references to situations i n which they interpreted the actions of health professionals as demonstrating a lack of respect f o r them as in d i v i d u a l s . A l l nine i n d i v i d u a l s who were approached by the researcher as po t e n t i a l study candidates, expressed varying l e v e l s of anxiety with regard to t h e i r discharge planning. At the i n i t i a l recruitment interviews a number of the partic i p a n t s conveyed to the researcher t h e i r concern and uncertainty regarding when and where they were being discharged and what to expect once they got there. I t i s c l e a r that these women were not privy to information that d i r e c t l y affected them. Being unaware of t h i s information put these women i n an i n f e r i o r power 75 p o s i t i o n . I t c o u l d be i n t e r p r e t e d t h a t the f a c t t h a t these p a t i e n t s chose t o r e l a y t h e i r concerns t o the r e s e a r c h e r as opposed t o the s t a f f on the u n i t meant t h a t they d i d not f e e l they were i n a p o s i t i o n t o take c o n t r o l and seek answers t o t h e i r q u e s t i o n s . Perhaps they sensed t h a t the balance o f power was not i n t h e i r f a v o u r and t h e r e f o r e they chose not t o c o n f r o n t the s t a f f r e g a r d i n g t h i s l a c k o f c o l l a b o r a t i o n (Lanceley, 1985; Y u r i c k , S p i e r & Robb, 1984). Through impersonal i n t e r a c t i o n , adherence t o sta n d a r d procedures and l a c k o f c o l l a b o r a t i o n h e a l t h p r o f e s s i o n a l s u n i n t e n t i o n a l l y conveyed t o p a r t i c i p a n t s t h a t they were more concerned w i t h the completion o f t h e i r t a s k s than w i t h the i n d i v i d u a l p a t i e n t . B u z z e l l and Gibbon (1991) b e l i e v e t h a t d e p e r s o n a l i z a t i o n occurs when s t a f f f a i l t o r e c o g n i z e the i n d i v i d u a l ' s r i g h t and need t o be i n c o r p o r a t e d i n t o the d e c i s i o n making p r o c e s s . They b e l i e v e t h a t the tendency o f both m e d i c a l and n u r s i n g s t a f f t o d e p e r s o n a l i z e p a t i e n t s i s a f a c t o r t h a t c o n t r i b u t e s not o n l y t o t h e i r l o s s o f c o n t r o l but t o the development o f powerlessness and the e r o s i o n o f i n d i v i d u a l i z e d c a r e . 76 P a r t i c i p a n t s v o l u n t e e r e d t h e i r p e r c e p t i o n s r e g a r d i n g the n u r s i n g care they r e c e i v e d . I t i s i n t e r e s t i n g t o note t h a t although p a r t i c i p a n t s g e n e r a l l y p e r c e i v e d t h e i r n u r s i n g care as b e i n g s a t i s f a c t o r y , they a l l commented on how the a c t i o n s o f at l e a s t two or t h r e e nurses conveyed a l a c k o f r e s p e c t f o r t h e i r p a t i e n t s as i n d i v i d u a l s . The nurses' a c t i o n s had the p o t e n t i a l t o n e g a t i v e l y a f f e c t the women's sense o f s e l f - e s t e e m . The nurses were q u i t e understanding. There were o n l y o r two t h a t , and they were on n i g h t duty and I t h i n k they were v e r y t i r e d . That I f e l t were, they were k i n d o f abrupt w i t h people. But not wi t h me. I had no o c c a s i o n t o t a l k t o them. But I t h i n k they were coming t o the end o f t h e i r l o n g day probably. Some o f i t i s pro b a b l y due t o a shortage i n t h e i r s t a f f . T r y i n g t o be f a i r . But i t s t i l l doesn't excuse, you know the impersonal, v e r y c o l d a t t i t u d e o f some o f them. I t was common f o r p a r t i c i p a n t s t o f i n d a reason t h a t would e x p l a i n o r r a t i o n a l i z e the nurses' c u r t 77 behaviour. Being overworked o r tremendously busy was a common e x p l a n a t i o n . Other p a r t i c i p a n t s p e r c e i v e d t h a t c e r t a i n nurses h u r r i e d through t h e i r p r o v i s i o n o f care and s e t t l i n g r o u t i n e so t h a t they would not have t o be bothered by the " o l d women" f o r a prolonged p e r i o d . These statements were g l a r i n g l y obvious examples o f how p a r t i c i p a n t s ' i n t e r p r e t a t i o n s o f nurses' busy and rushed behaviour l e d t o a decrease i n t h e i r s e l f -esteem. Y u r i c k and c o l l e a g u e s (1984) suggest t h a t nurses and p a t i e n t s use each o t h e r ' s behaviour t o r e i n f o r c e o r change t h e i r s e l f - e s t e e m and e v e n t u a l l y t h e i r s e l f - c o n c e p t . The authors b e l i e v e t h a t p a t i e n t s observe what the nurse does and then i n t e r p r e t s t he nurse's behaviour as an i n d i c a t i o n o f what the nurse t h i n k s o f them as p a t i e n t s . The p a t i e n t s take t h i s i n t e r p r e t a t i o n f u r t h e r t o the p o i n t o f b e l i e v i n g t h a t i f t h i s i s what the nurse t h i n k s o f them then t h i s i s what they must be. Y u r i c k and c o l l e a g u e s (1984) suggest t h a t nurses have the same thought p r o c e s s but the nurse's s e l f - e s t e e m i s enhanced w h i l e the p a t i e n t ' s i s decreased. Nurses' s e l f - e s t e e m i s enhanced because the balance o f power i s i n t h e i r favour. These women repeatedly made reference to the f a c t that they t r i e d to avoid confrontational interactions or interactions where they may be seen i n a negative l i g h t . This finding i s supported i n the l i t e r a t u r e (Kenny, 1990). Skipper (1965) reports that patients refrained from communicating with nurses due to t h e i r fear of receiving a negative reaction from them and a perception that nurses were always too busy and overworked. Gottesman and Brody (1975) reported that nursing s t a f f regard "good patients" as being quiet. According to Davies (1968) the expectations of the nurse may assume great importance fo r the h o s p i t a l i z e d patient. Consequently, patients may s t r i v e to behave according to the nurses' expectations. I f the nurses' views are based on stereotyped b e l i e f s that associate age with i l l n e s s and dependency then they may expect "good e l d e r l y patients" to be passive and quiet. Considering these findings, i t would not be s u r p r i s i n g to f i n d that nurse-patient interactions occur infrequently and are considered by e l d e r l y i n d i v i d u a l s to be an added source of stress. As can be seen from the p a r t i c i p a n t s ' descriptions, patients are r e a d i l y attuned to the non-79 verbal messages implied by the actions of t h e i r care givers. As one pa r t i c i p a n t stated: You could r e a l l y pick out the dedicated ones by t h e i r attitude you know, when they came i n . C l e a r l y p a r t i c i p a n t s valued interactions with health professionals that were of a personal nature regardless of how b r i e f . These interactions conveyed to the patients that the professional cared about them as an i n d i v i d u a l . I think that doctors and nurses are a very busy l o t of people and i t i s kind of nice when they take the time to, to t a l k to people that way you know and say something. Participants' interactions with physiotherapists were consistently described as being p o s i t i v e , meaningful encounters that supported t h e i r self-esteem. Physiotherapists empowered these i n d i v i d u a l s by providing them with the resources they needed to regain a sense of control over t h e i r body's functioning. The physiotherapists were sensi t i v e to the pa r t i c i p a n t s ' fear of f a l l i n g and took constructive measures to a s s i s t them to deal with these fears. They not only helped p a r t i c i p a n t s increase t h e i r strength and 80 mobility but taught them s k i l l s which would help them move safely and decrease the l i k e l i h o o d of f a l l i n g . Thus, the physiotherapists demonstrated t h e i r s e n s i t i v i t y to what was r e a l l y meaningful and of utmost importance to the pa r t i c i p a n t s . Participants described how they maintained t h e i r p o s i t i v e attitude by comparing themselves with people who were more incapacitated than themselves. M i l l e r (1983) refers to t h i s process of comparing s e l f with others as a " r e a l i t y surveillance", a cognitive task i n which the i n d i v i d u a l searches fo r clues that confirm that the maintenance of hope i s fe a s i b l e . When the in d i v i d u a l confirms that i t i s r e a l i s t i c to maintain hope, he or she fe e l s encouraged and invests more time and energy i n s t r i v i n g f o r success and recovery. The need to give back to others was a common theme fo r a number of pa r t i c i p a n t s . Giving to someone else was a means of maintaining a p o s i t i v e attitude and attempting to regain-elements of t h e i r s o c i a l role and feelings of competence. The importance of maintaining a p o s i t i v e attitude i s supported by Cox (1990) who believes that adaptation and su r v i v a l are associated with a p o s i t i v e s e l f - a t t i t u d e and with a continued 81 sense of ongoing usefulness. This desire to be useful and to give back to others was evident during the i n i t i a l recruitment interviews. As was previously described, i t was common for study p a r t i c i p a n t s to consent to being i n the study i f " i t would help other ol d ladies l i k e myself". Being able to i d e n t i f y at lea s t one b e n e f i c i a l or at lea s t p o s i t i v e outcome from t h e i r hip fracture also a s s i s t e d p a r t i c i p a n t s to make sense of t h e i r experience. Being able to persevere through a s i t u a t i o n was considered to be a valuable a b i l i t y and a source of pride f o r these women. Their natural reaction was to re l y upon themselves i f at a l l possible to avoid having to depend upon, or perhaps bother other people. Perseverance and s e l f - r e l i a n c e were common attri b u t e s which appeared to f a c i l i t a t e p a r t i c i p a n t s ' f e e l i n g of being competent and i n control. Drevdahl (1989) contends that from childhood people learn that with perseverance and hard work most of l i f e ' s obstacles can be overcome or controlled. As people get older t h e i r capacity to deal with adversity declines. As older people experience losses that reduce t h e i r power over t h e i r physical and psychological environments t h e i r 82 a b i l i t y t o m a i n t a i n independence d e c l i n e s (Drevdahl, 1989). When i t was a b s o l u t e l y necessary p a r t i c i p a n t s chose t o accept support form o t h e r s . They d i d , however, m a i n t a i n an element o f s e l f - r e l i a n c e by choosing t o keep thoughts about t h e i r d i s a b i l i t y t o themselves. P a r t i c i p a n t s p r i d e d themselves on t h e i r a b i l i t y t o persevere by not burdening o t h e r s w i t h t h e i r w o r r i e s and concerns. By a v o i d i n g t h i s t emptation they f e l t more p o s i t i v e about themselves and perhaps more capable. Being a b l e t o be mobile and independent were a b i l i t i e s t h a t these women had p r e v i o u s l y taken f o r granted. They were a b i l i t i e s t h a t p a r t i c i p a n t s equated w i t h b e i n g a hea l t h y , a c t i v e and e n e r g e t i c s e n i o r . F o l l o w i n g the h i p f r a c t u r e , the p a r t i c i p a n t s ' l e v e l s o f independence were s e v e r e l y l i m i t e d . R e s t r i c t i o n s i n m o b i l i t y , range o f motion and ease o f movement n e c e s s i t a t e d a c e r t a i n degree o f e n f o r c e d dependence. T h i s unexpected and presumably temporary l o s s o f independence r e p r e s e n t e d a f u r t h e r l o s s o f c o n t r o l and an a s s a u l t t o p a r t i c i p a n t s ' s e l f - e s t e e m . C u l b e r t and Kos (1971) s t a t e t h a t independence, o r the a b i l i t y t o 83 p r o v i d e f o r one's needs, i s the most important aim o f the m a j o r i t y o f e l d e r l y r e g a r d l e s s o f t h e i r s t a t e o f h e a l t h . They suggest t h a t the e l d e r l y may experience a sense o f c o n t r o l when independence i s achieved. The l o s s o f independence may p r e c i p i t a t e f e e l i n g s o f powerlessness o r the p e r c e p t i o n o f l o s s o f c o n t r o l . T h i s c o n t e n t i o n proved t o be a r e a l i t y f o r study p a r t i c i p a n t s . The p e r c e i v e d slowness o f t h e i r r e c o v e r y prompted these women t o r e e v a l u a t e t h e i r e x p e c t a t i o n s and s e l f -p e r c e p t i o n s . F o r many i t was t h e i r most dramatic experience o f coming t o terms w i t h t h e i r e x p e c t a t i o n s and t h e i r b e l i e f s about aging. The thought o f an incomplete r e c o v e r y was a source o f f u r t h e r a n x i e t y . Incomplete r e c o v e r y was i n c o n s i s t e n t w i t h the p a r t i c i p a n t s ' s e l f - c o n c e p t . They viewed themselves as a c t i v e , v i t a l e l d e r l y women w i t h no v i s i b l e d i s a b i l i t i e s . The women's knowledge r e g a r d i n g o t h e r people's poor r e c o v e r y from h i p f r a c t u r e generated a c e r t a i n amount o f s e l f - d o u b t and a n x i e t y r e g a r d i n g t h e i r own recover y . P a r t i c i p a n t s ' statements i n d i c a t e d t h a t they r e c o g n i z e d the f a c t t h a t an incomplete r e c o v e r y o f p h y s i c a l f u n c t i o n i n g would j e o p a r d i z e t h e i r 84 a b i l i t y t o remain i n the community. They o f t e n made r e f e r e n c e t o o t h e r people who f o l l o w i n g h i p f r a c t u r e were too d e b i l i t a t e d o r t o o f r i g h t e n e d t o walk as much as they had p r i o r t o t h e i r f r a c t u r e and i n some cases were then unable t o r e t u r n t o t h e i r d w e l l i n g i n the community. These e l d e r l y women had numerous concerns r e l a t e d t o t h e i r m e d i c a l c o n d i t i o n and t h e i r f e a r o f f a l l i n g . Yet these concerns were e i t h e r not d i r e c t l y brought t o the a t t e n t i o n o f the s t a f f o r the s t a f f f a i l e d t o r e c o g n i z e and address the p a t i e n t s ' u n d e r l y i n g f e a r s and a n x i e t i e s . T h i s meant t h a t these women co n t i n u e d t o experience a n x i e t y p r o v o k i n g thoughts t h a t hampered t h e i r l e v e l o f a c t i v i t y and the q u a l i t y o f t h e i r l i v e s . In g e n e r a l p a r t i c i p a n t s expected t h a t they would e v e n t u a l l y be a b l e t o r e t u r n t o t h e i r p r e v i o u s l e v e l o f f u n c t i o n i n g , although they would be approaching l i f e a t a slower pace. I expect t o do p r e t t y much the same t h i n g s as I was doing. Maybe c u t t i n g down a l i t t l e b i t and not going a t i t so v i g o r o u s l y . And a l s o I am an o l d e r person and t h e r e f o r e you don't expect t o be r u s h i n g and t e a r i n g around as i f you were younger. 85 L e a r n i n g t o be more c a u t i o u s by t a k i n g l i f e a t a slower pace d i d not appear t o come n a t u r a l l y t o these women. They needed t o make a conscious e f f o r t t o go more s l o w l y and t o not take t h e i r m o b i l i t y f o r granted. I t r e q u i r e d t h a t they r e a d j u s t t h e i r e x p e c t a t i o n s and s e l f - p e r c e p t i o n s so t h a t they were congruent w i t h the l i m i t a t i o n s imposed by t h e i r a g ing b o d i e s . The U.B.C. Model f o r Nur s i n g In the f o l l o w i n g s e c t i o n the U.B.C. Model f o r Nu r s i n g i s used t o f u r t h e r h i g h l i g h t the f i n d i n g s o f the study. The U.B.C. Model f o r N u r s i n g i s a t h e o r e t i c a l framework t h a t can be used as a means o f c o n c e p t u a l i z i n g the i n d i v i d u a l i n t h i s study. In t h i s model the i n d i v i d u a l i s viewed as a b e h a v i o u r a l system made o f nine subysystems: a c h i e v i n g , a f f e c t i v e , ego-v a l u a t i v e , e x c r e t o r y , i n g e s t i v e , p r o t e c t i v e , r e p a r a t i v e , r e s p i r a t o r y and s a t i a t i v e . F r a c t u r i n g a h i p i s c o n s i d e r e d an u n p r e d i c t a b l e event t h a t a f f e c t s the e n t i r e b e h a v i o u r a l system and r e q u i r e s the development o f s u i t a b l e c o p i n g behaviours t o s a t i s f y b a s i c human needs, achieve s t a b i l i t y and reach o p t i m a l h e a l t h . Each subsystem i s composed o f an i n n e r 86 p e r s o n a l r e g i o n w h i c h i n c l u d e s a need and a b i l i t i e s t o meet t h a t need as w e l l as a p s y c h o l o g i c a l environment w h i c h i n c l u d e s f o r c e s and a g o a l . F r a c t u r i n g a h i p i s c o n s i d e r e d a f o r c e t h a t has meaning f o r t h e p s y c h o l o g i c a l environment o f one o r more subsystems. The impact o f f r a c t u r i n g a h i p was most r e a d i l y a p p a r e n t i n t h e a c h i e v i n g , a f f e c t i v e , e g o - v a l u a t i v e , p r o t e c t i v e and r e p a r a t i v e subsystems. Lack o f g o a l achievement was e v i d e n t i n t h e a c h i e v i n g subsystem due t o t h e f a c t t h a t f a l l i n g was i n c o n s i s t e n t w i t h t h e p a r t i c i p a n t s ' s e l f - e x p e c t a t i o n s and l e v e l o f p e r c e i v e d competence. The l e n g t h y p r o c e s s o f r e c o v e r y was a l s o i n c o n s i s t e n t w i t h p a r t i c i p a n t s ' e x p e c t a t i o n s and was a n e g a t i v e f o r c e e f f e c t i n g p a r t i c i p a n t s ' f e e l i n g s o f accomplishment and t h e i r need f o r m a stery. The f a c t t h a t p a r t i c i p a n t s were s t i l l dependent upon o t h e r s p o s t d i s c h a r g e was i n c o n s i s t e n t w i t h t h e i r e x p e c t a t i o n s and caused them a g r e a t d e a l o f d i s t r e s s . T h i s s t r e s s n e g a t i v e l y e f f e c t e d p a r t i c i p a n t s ' a f f e c t i v e subsystem as t h e y f e l t u n d u l y dependent upon o t h e r s w h i c h was an i n d i c a t i o n o f l a c k o f g o a l achievement w i t h i n t h i s subsystem. 87 P a r t i c i p a n t s ' i n a b i l i t y t o c o n s i s t e n t l y l i v e up t o t h e i r own performance e x p e c t a t i o n s n e g a t i v e l y a f f e c t e d t h e i r s e l f - e s t e e m . T h e i r p e r c e p t i o n t h a t t h e y were a t t i m e s t r e a t e d w i t h a l a c k o f r e s p e c t w h i l e i n h o s p i t a l a l s o c o n t r i b u t e d t o a l a c k o f g o a l achievement i n t h e e g o - v a l u a t i v e subsystem. P a r t i c i p a n t s ' e x p e r i e n c e d numerous f e a r s and c o n c e r n s r e l a t e d t o t h e i r l e n g t h y r e c o v e r y p e r i o d , t h e e x t e n t o f t h e i r r e c o v e r y and p o t e n t i a l t h a t t h e y c o u l d e x p e r i e n c e another, p o s s i b l y more d e v a s t a t i n g f a l l . The f a c t t h a t p a r t i c i p a n t s s t i l l e x p e r i e n c e d t h e s e overwhelming f e a r s p o s t d i s c h a r g e i s e v i d e n c e o f l a c k o f system i n t e g r i t y and i n d i c a t e s a l a c k o f g o a l achievement w i t h i n t h e p r o t e c t i v e subsystem. The h i p f r a c t u r e s e v e r e l y l i m i t e d p a r t i c i p a n t s ' c a p a c i t y f o r a c t i v i t y . The f a c t t h a t t h e y e x p e r i e n c e d an u n a n t i c i p a t e d d e c r e a s e i n t h e i r l e v e l o f energy p o s t d i s c h a r g e p r e v e n t e d them from b e i n g as a c t i v e and i ndependent as t h e y d e s i r e d . T h i s i n a b i l i t y t o b a l a n c e t h e p r o d u c t i o n o f energy w i t h energy e x p e n d i t u r e i n d i c a t e d a l a c k o f g o a l achievement w i t h r e s p e c t t o t h e r e p a r a t i v e subsystem. The U.B.C. Model f o r N u r s i n g (1980) s t a t e s t h a t the nurse's r o l e i s t o n u r t u r e the i n d i v i d u a l d u r i n g u n p r e d i c t a b l e events such as f r a c t u r i n g a h i p . Nursing's r o l e i n n u r t u r i n g i n d i v i d u a l s i s f o u r - f o l d : t o f o s t e r , p r o t e c t , s u s t a i n and t e a c h . D i r e c t i o n f o r f u l f i l l i n g t h i s r o l e i s p r o v i d e d by the Model's c o n c e p t u a l i z a t i o n o f the i n d i v i d u a l . N u r s i n g i n t e r v e n t i o n s , the medium f o r n u r t u r i n g , focus on coping behaviours r e l a t e d t o subsystem g o a l achievement. I n t e r v e n t i o n s are aimed a t d i s c o u r a g i n g o r e l i m i n a t i n g coping behaviours a s s o c i a t e d w i t h l a c k o f g o a l achievement and p o t e n t i a l l a c k o f g o a l achievement, and encouraging and d e v e l o p i n g those behaviours capable o f m a i n t a i n i n g and promoting g o a l achievement. Change i n r e l a t i o n t o a c l i e n t ' s coping behaviours can be f a c i l i t a t e d by t h r e e i n t e r v e n t i o n modes: r e d u c t i o n o f n e g a t i v e f o r c e s , maintenance and s t r e n g t h e n i n g o f p o s i t i v e f o r c e s and f o s t e r i n g the development o f c o g n i t i v e and e x e c u t i v e a b i l i t i e s (U.B.C. Model f o r Nursing, 1980). N u r s i n g i n t e r v e n t i o n s t o a s s i s t p a t i e n t s t o cope w i t h the h i p f r a c t u r e experience w i l l be d e s c r i b e d i n the f o l l o w i n g chapter. 89 Chapter Summary In t h i s chapter the f i n d i n g s o f the study were f i r s t p r e s e n t e d and then d i s c u s s e d . Throughout the p r e s e n t a t i o n the f i n d i n g s were i l l u s t r a t e d w i t h v e r b a t i m e x c e r p t s from p a r t i c i p a n t ' s accounts. P e r t i n e n t l i t e r a t u r e was a l s o p r e s e n t e d t o h e l p c l a r i f y and i l l u s t r a t e the key themes. General c o n c l u s i o n s r e g a r d i n g the meaning o f f r a c t u r i n g a h i p f o r e l d e r l y community-dwelling women were p r e s e n t e d i n the D i s c u s s i o n s e c t i o n . I t was determined t h a t the o v e r a l l e x perience o f f r a c t u r i n g a h i p was c h a r a c t e r i z e d by a p e r v a s i v e sense o f l o s s o f c o n t r o l . The l o s s o f c o n t r o l t h r e a t e n e d the e l d e r l y women's s e l f - e s t e e m and caused them t o r e e v a l u a t e t h e i r s e l f - p e r c e p t i o n s , ' b e l i e f s about aging and e x p e c t a t i o n s f o r the f u t u r e . The f i n d i n g s were then c o n s i d e r e d i n r e l a t i o n t o s e l e c t e d subsystems i n the U.B.C. Model f o r N u r s i n g . In the next chapter a summary o f the study i s p r e s e n t e d and i m p l i c a t i o n s o f the f i n d i n g s and recommendations f o r n u r s i n g p r a c t i c e , e d u c a t i o n and r e s e a r c h a re d i s c u s s e d . 90 CHAPTER FIVE SUMMARY, IMPLICATIONS AND RECOMMENDATIONS FOR NURSING This f i n a l chapter presents a summary of the study. In addition, implications of the findings and recommendations fo r nursing practice, education and research are discussed. Summary Hip fractures are a leading cause of d i s a b i l i t y among the e l d e r l y and one of the acute health events that may lead to permanent changes i n the l e v e l of functioning of the e l d e r l y i n d i v i d u a l (Furstenberg, 1986). With people l i v i n g longer and with the expected increase i n the numbers of seniors, nurses i n a v a r i e t y of care settings w i l l increasingly f i n d themselves caring f o r e l d e r l y i n d i v i d u a l s with hip fractures. There i s a dearth of l i t e r a t u r e which describes what i t i s l i k e f o r e l d e r l y people to fracture a hip. Therefore, t h i s study explored the meaning of f r a c t u r i n g a hip from the e l d e r l y i n d i v i d u a l ' s perspective. S p e c i f i c a l l y the study focused on the e l d e r l y woman's perspective, i n recognition of the f a c t that approximately 75% of the people who fracture t h e i r hip are women. Giorgi's phenomenological approach was 91 used to develop a description of the meaning of f r a c t u r i n g a hip according to the perceptions of six e l d e r l y community-dwelling women. The findings indicate that the o v e r a l l experience of f r a c t u r i n g a hip i s characterized by a pervasive sense of loss of control. The loss of control threatens the e l d e r l y i n d i v i d u a l ' s self-esteem and causes them to reevaluate t h e i r self-perceptions, b e l i e f s about aging and t h e i r expectations f o r the future. Certain forces impacted upon par t i c i p a n t s ' perceptions of loss of control and the way they coped with t h e i r s i t u a t i o n . These forces included: p a r t i c i p a n t s ' expectations regarding recovery, t h e i r self-perceptions, the actions of a v a r i e t y of d i f f e r e n t health care professionals, a v a i l a b i l i t y of family and support persons, the fear of f a l l i n g and concerns regarding the extent of t h e i r recovery. Participants expressed a strong b e l i e f i n t h e i r a b i l i t y to p o s i t i v e l y influence and therefore exert some control over t h e i r r e h a b i l i t a t i o n . The coping behaviours they described involved making sense of the f a l l , taking action, thinking p o s i t i v e l y and 9 2 maintaining a p o s i t i v e attitude. The process of making sense involved determining a cause fo r the f a l l . In doing t h i s p a r t i c i p a n t s attempted to regain elements of control over t h e i r s i t u a t i o n . Taking action referred to coping behaviours that p a r t i c i p a n t s engaged i n as a means of f e e l i n g a c t i v e l y involved i n t h e i r recovery process, thereby regaining some element of control and independence. The repertoire of coping behaviours rel a t e d to taking action included, declaring r e s p o n s i b i l i t y f o r t h e i r f a l l , adhering to recommended guidelines, planning a timetable f o r resumption of a c t i v i t i e s , i d e n t i f y i n g progress, performing prescribed exercises, persevering, accepting support when necessary and learning to be more cautious. Thinking p o s i t i v e l y was a coping behaviour that a l l p a r t i c i p a n t s engaged i n as a response to threats to t h e i r self-esteem and as a means of f e e l i n g l e s s negative about t h e i r s i t u a t i o n . Thinking p o s i t i v e l y involved three d i f f e r e n t strategies, d e l i b e r a t e l y choosing not to dwell on elements of t h e i r s i t u a t i o n over which they had no control, looking toward the future to focus on recovery and making comparisons with others. These strategies a s s i s t e d p a r t i c i p a n t s to 93 b e l i e v e t h a t t h e i r s i t u a t i o n would improve and ser v e d t o weaken the t h r e a t o f f u r t h e r l o s s . M a i n t a i n i n g a p o s i t i v e a t t i t u d e i n v o l v e d t h r e e d i f f e r e n t s t r a t e g i e s , r e a d j u s t i n g e x p e c t a t i o n s i n an e f f o r t t o come t o terms w i t h t h e i r b e l i e f s about aging, g i v i n g back t o o t h e r s and keeping thoughts t o one's s e l f . Engaging i n these s t r a t e g i e s a s s i s t e d p a r t i c i p a n t s t o m a i n t a i n t h e i r s e l f - r e s p e c t and r e a f f i r m t h e i r s e l f - e s t e e m . The f o l l o w i n g s e c t i o n d e s c r i b e s the i m p l i c a t i o n s o f the f i n d i n g s o f the study f o r n u r s i n g p r a c t i c e , e d u c a t i o n and r e s e a r c h . I m p l i c a t i o n s and Recommendations f o r N u r s i n g N u r s i n g P r a c t i c e The p r o v i s i o n o f s e n s i t i v e , meaningful i n d i v i d u a l i z e d n u r s i n g care c o u l d mean the d i f f e r e n c e between p a t i e n t s ' s e l f - i m p o s e d r e s t r i c t i o n i n a c t i v i t y and t h e i r r e t u r n t o en j o y a b l e and p r o d u c t i v e l i v e s . To p r o v i d e i n d i v i d u a l i z e d c a r e the nurse must c o l l a b o r a t e w i t h the p a t i e n t and take the time t o develop i n s i g h t i n t o and an understanding of, the meaning t h a t f r a c t u r i n g a h i p has f o r each i n d i v i d u a l . T h i s i n s i g h t i s d e r i v e d from a thorough assessment t h a t begins a t admission. I t i s important f o r nurses 94 planning care, that they consider the patients' i n d i v i d u a l biopsychosocial variables as well as t h e i r unique power resources, coping st y l e s and opinions. A thorough nursing assessment enables the nurse to discover the patient's unique perspective and c a p a b i l i t i e s . I t also allows the nurse to determine what can be done to f a c i l i t a t e the patient's perceptions of control. Other suggestions that f a c i l i t a t e patients' perceptions of control and the provision of. i n d i v i d u a l i z e d nursing care follow. Not being informed of what to expect appeared to have been the most anxiety provoking experience f o r these e l d e r l y women while i n ho s p i t a l . Not knowing what and when things were going to happen contributed to t h e i r perception of loss of control. Nurses may be better able to provide q u a l i t y care by seeking to empower t h e i r patients. One very simple means of empowering people i s to provide them with the information they need to f e e l i n control of t h e i r environment from the time they are admitted to the hos p i t a l u n t i l they are discharged home. Unlike patients who are admitted to the h o s p i t a l f o r e l e c t i v e surgery, the patient with a hip fracture 95 does not have the chance t o have her f e a r s a l l a y e d by c a r e f u l p r e p a r a t i o n and p a t i e n t t e a c h i n g . The h i p f r a c t u r e e x p e r i e n c e i s a t r a u m a t i c and u n p r e d i c t a b l e event. The nurse i n the emergency department i s i n a p o s i t i o n t o i d e n t i f y and decrease the p a t i e n t ' s a n x i e t y and prepare her t o be a c t i v e l y i n v o l v e d i n her r e c o v e r y . Brown (1982) b e l i e v e s t h a t i n a d d i t i o n t o e x p l a i n i n g procedures, r o u t i n e s and what t o expect i n the r e c o v e r y room t h a t the emergency room nurse s h o u l d ask p a t i e n t s what they are most w o r r i e d about. A s k i n g an open-ended q u e s t i o n l i k e t h i s can uncover any f e a r s the p a t i e n t may harbour. Once u n d e r l y i n g f e a r s are i d e n t i f i e d the nurse i n the emergency room can then a s s i s t the p a t i e n t t o adequately d e a l w i t h these f e a r s . F o l l o w i n g surgery i t i s important t h a t the nurses on the ward keep the p a t i e n t informed and c o l l a b o r a t e w i t h the p a t i e n t r e g a r d i n g t h e i r o v e r a l l p l a n o f c a r e . R e c o g n i z i n g the e x i s t e n c e o f i n d i v i d u a l d i f f e r e n c e s and the r e a c t i o n s o f p a t i e n t s t o h o s p i t a l i z a t i o n and h i p f r a c t u r e i s o f primary importance. Taking the time t o e x p l o r e what the experience may mean t o o l d e r p a t i e n t s i n terms o f f e a r o f death, e x p e c t a t i o n s r e g a r d i n g recovery, a n x i e t y over a n t i c i p a t e d procedures o r 96 a s s o c i a t i o n w i t h p a s t experiences p r o v i d e s b a s e l i n e data from which nurses can develop an i n d i v i d u a l i z e d care p l a n (Ryan & Robinson-Smith, 1990). Nurses need t o a s s i s t e l d e r l y p a t i e n t s w i t h h i p f r a c t u r e s t o make sense o f t h e i r f a l l and t h e i r h o s p i t a l s t a y . F u r s t e n b e r g (1988) suggests t h a t i n r e c o u n t i n g and f r e q u e n t l y r e p e a t i n g t h e i r f a l l s t o r y , i n d i v i d u a l s c r e a t e an o r d e r e d account o f the event, thereby h e l p i n g them t o r e e s t a b l i s h a sense o f c o n t r o l over the event i t s e l f . Ryan and Robinson-Smith (1990) suggest t h a t encouraging p a t i e n t s t o f i n d meaning i n t h e i r h o s p i t a l s t a y i s a v a l i d way o f f a c i l i t a t i n g the p a t i e n t ' s p e r c e p t i o n o f c o n t r o l . I t t h e r e f o r e seems a p p r o p r i a t e t o suggest t h a t nurses c o n s c i o u s l y make time t o enquire about the p a t i e n t ' s experience w i t h f r a c t u r i n g a h i p , not o n l y a t the time o f admission but d u r i n g the p e r i o d o f r e c o v e r y . To t r u l y understand the s i g n i f i c a n c e o f the experience f o r p a t i e n t s , i t i s e s s e n t i a l t h a t d u r i n g t h e i r i n t e r a c t i o n s , nurses a c t i v e l y l i s t e n and a t t e n d t o the u n d e r l y i n g meanings e v i d e n t i n the p a t i e n t s ' n a r r a t i v e s . The meaning o f the h o s p i t a l s t a y i s a l s o formed i n p a r t by the behaviour and a t t i t u d e s o f the h e a l t h care 97 p r o f e s s i o n a l s w i t h whom p a t i e n t ' s i n t e r a c t (Ryan & Robinson-Smith, 1990). T h e r e f o r e nurses need t o be cogn i z a n t o f the a f f e c t o f t h e i r behaviour on t h e i r e l d e r l y p a t i e n t s . I t i s w e l l documented i n the l i t e r a t u r e t h a t e l d e r l y people are the t a r g e t s o f many f a l s e l a b e l s , myths and s t e r e o t y p e s . They are c h a r a c t e r i z e d as b e i n g r i g i d , i n f l e x i b l e , i n t o l e r a n t and s e n i l e ( M i l l e r , 1983). P e r p e t u a t i o n o f these myths has the p o t e n t i a l t o d e s t r o y an i n d i v i d u a l ' s s e l f -esteem, cause i n f e r i o r i t y and induce powerlessness. T h e r e f o r e nurses s h o u l d be aware o f t h e i r own a t t i t u d e s toward the e l d e r l y and the i n f l u e n c e these a t t i t u d e s may have upon t h e i r p r o v i s i o n o f care. When i n t e r a c t i n g w i t h p a t i e n t s , nurse s h o u l d a c t i v e l y work t o uncover u n d e r l y i n g a n x i e t i e s p a t i e n t s may have r e l a t e d t o t h e i r r e c o v e r y p r ocess, a c t i v i t y l e v e l and concerns r e g a r d i n g d i s c h a r g e . P r o v i d i n g p a t i e n t s w i t h i n f o r m a t i o n r e g a r d i n g the pro c e s s and the mi l e s t o n e s i n v o l v e d i n r e c u p e r a t i n g from h i p f r a c t u r e h e l p s them t o be informed so t h a t they are b e t t e r a b l e t o cope w i t h the leng t h y p e r i o d o f recover y and w i t h any problems t h a t may a r i s e . The p a t i e n t s are then b e t t e r equipped t o be r e a l i s t i c i n forming e x p e c t a t i o n s 98 r e l a t e d to the speed of recovery. At the same time being informed of what to expect reduces the fear and anxiety associated with the unknown. I t takes away a ce r t a i n degree of uncertainty and f a c i l i t a t e s the maintenance of control and self-esteem. Ensuring patients have s u f f i c i e n t s o c i a l support avai l a b l e to help them adequately cope a f t e r discharge i s another means by which nurses can help e l d e r l y hip fracture patients to recover. Schaefer, Anderson and Simms (1990) reported that a number of factors need to be present before patients f e e l ready to be discharged home. They must perceive that t h e i r strength and energy are increasing, t h e i r emotions are returning to normal, they are independent i n a c t i v i t i e s of d a i l y l i v i n g and the doctor has provided assurance that i t i s safe f o r them to leave the h o s p i t a l . V a l i d a t i n g the patient's perceptions of these factors should be a nursing intervention that occurs regularly as a part of the discharge planning process. The patient can share her perceptions regarding her discharge needs with the s t a f f i n informal discharge planning rounds that are organized by the nursing unit s t a f f . By i n v i t i n g these e l d e r l y women to attend these rounds they are able to 99 be p a r t o f the d e c i s i o n making p r o c e s s . T h i s involvement conveys the s t a f f ' s r e s p e c t f o r the p a t i e n t s as capable human bein g s . The nature o f the h e l p i n g r e l a t i o n s h i p e s t a b l i s h e d by the nurse w i l l i n f l u e n c e the p a t i e n t ' s s e l f - e s t e e m . T h i s r e l a t i o n s h i p should be c h a r a c t e r i z e d by c a r i n g , concern, empathy, u n c o n d i t i o n a l acceptance and r e s p e c t (Raskin & Rogers, 1989). Nurses' responsiveness t o the i n d i v i d u a l s ' unique a b i l i t i e s enhances the p a t i e n t s ' f e e l i n g s o f worth. I t communicates t o the p a t i e n t the nurse i s i n t e r e s t e d i n the p a t i e n t as a whole person and not j u s t as a body w i t h a h i p f r a c t u r e . Nurses need t o i n c r e a s e t h e i r emphasis on t h e i r r e l a t i o n s h i p s k i l l s w i t h e l d e r l y i n d i v i d u a l s . T h i s can be accomplished through the use o f s p e c i a l l y designed workshops and p a t i e n t care conferences. Implementing e d u c a t i o n a l s t r a t e g i e s t h a t emphasize the s p e c i a l needs o f the e l d e r l y i s a c o n s t r u c t i v e means o f promoting p a t i e n t care. To f a c i l i t a t e r e c o v e r y from h i p f r a c t u r e , nurses sh o u l d i n c r e a s i n g l y focus on p r o v i d i n g r e h a b i l i t a t i v e as opposed t o c u s t o d i a l care f o r t h e i r e l d e r l y p a t i e n t s . Primary n u r s i n g care o r the implementation 100 of case management for hip fractured patients may be useful methods that promote the provision of h o l i s t i c q u a l i t y care to these e l d e r l y i n d i v i d u a l s . A more collaborative approach between the h o s p i t a l and community-based health care services may also promote the provision of q u a l i t y care. I t would be advantageous fo r nurses to be p o l i t i c a l l y involved i n lobbying f o r s u f f i c i e n t funds and services to a s s i s t the e l d e r l y community-dwelling i n d i v i d u a l to recover from hip fracture at home as opposed to the h o s p i t a l . Given the appropriate community support patients who fracture t h e i r hip could be r e h a b i l i t a t e d i n t h e i r own environment where i t i s easier f o r them to f e e l i n control, competent and confident. Nursing Education It has been estimated that by the year 2031 the number of e l d e r l y persons w i l l more than t r i p l e (Robertson, Louis & Stadler, 1982). I t i s therefore e s s e n t i a l that new graduates be knowledgeable regarding the nursing care of the e l d e r l y . Since hip fractures are a leading cause of d i s a b i l i t y within the g e r i a t r i c population, i t would seem a l o g i c a l t o p i c f o r educators to discuss with t h e i r students. As the findings of the 101 study i n d i c a t e , the h i p f r a c t u r e experience i n v o l v e s m u l t i p l e l o s s e s and r e q u i r e s the e l d e r l y i n d i v i d u a l t o use a v a r i e t y o f coping behaviours. I t t h e r e f o r e i s a u s e f u l p r o t o t y p e t o d i s c u s s the n u r s i n g care and management o f the e l d e r l y i n d i v i d u a l . I t i s i m p e r a t i v e t h a t students understand t h a t the care o f the e l d e r l y needs t o be h o l i s t i c care i n nature and be d e l i v e r e d i n a way t h a t conveys r e s p e c t f o r the e l d e r l y p a t i e n t as a person r a t h e r than as a medical diagnoses. The p a r t i c i p a n t s ' d e s c r i p t i o n s i l l u s t r a t e the need f o r nurses t o possess not o n l y t e c h n i c a l but w e l l developed r e l a t i o n s h i p s k i l l s . I n c r e a s e d emphasis on t h e r a p e u t i c communication w i t h i n the n u r s i n g c u r r i c u l u m i s j u s t i f i e d . T h i s can be accomplished through the use o f s p e c i a l l y designed workshops and p a t i e n t care conferences. A nurse's a t t i t u d e can impact the d e l i v e r y o f care t h e r e f o r e , i t i s important f o r student nurses t o be aware o f t h e i r own v a l u e s and a t t i t u d e s toward the e l d e r l y . T h i s awareness can be a c h i e v e d through the use o f v a l u e s c l a r i f i c a t i o n e x e r c i s e s . P r e j u d i c i a l a t t i t u d e s toward the e l d e r l y need t o be e x p l o r e d and myths and misconceptions d i s p e l l e d . T h i s e x p l o r a t i o n can be f a c i l i t a t e d through the p r o c e s s o f 102 d i s c u s s i o n d u r i n g seminar s e s s i o n s . Role p l a y i n g i s a v a l u a b l e s t r a t e g y t h a t can be used d u r i n g seminar s e s s i o n s t o s e n s i t i z e student nurses t o f a c t o r s i n the environment t h a t c o n t r i b u t e t o the e l d e r l y i n d i v i d u a l s ' p e r c e p t i o n o f powerlessness. A v a r i e t y o f e d u c a t i o n a l and e x p e r i e n t i a l games use r o l e p l a y i n g as a means o f i n c r e a s i n g students' awareness r e g a r d i n g the need t o a s s i s t e l d e r l y p a t i e n t s t o r e g a i n elements o f c o n t r o l and overcome powerlessness. R e l a t i n g these e d u c a t i o n a l s t r a t e g i e s t o focus on the care and management o f the p a t i e n t w i t h a h i p f r a c t u r e not o n l y a s s i s t s student t o understand the experience o f f r a c t u r i n g a h i p but a s s i s t s them t o b e t t e r understand the e x p e r i e n c e o f e l d e r l y i n d i v i d u a l s i n g e n e r a l . N u r s i n g Research There i s an overwhelming need f o r r e s e a r c h on the n u r s i n g care o f the e l d e r l y , p a r t i c u l a r l y r e s e a r c h r e l a t e d t o the p s y c h o s o c i a l aspects o f c a r e . Loss o f c o n t r o l , independence and s e l f - e s t e e m were predominant f i n d i n g s which c h a r a c t e r i z e d the h i p f r a c t u r e e x p e r i e n c e . Research which focuses on i n t e r v e n t i o n s t h a t f a c i l i t a t e e l d e r l y i n d i v i d u a l s ' p e r c e p t i o n s o f 103 c o n t r o l , t h e i r s e l f - c a r e a b i l i t y and the enhancement o f t h e i r s e l f - e s t e e m are e s s e n t i a l . From the study i t would appear t h a t the i n s t i t u t i o n o f primary care n u r s i n g , case management o r community-based r e h a b i l i t a t i o n f o r p a t i e n t s w i t h h i p f r a c t u r e s may be o f b e n e f i t i n terms o f both c o s t e f f e c t i v e n e s s and o v e r a l l p a t i e n t outcome. F u r t h e r i n v e s t i g a t i o n i n t o these care d e l i v e r y systems i s r e q u i r e d . Research from the nurse's p e r s p e c t i v e , on what i t i s l i k e t o care f o r e l d e r l y i n d i v i d u a l s w i t h h i p f r a c t u r e s would a l s o p r o v i d e u s e f u l i n f o r m a t i o n and i n s i g h t i n t o care d e l i v e r y . F u r t h e r i n v e s t i g a t i o n i n t o the meaning o f f r a c t u r i n g a h i p w i l l i n c r e a s e our understanding about what the experience i s l i k e and w i l l p r o v i d e d i r e c t i o n f o r nurses t o a s s i s t p a t i e n t s t o cope w i t h t h e i r h i p f r a c t u r e . The meaning o f f r a c t u r i n g a h i p may w e l l be i n f l u e n c e d by gender and community-dwelling s t a t u s . T h e r e f o r e r e s e a r c h i n t o the meaning o f f r a c t u r i n g a h i p f o r men and f o r i n d i v i d u a l s who do not r e s i d e i n the community would be j u s t i f i e d . 104 Concluding Remarks It seems appropriate to conclude t h i s report by focusing on the nurse's role i n the exploration of the meaning of f r a c t u r i n g a hip to e l d e r l y community-dwelling i n d i v i d u a l s . Ryan and Robinson-Smith (1990) contend that "the extent to which patients are supported i n the search f o r meaning marks the degree to which nurses practice the art of the profession. Our a b i l i t y as nurses to step out of our own r e a l i t y and consider the world of our patients i s at the core of our professional selves" (p. 19). I t i s what allows us to provide relevant, meaningful and i n d i v i d u a l i z e d care by s t a r t i n g from "where the patient i s " . R e f e r e n c e s American Psychological Association (1983). Publication  manual of the American Psychological Association (3rd ed.). Washington, DC: Author. Anderson, J.M., E l f e r t , H., & L a i , M. (1989). Ideology i n the c l i n i c a l context: chronic i l l n e s s , e t h n i c i t y and the discourse on normalization. Sociology of Health and I l l n e s s , 11(3), 253-278. Auerbach, I., & Gerber, A. (1976). Implications of the  changing age structure of the Canadian population (Perceptions 2). Ottawa: Science Council of Canada. Bauer, G., Hansson, L., Lidgren, L., Stromqvist, B., & Thorngren, K. (1985). Comprehensive care of hip fractures. American Academy of Orthopedic  Surgeons. S c i e n t i f i c Exhibit: Las Vegas. Beals, R.K. (1972). Survival following hip fracture. Journal of Chronic Disease, 25, 235-244. Brown, S.L. (1982). Avoiding post-op p i t f a l l s with hip fracture patients. RN, 4_5, 49-55. Buzzell, M., & Gibbon, M. (1991). Personhood. The  Canadian Nurse, 8J7(6), 32-33. Catanzaro, M. (1988). Using q u a l i t a t i v e a n a l y t i c a l techniques. In N.F. Woods & M. Catanzaro (Eds.), Nursing research: Theory and practice (pp. 437-456). Washington, DC: The C.V. Mosby Company. Ceder, L., Thorngren, K., & Wallden, B. (1980). Prognostic indicators and early home r e h a b i l i t a t i o n i n e l d e r l y patients with hip fractures. C l i n i c a l Orthopedics and Related  Research, 152(9), 173-184. Cobey, J . C , Cobey, J.H., Conant, L., Weil, U.H., & Greenwald, W.F. (1976). Indicators of recovery from fractures of the hip. C l i n i c a l  Orthopedics, 117, 258-262. 106 C o l b e r t , D.S., & O'Muircheartaigh, I. (1976). M o r b i d i t y a f t e r h i p f r a c t u r e and assessment o f some c o n t r i b u t o r y f a c t o r s . I r i s h J o u r n a l o f  M e d i c a l Science, 145, 44-50. Cox, V. L. (1990). P s y c h o l o g i c a l adjustments a s s o c i a t e d w i t h the ag i n g p r o c e s s . N u r s i n g Homes, 39(2), 21-25. C u l b e r t , P., & Kos, B. (1971). Aging: C o n s i d e r a t i o n s f o r h e a l t h t e a c h i n g . N u r s i n g C l i n i c s o f North  America, 6, 605-614. Dahl, E. (1980). M o r t a l i t y and l i f e expectancy a f t e r h i p f r a c t u r e s . A c t a Orthopedica S c a n d i n a v i c a , 51, 163-170. Davies, R. W. (1968). P s y c h o l o g i c a l aspects o f g e r i a t r i c n u r s i n g . American J o u r n a l o f Nursing, 68, 802-804. Dougherty, E., Lyons, C , Powell, E., & Wofsy, N. (1984). Masters p r o f e s s i o n a l p r o j e c t . Ethnomedicine and Aging. Pennsylvania, P h i l a d e l p h i a : U n i v e r s i t y o f Pe n n s y l v a n i a . Drevdahl, D. (1989). Promoting power and c o n t r o l i n the e l d e r l y c l i e n t . J o u r n a l o f Post A n a e s t h e s i a  Nursing, 4(1), 22-26. Dubrovskis, V., & Wells, D. (1988). Hip f r a c t u r e i n the e l d e r l y . The Canadian Nurse, 5, 20-22. F i e l d , P. A., & Morse, J . M. (1985). N u r s i n g r e s e a r c h :  The a p p l i c a t i o n o f Q u a l i t a t i v e approaches. R o c k v i l l e , Maryland: Aspen P u b l i s h e r s . F i t t s , W. T., Lehr, H. G., Schor, S., & Roberts, B. (1959). L i f e expectancy a f t e r f r a c t u r e o f the h i p . Surgery, Gynecology and O b s t e t r i c s , 108, 7-12. Furstenberg, A. L. (1986). E x p e c t a t i o n s about outcome f o l l o w i n g h i p f r a c t u r e among o l d e r people. S o c i a l  Work i n H e a l t h Care, 11(4), 33-47. 107 Furstenberg, A. L. (1988). At t r i b u t i o n s of control by hip fracture patients. Health and So c i a l Work, 13(1), 43-48. Gaudine, A. (1986). Not another fractured hip! The  Canadian Nurse, 6, 35-36. Giorgi, A. (1985). Sketch of a psychological phenomenological method. In A. Giorgi (Ed.), Phenomenology and Psychological Research (pp. 8-22). Pittsburgh, PA: Duquesne University Press. Gottesman, I., & Brody, S. J. (1975). Cited i n Kenny, T. (1990). Erosion of i n d i v i d u a l i t y i n care of el d e r l y people i n hos p i t a l - an al t e r n a t i v e approach. Journal of Advanced Nursing, 15(5), 571-576. Jensen, S., & Bagger, J. (1982). Long-term s o c i a l prognosis a f t e r hip fractures. Acta Othropedica  Scandinavica, 53, 97-101. Johnell, O., Nilsson, B., Obrant, K., & Sernbo, I. (1984). Age and sex patterns of hip fracture -changes i n 30 years. Acta Orthopedica  Scandinavica, 55, 290-292. Katz, S., Ford, A., Heiple, K., & Newill, V. (1964). Studies of i l l n e s s i n the aged: Recovery a f t e r fracture of the hip. Journal of Gerontology, 19, 285-293. Kelley, H. H. (1971). A t t r i b u t i o n s i n s o c i a l i n t e r a c t i o n . Morristown, New Jersey: General Learning Corporation. Kelsey, J. L., & Hoffman, S. (1987). Risk factors f o r hip fracture. The New England Journal of  Medicine, 2(2), 404-405. Kenny, T. (1990).. Erosion of i n d i v i d u a l i t y i n care of el d e r l y people i n h o s p i t a l - an a l t e r n a t i v e approach. Journal of Advanced Nursing, 15, 571-576. 108 Knaack, P. (1984). Phenomenological research. Western  Journal of Nursing Research, 6(1), 107-111. Lanceley, A. (1985). Use of c o n t r o l l i n g language i n the r e h a b i l i t a t i o n of the e l d e r l y . Journal of  Advanced Nursing, 10, 125-135. Lewinnek, G., Kelsey, J., White, A., & Kreiger, N. (1980). The si g n i f i c a n c e and a comparative analysis of the epidemiology of hip fractures. C l i n i c a l Orthopedics and Related Research, 152(9), 35-43. Melton, L. J., & Riggs, B. L. (1983). Epidemiology of age-related fractures. In L. V. A v i o l o i (Ed.), The Osteoporotic Syndrome (pp. 45-72). New York: Grune & Stratton. M i l l e r , C. W. (1978). Survival and ambulation following hip fracture. Journal of Bone and Joint  Surgery, 60, 930-933. M i l l e r , J. F. (1983). Coping with chronic i l l n e s s :  Overcoming powerlessness. Philadelphia: F.A. Davis Company. Mossey, J., Mutran, E., Knott, K., & Craik, R. (1989). Determinants of recovery 12 months a f t e r hip fracture: The importance of psychosocial factors. American Journal of Public Health, 79(3), 279-287. Oi l e r , C. (1982). The phenomenological approach to nursing research. Nursing Research, 31, 49-63. Oi l e r , C. (1986). Phenomenology: The method. In P. Munhall, & C. O i l e r (Eds.), Nursing Research- A  Qualitative Perspective, (pp. 69-84). Norwalk, Connecticut: Appleton-Century-Crofts. Omery, A. (1983). Phenomenology: A method f o r nursing research. Advances i n Nursing Science, 5, 49-63. Raskin, J. R., & Rogers, C. R. (1989). Person-centred therapy. In R.J. C o r s i n i & D. Wedding (Eds.), Current psychotherapies> (pp.155-194). Itasca, I l l i n o i s : F.E. Peacock Publishers Inc. 109 Reinhard, S. C. (1988). Case managing community services f o r hip fractured elders. Orthopaedic  Nursing, 7(5), 43-49. Rieman, D. J. (1986). The es s e n t i a l structure of a caring i n t e r a c t i o n . In P. Munhall & C. O i l e r (Eds.), Nursing Research - A Qua l i t a t i v e  Perspective (pp. 85-108). Norwalk, Connecticut: Appleton-Century-Crofts. Robertson, D., Louis, C , & Stadler, L. (1982). G e r i a t r i c assessment unit i n a teaching h o s p i t a l . Canadian Medical Association Journal, 126(5), 1060-1064. Ryan, M. C , & Robinson-Smith, G. (1990). What does i t mean? Making sense of the hospital experience. Journal of Gerontological Nursing, 16(8), 17-20. Sandelowski, M. (1986). The problem of r i g o r i n q u a l i t a t i v e research. Advances i n Nursing  Science, 8(3), 27-37. Schaefer, A. L., Anderson, J. E., & Simms, L. M. (1990). Are they ready? Discharge planning f o r older s u r g i c a l patients. Journal of Gerontological Nursing, 16(10), 16-19. Seligman, M. (1975). Helplessness: On depression,  development and death. San Francisco: W.H. Freeman & Company. Sikorski, J., Davis, N., & Senior, J. (1985). The rapid t r a n s i t system f o r patients with fractures of proximal femur. B r i t i s h Medical Journal, 290(2), 439-443. Skipper, J. K. (1965). Social i n t e r a c t i o n and patient  care. Philadelphia: J.B. Lippincott Company. Spiegelberg, H. (1970). On some human uses of phenomenology. In F. J. Smith (Ed.), Phenomenology i n perspective (pp 16-31). The Hague: Martinus Ni j h o f f . 110 S t a t i s t i c s Canada. (1991). Number o f p a t i e n t s 65 years o f age and over d i s c h a r g e d from Canadian h o s p i t a l s w i t h a d i a g n o s i s o f f r a c t u r e o f the neck o f the femur. 1987-1988. P e r s o n a l communication. T a y l o r , S. E. (1983). Adjustment t o t h r e a t e n i n g events. American P s y c h o l o g i s t , 38, 1161-1173. U.B.C. School o f Nursing. (1980). The UBC Model f o r Nursing. Vancouver, BC: Author. Wortman, C. B. (1976). Causal A t t r i b u t i o n s and p e r s o n a l c o n t r o l . In J . H. Harvey, W. J . Ickes, & R. F. K i d d (Eds.), New d i r e c t i o n s i n a t t r i b u t i o n  r e s e a r c h (pp. 23-52). H i l l s d a l e , New J e r s e y : Erlbaum A s s o c i a t e s . Y u r i c k , A., S p i e r , B., & Robb, S. (1984). The aged  person and the n u r s i n g p r o c e s s . Norwalk, C o n n e c t i c u t : A p p l e t o n - C e n t u r y - C r o f t s . I l l APPENDICES 112 Appendix A I n t r o d u c t o r y L e t t e r t o P o t e n t i a l V o l u n t e e r s My name i s P a u l i n e U r s i c and I am a r e g i s t e r e d nurse doing Graduate work a t the U n i v e r s i t y o f B r i t i s h Columbia's School o f Nursing. I would l i k e t o l e a r n more about what a woman goes through when she has f r a c t u r e d her h i p . I f you agree t o p a r t i c i p a t e i n t h i s study e n t i t l e d " The Meaning o f F r a c t u r i n g a Hip f o r E l d e r l y Community D w e l l i n g Women", I w i l l arrange a convenient time t o i n t e r v i e w you f o r approximately one hour i n your home. During the i n t e r v i e w , I w i l l ask you q u e s t i o n s about your e x p e r i e n c e . I f you wish you may r e f u s e t o answer any q u e s t i o n s . The i n t e r v i e w w i l l be tape recorded. Names o r i d e n t i f y i n g i n f o r m a t i o n w i l l not be used i n the tape o r i n the t r a n s c r i p t s . The o n l y people who might l i s t e n t o the tape o r see the t r a n s c r i p t i o n w i l l be myself, my t y p i s t and my t h e s i s a d v i s o r s . E x c e r p t s o f the i n t e r v i e w might be i n c l u d e d i n w r i t t e n r e p o r t s o f my study, but no names or i d e n t i f y i n g f a c t o r s w i l l appear. When my study i s f i n i s h e d the tapes w i l l be erased. 113 A few weeks a f t e r t h e f i r s t i n t e r v i e w , I may r e q u e s t a second o r t h i r d i n t e r v i e w w h i c h would be co n d u c t e d i n t h e same manner as t h e f i r s t . Whether you p a r t i c i p a t e i n t h i s s t u d y o r n o t , w i l l i n no way j e o p a r d i z e y o u r n u r s i n g o r m e d i c a l c a r e . You a r e f r e e t o , w i t h d r a w from t h e s t u d y a t any t i m e , t o r e f u s e t o answer any q u e s t i o n and t o w i t h d r a w any i n f o r m a t i o n you w i s h from t h e s t u d y . I f you have any q u e s t i o n about t h e s t u d y , p l e a s e f e e l f r e e t o c o n t a c t me a t my home phone number. Yours s i n c e r e l y , P a u l i n e U r s i c , RN, BSN (phone number) 114 A p pendix B  Consent Form U n i v e r s i t y o f B r i t i s h Columbia S c h o o l o f N u r s i n g THIS I S TO CERTIFY THAT I , HEREBY, agree t o p a r t i c i p a t e as a v o l u n t e e r i n t h e r e s e a r c h s t u d y e n t i t l e d "The Meaning o f F r a c t u r i n g a H i p f o r E l d e r l y Community- D w e l l i n g Women" co n d u c t e d by P a u l i n e U r s i c . I agree t o be i n t e r v i e w e d a maximum o f t h r e e t i m e s and t o have t h e i n t e r v i e w ( s ) t a p e r e c o r d e d . I u n d e r s t a n d t h a t a t t h e c o m p l e t i o n o f t h e r e s e a r c h , t h e t a p e s w i l l be e r a s e d and t h a t my name w i l l n o t be a s s o c i a t e d w i t h any p u b l i s h e d o r u n p u b l i s h e d m a t e r i a l . I u n d e r s t a n d t h a t I am f r e e t o r e f u s e t o answer any q u e s t i o n s d u r i n g t h e i n t e r v i e w and t o have any p a r t o f t h e t a p e d i n t e r v i e w e r a s e d upon r e q u e s t . I a l s o u n d e r s t a n d t h a t I am f r e e t o wit h d r a w my c o n s e n t and t e r m i n a t e my p a r t i c i p a t i o n a t any t i m e , w i t h o u t p e n a l t y . 115 I have been g i v e n t h e o p p o r t u n i t y t o ask whatever q u e s t i o n s I d e s i r e , and a l l such q u e s t i o n s have been answered t o my s a t i s f a c t i o n . I have r e c e i v e d a copy o f t h e l e t t e r o f i n f o r m a t i o n and t h e c o n s e n t form. S i g n a t u r e : P a r t i c i p a n t P a u l i n e U r s i c (ph. number) Date Date 116 Appendix C  Sample Questions f o r I n i t i a l I n t e r v i e w P l e a s e t e l l me about f r a c t u r i n g your h i p ? What e f f e c t has f r a c t u r i n g your h i p had on your d a i l y l i f e ? How have you coped w i t h f r a c t u r i n g your h i p ? Has f r a c t u r i n g your h i p a f f e c t e d your o u t l o o k on l i f e i n any way? Has f r a c t u r i n g your h i p a f f e c t e d your e x p e c t a t i o n s f o r the f u t u r e ? I f so, how have your e x p e c t a t i o n s been a f f e c t e d ? 

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