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Hospital to home : perceived need for care and support Galloway, Sharon Eleanor 1991

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HOSPITAL TO HOME: PERCEIVED NEED FOR CARE AND SUPPORT By SHARON ELEANOR GALLOWAY B.N., The U n i v e r s i t y o f M a n i t o b a , 1976 MSN, The U n i v e r s i t y o f B r i t i s h C o l u m b i a , 1991 A THESIS SUBMITTED I N P A R T I A L FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE I N NURSING in THE FACULTY OF GRADUATE  STUDIES  (School of Nursing)  We a c c e p t t h i s  t h e s i s as c o n f o r m i n g  to the required  standard  THE UNIVERSITY OF B R I T I S H COLUMBIA S e p t e m b e r 1991 ©  Sharon  E l e a n o r G a l l o w a y , 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  NURSING  The University of British Columbia Vancouver, Canada Date  DE-6 (2/88)  1, mi  Abstract Falls  a r e a m a j o r h e a l t h p r o b l e m f o r o l d e r women.  B r i t i s h C o l u m b i a , women aged 75 y e a r s and o l d e r of  t h e t o t a l number o f i n d i v i d u a l s a d m i t t e d  a fall.  Falls  In  c o m p r i s e 85%  t o h o s p i t a l with  r e s u l t i n p h y s i c a l and p s y c h o l o g i c a l  consequences. A review of the l i t e r a t u r e on  falls  are epidemiological  that deal with on  i n d i c a t e s t h a t most  i n nature.  care  and s u p p o r t a s p e r c e i v e d  older for  purpose of t h i s study  home c a r e  i s to describe by women aged  75 y e a r s and  coordinators  from t h e H e a l t h  v a l i d a t e d , and/or d i s c o u n t e d  fall  Department.  interviews  g u i d e d by  T h e s e themes were i n subsequent  as both a s i g n i f i c a n t  analysis  verified,  interviews.  f i n d i n g s i n d i c a t e d t h a t t h e e l d e r l y women  life.  Eight  C e r t a i n themes emerged f r o m d a t a  were c o d e d a c c o r d i n g l y .  The  method.  were r e c r u i t e d t h r o u g h t h e l i a i s o n n u r s e s and  trigger questions.  their  t h e need f o r  human e x p e r i e n c e a s i t i s l i v e d .  women p a r t i c i p a t e d i n t h e r e p e a t e d  the  fall.  Phenomenology i s t h e chosen r e s e a r c h  method d e s c r i b e s Subjects  and  effect  r e t u r n i n g home t o l i v e a l o n e a f t e r a h o s p i t a l i z a t i o n  a fall.  This  and t h e i r  o f h e r need f o r c a r e and  support a f t e r h o s p i t a l i z a t i o n for a The  T h e r e a r e no s t u d i e s  t h e consequences o f the f a l l  t h e o l d e r woman's p e r c e p t i o n s  studies  and u n p r e d i c t a b l e  perceived  event i n  I t r e s u l t e d i n a change o f r o u t i n e as t h e y  ii  r e t u r n e d home t o l i v e women d e s c r i b e d their  self-esteem.  reciprocity  Use o f s o c i a l  social  were d i s c u s s e d  was one  behaviour  behaviour,  i n the friendships of elderly  implications f o rnursing  education  support  In describing this  a l s o concluded  i n using  A  were u s e d t o c o p e w i t h t h e t h r e a t s t o  was i m p o r t a n t  T h i s study  difficulties The  self-esteem, particularly to  f e e l i n g s o f i n d e p e n d e n c e , a c t i v i t y , and autonomy.  u s e d by a l l t h e women.  women.  I n response t o t h i s change, t h e  threats to their  v a r i e t y of behaviours their  alone.  t h a t t h e r e were numerous  supports  from a f o r m a l  r e s e a r c h , p r a c t i c e , and  i n l i g h t o f these  iii  findings.  program.  Table of Contents Page Abstract  i i  Table of Contents  iv  Acknowledgements  vi  C h a p t e r One: I n t r o d u c t i o n Introduction Background t o the Problem T h e o r e t i c a l Framework Statement o f the Problem Purpose Research Question S i g n i f i c a n c e f o r the P r o f e s s i o n D e f i n i t i o n o f Terms Fall Hospitalization I n t r o d u c t i o n t o the Methodology Assumptions Limitations Summary  1 1 2 5 7 7 7 8 8 8 8 8 9 10 10  C h a p t e r Two: C r i t i c a l R e v i e w o f t h e L i t e r a t u r e Introduction Falls S o c i a l Support P e r c e i v e d Need f o r C a r e and S u p p o r t Summary  12 12 12 23 26 31  Chapter Three: Methodology Introduction Methodological Issues Truth Value Applicability Consistency Neutrality P r o c e d u r e f o r P r o t e c t i o n o f Human R i g h t s S e l e c t i o n of P a r t i c i p a n t s Selection Criteria Recruitment Procedure C h a r a c t e r i s t i c s of the P a r t i c i p a n t s Data C o l l e c t i o n Data A n a l y s e s Summary  33 33 33 34 34 35 36 37 38 38 38 40 42 43 44  iv  Page Chapter Four: Data A n a l y s i s Introduction F a l l as a S i g n i f i c a n t E v e n t Health Care System Self-Esteem Independence Activity Autonomy Adaptability Use o f F a i t h / P o s i t i v e B e l i e f s Compliance Maintaining Control Prevention Plans f o r the Future Use o f S o c i a l S u p p o r t Summary  45 45 46 48 56 56 61 68 75 76 78 80 82 85 87 96  Chapter F i v e : Discussion of the Findings Introduction F a l l as a S i g n i f i c a n t E v e n t Self-Esteem Adaptation Summary  98 98 98 100 107 113  C h a p t e r S i x : Summary, C o n c l u s i o n s for Nursing Summary C o n c l u s i o n s I m p l i c a t i o n s f o r Research Implications for Practice Implications f o r Education  114 114 118 121 124  and  Implications  References  126  Appendices A p p e n d i x A: C o n s e n t Form A p p e n d i x B: L e t t e r o f I n f o r m a t i o n A p p e n d i x C: T r i g g e r Q u e s t i o n s  133 133 134 135  v  Acknowledgement I would the  like  t o t h a n k t h e p e o p l e who  preparation of t h i s My  for their  Thank y o u t o t h e e l d e r l y  I would  during  (Chair)  t o t h a n k my  and  positive  project.  women who  experience with  like  Perry  consistent direction,  e n c o u r a g e m e n t and e n t h u s i a s m f o r t h i s  and s h a r e d t h e i r  me  thesis.  s i n c e r e g r a t i t u d e g o e s t o J o Ann  A n g e l a Henderson  assisted  agreed t o  participate  me.  family  for their  ongoing  support a c r o s s the m i l e s . I would approach  like  t o t h a n k my  f r i e n d , Bev,  f o r her  positive  and h e r n e v e r - e n d i n g s u p p o r t .  A special i n k e e p i n g my  thank you head  t o my  friend, Craig,  who  above t h e f a s t - r i s i n g w a t e r .  vi  assisted  me  1  CHAPTER ONE:  INTRODUCTION  Introduction Falls  a r e a m a j o r h e a l t h p r o b l e m f o r o l d e r women.  1984-85 i n B r i t i s h C o l u m b i a , women aged comprised  75 y e a r s and o l d e r  85% o f t h e t o t a l number o f i n d i v i d u a l s a d m i t t e d t o  h o s p i t a l with the  In  a fall  ( S t a t i s t i c s Canada, 1989).  resultant injuries  are the s i x t h  F a l l i n g and  l e a d i n g cause o f death  among e l d e r l y i n d i v i d u a l s ( T i n e t t i , S p e e c h l e y , & G i n t e r , 1988) .  T h o s e o l d e r women who s u r v i v e  p h y s i c a l and p s y c h o l o g i c a l  falls  consequences  may  experience  (Hindmarsh & E s t e s ,  1989) . Kleinman's three  (1978) H e a l t h  Care Systems Model  s t r u c t u r a l arenas i n which " s i c k n e s s  reacted  t o " (p. 8 6 ) . Explanatory  models  contains  i s e x p e r i e n c e d and  (EMs) c a n be  elicited  f r o m p r a c t i t i o n e r s , p a t i e n t s , and f a m i l y members f o r  sickness  episodes i n the three  An  explanatory  interpret  care  to l i v e care the  m o d e l f o r an e l d e r l y woman's  t h e r e s u l t a n t p h y s i c a l and/or  consequences. for  arenas.  As w e l l , i t w i l l  Therefore,  i n order  will  psychological  e x p l a i n her perceived  and s u p p o r t when s h e r e t u r n s alone.  fall  need  home f r o m t h e h o s p i t a l  t o ensure c o n t i n u i t y of  f r o m h o s p i t a l t o home, n u r s e s must become f a m i l i a r w i t h e l d e r l y woman's e x p l a n a t o r y  model f o r a f a l l .  u n d e r s t a n d i n g o f t h i s model w i l l h e l p  An  t o ensure that  these  2 women's n e e d s f o r c a r e and s u p p o r t a r e met w i t h i n t h e community  setting. Background t o the Problem  Women who a r e 65 y e a r s o f age and o l d e r g r o w i n g segment o f t h e e l d e r l y p o p u l a t i o n  are the f a s t e s t -  (Fletcher  & Stone,  1982; R o b i n s o n , 1986).  Some 1.2 m i l l i o n C a n a d i a n women were  aged  i n 1978 ( F l e t c h e r  The  65 y e a r s and o l d e r  & Stone,  1982).  l a t e s t p r o j e c t i o n s f r o m S t a t i s t i c s C a n a d a s u g g e s t t h a t by  2 0 0 1 , more t h a n two m i l l i o n women w i l l older.  be aged 65 y e a r s and  Some p r o j e c t i o n s e n v i s a g e t h a t 7 t o 8% o f t h e  population w i l l  be women who a r e aged  75 y e a r s and o l d e r by  2021. A s i g n i f i c a n t problem f o r persons of e i t h e r y e a r s and o l d e r a fall.  living  at  i n t h e community, i s t h e o c c u r r e n c e o f  I t i s reported  among t h e e l d e r l y  living  that the annual incidence of f a l l s i n t h e community i n c r e a s e s from 25%  70 y e a r s o f age t o 35% a f t e r  Speechley, 1989). men u n t i l similar  75 y e a r s o f age ( T i n e t t i &  I n p a r t i c u l a r , women f a l l  t h e age o f 75 y e a r s , a f t e r w h i c h  i n both sexes  s e x , aged 65  (Nelson & Amin,  more o f t e n  than  the frequency i s  1990).  According to the International C l a s s i f i c a t i o n of Diseases  ( 1 9 8 9 ) , an a c c i d e n t a l f a l l  includes f a l l s  on o r f r o m  s t a i r s , on o r f r o m l a d d e r s , f r o m a b u i l d i n g o r o t h e r structure,  i n t o holes or other openings  f r o m one l e v e l t o a n o t h e r .  As w e l l ,  i n a s u r f a c e , and  falls  from  slipping,  3 t r i p p i n g , or stumbling, by  or with  included 1985,  from c o l l i s i o n ,  a n o t h e r p e r s o n , and f r o m u n s p e c i f i e d  i n the c l a s s i f i c a t i o n .  Included living  o f an a c c i d e n t a l f a l l  Statistics  t o h o s p i t a l with a  ( S t a t i s t i c s Canada,  i n this national statistic  inBritish  fractures are  I n C a n a d a , b e t w e e n 1984 and  40,311 i n d i v i d u a l s were a d m i t t e d  diagnosis  pushing, or shoving  1989).  were 4,383 i n d i v i d u a l s  Columbia.  substantiated  that  f a l l s were a s i g n i f i c a n t  p r o b l e m f o r o l d e r women ( S t a t i s t i c s C a n a d a , 1 9 8 9 ) . noted t h a t  24,235 i n d i v i d u a l s f r o m t h e n a t i o n a l f i g u r e o r 60%  w e r e women aged 75 y e a r s o r o l d e r .  Women i n t h i s age b r a c k e t  were more p r o m i n e n t i n t h e B r i t i s h C o l u m b i a Here, they comprised n e a r l y Falls associated  statistics.  8 5 % o r 3,716 i n d i v i d u a l s .  i n t h e e l d e r l y a r e due t o p h y s i o l o g i c a l c h a n g e s with  medications,  aging,  underlying  physical  and e n v i r o n m e n t a l h a z a r d s  illnesses,  (Nelson  Schulman & A c q u a v i v a , 1987).  W i t h many f a l l s ,  may be i n t e r a c t i n g w i t h  other.  The  1988). for  but are l i k e l y  from a f a l l Falls  hospitalized  a t an i n c r e a s e d  than younger persons  I t i s reported  for a fall  & Amin, 1990).  & Amin, 1 9 9 0 ; these  that  injury will Falls  factors  r i s k o f death  t o s u f f e r more s e v e r e (DeVito,  have p h y s i c a l and p s y c h o l o g i c a l  the e l d e r l y .  (Nelson  each  e l d e r l y are not only  from a f a l l , injuries  I t was  nonfatal eta l . ,  consequences  50% o f e l d e r l y p a t i e n t s  not s u r v i v e another  a l s o produce a lack of  year  4 c o n f i d e n c e and a f e a r o f f u r t h e r mobility  and i n d e p e n d e n c e  diminished and  (Hindmarsh & E s t e s ,  a c t i v i t y may r e s u l t i n f u r t h e r  physical decline As  i n j u r y w h i c h may  1989).  social  I t i s reported  that  there  was a t h r e e - f o l d  older  who l i v e a l o n e  isolation  home t o l i v e  i n C a n a d a , b e t w e e n 1961 and 1 9 7 6 ,  increase  (Fletcher  i n women aged  65 y e a r s and  & Stone, 1982).  There are  s e v e r a l f a c t o r s t h a t have c o n t r i b u t e d  t o the recent  increase  of older  alone.  i n t h e number and p r o p o r t i o n  S i g n i f i c a n t f a c t o r s a r e the longer  f o r women compared t o men, t h e i n c r e a s e older  rapid  women  life  living  expectancy  i n t h e number o f  widowed women, t h e a b s e n c e o f c h i l d r e n a v a i l a b l e f o r  family  living  (Fletcher 1990). during  a r r a n g e m e n t s , and t h e d e s i r e  f o r independence  & S t o n e , 1 9 8 2 ; R o b i n s o n , 1 9 8 6 ; Schank & L o u g h ,  L i v i n g a l o n e h a s a l s o become more s o c i a l l y the last  two d e c a d e s  (Fletcher  & Stone,  Women who a r e 75 y e a r s o f age a n d o l d e r experience d e f i c i t s  i n their informal  (Auslander & L i t w i n , 1990). include  nuclear  neighbours due  This  (Nelson & Amin, 1990).  w e l l , t h e s e women may be r e t u r n i n g  alone.  limit  Informal  support  acceptable  1982).  may a l s o networks  s u p p o r t n e t w o r k s may  f a m i l y members, o t h e r r e l a t i v e s , f r i e n d s , and  (Auslander & L i t w i n , 1990).  The d e f i c i t s may be  t o d e a t h o f t h e members, r e d u c e d m o b i l i t y among t h e  members, and r e d u c e d r e c i p r o c i t y on t h e p a r t women.  o f t h e aged  5 In aged  conclusion, f a l l s  a r e a s i g n i f i c a n t problem  75 y e a r s and o l d e r .  Trends i n d i c a t e  women l i v e a l o n e and h a v e i n s u f f i c i e n t networks. falls  t h a t many o f t h e s e  i n f o r m a l support  The p h y s i c a l and p s y c h o l o g i c a l c o n s e q u e n c e s o f  h a v e been w e l l - d o c u m e n t e d  little  f o r women  i n the l i t e r a t u r e .  Yet,  i s known a b o u t t h e e f f e c t o f t h e s e c o n s e q u e n c e s on  e l d e r l y women and t h e i r p e r c e i v e d need f o r c a r e and s u p p o r t as t h e y r e t u r n home a f t e r  a hospitalization  for a  fall.  T h e o r e t i c a l Framework The purpose  t h e o r e t i c a l framework and p r o v i d e s d i r e c t i o n  Catanzaro, proposed  1988).  study i s Kleinman"s  i n society  f o r the study design  The t h e o r e t i c a l  T h i s M o d e l i s an a t t e m p t healing  i s u s e f u l f o r the study  framework chosen f o r t h i s  (1978) H e a l t h C a r e  t o understand  as a c u l t u r a l  According t o Kleinman  health,  System  Model.  i l l n e s s , and  system.  (1978), h e a l t h care  c o n t a i n three s t r u c t u r a l arenas  (Woods &  i n which  systems  "sickness i s  e x p e r i e n c e d and r e a c t e d t o " ( p . 8 6 ) . The p o p u l a r a r e n a i s composed o f t h e f a m i l y c o n t e x t o f s i c k n e s s and c a r e , as w e l l as t h e s o c i a l n e t w o r k and c o m m u n i t y a c t i v i t i e s . p r o f e s s i o n a l arena  i s composed o f n u r s i n g , m e d i c i n e , and  other health professionals.  The f o l k  professional healing specialists. arenas arenas.  The  f o r t h i s study w i l l  arena  c o n s i s t s o f non-  The t w o most  important  be t h e p r o f e s s i o n a l and p o p u l a r  6 According  t o Kleinman  (1978), EMs can be e l i c i t e d  from  p r a c t i t i o n e r s , p a t i e n t s , and f a m i l y members f o r p a r t i c u l a r s i c k n e s s episodes. five  issues:  e t i o l o g y ; onset of symptoms,  course of s i c k n e s s treatment" interpret  EMs c o n t a i n " e x p l a n a t i o n of any or a l l of pathophysiology;  ( s e v e r i t y and type of s i c k r o l e ) ; and  (Kleinman,  1978, p.  88). I n d i v i d u a l s use EMs to  illness.  The EMs of p r o f e s s i o n a l s are most l i k e l y t o denote the d i s e a s e aspects of s i c k n e s s .  In t h i s model, "disease denotes  a m a l f u n c t i o n i n g i n or maladaptation p s y c h o l o g i c a l processes" t h i s i n c l u d e s the causes,  (Kleinman, risk  of b i o l o g i c a l and/or 1978, p. 88). F o r f a l l s ,  factors, resulting physical  and p s y c h o l o g i c a l consequences, and p r e v e n t i o n . In c o n t r a s t , the EMs of the popular arena are more l i k e l y t o i n c l u d e the experience o f the i l l n e s s event. the EMs are "most f r e q u e n t l y a r t i c u l a t e d p e r s o n a l , n o n - t e c h n i c a l , concrete life  Here,  i n a highly  idiom concerned  with the  problems that r e s u l t from s i c k n e s s " (Kleinman, 1978,  p. 88). E l d e r l y women w i l l i n t e r p r e t the p h y s i c a l and/or p s y c h o l o g i c a l consequences of a f a l l e x p l a n a t o r y model.  as p a r t of t h e i r  As w e l l , the consequences of a f a l l  will  a f f e c t these women's p e r c e p t i o n s of the need f o r care and support  as they r e t u r n home from the h o s p i t a l t o l i v e  alone.  These p e r c e p t i o n s w i l l a l s o be i n c l u d e d as p a r t of the e l d e r l y women's explanatory models f o r f a l l s .  7  Statement Falls  are a s i g n i f i c a n t problem  hospitalization women aged fastest  o f the Problem  or treatment  T h e s e women c o n s t i t u t e t h e  segment o f t h e e l d e r l y C a n a d i a n p o p u l a t i o n .  Once d i s c h a r g e d f r o m  the h o s p i t a l ,  home t o l i v e  As w e l l ,  alone.  i n f o r m a l support networks  t h e s e women may  return  t h e y may h a v e i n s u f f i c i e n t  i n t h e community.  F a l l s have  p h y s i c a l and p s y c h o l o g i c a l consequences f o r e l d e r l y Yet, l i t t l e  i na  i n an E m e r g e n c y D e p a r t m e n t f o r  75 y e a r s and o l d e r .  growing  t h a t may r e s u l t  i s known a b o u t t h e e f f e c t s  of these  women.  consequences  on t h e e l d e r l y women's p e r c e i v e d need f o r c a r e and s u p p o r t a s they  r e t u r n home t o l i v e a l o n e a f t e r  a hospitalization  for a  fall. Purpose The p u r p o s e  of t h i s study  i s t o d e s c r i b e t h e need f o r  c a r e and s u p p o r t a s p e r c e i v e d by women aged older for  r e t u r n i n g home t o l i v e  a  alone a f t e r  75 y e a r s and  a hospitalization  fall. Research  The p u r p o s e question:  of t h i s study  Question i s t o answer t h e o v e r a l l  What i s t h e need f o r c a r e and s u p p o r t a s p e r c e i v e d  by e l d e r l y women r e t u r n i n g home t o l i v e hospitalization  f o ra f a l l ?  alone a f t e r  a  8 Significance T h i s study  f o r the P r o f e s s i o n  has p r a c t i c a l s i g n i f i c a n c e  w i t h e l d e r l y women who s u f f e r a f a l l , hospitalization.  T h i s study  f o r nurses  which r e s u l t s  a l s o has value  working  ina  i n t h a t i t i s an  a t t e m p t t o d e s c r i b e t h e p e r c e i v e d need f o r c a r e and s u p p o r t f r o m t h e e l d e r l y woman's p e r s p e c t i v e a s s h e r e t u r n s home f r o m a hospitalization in  f o ra f a l l .  This  i n f o r m a t i o n may be u s e d  t h e p l a n n i n g o f community s e r v i c e s .  e x p e c t a t i o n s o f those considered.  A f t e r a l l , the  who u s e community s e r v i c e s s h o u l d be  As a r e s u l t ,  t h e gap w i l l  be r e d u c e d  between  s e r v i c e n e e d s and s e r v i c e a v a i l a b i l i t y . Definition Fall. to  o f Terms An untoward event  i n which the i n d i v i d u a l  r e s t u n i n t e n t i o n a l l y on t h e g r o u n d  comes  (Morris & Isaacs,  1980). Hospitalization. an  An a d m i s s i o n  i n p a t i e n t , or medical  Emergency o r O u t p a t i e n t  t o a h o s p i t a l f a c i l i t y as  a s s e s s m e n t and t r e a t m e n t  i n an  Department.  I n t r o d u c t i o n t o t h e Methodology Phenomenology i s t h e proposed study. itself  research design  G i o r g i (1986) s t a t e s t h a t p h e n o m e n o l o g y d e v o t e s t o the study  experience.  Oiler  o f how t h i n g s a p p e a r o r a r e g i v e n i n (1982) s t a t e s t h a t i t i s a r e s e a r c h  i n which t h e aim i s t o d e s c r i b e experience Our  for this  access  t o experience  i sperception.  method  as i t i s l i v e d .  Perception  i s being  9 there t o see, Oiler,  t o hear,  to experience,  t o know  (Munhall &  1986) .  P h e n o m e n o l o g y i s an i n d u c t i v e ,  descriptive,  research  method and i s p a r t i c u l a r l y a p p r o p r i a t e f o r n u r s i n g  research  where t h e g o a l i s t o u n d e r s t a n d  Therefore,  human e x p e r i e n c e .  the approach i s a p p r o p r i a t e f o r t h i s study, s i n c e t h e purpose i s t o understand the e l d e r l y  t h e p e r c e i v e d need f o r c a r e and s u p p o r t  woman's p e r s p e c t i v e a f t e r  hospitalization  fora  s h e r e t u r n s home f r o m a  fall.  In phenomenology, t h e r e s e a r c h e r e n t e r s of those people 1982).  whose e x p e r i e n c e  into the world  i s under study  (Oiler,  A s a r e s u l t , t h e r e s e a r c h e r becomes immersed i n t h e  subjects' In o r d e r  from  experiences to control  experience,  before attempting  to interpret  them.  bias i n the r e f l e c t i o n of lived  t h e r e s e a r c h e r b r a c k e t s o r h o l d s back one's  p r e v i o u s knowledge o r e x p e r i e n c e .  The r e s u l t  g e n e r a t i o n o f hypotheses r a t h e r than (Knaack, 1984). evoke d e s c r i p t i o n  i s the  hypothesis  testing  The r e s e a r c h e r ' s i n t e r v i e w t e c h n i q u e from t h e s u b j e c t s w i t h o u t  t o s a y (Knaack, 1984).  Therefore,  telling  them what  t h e use o f open-ended  questions provides the opportunity of exploring the s u b j e c t ' s e x p e r i e n c e  must  (Woods & C a t a n z a r o ,  the depths of  1988).  Assumptions 1. be  The e l d e r l y women p a r t i c i p a t i n g  i n t h i s study  will  a r t i c u l a t e i n e x p r e s s i n g t h e i r p e r c e i v e d need f o r c a r e and  10 support. 2.  A fall  may r e s u l t  consequences which a f f e c t need f o r c a r e and s u p p o r t , 3. illness fall  i n p h y s i c a l and/or p s y c h o l o g i c a l the i n d i v i d u a l ' s perceptions of the once d i s c h a r g e d  E l d e r l y women u s e e x p l a n a t o r y events.  event w i l l  from the h o s p i t a l .  models t o i n t e r p r e t  The e l d e r l y woman's e x p l a n a t o r y  model f o r a  c o n t a i n an i n t e r p r e t a t i o n o f t h e p h y s i c a l  and/or p s y c h o l o g i c a l consequences and t h e p e r c e i v e d care  need f o r  and s u p p o r t .  Limitations 1.  The p e r c e i v e d  need f o r c a r e and s u p p o r t  may be  i n f l u e n c e d by t h e e x t e n t o f t h e e l d e r l y woman's a w a r e n e s s o f available  resources. Summary  In  conclusion, f a l l s  o l d e r women. provided study.  remain a major h e a l t h problem f o r  I n C h a p t e r One, a b a c k g r o u n d t o t h i s p r o b l e m i s  a n d , t h e r e f o r e , e x p l a i n s t h e need f o r t h e p r o p o s e d As a l r e a d y d i s c u s s e d , t h e r e  i s a paucity of  i n f o r m a t i o n t h a t d e a l s w i t h t h e e l d e r l y woman's need f o r c a r e and  support  for  a fall.  question well,  a s s h e r e t u r n s home a l o n e The p r o b l e m s t a t e m e n t ,  f o r t h i s study  after  p u r p o s e , and r e s e a r c h  are stated i n this  an e x p l a n a t i o n o f t h e t h e o r e t i c a l  the study of both  i soutlined.  hospitalization  f i r s t chapter.  framework t h a t  As  guides  A d e f i n i t i o n o f t e r m s and a s t a t e m e n t  t h e a s s u m p t i o n s and l i m i t a t i o n s a r e a l s o i n c l u d e d i n  11 this chapter. also  A brief  included i n this  f o c u s on t h e c r i t i c a l detailed Chapter  first  chapter.  Subsequent  review of the l i t e r a t u r e  e x p l a n a t i o n of the methodology Four,  presented. Chapter  i n t r o d u c t i o n t o the methodology i s  and a more  f o r the study.  In  t h e f i n d i n g s and i n t e r p r e t a t i o n o f t h e d a t a a r e  A d i s c u s s i o n of the f i n d i n g s  Five.  chapters  F i n a l l y , Chapter  c o n c l u s i o n , and i m p l i c a t i o n s  i s presented i n  S i x i n c l u d e s a summary,  for nursing.  12  CHAPTER TWO:  C R I T I C A L REVIEW OF THE LITERATURE Introduction  The f o l l o w i n g r e v i e w research  and t h e o r e t i c a l  of the l i t e r a t u r e readings.  w i t h s t u d i e s t h a t f o c u s on f a l l s . what i s known a b o u t f a l l s . of f a l l s and  i n the e l d e r l y ,  includes  The f i r s t  section deals  This review  identifies  I t i n c l u d e s t o p i c s such as c a u s e s  associated risk  factors, physical  p s y c h o l o g i c a l c o n s e q u e n c e s , and f a l l  prevention.  explains the health p r o f e s s i o n a l s ' explanatory to  both  This  models  falls. The s e c o n d s e c t i o n d e a l s w i t h s t u d i e s t h a t f o c u s  s o c i a l support  networks.  that discusses the s o c i a l in  related  i n f o r m a l support  v a r i a b l e s t h a t may  This  review  reality  The t h i r d planning reviews  of l i v i n g  n e t w o r k s and l i v i n g  information  alone.  alone  are  Deficits important  i n f l u e n c e t h e e l d e r l y woman's p e r c e p t i o n s  o f t h e need f o r c a r e and s u p p o r t model f o r a f a l l  provides  on  as p a r t o f her e x p l a n a t o r y  event.  s e c t i o n d e a l s w i t h r e s e a r c h on  and p e r c e i v e d  discharge  n e e d s f o r c a r e and s u p p o r t .  t h e c u r r e n t r e s e a r c h on p e r c e i v e d  This  n e e d s f o r c a r e and  support. Falls The c a u s e s o f f a l l s extrinsic  and i n t r i n s i c .  i n t h e e l d e r l y c a n be c l a s s i f i e d Extrinsic  as  f a c t o r s are medications  13 and  environmental  fall  t o occur.  falling  that produce the opportunity f o r a  Medications  benzodiazepines, with  hazards  such  and t r i c y c l i c  independently  antidepressants are associated  of other  A m i n , 1990; T i d e i k s a a r , 1986). loose rugs, s l i p p e r y lighting, and  footwear, soles is  unlaced  (Nelson  badly  shoes,  t o note  walking  repaired steps,  1990).  However,  increased  lack of  ill-fitting without 1989).  that the environment-related  i t i s thought  (Nelson  t h a t many f a l l s  s t e m f r o m an i n t e r a c t i o n  environmental  include  poor  aids,  & Speechley,  f o r 30 t o 50% o f r e p o r t e d f a l l s  identifiable  hazards  h i g h h e e l s , and s l i p p e r s  account  accidents really  (Nelson &  as t o y s o r p e t s , low beds  & A m i n , 1990; T i n e t t i  interesting  factors  s u r f a c e s , o b j e c t s on f l o o r s ,  seats, poorly-maintained  h a n d r a i l s on s t a i r s ,  risk  Environmental  l o w - l y i n g o b j e c t s such  toilet  as p h e n o t h i a z i n e s ,  hazards,  individual susceptibility  It  factors  & Amin, attributed to  between  m e d i c a t i o n s , and t o hazards  from the  a c c u m u l a t e d e f f e c t s o f age and d i s e a s e . Intrinsic within  f a c t o r s a r e a g e - and d i s e a s e - r e l a t e d c h a n g e s  the i n d i v i d u a l that increase the l i k e l i h o o d  Intrinsic  c a u s e s i n c l u d e v i s u a l and h e a r i n g  n e u r o l o g i c and m u s c u l o s k e l e t a l d i s a b i l i t i e s , r e l a t e d c h a n g e s i n g a i t and m u s c u l a t u r e , hypotension  of f a l l s .  impairments, dementia, age-  and p o s t u r a l  ( N e l s o n & A m i n , 1990).  Factors associated with a risk  of f a l l i n g  are increased  14 age,  female sex, t h e presence  polypharmacy, decreased  changes i n g a i t  (Hindmarsh  & Estes,  v i s u a l p e r c e p t i o n , sway,  t o t h e home, d e m e n t i a ,  and a h i s t o r y o f f a l l i n g  1989).  most common p h y s i c a l c o n s e q u e n c e o f a f a l l  fractured referred  and/or  m o b i l i t y , confinement  depression, acute i l l n e s s ,  The  o f more t h a n one d i s e a s e ,  h i p (Reinhard, 1988).  i sa  T h i s type o f f r a c t u r e i s  t o a s t h e "widow's d i s e a s e " s i n c e  75% o f t h e c l i e n t s  w i t h h i p f r a c t u r e a r e f e m a l e , o f t e n widowed and l i v i n g prior  t o the f a l l  suggest  event.  Statistics  alone  from t h e U n i t e d S t a t e s  that the annual i n c i d e n c e of h i p f r a c t u r e s  will  i n c r e a s e f r o m t h e p r e s e n t f i g u r e o f 200,000 f r a c t u r e s t o 330,000 o v e r t h e n e x t 15 y e a r s . The fall  most common p s y c h o l o g i c a l c o n s e q u e n c e f o l l o w i n g a  i s an i n d i v i d u a l ' s f e a r o v e r  1986).  falling  again  (Tideiksaar,  I t i s r e p o r t e d t h a t an e l d e r l y p e r s o n who f a l l s may  become f e a r f u l o f g o i n g o u t d o o r s , o f b e c o m i n g h e l p l e s s , and of  incurring  Serious  serious  i n j u r y and subsequent  i n j u r y may l e a d t o t h e d e v e l o p m e n t o f i m m o b i l i t y w i t h  the e v e n t u a l l o s s o f f u n c t i o n a l lead  hospitalization.  t o l o s s o f muscle  perform the a c t i v i t i e s  independence.  I m m o b i l i t y may  strength, contractures, i n a b i l i t y to of d a i l y  l i v i n g , p r e s s u r e s o r e s and  depression. Factors individuals'  involved intrinsic  i n p r e v e n t i o n a r e assessment risk  factors,  of the  b a l a n c e and g a i t ,  e n v i r o n m e n t a l s a f e t y , and t h e h i s t o r y o f p r e v i o u s (Tinetti  & Speechley, 1989).  preventative with  a high  measures s h o u l d  After  the assessment,  be i m p l e m e n t e d f o r i n d i v i d u a l s  risk of f a l l i n g .  In reviewing  the l i t e r a t u r e ,  f a l l s were found t h a t d e a l t w i t h  two p r o s p e c t i v e  G i n t e r , 1989). reviewed r i s k  The f i r s t s t u d y  information  Speechley, &  ( C a m p b e l l e t a l . , 1989)  factors that contributed  that this  s t u d i e s on  community-based e l d e r l y  (Campbell, B o r r i e , & S p e a r s , 1989; T i n e t t i ,  indicated  falls  to f a l l s .  This  study  i s n e c e s s a r y t o improve  i n d i v i d u a l p a t i e n t management and f o r t h e d e v e l o p m e n t o f a public health prevention  program.  According  t h e o r e t i c a l framework, t h i s study p r o v i d e d information  f o r the explanatory  a r e n a on f a l l s  f o r b o t h men and women.  were 70 y e a r s o f age and o l d e r .  o f 761 s u b j e c t s  The r e s u l t s i n d i c a t e d  who that  o f women and 2 8 . 4 % o f men e x p e r i e n c e d a t l e a s t one  fall.  I n women, 84% o f t h e f a l l s  intrinsic 83%  further  model i n t h e p r o f e s s i o n a l  I n t h e s t u d y , t h e sample c o n s i s t e d  39.6%  t o the  factors.  of t h e f a l l s As  F o r men, t h e v a l u e  were due t o i n t r i n s i c  w e l l , the risk  different  were due s t r i c t l y t o  i n relation  was s i m i l a r i n t h a t factors.  f a c t o r s f o r women and men were to f a l l s .  I n women, t h e r i s k  w e r e t h e t o t a l number o f d r u g s , p s y c h o t r o p i c liable  t o cause p o s t u r a l h y p o t e n s i o n  factors  d r u g s , and d r u g s  (standing  systolic  blood  16  p r e s s u r e o f l e s s t h a n 110 mmHg), and t h e e v i d e n c e o f m u s c l e weakness.  I n men,  stroke, a r t h r i t i s  decreased  l e v e l s of p h y s i c a l  activity,  of the knees, impairment of g a i t ,  and  i n c r e a s e d body sway were a s s o c i a t e d w i t h an i n c r e a s e d  r i s k of  falls. In a n a l y z i n g discussed.  t h i s s t u d y , t h e s a m p l i n g s t r a t e g y was n o t  The s a m p l e c o n s i s t e d o f i n d i v i d u a l s  community and r e s i d e n t i a l homes. individuals data. related  changes, r e s u l t i n g  c h a n g e s may  have b i a s e d the  h a v e had more a g e - and  w e l l , the f a l l s  compared t o t h e c o m m u n i t y s a m p l e .  i n the f a c i l i t y  r e p o r t i n g was u s e d . t h a t men,  These  increased  may  h a v e been  As  accurately  r e c o r d e d compared t o t h e c o m m u n i t y s a m p l e where  reported  disease-  in institutionalization.  h a v e a l s o p r e d i s p o s e d them t o an  incidence of f a l l s ,  i n the  The d a t a f r o m t h e  i n t h e r e s i d e n t i a l homes may  T h e s e i n d i v i d u a l s may  living  self-  For example, Campbell et a l .  (1989)  i n p a r t i c u l a r , were r e l u c t a n t t o admit  h a v i n g f a l l e n and k n o w l e d g e o f a f a l l man's w i f e o r o t h e r o b s e r v e r .  was g a i n e d f r o m t h e  S e l f - r e p o r t i n g was  then  another l i m i t a t i o n of the study. The s e c o n d s t u d y  (Tinetti  et a l . ,  1988)  used a sample o f  336 i n d i v i d u a l s who were 75 y e a r s o f age o r o v e r , l i v i n g i n the community. stressed  This study a l s o reviewed  that a simple, c l i n i c a l  t h e e l d e r l y p e r s o n s who  risk-factors  assessment could  are at the g r e a t e s t  and  identify  r i s k of  falling.  Similar  to this  concluded  that  preventive  research  ( C a m p b e l l e t a l . , 1 9 8 9 ) , i t was  on r i s k  second study reported  l e a s t once.  subjects  study  factors resulted in  strategies.  This at  first  that  During the study,  (24%) who f e l l  32% o f t h e i r  i t was shown t h a t  had a s e r i o u s  The c a t e g o r y o f s e r i o u s  sample  fell  26  i n j u r y from a  fall.  i n j u r y was n o t c l e a r l y d e f i n e d  i n the  study. This  study b r i e f l y  addressed fear of f a l l i n g , a  p s y c h o l o g i c a l consequence o f a f a l l . subjects  (48%) who f e l l  falling.  reported  t h a t t h e y were a f r a i d o f  T w e n t y - e i g h t i n d i v i d u a l s (26%) r e p o r t e d  had  curtailed activities  due  to fear.  community.  This  need f o r c a r e  and s u p p o r t i n t h e  i s the type of i n f o r m a t i o n  The r e s u l t s o f t h e s t u d y increased  with  noted that medical,  that pertains to  event.  indicated that  the r i s k of  t h e number o f d i s a b i l i t i e s .  I t was  s u r g i c a l , r e h a b i l i t a t i v e , and  e n v i r o n m e n t a l i n t e r v e n t i o n s may be e f f e c t i v e i n r e d u c i n g prevalence of several r i s k  factors.  l i m i t a t i o n o f t h i s s t u d y was t h a t  the  Once a g a i n , t h e  i t relied  on t h e s u b j e c t s  t o remember t h e f a l l  event.  As w e l l , t h i s  the  level.  Even though t h e s t u d y  factor isolating  they  had an e f f e c t on t h e  EMs o r i n t e r p r e t a t i o n o f t h e i l l n e s s  falling  that  such as shopping o r h o u s e c l e a n i n g ,  Here, fear of f a l l i n g  individual's perceived  the  F i f t y - t w o o f t h e 108  s t u d y was done a t described  18 the i n t r i n s i c ,  activity,  the time of the f a l l s , Cummings, N e v i t t , of  factors present at  no c a u s a l r e l a t i o n s h i p s w e r e and K i d d  found.  (1988) s t u d i e d t h e a c c u r a c y  h i s t o r i e s o f f a l l s p r o v i d e d by e l d e r l y men and women f o r  specific to  and e n v i r o n m e n t a l  i n t e r v a l s o f t i m e o v e r one y e a r .  I t was i m p o r t a n t  review t h i s study s i n c e the accuracy of the h i s t o r i e s of  falls  was n o t e d  as a l i m i t a t i o n  f o rthe studies already  d iscussed. As p a r t o f a n o t h e r  research project  t o study  risk  f a c t o r s , Cummings e t a l . (1988) u s e d an i n t e n s i v e s y s t e m o f f o l l o w - u p on f a l l s . on  In t h i s study, the p a r t i c i p a n t s  a w e e k l y b a s i s by m a i l i n g  i n a post card.  s u b j e c t s were t o r e p o r t w h e t h e r a f a l l fall  was r e p o r t e d , a f o l l o w - u p v i s i t  health  reported  E a c h week, t h e  had o c c u r r e d .  Ifa  was made by a p u b l i c  nurse.  A t t h e end o f t h e s t u d y , a l l p a r t i c i p a n t s i n t e r v i e w e d by p h o n e .  In this  interview,  were  t h e y were a s k e d  w h e t h e r t h e y had f a l l e n d u r i n g t h e p a s t 12 months. During falls.  t h i s s t u d y , 179 o f 325 p a r t i c i p a n t s  confirmed  H o w e v e r , a t t h e end o f t h e s t u d y , 23 (13%) d i d n o t  r e c a l l having a f a l l . participants  One h u n d r e d and f o r t y - t h r e e  r e p o r t e d i n j u r i e s due t o a f a l l .  During the  s t u d y , 18 ( 1 3 % ) p a r t i c i p a n t s d i d n o t r e c a l l h a v i n g a and a  fall,  40 (28%) d i d n o t r e c a l l h a v i n g any i n j u r y a s a r e s u l t o f fall.  19  As  a result,  the  researchers concluded  s u b j e c t s do n o t o f t e n r e c a l l s p e c i f i c p e r i o d s of time. a p p e a r e d t o be  falls  T h i s may  12 months.  subjects  remembered t h e i r e n r o l l m e n t  examination. marked by  The  such  been d i f f i c u l t periods.  As  clinicians  distinct  be due  to the  and,  they concluded  counting  falls  over  the could  r e c a l l were  t h e r e f o r e , i t may  s h o u l d use methods b e s i d e s and  and  the  initial  6-month p e r i o d s o f events  falls  over  fact that  i n the study  f o r the s u b j e c t s t o r e c a l l  a result,  ascertaining  (3 months) o f  occurred d u r i n g the  3- and  during  r e c a l l of f a l l s  previous  remember w h e t h e r a f a l l  elderly  that occurred  Recent r e c a l l  l e s s complete than  that  a fall  not  have  during  these  that researchers  and  long-term  for  recall  specific periods  of  time. One factors  nursing study  i n d i c a t i v e of a high  ambulatory  elderly.  developing  and  prevent age,  (Craven  falls  living  & B r u n o , 1986)  risk  for falling  T h i s s t u d y was  testing  The  alone, v i s u a l d e f i c i t s ,  o f p r e d i c t o r s may  i n a group of  also p r e l i m i n a r y to  a teaching p r o t o c o l designed  i n the e l d e r l y .  neurologic problems.  identified  The  factors balance  identified problems,  researchers indicated  be u s e d t o i d e n t i f y p e r s o n s  l e a r n i n g about p r e v e n t i v e measures.  a l s o d i s c u s s e d the n u r s i n g i m p l i c a t i o n s of t h e i r study.  were and  that this  set  w i t h a need f o r  C r a v e n and  T h e s e i m p l i c a t i o n s were n o t p a r t o f t h e  to  Bruno  (1986)  findings.  20 One was  limitation  based  t o t h i s s t u d y was  t h a t the data  on s e l f - r e p o r t i n g o f p h y s i c a l d e f i c i t s  h e a l t h s t a t u s by p a r t i c i p a n t s . (convenience)  may  The  have i n f l u e n c e d  sample  collected  and  general  technique  s e l f - p e r c e p t i o n and  self-  r e p o r t i n g of these d e f i c i t s .  As a r e s u l t ,  have l i m i t e d  to other elderly populations.  The factors  generalizability  may  study's c o n c l u s i o n s p r o v i d e i n f o r m a t i o n about for falls.  As m e n t i o n e d  information that belongs  earlier,  t o t h e EMs  of  f a l l prevention.  this  F o r e x a m p l e , t h i s s t u d y r e p o r t e d t h a t 53  researchers concluded  falls.  falls  through mutual  i n the problem-  important. a l r e a d y been m e n t i o n e d  that fear of f a l l i n g  was  an i m p o r t a n t p s y c h o l o g i c a l c o n s e q u e n c e r e s u l t i n g  from a  Tinetti,  R i c h m a n , and  instrument  entitled  the F a l l E f f i c a c y S c a l e  falling. was  The  an i n d e p e n d e n t  Powell  o v e r a l l purpose  to determine  (1990) d e v e l o p e d (FES)  t o measure f e a r  of developing t h i s  the e x t e n t t o which  e f f e c t on  an  of  instrument  fear of f a l l i n g  f u n c t i o n a l d e c l i n e among  fall.  exerts  the  elderly. This  of  The  that i n v o l v i n g e l d e r l y persons  process of l e a r n i n g to prevent  I t has  i s the type of  of i n d i v i d u a l s i n  99 p a r t i c i p a n t s t o o k no a c t i o n t o p r e v e n t  s o l v i n g was  risk  professionals.  H o w e v e r , t h i s s t u d y does c o n s i d e r t h e EMs  the  the f i n d i n g s  i n s t r u m e n t was  designed  t o assess the degree of  21 perceived during daily  efficacy (i.e.,  self-confidence)  e a c h o f 10 r e l a t i v e l y living.  instrument  According  at avoiding  non-hazardous a c t i v i t i e s  fall  of  t o t h e t h e o r e t i c a l framework, the  w o u l d be m e a s u r i n g f e a r o f f a l l i n g  i n d i v i d u a l ' s EM.  a  In the development of the  as p a r t o f the instrument,  h e a l t h p r o f e s s i o n a l s such as p h y s i c a l t h e r a p i s t s , occupational  t h e r a p i s t s , r e h a b i l i t a t i o n nurses,  p h y s i c i a n s w e r e a s k e d t o name t h e 10 most activities requiring  important  e s s e n t i a l t o independent l i v i n g , some p o s i t i o n c h a n g e o r w a l k i n g ,  n o n - h a z a r d o u s t o most e l d e r l y p e r s o n s .  and  that  while  w o u l d be s a f e and  A second group o f  p r o f e s s i o n a l s were a s k e d w h e t h e r t h e y a g r e e d w i t h  the choice  of a c t i v i t i e s .  converted  i n t o the F a l l Tinetti the  The f i n a l  of a c t i v i t i e s  e t a l . (1990) s t a t e d t h a t t h e c o n s e n s u s among and p h y s i c i a n s  professionals'  two  concerning  i n the scale supported the v a l i d i t y  T h i s was t h e t y p e o f i n f o r m a t i o n  After  was  Efficacy Scale.  t h e r a p i s t s , nurses,  activities  list  EMs on  contained  of the items.  i n health  falls.  t h e development of the instrument,  pre-tests.  the  The p u r p o s e o f t h e f i r s t  i t underwent  p r e - t e s t was t o  d e t e r m i n e t h e t e s t - r e t e s t r e l i a b i l i t y o f t h e FES and t o examine t h e spread  i n responses t o i n d i v i d u a l  items.  The  p u r p o s e o f t h e s e c o n d p r e - t e s t was t o compare FES s c o r e s self-reported  fear of f a l l i n g  with  and t o e x a m i n e t h e r e l a t i o n s h i p  22  between s e l e c t e d  subject  c h a r a c t e r i s t i c s and FES  In the f i r s t p r e - t e s t , the  instrument resulted  c o r r e l a t i o n o f .71. measurements  (i.e.,  a high  product-moment  correlation indicated  stability  In t h e second p r e - t e s t ,  c o e f f i c i e n t revealed  were n o t a s s o c i a t e d analysis.  The FES was  a fall,  significantly regression  anxiety  associated  age 65. detect in  limitation  occasion.  s e x , age, depression  with  by r e c e n t  difficulty  fear  score,  FES s c o r e s  history  getting  and  As w e l l , d e p r e s s i o n  to this  s t u d y was  For the f i r s t p r e - t e s t ,  up  several  was  in multiple  that  the sample  As a r e s u l t , t h e r e associations  i n intermediary  with  may  over  h a v e been i n a d e q u a t e power t o  FES s c o r e s .  S i x of the i n d i v i d u a l s  i n the community, w h i l e care f a c i l i t i e s .  c o n v e n i e n c e s a m p l e was p r o b a b l y  sizes  the c o n v e n i e n c e sample  o f 18 c o g n i t i v e l y i n t a c t , a m b u l a t o r y p e r s o n s  t h e sample l i v e d  lived  with  t r a i t , general  associated  the  analysis.  were s m a l l . consisted  s t a t u s , and  In  t h e FES s c o r e s i n b i v a r i a t e  m e a s u r e s o f b a l a n c e and g a i t .  One  that  The s c o r e was a l s o n o t a f f e c t e d  of a f a l l . after  with  health  that  on e a c h  i t was d e t e r m i n e d  s i t u a t i o n , perceived  little  (Woods & C a t a n z a r o , 1 9 8 8 ) .  i n s t r u m e n t was m e a s u r i n g f e a r o f f a l l i n g  living  t h a t the  s c o r e s or r e s p o n s e s ) changed v e r y  b e t w e e n t h e t e s t and r e t e s t addition,  the t e s t - r e t e s t r e l i a b i l i t y of  i n a Pearson's  This  scores.  the remainder  As a r e s u l t , t h i s  less likely  to suffer  from  23  self-imposed  activity  r e s t r i c t i o n s than the spectrum o f  community-living e l d e r l y . Even though f u r t h e r t e s t i n g of t h i s instrument w i l l be required  i n the f u t u r e ,  psychological an  i t i s an attempt t o look at t h i s  consequence.  " I f fear of f a l l i n g proves t o be  independent f a c t o r i n f u n c t i o n a l d e c l i n e , and i f  i n d i v i d u a l s a t r i s k of developing f e a r of f a l l i n g can be i d e n t i f i e d , then fear of f a l l s e f f i c a c y should be a s p e c i f i c t a r g e t of c l i n i c a l 242).  This  colleagues  intervention"  ( T i n e t t i e t a l . , 1990, p.  study addressed fear of f a l l i n g , i n d i c a t e that we s t i l l  but T i n e t t i and  lack i n f o r m a t i o n  about how  t h i s f e a r may i n f l u e n c e the i n d i v i d u a l ' s need f o r care and support i n the community. In summary, the s t u d i e s on f a l l s were mostly epidemiological causes of f a l l s , This  i n nature.  There was a great  associated  i s the information  emphasis on the  r i s k f a c t o r s , and p r e v e n t i o n .  that c o n s t i t u t e s the EMs h e a l t h  p r o f e s s i o n a l s have regarding  falls.  In f a c t , the only way  the experience of the f a l l was addressed was through the EMs of h e a l t h  professionals.  As w e l l , there  were no s t u d i e s  addressed the p h y s i c a l and/or p s y c h o l o g i c a l falls and  that  consequences of  i n terms of t h e i r e f f e c t on the p e r c e i v e d  need f o r care  support of e l d e r l y women r e t u r n i n g home alone.  S o c i a l Support L i v i n g alone and having i n s u f f i c i e n t  informal  support  24 may be i m p o r t a n t v a r i a b l e s a s t h e e l d e r l y women d e s c r i b e t h e i r p e r c e p t i o n s o f t h e need f o r c a r e a n d s u p p o r t a s t h e y r e t u r n home f r o m a h o s p i t a l i z a t i o n is  f o ra f a l l .  Therefore, i t  i m p o r t a n t t o r e v i e w t h e l i t e r a t u r e on s o c i a l  i n c r e a s e one's u n d e r s t a n d i n g o f t h e s o c i a l  support t o  reality  of living  a l o n e f o r e l d e r l y women. The  term s o c i a l support not o n l y i n c l u d e s t h e c o n t a c t s  i n a s o c i a l network, but a l s o support, advice, guidance,  "encompasses t h e e m o t i o n a l  and a p p r a i s a l , a s w e l l a s t h e  m a t e r i a l a i d and s e r v i c e s t h a t p e o p l e o b t a i n f r o m social relationships"  (Ell,  1 9 8 4 , p. 1 3 4 ) . The two t y p e s o f  s o c i a l s u p p o r t a r e i n f o r m a l and f o r m a l . includes nuclear family, relatives. organized  Formal  to deliver  M e a l s on Wheels)  a particular  (Fletcher  draw i n i t i a l l y  by a d d i t i o n a l a i d f r o m  and o t h e r  i s a group t h a t i s d e l i b e r a t e l y type o f support  & Stone,  In r e v i e w i n g t h e l i t e r a t u r e , persons  Informal support  f r i e n d s , neighbours,  support  their  1982).  i t appears t h a t  on a i d f r o m  (i.e.,  elderly  i n f o r m a l supports followed  f o r m a l a g e n c i e s and o r g a n i z a t i o n s  ( O ' B r i e n & Wagner, 1 9 8 0 ) .  Chappell  o f home c a r e were more l i k e l y  (1985) f o u n d  to live  alone than  that users non-users,  confirming  t h e n o t i o n t h a t t h e more i s o l a t e d  receive formal  supports.  H o w e v e r , C h a p p e l l ' s s t u d y was done i n a p r o v i n c e  w h e r e t h e r e i s an e x p l i c i t p o l i c y o f home c a r e t h a t c o n s i d e r s the i n f o r m a l support  from a f a m i l y p r i o r  t o providing formal  25  support.  As a r e s u l t ,  this  generalizability  to other  support  locations.  i n other  Cafferta status,  who do n o t l i v e  alone.  Gatekeeping  controlling  living  with  the presence  others.  f o r the e l d e r l y person  Here, the s o c i a l network the e l d e r l y  I n d i v i d u a l s who l i v e  alone  people  r e f e r s t o t h e f a m i l y member's p e r c e p t i o n s  the time.  Chappell,  t o use s e r v i c e s than  on b e h a l f o f f a m i l y members and  individuals  formal support  in seeking  marital  individuals  T h i s f i n d i n g may r e f l e c t  behaviour  f r i e n d s f o r those  at  Her f i n d i n g s i n d i c a t e t h a t  a l o n e a r e more l i k e l y  of gatekeeping  use of f o r m a l  a r r a n g e m e n t s , and t h e u s e o f h e a l t h s e r v i c e s  by e l d e r l y p e r s o n s .  seeking  s a m p l e s and t h e i r  limited  (1987) s t u d i e d t h e r e l a t i o n s h i p b e t w e e n  living  who l i v e  f i n d i n g may h a v e  i s a significant  this  supports. difficulty  The s t u d i e s ( C a f f e r t a , 1 9 8 7 ;  & Wagner, 1980) c o n f i r m t h a t v a r i a b l e and w i l l p r o b a b l y  EMs o f e l d e r l y women i n t h i s p r o p o s e d Auslander  i s important i n  a l o n e may n o t e n c o u n t e r  1985; O'Brien  i s not required  i n d i v i d u a l ' s use o f f o r m a l  formal supports.  and L i t w i n  that  living  a f f e c t the  study.  (1990) a t t e m p t e d  t o c l a r i f y the  d e g r e e t o w h i c h f o r m a l h e l p s e e k i n g may be r e l a t e d t o d i m i n i s h e d network r e s o u r c e s .  According  t o the t h e o r e t i c a l  framework, t h i s would r e p r e s e n t a change i n t h e p o p u l a r arena.  Their findings revealed that individuals applying f o r  f o r m a l a s s i s t a n c e had s m a l l e r n e t w o r k s and f e l t  less  loved  26  and  a d m i r e d by t h e n e t w o r k members upon whom t h e y According  to t h i s study  t o Auslander  and L i t w i n ( 1 9 9 0 ) ,  was t h e i n s t r u m e n t  s o c i a l networks. Questionnaire  used t o gather  data  (NSSQ) h a s c o n s t r u c t and c o n t e n t  validity, i t  the  instrument  with  the e l d e r l y population,  as t o w h e t h e r t h e e l d e r l y between a f f e c t i v e ,  In using  i t was  i n d i v i d u a l s could  a f f i r m a t i o n a l , and i n s t r u m e n t a l a i d , t h e  of support  measured.  draw i n i t i a l l y  on a i d f r o m i n f o r m a l s u p p o r t s .  who l i v e a l o n e  a r e more l i k e l y  As w e l l ,  play a role Litwin,  increased  Individuals  age a n d f u n c t i o n a l c a p a c i t y (Auslander  e l d e r l y women's p e r c e p t i o n s  for care  as t h e y  Perceived  and s u p p o r t f o ra  r e t u r n home a l o n e  o f t h e need  after a  fall.  Need f o r C a r e and S u p p o r t  Besides the  &  These f i n d i n g s a r e r e l e v a n t as t h i s w r i t e r  attempts t o describe  hospitalization  persons  t o be r e c i p i e n t s o f f o r m a l  i n the use of formal supports  1990).  questioned  differentiate  I n summary, t h e s t u d i e s i n d i c a t e d t h a t e l d e r l y  supports.  on t h e  Even though t h e Norbeck S o c i a l S u p p o r t  been u s e d p r i m a r i l y w i t h y o u n g e r p o p u l a t i o n s .  types  rely.  one l i m i t a t i o n  has  three  could  identifying  n e e d s and p r o v i d i n g s e r v i c e s t o meet  needs from t h e h e a l t h p r o f e s s i o n a l s ' p e r s p e c t i v e o r  arena,  i ti s imperative  that the e l d e r l y p a r t i c i p a t e i n the  assessment o f needs, s e t t i n g o f p r i o r i t i e s , outcomes  (Canadian M e d i c a l  and e v a l u a t i o n o f  A s s o c i a t i o n , 1987; Hauser, 1987;  National Advisory  Council  on A g i n g , 1 9 8 1 ) .  As w e l l , attempts  must be made t o a d d r e s s i n d i v i d u a l c l i e n t ' s models w h i c h c o n t a i n for  care  i n t e r p r e t a t i o n s of the perceived  and s u p p o r t i n t h e community.  literature  explanatory  review w i l l  This  deal with perceived  need  s e c t i o n of the  n e e d s f o r c a r e and  s u p p o r t as they r e l a t e t o s e r v i c e u t i l i z a t i o n  and  discharge  planning. The  area of service u t i l i z a t i o n  According  t o C o u l t o n and F r o s t  criterion  f o rservice u t i l i z a t i o n .  both s u b j e c t i v e perceptions judgements  will  first.  ( 1 9 8 2 ) , need f a c t o r s a r e a These f a c t o r s c o m p r i s e  (self-assessed)  (professionally evaluated).  theoretical  be a d d r e s s e d  and o b j e c t i v e  According  f r a m e w o r k , need f a c t o r s w o u l d  t o the  involve  both  p r o f e s s i o n a l and p o p u l a r EMs. I n many s i t u a t i o n s , h e a l t h p r o f e s s i o n a l s  structure  s e r v i c e s on t h e b a s i s o f a h y p o t h e t i c a l t a r g e t rather  t h a n on t h e b a s i s o f s e l f - r e p o r t e d n e e d by e l d e r l y  service "It  population  r e c i p i e n t s (Connidis,  i s often  1985; W i l s o n & N e t t i n g ,  t h e case t h a t program o r agency f u n d i n g i s  r e l i a n t upon d e m o n s t r a t e d need b a s e d upon c a s e (Connidis, interest  1987).  1 9 8 5 , p. 4 ) . As a r e s u l t ,  i n documenting a high  load"  a g e n c i e s have a  demand f o r t h e i r  vested  services.  U s i n g Kleinman's t h e o r e t i c a l framework, s e r v i c e s a r e then b a s e d o n t h e EMs o f p r o f e s s i o n a l s i n d i v i d u a l s within the popular  rather  arena.  t h a n t h e EMs o f  28 I n one s t u d y  (Wilson  & Netting,  1987), there  d e g r e e o f i n c o n g r u e n c e between t h e p e r c e p t i o n e l d e r l y and t h o s e o f t h e p r o f e s s i o n a l s . indicated  i n contrast  overestimated  them.  o f needs o f t h e  One s p e c i f i c  that the e l d e r l y underestimated  disabilities  was a h i g h  their  finding  physical  t o h e a l t h p r o f e s s i o n a l s who  O v e r a l l , W i l s o n and N e t t i n g  concluded  t h a t h e a l t h p r o f e s s i o n a l s were n o t good p r e d i c t o r s o f t h e health  s t a t u s o r needs o f t h e e l d e r l y .  Starrett existed the  b e t w e e n t h e demand f o r s e r v i c e s by t h e e l d e r l y and  evaluation  well, the  ( 1 9 8 6 ) , i n h i s s t u d y , a l s o c o n c l u d e d t h a t a gap  this  o f n e e d s by t h e " e x p e r t "  study concluded  a r e a o f home c a r e  sociopsychological support.) consider only,  should  variables  the providers  States.  o f home  factors  1985; S t a r r e t t , 1986; W i l s o n & N e t t i n g ,  health  care  care  The s t u d i e s  support t o the thought that the e l d e r l y ' s  their  with  caregiver  and r e h a b i l i t a t i o n  i n b o t h C a n a d a and t h e U n i t e d  strong  programs that d e a l  (i.e., counselling,  the t r a d i t i o n a l health  As  f u t u r e program development i n  consider  At the present time,  (Connidis,  of  that  professional.  1987) l e n d perceptions  needs may n o t a l w a y s be c o n g r u e n t  with  the p r o f e s s i o n a l s c o m p l e t i n g t h e assessment. Several  studies  (Harding  & Modell,  1 9 8 9 ; Nay l o r , 1 9 9 0 ;  S c h a e f e r , A n d e r s o n , & Simms, 1 9 9 0 ; V i c t o r & V e t t e r , 1988) deal with for  the process of discharge  elderly individuals.  This  planning  i s important  i n the h o s p i t a l because  29 discharge planning professional  i n the h o s p i t a l  i s often  the f i r s t  c o n t a c t t o a s s e s s t h e p e r s o n ' s need f o r c a r e and  support a f t e r d i s c h a r g e from t h e h o s p i t a l . EMs o f t h e p r o f e s s i o n a l s  Here, a g a i n , t h e  may n o t be c o n g r u e n t w i t h t h e EMs o f  individuals. The elderly  first  study  individual's  ( H a r d i n g & M o d e l l , 1989) d e s c r i b e d t h e e x p e r i e n c e o f d i s c h a r g e from  A q u e s t i o n n a i r e was d e v e l o p e d and p i l o t beginning  the study.  interviewed within hospital. variety  The r e s u l t s  by f a m i l y ,  provided.  t h e y had r e q u i r e d  14  individuals  receiving  f r i e n d s , or that  by  Of  family,  individuals  the importance of  help appropriate t o their  and V e t t e r ' s  (1988) d e s c r i p t i v e  random s a m p l e o f 2,711 p a r t i c i p a n t s older.  38  A l t h o u g h t h i s s t u d y d i d n o t a d d r e s s any s p e c i f i c  p e r c e i v e d needs a t t h e time o f d i s c h a r g e from  and  that  more h e l p a t home t h a n was  n e e d s f o r c a r e and s u p p o r t , i t s t r e s s e d  Victor  for a  (42%) f e l t  77 i n d i v i d u a l s who were v i s i t e d  that  from  more h e l p a t home t h a n was p r o v i d e d .  n e i g h b o u r s , and/or p r o f e s s i o n a l s ,  felt  elderly  indicated  S i x t e e n o f t h e 38 i n d i v i d u a l s  remaining  friends, (18%)  had been h o s p i t a l i z e d  (33%) were n o t v i s i t e d  t h e y had r e q u i r e d the  f o u r weeks o f t h e i r d i s c h a r g e  of medical reasons.  neighbours.  prior to  One h u n d r e d and f i f t e e n p e o p l e were  The i n d i v i d u a l s  individuals  tested  hospital.  hospital.  study involved  a  who were 65 y e a r s o f age  T h r e e months a f t e r d i s c h a r g e f r o m h o s p i t a l , a  30  q u e s t i o n n a i r e was m a i l e d  to a l lparticipants.  q u e s t i o n n a i r e was t e s t e d f o r t e s t / r e t e s t specific  testing  concluded  forvalidity  The  reliability.  was m e n t i o n e d .  No  The s t u d y  t h a t 50% o f t h e s a m p l e was d i s c h a r g e d home w i t h o u t  any d i s c u s s i o n o f t h e i r c a r e n e e d s a t home.  This  i s an  i n t e r e s t i n g p o i n t and h a s r e l e v a n c e a s one d o e s r e s e a r c h elderly  females  Schaefer  with  r e t u r n i n g home f r o m h o s p i t a l .  e t a l . (1990)  studied the perceptions of  r e a d i n e s s f o r d i s c h a r g e and t h e need f o r f a m i l y and c o m m u n i t y resources  a t home among p e r s o n s  questionnaire served  as t h e d a t a c o l l e c t i o n  reliability  and v a l i d i t y  discussed.  The r e s u l t s  for  aged 65 y e a r s and o l d e r . instrument.  The  o f t h e q u e s t i o n n a i r e were n o t indicated  that post discharge  assistance included bathing, medications,  shopping,  A  needs  housekeeping,  m e a l p r e p a r a t i o n , t r a n s p o r t a t i o n , and wound c a r e .  The s t u d y ' s  r e s u l t s have l i m i t e d  generalizability  t o other  e l d e r l y p o p u l a t i o n s , due t o s a m p l e s i z e a n d t h e f a c t t h a t t h e m a j o r i t y o f t h e s a m p l e were As w e l l , difficult  the l i t e r a t u r e  t o address  (Connidis, 1985).  married. i n d i c a t e s t h a t i t may be  perceptions with a questionnaire  format  A q u e s t i o n n a i r e i s c o n s i d e r e d an  a p p r o p r i a t e d a t a c o l l e c t i o n method Since perception i s being  for quantitative studies.  there t o see, t o hear, t o  experience,  and t o know, i t i s b e s t a d d r e s s e d  qualitative  r e s e a r c h d e s i g n such  through  as phenomenology  a  (Munhall &  31 O i l e r , 1986). assessed  As a r e s u l t , the q u e s t i o n n a i r e  needs r a t h e r than p e r c e i v e d  l i m i t a t i o n , Schaefer's  needs.  addressed Despite  this  (1990) study was an attempt t o look a t  areas where people r e q u i r e a s s i s t a n c e a f t e r d i s c h a r g e the  self-  from  hospital. In c o n c l u s i o n , a r e c u r r e n t theme throughout the  literature  i s that h e a l t h p r o f e s s i o n a l s must s t a r t t o  document the p e r c e i v e d individuals  need f o r care and support  r e t u r n i n g home from h o s p i t a l .  review i n d i c a t e s that the i n d i v i d u a l s ' care and support situations,  The l i t e r a t u r e  perceived  t h e i r perceptions  are not even addressed.  As a  remains r e l e v a n t and necessary  s i n c e i t w i l l d e s c r i b e the p e r c e i v e d  need f o r care and  of e l d e r l y women r e t u r n i n g home alone  hospitalization  need f o r  i s not only misunderstood, but, i n many  r e s u l t , the proposed research  support  of e l d e r l y  after  for a f a l l . Summary  Chapter Two has provided s o c i a l support, The  a l i t e r a t u r e review on f a l l s ,  and the p e r c e i v e d need f o r care and support.  review presented  the c u r r e n t t h e o r e t i c a l  f i n d i n g s i n a l l three areas.  and research  As already mentioned, there  were no s t u d i e s that addressed how the p s y c h o l o g i c a l and/or p h y s i c a l consequences of a f a l l perceptions  may a f f e c t an o l d e r woman's  of the need f o r care and support  hospitalization  for a f a l l .  after  As w e l l , the importance of  32  l i v i n g alone was s t r e s s e d as these women draw on a i d from both i n f o r m a l and formal support networks as they attempt to meet t h e i r need f o r care and support i n the home s e t t i n g .  In  a d d i t i o n , the review i n d i c a t e d that an i n d i v i d u a l ' s need f o r care and support i s not only misunderstood situations,  but, i n many  the need i s not even addressed as they leave the  h o s p i t a l s e t t i n g t o r e t u r n home.  The next chapter  will  present a d i s c u s s i o n of the methodology f o r the proposed research.  33  CHAPTER THREE: METHODOLOGY Introduction In t h i s discussed. in Chapter  third  chapter,  Phenomenology One.  t h e methodology o f the study i s  h a s a l r e a d y been b r i e f l y  Due t o i t s d i f f e r e n c e f r o m t h e q u a n t i t a t i v e  r e s e a r c h method, t h e f i r s t the m e t h o d o l o g i c a l  s e c t i o n of t h i s chapter  issues.  This  i s f o l l o w e d by t h e  d i s c u s s i o n on t h e s e l e c t i o n o f p a r t i c i p a n t s . includes the selection c r i t e r i a ,  c o l l e c t i o n and d a t a a n a l y s i s p r o c e s s e s  Methodological  t o be b o t h  Lastly,  the data  are discussed.  Issues  i sa qualitative  i t i s considered  This discussion  r e c r u i t m e n t p r o c e d u r e s , and  the c h a r a c t e r i s t i c s o f t h e p a r t i c i p a n t s .  Phenomenology  addresses  The e t h i c a l c o n s i d e r a t i o n s o f t h e  proposed study a r e then addressed.  well,  described  r e s e a r c h method.  a philosophy  approach.  The g o a l o f p h e n o m e n o l o g i c a l  understand  human e x p e r i e n c e  As  and a n  research  i s to  from the i n d i v i d u a l ' s  perspective. The c r i t e r i a reviewed. value,  for evaluating qualitative  These c r i t e r i a  (b) a p p l i c a b i l i t y ,  neutrality.  r e s e a r c h w i l l be  consist of the following: (c) c o n s i s t e n c y , and (d)  (a) t r u t h  34 Truth  Value "The  t r u t h value of a q u a l i t a t i v e  investigation  g e n e r a l l y r e s i d e s ' i n the d i s c o v e r y of human phenomena or experiences as they are l i v e d  and p e r c e i v e d by s u b j e c t s ,  r a t h e r than i n the v e r i f i c a t i o n of a p r i o r i conceptions of these e x p e r i e n c e s " different  (Sandelowski,  1986,  p. 30).  This i s  from q u a n t i t a t i v e research where the t r u t h value,  typically called similarity they r e l a t e  i n t e r n a l v a l i d i t y , depends on the degree of  between the study data and (Guba & L i n c o l n ,  1981).  T h e r e f o r e , Guba and L i n c o l n credibility  the phenomena to which  (1981) suggest that  r a t h e r than i n t e r n a l v a l i d i t y be the c r i t e r i o n  which the t r u t h value of q u a l i t a t i v e  by  research i s e v a l u a t e d .  As a r e s u l t , the q u a l i t a t i v e r e s e a r c h e r i s most with t e s t i n g the c r e d i b i l i t y of f i n d i n g s and  concerned  interpretations  with the v a r i o u s sources from which the data are drawn. Applicability The second  criterion  i s a p p l i c a b i l i t y which r e f e r s to  f i t t i n g n e s s i n the q u a l i t a t i v e study and e x t e r n a l v a l i d i t y i n the q u a n t i t a t i v e study  (Guba & L i n c o l n , 1981).  i s when the f i n d i n g s of the study,  Fittingness  "whether i n the form of  d e s c r i p t i o n , e x p l a n a t i o n , or theory, which they are d e r i v e d " (Sandelowski,  'fit' 1986,  quantitative studies, external v a l i d i t y  the data  from  p. 32).  r e f e r s to the  In  generalizability  o f f i n d i n g s and  s u b j e c t s , t e s t s and  the r e p r e s e n t a t i v e n e s s of  conditions for testing  (Sandelowski,  1986). At i s s u e f o r t h i s c r i t e r i o n sampling  to ensure  (Sandelowski,  r e p r e s e n t a t i v e n e s s and  1986).  s i z e s a r e s m a l l e r due i n t e r v i e w s and 1983;  are the t e c h n i q u e s  In q u a l i t a t i v e  1986).  As w e l l ,  i s researching.  predetermined  sample  t o the l e n g t h of the d a t a - g a t h e r i n g  the s t u d y because t h e y have l i v e d investigator  generalizability  s t u d i e s , the  the d e t a i l of the complete  Sandelowski,  description  the experience  be  further  the  not  selection  p a r t i c i p a n t s , d e p e n d i n g on  t h e f i n d i n g s t h a t emerge  throughout  sample s i z e  The  i f s u b j e c t s i n the sample belong  who  the e x p e r i e n c e .  studies  c o n t r a s t , the sampling  techniques  i n c l u d e random s e l e c t i o n and  p a r t i c i p a n t s t o e x p e r i m e n t a l and sample s i z e s are predetermined  be  t o the group  As w e l l , r e p r e s e n t a t i v e n e s s  r e f e r s t o the data r a t h e r than the s u b j e c t s or In  of  i s considered to  representative have l i v e d  (Ornery,  s u b j e c t s are chosen f o r  Sample s i z e s are  b e c a u s e t h e r e may  the study.  used f o r  settings.  in quantitative  assignment of  c o n t r o l groups.  prior  As  to beginning  well,  data  collection. Consistency The  third  auditability  criterion  i s c o n s i s t e n c y which  i n q u a l i t a t i v e s t u d i e s and  pertains to  reliability  in  36  quantitative research the  studies  (Guba & L i n c o l n , 1981) .  Qualitative  emphasizes the "uniqueness of human s i t u a t i o n s and  importance of experiences that are not n e c e s s a r i l y  accessible 1986,  t o v a l i d a t i o n through the senses"  (Sandelowski,  p. 33). T h e r e f o r e , a u d i t a b i l i t y i s the c r i t e r i o n  should be used with q u a l i t a t i v e r e s e a r c h .  that  A study and i t s  f i n d i n g s are a u d i t a b l e  when another researcher i s able t o  follow  of events i n the study and understand  the p r o g r e s s i o n  their  logic.  audit  trail  Another term f o r t h i s i s the d e c i s i o n  t r a i l or  (Guba & L i n c o l n , 1981).  Reliability  in quantitative  research  r e s t s on the  assumption that the same data w i l l be c o l l e c t e d each time i n repeated o b s e r v a t i o n s of the same phenomena and that  there i s  an o b s e r v a b l e r e g u l a r i t y about human experience that  isa  f u n c t i o n of the experience not as a r e s u l t of the t e s t i n g procedure  (Babbie, 1986; Sandelowski, 1986).  Neutrality The  last factor  confirmability quantitative  i s n e u t r a l i t y which r e f e r s t o  i n q u a l i t a t i v e studies  research.  is established  Confirmability  in qualitative  studies  when a u d i t a b i l i t y , t r u t h value, and  a p p l i c a b i l i t y are present objectivity  and o b j e c t i v i t y i n  i n the study.  in quantitative  studies  In c o n t r a s t ,  i s achieved when  r e l i a b i l i t y and v a l i d i t y are e s t a b l i s h e d I t should be noted that Sandelowski  (Sandelowski, 1986). (1986) notes two  37 biases and  in qualitative  "holistic  research.  fallacy."  They a r e t h e " e l i t e  The e l i t e  bias"  b i a s must be r e c o g n i z e d i n  q u a l i t a t i v e s t u d i e s i n t h a t t h e s u b j e c t s who p a r t i c i p a t e i n the study  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 ,  h i g h - s t a t u s members o f t h e i r g r o u p " 32).  The h o l i s t i c  data  (Sandelowski,  1 9 8 6 , p.  r e f e r s t o the tendency  l o o k more p a t t e r n e d o r c o n g r u e n t  result, all  fallacy  accessible,  than  t o make t h e  they a r e .  the study's conclusions are presented  As a  as r e p r e s e n t i n g  the data.  Procedure  f o r P r o t e c t i o n o f Human R i g h t s  The a p p r o v a l o f t h e UBC B e h a v i o u r a l S c i e n c e s Committee f o r Research  and O t h e r  S u b j e c t s was o b t a i n e d p r i o r  Screening  S t u d i e s I n v o l v i n g Human  to data c o l l e c t i o n .  The  s t a n d a r d s , as a p p r o v e d by t h e c o m m i t t e e , were f o l l o w e d throughout  the study.  A l l p a r t i c i p a n t s were a s k e d ( s e e A p p e n d i x A) t o e n s u r e In  securing consent,  t o s i g n a consent  form  p r o t e c t i o n o f t h e i r human  each p a r t i c i p a n t  rights.  r e c e i v e d a v e r b a l and  w r i t t e n e x p l a n a t i o n of the purpose of the study, the nature of and  their  requested  involvement,  t h e amount o f t i m e r e q u i r e d ,  t h e means o f e n s u r i n g c o n f i d e n t i a l i t y  (see Appendix B ) .  The p a r t i c i p a n t s were a l s o a d v i s e d t h a t t h e y were f r e e t o w i t h d r a w f r o m t h e s t u d y a t any t i m e w i t h o u t their  compromising  r i g h t s f o r any t y p e o f s e r v i c e . The t a p e d  i n t e r v i e w s were c o d e d s o t h a t t h e  38 c o n f i d e n t i a l i t y o f t h e s u b j e c t s was  ensured.  The  data  was  n o t s h a r e d w i t h anyone e l s e b e s i d e s t h e t h e s i s  committee  members.  names i n  As w e l l ,  discussing writing could  t h e r e was  no m e n t i o n  t h e d a t a w i t h t h e t h e s i s c o m m i t t e e members.  the t h e s i s ,  identify  t h e s i s was  t h e r e was  the s u b j e c t s .  The lived  no  information reported that  A l l t a p e s were e r a s e d once  following 1.  Criteria s u b j e c t s were c h o s e n f o r t h e s t u d y b e c a u s e  f o r s e l e c t i o n d e s c r i b e d each  2.  they  researching.  individual  The  i n the  manner: F e m a l e , 75 y e a r s o f age o r o l d e r , and  e x p e r i e n c e d a f a l l which treatment  the  Participants  t h e e x p e r i e n c e t h e i n v e s t i g a t o r was  criteria  In  completed. S e l e c t i o n of  Selection  o f any  results  have  in a hospitalization  or  i n an E m e r g e n c y a n d / o r O u t p a t i e n t D e p a r t m e n t . Living  p a r t of a care  a l o n e i n a house or apartment  i s not  facility.  3.  Able to converse  4.  Living  5.  Alert  fluently  i n the C i t y of and  orientated  in English.  Vancouver. t o t i m e , p e r s o n , and p l a c e w i t h  no s i g n i f i c a n t c o g n i t i v e  impairment  f o l l o w i n g d i s c h a r g e from  hospital.  Recruitment  which  prior  to admission  or  Procedure  A s p e c i f i c procedure  t o a c q u i r e p a r t i c i p a n t s was  planned  39  and  followed.  The  U n i v e r s i t y of B r i t i s h Columbia  Screening  Approval  f o r t h e r e s e a r c h was o b t a i n e d  Committee f o r Research  Human S u b j e c t s .  (UBC) B e h a v i o u r a l  from Sciences  and O t h e r S t u d i e s I n v o l v i n g  A t t h e same t i m e , t h e E x e c u t i v e O f f i c e r f o r  N u r s i n g w i t h t h e V a n c o u v e r H e a l t h D e p a r t m e n t was c o n t a c t e d t o o b t a i n permission f o r the study. Nursing  agency's p e r m i s s i o n  (MSJ) was c o n t a c t e d  to recruit  l i a i s o n nurses  (STAT)  to obtain  this  subjects f o rthe study.  P a r t i c i p a n t s were r e c r u i t e d  from t h e community h e a l t h  (CHLNs) who f u n c t i o n a s d i s c h a r g e p l a n n e r s a t  Vancouver h o s p i t a l s .  P a r t i c i p a n t s were a l s o  recruited  t h e home c a r e c o o r d i n a t o r s a t t h e h e a l t h u n i t s  operated  by t h e C i t y o f V a n c o u v e r H e a l t h D e p a r t m e n t .  w e l l , p a r t i c i p a n t s were r e c r u i t e d STAT u n i t The  the D i r e c t o r of  f o r t h e S h o r t Term A s s e s s m e n t and T r e a t m e n t  U n i t a t Mount S a i n t J o s e p h  through  As w e l l ,  As  f r o m t h e head n u r s e  of the  a t MSJ. CHLNs, home c a r e c o o r d i n a t o r s , and head n u r s e  were  provided w i t h a w r i t t e n d e s c r i p t i o n o f the purpose o f the study  and t h e s a m p l e s e l e c t i o n  identified  criteria.  These p r o f e s s i o n a l s  p o t e n t i a l subjects f o r the study.  As w e l l ,  they  g a v e a v e r b a l e x p l a n a t i o n o f t h e s t u d y and p r o v i d e d t h e i n d i v i d u a l s w i t h an i n f o r m a t i o n l e t t e r (see A p p e n d i x B ) . permission contact  from t h i s  These p r o f e s s i o n a l s a l s o o b t a i n e d  from t h e i n d i v i d u a l s f o r t h i s  them.  researcher  researcher to  40  C h a r a c t e r i s t i c s of the P a r t i c i p a n t s There  were e i g h t  They r a n g e d eight  women who p a r t i c i p a t e d  i n age f r o m 75 t o 102 y e a r s o f a g e . O f t h e  i n d i v i d u a l s who w i s h e d  f i v e were r e f e r r e d  t o p a r t i c i p a t e i n t h i s study,  t o t h i s r e s e a r c h e r a t the time o f t h e i r  d i s c h a r g e from h o s p i t a l . sustained h i p fractures  Three  o f t h e f i v e women had  and were r e f e r r e d  rehabilitation unit within who  i n the study.  from a g e r i a t r i c  an a c u t e c a r e f a c i l i t y .  One woman  s u s t a i n e d i n j u r i e s t o h e r l o w e r back was r e f e r r e d  to this  r e s e a r c h e r a f t e r t r e a t m e n t a t a h o s p i t a l Emergency Department.  The l a s t woman was r e f e r r e d  upon h e r d i s c h a r g e  f r o m a s u r g i c a l ward i n an a c u t e c a r e f a c i l i t y . she s u s t a i n e d e x t e n s i v e l a c e r a t i o n s required The  r e m a i n i n g t h r e e women were r e f e r r e d  them.  One woman f r a c t u r e d  o t h e r woman s u s t a i n e d l a c e r a t i o n s  woman was r e f e r r e d  Even though  f o r attendance  by t h e home  her w r i s t .  t o her face.  As s t a t e d  The l a s t  a t t h e Day H o s p i t a l .  she d i d n o t have any s p e c i f i c i n j u r i e s ,  r e o c c u r r e d on a f r e q u e n t  her f a l l s  basis.  i n the c r i t e r i a  a l o n e a t home.  apartment  that  by t h e n u r s e a s s e s s o r a t t h e STAT u n i t .  was b e i n g s c r e e n e d  lived  legs  from t h e  Two o f t h e t h r e e women were r e f e r r e d  care s t a f f v i s i t i n g  She  lower  skin grafting.  community.  The  t o both  I n her f a l l ,  f o r t h e s t u d y , a l l t h e women  Seven o f t h e e i g h t  o r condominium complexes.  women l i v e d i n  The 1 0 2 - y e a r - o l d woman  41  was s t i l l  living  i n h e r own home.  T h r e e o f t h e e i g h t women h a d e x p e r i e n c e d  previous  falls.  Two o f t h e t h r e e women r e p o r t e d  t h a t t h i s was t h e i r  fall.  t h a t t h i s was h e r t w e l f t h  The t h i r d woman r e p o r t e d  second  fall. F o u r o f t h e e i g h t women were u n a b l e t o e x p l a i n t h e reason f o r t h e i r  fall.  undergoing extensive women i d e n t i f i e d  medical  reported  investigations.  the reason f o r t h e i r  f o u r women i d e n t i f i e d extrinsic  One o f t h e s e women was p r e s e n t l y four  Three o f the  an e n v i r o n m e n t a l h a z a r d a s p a r t o f t h e  cause f o r t h e i r tripping  fall.  The o t h e r  fall.  F o r e x a m p l e , one woman  on h e r b e d s p r e a d .  a s w e a t e r t h a t was t a n g l e d One woman i d e n t i f i e d  A n o t h e r woman t r i p p e d on  i n a chair. an i n t r i n s i c  The woman who had f a l l e n t w e l v e  cause f o r her f a l l s .  times stated that her f a l l s  were due t o e p i s o d e s o f w e a k n e s s t h a t were due t o a n e u r o muscular  disorder.  F o u r o f t h e e i g h t women r e p o r t e d living had  i n t h e Lower M a i n l a n d A r e a .  phone c o n t a c t  o r saw t h e i r  reported  T h r e e o f t h e s e f o u r women  c h i l d r e n on a f r e q u e n t  Two o f t h e e i g h t women r e p o r t e d consisted of nieces  and nephews.  that  their  The o t h e r  no f a m i l y w i t h i n t h e a r e a .  of f r i e n d s .  t h a t t h e y had c h i l d r e n  Their  family  basis.  support  t w o women supports  consisted  Data C o l l e c t i o n Since phenomenology was the chosen research d e s i g n , the i n t e r v i e w was the a p p r o p r i a t e process f o r data  collection.  T h i s w r i t e r a c t i v e l y engaged i n the i n t e r a c t i v e process and thereby entered i n t o the world of those people whose experiences were under study  (Oiler,  1982).  T h i s allowed  t h i s w r i t e r t o get as c l o s e as p o s s i b l e t o the s u b j e c t ' s experiences before attempting Effective listening technique of  to interpret  skills  (Knaack, 1984).  the e f f e c t i v e l i s t e n i n g  were used  i n the i n t e r v i e w  "The use of ' b r a c k e t i n g ' was p a r t skills.  T h i s s k i l l allowed  w r i t e r t o put aside any preconceived phenomenon  them.  thoughts  being s t u d i e d " ( O i l e r , 1982).  about the  I t allowed  i n f o r m a t i o n from the experience t o be understood i t was presented  ( G i o r g i , 1986).  this  p r e c i s e l y as  The use of b r a c k e t i n g  e s t a b l i s h e d the c r e d i b i l i t y or t r u t h value of the study and, t h e r e f o r e , ensured  that the study's f i n d i n g s were  r e p r e s e n t a t i v e of the true phenomenon as d e s c r i b e d by the subjects. All  i n t e r v i e w s were conducted  i n t e r v i e w s ranged tape-recorded. field used  notes.  from  by t h i s w r i t e r .  The  30 to 60 minutes i n l e n g t h , and were  As w e l l , t h i s w r i t e r made some w r i t t e n or A s e t of open-ended or t r i g g e r q u e s t i o n s were  t o guide the i n t e r v i e w (see Appendix C ) .  These  q u e s t i o n s helped the w r i t e r t o avoid p u t t i n g p e r s o n a l  43 i n t e r p r e t a t i o n s on t h e s u b j e c t s ' s t a t e m e n t s . data a n a l y s i s proceeded, based Four  new t r i g g e r  However, as t h e  q u e s t i o n s were  on t h e p r e v i o u s d a t a a n a l y s i s f r o m e a r l i e r o f e i g h t women p a r t i c i p a t e d  purpose  o f the second  participants understood  i n second  interviews.  interviews.  The  i n t e r v i e w was t o v e r i f y w i t h t h e  t h a t t h e meaning o f t h e e x p e r i e n c e  correctly  developed  by t h e r e s e a r c h e r  (Knaack,  was 1984).  Once  a g a i n , the i n t e r v i e w t e c h n i q u e evoked d e s c r i p t i o n from the p a r t i c i p a n t s without t e l l i n g  them what t o s a y .  v e r i f i c a t i o n of the data helped the  to establish  The  c r e d i b i l i t y of  study. Data A n a l y s i s The p r o c e s s o f d a t a c o l l e c t i o n  with data analysis.  A l l taped  a t y p i s t or t h i s w r i t e r . subsequently and  checked  occurred simultaneously  i n t e r v i e w s were t r a n s c r i b e d  A l l transcriptions  by t h e w r i t e r  were t h e n c o r r e c t e d t o e n s u r e  were  by l i s t e n i n g  reading the text simultaneously.  by  t o the tapes  A l l misconstrued  verbatim accounts  words  of the taped  interviews. Data Georgi  a n a l y s i s was done f o l l o w i n g  (1985) .  description  The f i r s t  the steps o u t l i n e d  s t e p was t o r e a d t h e e n t i r e  t o g e t a sense  of the whole.  The s e c o n d  t o r e a d t h e d e s c r i p t i o n s more s l o w l y and i d e n t i f y t h e meaning u n i t s or themes. eliminating  redundancies  by  This step also c o n s i s t e d of i n the u n i t s , c l a r i f y i n g or  step  was  44 elaborating  t h e meanings of t h e remaining  them t o e a c h o t h e r  and t o t h e w h o l e .  u n i t s by  relating  The m e a n i n g u n i t s t h a t  were c o n s t i t u t e d by t h i s p r o c e d u r e were v i e w e d as constituents. determined  According  t o G i o r g i (1985),  i n s u c h a way t h a t i t was  The t h i r d  i n t o concepts  transformations  place b a s i c a l l y  to  context-laden.  s t e p was t h e t r a n s f o r m a t i o n o f t h e s u b j e c t ' s  everyday expressions  of r e f l e c t i o n  a c o n s t i t u e n t was  took  of science. through  and i m a g i n a t i v e v a r i a t i o n .  a  process  The l a s t  i n t e g r a t e and s y n t h e s i z e t h e i n s i g h t s  i n t o an  d e s c r i p t i o n o f t h e phenomena o f t h e p e r c e i v e d and  Here, the  step  was  exhaustive  need f o r c a r e  support. The d a t a  a n a l y s i s i n Chapter Four w i l l  the use o f a c l e a r d e c i s i o n t r a i l . establish  auditability  be a r t i c u l a t e d  This w i l l  by  help to  of the study. Summary  This chapter design  examined the p h e n o m e n o l o g i c a l  used f o r t h i s  qualitative  study.  The c r i t e r i a  s t u d i e s was d i s c u s s e d .  for evaluating  The p r o c e d u r e f o r  t h e p r o t e c t i o n o f Human R i g h t s was p r e s e n t e d Following  research  t h i s d i s c u s s i o n , the c r i t e r i a  in this  chapter.  f o r s e l e c t i o n of  participants  and t h e r e c r u i t m e n t p r o c e d u r e were o u t l i n e d .  This chapter  also contained  participants.  Lastly,  a d e s c r i p t i o n of the  the process  a n a l y s i s o f d a t a was d i s c u s s e d . the  r e s u l t s of the data a n a l y s i s .  study's  f o r t h e c o l l e c t i o n and  The n e x t  chapter  contains  45  CHAPTER FOUR: DATA ANALYSIS Introduction The chapter  r e s u l t s of the data and d i s c u s s e d  theoretical currently  a n a l y s i s are presented  i n t h e next  chapter,  l i t e r a t u r e and r e s e a r c h  i n this  using the relevant  findings that are  available.  This chapter  provides  an i n d e p t h  phenomenon t h a t s u r f a c e d d u r i n g of t h e d a t a . significant  I t begins event,  exploration of the  t h e c o l l e c t i o n and a n a l y s i s  with a d e s c r i p t i o n of the f a l l  and p r o g r e s s e s  as a  t o a d e s c r i p t i o n of the  treatment  r e c e i v e d w i t h i n t h e H e a l t h Care System.  Following  this,  t h e c h a n g e s i n r o u t i n e upon t h e i r  home a r e d e s c r i b e d by t h e e l d e r l y women. a d e s c r i p t i o n of the threat t o t h e i r  This  discharge  i s f o l l o w e d by  s e l f - e s t e e m as t h e y  responded t o t h e changes i n t h e i r  routine.  how t h e women c o p e d w i t h t h e f a l l  and t h e s u b s e q u e n t t h r e a t s  to  their  self-esteem concludes  Two p r e d o m i n a n t c o n c e p t s were a s k e d t o d e s c r i b e t h e i r perceived  and  first  experience  i n relation  as they  returned  women to their home  fora f a l l .  c o n c e p t was s e l f - e s t e e m .  v e r i f i c a t i o n of the data,  treatment  chapter.  emerged a s t h e e l d e r l y  need f o r c a r e and s u p p o r t  after hospitalization The  this  A discussion of  From t h e a n a l y s i s  i t a p p e a r e d t h a t t h e f a l l and  w i t h i n the Health Care System r e s u l t e d i n p h y s i c a l  46 and p s y c h o l o g i c a l c o n s e q u e n c e s f o r t h e women a s t h e y r e t u r n e d home.  These consequences r e s u l t e d  home f o r them. differently  they viewed  than they d i d p r i o r  independence, self-esteem The  As a r e s u l t ,  i n a change o f r o u t i n e a t themselves  to the f a l l .  The themes o f  a c t i v i t y , and autonomy were i n t e r w o v e n i n t o t h e concept.  a d a p t a t i o n p r o c e s s was t h e s e c o n d  concept  that  emerged f r o m t h e a n a l y s i s o f t h e d a t a f r o m t h e e l d e r l y The  women t a l k e d  about  b e h a v i o u r s used  t o cope w i t h t h e  c h a n g e s i n r o u t i n e o n c e t h e y r e t u r n e d home. b e h a v i o u r s used self-esteem.  This  included  t o cope w i t h t h e p e r c e i v e d t h r e a t s t o t h e i r  E a c h woman c o p e d  u n i q u e way.  women.  with the s i t u a t i o n  i n h e r own  H o w e v e r , t h e r e w e r e common c a t e g o r i e s o f  b e h a v i o u r s used.  As w e l l ,  f o c u s e d and e m o t i o n - f o c u s e d  t h e two m a j o r  themes o f p r o b l e m -  c o p i n g b e h a v i o u r s were  identified. Fall  as a S i g n i f i c a n t The  fall  the study.  was a s i g n i f i c a n t  Even though  experience of a f a l l , s e v e r a l women a s k e d this writer. detail. of  Event event  f o r a l l t h e women i n  t h i s s t u d y d i d n o t f o c u s on t h e  during the course of the interview  i f they c o u l d d e s c r i b e t h e i r  The d e s c r i p t i o n s o f t h e f a l l  F o r e x a m p l e , some o f t h e d e t a i l s  e v e n t were r i c h i n i n c l u d e d t h e time  the event, a c t i v i t i e s preceding the f a l l ,  the f a l l  itself,  fall for  and s e q u e n c e o f e v e n t s a f t e r  a description of the f a l l .  The  following descriptions illustrate I'd  these  I was  of  g o i n g o v e r t o my  t h e d r e s s I was  2 - p i e c e d r e s s and t h a t and  daughter's f o r  g o i n g t o wear was  the s k i r t  a  needed p r e s s i n g and  I w a s n ' t r e a c h i n g up h i g h j u s t  I did  from the  second  incident  description gives details  as t o how  the  happened:  I opened t h e f r i d g e d o o r think  i t was  supposed  and g o t s o m e t h i n g  out  t o be a s p r i n g on t h e  and door,  they c l o s e a u t o m a t i c a l l y , but t h i s d i d n ' t c l o s e t h e r e was of  this  the bottom  square  so I grabbed it,  and  vegetable container s t i c k i n g  W e l l , I expected a l i t t l e  to p u l l ,  time  resistance  and  went down, h i t t h e back o f  the c o u n t e r ; I don't  know i f I  t h e c o u n t e r , I h i t t h e b a c k o f t h e k i t c h e n — t h e n I_^  g o t t o t h e phone and phoned my The  out  b e c a u s e y o u ' v e g o t t o s o r t o f yank  I j u s t swung back and  the k i t c h e n cupboards hit  because  s h e l f s o when i t went b a c k t h e n e x t  i t wasn't c l o s e d .  the  handle  t h a t d o o r when I went down.  The  I  study  points:  hung up,  d i n n e r and  f r o m f o u r women i n t h e  friend  and  she came o v e r .  next s u b j e c t d e s c r i b e d the sequence of events  after  fall: T h i s t i m e t h i s was  a terrifying  experience, i t r e a l l y  was.  so h e l p l e s s ,  and  I never  felt  h a p p e n e d i n t h e b a t h r o o m , you  see  I lay there.  I had  three  It  stitches  in  here  (points t o head).  the t a p s , f e l l , water.  My head must o f h i t one o f  I l a y t h e r e on t h e f l o o r , b l o o d and  How I e v e r , t o t h i s d a y , how I e v e r g o t u p ,  g r a b b e d t h e r a g , w i p e d my f a c e , p i c k e d me up a n d w a l k e d o u t o f t h e bedroom. Another  I d o n ' t know.  woman d e s c r i b e d t h e e v e n t s  But I d i d .  after  the f a l l :  W e l l , b e c a u s e I went o u t t h e back o f t h e bus one d a y , and  I l a n d e d up on t h e s i d e w a l k .  down, I c a n ' t g e t u p .  Y o u s e e , when I g e t  S o , I'm t h e r e on my h a n d s and  k n e e s on t h e s i d e w a l k , and some woman came a l o n g and said, fell  "What a r e y o u d o i n g down t h e r e ? "  I said,  o f f t h e b u s , and I c a n ' t g e t up."  c a n ' t g e t u p ? " And I s a i d , r i g h t across the sidewalk myself  u p , y o u know?  embarrassing,  "No."  "Well, I  S h e s a i d , "You  I would have t o c r a w l  t o g e t t o something  to pull  A t my a g e , i t ' s a b i t  really."  H e a l t h Care System All  t h e women t a l k e d  H e a l t h Care System.  about t h e i r  Treatment w i t h i n t h i s  the care w i t h i n t h e i n s t i t u t i o n , the community s e t t i n g . fall  event,  their  experience within the  Similar  system  as w e l l a s t h e c a r e  within  t o the d e s c r i p t i o n of the  s t o r i e s were a l s o d e t a i l e d .  women were d i s s a t i s f i e d  included  w i t h the care they  Most o f t h e  r e c e i v e d from t h e  H e a l t h Care System. One woman d e s c r i b e d t h e e v e n t s p r i o r  t o her discharge.  49 She had r e q u e s t e d  t o be d i s c h a r g e d on F r i d a y , b u t t h e s t a f f  a d v i s e d h e r t h a t s h e had t o w a i t u n t i l Monday. h e r d o c t o r w o u l d be a v a i l a b l e  On  Monday,  to discharge her:  They d i d n ' t e v e n want t o l e t me o u t o f t h e r e . I c o u l d n ' t go o u t a t a c e r t a i n ready  not  I felt  how t h a t s i t u a t i o n made h e r f e e l ,  made h e r f e e l a n g r y b e c a u s e she f e l t listening  to her.  H e r e , t h e woman  d i s s a t i s f a c t i o n with the s t a f f  i n c i d e n t was h e r f i r s t were n o t r e s p e c t e d .  t h a t the s t a f f  regarding their  process.  t h a t her wishes  surrounding  her  ...  i s that the other  o p e r a t i o n s I h a v e e v e r had a t t h e h o s p i t a l t h e y w h e e l e d y o u o u t t o t h e t h i n g , y o u know, w h a t e v e r t h e c a r y o u were g o i n g home i n . B u t , l i s t e n ,  But,  always . . .  I called a  and had t o t a k e my own bag down ( l a u g h s ) .  She s t a t e d t h a t she managed represented  will  facility:  The o n l y t h i n g t h a t s u r p r i s e d me  t a x i by m y s e l f  This  i s discussed.  A n o t h e r woman d e s c r i b e d t h e e v e n t s care  were  i n a b i l i t y to  F u r t h e r d i s c u s s i o n on t h i s p o i n t  from the acute  that  expressed  exposure t o the f a c t  as t h e theme o f autonomy  discharge  t h a t I was  she r e p l i e d  l i s t e n and i n v o l v e h e r i n t h e d e c i s i o n - m a k i n g  occur  said  t o go b u t t h e y d i d n ' t want t o l e t me go home.  When a s k e d it  time.  They  t o do i t .  However, t h i s  process  an i n c o n s i s t e n c y i n h e r c a r e :  f o r a l l my o t h e r , "Don't d o — y o u c a n ' t do i t . "  just s i tthere l i k e  a silly  i n a wheelchair  You  r i g h t down  and y o u d i d n ' t r e a l l y  need i t . You c o u l d have w a l k e d  down. A n o t h e r woman d e s c r i b e d h e r t r i p D e p a r t m e n t f o r back x - r a y s ,  t o an  Emergency  t h r e e weeks a f t e r h e r  original  fall: And, I went  i n t o Emergency  afternoon.  They d i d some t e s t s .  intravenous.  A n d , a t 7:00  g e t t i n g you d r e s s e d . the ambulance w i l l  3 1/2 laid  hours,  me a l l  They p u t me  o'clock,  they  on  said,  "We're  You c a n s i t i n t h e w h e e l c h a i r  properly.  ...  i t was  S o , I was  I finally  cold  there f o r  went o v e r  down on some c h a i r s and a woman t o l d me was made up and n e v e r  and  that the  occupied.  one o f h e r f r i e n d s p i c k e d h e r up and t o o k  s i n c e t h e r e were no a m b u l a n c e s  and  I went up i n t h e  up i n a b l a n k e t .  i n PAIN.  bed I had v a c a t e d Finally,  kept  come." I was o u t t h e r e ;  and I w a s n ' t d r e s s e d ambulance, r o l l e d  and t h e y  h e r home  available.  A n o t h e r woman t a l k e d a b o u t t h e b e d s i d e  care  she  rece i v e d : I like  i t a l o t i n the h o s p i t a l .  But, there could  be  some i m p r o v e m e n t s made t h e r e , e s p e c i a l l y w i t h what  do  you c a l l  these, F i l i p i n o nurses  goodness, they  are rough.  bedside  Oh y e s , d e a r ,  care.  (lowers v o i c e ) .  My  They need more t r a i n i n g i n oh y e s .  I know, e s p e c i a l l y  when t h e p a t i e n t i s h e l p l e s s and s o r e a l l o v e r .  They  51  can't push t h e people the h e l p When a s k e d replied,  around l i k e t h a t .  i s needed.  how t h a t t y p e o f t r e a t m e n t  made h e r f e e l , s h e  "Oh, d e p e n d e n t on o t h e r s , w h i c h I d o n ' t l i k e . "  t h o u g h s t a t e d b r i e f l y , i t was t h e b e g i n n i n g her  self-esteem.  the chapter.  As w e l l ,  T h i s theme w i l l i t was p r o b a b l y  a d a p t a t i o n t o h e r change i n r o u t i n e . developing  new c o p i n g  behaviours,  discussed  later  Community Home C a r e P r o g r a m .  Oh,  H e r e , s h e was as u s i n g  social  T h i s theme w i l l  experience  The f i r s t  a l s o be  with the  woman d e s c r i b e d h e r  w i t h t h e homemakers who were s e n t t o h e r home:  yes, they're h e l p f u l .  The g i r l s  a r e very n i c e .  T h e y ' v e g i v e n me a [ s i c ] sponge b a t h s . Filipinos, thing  of her  i n the chapter.  Two women t a l k e d a b o u t t h e i r  experience  t o the  be d i s c u s s e d l a t e r i n the beginning  such  t o deal with her s i t u a t i o n .  Even  of the threat t o  M o r e s p e c i f i c a l l y , t h i s was r e l a t e d  theme o f i n d e p e n d e n c e .  support  T h a t i s where  they a r e very hard  I resent  isfirst  you'll  [ t i m e ] and y o u h a v e t o t e l l  t o make o u t and a n o t h e r get a d i f f e r e n t  them, h o l l e r  t h e k i t c h e n , where t h i n g s a r e .  They a r e a l l  one e v e r y  from here i n  W e l l now, t h e l i t t l e one  t h a t came t h i s m o r n i n g , s h e knows, s h e ' s b e e n h e r e about f i v e o r s i x t i m e s .  She knows where t h i n g s a r e ,  but  t h e y d o n ' t g i v e y o u one p e r s o n  you  have t o t e l l  them e v e r y  a n d t h e y d o n ' t know;  t i m e a new g i r l  comes; y o u  52  h a v e t o go i n t o a b i g d i s c u s s i o n and t h e y c a n ' t  find  things. When a s k e d  how t h i s made h e r f e e l ,  she r e p l i e d , " F r u s t r a t e d . "  Once a g a i n , t h i s d e s c r i p t i o n s t a t e d some o f t h e p r o b l e m s i n terms o f a c c e p t i n g h e l p from o t h e r s . supports,  the importance  social  o f c o n t i n u i t y o f c a r e and  c o m m u n i c a t i o n were a d d r e s s e d .  As w e l l , t h e work p e r f o r m a n c e  o f t h e i n d i v i d u a l s was i m p o r t a n t . later  In using  This discussion w i l l  occur  i n the chapter. Another s u b j e c t t a l k e d about h e r i n a b i l i t y  to obtain  home h e l p o n c e s h e r e t u r n e d home: Not  only a l i t t l e  tried should  b u t I am r e a l l y p e e v e d a b o u t i t . I  s e v e r a l times I say,  nicey-nice.  and t h e n  t h e y came o v e r  from t h e o f f i c e ,  and t h e y  here,  what  s p o k e t o me  To me, i t w a s n ' t n i c e y - n i c e , i t was j u s t  words t o g e t me t o make me f e e l b e t t e r t o w a r d s  them.  B e c a u s e I was w r o n g e d . She  s t a t e d t h a t s h e was i n i t i a l l y  accepted  and t h e n  t h a t h e r income was t o o h i g h and s h e d i d n o t q u a l i f y help assistance.  None, e v e n a b a t h , w h i c h I  [ s i c ] them t o do b e f o r e when I f e l l  scared the f i r s t  time.  b e c a u s e I was  I begged them t o , j u s t  me a b a t h b u t t h e y d i d n ' t e v e n do t h a t . own, t o o .  f o r home  She i n d i c a t e d :  I h a v e h a d no h e l p a t a l l . beg  told  to give  I d i d i t on my  When a s k e d how s h e f e l t a b o u t  t h e way s h e was t r e a t e d , s h e  responded: Oh, I am r e a l l y d i s a p p o i n t e d . s y s t e m was b e t t e r t h a n t h a t .  I guess I thought t h e And I h e a r d f r o m o t h e r  p e o p l e t h a t t h e y g i v e you h e l p , b u t I never g o t any h e l p at  a l l w h i c h I t h o u g h t was r e a l l y  people l i k e own.  me need any h e l p .  bad. Because,  like  They c a n ' t do i t on t h e i r  B u t we a r e e x p e c t e d t o .  For  t h i s woman, t h i s  for  h e r autonomy.  experience reflected  I t also reflected  a lack of regard  a decision-making  process that d i d not regard her requests f o r help. Another subject's d e s c r i p t i o n of the contact with a n e u r o l o g i s t was d e t a i l e d  i n the following  account.  woman was u n d e r g o i n g m e d i c a l i n v e s t i g a t i o n s  This  t o determine the  reasons f o r her f a l l s : They j u s t s a y t h e m u s c l e s the  a r e d y i n g ; t h i s clown over a t  h o s p i t a l t o l d me, my n e u r o l o g i s t  t o l d me my  and n e r v e s were d y i n g , and when I s a i d , "Nothing."  Very c h e e r f u l l y ,  muscles  "What?" he s a i d ,  he s a y s , "We d o n ' t  know  what c a u s e s i t , s o we d o n ' t know what c u r e s i t , s o come b a c k and s e e me i n a y e a r . "  Y o u know, t h a t ' s  nice,  isn't i t ? When a s k e d how s h e f e l t a b o u t in  the following  him."  statement:  She commented  t h a t , h e r a n g e r was r e f l e c t e d " I t made me f e e l l i k e  kicking  f u r t h e r a s t o how s h e c o p e d w i t h  this  situation: I went b a c k o n c e more and t h e n my d o c t o r i t was t i m e t o go b a c k . him. had  with  [ t h a t ] type  autonomy i n t r y i n g condition.  of  All  treatment.  t o o b t a i n more m e d i c a l  information  o f t h e women t a l k e d a b o u t t h e i r  know v e r y  change i n r o u t i n e  situation  their  fall.  One "Well,  do t h e t h i n g s a f t e r y o u ' v e h a d  t h a t , t h a t y o u c o u l d do b e f o r e . " their  of trying  s u c c i n c t l y t h e change i n h e r r o u t i n e :  w e l l you can't  about  the s i t u a t i o n .  s i n c e c o m i n g home f r o m t h e h o s p i t a l a f t e r  you  t o exert her  H e r e , t h e woman u s e d t h e b e h a v i o u r  woman d e s c r i b e d  back t o  t h a t I was n o t  t h e woman's a b i l i t y  e x e r t some c o n t r o l t o c o p e w i t h  time  I f e l t that I just  t o h a v e a s a y i n t e l l i n g my d o c t o r  This d e s c r i p t i o n reflected  to  "I'm n o t g o i n g  I want t o s e e someone e l s e . "  satisfied  her  I said,  said this  S e v e r a l women commented on  i n t e r m s o f m e a l p r e p a r a t i o n a t home.  d e s c r i p t i o n s were d e t a i l e d i n t h e f o l l o w i n g  These  accounts:  Now s h e ' d made a s a n d w i c h f o r I [ s i c ] e a t f o r l u n c h and t h a t and I t h i n k s h e ' s g o t my s o u p made f o r t o n i g h t , b e c a u s e I ' l l be a l o n e w i t h my w a l k e r  b u t I w i l l have t o c r a w l , w e l l  r i g h t a r o u n d t h e r e y o u know, i t ' s p r e t t y  hard . Not is hard. sore.  that great.  I h a v e t o make my own m e a l s w h i c h  I have t o s t a n d  Then i t g e t s  sore  i n one s p o t and i t g e t s  b e c a u s e my l e g i s really  like  cramps.  55 When t h e l a s t woman was a s k e d t o e x p l a i n more a b o u t why she  felt  i t was h a r d ,  Well, just and  she r e p l i e d :  t o g e t a m e a l , y o u h a v e t o wander o v e r  over there  and i t ' s n o t t h a t e a s y .  wander b a c k and f o r t h .  We h a v e t o  You b r i n g t h i n g s f r o m t h e r e , y o u  m i s s s o m e t h i n g y o u h a v e t o go b a c k , t h i n g s l i k e which For  these  One care to  that  i s n ' t abnormal i n t h e k i t c h e n . women, t h e t e r m " h a r d "  seems t o r e f l e c t  s t r u g g l e f o r them i n m a n a g i n g a t home. t h a t they  here  were i n d e p e n d e n t i n t h e s e subject explained  needs a f t e r  B o t h women  tasks prior  reported  t o the f a l l .  t h e change i n m e e t i n g h e r p e r s o n a l  the f a l l .  fear resulting  a degree of  She d e s c r i b e d  t h i s d i f f i c u l t y due  i n a loss of confidence.  "They b a t h e d me,  s h o w e r e d me, b e c a u s e I was f r i g h t e n e d t o g e t i n t h e shower myself a t f i r s t all  with  this  funny c a s t — t h i s Hoffman t h i n g  with  the metal i n i t . " A n o t h e r woman t a l k e d a b o u t h e r l o s s o f c o n f i d e n c e  resulting  i n a change o f r o u t i n e .  c e r t a i n l y a f t e r having bit  more.  I didn't  had a f a l l .  feel  like  S e v e r a l women r e p o r t e d feelings of fatigue after  going  "You l o s e y o u r I stayed  home a  little  o u t on my own."  a change i n t h e i r  the f a l l .  confidence,  strength or  The f o l l o w i n g t w o  accounts are described: Once y o u a r e h u r t , e s p e c i a l l y when y o u a r e h i t , i t t a k e s a l o t o u t o f you.  Y o u f e e l weak.  I t i s slow.  Really  56  slow.  I was s t r o n g a t one t i m e . I can't  B u t , now I am n o t .  s t a y up l o n g e n o u g h .  I h u r t t h e upper p a r t  o f my b a c k .  The u p p e r p a r t and I g e t t i r e d  s t a y up l o n g  enough.  One woman d e v e l o p e d being  s e n t home.  treatment. time,  o s t e o m y e l i t i s i n her wrist  S h e was r e - a d m i t t e d  Upon h e r d i s c h a r g e  she s t a t e d :  and I d o n ' t  after  to hospital for  from h o s p i t a l , t h e second  "Oh, I was v e r y ,  very  ill.  V e r y weak f o r  awhile." Upon f u r t h e r a n a l y s i s and v e r i f i c a t i o n appeared  of the data, i t  t h e change i n r o u t i n e r e s u l t e d i n t h r e a t s t o t h e  e l d e r l y women's s e l f - e s t e e m .  As i n d i c a t e d e a r l i e r ,  themes were i n d e p e n d e n c e , p r o d u c t i v i t y  the three  o r a c t i v i t y , and  autonomy. Self-Esteem Independence All  o f t h e women i n t h e s t u d y p e r c e i v e d  independent p r i o r  t o the f a l l .  ability  t o provide  needs.  As d i s c l o s e d e a r l i e r ,  reflected  t h e m s e l v e s t o be  I n d e p e n d e n c e was s e e n a s t h e  f o r o n e ' s own p h y s i c a l and e m o t i o n a l  a change i n t h e i r  theme i s i l l u s t r a t e d  t h e c h a n g e i n r o u t i n e a t home  l e v e l o f independence.  This  i n t h e s t o r i e s o f s e v e r a l women i n t h e  study. Upon r e t u r n i n g home, t h e 1 0 2 - y e a r - o l d that everything  i n her l i f e  had c h a n g e d .  woman r e m a r k e d Her p e r c e p t i o n of  57 her  situation, prior  was  contained  Because  t o the f a l l  compared t o a f t e r  i n the f o l l o w i n g passage:  "Very  the f a l l ,  different.  I hadn't been w e l l , n u r s e , p r e v i o u s l y b u t I had  c a r r i e d o n i n a m i n i m a l way and t h a t g i v e s y o u a s e n s e o f independence t h e o t h e r t a k e s from you." explain  f u r t h e r about her s i t u a t i o n  stated:  " W e l l , f o r one t h i n g ,  helpless."  her  she r e p l i e d :  "Awful!  N o t o n l y was I l e s s  awful."  When a s k e d i f i n d e p e n d e n c e was an i m p o r t a n t  p a r t o f how s h e v i e w e d h e r s e l f , The f a l l  threatened  When a s k e d how t h a t f e l t , hard.  absolutely  t h i s woman, i n d e p e n d e n c e was an i m p o r t a n t p a r t o f  self-esteem.  so."  t h e f a l l , she  I was h e l p l e s s ,  A w f u l , t o a n i n d e p e n d e n t o l d me.  For  after  When a s k e d how t h a t f e l t ,  independent, but I f e l t  When a s k e d t o  she s t a t e d :  " Y e s , v e r y much  t h e e l d e r l y woman's s e l f - e s t e e m . she r e s p o n d e d :  I h a d no s e n s e o f d i r e c t i o n ,  "Hard,  awfully  and y o u w o n d e r , i t i s a  more a s e n s e o f a n x i e t y w o n d e r i n g a b o u t t h e f u t u r e . " A n o t h e r woman t a l k e d a b o u t t h e f a l l  i n terms o f i t s  e f f e c t on h e r l e v e l o f i n d e p e n d e n c e : Well, very  I have n e v e r been n o t a b l e t o do f o r m y s e l f . independent.  And when I f e l l  this  last  t i m e by  o p e n i n g t h e f r i d g e d o o r and s w i n g i n g on i t , w e l l , been h e l p l e s s more o r l e s s e v e r s i n c e . terrible.  And i t ' s  I can't stand i t .  When a s k e d t o e x p l a i n  further,  I am  about her f e e l i n g s , she  I have  58 stated: that  " I t makes me f e e l a n g r y .  I t makes me f e e l  angry  I am n o t a b l e t o do f o r m y s e l f and h a v e t o h a v e h e l p  in."  Similar  t o t h e o t h e r woman, i n d e p e n d e n c e  important part of her self-esteem. accounts, l o s s of independence their  self-esteem.  was an  F r o m b o t h women's  was p e r c e i v e d a s a t h r e a t t o  This threat  resulted  i n f e e l i n g s of  a n g e r , h e l p l e s s n e s s , a n x i e t y , and w o r r y . A t h i r d woman a l s o c o n f i r m e d t h a t  independence  important p a r t o f h e r f e e l i n g s about h e r s e l f . "Oh, v e r y much. me t o d e a t h . she  liked  She s t a t e d :  t h a t would  B u t , I am v e r y i n d e p e n d e n t . "  just  smother  When a s k e d what  about b e i n g independent, she responded:  But, and  I have a n i c e f r i e n d  was an  I l i k e my own way o f d o i n g t h i n g s . I think  people.  And I j u s t  t h a t way y o u g e t more f r e e d o m back  love  from the  They d o n ' t f e e l a s i f t h e y ' r e v e r y p u t u p o n ,  l o o k i n g a f t e r you i f you're  independent.  I think  that  you h a v e a b e t t e r r e l a t i o n s h i p w i t h p e o p l e . When a s k e d to so. You  i f she f e l t  f a m i l y and f r i e n d s , Oh, y e s .  i t was i m p o r t a n t t o p r o j e c t t h i s she responded:  "Oh, y e s .  Very  image much  I am n o t f r i g h t e n e d o f g o i n g anywhere m y s e l f .  know, I do t h i n g s on my own." T h i s woman was a s k e d a b o u t h e r f e e l i n g s  l o s s of independence. I  never f e l t  related  t o her  She s t a t e d :  helpless,  even  i f I had t o c r a w l .  just g r a t e f u l f o r the wonderful care I received.  I was I knew  59  I was  s i c k but  I a l s o knew I w o u l d g e t  T h i s woman e x p e r i e n c e d two  better.  dependency d i f f e r e n t l y  from the  other  women. A fourth subject  l e v e l of  the  fall's  e f f e c t on  her  independence:  I f e e l that can  also described  do,  i t a f f e c t e d my  what I c a n ' t do;  much; you  w h o l e e n t i r e s y s t e m ; what I  you  c a n ' t move a r o u n d  h a v e t o keep y o u r s e l f l i m i t e d ,  that  i n what you  can  do! Her  feelings in relation Well,  t o the  l o s s of  i t wasn't t h a t g r e a t .  d i d n ' t get  any  help.  So,  independence were:  I w a n t e d more h e l p , b u t  that r e a l l y  t h a t b e c a u s e I t h o u g h t t h e r e was  I was  peeved  more h e l p  I  with  coming  to  t h a t r e c e i v i n g some s u p p o r t  at  Seniors. T h i s p a r t i c u l a r woman f e l t home w o u l d h a v e h e l p e d l e s s e n i n g the  t o make h e r  t h r e a t t o her  more i n d e p e n d e n t ,  self-esteem.  provided  w i t h homemaking o r n u r s i n g  returned  home.  Her  d i r e c t e d at the  adequate supports  to her.  She  important  i n terms of her  herself.  When a s k e d what she  stated:  " W e l l , j u s t t o be  f r e e , do  as you  please,  her  loss  self-esteem liked  not  or  she  of  system f o r not  agreed that  providing  independence  was  f e e l i n g s about  about independence,  more a g g r e s s i v e  w h i c h you  was  a s s i s t a n c e once  anger, regarding  i n d e p e n d e n c e , was  She  thereby  c a n ' t do  and now."  you  know,  she feel  When a s k e d  60  to c l a r i f y Well,  what s h e meant by a g g r e s s i v e ,  she s a i d :  s a y f o r i n s t a n c e , now I c a n ' t go o u t and weed i n  t h e g a r d e n b e c a u s e I c a n ' t bend down and s t u f f  like  that.  around  being  I am u s e d t o h a r d w o r k . like,  I say,  I love working  independent.  I c a n ' t do i t now.  E v e n t h o u g h t h i s woman was e x p e r i e n c i n g ability  threats t o her  t o be i n d e p e n d e n t , s h e was h o p e f u l  return t o her previous  level of functioning.  A n o t h e r woman t a l k e d a b o u t l i v i n g husband d i e d  t h a t she would  alone since her  15 y e a r s a g o . She s t a t e d t h a t s h e :  Managed my own t h i n g s  and I a l w a y s managed my own  b a n k i n g , my own e v e r y t h i n g .  I w a s n ' t d e p e n d e n t on  a n y b o d y and I d o n ' t want t o be d e p e n d e n t on my d a u g h t e r because she's a very After discharge  busy l i t t l e  f r o m t h e h o s p i t a l , s h e was r e c e i v i n g  homemaker s e r v i c e s t o a s s i s t w i t h living  i n t h e community.  little  girl,  couldn't times."  girl.  her a c t i v i t i e s  She s t a t e d :  i t w o u l d be q u i t e h a r d  of daily  " I f I d i d n ' t have  this  ' c a u s e I know my d a u g h t e r  come a n y more t h a n a c o u p l e o f t i m e s a week o r t h r e e S h e went on t o s a y t h a t h e r g r e a t e s t  fear over the  l o s s o f h e r i n d e p e n d e n c e was t h e d e p e n d e n c e on h e r d a u g h t e r . Here, again,  f e e l i n g s o f f e a r were s t a t e d t o l o s s o f  independence. The her  l a s t d e s c r i p t i o n was f r o m a woman who t a l k e d  recovery  o v e r a 6-week p e r i o d .  about  I n i t i a l l y , she s t a t e d  61 that she was q u i t e dependent but now was f e e l i n g as independent as she was p r i o r t o the f a l l .  She s t a t e d  that  she was f r u s t r a t e d due t o the f a c t that her f r i e n d s s t i l l viewed her as dependent: I don't want t o be t r e a t e d  l i k e a baby.  Good heavens!  Some of my f r i e n d s have been over s o l i c i t o u s . n e a r l y died when I t o l d them I went downtown They s a i d , "Why d i d n ' t you t e l l  They yesterday.  us and we would have  d r i v e n you."  But, as I say,  I don't want t o be t r e a t e d  l i k e a baby.  I f I can go out and do t h i n g s  f o r myself,  I want t o be able t o do t h a t . She  s t a t e d that she recognized  her own l i m i t a t i o n s a f t e r t h i s  experience but i t was s t i l l important f o r her t o s t r i v e f o r independence.  She became f r u s t r a t e d when her f r i e n d s became  over-protective  or t r e a t e d her as i f she was dependent.  Activity P r o d u c t i v i t y or a c t i v i t y was another theme w i t h i n the self-esteem interviews. their life  life  concept that was i d e n t i f i e d  A l l of the women s t a t e d that t h e i r a c t i v i t y i n changed a f t e r the f a l l .  p r i o r t o the f a l l .  doing e v e r y t h i n g , interview, fall.  throughout the  yes,  "Oh, going out and having fun and no t r o u b l e a t a l l . "  she spoke again  She s t a t e d :  wherever I want.  One woman d e s c r i b e d her  Later  i n the  about her a c t i v i t y p r i o r t o the  "Going down t o the g o l f c l u b or going There was nothing  wrong with me; I was j u s t  62 as n a t u r a l as you a f t e r the f a l l , replied, it  are."  When asked to d e s c r i b e her  she commented on the  very n i c e , sometimes always alone."  that she had out of her  She  been home f o r about three weeks and  apartment once.  She  when her daughter's f r i e n d was appointment.  can't  length of the days.  "Well, I guess they could be s h o r t e r , j u s t you  i s not  activity  life  When asked how  l e v e l , she  was  responded:  know,  stated  had  not  been  l o o k i n g forward to F r i d a y  t a k i n g her  she  She  to a h a i r  f e l t about the change i n her "Well, you  do the things a f t e r you've had  know very w e l l  t h a t , that you  could  a c t i v i t y p r i o r to  the  you do  before." Another s u b j e c t d e s c r i b e d fall: day,  "I was  a c t i v e before  more or l e s s .  woman was  her  I had  the f a l l .  on her  lower l e g s .  h o s p i t a l , she d e s c r i b e d I stayed going  her  home a l i t t l e  out on my  own,  required  I was  A c t i v i t y was perceptions  an  of s e l f .  tired.  b i t more.  the data,  from  activity: I didn't f e e l  like  f r i e n d s would take me I was  I t takes a l o t out of  if I quite  you.  important p a r t of these e l d e r l y women's As documented, a l l the women t a l k e d  about t h e i r v a r i o u s a c t i v i t i e s p r i o r to the f a l l . analyzing  This same  A f t e r her discharge  l e v e l of  but my  every  s k i n g r a f t i n g to  wanted to go anywhere s p e c i a l i n the c a r . content;  out  I went shopping, go downtown."  admitted to h o s p i t a l and  the abrasions  I was  there were s e v e r a l d i f f e r e n t  In types of  activities.  Some o f t h e women t a l k e d a b o u t  activities.  O t h e r women t a l k e d  social  about a c t i v i t i e s  goal-directed,  such as p r o v i d i n g  a s s i s t i n g with  t h e c a r e o f o t h e r f a m i l y members.  t a l k e d about a c t i v i t i e s  that  were  support t o friends or  s u c h a s c r a f t work t h a t  O t h e r women kept  them  b u s y a t home. Several  o f t h e women t a l k e d  activities  prior  following:  " I used t o l o v e  (Laughs).  I l o v e m u s i c and d a n c i n g .  before I f e l l ,  to the f a l l .  about t h e i r  social  One woman d e s c r i b e d t h e  d a n c i n g , b u t I c a n ' t do i t now. I still  I had been o u t d a n c i n g . "  do.  Just  T h i s woman  experienced a f r a c t u r e o f her h i p and, a t the time o f t h i s interview,  s h e was s t i l l  Another subject within  walking with  described  a walker.  some o f h e r s o c i a l  activities  t h e S e n i o r ' s c o m p l e x where s h e r e s i d e d :  We u s u a l l y , we go down f o r t h e m a i l ,  and u s u a l l y , y o u  know, t h e r e a r e two o r t h r e e down t h e r e and we s i t a n d yap.  B u t , and t h e n we h a v e a n i c e  we go o n c e a week f o r a f t e r n o o n Another subject  who f r a c t u r e d  social activities prior  room u p s t a i r s  where  tea.  her w r i s t described her  t o the f a l l .  She s t a t e d :  "You know,  I h a v e f u n and I h a v e a l o t o f p a r t i e s and go t o a l o t o f d i n n e r s a t t h e c l u b , y o u know." had  to cancel  to drive  a trip  to Whistler,  She went on t o s a y t h a t s h e B.C. b e c a u s e s h e was u n a b l e  h e r c a r , due t o t h e f r a c t u r e .  She was p l a n n i n g t o  64 go  on a 35-day c r u i s e t o t h e S o u t h S e a I s l a n d s  Besides s o c i a l a c t i v i t i e s , activity there  t h i s woman a l s o d e s c r i b e d h e r  i n terms o f p r o v i d i n g  support t o others.  Here,  was some f e e l i n g o f p r o d u c t i v i t y i n h e r l i f e .  been a t e a c h e r had  i n September.  and h e r h u s b a n d had b e e n a p s y c h o l o g i s t .  no c h i l d r e n o f t h e i r own b u t s t a t e d  provided  that  children adjust  supporting  a niece  [we] h a v e been  to difficulties.  down i n C a l i f o r n i a . "  the h o s p i t a l , she p r o v i d e d  They  t h e y had  s u p p o r t t o many c h i l d r e n t h r o u g h t h e y e a r s :  t h a t was my h u s b a n d ' s and my l i f e ; helping  She had  Right  "And  helping,  now, I am  Apparently,  while i n  some s u p p o r t t o t h e woman i n t h e  next bed: If  I can h e l p  somebody e l s e .  She was s o n e r v o u s ,  l i t t l e woman, a b s o l u t e l y p a n i c k y ; some s u p p o r t .  Although  i f I could  that  give her  i t was h a r d on m y s e l f .  I do  t h a t and I want t o do i t . When a s k e d how i t f e l t she  to give  s u p p o r t t o someone e l s e when  wasn't f e e l i n g w e l l h e r s e l f , she s t a t e d :  "No, i t j u s t  came o u t . " Similar  t o t h i s woman's g o a l - d i r e c t e d  woman t a l k e d a b o u t h e r r o l e a s a c a r e g i v e r  activity,  another  t o an o l d e r  sister: I was a l w a y s a b u s y p e r s o n and on t o p o f t h a t , I have an older  sister  that didn't  h a v e , w e l l , s h e had a v e r y  h u s b a n d , b u t he p a s s e d away and s h e n e v e r had a n y  fine  65 c h i l d r e n , so about 10 years ago she moved up here t o be near me and my c h i l d r e n . This 79-year-old woman was d r i v i n g her own c a r p r i o r t o the fall.  She s t a t e d that she v i s i t e d  b a s i s i n the p r i v a t e care she  her s i s t e r on a d a i l y  facility.  Besides v i s i t i n g h e r ,  a l s o shopped f o r any c l o t h e s or t o i l e t r y  sister  items that her  required.  Another s u b j e c t  t a l k e d about her a c t i v i t y  of the c r a f t work she d i d a t home.  l e v e l i n terms  She t a l k e d about  completing a l l the c r o s s - s t i t c h and p e t i t - p o i n t p i c t u r e s i n her  apartment: But  that way I keep myself o c c u p i e d .  I can s i t f o r  hours and embroider and enjoy i t and watch the t e l e v i s i o n and a l l the s i l l y you It  s t u f f on there, but s t i l l —  l e a r n more.  was i n t e r e s t i n g t o note that three of the women  incorporated concept. activity  t h e i r past a c t i v i t i e s  i n t o t h e i r present  One woman, i n response t o a question i n her l i f e ,  responded:  Upon f u r t h e r q u e s t i o n i n g ,  self-  about the  "I used t o work every day."  she i n d i c a t e d that she had worked  up u n t i l a couple of years ago. When asked about the type of work, she s t a t e d :  "Hard work.  I worked i n the f i s h  I used t o c a r r y f i s h and a l l that s t u f f , hard a l l my l i f e . "  ice—I  market.  r e a l l y worked  Even though she had not worked r e c e n t l y ,  t h i s past work had important meaning t o her.  66 The  second  woman t a l k e d a b o u t h e r p a s t  These a c t i v i t i e s  remained  s e l f - c o n c e p t and  resultant  an  p l a y e d , and just  loved i t .  A t one  this writer  a picture  present  " W e l l , t h a t ' s i f you  j u s t b e f o r e , b u t a l l my  bowled 1 0 - p i n s . "  She  course  t h a t had  life  went on t o s a y t h a t  p o i n t , she had  E x e c u t i v e of a p r i v a t e g o l f  of  i m p o r t a n t p a r t of her  self-esteem:  see, p l a y i n g g o l f , w e l l not  activities.  she  been a member o f  i n Vancouver.  She  I  the showed  been t a k e n o f a l l p a s t members  the E x e c u t i v e : These a r e a l l t h e p a s t - p r e s i d e n t s and think  i t ' sa lovely picture.  y e a r and  he's  We  I'm  there.  I  have the banquet once a  going t o c o n t i n u e t a k i n g p i c t u r e s of  us  e v e r y y e a r , so t h a t ' s a l l r i g h t . Another  women t a l k e d  a b o u t h e r y e a r s as a n u r s e .  she had  not p r a c t i c e d  implied  t h a t t h i s p a r t of her  of  her s e l f - c o n c e p t :  to  be o l d - h a n d  General  f o r many y e a r s .  Y e t , her  remained  an  "I graduated  i n 1930,  so I am  I graduated  [Regina, Saskatchewan]."  She  important part  from the  was  83,  description  life  at the j o b .  At  getting  Regina  looking  forward  to  a r e u n i o n of her n u r s i n g s c h o o l i n September: It  i s j u s t a wonderful evening.  will after  be o k a y and I graduated  nurses.  And  I will  be g o i n g .  Hopefully, everything I s t a y e d on  staff  f o r 13 y e a r s so I know a l o t o f  t h e y know me.  They remember  me.  the  67 All  o f t h e women c o n f i r m e d  p r o d u c t i v e was resultant  an  important  self-esteem.  a c t i v i t y was The  woman who  was  an  that being  aspect  of t h e i r  provided  support  p a r t of her  to her  than  the  and  one others.  family stated that  this  self-esteem.  A n o t h e r woman d e s c r i b e d  the events  response t o the q u e s t i o n about the her  self-concept  I t d i d n o t a p p e a r t h a t any  j u d g e d t o be more i m p o r t a n t  important  a c t i v e or  of the morning i n  importance of a c t i v i t y  for  self-esteem: W e l l , t h i s m o r n i n g , I g o t up some c o r n f l a k e s and b o n e s on can  I put  t o s t e w b e c a u s e I had  of l e f t o v e r  t h a t and  then  and  chicken  t h e b r o t h and  soup. put  made c o f f e e .  I  some c h i c k e n on some l e f t o v e r I took  had too,  chicken,  t h e meat o f f o f  t h a t away.  W e l l , I made  dishes. When a s k e d a b o u t t h i s  l e v e l of a c t i v i t y ,  I am  I was  more a c t i v e t h a n  about m y s e l f . " home a f t e r first  T h i s woman had  i n t e r v i e w had  approximately was  feel  been done w i t h h e r p l a c e on  dressed,  the  a b l e t o s i t on  The  fall  posed a t h r e a t t o her  the  at  The  i n bed.  The  second i n t e r v i e w ,  During  and  and  lying  "But,  better  s p e n t t h r e e weeks i n bed  f i v e weeks l a t e r .  l e n g t h of time. had  t h a t makes me  responded:  r e t u r n i n g from the Emergency Department.  above c o n v e r s a t i o n took  she  and  she  the second i n t e r v i e w ,  the couch f o r the  entire  r e s u l t a n t change i n r o u t i n e  self-esteem  i n terms of  activity.  68  It was evident that even though her a c t i v i t y changed s i n c e the f a l l ,  l e v e l had  she s t i l l p l a c e d value on the  a c t i v i t y component of her s e l f - e s t e e m . Autonomy A theme of autonomy emerged from the data a n a l y s i s as t h i s w r i t e r t r i e d t o determine the e l d e r l y women's p e r c e p t i o n s of t h e i r need f o r care and support Matteson and McConnell  at home.  (1988) s t a t e d that autonomy or s e l f -  d e t e r m i n a t i o n meant that i n d i v i d u a l s were respected as decision-makers  about t h e i r own c a r e .  W i t h i n the theme of  autonomy, the e l d e r l y women d e s c r i b e d three d i f f e r e n t decision-making  processes.  These processes were w e l l -  represented along a continuum.  At one end,  the women  d e s c r i b e d d e c i s i o n s made s o l e l y by themselves i n r e l a t i o n t o t h e i r medical c a r e .  In the middle  were d e c i s i o n s made by the  women i n c o n s u l t a t i o n with f a m i l y , f r i e n d s , and/or h e a l t h professionals.  The other end of the continuum was  represented by d e c i s i o n s made f o r the e l d e r l y women by h e a l t h p r o f e s s i o n a l s and o t h e r s i n v o l v e d i n t h e i r The  first  process of decision-making  care. was represented by  those d e c i s i o n s s o l e l y made by the women regarding care.  One woman t a l k e d about the decision-making  involved wrist. of  their process  i n d e c i d i n g whether t o have surgery on her f r a c t u r e d The surgery o p t i o n arose a f t e r the i n i t i a l  p u t t i n g her w r i s t i n a c a s t was not s u c c e s s f u l :  treatment "I'm i n  charge of ray l i f e . o p e r a t i o n and could." She  was  I c e r t a i n l y decided  I decided  She decided  that I wanted to go home as f a s t as I  to have the surgery and  home f o r approximately  admitted  that I wanted the  three weeks and  to h o s p i t a l with o s t e o m y e l i t i s .  discharge after t h i s Yes,  returned home. then was  re-  She d e s c r i b e d her  hospitalization:  i n f a c t I probably  shouldn't have been home alone,  but I wanted to be home alone so much.  I wanted to be  in my  alone.  own  home that I put up with being  Here, again, t h i s woman's a b i l i t y regarding her care was  to make her own  decisions  evident.  Another woman t a l k e d about her r o l e i n the d e c i s i o n making regarding some type of abdominal surgery. y e a r - o l d woman had due  to anemia.  her bowel.  experienced  She  was  a fall  This  102-  r e l a t e d to d i z z i n e s s  e x p e r i e n c i n g a l o s s of blood  She d e s c r i b e d the experience of seeing  through  the  surgeon: He examined me  down here  (points to lower  abdomen).  I d i d n ' t ask him any q u e s t i o n s because I had my made up. And am  I was  not having  surgery.  No,  not me.  I had no d e s i r e when the c a l l comes f o r me, ready.  That's a l l important.  anything that would hasten t h i s would help me; When asked  And  mind No! nurse, I  I don't want to do  i t . I c o u l d n ' t see where  I haven't got what i t would  take.  i f she f e l t her wishes were respected, she s t a t e d :  "I  d o n ' t t h i n k D r . G. l i k e d  stated  i t but don't say anything."  t h a t h e r w i s h e s were r e s p e c t e d .  t o be.  "They  I w o u l d n e v e r h a v e gone on t h e n .  t h a t , and i t r e m a i n s w i t h  the Lord  [wishes]  She have  No, I have had a l l  what t h e f u t u r e h o l d s f o r  me. " I n t h e m i d d l e o f t h e c o n t i n u u m were d e c i s i o n s made by the  e l d e r l y women i n c o n s u l t a t i o n w i t h  a n d / o r f a m i l y members. occupational discharge. for  health  professionals  One woman t a l k e d a b o u t t h e  therapist's v i s i t  t o her apartment p r i o r  She was r e t u r n i n g home a f t e r b e i n g  a fractured  t o her  hospitalized  hip:  They d i d a l l t h a t  from the General H o s p i t a l ; the g i r l  came and s a i d t h i s had t o be r a i s e d b e c a u s e i t ' s t o o l o w to get out, and,  y o u know, and s o t h e y d i d , t h e y g o t t h i s  oh, they d i d a l o t o f t h i n g s ;  I think  t h a t we d i d a  good j o b . Upon f u r t h e r q u e s t i o n i n g , had in  discussed  her recommendations w i t h  agreement w i t h This  she i n d i c a t e d t h a t t h e t h e r a p i s t  t h e equipment being  h e r and t h a t s h e was ordered.  same woman a l s o t a l k e d a b o u t h e r i n v o l v e m e n t i n t h e  decision-making process regarding  personal  home  placement.  She d e s c r i b e d  this  " B u t I t h o u g h t , n o , I c a n ' t g o , I c a n ' t go a n d  idea:  leave you  her i n i t i a l  care  ambivalence  towards  my f r i e n d s , and I h a v e a l o t o f f r i e n d s i n V a n c o u v e r ,  know, t h e g o l f c l u b . "  Upon f u r t h e r r e f l e c t i o n and  d i s c u s s i o n with her daughter: When I s t a r t e d t o t h i n k  a b o u t i t how many f r i e n d s do  come and v i s i t y o u i f y o u c a n n e v e r go o u t , y o u know, s o I thought, w e l l , gee, I'd r a t h e r is.  S o , we've t a l k e d  be where my d a u g h t e r  i t a l l o u t and we've d e c i d e d and I  t h i n k we've made a good d e c i s i o n . D u r i n g t h e c o u r s e o f t h e s t u d y , t h i s woman moved t o a personal  care  home i n L a n g l e y , B.C. w h i c h was c l o s e r t o h e r  daughter. Another subject decisions  regarding  made i t e x p l i c i t ultimately,  t a l k e d a b o u t i n v o l v i n g f a m i l y members i n personal  that  m a t t e r s such as f i n a n c e s .  she d i s c u s s e d  the matter with  She  them b u t ,  i t was h e r d e c i s i o n :  I h a v e a w o n d e r f u l f i n a n c i a l a d v i s o r , my c o u s i n , made money f o r me and l o o k s I, l i k e with go?"  things  out.  I s a i d , "Do y o u t h i n k  Go and h a v e f u n now."  w i t h my a u n t and t h i n g s  i t i s my d e c i s i o n , v e r y  Finally, decisions  trip,  And i f I  should  he s a i d , "By a l l means, b e c a u s e y o u r t i m e i s  running  but  this  a f t e r me t h a t way.  that's  at the other  like  And we that.  much i n my  discuss I discuss i t  life.  end o f t h e c o n t i n u u m were  made by h e a l t h p r o f e s s i o n a l s f o r t h e s e women.  Here, the h e a l t h p r o f e s s i o n a l s appeared decision-making  i n c o n t r o l of the  process.  One woman t a l k e d a b o u t w a n t i n g t o c h a n g e h e r p h y s i c i a n  72 t o a p h y s i c i a n w i t h a d m i t t i n g p r i v i l e g e s t o the hospital.  She  described  over t h i s matter: very  But  her  d i s c u s s i o n w i t h her  I b r o u g h t i t up  happy a b o u t i t . "  She  local  explained  t o him  physician  and  he  wasn't  f u r t h e r the r a t i o n a l e  f o r her d e c i s i o n : The  t h i n g was,  hospital. do  fall  i s t h a t he  And  and  at the  b r e a k my  t h e h o s p i t a l , he whoever t h e y very She  back o f my  resulting  d i s h out  come.  her  get  landed  I have t o j u s t  t o me.  doctor's  So,  I said this  and  see  you  sitting  you,"  in  take  Which I don't t h i n k i s  r e a c t i o n t o her  t o him,  and  beside  suggestion  and  her  and  he  said,  I nearly said, my  bed,  but  " W e l l , I w o u l d come  " W e l l , I'd  i f you  love to  can't  do  see  anything  me."  She  s t a t e d t h a t she  and  t h e n she  r e f e r her  p l a n n e d t o s t a y w i t h him  would t r y t o get him  to accept  until the  autumn  idea  and  t o someone e l s e .  A second s u b j e c t d e s c r i b e d i n the d e c i s i o n - m a k i n g  She  a f t e r her  and  frustration:  for  care.  mind, I thought, " I f I  h i p or anything  can't  any  satisfactory.  described  involved  does not p r a c t i c e at  t a l k e d about not hospitalization  her  experience  process  of not  regarding  r e c e i v i n g any  her  home c a r e  for a fractured hip:  being own  help  73  They c o u l d h a v e g i v e n up  and g o i n g ,  me more h e l p , y o u know, t o g e t me  but they d i d n ' t ; l i k e  want t o e v e n g i v e me h e l p  I said,  f o r a bath.  they  didn't  They c o u l d  have  come a c o u p l e o f t i m e s and t h e n I w o u l d have s a i d , "You d o n ' t h a v e t o come any more."  I would have b u t they  d i d n ' t e v e n s a y t h a t - - i t was j u s t , n o — t h a t was i t . When a s k e d why s h e d i d n o t g e t any h e l p , s h e r e s p o n d e d : " I t ' s j u s t more o r l e s s b e c a u s e t h e y t o l d me y o u h a v e t o make so much money and i f y o u make t h a t much y o u have t o p a y The  only  s u p p o r t t h i s woman r e c e i v e d  to assess  her walking.  She d e s c r i b e d  was t h e p h y s i o t h e r a p i s t this  experience:  s e n d t h a t woman o u t h e r e t o w a l k w i t h me. myself! she  advised She take  t o go w a l k i n g  f o r short distances  the therapists that their  described  her:  So I t e l l  them."  She d e s c r i b e d  " W e l l , t h e y s a i d we h a v e t o come.  h a v e t o come.' whatever l i k e  I s t h a t what I s h o u l d  in stopping going.  She  necessary.  Who n e e d s  their  that?  response t o  I can't see t h a t  say?  'we  Regulation or  that."  At t h e time o f t h e second weeks l a t e r ,  each day.  that  "I'm c o m i n g down t o  y o u o u t f o r a w a l k . I d o n ' t need t h a t .  I don't.  She s t a t e d  v i s i t s were n o t  the following experience:  "They  I c a n w a l k by  T h a t d o e s n ' t make s e n s e , d o e s i t ? "  tried  it."  interview, approximately  s h e s t a t e d t h a t s h e had f i n a l l y their  visits:  "I just  told  T h a t was i t , b e c a u s e I d i d n ' t  four  been s u c c e s s f u l  h e r t h a t I am n o t  s e e t h e s e n s e i t made."  74 In order  f o r i n d i v i d u a l s t o be a u t o n o m o u s , t h e y must be  p r o v i d e d w i t h adequate m e d i c a l status.  T h i s was a n o t h e r  important  S e v e r a l women d e s c r i b e d t h e i r understanding The  medical  health  theme i n t h e d a t a .  attempts  t o increase  their  a b o u t what was h a p p e n i n g t o them.  woman who r e m a i n e d  discharge  i n f o r m a t i o n about t h e i r  i n bed f o r t h r e e weeks a f t e r h e r  from h o s p i t a l t a l k e d about t r y i n g  follow-up to obtain medical  t o organize  information.  This  d i s c u s s i o n t o o k p l a c e on t h e s e c o n d i n t e r v i e w : So,  then today  C,  he's a t the A r t h r i t i c Centre.  not  the top doctors  sending  I phoned.  I am n o t w e l l .  He's one o f t h e , i f  i n Canada on a r t h r i t i s .  very poor.  some w h e e l s  t o the dermati  Of c o u r s e ,  inflammation.  I t drags  this  myositis.  work.  My m u s c l e s a r e  a w f u l r a s h on my head i s  y o u down.  S o anyway, we've g o t  going.  Another s u b j e c t t a l k e d about h e r t r i p  back t o an  Emergency d e p a r t m e n t t o have h e r c a s t c h e c k e d . been a p p l i e d two d a y s That was a j o k e .  T h i s c a s t had  earlier: I went o v e r  t h e r e when I c r a c k e d i t ,  one d o c t o r bound me up i n a c a s t , some new k i n d o f  c a s t , and s a i d , and  He's  someone i n t o m o r r o w t o do some b l o o d  That's related  and  I phoned D r .  "Now t h a t ' s g o t t o s t a y on f o r one week  you see t h e doctor  worked l o o s e .  then."  So I t h o u g h t ,  And i n two d a y s i t had w e l l — s o I went b a c k  over.  75  The  n u r s e was r a t h e r p e r t u r b e d  said,  "Well,  I really didn't  a t my c o m i n g b a c k . know what t o d o .  I  I t ' s no  good t h i s way." The treated  woman who saw t h e n e u r o l o g i s t too indifferently.  I do f i n d you  i t rather  t h a t s h e h a d been  She s t a t e d :  aggravating.  I mean, i f y o u b e c a u s e  don't k n o w — I suppose you c a n ' t f i n d a n y t h i n g  a m e d i c a l book and r e a d  part  felt  i t . B u t y o u d o n ' t want t o end  up  i n a wheelchair  As  n o t e d , autonomy was a l s o p e r c e i v e d  of their  o r what y o u ' r e g o i n g t o d o .  self-esteem.  a s an i m p o r t a n t  I t appeared t h a t as t h e d e c i s i o n -  making s h i f t e d  from t h e i r  responsibility  o f t h e h e a l t h p r o f e s s i o n a l s , t h e women  experienced a threat medical information ability  t o get  own r e s p o n s i b i l i t y  to their played  self-esteem.  to the  As w e l l ,  an i m p o r t a n t r o l e  lack of  i n their  t o make autonomous d e c i s i o n s .  Adaptability I n t h e i n t e r v i e w s , t h e women t a l k e d a b o u t that  they used t o cope w i t h  threats to their  their  self-esteem.  threats t o self-esteem  behaviours  c h a n g e i n r o u t i n e and  As d i s c u s s e d  e a r l i e r , the  c h a n g e s were p r i m a r i l y r e l a t e d t o  i n d e p e n d e n c e , a c t i v i t y , and autonomy. E a c h woman c o p e d w i t h way.  However, t h e r e  the s i t u a t i o n  were s t i l l  b e h a v i o u r s t h a t were i d e n t i f i e d .  i n h e r own u n i q u e  common c a t e g o r i e s o f As w e l l ,  t h e two major  76  themes o f p r o b l e m - f o c u s e d identified.  Both  with the f a l l care  and e m o t i o n - f o c u s e d  b e h a v i o u r s were used  event  behaviours  were  by t h e women i n c o p i n g  and r e s u l t a n t t r e a t m e n t  within the health  system. The  c o p i n g b e h a v i o u r s o r r e s o u r c e s t h a t were  identified  were t h e f o l l o w i n g :  use o f p o s i t i v e  c o n t r o l , compliance,  p r e v e n t i o n , u s e o f s o c i a l s u p p o r t s , and  planning  f o rthe future.  identified  as b e i n g used  beliefs, maintaining  Some o f t h e s e b e h a v i o u r s were i n other s t r e s s f u l  Some o f t h e o t h e r b e h a v i o u r s d e v e l o p e d fall Use  life  events.  i n response  t o the  event. of Faith/Positive  Beliefs  Most o f t h e women i n t h e s t u d y s p o k e o f t h e u s e o f f a i t h and/or p o s i t i v e to  t h i n k i n g as a c o p i n g b e h a v i o u r  cope w i t h l i f e  this  behaviour  difficulties.  In p a r t i c u l a r ,  emotion-focused  1 0 2 - y e a r - o l d woman c o n t i n u e d t o e x p e r i e n c e  difficulties resulted  a t home a f t e r h e r f a l l .  Her bowel  i n p e r i o d s o f d i z z i n e s s and w e a k n e s s .  that the f a l l  had a f f e c t e d  felt  the f a i t h  condition She s t a t e d  her l e v e l o f independence.  spoke o f h a v i n g a s u s t a i n i n g C h r i s t i a n F a i t h .  It  they had used  behaviour.  The  she  used  t o cope w i t h t h e consequences o f t h e f a l l .  T h i s was c o n s i d e r e d t o be an e x a m p l e o f an coping  t h a t they  She  When a s k e d i f  helped her t o cope, she responded:  i s e v e r y t h i n g t o me, e v e r y t h i n g .  I know i n whom I  have b e l i e v e d . everything  I am p e r s u a d e d  stated  be e v e n more h e l p l e s s ,  I am n o t h o p e l e s s ,  Another subject positive  nurse.  t a l k e d about h e r a b i l i t y  side of l i f e .  When a s k e d how s h e f e l t  dependency,  on h e r r e t u r n home f r o m she coped w i t h t h e  Just being  I am s o r t o f a p o s i t i v e t h i n k e r .  with mental health own  on t h e  she s t a t e d :  I'm l o o k i n g a t t h e p o s i t i v e . can.  t o look  She had f r a c t u r e d h e r w r i s t and had  t h a t s h e was q u i t e d e p e n d e n t  hospital.  t o do  f o r me and when t h e t i m e comes, i f I d i d n ' t  have t h a t , d e a r , I w o u l d hopeless.  t h a t He i s a b l e  as p a t i e n t V e r y much s o  and my h u s b a n d ' s b a c k g r o u n d  f e e l i n g s towards  life  as I  and my  t h a t y o u h a v e c o u r a g e , march  on. Throughout  t h e two i n t e r v i e w s ,  t h i s p o s i t i v e outlook  provided  she s t a t e d  s e v e r a l times  support t o her.  A t h i r d woman a l s o r e f e r r e d t o h e r p o s i t i v e She  stated  fall. stated: was  t h a t s h e was a n g r y a b o u t b e i n g  When a s k e d how s h e c o p e d  with  " I was a n g r y b u t I d o n ' t  mad a t m y s e l f f o r f a l l i n g .  o p t i m i s t i c and h a v e a p o s i t i v e  this  a f t e r h e r r e t u r n home.  outlook.  dependent  a f t e r her  f e e l i n g , she  l e t things  g e t me down.  I  H o w e v e r , I t r y t o be outlook."  A n o t h e r woman t a l k e d a b o u t n o t b e i n g car  that  She d e s c r i b e d  able  t o drive her  the experience of  a l l o w i n g her daughter t o d r i v e the c a r while  she s a t i n t h e  78 back s e a t :  " I s i t i n t h e back and we h a v e f u n p r e t e n d i n g  s h e ' s my c h a u f f e u r . " she  stated  of  life: Oh,  When a s k e d a b o u t u s i n g  t h a t she always t r i e d t o look  sure,  grapes.  t h a t ' s what l i f e  on t h e p o s i t i v e s i d e  i s , y o u know, i f y o u ' r e  I guess i t ' s r e a l l y d r e a d f u l  maybe y o u c o u l d n ' t things.  I think  help  humour,  sour  i f you're i l l ;  i t . No, y o u ' v e g o t t o l a u g h a t  t h e more y o u t h i n k y o u ' r e f i n e y o u do  get  b e t t e r w h e r e a s i f y o u f o c u s on a l l t h e bad t h i n g s ,  you  will  feel  The  last  i l l u s t r a t i o n o f t h i s p o s i t i v e a p p r o a c h was f r o m  worse.  t h e woman who was d e n i e d home c a r e from h o s p i t a l . recovering  She t a l k e d a b o u t h e r p o s i t i v e a p p r o a c h i n  from h e r f r a c t u r e d h i p :  purposefully,  s u p p o r t s upon h e r r e t u r n  but nevertheless,  "I didn't  do i t  y o u have t o l i v e w i t h  i t ; you  h a v e t o come o v e r t h e hump and g e t b e t t e r . " Compliance Another behaviour pattern t h e p h y s i c a l and p s y c h o l o g i c a l compliance.  This  medical condition. their  i n their  with  t o be an e x a m p l e  M o s t o f t h e women e x p e r i e n c e d activity level  related to their  F o r e x a m p l e , t h e women who f r a c t u r e d  h i p s were r e s t r i c t e d  flexion  i n coping  c o n s e q u e n c e s o f t h e f a l l was  b e h a v i o u r was c o n s i d e r e d  of problem-focused coping. some r e s t r i c t i o n s  t h a t was u s e d  i n their  of the affected leg.  w e i g h t - b e a r i n g and  O t h e r women w e r e  given  79 e x e r c i s e s o r o t h e r regimes All  such  o f t h e e l d e r l y women d e s c r i b e d t h e i r  compliance  t o these  women t a l k e d  intelligent something,  Most o f t h e  this point:  restriction.  "But I'm  enough t o know t h a t when y o u h a v e t o do y o u h a v e t o do i t and h a v e t o do e v e r y t h i n g t h a t I  As m e n t i o n e d e a r l i e r , t o weight-bearing  described  adherence o r  i n an a c c e p t i n g manner a b o u t t h e s e  t o do t o g e t b e t t e r , w h i c h  related  t o f o l l o w a t home.  r e s t r i c t i o n s or regimes.  One woman's comment i l l u s t r a t e d  had  as d i e t s  I ' v e done."  some o f t h e i n s t r u c t i o n s on t h e a f f e c t e d  leg.  were  One woman  this:  I still  am n o t s u p p o s e d t o p u t my w h o l e w e i g h t  when I w a l k .  I p u t my w e i g h t  on t h i s  on t h i s  and my h a n d .  I  t o u c h my f o o t down k i n d o f on my t o e s and p u t n o t t h e full  weight  on i t .  I have t o w a i t u n t i l  when I c a n p u t my f u l l  weight  t a l k e d about n o t b e i n g a b l e t o have a b a t h .  held  shower:  When a s k e d told  fractured  hips  on a b a t h b o a r d  They d e s c r i b e d  and u s i n g a h a n d -  j u s t s i t t i n g on t h a t s i l l y  how t h a t f e l t ,  she s t a t e d :  "Awful!  board." They h a v e n ' t  me y e t t h a t I c a n g e t i n t o t h e t u b . " A n o t h e r  described like  "Still,  me  on i t .  S e v e r a l o f t h e women who had e x p e r i e n c e d  the e x p e r i e n c e o f s i t t i n g  they t e l l  this experience:  a bath—not  more o r l e s s . "  like  " Q u i t e what s h o u l d  a good b a t h ; w a t e r  woman  I s a y , not  s p l a s h e d on y o u ,  The  woman w i t h  the fractured wrist talked  e x e r c i s i n g h e r f i n g e r s o f t h e a f f e c t e d hand: told  about "He  [physician]  me t o w i g g l e i t a s much a s I c a n . S o , I c o u l d  m u s c l e s down t h e r e a cast  moving.  I think  s e e ray  i t i s almost better  than  f o r moving."  As one woman p r o g r e s s e d  from a w a l k e r t o a cane, she  began t o t h i n k about d r i v i n g h e r c a r a g a i n .  Here, again, her  compliance t o the health p r o f e s s i o n a l ' s advice I feel the  that I could  t o the l e f t .  "Don't s t a r t u n t i l  evident:  d r i v e b e c a u s e y o u s e e a l l me,  g a s and t h e b r a k e i s w i t h  nothing  was  the r i g h t foot,  like  there's  I ' v e been w a r n e d by f r i e n d s ,  your doctor  or your physio  s a y s y o u c a n , b e c a u s e i f y o u h a d an a c c i d e n t ,  tells, they say  t h a t ' s t h e f i r s t t h i n g t h e y d o , i s check back on y o u r h i s t o r y , so I wouldn't She  dare.  r e f r a i n e d from d r i v i n g u n t i l  permission.  the doctor  I t was i n t e r e s t i n g t o n o t e t h a t  women d i d n o t e x p e r i e n c e a n y d i f f i c u l t i e s  gave h e r these e l d e r l y  adhering t o the  restrictions. Maintaining  Control  Several felt  o f t h e women d e s c r i b e d  t h e need t o m a i n t a i n  environment.  This  s i t u a t i o n s where  some c o n t r o l o v e r  This  focused coping.  their  b e h a v i o u r a p p e a r e d t o be r e l a t e d t o t h o s e  s i t u a t i o n s where t h e women e x p e r i e n c e d autonomy.  they  threats  to their  b e h a v i o u r was a l s o an e x a m p l e o f p r o b l e m As a l r e a d y  m e n t i o n e d , one woman f e l t t h e  81 need t o t e l l  h e r p h y s i c i a n t h a t she wanted t o see a n o t h e r  neurologist:  " I went back o n c e more and t h e n my d o c t o r  this  time  i t was t i m e t o go b a c k .  back t o him.' him.'  I said,  'There's  I said,  said  'I'm n o t g o i n g  no way I'm g o i n g back t o  So t h e n , t h a t ' s when I went up t o U.B.C." A second  subject described her experience i n r e l a t i o n to  giving directions  t o t h e home h e l p e r s :  W e l l , I g u e s s t h e y g e t s o r t o f a n n o y e d w i t h me. go o u t i n t h e k i t c h e n and s a y ,  "Oh, h e a t  c h i c k e n up i n t h i s p a c k a g e o f b o u i l l o n , bouillon."  I try to t e l l  this  But,I  leftover  chicken  them how t o do t h i n g s w h i c h  I  guess they don't a p p r e c i a t e . Control w i l l behaviour  a l s o be d i s c u s s e d f u r t h e r  of using s o c i a l  Another felt  consulting a medical  you this  She made t h e d e c i s i o n  and I g u e s s t h e y g a v e i t t o me a l l  I was i n h o s p i t a l ,  I don't  I read about t h i s medicine l o s e your  appetite;  i s happening.'  lose your  after  dictionary:  some m e d i c i n e  the time then  supports.  woman d e s c r i b e d s t o p p i n g a m e d i c a t i o n t h a t s h e  was m a k i n g h e r s i c k .  I took  i n the coping  know, b u t I know,  and t h e y s a i d  'be s u r e t o t e l l  your  i t makes doctor i f  I t o l d my d o c t o r t o o and i f y o u  a p p e t i t e and y o u ' r e  s t r o n g e r , and y o u do t h i s  thirst  and I t h i n k  t h a t t h e y s a i d would happen w i t h t h i s  i s getting  a little  I had e v e r y t h i n g pill.  P r i o r t os t o p p i n g t h e pill, s h e c o n s u l t e d h e rd o c t o r a b o u t h e rl o s so fa p p e t i t e .  S h e w a s t o l dt h a t this h a p p e n e d w i t h  m a n y m e d i c a t i o n s . U l t i m a t e l y , s h e s t o p p e d t h e m e d i c a t i o n . P r e v e n t i o n P r e v i o u s falls h a d b e e n e x p e r i e n c e d b y  3 o ft h e8 w o m e n  T h e o t h e r five w o m e n c o p e d w i t h t h e p h y s i c a l a n d p s y c h o l o g i c a l c o n s e q u e n c e s o ft h e i r first fall.  T h e d a t a w a s  rich i n detail i nr e l a t i o nt ot h e w o m e n t r y i n gt o d e t e r m i n e w h y t h e fall o c c u r r e d . S u b s e q u e n t l y ,t h e w o m e n t a l k e d a b o u t b e i n g m o r e c a r e f u l o rt a k i n g p r e v e n t a t i v es t e p s t o p r o t e c t t h e m s e l v e s f r o m a n o t h e r fall.  P r e v e n t i o n w a s v e iw e d a s  a n o t h e rp r o b l e m f o c u s e d c o p i n g b e h a v i o u r . T h e r e w a s c o n s i d e r a b l e w o r r y o v e rt h e possibility o f e x p e r i e n c i n g a n o t h e r fall.  S o m e o ft h e w o m e n t a l k e d a b o u t  g e n e r a l s a f e t ym e a s u r e s s u c h a s p u t t i n gt h er u b b e rm a t d o w n in t h et u b d u r i n g a b a t h o rs h o w e r . T h i se x a m p e l w a s f r o m t h e w o m a n w h o t r i p p e d o n t h es w e a t e rw r a p p e d a r o u n d t h e chair.  S e v e r a l o ft h ew o m e n t a l k e da b o u t b e i n g m o r e c a r e f u l i n relation t o all t h e i r activities.  T h e w o m a n w h o h a d  f r a c t u r e d h e r h i p a f t e r t r i p p i n go n h e rb e d s p r e a d d e s c r i b e d h e rw o r r y o v e rh e r first f e w o u t i n g s o u t s i d et h e h o m e : " T h e r e is n o g u a r a n t e e t h a t it c a n ' th a p p e n . It c o u l d h a p p e n a n y t i m e .  E v e n w h e n I g o o u t o n t h es t r e e t it c o u l d h a p p e  W h e n a s k e d h o w s h e c o p e d w i t h this w o r r y ,s h e s t a t e d :  83 W e l l ,y o u h a v e t ob e m o r e careful, w a t c h o u t f o r e v e r y t h i n g t h a tc o m e s y o u rw a y . F o ri n s t a n c e ,y o u a r e w a l k i n g o n t h es t r e e t i nc a s e a b i k ec o m e s a l o n g y o u w o r r y b e c a u s e y o u a r eg o i n g t og e t hit o r w h a t e v e r . T h a tc o u l d h a p p e n v e r y easily. S e v e r a l o ft h e w o m e n d e s c r i b e d c h a n g i n g t h e i r a p p r o a c h t ot h e activities in t h e i r life.  F o re x a m p l e ,t a k i n g m o r e  t i m e o rn o tr u s h i n g all t h et i m e .  T h i sa c c o u n t w a s f r o m t h e  w o m a n w h o t r i p p e d o n h e rs w e a t e ra n d b r o k e h e r wrist: w a t c h i n g  it b e t t e r .  " I a m  I d o n ' tr u s h t h e w a y I u s u a l l y g o .  M a y b e I will g e to v e r t h a t . " F r o m t h e s e s t a t e m e n t s ,s l o w i n g d o w n m a y n o t b e a p e r m a n e n t b e h a v i o u rc h a n g e . S e v e r a l o t h e rw o m e n w e r e m o r e c o m m t i t e d t ot h e p r o p o s e d c h a n g e in lifestyle.  O n e w o m a n  d e t a i l e dt h ef o l l o w i n g a c c o u n t o fh e r c h a n g e : B u t I f i n do n e t h i n gt h a tI m u s t n o t d o is t o l e a v e a n y t h i n g t ot h e last m i n u t e ,a n d r u s h .  I g e tv e r y ,  v e r y  s h a k y a n d n e r v o u s if I h a v e t o p u s h m y s e l ft o o far.  A n  I u s u a l l y try, if I g o o u t o n e d a y ,t om o r e o rl e s s r e s t u p t h e n e x t d a y .  T h e a b o v e a c c o u n t w a s f r o m t h ew o m a n w h o h a d e x p e r i e n c e d falls in t h e p a s t .  T h i s w o m a n h a d d e v e l o p e d w a y s o f  b a l a n c i n g t h e activity i nh e r life.  A n o t h e r w o m a n a l s ot a l k e da b o u t a s l o w e rp a c e . S h e h a d e x p e r i e n c e d t w o falls i nt h e last e i g h tm o n t h s . S h e d i d n o t  84 k n o w t h e c a u s e f o rh e r falls.  A s a r e s u l to fh e rw o r r y o v e r  m o r e falls, s h e h o p e d t h a ta s l o w e rp a c e w o u d l h e l p t o p r e v e n tt h e m . S h e i n d i c a t e dt h a ts h e h a d a w l a y s m o v e d f a s t t og e t all t h et h i n g s d o n e t h a ts h e h a d t od o . S h e d e s c r i b e d t h ew o r r y ,a n d t h es l o w i n g o fh e r p a c e o f activities: S o , I k e e p o n ,b u t w o r r y i n g ,b a c k in m y m i n d ,  a l t h o u g h  t h e p h y s i o t h a tc a m e t ot h e h o u s e s a i dt oj u s t r e l a x a n d d o n ' tr u s h ;t h a tm g ih t h a v e a c e r t a i na m o u n t t od o w i t h it.  W h e n a s k e d h o w it felt t os o lw d o w n , s h e r e p l i e dt h a ts h e w  l e a r n i n gt os o lw d o w n . T h i s w o m a n v e iw e d s l o w i n g d o w n a s a c o p i n g b e h a v i o u rt op r e v e n t m o r e falls.  U l t i m a t e l y , it w a s  a l s oa b e h a v i o u rt op r o t e c th e r level o f activity a n d n id e p e n d e n c e : A n d s oI j u s th a v e t os t o p a n d t h i n k a little bit o f m y s e l f . A n d  it isn't o n l y o fm y s e l f ,b u t m y f a m i l y ,  b e c a u s e if I, y o u k n o w , I m ' ill, it's m o r e w o r k  f o r  t h e m . F r o m t h e d a t a analysis, it w a s a l s oi n t e r e s t i n gt on o t e t h a t s e v e r a l w o m e n identified w a y s o fw a l k i n g t h a tm g ih t p r e v e n t f u r t h e r falls.  H e r e ,p r o b l e m s o l v i n g skills w e r e q u i t e  e v i d e n t . B e s i d e s s l o w i n g h e rp a c e ,t h e w o m a n w h o h a d fallen 12 t i m e s d e s c r i b e d h e rc o n s c i o u s a p p r o a c h t o w a l k i n g : If I r e m e m b e r t ol e a d w i t h this leg, y o u s e e m y r i g h t l e g is m y w e a k  l e g a n d s o m e m t i e s I s t e p d o w n o n t h a t  85 t h e n it j u s tg o e s o n m e , a n d h a v e a n y w a r n i n g ; t i m e o n t h eb u s .  I j u s tc o l l a p s e ,I d o n ' t  a n d that's w h a t h a p p e n e d this last I w e n t d o w n o n m y r i g h t leg. B u t ,  I r e m e m b e r t ou s e this leg, t h e n I u s u a l l ym a k e right.  it all  S o far, s o g o o d .  T h e w o m a n w h o fell w h i l e o p e n i n g t h ef r i d g ed o o r a l s o t a l k e da b o u t r e m i n d i n g h e r s e l ft o w a k l in a c e r t a i n w a y . E v e n t h o u g h this b e h a v i o u rw a s n o t specifically r e l a t e d t o this fall, s h e h a d o b v i o u s l yb e e n t h i n k i n g a b o u t it: W h a t I t h i n k is, I d o n ' tw h e n I m ' tired m a y b e r a i s e this  f o o ta s h i g h a s I s h o u l d a n d w h a t I a w l a y s s a y t o m is, " R a i s e y o u r feet, r a i s ey o u r feet."  I d o n ' tt h i n kI  r a i s et h a t left foot. It w a s e v i d e n t ,f r o m t h e s e a c c o u n t s ,t h a tp r e v e n t i o n o f f u r t h e r falls w a s a n i m p o r t a n ti s s u ef o r t h e s e e l d e r l y w o m e n . P l a n sf o r t h e F u t u r e A s a r e s u l to ft h e fall, s e v e r a l w o m e n in t h e s t u d y b e g a n t oc o n t e m p l a t e a n d m a k e p l a n sf o r t h ef u t u r e . T h i s p l a n n i n g w a s v e iw e d a s a n e w c o p i n g b e h a v i o u r i nr e s p o n s e  their p e r c e i v e d n e e d f o rc a r e a n d s u p p o r t . T h i s p l a n n i n g w a s clearly r e l a t e dt ot h e i r l o s so fn id e p e n d e n c e a n d t h e i r d e s i r et on o tb e a b u r d e n t of a m i l ya n d friends.  T h e r e w e r e  v a r y i n g d e g r e e s o fa c c e p t a n c e t op a lc e m e n t a s s o m e o f t h e w o m e n t a l k e da b o u t t h e i r p l a n s .  O n e w o m a n t a l k e da b o u t p l a n n i n g a t o u ro ft h e facilities  86  w i t h s o m e o ft h ew o m e n i nh e rS e n i o r ' s C o m p e lx . S h e a p p e a r e d t oa p p r o a c h t h ei s s u e o fn u r s i n g h o m e p a lc e m e n t in a m a t t e r of-fact w a y : " W e l l ,s o m e m t i e s that's w h y I t h i n kt h a t y o u k n o w w e v 'e all g o tt of a c e it; we'll p r o b a b l y e n d u p in a n u r s i n g h o m e " . W h e n a s k e d  if s h e h a d a n y f e e l i n g so f w h a t  life w o u d l b e like in a facility, s h e r e s p o n d e d : W e l l ,I m ' n o tt o o , a lot o fp e o p l e d r e a d really.  it.  I d o n ' t  I t h i n k if y o u g e t in a h a l f w a yd e c e n t p l a c e ,  y o u h a v e t om a k e y o u ro w n w a y . I m e a n , h a v e y o u r o w n i n t e r e s t sa n d j u s td o t h eb e s ty o u c a n . Really, I w o u l d n t ' g o w i t h f a m i l y . T h i s w o m a n h a d m a d e n o definite p l a n sf o r p l a c e m e n t . I nc o n t r a s t ,t w o w o m e n t a l k e da b o u t t h e i r p l a n s f o r  p e r s o n a l c a r e h o m e p l a c e m e n t . O n e w o m a n h a d h e rn a m e p l a c e o n a list b e f o r e s h e left t h eh o s p i t a l t or e t u r nt o t h e c o m m u n t i y . T h e o t h e rw o m a n w a s c o n s i d e r i n gt h i s o p t i o n d u r i n g t h e first i n t e r v i e ww i t h h e r .  S h e h a d s t r a i n e d h e r  b a c k d u r i n g h e r fall a n d h a d s p e n tt h r e e w e e k s i nb e d a f t e r h e rd i s c h a r g ef r o m hospital.  D u r i n g t h es e c o n d i n t e r v i e w ,  s h e i n d i c a t e dt h a ts h e h a d m a d e s o m e a r r a n g e m e n t s f o r p a lc e m e n t w i t h t h eL o n g T e r m C a r e c o o r d i n a t o r .  B o t h o ft h e s e w o m e n t a l k e da b o u t m o v n ig t ot h e facility o n c e t h e y w e r e m o r e illustrate this p o i n t : h o m e w h e n  i n d e p e n d e n t . T h e f o l l o w i n g a c c o u n t s " I ' mg o i n g — I a m g o i n g i n t oa n u r s i n g  I g e tb e t t e r ;I ' v e g o tm y n a m e in";  a n d :  87 I want t o g e t take  w i t h me  t o go The  b e t t e r enough t o g a t h e r and  go  i n r i g h t now;  into a nursing I want t o g e t  that people entered  longer  to care  able  further with  for themselves.  t h e women, t h e  i f t h e r e was  going  functional status. i n her Despite as  present the  option  perception  o n c e t h e y were  no  explored  She  she  wanted  to  improvement i n her  a b i g d e c i s i o n f o r her  as  she  had  1964.  a p p e a r e d t o be  time f o r the  some a m b i v a l e n c e  about  d e c i s i o n drew n e a r e r .  This  h a v e r e f l e c t e d t h e i r hope f o r r e c o v e r y .  in a facility  a d j u s t m e n t between  independent versus  meant t h a t t h e y w o u l d now  their  the  It  their  fact  that  r e q u i r e some  care.  of S o c i a l Support  independence, the t h e use  various and  the  r i g h t time.  In response to t h e i r p e r c e p t i o n  was  feet.  When t h i s was  apartment s i n c e  o f t h e m s e l v e s as  assistance with Use  any  a l s o h a v e been r e l a t e d t o t h e  being  my  f a c t t h a t t h e women t a l k e d a b o u t p l a c e m e n t  as t h e  a m b i v a l e n c e may may  on  to  I d o n ' t want  s e c o n d woman r e s p o n d e d t h a t  t o be  I t was  i n e v i t a b l e , there  this  home.  facilities  w a n t e d t o make t h e d e c i s i o n a t t h e  lived  what I want  n o t i o n of g e t t i n g b e t t e r c o n t r a d i c t e d  information  see  up  l a s t coping  of t h e i r  decreased  b e h a v i o u r t h a t was  of s o c i a l supports.  The  described  s o c i a l s u p p o r t came f r o m  s o u r c e s s u c h as n e i g h b o u r s , f r i e n d s , f a m i l y members,  homemakers.  The  homemakers were f r o m t h e  g o v e r n m e n t Long  88 Term C a r e p r o g r a m s  o r p r i v a t e companies.  t a l k e d about her p r i v a t e c l e a n i n g  One s u b j e c t  lady.  The theme o f s o c i a l s u p p o r t u s e was d i v i d e d different categories. help.  The f i r s t  also  i n t o two  c a t e g o r y was t h e t y p e o f  The s e c o n d c a t e g o r y was t h e e x p e c t a t i o n s f o r t h e h e l p  t h a t was p r o v i d e d The  first  i n their  homes.  c a t e g o r y o f t h e t y p e o f h e l p was e a s i l y  r e p r e s e n t e d on a c o n t i n u u m .  The c o n t i n u u m r a n g e d f r o m one  end o f a c c e p t i n g f o r m a l s u p p o r t s (home c a r e ) t o t h e o t h e r end w h e r e h e l p was o n l y p r o v i d e d by i n f o r m a l s u p p o r t s ( f a m i l y and friends) . At  t h e end o f t h e c o n t i n u u m where t h e m a i n s u p p o r t was  home c a r e , t h e women t a l k e d family or friends. to  about n o t wanting t o burden  One woman t a l k e d  about n o t being a burden  her friends: They a r e my f r i e n d s , o k a y , b u t I d o n ' t want t o c a l l . They h a v e t h i n g s t o do w i t h They h a v e a l i f e involved  to live  i n that.  Plus,  their  too.  c h i l d r e n o r whatever.  I d o n ' t want them t o g e t  they l i v e  q u i t e f a r away f r o m  me, s o I d o n ' t want t o g e t them i n v o l v e d disturb  them.  A n o t h e r woman t a l k e d her  i n that or  about h e r f e a r o f becoming  a burden t o  family: You know, I c a n g e t on b e c a u s e I've g o t t h e g i r l  I ' v e g o t t h e w a l k e r and  i n and I ' v e made m y s e l f a b l e t o d o ,  89 b e c a u s e I didn't w a n t p e o p l e to, I didn't w a n t t o h a v e t og o a n d live w i t h m y d a u g h t e ra n d r u i n h e r life u p . O n t h em i d d l e o ft h ec o n t i n u u m ,s e v e r a l w o m e n t a l k e d a b o u tr e c e i v i n g h o m e c a r e a n d s o m e h e l pf r o m t h e i r f r i e n d s a n d f a m i l y .  O n e w o m a n d e s c r i b e d this e x p e r i e n c e :  O h ,I a m h e l p l e s s .  T h e r e ' s a girl a t t h ee n d o f t h e  hall; s h e ' sn o t well.  I d o n ' t like calling o n f r i e n d s  t o w a i to n m e . Y o u k n o w ,  I d o n ' tw a n t t ob r i n gt h e m i n  o n m y t r o u b l e s . W h e n e x p l o r i n g t h e s ef e e l i n g sf u r t h e r ,s h e s t a t e dt h a t s o m e o fh e rf r i e n d s h a d v o l u n t e e r e d t h e i r h e l p : A c h a p b r i n g s g r o c e r i e s .  A n o t h e rf r i e n d will b e d r i v i n g  m e t o m y d o c t o r ' sa p p o i n t m e n t s . I d o n ' tw a n t t h e m t o d a n y t h i n g like h e l p i n g m e . I c o u l d n ' ta s k m y f r i e n d s t o  d o w h a t t h e h o m e m a k e r s ' d o i n g f o rm e . I d o n ' tw a n t m y f r i e n d st oh a v e total r e s p o n s i b i l i t yf o rm y c a r e .  H o m e c a r e w a s t h e n v e iw e d a s a c o m p r o m s ie s o t h a th e r f r c o u l d assist h e r ,b u t ,a t t h es a m e t i m e ,n o t h a v e total responsibility f o rh e r c a r e . A t t h eo t h e re n d o ft h ec o n t n iu u m w e r e t h ew o m e n w h o relied s o l e l yo n t h eh e l pf r o m t h e i r f r i e n d so rf a m i l y .  O n e  w o m a n d e s c r i b e d h e re x p e r i e n c e o fr e l y i n go n h e rd a u g h t e r a n d c l e a n i n gl a d ya f t e r h e rd i s c h a r g ef r o m hospital: I w a s s o tired o fp e o p l e ,a s I t o l dy o u . p u b l i cw a r d ,  I n e v e r h a d a  o r a 4-bed, w h a t e v e r y o u call it, i n m y  90 life b e f o r e ,a n d I w a s s o tired o fp e o p l e — listening t o t h e m t a l ka b o u t t h e i r a i l m e n t sa n d e v e r y t h i n g ,t h a tI c o u l d n ' tp u t u p w i t h a h o m e m a k e r a n d  I h a p p e n e d t o h a v e  a g o o d c l e a n i n g w o m a n , a n d s o w e c o p e d . R e c i p r o c i t ya p p e a r e d t ob e a n i m p o r t a n td e t e r m i n a n t o f w h e t h e rt oa s k a f r i e n df o ra s s i s t a n c e . O n e w o m a n s t a t e d t h a tr e l y i n g o n h e rf r i e n d sa n d f a m i l yw a s p a r to f t h e i r r e c i p r o c a lr e l a t i o n s h i p :  " T h e y j u s ts w a m p e d m e w i t h t h e i r  k i n d n e s s a n d a l m o s t — I c a n ' tb e l i e v e it.  O h , this  is  w o n d e r f u l . " H e rf r i e n d s h a d a s s i s t e dh e rw i t h n u m e r o u s t a s k s s u c h a s h o u s e h o d l c h o r e s ,m e a l p r e p a r a t i o n ,s h o p p n ig a n d p e r s o n a l c a r e . W h e n a s k e d h o w s h e felt a b o u t h e r f r i e n d s p r o v i d i n g s u p p o r tt oh e r ,s h e s t a t e d :  " I w o u d l d o t h e s a m e  t h i n gf o rt h e m . T h e y s a y it's t i m e y o u g o t h o m e c a r e ; b e e n s o g o o d t ou s .  y o u v 'e  S o it is v e r y m u t u a l . "  A n o t h e rw o m a n d e s c r i b e dt h er e c i p r o c i t yi n h e r r e l a t i o n s h i p sw i t h t h en e i g h b o u r s in t h e b l o c k : T h e r e a r e p e o p l e in t h eb u i l d i n gt h a t will h e l p , y o u k n o w ; w e h e l p e a c h o t h e rq u i t e a bit. d o w n t h e hall, J e h o v a h s ' W i t n e s s e s ,a n d k i n d o fl e e r yo ft h e m ,  b u t y o u k n o w ,  I ' v e g o tt w o g a l s I ' v e a w l a y s b e e n  t h e y ' r es o nice,  they'll d o a n y t h i n g ; if I w a n t h e l p , they'll d o a n y t h i n g . W e t r yt oh e l p e a c h o t h e r . A n o t h e re x a m p e l o fr e c i p r o c i t yw a s t h e w o m a n w h o d e c i d e d t o a c c e p t h o m e c a r et o alleviate b e i n g totally d e p e n d e n t o n h e r  91  friends.  T h e t h e m e o fr e c i p r o c i t yw a s i m p o r t a n ta s t h e w o m e n  d e c i d e d w h o t oa s k f o ra s s i s t a n c e .  It w a s  i n t e r e s t i n g t o  n o t e t h a tt h ei n v o l v e m e n t o ff r i e n d s o rf a m i l yw a s d e p e n d e n t o n t h e w o m e n s ' p e r c e p t i o n o ft h e i r r e l a t i o n s h i pw i t h t h e s e d i f f e r e n tp e o p l e . T h e e l d e r l yw o m e n s ' a u t o n o m y w a s in t h ed e c i s i o n t oi n v o l v ef a m i l yo r  i m p o r t a n t  friends.  T h e s e c o n d c a t e g o r yw i t h i n t h eu s e o ft h e social s u p p o r t t h e m e w a s d e f i n e d a s e x p e c t a t i o n s o f t h eh e l p . S i n c e5 o f t h e8 w o m e n r e c e i v e d h o m e c a r e ,t h ee x p e c t a t i o n s o ft h e h e l p w a s p r i m a r i l yr e l a t e dt o this service.  H o w e v e r ,  t h e r e w e r e  a l s os o m e e x a m p e ls o fe x p e c t a t i o n sf r o m t h e w o m e n w h o relied s o l e l yo n f a m i l ya n d friends.  It w a s i n t e r e s t i n gt o n o t e  t h a tm o s t o ft h ew o m e n m e n t o in e d t h er a c e o ft h e h o m e m a k e r s . F o rs e v e r a l w o m e n , this w a s a n i m p o r t a n t i s s u eb e c a u s e t h e y h a d difficulty c o m m u n c ia t n ig w i t h t h eh o m e m a k e r s . T h e w o m a n  w h o h a d laid i nb e d f o r t h r e e w e e k s a f t e r h e rd i s c h a r g e f r o m h o s p i t a l d e s c r i b e d this e x p e r i e n c e : t h e y a r ev e r y h a r d t o m a k e o u t . "  " T h e y a r e all Filipino; T h i sc o m m u n c ia t o in p r o b e lm  w a s c o m p l i c a t e d f u r t h e rd u e t ot h el a c ko fc o n t i n u i t y in s e n d i n g t h es a m e h o m e m a k e r t ot h e w o m a n s ' h o m e .  S h e  d e s c r i b e d this e x p e r i e n c e : A n d a n o t h e r thing, I r e s e n t is first you'll g e t a d i f f e r e n to n e e v e r yt i m e a n d y o u h a v e t o tell t h e m , h o l l e r f r o m h e r e in t h ek i t c h e n w h e r e t h i n g s are. W e l l n o w ,  t h e little o n e t h a tc a m e this m o r n i n g ,s h e k n o w s ,  she's  been h e r e  where t h i n g s they don't and  a r e , but they don't  g i v e y o u one p e r s o n and  things.  woman t a l k e d a b o u t h e r c o m m u n i c a t i o n  her Spanish cleaning  lady.  c o n t i n u i t y was n o t a p r o b l e m communication  problems  Even though l a c k o f  i n t h i s p r i v a t e arrangement, the  was a s o u r c e o f f r u s t r a t i o n :  J u s t h a v i n g t o a c c e p t my l i t t l e from—I  She knows  know; y o u h a v e t o go i n t o a b i g d i s c u s s i o n  they can't f i n d  Another with  about f i v e or s i x t i m e s .  forget—not  cleaning  girl.  She's  S p a i n , b u t some p l a c e s o u t h , and  s h e ' s Span-ish and d o e s n ' t  speak E n g l i s h v e r y w e l l .  s o s o m e t i m e s when s h e g o e s s h o p p i n g , back t h e r i g h t t h i n g s .  That's  she wouldn't  the only  And bring  frustration I  had. The for  l a c k o f c o n t i n u i t y o f homemakers a l s o was a  s e v e r a l o f t h e o t h e r women i n t h e s t u d y .  were n o t s p e c i f i c a l l y One  T h e s e comments  r e l a t e d t o any communication  woman who was r e c e i v i n g homemakers on a d a i l y  described got used  this experience: t o L . , and I l i k e  s t a y w i t h me."  When a s k e d  problem  issue. basis  "And t h e y were n i c e t o o b u t I ' v e R., and I hope s h e ' l l be a b l e t o t o e x p l a i n f u r t h e r why i t was  i m p o r t a n t t o h a v e t h e same p e r s o n ,  she responded:  f o r s h e g e t s t o know where e v e r y t h i n g  "Itis,  i s and my way and h e r  way. " From t h e s e a c c o u n t s ,  t h e women e x p r e s s e d  frustration in  93 r e c e i v i n g h o m e c a r e h e l pf r o m p e o p l e w h o m t h e y c o u l d n o t c o m m u n c ia t e w i t h . A s well, it w a s i m p o r t a n tt o h a v e c o n t i n u i t yo fh o m e m a k e r s . T h e c o n t i n u i t yo fh o m e m a k e r s w a s a l s oi m p o r t a n tf o rc o m m u n c ia t o in a n de n s u r i n g s o m e familiarity w i t h t h ee l d e r l yw o m e n s ' r o u t i n e s in t h e h o m e . A n o t h e ri m p o r t a n t e x p e c t a t i o n o ft h eh o m e m a k e r s w a s t h a t t h e y b eg o o d h o u s e c l e a n e r s . H e r e ,t h ew o m e n c o m m e n e td t h a t t h e y w e r e n i c e girls b u tt h e yr e m a n ie d critical o ft h e girls' h o u s e k e e p n i g skills.  T h e 102-year-old w o m a n d e s c r i b e d h e r  h o m e m a k e r : S h e ' s an i c e p e r s o n b u ts h e l e a v e s m u c h t ob ed e s i r e d o n h o u s e w o r k t h ew a y I d o it m y s e l f ,b u tt h e n ,I a m a f u s s y old d u c k .  I like t h i n g s d o n e r i g h t ( w h i s p e r s )  a n d  I like t o w o r k . H e r e , this w o m a n s ' e x p e c t a t i o n sf o rh e r s e l f w e r e p a s s e d o n t o t h e h o m e m a k e r s . O n ew o m a n c o m m e n e td o nt h e i r l a c ko ft r a i n i n gw h c ih s h e b e l i e v e dt ob et h e m a o jr p r o b l e m . A s a result, t h e y w e r e p o o r h o u s e k e e p e r s : I h a v e this girl, c o m e s in o n c e a w e e k a n dd o e s t h e v a c u u m n ig a n d af e w o t h e r j o b s ,a n d I h a v e e v e r y t h i n g t o p u ta w a y w h e n s h eg o e s . T h e y d o n ' t train t h e m , y o u k n o w . I d o n ' tk n o w w h y , I d o n ' tk n o w w h y t h e y d o n ' t train t h e m p r o p e r l y .  S h e s ' av e r yn i c e little girl,  v e r y willing t od ot h i n g s ,b u t w h e n t h e y ' r e finished,  94  they and  j u s t drop e v e r y t h i n g  and t h e n i t ' s up t o y o u t o go  s t r a i g h t e n t h i n g s u p , and p u t t h i n g s away.  I t was a p p a r e n t t h a t t h e homemakers' l a c k o f s k i l l s was another source  of frustration  f o r t h e women i n t h e s t u d y .  Another expectation of the help show some r e s p e c t  they  f o r t h e women's way o f m a n a g i n g h e r  household a c t i v i t i e s . be  r e c e i v e d was t h a t  From t h e i n t e r v i e w s , t h e r e a p p e a r e d t o  e v i d e n c e o f t h e e l d e r l y women e x e r t i n g o r t r y i n g t o  maintain  some c o n t r o l .  referred  to earlier  T h i s m a i n t e n a n c e o f c o n t r o l was  i n t h i s paper.  One woman d e s c r i b e d h e r  organization of the tasks that required completion. r e l y i n g o n h e r f r i e n d s and f a m i l y f o r The  girls  everything  support:  a l l phone, a s k i n g c a n they l i n e d up.  Cornflakes  She was  help?  And I h a v e  box t h a t n e e d s  o p e n i n g , t o b u t t e r t h a t n e e d s c u t t i n g , and i t i s a l l lined  up and t h e y  go r i g h t  A n o t h e r woman d e s c r i b e d  to i t .  her experience  with the  homemakers f r o m a p r i v a t e a g e n c y : W e l l , I guess they  g e t s o r t o f a n n o y e d w i t h me.  go o u t i n t h e k i t c h e n and s a y , chicken  up i n t h i s p a c k a g e o f b o u i l l o n ,  bouillon." guess they During had  "Oh, h e a t t h i s  I try to t e l l don't  the course  But,  leftover  chicken  them how t o do t h i n g s w h i c h i  appreciate. of the interview with  opened f i v e c o n t a i n e r s  i n her f r i d g e ,  t h i s woman, s h e  trying  t o find the  I  95 margarine. l i k e her and own,  do  She  had  own.  stated that this place  When a s k e d how  t h i n g s f o r you  she  responded:  But  my  t h a t you  and  the other  like  she  they are  just  f o l d them and i f she  or u t e n s i l s .  My  just  towels  i n the  them.  But,  (Laughs). are  hall,  I have  the  folded  s t o r e or shops.  a l l nice g i r l s ,  set  I am But,  fussy, you  got  are  silver. just  Well,  so,  they  up. her  ways,  t h i n g s but she  she  was  how  they're  complaint  young. about  I guess; fussy o l d maid. be  80  n e x t week and  " I am  she  t o l d t h e homemakers how  r e l u c t a n t t o a d m i t t h a t t h i s was  w a n t i n g t o c o m p l a i n about the  t o come i n . "  I h a v e n ' t any  know, I w i l l  wanted t h i n g s done.  service:  r e a l l y , but  you  i n y o u r ways.  H e r e , t h e woman d e s c r i b e d  the  in with  my  replied:  They're a l l nice g i r l s .  way  i n my  t h r o w them  your  Some o f them  w a n t e d t h e homemakers t o r e s p e c t  Well, they're  do  on  drawer f o r s i l v e r ,  t h e y were a l l m i x e d  T h a t a n n o y e d me.  seemed  t o h a v e p e o p l e come i n  d r a w e r f o r u t e n s i l s , and  a l o t of knick-knacks never used but  longer  were u s e d t o d o i n g  k n i f e d r a w e r , I h a v e one  silver  When a s k e d  i t felt  no  very  A l s o , t h e r e was  the  a f e e l i n g of  s e r v i c e b e c a u s e she  to  not  required  t h a n k f u l t h a t t h e y come i n ; someone  96 S u m m a r y I ns u m m a r y , this c h a p t e r h a s p r e s e n t e d t h er e s u l t s o f t h e d a t a analysis.  B o t h t h e fall a n d t r e a t m e n t w i t h i n t h e  H e a l t h C a r e s y s t e m r e s u l t e di na c h a n g e o fr o u t i n ef o r t h e s e w o m e n , u p o n their r e t u r n h o m e . T h e c h a n g e  in t h er o u t i n e w a s  d u e t ot h e p h y s i c a l a n d p s y c h o l o g i c a l c o n s e q u e n c e s o f t h e fall. T h e c h a n g e i nr o u t i n er e s u l t e di nt h r e a t st ot h e e l d e r l y w o m e n s ' s e l f e s t e e m .  T h e t h e m e s t h a tw e r e  identified a s p a r t  o ft h es e l f e s t e e m c o n c e p t w e r e i n d e p e n d e n c e , activity,  a n d  a u t o n o m y . All o ft h e w o m e n i nt h es t u d y d e s c r i b e d h o w t h e i r d e g r e e o fn id e p e n d e n c e w a s a f f e c t e da f t e r t h e fall. T h e  ability t o m e e t o n e ' s p h y s i c a la n d e m o t i o n a l n e e d s w a s v a l u e d h i g h l yb y all t h e w o m e n . S o m e w o m e n r e p o r t e d a l o s s o f c o n f i d e n c ea f t e r t h e fall.  O t h e r w o m e n r e p o r t e d t h a t t h e y  r e q u i r e d a s s i s t a n c ew i t h t h e i r p e r s o n a l c a r e o ri n t h e m a n a g e m e n t o fh o u s e h o d l t a s k s . All o ft h e w o m e n d e s c r i b e d t h e i r activity level p r i o r t o t h e fall.  Activity w a s a n i m p o r t a n tc o m p o n e n t o ft h e i r self-  e s t e e m . D e s p i t et h e d i f f e r e n t t y p e s o f activity, t h e w o m e n p e r c e i v e dt h e m all t ob e i m p o r t a n t . T h e w o m e n s ' level o f activity c h a n g e d a f t e r t h e fall.  T h i s w a s a s o u r c e o f  c o n c e r n f o r t h e w o m e n i nt h es t u d y . A u o tn o m y w a s t h e l a s t t h e m e t h a tt h e e l d e r l yw o m e n d e s c r i b e d . A u t o n o m y , o r selfd e t e r m i n a t i o n ,w a s i m p o r t a n tt ot h e s e w o m e n . T h e d a t a  97 r e v e a l e d t h r e e d i f f e r e n tp r o c e s s e s o fd e c i s i o n m a k i n g t h a t t h e w o m e n e n c o u n t e r e d a f t e r t h e i r fall.  A s well, it w a s  i m p o r t a n tf o r t h e w o m e n t oh a v e a d e q u a t e m e d i c a l i n f o r m a t i o n a b o u t t h e i r h e a l t h s t a t u s . T h e s e c o n d c o n c e p t w a s a d a p t a t i o n . T h e w o m e n u s e d c o p i n g b e h a v i o u r s in o r d e rt oc o p e w i t h t h et h r e a tt o t h e i r s e l f e s t e e m . S o m e o ft h e s e b e h a v i o u r s w e r e e m o t i o n f o c u s e d c o p i n g ,w h i l e o t h e rb e h a v i o u r s w e r e p r o b l e m f o c u s e d .  T h e r e  w a s a w d ie r a n g e o fb e h a v i o u r s t h a tw e r e u s e d b y t h e e l d e w o m e n . T h e d i f f e r e n tc a t e g o r i e s o fb e h a v i o u r si n c l u d e d t h e f o l l o w i n g :  ( a ) u s e o f faith/positive beliefs,  ( b ) c o m p l i a n c e , ( c ) m a i n t a i n i n g control, ( d ) ( e ) p l a n n i n g f o r t h e future, a n d S o m e b e h a v i o u r s w e r e u s e d  p r e v e n t i o n ,  (f) u s e o f social s u p p o r t .  in p a s t life-events. O t h e r  b e h a v i o u r s w e r e l e a r n e d in r e s p o n s e t ot h e fall a n d c h a n g e  i n  r o u t ine. T h i s c h a p t e rh a s p r e s e n t e d t h ef i n d i n g so f this s t u d y . I nt h en e x t c h a p t e r ,t h e s e f i n d i n g sa r e d i s c u s s e d a n d r e l a t e d t ot h ec u r r e n tr e s e a r c h a n d t h e o r e t i c a lf i n d i n g st h a t a r e c u r r e n t l y available.  98  CHAPTER F I V E : DISCUSSION OF THE FINDINGS Introduction This chapter findings.  presents  a discussion of the study's  Here, the f i n d i n g s w i l l  be more f u l l y  conjunction with the t h e o r e t i c a l l i t e r a t u r e findings currently available. the  The l a s t  explored i n  and r e s e a r c h  chapter  will  discuss  i m p l i c a t i o n s f o r n u r s i n g r e s e a r c h , e d u c a t i o n , and  practice will  that arise  from t h e study's  a l s o include the study's  results.  Chapter S i x  summary and c o n c l u s i o n s .  Kleinman's H e a l t h Care Systems Model  (1978) p r o v i d e d t h e  f r a m e w o r k f o r e x p l o r i n g t h e e l d e r l y women's e x p l a n a t o r y models f o r f a l l s . explanatory  As mentioned  models c o n t a i n e d  i n C h a p t e r One, t h e  i n t e r p r e t a t i o n s of the  r e s u l t a n t p h y s i c a l and p s y c h o l o g i c a l c o n s e q u e n c e s o f a f a l l . T h e s e i n t e r p r e t a t i o n s i n f l u e n c e d t h e women's p e r c e p t i o n s o f t h e need f o r c a r e and s u p p o r t hospital to live the data  alone.  and s u p p o r t .  Fall  as a S i g n i f i c a n t  home f r o m t h e  S e v e r a l m a j o r themes emerged  from  t h e need f o r  Event  E a c h woman p e r c e i v e d unexpected event i n t h e i r  and  returned  a n a l y s i s a s t h e e l d e r l y women d e s c r i b e d  care  in  as they  the f a l l lives.  r o u t i n e a t home r e s u l t i n g  as both  They d e s c r i b e d  from t h e f a l l  p s y c h o l o g i c a l consequences.  a s i g n i f i c a n t and t h e changes  and i t s p h y s i c a l  One m a j o r c o n s e q u e n c e was  the  d e s c r i p t i o n of the threat t o t h e i r  fall the  event.  is  (1984) p r o v i d e d  event.  and a d j u s t m e n t t o l i f e  i n the l i t e r a t u r e .  a breakdown o f s t r e s s f a c t o r s t h a t  of attack,  restraint,  t o be u s e f u l i n h e l p i n g  difficulty  of adjusting  Attack discomfort  events.  (Hanley & B a i k i e , 1984).  In this  category.  included  Restraint  the  e x t e r n a l r e s t r i c t i o n s on a c t i v i t i e s w h i c h were  for  the s a t i s f a c t i o n  o f b a s i c human n e e d s .  constituted  their  L o s s was  defined  the removal o f e x t e r n a l circumstances which i n d i v i d u a l s  r e l i e d on t o s a t i s f y this after an  necessary  From t h e e l d e r l y  women's d e s c r i p t i o n s , t h e c h a n g e i n r o u t i n e , upon t o t h i s category.  produced  study, the f a l l  was  as  were  t o understand the r e l a t i v e  was v i e w e d a s an e x t e r n a l f o r c e w h i c h  r e t u r n home, was r e l e v a n t  were The f o u r  l o s s , and t h r e a t  to different l i f e  i n the attack  events  H a n l e y and B a i k i e  t o t h e f i n d i n g s f r o m t h e e l d e r l y women.  categories believed  a f t e r the f a l l  process of perception  well-documented  relevant  a f t e r the  I n t h e i r own u n i q u e w a y s , t h e women a d a p t e d t o  changes i n r o u t i n e The  self-esteem  their  needs.  An e x a m p l e o f l o s s , f r o m  s t u d y , was t h e l o s s o f a c t i v i t y the f a l l .  This  activity  i m p o r t a n t way t o s a t i s f y  F i n a l l y , H a n l e y and B a i k i e  o r p r o d u c t i v i t y was v i e w e d a s  their  need f o r s e l f - e s t e e m .  (1984) d e f i n e d  e v e n t w h i c h warned o f p o s s i b l e restraint.  t h e women e x p e r i e n c e d  future  Here, the p o s s i b i l i t y  the threat  as any  l o s s , attack, or  o f more f a l l s  and t h e i r  100 physical elderly  and p s y c h o l o g i c a l c o n s e q u e n c e s p o s e d a t h r e a t t o t h e women i n t h i s  The  study.  importance o f the f a l l  congruent with Lazarus coping. dual  goals  of p r o b l e m - r e s o l u t i o n  process  revealed  first  that i t s  and e m o t i o n - r e g u l a t i n g  systems of t h e i n d i v i d u a l .  and b e h a v i o u r a l  The c o g n i t i v e s y s t e m was  t o be engaged when t h e p e r s o n was e x p o s e d  stressor,  such as t h e f a l l  event.  The i n d i v i d u a l  to the  attempted  d i s c e r n the s i g n i f i c a n c e o f the s t r e s s o r i n terms of h i s  or h e r w e l l - b e i n g . in  (1984) s t u d i e s on  i n to play the c o g n i t i v e , a f f e c t i v e ,  response  to  and F o l k m a n ' s  T h e i r work on t h e c o p i n g  brought  the  e v e n t t o t h e women was a l s o  one o f f o u r w a y s :  loss, fall  As a r e s u l t ,  a s a t h r e a t , as a s o u r c e  o r more as a c h a l l e n g e . e v e n t was i m p o r t a n t  adaptation  t h e s t r e s s o r was i n t e r p r e t e d  Again,  the p e r c e p t i o n of t h e  i n determining  t o the r e s u l t a n t changes  o f harm, as a  t h e women's  in their  life.  Self-Esteem Self-esteem during  the data  described fall  identified  the  analysis.  threats to their  event.  concept.  was one o f t h e m a j o r c o n c e p t s As d i s c u s s e d , self-esteem  Independence, a c t i v i t y , as i m p o r t a n t  identified  the e l d e r l y  resulting  women  from t h e  and autonomy were  themes w i t h i n t h e s e l f - e s t e e m  These a r e s i g n i f i c a n t  f i n d i n g s and f i t w e l l w i t h  t h e o r e t i c a l work on s e l f - e s t e e m . Before  d i s c u s s i n g these  individual  themes,  i t is  important  to provide a d e f i n i t i o n  ambiguities  i n the l i t e r a t u r e .  focus of t h e o r e t i c a l w r i t i n g s  i n psychology  her  and s o c i o l o g y  A review of the l i t e r a t u r e  i m p o r t a n t p o i n t s t o be i n c l u d e d i n t h e d e f i n i t i o n .  Self-esteem which  due t o  S e l f - e s t e e m h a s been t h e  s i n c e t h e 1 9 3 0 s (Mead, 1 9 3 4 ) . highlights  f o r the concept  i s a dynamic f e e l i n g  that reflects  the degree t o  an i n d i v i d u a l a c c e p t s , r e s p e c t s , a n d / o r v a l u e s h i m o r  self  (Mead, 1 9 3 4 ; R o s e n b e r g , 1 9 8 5 ) .  i n f l u e n c e d by t h e r e f l e c t e d (Cooley, 1964; S u l l i v a n ,  appraisals of significant  1953),  f e e l i n g s o f c o m p e t e n c e and w o r t h in society  Self-esteem i s  ( F e l k e r , 1974; T a f t ,  Independence, a c t i v i t y ,  a n d by t h e i n d i v i d u a l ' s related  to his effectiveness  1985).  and autonomy were  important  c o m p o n e n t s o f t h e e l d e r l y women's s e l f - e s t e e m . findings related literature.  These  t o s e l f - e s t e e m were s u p p o r t e d  Kaufman ( 1 9 8 6 ) ,  others  i n the  i n h e r work, found  that  these  themes were an i m p o r t a n t p a r t o f s e l f - e s t e e m f o r t h e e l d e r l y individuals.  H e r s a m p l e c o n s i s t e d o f 60 men and women  t h e age o f 70. important birth  She c o n c l u d e d  themes were b a s e d on  values f o r that generation or b i r t h  cohort referred  certain  that these  time-frame.  t o a l l i n d i v i d u a l s born She s t a t e d t h a t t h e s e  the i n d i v i d u a l ' s c o n f o r m i t y t o shared i n d i c e s of s o c i a l worth.  over  cohort.  A  during a  values  and f a i r l y  The i n d i v i d u a l s w i t h i n  emphasized explicit the cohort  s t a r e d common i d e a l s d e r i v e d f r o m common e x p e r i e n c e s .  These  102 values  were e v i d e n t  i n t h e women i n t e r v i e w e d  I n d e p e n d e n c e was v i e w e d a s t h e a b i l i t y o n e ' s own p h y s i c a l and e m o t i o n a l descriptions,  i t was e v i d e n t  needs.  described upon t h e i r  posed a t h r e a t t o t h e  o f t h e m s e l v e s as independent.  t h e a s s i s t a n c e t h a t was r e q u i r e d w i t h r e t u r n home f r o m h o s p i t a l .  Examples care.  t h a t i n d e p e n d e n c e was an i m p o r t a n t  women's s e l f - e s t e e m . supported 1986).  t o provide f o r  From t h e r i c h  s h o p p i n g , m e a l p r e p a r a t i o n , and p e r s o n a l concluded  T h i s was a s i g n i f i c a n t  by t h e l i t e r a t u r e  In fact,  important  T h e women  activities included This  component o f t h e finding  and was  ( H i r s t & M e t c a l f , 1 9 8 4 ; Kaufman,  aim o f the m a j o r i t y of the e l d e r l y  population  s t a t e o f h e a l t h (Culbert & Kos, 1971).  A c t i v i t y was t h e s e c o n d theme i d e n t i f i e d d u r i n g The e l d e r l y women v i e w e d a c t i v i t y  important  component o f t h e i r  described  t h e i r past  self-esteem.  working l i v e s .  t h e i r present-day a c t i v i t i e s .  f u n c t i o n s , and s o l i t a r y the perception  Another  important  the data  as a n o t h e r  S e v e r a l women  A l l t h e women d e t a i l e d  T h e s e a c t i v i t i e s were v a r i e d .  Examples i n c l u d e d t h e p r o v i s i o n o f support  was  study  i n d e p e n d e n c e was v i e w e d a s t h e most  regardless of their  analysis.  study.  t h a t t h e p h y s i c a l and  p s y c h o l o g i c a l consequences o f t h e f a l l women's p e r c e p t i o n s  i n this  c r a f t work.  to others,  A significant  t h a t a l l a c t i v i t i e s were f i n d i n g was t h a t t h e women  decreased o p p o r t u n i t i e s f o r a c t i v i t y  social  finding  meaningful. experienced  due t o t h e p h y s i c a l a n d  103 p s y c h o l o g i c a l consequences of the f a l l . perceived The was  threats to t h e i r importance  supported  been o n - g o i n g important  by  s i n c e the e a r l y  society.  Research  1960s.  The  self-esteem  Today, a c t i v i t y tendency  on a c t i v i t y  During  (Neugarten,  r e m a i n s an  and  this  has  time,  relationship Havighurst,  important  remains t o d e s c r i b e a  i n t e r m s o f h i s o r h e r work r o l e  Stahmer, 1986).  The  t o t h e women's s e l f - e s t e e m  l i n k s have been e s t a b l i s h e d i n t h e  T o b i n , 1968).  worth  of a c t i v i t y  and  they  self-esteem.  the l i t e r a t u r e .  between a c t i v i t y  identity  As a r e s u l t ,  value i n  person's  (Kaufman,  1986;  I t r e m a i n s an a c c e p t a b l e measure o f human  thereby a f f e c t s finding  f e e l i n g s of s e l f - e s t e e m .  that a l l a c t i v i t i e s ,  not  just  o n e s were p e r c e i v e d t o be m e a n i n g f u l ,  was  a l s o supported  the l i t e r a t u r e . shifting 1990).  Perceptions related  S o c i e t y i s now  approaching  a time  the l a s t  t h e women d e s c r i b e d t h e i r  important experiences  t h e l a s t component o f t h e i r  identified  in this  study.  care  are  i n human h i s t o r y and  important. theme t h a t emerged after  the f a l l  as  event.  self-esteem that  was  Autonomy, o r s e l f - d e t e r m i n a t i o n ,  meant t h a t i n d i v i d u a l s were r e s p e c t e d as a b o u t t h e i r own  in  (Coleman,  v o l u n t a r y c o m m u n i t y work  c r e a t i v e e x p r e s s i o n a r e b e c o m i n g more Autonomy was  work-related  to meaningfulness  away f r o m t r a d i t i o n a l work a c t i v i t i e s  where l e i s u r e t i m e p u r s u i t s ,  T h i s was  and  (Matteson  decision-makers  & McConnell,  1988).  There  104 were s e v e r a l s i g n i f i c a n t autonomy.  Firstly,  decisions  any  t h e women d e s c r i b e d  about t h e i r  professionals. formal  medical care  s u p p o r t s upon d i s c h a r g e  threatened  by t h e i r  lacked  status.  follow-up This  were made s o l e l y  lack of involvement  finding  adequate m e d i c a l i n f o r m a t i o n Several  women a r r a n g e d t h e i r  f o r the purpose of o b t a i n i n g  more  described  Wright  (cited  about  felt  their  own m e d i c a l information. as a t h r e a t t o  values,  understanding,  as:  (b) u t i l i z i n g  a d e q u a t e i n f o r m a t i o n and  b a s e d o n r e a s o n and d e l i b e r a t i o n . i n d i v i d u a l s need t o be i n v o l v e d  a r e no l o n g e r  professionals individual,  medical care.  or r e s t r a i n t ,  Based on t h e s e  significant  1989). others,  and (d) criteria,  i n the decision-making Decisions  the sole prerogative  (Reilly,  review  (a) t h o s e b a s e d on t h e  (c) f r e e f r o m c o e r c i o n  p r o c e s s about t h e i r  the l i t e r a t u r e  i n M c E l m u r r y & Z a b r o c k i , 1989)  autonomous d e c i s i o n s  individual  care  t h e women  autonomy.  autonomy.  all  visits  i n the d e c i s i o n -  was t h a t  These f i n d i n g s were c o n g r u e n t w i t h on  not r e c e i v i n g  home and u n w a n t e d  l a c k o f m e d i c a l k n o w l e d g e was p e r c e i v e d  their  by h e a l t h  H e r e , t h e women's autonomy was  second s i g n i f i c a n t  they  health  s i t u a t i o n s where  process.  The that  study r e l a t e d t o  Examples from t h e d a t a i n c l u d e d  from a p h y s i o t h e r a p i s t .  making  findings i n this  Instead,  about  health  of health t h e y must i n v o l v e t h e  and h e a l t h  professionals.  105 S e v e r a l s t u d i e s a l s o supported the importance of r e l a t i o n s h i p between autonomy, p e r c e i v e d esteem  (Berkowitz,  the  c o n t r o l , and  Waxman, & Y a f f e , 1988;  Langer,  self-  1983;  Rodin, 1986) . Langer nursing  (1983) s t u d i e d p e r c e i v e d  home r e s i d e n t s .  by an a d m i n i s t r a t o r group was  One  who  group of r e s i d e n t s was  addressed  emphasized t h e i r autonomy.  This  encouraged to make d e c i s i o n s f o r themselves,  d e c i s i o n s to make, and  given  o u t s i d e of themselves. a different stressed  c o n t r o l i n a group of  responsibility  f o r something  A second group of r e s i d e n t s  speech from the same a d m i n i s t r a t o r .  the s t a f f ' s  responsibility  given  received  T h i s speech  f o r t h e i r care  and  management i n the home. Of the a c t i v e , and contrast,  first  group, 93%  experienced  70%  f e l t happier,  became more  a f e e l i n g of competence.  In  of the second group became more d e b i l i t a t e d  w i t h i n a 3-week p e r i o d .  Langer  (1983) concluded  that  i n c r e a s i n g environmental c o n t r o l , thereby f o s t e r i n g autonomy, was  r e l a t e d to i n c r e a s e s  in self-esteem  f o r the  study's  participants. Berkowitz et a l . (1988) made s i m i l a r c o n c l u s i o n s . community-residing making, and  i n d i v i d u a l s who  advocating  participated in decision-  f o r t h e i r own  t e s t s measuring s e l f - e s t e e m .  Here,  needs, scored  Once again,  lack of  i n decision-making r e s u l t e d i n lower scores on the  higher  on  involvement self-  106 esteem t e s t s .  t h e s e two  studies  supported  findings  t h a t t h e women e x p e r i e n c e d  threats  to t h e i r  when n o t  involved  The  in t h e i r medical  supported  by  the  literature.  vulnerable  information  & Zabrocki, threatened  this  described  H e r e , an type of  the  the  i n d i v i d u a l ' s autonomy process.  aforementioned  f o r autonomous d e c i s i o n s  stigmatized  dependent, i r r i t a b l e ,  old  as and  nurses r e f l e c t  the  negative  and  students  impact as  discrimination  ( B u t l e r , 1975).  Older  l o n e l y , absent-minded,  possessing  & Streeter,  poor  health  1989).  s o c i e t y , and  v i e w s a b o u t t h e aged Sarver  Matteson  a powerful  views of s o c i e t y i n which  by K n o w l e s and  baccalaureate  1990;  Ageism i s d e f i n e d  being  Ageism remains a p r o b l e m i n our  study  (French,  stereotyping  people because they are often  i s s u e of ageism i s  w e l l , a g e i s m has  (Terpstra, Terpstra, Plawecki,  hold  was  many o f t h e  As  in  (McElmurry  in determining  p r o c e s s of s y s t e m a t i c  senile,  concern  the  p e r s o n s are  may  in health decisions  l a r g e r concept of s e l f - e s t e e m .  against  i n d i v i d u a l s were  literature,  and M c C o n n e l l , 1988) .  medical  also  i n the  conditions  on  Less-informed  t o engaging  autonomy  i m p o r t a n c e of  d e f i c i t s were a s e r i o u s  1989). by  important  the  the  decisions.  i n m a k i n g autonomous d e c i s i o n s , was  particularly  As  care  second f i n d i n g , r e g a r d i n g  information  which  Therefore,  they  (Burnside,  (1985) d o c u m e n t s  because live, 1990).  that  i n a u n i v e r s i t y program l e a s t  they One  107 p r e f e r p a t i e n t s over h a v e n o t been f o u n d (Maddox & T i l l e y , elderly  75 y e a r s o f a g e . E v e n t h o u g h ,  nurses  t o be any more n e g a t i v e t h a n o t h e r  1988),  i t remains d i f f i c u l t  groups  t o a s s e s s an  i n d i v i d u a l ' s v a l u e s when n e g a t i v e s t e r e o t y p e s a r e  held. Self-esteem of the e l d e r l y view  toward  definition  them.  i s t h e n a f f e c t e d by s o c i e t y ' s  T h i s comment p e r t a i n s t o t h e a s p e c t o f t h e  that refers t o the reflected  significant  others.  appraisals of  These a p p r a i s a l s a r e i m p o r t a n t  t h e women i n t h i s s t u d y  received treatment  since a l l  within the Health  Care System. Adaptation A d a p t a t i o n was t h e s e c o n d data a n a l y s i s . research. will  T h i s concept  t h a t emerged f r o m t h e  has a l s o undergone  exhaustive  Due t o i t s m a g n i t u d e , t h e d i s c u s s i o n o f a d a p t a t i o n  be r e s t r i c t e d  were i d e n t i f i e d The  concept  t o t h e d i f f e r e n t methods o f c o p i n g  i n this  that  s t u d y on e l d e r l y women.  p r o c e s s o f a d a p t a t i o n o r c o p i n g was d e f i n e d a s t h e  " c o n s t a n t l y changing  c o g n i t i v e and b e h a v i o u r a l e f f o r t s t o  manage s p e c i f i c e x t e r n a l a n d / o r i n t e r n a l demands t h a t a r e a p p r a i s e d as t a x i n g o r e x c e e d i n g ( L a z a r u s & F o l k m a n , 1 9 8 4 , p.  the resources of the person"  141).  I n t h i s s t u d y , t h e women u s e d a v a r i e t y o f b e h a v i o u r s t o cope w i t h t h e f a l l  event  and r e s u l t a n t c h a n g e i n r o u t i n e .  Examples o f coping b e h a v i o u r s  f r o m t h e f i n d i n g s were u s e o f  108 positive beliefs, maintaining control,  compliance,  p r e v e n t i o n , p l a n n i n g f o r t h e f u t u r e , and u s e o f s o c i a l supports.  As d e s c r i b e d i n t h e l i t e r a t u r e ,  were d e t e r m i n e d 1984).  by t h e p e r s o n ' s  resources  coping  behaviours  (Lazarus & Folkman,  T h e r e were s e v e r a l m a j o r c a t e g o r i e s o f r e s o u r c e s .  They i n c l u d e d p h y s i c a l r e s o u r c e s psychological resources  ( h e a l t h and e n e r g y ) ,  (positive beliefs),  ( p r o b l e m - s o l v i n g and s o c i a l s k i l l s ) , material  competencies  s o c i a l s u p p o r t , and  resources.  Inherent  i n the study's  types of coping. type of coping.  f i n d i n g s were two d i f f e r e n t  Use o f p o s i t i v e  beliefs  I n c o n t r a s t , t h e second  i n v o l v e d more p r o b l e m - s o l v i n g b e h a v i o u r s .  r e p r e s e n t e d one type of coping F o r example,  p r o b l e m - s o l v i n g was e v i d e n t a s t h e women d e s c r i b e d compliance prevent  to medical  regimes,  p r e v e n t a t i v e steps taken t o  the reoccurrence of another  the f u t u r e . supported  This d i s t i n c t i o n  i n the l i t e r a t u r e .  problem-focused  their  fall,  and p l a n n i n g f o r  between c o p i n g b e h a v i o u r s The two t y p e s o f c o p i n g  and e m o t i o n - f o c u s e d  was  were  (Folkman & L a z a r u s ,  1980) . Problem-focused  coping behaviours  s t r a t e g i e s used f o r p r o b l e m - s o l v i n g 1984).  These i n c l u d e d d e f i n i n g  alternative their  were s i m i l a r t o  (Lazarus & Folkman,  the problem,  generating  solutions, weighting the a l t e r n a t i v e s  c o s t and b e n e f i t s , c h o o s i n g  i n terms of  among t h e m , and a c t i n g .  As  109 w e l l , problem-focused were d i r e c t e d changes.  coping a l s o included s t r a t e g i e s  that  inward, such as m o t i v a t i o n a l or c o g n i t i v e  Examples encompassed l e a r n i n g new s k i l l s ,  finding  a l t e r n a t i v e channels of g r a t i f i c a t i o n , and developing new standards of behaviour. Emotion-focused  coping was d i r e c t e d a t l e s s e n i n g  emotional d i s t r e s s and i n v o l v e d s t r a t e g i e s , such as d i s t a n c i n g , escape/avoidance,  s e l f - c o n t r o l , accepting  r e s p o n s i b i l i t y , use of p o s i t i v e b e l i e f s , and seeking s o c i a l support  (Lazarus & Folkman,  The  1984).  f i n d i n g s from the study concluded that the e l d e r l y  women used more problem-focused T h i s f i n d i n g was s i g n i f i c a n t  than emotion-focused  i n that  coping.  i t was r e l a t e d t o the  p e r c e p t i o n of the women r e g a r d i n g the c h a n g e a b i l i t y of the situation.  Research has been conducted  t o determine the  extent t o which i n d i v i d u a l s used these d i f f e r e n t types of coping  (Folkman  & Lazarus, 1980; Folkman, L a z a r u s , Drunkel-  S c h e t l e r , D e l o n g i s , & Gruen, 1986).  The r e s u l t s concluded  that the type of coping depends f i r s t l y  on the primary  a p p r a i s a l or the p e r s o n a l s i g n i f i c a n c e of the encounter. importance discussed event.  of primary a p p r a i s a l of the s t r e s s o r was a l r e a d y i n the e a r l i e r s e c t i o n on the f a l l as a s i g n i f i c a n t  Secondly, the type of coping was a l s o c o n t i n g e n t on  the secondary a p p r a i s a l of the event. for  The  changing  the person-environment  This involved options  relation.  One study  110 showed t h a t p r o b l e m - f o c u s e d  c o p i n g was more p r o b a b l e when  c o n d i t i o n s were a p p r a i s e d as a m e n a b l e t o c h a n g e L a z a r u s , P i m l e y , & Novacek, 1987). from  Therefore, the findings  t h e e l d e r l y women were c o n g r u e n t  with the l i t e r a t u r e .  The u s e o f s o c i a l s u p p o r t was a c o p i n g d e s c r i b e d by a l l t h e women i n t h i s study's findings, discussed  i n relation  study.  advice, guidance,  relationships  t o t h i s b e h a v i o u r , w i l l be  and a p p r a i s a l ,  support,  as w e l l as t h e m a t e r i a l a i d  o b t a i n e d from t h e i r  ( E l l , 1984, p. 1 3 4 ) .  s u p p o r t were i n f o r m a l and f o r m a l .  social  The t w o c a t e g o r i e s o f As w e l l ,  i t s h o u l d be  t h a t u s e o f s o c i a l s u p p o r t was i n c l u d e d i n b o t h  emotion-focused Folkman,  assistance friends.  and p r o b l e m - f o c u s e d  behaviours  (Lazarus &  1984).  One f i n d i n g  f r o m t h e s t u d y was t h a t t h e women d e s c r i b e d  r e c e i v e d from  i n f o r m a l s u p p o r t s s u c h a s f a m i l y and  S e v e r a l women d e s c r i b e d t h e i r  f o r m a l s u p p o r t s such this  As a r e s u l t , the  encompassed t h e " e m o t i o n a l  s e r v i c e s that people  noted  behaviour  in detail.  S o c i a l support  and  (Folkman,  finding  as homemakers.  that e l d e r l y persons  reluctance t o accept  The l i t e r a t u r e  supported  drew i n i t i a l l y on a i d f r o m  i n f o r m a l s u p p o r t s f o l l o w e d by a d d i t i o n a l a i d f r o m  formal  a g e n c i e s and o r g a n i z a t i o n s ( C h a p p e l l , 1 9 8 5 ; O ' B r i e n  & Wagner,  1980) . Another  interesting  f i n d i n g was t h a t t h e women d e s c r i b e d  Ill their Due  f e a r o f becoming a burden  to this  pertained  feeling,  t o f a m i l y members o r  they accepted  t o f a m i l y members, t h i s  in the l i t e r a t u r e .  formal supports. finding  decrease  t h e burden  As i t  was n o t s u p p o r t e d  C o n t r a r y t o t h e women's b e l i e f  a c c e p t i n g h e l p would  friends.  that  for families,  s t u d i e s h a v e shown t h a t t h e p r o v i s i o n o f home c a r e d o e s n o t lessen the f a m i l y ' s involvement 1985;  Shapiro,  i n their  care  1986).  A c c e p t i n g s o c i a l support from f r i e n d s decision. was  One s i g n i f i c a n t  the importance  relationships. literature  finding  of reciprocity  This particular  to this  decision  i n t h e women's  finding  was s u p p o r t e d by t h e  (Rook, 1 9 8 7 ; T i l d e n & W e i n e r t ,  t o the importance  was a n o t h e r  related  R e c i p r o c i t y was a s i g n i f i c a n t Due  (Chappell,  1987).  finding  of reciprocity,  from t h i s  the e l d e r l y  women knew  t h e t y p e o f a s s i s t a n c e t h a t c o u l d be r e q u e s t e d f r o m individuals.  Although t h i s  finding  was r e l a t e d  study.  certain  to the  d i s c u s s i o n o n autonomy, i t was a l s o s u p p o r t e d b y t h e literature.  Rook  (1987) s t a t e d  that reciprocity  d e p e n d e n t on t h e p r e v i o u s r e l a t i o n s h i p  with  t h e f r i e n d , and  the type o f s u p p o r t o r s o c i a l exchange r e q u i r e d . referred  t o any o f t h e f o l l o w i n g  types:  was  Exchange  companionship,  i n s t r u m e n t a l s u p p o r t s u c h a s s h o p p i n g , and e m o t i o n a l s u p p o r t . Another  significant  finding  f r o m t h e s t u d y was t h e  women's d e s c r i p t i o n o f t h e i r e n c o u n t e r s w i t h helpers.  In having  women e x p e r i e n c e d  t h e homemakers  come t o t h e i r  As w e l l ,  i n t h a t t h e women d e a l t w i t h  the s e r v i c e lacked c o n t i n u i t y , s e v e r a l homemakers  The women were a l s o d i s s a t i s f i e d  homemakers'  homes, t h e  p r o b l e m s w i t h c o m m u n i c a t i o n , due t o  language b a r r i e r s .  one week.  t h e home  work p e r f o r m a n c e .  throughout  with the  These were i m p o r t a n t  R e s e a r c h was f o u n d t h a t d e a l t w i t h home n u r s i n g  findings.  i n terms o f  s e r v i c e needs, c o n t i n u i t y o f c a r e , e d u c a t i o n a l p r e p a r a t i o n o f nurses,  and c l i e n t  However, t h e r e homemakers. the p r i m a r y received  satisfaction  s i n c e t h e homemakers  supports.  important  f i n d i n g was r e l a t e d t o t h e women's  r e s p o n s e s t o t h e homemakers. c o n t r o l and t o l d  They began t o e x e r t some  t h e homemakers  how t o c o m p l e t e t a s k s i n  I t a p p e a r e d t h a t t h e women's autonomy and  i n d e p e n d e n c e were f u r t h e r t h r e a t e n e d  by t h e homemaker's  actions.  by t h e l i t e r a t u r e .  Again,  This  Langer's  relevant here. support and  were  c a r e w o r k e r s f o r s e v e r a l o f t h e women who  formal  home.  1988).  a p p e a r e d t o be a p a u c i t y o f r e s e a r c h on  T h i s was i n t e r e s t i n g  The l a s t  their  ( K i n g , 1986; McNeese,  f i n d i n g was s u p p o r t e d (1983) s t u d y Rowe and Kahn  on autonomy and c o n t r o l was (1987) s t a t e d t h a t  social  a p p e a r e d t o e i t h e r i n c r e a s e o r d e c r e a s e t h e autonomy  c o n t r o l of the r e c i p i e n t .  T e a c h i n g , e n a b l i n g , and  e n c o u r a g i n g were a u t o n o m y - i n c r e a s i n g modes o f s u p p o r t .  113 C o n s t r a i n i n g , "doing f o r , " and warning  beyond the  requirements of the s i t u a t i o n conveyed  c a r i n g but they taught  helplessness.  Again, there was a dearth of research on the  types of support provided by homemakers. Summary T h i s chapter provided a summary of the major f i n d i n g s of the study.  The f i n d i n g s were d i s c u s s e d and supported by  c u r r e n t research and t h e o r e t i c a l  findings.  This chapter began with a d i s c u s s i o n of the s i g n i f i c a n c e of the f a l l  event.  I t was f o l l o w e d by the d i s c u s s i o n on  self-esteem.  The f i n d i n g s r e l a t e d t o the themes of  independence,  a c t i v i t y , and autonomy w i t h i n the s e l f - e s t e e m  concept were then p r e s e n t e d . was  A b r i e f d i s c u s s i o n on ageism  a l s o i n c l u d e d i n the d i s c u s s i o n of s e l f - e s t e e m . The process of a d a p t a t i o n was presented as i t r e l a t e d t o  the study's f i n d i n g s .  The d i f f e r e n t  resources were reviewed. on the problem-focused  types of coping  T h i s was f o l l o w e d by a d i s c u s s i o n  and emotion-focused  that were used by the e l d e r l y women.  coping  behaviours  The use of s o c i a l  support was d i s c u s s e d i n d e t a i l s i n c e a l l the women used behaviour.  T h i s d i s c u s s i o n was f o l l o w e d by a p r e s e n t a t i o n on  the importance Finally,  this  of r e c i p r o c i t y  in social  relationships.  the women's experiences with the homemakers from  formal programs was d i s c u s s e d .  114 CHAPTER S I X : SUMMARY, CONCLUSIONS, AND IMPLICATION FOR NURSING Summary C o n c l u s i o n s This study  i s designed  t o d e s c r i b e t h e need f o r c a r e and  s u p p o r t a s p e r c e i v e d by women aged 75 y e a r s and o l d e r r e t u r n i n g home t o l i v e fall.  Falls  constitute  alone a f t e r h o s p i t a l i z a t i o n  are a s i g n i f i c a n t problem  t h e f a s t e s t growing  elderly population.  Falls  f o r t h e s e women who  segment o f t h e C a n a d i a n  h a v e numerous p h y s i c a l a n d  p s y c h o l o g i c a l consequences. r e t u r n home t o l i v e  I n many c a s e s , t h e s e women  alone a f t e r h o s p i t a l i z a t i o n  A review of the l i t e r a t u r e  indicates  consequences o f f a l l s perceived  T h e r e a r e no  t h e p h y s i c a l and/or p s y c h o l o g i c a l i n terms o f t h e i r  e f f e c t on t h e  I n many s i t u a t i o n s , t h e i n d i v i d u a l ' s  p e r c e i v e d need f o r c a r e and s u p p o r t misunderstood,  i s not only  b u t t h e p e r c e p t i o n s a r e n o t even  S t u d i e s on s o c i a l s u p p o r t  age  fall.  need f o r c a r e and s u p p o r t o f e l d e r l y women  r e t u r n i n g home a l o n e .  initially  fora  t h a t t h e s t u d i e s on  f a l l s were m o s t l y e p i d e m i o l o g i c a l i n n a t u r e . s t u d i e s that addressed  f o ra  on a i d s f r o m  addressed.  i n d i c a t e that e l d e r l y persons  informal supports.  and f u n c t i o n a l c a p a c i t y p l a y a r o l e  draw  As w e l l , i n c r e a s e d  i n t h e use o f f o r m a l  supports. Kleinman's direction  H e a l t h Care  f o r t h e purpose  System Model  (1978) p r o v i d e s t h e  and m e t h o d o l o g y o f t h e s t u d y .  This  115  model c o n c e p t u a l i z e s the m e d i c a l system distinct  but  interrelated  p r o f e s s i o n a l , and is  "experienced  popular arena and  folk  and  arenas:  arenas.  c o n s i s t i n g of  the popular,  The  arenas  the  a r e where s i c k n e s s  reacted t o " (Kleinman,  1978,  p.  The  n u r s i n g , and  o t h e r p r o f e s s i o n a l s , whereas the f o l k  p r o f e s s i o n a l arena  i s composed o f  c o n s i s t s of n o n - p r o f e s s i o n a l h e a l i n g Kleinman  EMs  (1978)  from  individuals  and  specialists.  treatment  the e t i o l o g y , of the  illness  t o denote the  to i n c l u d e the experience of  result  may  t h e EMs  not agree  i n care c o n s i s t i n g of  i n the  u s e d by  The  popular the  individuals  w i t h each o t h e r .  incongruent  This  direction  In c o n c l u s i o n , K l e i n m a n s Model p r o v i d e s 1  i n d e s c r i b i n g t h e EMs  o f e l d e r l y women as  r e l a t e t o t h e p e r c e i v e d need f o r c a r e and community a f t e r In o r d e r  a hospitalization  t o d e s c r i b e t h e EMs,  in may  o b j e c t i v e s and  o u t c o m e s as t h e i n d i v i d u a l e n t e r s t h e p r o f e s s i o n a l a r e n a treatment.  EMs  disease  arena  As a r e s u l t ,  can  arenas.  event.  I n c o n t r a s t , t h e EMs  a r e more l i k e l y  (EMs)  symptoms,  aspects of s i c k n e s s .  the d i f f e r e n t arenas  arena  i n the t h r e e d i f f e r e n t  o f p r o f e s s i o n a l s a r e most l i k e l y  event.  medicine,  s t a t e s t h a t e x p l a n a t o r y models  a r e used t o u n d e r s t a n d  pathophysiology  illness  The  community  activities.  The  86).  i s composed o f t h e f a m i l y c o n t e x t o f s i c k n e s s  c a r e , as w e l l as t h e s o c i a l n e t w o r k and  be e l i c i t e d  three  support  for a f a l l  they  i n the  event.  the r e s e a r c h d e s i g n  of  for  116 p h e n o m e n o l o g y was c h o s e n . lived  In the attempt  e x p e r i e n c e , e i g h t women s u b j e c t s w e r e r e c r u i t e d who had  experienced  a fall  event  resulting  t h e s u b j e c t s were r e c r u i t e d Department. alone  through  the Vancouver  of Vancouver.  o r i e n t e d t o time, person, impairment  d i s c h a r g e from  prior  tape-recorded  living  was n o t p a r t o f a c a r e A s w e l l , t h e y were  alert  and p l a c e w i t h no s i g n i f i c a n t  t o admission or following  hospital.  D a t a were c o l l e c t e d  through  interviews.  s u b j e c t ' s home.  t h e use o f u n s t r u c t u r e d  The i n t e r v i e w s t o o k p l a c e i n t h e  F i v e o f t h e s u b j e c t s were i n t e r v i e w e d t w i c e ,  one s u b j e c t was i n t e r v i e w e d t h r e e t i m e s  interviews.  Health  The women were 75 y e a r s o f age and o l d e r ,  i n the City  cognitive  and  i n a hospitalization. A l l  i n a house o r apartment which  facility and  t o understand the  S e v e r a l telephone  s u b j e c t s throughout  the course  q u e s t i o n s were u s e d t o g u i d e data a n a l y s i s proceeded,  f o r a t o t a l o f 14  c a l l s were a l s o made t o t h e of the study.  the i n i t i a l  the t r i g g e r  Four  trigger  interviews.  q u e s t i o n s were  As t h e revised,  b a s e d on t h e common themes e m e r g i n g f r o m t h e d a t a . A l l i n t e r v i e w s were t r a n s c r i b e d  verbatim t o ensure  account  D a t a a n a l y s i s was done  o f t h e phenomenon.  t h e s t e p s o u t l i n e d by G i o r g i noted  and c o d e d a c c o r d i n g l y .  clarified, with  (1985).  the subjects.  following  Common themes were  Subsequently,  v a l i d a t e d , and d i s c o u n t e d  an e x a c t  t h e themes were  i n subsequent i n t e r v i e w s  I n t h i s p r o c e s s , t h e p e r c e i v e d need f o r  117 care and support described.  from the e l d e r l y woman's experience was  The p e r c e i v e d need f o r care and support  once the  women returned home t o l i v e alone was u l t i m a t e l y i n f l u e n c e d by the f a l l System.  event  and treatment  w i t h i n the Health Care  The f i n d i n g s are complex and i n t e r - r e l a t e d and  summarized i n the f o l l o w i n g manner: 1. as both The  The e l d e r l y women i n t h i s study p e r c e i v e d the f a l l a s i g n i f i c a n t and u n p r e d i c t a b l e event  f a l l event  they  women d e s c r i b e d t h r e a t s t o t h e i r  A f t e r r e t u r n i n g home, the self-esteem.  Autonomy, a c t i v i t y and independence were  components of s e l f - e s t e e m that were threatened event  important  by the f a l l  and r e s u l t a n t change i n r o u t i n e . 3.  of  life.  r e s u l t e d i n a change of r o u t i n e a t home once  returned home t o l i v e alone.  2.  in their  The women i d e n t i f i e d a c t i v i t y as an important  t h e i r self-esteem.  decreased  A f t e r the f a l l ,  the women  experienced  o p p o r t u n i t i e s f o r a c t i v i t y due t o the p h y s i c a l and  p s y c h o l o g i c a l consequences of the f a l l . as a t h r e a t t o t h e i r 4.  part  T h i s was p e r c e i v e d  self-esteem.  The women wanted t h e i r autonomy respected.  experienced  t h r e a t s t o t h e i r autonomy.  They  They had d e c i s i o n s  about t h e i r care made f o r them by h e a l t h p r o f e s s i o n a l s . As w e l l , they wanted more i n f o r m a t i o n about t h e i r h e a l t h s t a t u s . 5.  The e l d e r l y women used behaviours  threats to t h e i r self-esteem.  According  t o cope with the  t o the a p p r a i s a l of  118  the s i t u a t i o n ,  different  t y p e s o f b e h a v i o u r s were  These i n c l u d e d use o f p o s i t i v e  beliefs,  used.  compliance  m a i n t a i n i n g c o n t r o l , p r e v e n t i o n , p l a n n i n g f o r t h e f u t u r e , and use  of s o c i a l support.  both problem-focused 6. used was  These s p e c i f i c  behaviours  and e m o t i o n - f o c u s e d  coping  strategies.  T h e u s e o f s o c i a l s u p p o r t was a c o p i n g  by a l l t h e women i n t h e s t u d y . important  encompassed  behaviour  R e c i p r o c i t y o f exchange  i n t h e women's u s e o f s o c i a l  support  from  friends. 7. with  The women i n t h i s s t u d y e n c o u n t e r e d  the s o c i a l  support from  experienced problems with barriers,  difficulties  the f o r m a l programs.  (a) c o m m u n i c a t i o n  due t o l a n g u a g e  and (b) a s e r v i c e t h a t l a c k e d c o n t i n u i t y o r t h e  ability  t o send  basis.  As w e l l ,  t h e same homemaker t o them on an o n g o i n g t h e r e were p r o b l e m s w i t h t h e women's  e x p e c t a t i o n s f o r t h e homemaker's p e r f o r m a n c e .  These  p r o b l e m s were a l s o p e r c e i v e d as a t h r e a t t o t h e i r and  The women  autonomy  independence. The  women's d e s c r i p t i o n o f t h e i r  need f o r c a r e and  s u p p o r t o n c e t h e y r e t u r n home h a s numerous i m p l i c a t i o n s f o r nursing research, practice,  and e d u c a t i o n .  i m p l i c a t i o n s w i l l be a d d r e s s e d  These  i n the following  sections.  I m p l i c a t i o n s f o r Research The  e l d e r l y women who f e l l  s e l f - e s t e e m upon t h e i r  described threats to their  r e t u r n home.  Ultimately,  these  119  threats affected support  t h e i r p e r c e p t i o n o f t h e need f o r c a r e and  i n t h e home.  S e v e r a l women d e s c r i b e d t h e i r  d i s s a t i s f a c t i o n w i t h t h e homemakers f r o m t h e f o r m a l programs.  I t was o b v i o u s  that this  s e r v i c e d i d n o t meet  t h e i r p e r c e i v e d need f o r c a r e and s u p p o r t  i n t h e community.  Homemakers a r e t h e l o w e s t p a i d and l e a s t prepared  support  members o f t h e h e a l t h c a r e t e a m .  educationally-  Y e t , these  i n d i v i d u a l s were c o n s i d e r e d t o be t h e p r i m a r y c a r e g i v e r s f o r s e v e r a l women i n t h i s There remains  study.  a paucity of research that deals with the  a t t i t u d e s , m o t i v a t i o n s , knowledge, s k i l l s , needs o f t h e s e w o r k e r s . their  As w e l l , r e s e a r c h i s l a c k i n g on  a s s e s s m e n t and c o m m u n i c a t i o n  research  skills.  Furthermore,  i s r e q u i r e d on t h e r e l a t i o n s h i p b e t w e e n t h e  i n d i v i d u a l ' s need f o r s u p p o r t support  and e d u c a t i o n  ( o b j e c t i v e and p e r c e i v e d ) , t h e  r e c e i v e d f r o m t h e homemakers, and t h e e f f e c t  s u p p o r t h a s on o t h e r p r e d i c t o r s o f s u c c e s s s u c h and  autonomy.  autonomy r e s u l t i n g Consequently, these  that  i n d e p e n d e n c e and  f r o m t h e homemaker's a c t i o n s .  t h e women e x e r t e d c o n t r o l  i n o r d e r t o cope w i t h  threats. Research  there  as c o n t r o l  The f i n d i n g s f r o m t h i s s t u d y c o n c l u d e d  t h e e l d e r l y women p e r c e i v e d t h r e a t s t o t h e i r  that  i s required i n the aforementioned  i s an i n c r e a s i n g movement t o m a i n t a i n more  elderly  areas, since frail,  i n d i v i d u a l s u s i n g homemakers i n t h e c o m m u n i t y  120 setting.  This  information  implications. implications that  Firstly,  Secondly, the  i n f o r m a t i o n w o u l d have  the  t y p e and  amount o f  supervision  f o r these workers i n c a r e g i v i n g s i t u a t i o n s .  educational  documented, thereby programs are  this  for planning  i s required  would have s e v e r a l p o l i c y  needs of t h e s e w o r k e r s would  ensuring  that appropriate  e s t a b l i s h e d f o r them.  may  be p e r c e i v e d  as m e e t i n g an  and  support i n the  As  be  educational  a result,  homemakers  e l d e r l y p e r s o n ' s need f o r  community, r a t h e r than p o s i n g  care  a further  threat to i t . The of  last  i m p l i c a t i o n for research  autonomy and  s t e r e o t y p i n g of  the  r e l a t e s to the  elderly.  t h e e l d e r l y among h e a l t h p r o f e s s i o n a l s has the  literature  Mead, 1 9 8 4 ) .  (Maddox & T i l l e r y ,  1988;  However, n u r s e s w o r k i n g  s e t t i n g s h a v e been t h e m a j o r f o c u s Since it  a l l t h e women were a s s e s s e d  Stereotyping  of  been documented  in  Penner,' L u d e n i a ,  &  i n long-term  care  this  research.  type of  i n an E m e r g e n c y d e p a r t m e n t ,  i s c r u c i a l to conduct research  towards e l d e r l y i n d i v i d u a l s .  of  area  on  This  expose a hidden source of negative  these nurses'  research  may  attitudes  help  s t e r e o t y p i n g of  to the  elderly. In c o n c l u s i o n , education an  and  important  setting.  As  further research  i s r e q u i r e d on  t r a i n i n g o f homemakers as r o l e i n care well,  of the  they continue  e l d e r l y i n the  further research  the to  community  i s r e q u i r e d on  the  play  121 a t t i t u d e s o f the nurses working i n Emergency Departments towards the e l d e r l y . Implications for Practice In order t o understand  the p e r c e i v e d need f o r care and  support of e l d e r l y women a f t e r a f a l l to  gather  it  i s important  event,  i t i s important  i n f o r m a t i o n on t h e i r value systems. f o r nurses  In p a r t i c u l a r ,  t o l e a r n about an i n d i v i d u a l ' s  values as they r e l a t e t o f e e l i n g s about f a l l s , acute and chronic i l l n e s s , for  health care.  l o s s of f u n c t i o n a l a b i l i t y , In t h i s study,  aspects of t h e i r s e l f - e s t e e m . in  understanding  and support  and e x p e c t a t i o n s  the women's values  reflected  These values were fundamental  the e l d e r l y women's p e r c e i v e d need f o r care  i n the community.  In the present Health Care System, most p a t i e n t i n f o r m a t i o n i s gathered forms.  on p a t i e n t assessment and h i s t o r y  However, most of t h i s  i n f o r m a t i o n i s focused on the  p h y s i c a l and f u n c t i o n a l aspects of i n d i v i d u a l s .  Information  about an i n d i v i d u a l ' s values a l s o needs t o be documented and communicated t o a l l nurses The  i n c l u s i o n of t h i s  i n v o l v e d i n the c l i e n t ' s c a r e .  i n f o r m a t i o n has i m p l i c a t i o n s f o r the  f o r m u l a t i o n of h e a l t h assessment forms w i t h i n both i n s t i t u t i o n a l and community  settings.  In order t o p r o v i d e care that promotes the autonomy of e l d e r l y women a f t e r a f a l l that adequate medical  event,  the nurses must ensure  i n f o r m a t i o n i s provided t o these  122 individuals.  As w e l l , a l l h e a l t h p r o f e s s i o n a l s need  reminding that d e c i s i o n s i n v o l v i n g the c l i e n t s ' h e a l t h are no longer  care  the s o l e p r e r o g a t i v e o f h e a l t h p r o f e s s i o n a l s .  The aforementioned are two important c o n d i t i o n s f o r autonomous decisions-making  by i n d i v i d u a l s .  Nurses and other  h e a l t h p r o f e s s i o n a l s r e q u i r e i n s e r v i c e s on the e t h i c a l p r i n c i p l e of autonomy.  As w e l l , nurses r e q u i r e  education  about the concept of advocacy i n the p r a c t i c e s e t t i n g . In many s i t u a t i o n s , the nurse may need t o assume the r o l e of p a t i e n t advocate t o ensure that autonomous decision-making occurs.  T h i s promotion of autonomy f o r e l d e r l y women w i l l  help t o meet t h e i r p e r c e i v e d  need f o r care and support as  they r e t u r n home a f t e r a h o s p i t a l i z a t i o n f o r a f a l l . Nurses need t o be aware of the importance of r e c i p r o c i t y in the s o c i a l r e l a t i o n s h i p s of e l d e r l y women.  This  r e c i p r o c i t y was important as the women d e s c r i b e d perceived Therefore,  need f o r care and support  i n the community.  i t i s a c r u c i a l p o i n t t o remember as nurses  d i s c u s s with  e l d e r l y women the d e c i s i o n t o i n v o l v e  f r i e n d s as a support to be c o n s u l t e d that person.  i n the d i s c h a r g e  plan.  their  The women need  about who t o phone and what t o request of  T h i s f i n d i n g may have important p o l i c y  i m p l i c a t i o n s f o r the p r o v i s i o n of formal  supports t o those  women who do not want t h e i r f r i e n d s i n v o l v e d plan.  their  i n the discharge  123  H e a l t h p r o f e s s i o n a l s a l s o need t o i n c r e a s e t h e i r awareness o f the importance  of their  t h e s e l f - e s t e e m o f e l d e r l y women. has  a l r e a d y been d i s c u s s e d .  with of  the e l d e r l y ,  source  The i m p o r t a n c e  Nurses,  f o rself-esteem feelings.  care tasks.  As w e l l ,  identifying  interactions  5,  As d i s c u s s e d i n C h a p t e r  acknowledgement f o r accomplishments  concept.  i n their  Nurses  aspects of their  self-  unspoken a c t i o n s appraisals.  T h e r e f o r e , n u r s e s must become c o g n i z a n t o f t h e i r and v o i c e t o n e when  facial interacting  the e l d e r l y . It  events fall  self-  individuals i n  Besides p r o v i d i n g v e r b a l feedback,  e x p r e s s i o n s , body l a n g u a g e ,  this i s  or newly-regained  they can a s s i s t  s t r e n g t h s and p o s i t i v e  appraisal  can provide  are a l s o important i n p r o v i d i n g the r e f l e c t e d  with  o f autonomy  are able t o provide the r e f l e c t e d  significant others.  one  actions i n supporting  i s important  f o rnurses  t o e l d e r l y women.  event  perceived  From t h i s  s t u d y , t h e meaning o f t h e  h a d a t r e m e n d o u s i n f l u e n c e on t h e women's need f o r c a r e and s u p p o r t  alone a f t e r  a hospitalization  transcends the reasons  is  important  of  nursing care objectives  as they  for a f a l l .  f o r the f a l l  f r o m an o u t s i d e o b s e r v e r .  In  t o l e a r n t h e meanings o f  r e t u r n e d home T h i s meaning  or the report of the f a l l  An u n d e r s t a n d i n g o f t h e f a l l  event  i n t h e p r o c e s s o f a s s e s s m e n t and t h e f o r m u l a t i o n i n the care of e l d e r l y  conclusion, the implications  women.  for practice include  124 four and  recommendations f o r n u r s e s .  Firstly,  document t h e v a l u e s o f e l d e r l y  individuals.  nurses  must remember t h e i m p o r t a n c e  social  r e l a t i o n s h i p s o f e l d e r l y women.  nurses  i n promoting  addressed.  of the f a l l  must b e g i n event  assess  Secondly,  of r e c i p r o c i t y Thirdly,  the self-esteem of e l d e r l y  L a s t l y , nurses  understanding  t h e y must  i n the  the role of  individuals i s  to increase  their  a s e l d e r l y women r e t u r n home  alone. Implications f o r Education Over t h e l a s t  15 y e a r s , t h e r e h a s b e e n i n c r e a s i n g  e m p h a s i s on t h e s t u d y o f G e r o n t o l o g y profession.  Despite  this  by t h e n u r s i n g  f o c u s , t h e r e r e m a i n many  negative  stereotypes of the e l d e r l y w i t h i n the p r o f e s s i o n . The  curriculums i n nursing schools provide opportunities  for students situations and  t o care  f o r the e l d e r l y .  H o w e v e r , many o f t h e s e  i n v o l v e c a r i n g f o r t h e e l d e r l y w i t h many p h y s i c a l  c o g n i t i v e l i m i t a t i o n s w i t h i n i n s t i t u t i o n a l and c o m m u n i t y  settings.  A g r e a t e r f o c u s on t h e w e l l e l d e r l y  within the nursing school curriculum. p r a c t i t i o n e r s would begin generation.  Here,  i s required  beginning  t o l e a r n about the values o f t h i s  T h i s w o u l d h e l p t o e l i m i n a t e some o f t h e  s t e r e o t y p i c a l views o f the e l d e r l y .  As w e l l ,  the experience  i n c a r i n g f o r t h e w e l l e l d e r l y w o u l d h e l p t o p r o m o t e more positive  a t t i t u d e s toward  Besides  the aging  process.  p r o v i d i n g a c u r r i c u l u m f o c u s on w e l l n e s s i n  125 aging, i t i s important prepared  that there be adequate  faculty  at the master's l e v e l i n g e r o n t o l o g i c a l n u r s i n g .  Here, the students would b e n e f i t from the expanded knowledge and  skill  l e v e l s of the g e r o n t o l o g i c a l c l i n i c a l  s p e c i a l i s t w i t h i n the p r a c t i c e s e t t i n g . students would observe  role-models  p a t t e r n t h e i r own behaviours the  nurse  As w e l l , the  on which they could  i n l e a r n i n g s e n s i t i v e care t o  elderly. In c o n c l u s i o n , there needs to be more emphasis on  w e l l n e s s i n order to e l i m i n a t e negative s t e r e o t y p e s of the e l d e r l y among beginning p r a c t i t i o n e r s i n the n u r s i n g profession.  As w e l l , n u r s i n g students r e q u i r e more  o p p o r t u n i t y t o l e a r n and work with masters-prepared nurse s p e c i a l i s t s  i n gerontology.  clinical  126 References American P s y c h o l o g i c a l A s s o c i a t i o n . (1983). 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S u l l i v a n , H. S. (19 5 3 ) . The i n t e r p e r s o n a l t h e o r y o f psychiatry. New Y o r k : N o r t o n . T a f t , L. B. (1985). Self-esteem i n l a t e r N u r s i n g S c i e n c e s , J8(l), 77-84. T e r p s t r a , T. L. , Streeter, J. identification Gerontological  life.  Advances i n  T e r p s t r a , T e r r y L . , P l a w e c k i , H. M., & A s y o u n g a s y o u f e e l : Age among t h e e l d e r l y . Journal of N u r s i n g , 1_5(12), 4 - 1 0 .  (1989).  T i d e s i k s a a r , R. (1986). H e a l t h c a r e N u r s e , 4(2),  Geriatric 14-23.  falls  i n t h e home.  Home  T i l d e n , V. R., & W e i n e r t , C. (1987). S o c i a l s u p p o r t and t h e chronically i l l individual. Nursing C l i n i c s of North A m e r i c a , 22(3), 613-620. T i n e t t i , M. E . , R i c h m a n , D., & P o w e l l , L. (1990). Falls e f f i c a c y a s a measure o f f e a r o f f a l l i n g . Journal of G e r o n t o l o g y : P s y c h o l o g i c a l S c i e n c e s , J5_(6), 239-243.  132 T i n e t t i , M. E . , & S p e e c h l e y , M. (1989). Prevention of f a l l s among t h e e l d e r l y . New E n g l a n d J o u r n a l o f M e d i c i n e , 3 2 0 ( 1 6 ) , 1955-1958. T i n e t t i , M. E . , S p e e c h l e y , M., & G i n t e r , S. F. (1988). Risk f a c t o r s f o r f a l l s among e l d e r l y p e r s o n s l i v i n g i n t h e community. New E n g l a n d J o u r n a l o f M e d i c i n e , 3 1 9 ( 2 6 ) , 1701-1707. V i c t o r , C. R., & V e t t e r , N. J . ( 1 9 8 8 ) . P r e p a r i n g t h e e l d e r l y f o r d i s c h a r g e from h o s p i t a l : A n e g l e c t e d aspect of p a t i e n t c a r e . Age and A g i n g , 17, 1 5 5 - 1 6 3 . W i l s o n , C., & N e t t i n g , F. E. ( 1 9 8 7 ) . C o m p a r i s o n o f s e l f and h e a l t h p r o f e s s i o n a l s r a t i n g o f t h e h e a l t h o f community based e l d e r l y . I n t e r n a t i o n a l J o u r n a l o f A g i n g a n d Human D e v e l o p m e n t , .25(1) , 11-25. Woods, N. F., & C a t a n z a r o , M. (1988). Nursing research: T h e o r y and p r a c t i c e . T o r o n t o : C. V. Mosby. W r i g h t , R. A. (1987). practice of ethics.  Human v a l u e s i n h e a l t h c a r e : The New Y o r k : McGraw H i l l .  133 Appendix A C o n s e n t Form T i t l e o f the Study: H o s p i t a l t o Home: What i s t h e p e r c e i v e d need f o r c a r e and s u p p o r t o f e l d e r l y women h o s p i t a l i z e d f o r a f a l l ? Purpose: The p u r p o s e o f t h i s s t u d y i s t o d e s c r i b e t h e need f o r c a r e and s u p p o r t a s p e r c e i v e d by women aged 75 y e a r s and o l d e r r e t u r n i n g home t o l i v e a l o n e a f t e r a h o s p i t a l i z a t i o n f o r a fall. Investigator: Sharon Galloway The p u r p o s e o f t h i s s t u d y h a s b e e n e x p l a i n e d t o me by S h a r o n G a l l o w a y and I a g r e e t o p a r t i c i p a t e i n t h i s r e s e a r c h project. I u n d e r s t a n d t h a t t h i s s t u d y i n v o l v e s two t o t h r e e i n t e r v i e w s o f 30-60 m i n u t e s d u r a t i o n i n my home and t h a t t h e i n t e r v i e w s w i l l be 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 my i n v o l v e m e n t i n t h e s t u d y w i l l be c o n f i d e n t i a l and t h a t my name a n d a n y i d e n t i f y i n g f e a t u r e s w i l l be d e l e t e d f r o m a l l s o u r c e s o f i n f o r m a t i o n . I u n d e r s t a n d t h a t I may r e f u s e t o a n s w e r a n y q u e s t i o n s and may w i t h d r a w my c o n s e n t a t a n y t i m e w i t h o u t r i s k t o f u t u r e and p r e s e n t h e a l t h c a r e . I f I have any f u r t h e r q u e s t i o n s a b o u t t h e s t u d y , I u n d e r s t a n d t h a t I may c o n t a c t S h a r o n G a l l o w a y a t x x x - x x x x f o r c l a r i f i c a t i o n . As w e l l , I u n d e r s t a n d t h a t I may c o n t a c t t h e s u p e r v i s o r o f t h e p r o j e c t ( J o Ann P e r r y ) a t x x x - x x x x w i t h q u e s t i o n s a t any time. I a c k n o w l e d g e r e c e i p t o f a copy o f t h i s  S ignature  Date  1991  consent  form.  134  Appendix B L e t t e r of  Information  My name i s S h a r o n G a l l o w a y . I am a R e g i s t e r e d N u r s e c u r r e n t l y w o r k i n g on my t h e s i s f o r t h e M a s t e r o f S c i e n c e i n N u r s i n g a t The U n i v e r s i t y o f B r i t i s h C o l u m b i a . I am s t u d y i n g t h e p e r c e i v e d need f o r c a r e and s u p p o r t o f e l d e r l y women who r e t u r n home t o l i v e a l o n e a f t e r a h o s p i t a l i z a t i o n f o r a f a l l . T h i s l e t t e r i s an i n v i t a t i o n f o r y o u t o p a r t i c i p a t e i n my s t u d y . You a r e u n d e r no o b l i g a t i o n t o p a r t i c i p a t e and i f y o u c h o o s e t o p a r t i c i p a t e you may w i t h d r a w f r o m t h e s t u d y a t any t i m e . The h e a l t h c a r e t h a t you r e c e i v e w i l l i n no way be a f f e c t e d by y o u r d e c i s i o n t o p a r t i c i p a t e o r n o t p a r t i c i p a t e . I f y o u a r e i n t e r e s t e d i n t a l k i n g w i t h me a b o u t y o u r e x p e r i e n c e upon d i s c h a r g e f r o m h o s p i t a l , I w o u l d l i k e t o meet w i t h y o u i n y o u r home a p p r o x i m a t e l y two t o t h r e e t i m e s . Each i n t e r v i e w w i l l l a s t f o r 30 t o 60 m i n u t e s . On t h e i n i t i a l i n t e r v i e w , I w i l l ask q u e s t i o n s a b o u t y o u r c o n c e r n s f o r c a r e and s u p p o r t a t home a f t e r a h o s p i t a l i z a t i o n f o r a f a l l . S u b s e q u e n t i n t e r v i e w s w i l l be a p p r o x i m a t e l y f o u r weeks l a t e r and w i l l p r o v i d e an o p p o r t u n i t y f o r you and me t o c l a r i f y and e x p a n d on t h e i n f o r m a t i o n t h a t you i n i t i a l l y s h a r e d w i t h me. E a c h i n t e r v i e w w i l l be t a p e - r e c o r d e d s o t h a t I may l i s t e n t o what you a r e s a y i n g . As w e l l , I w i l l t a k e some w r i t t e n notes. A l l i n f o r m a t i o n t h a t you s h a r e w i t h me i s c o n f i d e n t i a l ; t h e t a p e s w i l l be numbered s o t h a t y o u r name w i l l n o t a p p e a r on them and a c o d e w i l l be u s e d when t h e tapes are t r a n s c r i b e d . A c c e s s t o t h e t a p e s and t y p e d t r a n s c r i p t s w i l l be l i m i t e d t o my t h e s i s a d v i s o r s , my t y p i s t , and m y s e l f . You may r e q u e s t e r a s u r e s o f t a p e d i n f o r m a t i o n a t any t i m e and a t t h e c o m p l e t i o n o f t h e s t u d y , a l l t a p e s w i l l be d e s t r o y e d . A l l w r i t t e n m a t e r i a l a r i s i n g from t h i s study w i l l m a i n t a i n your anonymity. P a r t i c i p a t i o n i n t h i s s t u d y i s v o l u n t a r y . I t i s hoped t h a t the i n f o r m a t i o n p r o v i d e d w i l l h e l p nurses t o b e t t e r u n d e r s t a n d t h e need f o r c a r e and s u p p o r t i n t h e c o m m u n i t y f o r e l d e r l y women who f a l l . P a r t i c i p a n t s who a r e i n t e r e s t e d w i l l be s e n t a summary upon c o m p l e t i o n o f t h e s t u d y . I f you a r e 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 or have f u r t h e r q u e s t i o n s r e g a r d i n g t h e s t u d y , p l e a s e c a l l me a t x x x - x x x x . The s u p e r v i s o r f o r t h i s p r o j e c t i s J o Ann P e r r y . Her o f f i c e phone number i s x x x - x x x x . When y o u r n u r s e g i v e s me y o u r name, I w i l l phone you t o c l a r i f y any q u e s t i o n s y o u h a v e and to i n q u i r e about your i n t e r e s t i n p a r t i c i p a t i n g . I look forward t o speaking w i t h you. S incerely, Sharon  Galloway  Appendix C Trigger 1.  Questions  How do you f e e l you are managing at home s i n c e the  hospitalization? 2.  How has the f a l l  a f f e c t e d your d a i l y  3.  How has the f a l l  affected  life?  your need f o r a s s i s t a n c e  or h e l p at home? 4.  How do you f e e l the f a l l has a f f e c t e d  care at home?  your need f o r  

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