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UBC Theses and Dissertations

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 IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i n THE FACULTY OF GRADUATE STUDIES ( S c h o o l of N u r s i n g ) We a c c e p t t h i s t h e s i s as con f o r m i n g t o the r e q u i r e d s t a n d a r d THE UNIVERSITY OF BRITISH COLUMBIA September 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 N U R S I N G The University of British Columbia Vancouver, Canada Date 1, mi DE-6 (2/88) A b s t r a c t F a l l s a r e a major h e a l t h problem f o r o l d e r women. In 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 comprise 85% of t h e t o t a l number of 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 w i t h a f a l l . F a l l s 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 r e v i e w o f the l i t e r a t u r e i n d i c a t e s t h a t most s t u d i e s on f a l l s are e p i d e m i o l o g i c a l i n n a t u r e . There a re no s t u d i e s t h a t d e a l w i t h the consequences of the f a l l and t h e i r e f f e c t on the o l d e r woman's p e r c e p t i o n s o f her need f o r c a r e and su p p o r t a f t e r h o s p i t a l i z a t i o n f o r a f a l l . The purpose of t h i s s tudy i s t o d e s c r i b e the need f o r care and s u p p o r t as p e r c e i v e d by women aged 75 ye 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 f a l l . Phenomenology i s the chosen r e s e a r c h method. T h i s method d e s c r i b e s human e x p e r i e n c e as i t i s l i v e d . S u b j e c t s were r e c r u i t e d through the l i a i s o n n u r s e s and home c a r e c o o r d i n a t o r s from the H e a l t h Department. E i g h t women p a r t i c i p a t e d i n the r e p e a t e d i n t e r v i e w s g u i d e d by t r i g g e r q u e s t i o n s . C e r t a i n themes emerged from d a t a a n a l y s i s and were coded a c c o r d i n g l y . These themes were v e r i f i e d , v a l i d a t e d , and/or d i s c o u n t e d i n subsequent i n t e r v i e w s . The f i n d i n g s i n d i c a t e d t h a t the e l d e r l y women p e r c e i v e d the f a l l as both 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 i n t h e i r l i f e . I t r e s u l t e d i n a change of r o u t i n e as they i i r e t u r n e d home t o l i v e a l o n e . I n response t o t h i s change, the women d e s c r i b e d t h r e a t s t o t h e i r s e l f - e s t e e m , p a r t i c u l a r l y t o t h e i r f e e l i n g s o f independence, a c t i v i t y , and autonomy. A v a r i e t y of b e h a v i o u r s were used t o cope w i t h the t h r e a t s t o t h e i r s e l f - e s t e e m . Use o f s o c i a l s u p p o r t was one b e h a v i o u r used by a l l the women. In d e s c r i b i n g t h i s b e h a v i o u r , r e c i p r o c i t y was i m p o r t a n t i n the f r i e n d s h i p s of e l d e r l y women. T h i s study a l s o c o n c l u d e d t h a t t h e r e were numerous d i f f i c u l t i e s i n u s i n g s o c i a l s u p p o r t s from a f o r m a l program. The 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 , p r a c t i c e , and e d u c a t i o n were d i s c u s s e d i n l i g h t of these f i n d i n g s . i i i T a b l e o f C o n t e n t s Page A b s t r a c t i i Table of C o n t e n t s i v Acknowledgements v i Chapter One: I n t r o d u c t i o n 1 I n t r o d u c t i o n 1 Background t o the Problem 2 T h e o r e t i c a l Framework 5 Statement o f the Problem 7 Purpose 7 Research Q u e s t i o n 7 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 8 D e f i n i t i o n of Terms 8 F a l l 8 H o s p i t a l i z a t i o n 8 I n t r o d u c t i o n t o the Methodology 8 Assumptions 9 L i m i t a t i o n s 10 Summary 10 Ch a p t e r Two: C r i t i c a l Review of the L i t e r a t u r e 12 I n t r o d u c t i o n 12 F a l l s 12 S o c i a l Support 2 3 P e r c e i v e d Need f o r Care and Supp o r t 26 Summary 31 Ch a p t e r Three: Methodology 33 I n t r o d u c t i o n 33 M e t h o d o l o g i c a l I s s u e s 33 T r u t h Value 34 A p p l i c a b i l i t y 34 C o n s i s t e n c y 35 N e u t r a l i t y 36 Procedure f o r P r o t e c t i o n o f Human R i g h t s 37 S e l e c t i o n of P a r t i c i p a n t s 38 S e l e c t i o n C r i t e r i a 38 R e c r u i t m e n t P r o c e d u r e 38 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 40 Data C o l l e c t i o n 42 Data A n a l y s e s 43 Summary 44 i v Page C h a p t e r F o u r : Data A n a l y s i s 45 I n t r o d u c t i o n 45 F a l l as a S i g n i f i c a n t Event 46 H e a l t h Care System 48 S e l f - E s t e e m 56 Independence 56 A c t i v i t y 61 Autonomy 68 A d a p t a b i l i t y 75 Use o f F a i t h / P o s i t i v e B e l i e f s 76 Compliance 78 M a i n t a i n i n g C o n t r o l 80 P r e v e n t i o n 82 P l a n s f o r the F u t u r e 85 Use of S o c i a l Support 87 Summary 96 Cha p t e r F i v e : D i s c u s s i o n o f the F i n d i n g s 98 I n t r o d u c t i o n 98 F a l l as a S i g n i f i c a n t Event 98 S e l f - E s t e e m 100 A d a p t a t i o n 107 Summary 113 Cha p t e r S i x : Summary, C o n c l u s i o n s and I m p l i c a t i o n s f o r N u r s i n g 114 Summary C o n c l u s i o n s 114 I m p l i c a t i o n s f o r Research 118 I m p l i c a t i o n s f o r P r a c t i c e 121 I m p l i c a t i o n s f o r E d u c a t i o n 124 R e f e r e n c e s 126 Appendices 133 Appendix A: Consent Form 133 Appendix B: L e t t e r o f I n f o r m a t i o n 134 Appendix C: T r i g g e r Q u e s t i o n s 135 v Acknowledgement I would l i k e t o thank the p e o p l e who a s s i s t e d me d u r i n g the p r e p a r a t i o n o f t h i s t h e s i s . My s i n c e r e g r a t i t u d e goes t o J o Ann P e r r y ( C h a i r ) and A n g e l a Henderson f o r t h e i r c o n s i s t e n t d i r e c t i o n , p o s i t i v e encouragement and e n t h u s i a s m f o r t h i s p r o j e c t . Thank you t o the e l d e r l y women who agreed t o p a r t i c i p a t e and shared t h e i r e x p e r i e n c e w i t h me. I would l i k e t o thank my f a m i l y f o r t h e i r ongoing support a c r o s s the m i l e s . I would l i k e t o thank my f r i e n d , Bev, f o r her p o s i t i v e approach and her n e v e r - e n d i n g s u p p o r t . A s p e c i a l thank you t o my f r i e n d , C r a i g , who a s s i s t e d me i n k e e p i n g my head above the f a s t - r i s i n g water. v i 1 CHAPTER ONE: INTRODUCTION I n t r o d u c t i o n F a l l s are a major h e a l t h problem f o r o l d e r women. In 1984-85 i n 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 c o m p r i sed 85% of the t o t a l number of 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 w i t h a f a l l ( S t a t i s t i c s Canada, 1989). F a l l i n g and the r e s u l t a n t i n j u r i e s are the s i x t h 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) . Those o l d e r women who s u r v i v e f a l l s may e x p e r i e n c e p h y s i c a l and p s y c h o l o g i c a l consequences (Hindmarsh & E s t e s , 1989) . Kleinman's (1978) H e a l t h Care Systems Model c o n t a i n s t h r e e s t r u c t u r a l arenas i n which " s i c k n e s s i s e x p e r i e n c e d and r e a c t e d t o " (p. 86). E x p l a n a t o r y models (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 s i c k n e s s e p i s o d e s i n the t h r e e a r e n a s . An e x p l a n a t o r y model f o r an e l d e r l y woman's f a l l w i l l i n t e r p r e t the r e s u l t a n t p h y s i c a l and/or p s y c h o l o g i c a l consequences. As w e l l , i t w i l l e x p l a i n her 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 when she r e t u r n s home from the h o s p i t a l t o l i v e a l o n e . T h e r e f o r e , i n o r d e r t o ensure c o n t i n u i t y of c a r e from h o s p i t a l t o home, nu r s e s must become f a m i l i a r w i t h 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 f a l l . An 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 t o ensure t h a t t h e s e 2 women's needs f o r c a r e and s u p p o r t are met w i t h i n the community s e t t i n g . Background t o the Problem Women who are 65 y e a r s o f age and o l d e r are the f a s t e s t -growing segment of the e l d e r l y p o p u l a t i o n ( F l e t c h e r & Stone, 1982; R o b i n s o n , 1986). Some 1.2 m i l l i o n Canadian women were aged 65 y e a r s and o l d e r i n 1978 ( F l e t c h e r & Stone, 1982). The l a t e s t p r o j e c t i o n s from S t a t i s t i c s Canada suggest t h a t by 2001, more than two m i l l i o n women w i l l be aged 65 ye a r s and o l d e r . 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 to 8% of the p o p u l a t i o n w i l l be women who are aged 75 ye 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 s e x , aged 65 y e a r s and o l d e r l i v i n g i n the community, i s the o c c u r r e n c e of a f a l l . I t i s r e p o r t e d t h a t the a n n u a l i n c i d e n c e of f a l l s among the e l d e r l y l i v i n g i n the community i n c r e a s e s from 25% at 70 ye a r s of age t o 35% a f t e r 75 years of age ( T i n e t t i & S p e e c h l e y , 1989). I n p a r t i c u l a r , women f a l l more o f t e n than men u n t i l the age o f 75 y e a r s , a f t e r which the f r e q u e n c y i s s i m i l a r i n both sexes (Nelson & Amin, 1990). A c c o r d i n g t o the I n t e r n a t i o n a l C l a s s i f i c a t i o n of D i s e a s e s (1989), an a c c i d e n t a l f a l l i n c l u d e s f a l l s on or from s t a i r s , on or from l a d d e r s , from a b u i l d i n g or o t h e r s t r u c t u r e , i n t o h o l e s or o t h e r openings i n a s u r f a c e , and from one l e v e l t o a n o t h e r . As w e l l , f a l l s from s l i p p i n g , 3 t r i p p i n g , or s t u m b l i n g , from c o l l i s i o n , p u s h i n g , or s h o v i n g by or w i t h another p e r s o n , and from u n s p e c i f i e d f r a c t u r e s are i n c l u d e d i n the c l a s s i f i c a t i o n . In Canada, between 1984 and 1985, 40,311 i n d i v i d u a l s were a d m i t t e d t o h o s p i t a l w i t h a d i a g n o s i s of an a c c i d e n t a l f a l l ( S t a t i s t i c s Canada, 1989). I n c l u d e d i n t h i s n a t i o n a l s t a t i s t i c were 4,383 i n d i v i d u a l s l i v i n g i n B r i t i s h C o l u m b i a . S t a t i s t i c s s u b s t a n t i a t e d t h a t f a l l s were a s i g n i f i c a n t p r o b l em f o r o l d e r women ( S t a t i s t i c s Canada, 1989). I t was noted t h a t 24,235 i n d i v i d u a l s from the n a t i o n a l f i g u r e or 60% were women aged 75 y e a r s or o l d e r . Women i n t h i s age b r a c k e t were more prominent i n the B r i t i s h Columbia s t a t i s t i c s . Here, they comprised n e a r l y 85% or 3,716 i n d i v i d u a l s . F a l l s i n the e l d e r l y are due t o p h y s i o l o g i c a l changes a s s o c i a t e d w i t h a g i n g , u n d e r l y i n g p h y s i c a l i l l n e s s e s , m e d i c a t i o n s , and e n v i r o n m e n t a l h a z a r d s (Nelson & Amin, 1990; Schulman & A c q u a v i v a , 1987). W i t h many f a l l s , t hese f a c t o r s may be i n t e r a c t i n g w i t h each o t h e r . The e l d e r l y are not o n l y a t an i n c r e a s e d r i s k of death from a f a l l , but are l i k e l y t o s u f f e r more s e v e r e n o n f a t a l i n j u r i e s from a f a l l than younger p e r s o n s ( D e V i t o , e t a l . , 1988). 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 the e l d e r l y . I t i s r e p o r t e d t h a t 50% of e l d e r l y p a t i e n t s h o s p i t a l i z e d f o r a f a l l i n j u r y w i l l not s u r v i v e a n other y e a r (Ne l s o n & Amin, 1990). F a l l s a l s o produce a l a c k of 4 c o n f i d e n c e and a f e a r of f u r t h e r i n j u r y which may l i m i t m o b i l i t y and independence (Hindmarsh & E s t e s , 1989). T h i s d i m i n i s h e d a c t i v i t y may r e s u l t i n f u r t h e r s o c i a l i s o l a t i o n and p h y s i c a l d e c l i n e (Nelson & Amin, 1990). As w e l l , these women may be r e t u r n i n g home t o l i v e a l o n e . I t i s r e p o r t e d t h a t i n Canada, between 1961 and 1976, t h e r e was a t h r e e - f o l d i n c r e a s e i n women aged 65 years and o l d e r who l i v e a l o n e ( F l e t c h e r & S t o n e , 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 r e c e n t r a p i d i n c r e a s e i n the number and p r o p o r t i o n o f o l d e r women l i v i n g a l o n e . S i g n i f i c a n t f a c t o r s a r e the l o n g e r l i f e e x p e c t a n c y f o r women compared t o men, the i n c r e a s e i n the number of o l d e r widowed women, the absence of c h i l d r e n a v a i l a b l e f o r f a m i l y l i v i n g arrangements, and the d e s i r e f o r independence ( F l e t c h e r & Stone, 1982; R o b i n s o n , 1986; Schank & Lough, 1990). L i v i n g a l o n e has a l s o become more s o c i a l l y a c c e p t a b l e d u r i n g the l a s t two decades ( F l e t c h e r & Stone, 1982). Women who are 75 y e a r s o f age and o l d e r may a l s o e x p e r i e n c e d e f i c i t s i n t h e i r i n f o r m a l s u p p o r t networks ( A u s l a n d e r & L i t w i n , 1990). I n f o r m a l s u p p o r t networks may i n c l u d e n u c l e a r 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 ne i g h b o u r s ( A u s l a n d e r & L i t w i n , 1990). The d e f i c i t s may be due t o death o f the members, reduced m o b i l i t y among the members, and reduced r e c i p r o c i t y on the p a r t of the aged women. 5 In c o n c l u s i o n , f a l l s are a s i g n i f i c a n t problem f o r women aged 75 y e a r s and o l d e r . Trends i n d i c a t e t h a t many of these women l i v e a l o n e and have i n s u f f i c i e n t i n f o r m a l s u p p o r t networks. 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 f a l l s have been well-documented i n the l i t e r a t u r e . Y e t , l i t t l e i s known about the e f f e c t of these consequences 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 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 . T h e o r e t i c a l Framework The t h e o r e t i c a l framework i s u s e f u l f o r the study purpose and p r o v i d e s d i r e c t i o n f o r the s t u d y d e s i g n (Woods & C a t a n z a r o , 1988). The t h e o r e t i c a l framework chosen f o r t h i s proposed s t u d y i s Kleinman"s (1978) H e a l t h Care System Model. T h i s Model i s an attempt t o u n d e r s t a n d h e a l t h , i l l n e s s , and h e a l i n g i n s o c i e t y as a c u l t u r a l system. A c c o r d i n g t o Kleinman (1978), h e a l t h c a r e systems c o n t a i n t h r e e s t r u c t u r a l arenas i n which " s i c k n e s s 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 arena i s composed o f the f a m i l y c o n t e x t of s i c k n e s s and c a r e , as w e l l as the s o c i a l network and community a c t i v i t i e s . The 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 o t h e r h e a l t h p r o f e s s i o n a l s . The f o l k arena c o n s i s t s of non-p r o f e s s i o n a l h e a l i n g s p e c i a l i s t s . The two most i m p o r t a n t arenas f o r t h i s s t u d y w i l l be the p r o f e s s i o n a l and p o p u l a r a r e n a s . 6 According to 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 , patients, and family members for particular sickness episodes. EMs contain "explanation of any or a l l of fi v e issues: etiology; onset of symptoms, pathophysiology; course of sickness (severity and type of sick r o l e ) ; and treatment" (Kleinman, 1978, p. 88). Individuals use EMs to interpret i l l n e s s . The EMs of professionals are most l i k e l y to denote the disease aspects of sickness. In t h i s model, "disease denotes a malfunctioning in or maladaptation of b i o l o g i c a l and/or psychological processes" (Kleinman, 1978, p. 88). For f a l l s , this includes the causes, risk factors, r e s u l t i n g physical and psychological consequences, and prevention. In contrast, the EMs of the popular arena are more l i k e l y to include the experience of the i l l n e s s event. Here, the EMs are "most frequently a r t i c u l a t e d in a highly personal, non-technical, concrete idiom concerned with the l i f e problems that result from sickness" (Kleinman, 1978, p. 88). El d e r l y women w i l l interpret the physical and/or psychological consequences of a f a l l as part of their explanatory model. As well, the consequences of a f a l l w i l l a ffect these women's perceptions of the need for care and support as they return home from the hos p i t a l to l i v e alone. These perceptions w i l l also be included as part of the eld e r l y women's explanatory models for f a l l s . 7 Statement of the Problem F a l l s are a s i g n i f i c a n t problem t h a t may r e s u l t i n a h o s p i t a l i z a t i o n or t r e a t m e n t i n an Emergency Department f o r women aged 75 y e a r s and o l d e r . These women c o n s t i t u t e the f a s t e s t growing segment o f the e l d e r l y Canadian p o p u l a t i o n . Once d i s c h a r g e d from the h o s p i t a l , t h e s e women may r e t u r n home t o l i v e a l o n e . As w e l l , they may have i n s u f f i c i e n t i n f o r m a l s u p p o r t networks i n the 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 women. Y e t , l i t t l e i s known about the e f f e c t s of these consequences on the 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 as 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 h o s p i t a l i z a t i o n f o r a f a l l . Purpose The purpose of t h i s s t u d y i s t o d e s c r i b e the need f o r c a r e and s u p p o r t as 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 f a l l . R esearch Q u e s t i o n The purpose of t h i s s t u d y i s t o answer the o v e r a l l q u e s t i o n : What i s the need f o r c a r e and su p p o r t as 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 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 ? 8 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 T h i s s t u d y has p r a c t i c a l s i g n i f i c a n c e f o r n u r s e s working w i t h e l d e r l y women who s u f f e r a f a l l , which r e s u l t s i n a h o s p i t a l i z a t i o n . T h i s study a l s o has v a l u e i n t h a t i t i s an attempt t o d e s c r i b e 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 from the e l d e r l y woman's p e r s p e c t i v e as she r e t u r n s home from 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 i n f o r m a t i o n may be used i n t he p l a n n i n g o f community s e r v i c e s . A f t e r a l l , the e x p e c t a t i o n s o f those who use community s e r v i c e s s h o u l d be c o n s i d e r e d . As a r e s u l t , the gap w i l l be reduced between s e r v i c e needs and s e r v i c e a v a i l a b i l i t y . D e f i n i t i o n of Terms F a l l . An untoward event i n which the i n d i v i d u a l comes to r e s t u n i n t e n t i o n a l l y on the ground ( M o r r i s & I s a a c s , 1980). H o s p i t a l i z a t i o n . An a d m i s s i o n t o a h o s p i t a l f a c i l i t y as an i n p a t i e n t , or m e d i c a l assessment and t r e a t m e n t i n an Emergency or O u t p a t i e n t Department. I n t r o d u c t i o n t o the Methodology Phenomenology i s the proposed r e s e a r c h d e s i g n f o r t h i s s t u d y . G i o r g i (1986) s t a t e s t h a t phenomenology d e v o t e s i t s e l f t o the stu d y of how t h i n g s appear o r are g i v e n i n e x p e r i e n c e . O i l e r (1982) s t a t e s t h a t i t i s a r e s e a r c h method i n which the aim i s t o d e s c r i b e e x p e r i e n c e as i t i s l i v e d . Our a c c e s s t o e x p e r i e n c e i s p e r c e p t i o n . P e r c e p t i o n i s b e i n g 9 t h e r e t o see, t o h e a r , t o e x p e r i e n c e , t o know (Munhall & O i l e r , 1986) . Phenomenology i s an i n d u c t i v e , d e s c r i p t i v e , r e s e a r c h 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 r e s e a r c h where the g o a l i s t o un d e r s t a n d human e x p e r i e n c e . T h e r e f o r e , the approach i s a p p r o p r i a t e f o r t h i s s t u d y , s i n c e the purpose i s t o un d e r s t a n d the p e r c e i v e d need f o r c a r e and sup p o r t from the e l d e r l y woman's p e r s p e c t i v e a f t e r she r e t u r n s home from a h o s p i t a l i z a t i o n f o r a f a l l . In phenomenology, the r e s e a r c h e r e n t e r s i n t o the w o r l d of t h o s e p e o p l e whose e x p e r i e n c e i s under study ( O i l e r , 1982). As a r e s u l t , the r e s e a r c h e r becomes immersed i n the s u b j e c t s ' e x p e r i e n c e s b e f o r e a t t e m p t i n g t o i n t e r p r e t them. In o r d e r t o c o n t r o l b i a s i n the r e f l e c t i o n o f l i v e d e x p e r i e n c e , the r e s e a r c h e r b r a c k e t s or h o l d s back one's p r e v i o u s knowledge or e x p e r i e n c e . The r e s u l t i s the g e n e r a t i o n of hypotheses r a t h e r than h y p o t h e s i s t e s t i n g (Knaack, 1984). 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 must evoke d e s c r i p t i o n from the s u b j e c t s w i t h o u t t e l l i n g them what t o say (Knaack, 1984). T h e r e f o r e , the use of open-ended q u e s t i o n s p r o v i d e s the o p p o r t u n i t y o f e x p l o r i n g the depths of the s u b j e c t ' s e x p e r i e n c e (Woods & C a t a n z a r o , 1988). Assumptions 1. 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 s t u d y w i l l be 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 s u p p o r t . 2. A f a l l may r e s u l t 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 consequences which a f f e c t the i n d i v i d u a l ' s p e r c e p t i o n s of the need f o r c a r e and s u p p o r t , once d i s c h a r g e d from the h o s p i t a l . 3. E l d e r l y women use e x p l a n a t o r y models t o i n t e r p r e t i l l n e s s e v e n t s . 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 f a l l event w i l l c o n t a i n an i n t e r p r e t a t i o n of 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 and 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 . L i m i t a t i o n s 1. The p e r c e i v e d need f o r c a r e and su p p o r t may be i n f l u e n c e d by the e x t e n t o f the e l d e r l y woman's awareness of a v a i l a b l e r e s o u r c e s . Summary In c o n c l u s i o n , f a l l s remain a major h e a l t h problem f o r o l d e r women. In Chapter One, a background t o t h i s problem i s p r o v i d e d and, t h e r e f o r e , e x p l a i n s the need f o r the proposed s t u d y . 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 p a u c i t y 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 the e l d e r l y woman's need f o r c a r e and s u p p o r t as she r e t u r n s home a l o n e a f t e r h o s p i t a l i z a t i o n f o r a f a l l . The problem s t a t e m e n t , p u r p o s e , and r e s e a r c h q u e s t i o n f o r t h i s s t u d y are s t a t e d i n t h i s f i r s t c h a p t e r . As w e l l , an e x p l a n a t i o n of the t h e o r e t i c a l framework t h a t g u i d e s the s t u d y i s o u t l i n e d . A d e f i n i t i o n o f terms and a statement of both the assumptions 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 t h i s c h a p t e r . A b r i e f i n t r o d u c t i o n t o the methodology i s a l s o i n c l u d e d i n t h i s f i r s t c h a p t e r . Subsequent c h a p t e r s f o c u s on the c r i t i c a l r e v i e w o f the l i t e r a t u r e and a more d e t a i l e d e x p l a n a t i o n of the methodology f o r the s t u d y . In Chapter F o u r , the 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 the d a t a are p r e s e n t e d . A d i s c u s s i o n o f the f i n d i n g s i s p r e s e n t e d i n Chapter F i v e . F i n a l l y , Chapter S i x i n c l u d e s a summary, c o n c l u s i o n , and i m p l i c a t i o n s f o r n u r s i n g . 12 CHAPTER TWO: CRITICAL REVIEW OF THE LITERATURE I n t r o d u c t i o n The f o l l o w i n g r e v i e w of the l i t e r a t u r e i n c l u d e s both r e s e a r c h and t h e o r e t i c a l r e a d i n g s . The f i r s t 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 on f a l l s . T h i s r e v i e w i d e n t i f i e s what i s known about f a l l s . I t i n c l u d e s t o p i c s such as causes of f a l l s i n the e l d e r l y , a s s o c i a t e d r i s k f a c t o r s , p h y s i c a l and p s y c h o l o g i c a l consequences, and f a l l p r e v e n t i o n . T h i s e x p l a i n s the h e a l t h p r o f e s s i o n a l s ' e x p l a n a t o r y models r e l a t e d t o f a l l s . The second 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 on s o c i a l s u p p o r t networks. T h i s r e v i e w p r o v i d e s i n f o r m a t i o n t h a t d i s c u s s e s the s o c i a l r e a l i t y of l i v i n g a l o n e . D e f i c i t s i n i n f o r m a l s u p p o r t networks and l i v i n g a l o n e are i m p o r t a n t v a r i a b l e s t h a t may i n f l u e n c e the e l d e r l y woman's p e r c e p t i o n s of the need f o r c a r e and s u p p o r t as p a r t of her e x p l a n a t o r y model f o r a f a l l e v e n t . The t h i r d 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 d i s c h a r g e p l a n n i n g and p e r c e i v e d needs f o r c a r e and s u p p o r t . T h i s r e v i e w s the 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 needs f o r c a r e and s u p p o r t . F a l l s The causes of f a l l s i n the e l d e r l y can be c l a s s i f i e d as e x t r i n s i c and i n t r i n s i c . E x t r i n s i c f a c t o r s are m e d i c a t i o n s 13 and e n v i r o n m e n t a l h a z a r d s t h a t produce the o p p o r t u n i t y f o r a f a l l t o o c c u r . M e d i c a t i o n s such as p h e n o t h i a z i n e s , b e n z o d i a z e p i n e s , and t r i c y c l i c a n t i d e p r e s s a n t s are a s s o c i a t e d w i t h f a l l i n g i n d e p e n d e n t l y of o t h e r r i s k f a c t o r s (Nelson & Amin, 1990; T i d e i k s a a r , 1986). E n v i r o n m e n t a l h a z a r d s i n c l u d e l o o s e r u g s , s l i p p e r y s u r f a c e s , o b j e c t s on f l o o r s , poor l i g h t i n g , l o w - l y i n g o b j e c t s such as t o y s or p e t s , low beds and t o i l e t s e a t s , p o o r l y - m a i n t a i n e d w a l k i n g a i d s , l a c k of h a n d r a i l s on s t a i r s , b a d l y r e p a i r e d s t e p s , i l l - f i t t i n g f o o t w e a r , u n l a c e d shoes, h i g h h e e l s , and s l i p p e r s w i t h o u t s o l e s (Nelson & Amin, 1990; T i n e t t i & S p e e c h l e y , 1989). I t i s i n t e r e s t i n g t o note t h a t the e n v i r o n m e n t - r e l a t e d f a c t o r s account f o r 30 t o 50% of r e p o r t e d f a l l s (Nelson & Amin, 1990). However, i t i s thought t h a t many f a l l s a t t r i b u t e d t o a c c i d e n t s r e a l l y stem from an i n t e r a c t i o n between i d e n t i f i a b l e e n v i r o n m e n t a l h a z a r d s , m e d i c a t i o n s , and i n c r e a s e d i n d i v i d u a l s u s c e p t i b i l i t y t o h a z a r d s from the accumulated e f f e c t s of age and d i s e a s e . I n t r i n s i c f a c t o r s a re age- and d i s e a s e - r e l a t e d changes w i t h i n the i n d i v i d u a l t h a t i n c r e a s e the l i k e l i h o o d of f a l l s . I n t r i n s i c causes i n c l u d e v i s u a l and h e a r i n g i m p a i r m e n t s , 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 , d ementia, age-r e l a t e d changes i n g a i t and m u s c u l a t u r e , and p o s t u r a l h y p o t e n s i o n (Nelson & Amin, 1990). F a c t o r s a s s o c i a t e d w i t h a r i s k of f a l l i n g are i n c r e a s e d 14 age, female s e x , the pr e s e n c e of more than one d i s e a s e , polypharmacy, changes i n g a i t and/or v i s u a l p e r c e p t i o n , sway, de c r e a s e d m o b i l i t y , confinement t o the home, dementia, d e p r e s s i o n , a c u t e i l l n e s s , and a h i s t o r y of f a l l i n g (Hindmarsh & E s t e s , 1989). The most common p h y s i c a l consequence of a f a l l i s a f r a c t u r e d h i p ( R e i n h a r d , 1988). T h i s type o f f r a c t u r e i s r e f e r r e d t o as the "widow's d i s e a s e " s i n c e 75% of the 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 fe m a l e , o f t e n widowed and l i v i n g a l o n e p r i o r t o the f a l l e v e n t . S t a t i s t i c s from the U n i t e d S t a t e s s u g g e s t t h a t the annual i n c i d e n c e of h i p f r a c t u r e s w i l l i n c r e a s e from the p r e s e n t f i g u r e of 200,000 f r a c t u r e s t o 330,000 over the next 15 y e a r s . The most common p s y c h o l o g i c a l consequence f o l l o w i n g a f a l l i s an i n d i v i d u a l ' s f e a r over f a l l i n g a g a i n ( T i d e i k s a a r , 1986). 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 goi n g o u t d o o r s , of becoming h e l p l e s s , and of i n c u r r i n g s e r i o u s i n j u r y and subsequent h o s p i t a l i z a t i o n . S e r i o u s i n j u r y may l e a d t o the development of 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 independence. I m m o b i l i t y may l e a d t o l o s s of muscle s t r e n g t h , c o n t r a c t u r e s , i n a b i l i t y t o p e r f o r m the a c t i v i t i e s 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 d e p r e s s i o n . F a c t o r s i n v o l v e d i n p r e v e n t i o n a re assessment o f the i n d i v i d u a l s ' i n t r i n s i c r i s k f a c t o r s , 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 the h i s t o r y of p r e v i o u s f a l l s ( T i n e t t i & S p e e c h l e y , 1989). A f t e r the assessment, p r e v e n t a t i v e measures s h o u l d be implemented f o r i n d i v i d u a l s w i t h a h i g h r i s k of f a l l i n g . I n r e v i e w i n g the l i t e r a t u r e , two p r o s p e c t i v e s t u d i e s on f a l l s were found t h a t d e a l t w i t h 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 , S p e e c h l e y , & G i n t e r , 1989). The f i r s t study (Campbell e t a l . , 1989) reviewed r i s k f a c t o r s t h a t c o n t r i b u t e d t o f a l l s . T h i s s t u d y i n d i c a t e d t h a t t h i s i n f o r m a t i o n 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 the development of a p u b l i c h e a l t h p r e v e n t i o n program. A c c o r d i n g t o the t h e o r e t i c a l framework, t h i s s t u d y p r o v i d e d f u r t h e r i n f o r m a t i o n f o r the e x p l a n a t o r y model i n the p r o f e s s i o n a l arena on f a l l s f o r both men and women. I n the s t u d y , the sample c o n s i s t e d of 761 s u b j e c t s who were 70 ye a r s o f age and o l d e r . The r e s u l t s i n d i c a t e d t h a t 39.6% of women and 28.4% of men e x p e r i e n c e d a t l e a s t one f a l l . I n women, 84% of the f a l l s were due s t r i c t l y t o i n t r i n s i c f a c t o r s . F o r men, the v a l u e was s i m i l a r i n t h a t 83% of the f a l l s were due t o i n t r i n s i c f a c t o r s . As w e l l , the r i s k f a c t o r s f o r women and men were d i f f e r e n t i n r e l a t i o n t o f a l l s . In women, the r i s k f a c t o r s were the t o t a l number of d r u g s , p s y c h o t r o p i c d r u g s , and drugs l i a b l e t o cause p o s t u r a l h y p o t e n s i o n ( s t a n d i n g s y s t o l i c b l o o d 16 p r e s s u r e o f l e s s than 110 mmHg), and the e v i d e n c e o f muscle weakness. I n men, d e c r e a s e d l e v e l s of p h y s i c a l a c t i v i t y , s t r o k e , a r t h r i t i s 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 f a l l s . In a n a l y z i n g t h i s s t u d y , the s a m p l i n g s t r a t e g y was not d i s c u s s e d . The sample c o n s i s t e d o f i n d i v i d u a l s l i v i n g i n the community and r e s i d e n t i a l homes. The d a t a from the i n d i v i d u a l s i n the r e s i d e n t i a l homes may have b i a s e d the d a t a . These i n d i v i d u a l s may have had more age- and d i s e a s e -r e l a t e d changes, r e s u l t i n g i n i n s t i t u t i o n a l i z a t i o n . These changes may have a l s o p r e d i s p o s e d them t o an i n c r e a s e d i n c i d e n c e of f a l l s , compared t o the community sample. As w e l l , the f a l l s i n the f a c i l i t y may have been a c c u r a t e l y r e c o r d e d compared t o the community sample where s e l f -r e p o r t i n g was used. For example, Campbell e t a l . (1989) r e p o r t e d t h a t men, 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 knowledge o f a f a l l was ga i n e d from the man's w i f e or o t h e r o b s e r v e r . 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 o f the s t u d y . The second s t u d y ( T i n e t t i e t a l . , 1988) used a sample of 336 i n d i v i d u a l s who were 75 y e a r s of age or o v e r , l i v i n g i n the community. T h i s s t u d y a l s o reviewed r i s k - f a c t o r s and s t r e s s e d t h a t a s i m p l e , c l i n i c a l assessment c o u l d i d e n t i f y the e l d e r l y persons who are a t the g r e a t e s t r i s k of f a l l i n g . S i m i l a r t o t h i s f i r s t s t u d y (Campbell e t a l . , 1989), i t was c o n c l u d e d t h a t r e s e a r c h on r i s k f a c t o r s r e s u l t e d i n p r e v e n t i v e s t r a t e g i e s . T h i s second s t u d y r e p o r t e d t h a t 32% of t h e i r sample f e l l a t l e a s t once. D u r i n g the s t u d y , i t was shown t h a t 26 s u b j e c t s (24%) who f e l l had a s e r i o u s i n j u r y from a f a l l . The c a t e g o r y of s e r i o u s i n j u r y was not c l e a r l y d e f i n e d i n the s t u d y . T h i s s t u d y b r i e f l y a d d r e s s e d f e a r o f 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 . F i f t y - t w o o f the 108 s u b j e c t s (48%) who f e l l r e p o r t e d t h a t they were a f r a i d o f f a l l i n g . 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 t h a t they had c u r t a i l e d a c t i v i t i e s such as shopping or h o u s e c l e a n i n g , due t o f e a r . Here, f e a r of f a l l i n g had an e f f e c t on the 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 i n the community. T h i s i s the type of i n f o r m a t i o n t h a t p e r t a i n s t o the EMs or i n t e r p r e t a t i o n o f the i l l n e s s e v e nt. The r e s u l t s of the st u d y i n d i c a t e d t h a t the r i s k of f a l l i n g i n c r e a s e d w i t h the number o f d i s a b i l i t i e s . I t was noted t h a t m e d i c a l , 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 the p r e v a l e n c e of s e v e r a l r i s k f a c t o r s . Once a g a i n , the 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 i t r e l i e d on the s u b j e c t s t o remember the f a l l e vent. As w e l l , t h i s study was done a t the f a c t o r i s o l a t i n g l e v e l . Even though the s t u d y d e s c r i b e d 18 the i n t r i n s i c , a c t i v i t y , and e n v i r o n m e n t a l f a c t o r s p r e s e n t a t the time of the f a l l s , no c a u s a l r e l a t i o n s h i p s were found. Cummings, N e v i t t , and K i d d (1988) s t u d i e d the a c c u r a c y of h i s t o r i e s of 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 s p e c i f i c i n t e r v a l s o f time over one y e a r . I t was i m p o r t a n t t o r e v i e w t h i s s tudy s i n c e the a c c u r a c y of the h i s t o r i e s of f a l l s was noted as a l i m i t a t i o n f o r the s t u d i e s a l r e a d y d i s c u s s e d . As p a r t of another r e s e a r c h p r o j e c t t o s t u d y r i s k f a c t o r s , Cummings e t a l . (1988) used an i n t e n s i v e system of f o l l o w - u p on f a l l s . In t h i s s t u d y , the p a r t i c i p a n t s r e p o r t e d on a weekly b a s i s by m a i l i n g i n a p o s t c a r d . Each week, the s u b j e c t s were t o r e p o r t whether a f a l l had o c c u r r e d . I f a f a l l was r e p o r t e d , a f o l l o w - u p v i s i t was made by a p u b l i c h e a l t h n u r s e . At the end o f the s t u d y , a l l p a r t i c i p a n t s were i n t e r v i e w e d by phone. I n t h i s i n t e r v i e w , they were asked whether they had f a l l e n d u r i n g the p a s t 12 months. D u r i n g t h i s s t u d y , 179 of 325 p a r t i c i p a n t s c o n f i r m e d f a l l s . However, a t the end o f the s t u d y , 23 (13%) d i d not r e c a l l h a v i n g a f a l l . One hundred and f o r t y - t h r e e p a r t i c i p a n t s r e p o r t e d i n j u r i e s due t o a f a l l . D u r i n g the s t u d y , 18 (13%) p a r t i c i p a n t s d i d not r e c a l l h a v i n g a f a l l , and 40 (28%) d i d not r e c a l l h a v i n g any i n j u r y as a r e s u l t of a f a l l . 19 As a r e s u l t , the r e s e a r c h e r s c o n c l u d e d t h a t e l d e r l y s u b j e c t s do not o f t e n r e c a l l f a l l s t h a t o c c u r r e d d u r i n g s p e c i f i c p e r i o d s of t i m e . Recent r e c a l l (3 months) of f a l l s appeared t o be l e s s complete than r e c a l l o f f a l l s over the p r e v i o u s 12 months. T h i s may be due t o the f a c t t h a t the s u b j e c t s remembered t h e i r e n r o l l m e n t i n the study and c o u l d remember whether a f a l l o c c u r r e d d u r i n g the i n i t i a l e x a m i n a t i o n . The 3- and 6-month p e r i o d s o f r e c a l l were not marked by such d i s t i n c t e v e n t s and, t h e r e f o r e , i t may have been d i f f i c u l t f o r the s u b j e c t s t o r e c a l l a f a l l d u r i n g these p e r i o d s . As a r e s u l t , they c o n c l u d e d t h a t r e s e a r c h e r s and c l i n i c i a n s s h o u l d use methods b e s i d e s l o n g - t e r m r e c a l l f o r a s c e r t a i n i n g and c o u n t i n g f a l l s over s p e c i f i c p e r i o d s of t i m e . One n u r s i n g s t u d y (Craven & Bruno, 1986) i d e n t i f i e d f a c t o r s i n d i c a t i v e o f a h i g h r i s k f o r f a l l i n g i n a group of ambulatory e l d e r l y . T h i s s t u d y was a l s o p r e l i m i n a r y t o d e v e l o p i n g and t e s t i n g a t e a c h i n g p r o t o c o l d e s i g n e d t o p r e v e n t f a l l s i n the e l d e r l y . The f a c t o r s i d e n t i f i e d were age, l i v i n g a l o n e , v i s u a l d e f i c i t s , b a l a n c e problems, and n e u r o l o g i c problems. The r e s e a r c h e r s i n d i c a t e d t h a t t h i s s e t o f p r e d i c t o r s may be used t o i d e n t i f y p e r s o n s w i t h a need f o r l e a r n i n g about p r e v e n t i v e measures. Craven and Bruno (1986) 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 o f t h e i r f i n d i n g s . These i m p l i c a t i o n s were not p a r t of the s t u d y . 20 One l i m i t a t i o n t o t h i s s t u d y was t h a t the d a t a c o l l e c t e d was based on s e l f - r e p o r t i n g of p h y s i c a l d e f i c i t s and g e n e r a l 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 . The sample t e c h n i q u e ( c o n v e n i e n c e ) may have i n f l u e n c e d s e l f - p e r c e p t i o n and s e l f -r e p o r t i n g o f t h e s e d e f i c i t s . As a r e s u l t , the f i n d i n g s may have l i m i t e d g e n e r a l i z a b i l i t y t o o t h e r e l d e r l y p o p u l a t i o n s . The s t u d y ' 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 r i s k f a c t o r s f o r f a l l s . As mentioned e a r l i e r , t h i s i s the type of i n f o r m a t i o n t h a t belongs t o the EMs o f p r o f e s s i o n a l s . However, t h i s s t u d y does c o n s i d e r the EMs o f i n d i v i d u a l s i n f a l l p r e v e n t i o n . For example, t h i s s t u d y r e p o r t e d t h a t 53 of the 99 p a r t i c i p a n t s took no a c t i o n t o p r e v e n t f a l l s . The r e s e a r c h e r s c o n c l u d e d t h a t i n v o l v i n g e l d e r l y p e r s o n s i n the p r o c e s s o f l e a r n i n g t o p r e v e n t f a l l s t h r o u g h mutual problem-s o l v i n g was i m p o r t a n t . I t has a l r e a d y been mentioned t h a t f e a r o f 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 consequence r e s u l t i n g from a f a l l . T i n e t t i , Richman, and P o w e l l (1990) dev e l o p e d an i n s t r u m e n t e n t i t l e d the F a l l E f f i c a c y S c a l e (FES) t o measure f e a r of f a l l i n g . The o v e r a l l purpose o f d e v e l o p i n g t h i s i n s t r u m e n t was t o d e t e r m i n e the e x t e n t t o which f e a r o f f a l l i n g e x e r t s an independent e f f e c t on f u n c t i o n a l d e c l i n e among the e l d e r l y . T h i s i n s t r u m e n t was d e s i g n e d t o a s s e s s the degree of 21 p e r c e i v e d e f f i c a c y ( i . e . , s e l f - c o n f i d e n c e ) a t a v o i d i n g a f a l l d u r i n g each of 10 r e l a t i v e l y non-hazardous a c t i v i t i e s of d a i l y l i v i n g . A c c o r d i n g t o the t h e o r e t i c a l framework, the i n s t r u m e n t would be measuring f e a r o f f a l l i n g as p a r t of the i n d i v i d u a l ' s EM. In the development of the i n s t r u m e n t , 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 , o c c u p a t i o n a l t h e r a p i s t s , r e h a b i l i t a t i o n n u r s e s , and p h y s i c i a n s were asked t o name the 10 most i m p o r t a n t a c t i v i t i e s e s s e n t i a l t o independent l i v i n g , t h a t w h i l e r e q u i r i n g some p o s i t i o n change or w a l k i n g , would be s a f e and non-hazardous t o most e l d e r l y p e r s o n s . A second group of p r o f e s s i o n a l s were asked whether they agreed w i t h the c h o i c e of a c t i v i t i e s . The f i n a l l i s t of a c t i v i t i e s was c o n v e r t e d i n t o the F a l l E f f i c a c y S c a l e . T i n e t t i e t a l . (1990) s t a t e d t h a t the consensus among the t h e r a p i s t s , n u r s e s , and p h y s i c i a n s c o n c e r n i n g the a c t i v i t i e s i n the s c a l e s u p p o r t e d the v a l i d i t y of the i t e m s . T h i s was the type o f i n f o r m a t i o n c o n t a i n e d i n h e a l t h p r o f e s s i o n a l s ' EMs on f a l l s . A f t e r the development of the i n s t r u m e n t , i t underwent two p r e - t e s t s . The purpose of the f i r s t p r e - t e s t was t o dete r m i n e the t e s t - r e t e s t r e l i a b i l i t y of the FES and t o examine the spread i n responses t o i n d i v i d u a l i t e m s . The purpose of the second p r e - t e s t was t o compare FES s c o r e s w i t h s e l f - r e p o r t e d f e a r of f a l l i n g and t o examine the r e l a t i o n s h i p 22 between s e l e c t e d s u b j e c t c h a r a c t e r i s t i c s and FES s c o r e s . I n the f i r s t p r e - t e s t , the t e s t - r e t e s t r e l i a b i l i t y of the i n s t r u m e n t r e s u l t e d i n a P e a r s o n ' s product-moment c o r r e l a t i o n o f .71. T h i s c o r r e l a t i o n i n d i c a t e d t h a t the measurements ( i . e . , s c o r e s or responses) changed v e r y l i t t l e between the t e s t and r e t e s t (Woods & C a t a n z a r o , 1988). In a d d i t i o n , a h i g h s t a b i l i t y c o e f f i c i e n t r e v e a l e d t h a t the i n s t r u m e n t was measuring f e a r of f a l l i n g on each o c c a s i o n . In t h e second p r e - t e s t , i t was determined t h a t s e x , age, l i v i n g s i t u a t i o n , p e r c e i v e d h e a l t h s t a t u s , and d e p r e s s i o n were not a s s o c i a t e d w i t h the FES s c o r e s i n b i v a r i a t e a n a l y s i s . The s c o r e was a l s o not a f f e c t e d by r e c e n t h i s t o r y of a f a l l . The FES was a s s o c i a t e d w i t h d i f f i c u l t y g e t t i n g up a f t e r a f a l l , a n x i e t y t r a i t , g e n e r a l f e a r s c o r e , and s e v e r a l measures of b a l a n c e and g a i t . As w e l l , d e p r e s s i o n was s i g n i f i c a n t l y a s s o c i a t e d w i t h FES s c o r e s i n m u l t i p l e r e g r e s s i o n a n a l y s i s . One l i m i t a t i o n t o t h i s s t u d y was t h a t the sample s i z e s were s m a l l . F o r the f i r s t p r e - t e s t , the co n v e n i e n c e sample c o n s i s t e d o f 18 c o g n i t i v e l y i n t a c t , ambulatory p e r s o n s over age 65. As a r e s u l t , t h e r e may have been inadequate power t o d e t e c t a s s o c i a t i o n s w i t h 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 sample l i v e d i n the community, w h i l e the remainder l i v e d i n i n t e r m e d i a r y c a r e f a c i l i t i e s . As a r e s u l t , t h i s c o n v e n i e n c e sample was p r o b a b l y l e s s l i k e l y t o s u f f e r from 23 self-imposed a c t i v i t y r e s t r i c t i o n s than the spectrum of community-living e l d e r l y . Even though further testing of this instrument w i l l be required in the future, i t is an attempt to look at this psychological consequence. "If fear of f a l l i n g proves to be an independent factor in functional decline, and i f individuals at risk of developing fear 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 target of c l i n i c a l intervention" ( T i n e t t i et a l . , 1990, p. 242). This study addressed fear of f a l l i n g , but T i n e t t i and colleagues indicate that we s t i l l lack information about how this fear may influence the individual's need for care and support in the community. In summary, the studies on f a l l s were mostly epidemiological in nature. There was a great emphasis on the causes of f a l l s , associated risk factors, and prevention. This i s the information that constitutes the EMs health professionals have regarding f a l l s . In fact, the only way the experience of the f a l l was addressed was through the EMs of health professionals. As well, there were no studies that addressed the physical and/or psychological consequences of f a l l s in terms of their effect on the perceived need for care and support of elderly women returning home alone. So c i a l Support Living 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 as the 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 of the need f o r c a r e and s u p p o r t as they r e t u r n home from 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 e r e f o r e , i t i s i m p o r t a n t t o re v i e w the l i t e r a t u r e on s o c i a l s u p p o r t t o i n c r e a s e one's u n d e r s t a n d i n g of the s o c i a l r e a l i t y o f l i v i n g a l o n e f o r e l d e r l y women. The term s o c i a l s u p p o r t not o n l y i n c l u d e s the c o n t a c t s i n a s o c i a l network, but a l s o "encompasses the e m o t i o n a l s u p p o r t , a d v i c e , g u i d a n c e , and a p p r a i s a l , as w e l l as the 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 from t h e i r s o c i a l r e l a t i o n s h i p s " ( E l l , 1984, p. 134). The two t y p e s of s o c i a l s u p p o r t a re i n f o r m a l and f o r m a l . I n f o r m a l s u p p o r t i n c l u d e s n u c l e a r f a m i l y , f r i e n d s , n e i g h b o u r s , and o t h e r r e l a t i v e s . F o r m a l s u p p o r t i s a group t h a t i s d e l i b e r a t e l y o r g a n i z e d t o d e l i v e r a p a r t i c u l a r t y pe o f s u p p o r t ( i . e . , M e als on Wheels) ( F l e t c h e r & S t o n e , 1982). In r e v i e w i n g the l i t e r a t u r e , i t appears t h a t e l d e r l y p e r s o n s draw i n i t i a l l y on a i d from 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 from 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, 1980). C h a p p e l l (1985) found t h a t u s e r s of home c a r e were more l i k e l y t o l i v e a l o n e than n o n - u s e r s , c o n f i r m i n g the n o t i o n t h a t the more i s o l a t e d r e c e i v e f o r m a l s u p p o r t s . However, 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 where t h e r e i s an e x p l i c i t p o l i c y of 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 s u p p o r t from a f a m i l y p r i o r t o p r o v i d i n g f o r m a l 25 s u p p o r t . As a r e s u l t , t h i s f i n d i n g may have l i m i t e d g e n e r a l i z a b i l i t y t o o t h e r samples and t h e i r use of f o r m a l s u p p o r t i n o t h e r l o c a t i o n s . C a f f e r t a (1987) s t u d i e d the r e l a t i o n s h i p between m a r i t a l s t a t u s , l i v i n g arrangements, and the use 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 . Her f i n d i n g s i n d i c a t e t h a t i n d i v i d u a l s who l i v e a l o n e a re more l i k e l y t o use s e r v i c e s than people who do not l i v e a l o n e . T h i s f i n d i n g may r e f l e c t the pr e s e n c e o f g a t e k e e p i n g b e h a v i o u r on b e h a l f o f f a m i l y members and f r i e n d s f o r tho s e i n d i v i d u a l s l i v i n g w i t h o t h e r s . G a t e k e e p i n g r e f e r s t o the f a m i l y member's p e r c e p t i o n s t h a t s e e k i n g f o r m a l s u p p o r t f o r the e l d e r l y p e r s o n i s not r e q u i r e d a t the t i m e . Here, the s o c i a l network i s i m p o r t a n t i n c o n t r o l l i n g the e l d e r l y i n d i v i d u a l ' s use o f f o r m a l s u p p o r t s . I n d i v i d u a l s who l i v e a l o n e may not en c o u n t e r t h i s d i f f i c u l t y i n s e e k i n g f o r m a l s u p p o r t s . The s t u d i e s ( C a f f e r t a , 1987; C h a p p e l l , 1985; O' B r i e n & Wagner, 1980) c o n f i r m t h a t l i v i n g a l o n e i s a s i g n i f i c a n t v a r i a b l e and w i l l p r o b a b l y a f f e c t the EMs o f e l d e r l y women i n t h i s proposed s t u d y . A u s l a n d e r and L i t w i n (1990) attempted t o c l a r i f y the degree t o which 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 . A c c o r d i n g 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 the p o p u l a r a r e n a . T h e i r f i n d i n g s r e v e a l e d t h a t i n d i v i d u a l s a p p l y i n g 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 networks and f e l t l e s s l o v e d 26 and admired by the network members upon whom they c o u l d r e l y . A c c o r d i n g t o A u s l a n d e r and L i t w i n ( 1 9 9 0 ) , one l i m i t a t i o n t o t h i s s t u d y was the i n s t r u m e n t used t o g a t h e r d a t a on the s o c i a l n etworks. Even though the Norbeck S o c i a l Support Q u e s t i o n n a i r e (NSSQ) has c o n s t r u c t and c o n t e n t v a l i d i t y , i t has been used p r i m a r i l y w i t h younger p o p u l a t i o n s . I n u s i n g the i n s t r u m e n t w i t h the e l d e r l y p o p u l a t i o n , i t was q u e s t i o n e d as t o whether the e l d e r l y i n d i v i d u a l s c o u l d d i f f e r e n t i a t e between a f f e c t i v e , 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 , the t h r e e t y p e s of su p p o r t measured. In summary, the 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 p e r s o n s draw i n i t i a l l y on a i d from i n f o r m a l s u p p o r t s . I n d i v i d u a l s who l i v e a l o n e a re more l i k e l y t o be r e c i p i e n t s of f o r m a l s u p p o r t s . As w e l l , i n c r e a s e d age 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 i n the use of f o r m a l s u p p o r t s ( A u s l a n d e r & L i t w i n , 1990). These f i n d i n g s a re r e l e v a n t as t h i s w r i t e r a t t e m p t s t o d e s c r i b e e l d e r l y women's p e r c e p t i o n s o f the need f o r c a r e and su p p o r t as they r e t u r n home 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 . P e r c e i v e d Need f o r Care and Support B e s i d e s i d e n t i f y i n g needs and p r o v i d i n g s e r v i c e s t o meet the needs from the 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 or ar e n a , i t i s i m p e r a t i v e t h a t 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 of p r i o r i t i e s , and e v a l u a t i o n of outcomes (Canadian M e d i c a l A s s o c i a t i o n , 1987; Hauser, 1987; N a t i o n a l A d v i s o r y C o u n c i l on A g i n g , 1981). As w e l l , a t t e m p t s must be made t o address i n d i v i d u a l c l i e n t ' s e x p l a n a t o r y models which c o n t a i n i n t e r p r e t a t i o n s of 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 i n the community. T h i s s e c t i o n o f the l i t e r a t u r e r e v i e w w i l l d e a l w i t h p e r c e i v e d needs 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 d i s c h a r g e p l a n n i n g . The a r e a o f s e r v i c e u t i l i z a t i o n w i l l be a d d r e s s e d f i r s t . A c c o r d i n g t o C o u l t o n and F r o s t (1982), need f a c t o r s are a c r i t e r i o n f o r s e r v i c e u t i l i z a t i o n . These f a c t o r s c o m prise both s u b j e c t i v e p e r c e p t i o n s ( s e l f - a s s e s s e d ) and o b j e c t i v e judgements ( p r o f e s s i o n a l l y e v a l u a t e d ) . A c c o r d i n g t o the t h e o r e t i c a l framework, need f a c t o r s would i n v o l v e both p r o f e s s i o n a l and p o p u l a r EMs. In 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 s t r u c t u r e s e r v i c e s on the b a s i s of a h y p o t h e t i c a l t a r g e t p o p u l a t i o n r a t h e r t h a n on the b a s i s of s e l f - r e p o r t e d need by e l d e r l y s e r v i c e r e c i p i e n t s ( C o n n i d i s , 1985; W i l s o n & N e t t i n g , 1987). " I t i s o f t e n the case t h a t program or agency f u n d i n g i s r e l i a n t upon demonstrated need based upon case l o a d " ( C o n n i d i s , 1985, p. 4 ) . As a r e s u l t , a g e n c i e s have a v e s t e d i n t e r e s t i n documenting a h i g h demand f o r t h e i r s e r v i c e s . 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 are then based on the EMs o f p r o f e s s i o n a l s r a t h e r than the EMs of i n d i v i d u a l s w i t h i n the p o p u l a r a r e n a . 28 In one s t u d y (Wilson & N e t t i n g , 1987), t h e r e was a h i g h degree of incongruence between the p e r c e p t i o n o f needs of the e l d e r l y and those o f the p r o f e s s i o n a l s . One s p e c i f i c f i n d i n g i n d i c a t e d t h a t the e l d e r l y u n d e r e s t i m a t e d t h e i r p h y s i c a l d i s a b i l i t i e s i n c o n t r a s t 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 e s t i m a t e d them. O v e r a l l , W i l s o n and N e t t i n g c o n c l u d e d t h a t h e a l t h p r o f e s s i o n a l s were not good p r e d i c t o r s o f the h e a l t h s t a t u s or needs o f the e l d e r l y . S t a r r e t t (1986), 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 e x i s t e d between the demand f o r s e r v i c e s by the e l d e r l y and the e v a l u a t i o n o f needs by the " e x p e r t " p r o f e s s i o n a l . As w e l l , t h i s s tudy c o n c l u d e d t h a t f u t u r e program development i n the a r e a o f home c a r e s h o u l d c o n s i d e r programs t h a t d e a l w i t h s o c i o p s y c h o l o g i c a l v a r i a b l e s ( i . e . , c o u n s e l l i n g , c a r e g i v e r s u p p o r t . ) At the p r e s e n t t i m e , the p r o v i d e r s o f home c a r e c o n s i d e r the t r a d i t i o n a l h e a l t h and r e h a b i l i t a t i o n f a c t o r s o n l y , i n both Canada and the U n i t e d S t a t e s . The s t u d i e s ( C o n n i d i s , 1985; S t a r r e t t , 1986; W i l s o n & N e t t i n g , 1987) len d s t r o n g s u p p o r t t o the thought t h a t the e l d e r l y ' s p e r c e p t i o n s o f t h e i r h e a l t h c a r e needs may not always be congruent w i t h the p r o f e s s i o n a l s c o m p l e t i n g the assessment. S e v e r a l s t u d i e s (Harding & M o d e l l , 1989; Nay l o r , 1990; S c h a e f e r , Anderson, & Simms, 1990; V i c t o r & V e t t e r , 1988) d e a l w i t h the p r o c e s s of d i s c h a r g e p l a n n i n g i n the h o s p i t a l f o r e l d e r l y i n d i v i d u a l s . T h i s i s i m p o r t a n t because 29 d i s c h a r g e p l a n n i n g i n the h o s p i t a l i s o f t e n the f i r s t p r o f e s s i o n a l c o n t a c t t o a s s e s s the p e r s o n ' s need f o r c a r e and su p p o r t a f t e r d i s c h a r g e from the h o s p i t a l . Here, a g a i n , the EMs o f the p r o f e s s i o n a l s may not be congrue n t w i t h the EMs of i n d i v i d u a l s . The f i r s t s t u d y (Harding & M o d e l l , 1989) d e s c r i b e d the e l d e r l y i n d i v i d u a l ' s e x p e r i e n c e o f d i s c h a r g e from h o s p i t a l . A q u e s t i o n n a i r e was developed and p i l o t t e s t e d p r i o r t o b e g i n n i n g the s t u d y . One hundred and f i f t e e n p e o p l e were i n t e r v i e w e d w i t h i n f o u r weeks 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 . The i n d i v i d u a l s had been h o s p i t a l i z e d f o r a v a r i e t y o f m e d i c a l r e a s o n s . The r e s u l t s i n d i c a t e d t h a t 38 i n d i v i d u a l s (33%) were not v i s i t e d by f a m i l y , f r i e n d s , or n e i g h b o u r s . S i x t e e n of the 38 i n d i v i d u a l s (42%) f e l t t h a t they had r e q u i r e d more h e l p a t home than was p r o v i d e d . Of the r e m a i n i n g 77 i n d i v i d u a l s who were v i s i t e d by f a m i l y , f r i e n d s , 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 , 14 i n d i v i d u a l s (18%) f e l t t h a t they had r e q u i r e d more h e l p a t home than was p r o v i d e d . A l t h o u g h t h i s s tudy d i d not ad d r e s s any s p e c i f i c needs 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 the importance o f e l d e r l y i n d i v i d u a l s r e c e i v i n g h e l p a p p r o p r i a t e t o t h e i r p e r c e i v e d needs a t the time o f d i s c h a r g e from h o s p i t a l . V i c t o r and V e t t e r ' s (1988) d e s c r i p t i v e s tudy i n v o l v e d a random sample o f 2,711 p a r t i c i p a n t s who were 65 y e a r s o f age and o l d e r . Three months a f t e r d i s c h a r g e from 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 t o a l l p a r t i c i p a n t s . The 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 r e l i a b i l i t y . No s p e c i f i c t e s t i n g f o r v a l i d i t y was mentioned. The s t u d y c o n c l u d e d t h a t 50% o f the sample 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 needs a t home. T h i s i s an i n t e r e s t i n g p o i n t and has r e l e v a n c e as one does r e s e a r c h w i t h e l d e r l y f e males r e t u r n i n g home from h o s p i t a l . S c h a e f e r e t a l . (1990) s t u d i e d the p e r c e p t i o n s of r e a d i n e s s f o r d i s c h a r g e and the need f o r f a m i l y and community r e s o u r c e s a t home among pers o n s aged 65 y e a r s and o l d e r . A q u e s t i o n n a i r e s e r v e d as the d a t a c o l l e c t i o n i n s t r u m e n t . The r e l i a b i l i t y and v a l i d i t y of the q u e s t i o n n a i r e were not d i s c u s s e d . The r e s u l t s i n d i c a t e d t h a t p o s t d i s c h a r g e needs f o r a s s i s t a n c e i n c l u d e d b a t h i n g , m e d i c a t i o n s , housekeeping, s h o p p i n g , meal 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 g e n e r a l i z a b i l i t y t o o t h e r e l d e r l y p o p u l a t i o n s , due t o sample s i z e and the f a c t t h a t the m a j o r i t y o f the sample were m a r r i e d . As w e l l , the l i t e r a t u r e i n d i c a t e s t h a t i t may be d i f f i c u l t t o address p e r c e p t i o n s w i t h a q u e s t i o n n a i r e format ( C o n n i d i s , 1 9 8 5 ) . 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 f o r q u a n t i t a t i v e s t u d i e s . S i n c e p e r c e p t i o n i s b e i n g t h e r e t o see, t o h e a r , t o e x p e r i e n c e , and t o know, i t i s b e s t a d d r e s s e d through a q u a l i t a t i v e r e s e a r c h d e s i g n such as phenomenology (Munhall & 31 O i l e r , 1986). As a result, the questionnaire addressed s e l f -assessed needs rather than perceived needs. Despite this l i m i t a t i o n , Schaefer's (1990) study was an attempt to look at areas where people require assistance after discharge from the h o s p i t a l . In conclusion, a recurrent theme throughout the l i t e r a t u r e i s that health professionals must start to document the perceived need for care and support of elde r l y individuals returning home from h o s p i t a l . The l i t e r a t u r e review indicates that the individuals' perceived need for care and support i s not only misunderstood, but, in many situations, their perceptions are not even addressed. As a res u l t , the proposed research remains relevant and necessary since i t w i l l describe the perceived need for care and support of elderly women returning home alone after h o s p i t a l i z a t i o n for a f a l l . Summary Chapter Two has provided a l i t e r a t u r e review on f a l l s , s o c i a l support, and the perceived need for care and support. The review presented the current t h e o r e t i c a l and research findings in a l l three areas. As already mentioned, there were no studies that addressed how the psychological and/or physical consequences of a f a l l may affe c t an older woman's perceptions of the need for care and support after h o s p i t a l i z a t i o n for a f a l l . As well, the importance of 32 l i v i n g alone was stressed as these women draw on aid from both informal and formal support networks as they attempt to meet their need for care and support in the home se t t i n g . In addition, the review indicated that an individual's need for care and support i s not only misunderstood but, in many sit u a t i o n s , the need is not even addressed as they leave the hospital setting to return home. The next chapter w i l l present a discussion of the methodology for the proposed research. 33 CHAPTER THREE: METHODOLOGY I n t r o d u c t i o n In t h i s t h i r d c h a p t e r , the methodology o f the st u d y i s d i s c u s s e d . Phenomenology has a l r e a d y been b r i e f l y d e s c r i b e d i n C h a p t e r One. Due t o i t s d i f f e r e n c e from the q u a n t i t a t i v e r e s e a r c h method, the f i r s t s e c t i o n o f t h i s c h a p t e r a d d r e s s e s the m e t h o d o l o g i c a l i s s u e s . The e t h i c a l c o n s i d e r a t i o n s of the proposed s t u d y a re then a d d r e s s e d . T h i s i s f o l l o w e d by the d i s c u s s i o n on the s e l e c t i o n of p a r t i c i p a n t s . T h i s d i s c u s s i o n i n c l u d e s the s e l e c t i o n c r i t e r i a , 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 the p a r t i c i p a n t s . L a s t l y , t he d a t 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 a re d i s c u s s e d . M e t h o d o l o g i c a l I s s u e s Phenomenology i s a q u a l i t a t i v e r e s e a r c h method. As w e l l , i t i s c o n s i d e r e d t o be both a p h i l o s o p h y and an approach. The g o a l o f p h e n o m e n o l o g i c a l r e s e a r c h i s t o un d e r s t a n d human e x p e r i e n c e from the i n d i v i d u a l ' s p e r s p e c t i v e . The c r i t e r i a f o r e v a l u a t i n g q u a l i t a t i v e r e s e a r c h w i l l be re v i e w e d . These c r i t e r i a c o n s i s t o f the f o l l o w i n g : (a) t r u t h v a l u e , (b) a p p l i c a b i l i t y , (c) c o n s i s t e n c y , and (d) n e u t r a l i t y . 34 Truth Value "The truth value of a q u a l i t a t i v e investigation generally resides'in the discovery of human phenomena or experiences as they are li v e d and perceived by subjects, rather than in the v e r i f i c a t i o n of a p r i o r i conceptions of these experiences" (Sandelowski, 1986, p. 30). This i s d i f f e r e n t from quantitative research where the truth value, t y p i c a l l y c a l l e d i n t e r n a l v a l i d i t y , depends on the degree of s i m i l a r i t y between the study data and the phenomena to which they relate (Guba & Lincoln, 1981). Therefore, Guba and Lincoln (1981) suggest that c r e d i b i l i t y rather 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 by which the truth value of q u a l i t a t i v e research i s evaluated. As a r e s u l t , the q u a l i t a t i v e researcher i s most concerned with testing the c r e d i b i l i t y of findings and interpretations with the various sources from which the data are drawn. A p p l i c a b i l i t y The second c r i t e r i o n i s a p p l i c a b i l i t y which refers to f i t t i n g n e s s in the q u a l i t a t i v e study and external v a l i d i t y in the quantitative study (Guba & Lincoln, 1981). Fittingness i s when the findings of the study, "whether in the form of description, explanation, or theory, ' f i t ' the data from which they are derived" (Sandelowski, 1986, p. 32). In quantitative studies, external v a l i d i t y refers to the g e n e r a l i z a b i l i t y of f i n d i n g s and the r e p r e s e n t a t i v e n e s s of s u b j e c t s , t e s t s and c o n d i t i o n s f o r t e s t i n g ( S a n d e l o w s k i , 1986). At i s s u e f o r t h i s c r i t e r i o n a re the t e c h n i q u e s used f o r s a m p l i n g t o ensure r e p r e s e n t a t i v e n e s s and g e n e r a l i z a b i l i t y ( S a n d e l o w s k i , 1986). In q u a l i t a t i v e s t u d i e s , the sample s i z e s are s m a l l e r due t o the l e n g t h of the d a t a - g a t h e r i n g i n t e r v i e w s and the d e t a i l of the complete d e s c r i p t i o n (Ornery, 1983; S a n d e l o w s k i , 1986). As w e l l , s u b j e c t s are chosen f o r the s t u d y because they have l i v e d the e x p e r i e n c e the i n v e s t i g a t o r i s r e s e a r c h i n g . Sample s i z e s are not p r e d e t e r m i n e d because t h e r e may be f u r t h e r s e l e c t i o n of p a r t i c i p a n t s , depending on the f i n d i n g s t h a t emerge throu g h o u t the s t u d y . The sample s i z e i s c o n s i d e r e d t o be r e p r e s e n t a t i v e i f s u b j e c t s i n the sample belong t o the group who have l i v e d the e x p e r i e n c e . 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 d a t a r a t h e r than the s u b j e c t s or s e t t i n g s . In c o n t r a s t , the s a m p l i n g t e c h n i q u e s i n q u a n t i t a t i v e s t u d i e s i n c l u d e random s e l e c t i o n and assignment of 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 c o n t r o l groups. As w e l l , sample s i z e s are p r e d e t e r m i n e d p r i o r t o b e g i n n i n g d a t a c o l l e c t i o n . C o n s i s t e n c y The t h i r d c r i t e r i o n i s c o n s i s t e n c y which p e r t a i n s t o a u d i t a b i l i t y i n q u a l i t a t i v e s t u d i e s and r e l i a b i l i t y i n 36 quantitative studies (Guba & Lincoln, 1981) . Qualitative research emphasizes the "uniqueness of human situations and the importance of experiences that are not necessarily accessible to validation through the senses" (Sandelowski, 1986, p. 33). Therefore, a u d i t a b i l i t y is the c r i t e r i o n that should be used with q u a l i t a t i v e research. A study and i t s findings are auditable when another researcher is able to follow the progression of events in the study and understand their l o g i c . Another term for th i s is the decision t r a i l or audit t r a i l (Guba & Lincoln, 1981). R e l i a b i l i t y in quantitative research rests on the assumption that the same data w i l l be collected each time in repeated observations of the same phenomena and that there i s an observable regularity about human experience that i s a function of the experience not as a result of the testing procedure (Babbie, 1986; Sandelowski, 1986). Neutrality The l a s t factor i s ne u t r a l i t y which refers to confi r m a b i l i t y in q u a l i t a t i v e studies and o b j e c t i v i t y in quantitative research. Confirmability in q u a l i t a t i v e studies i s established when a u d i t a b i l i t y , truth value, and a p p l i c a b i l i t y are present in the study. In contrast, o b j e c t i v i t y in quantitative studies 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 established (Sandelowski, 1986). It should be noted that Sandelowski (1986) notes two 3 7 b i a s e s i n q u a l i t a t i v e r e s e a r c h . They are the " e l i t e b i a s " and " h o l i s t i c f a l l a c y . " The e l i t e 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 the s u b j e c t s who p a r t i c i p a t e i n the s t u d y are " f r e q u e n t l y the most a r t i c u l a t e , a c c e s s i b l e , h i g h - s t a t u s members of t h e i r group" ( S a n d e l o w s k i , 1986, p. 3 2 ) . The h o l i s t i c f a l l a c y r e f e r s t o the tendency t o make the d a t a l o o k more p a t t e r n e d or congruent than they a r e . As a r e s u l t , the s t u d y ' s c o n c l u s i o n s are p r e s e n t e d as r e p r e s e n t i n g a l l the d a t a . P r o c e d u r e f o r P r o t e c t i o n of Human R i g h t s The a p p r o v a l of the UBC B e h a v i o u r a l S c i e n c e s S c r e e n i n g Committee f o r Research and Other S t u d i e s I n v o l v i n g Human S u b j e c t s was o b t a i n e d p r i o r t o d a t a c o l l e c t i o n . The s t a n d a r d s , as approved by the committee, were f o l l o w e d t h r o u g h o u t the s t u d y . A l l p a r t i c i p a n t s were asked t o s i g n a consent form (see Appendix A) t o ensure p r o t e c t i o n of t h e i r human r i g h t s . In s e c u r i n g c o n s e n t , each p a r t i c i p a n t 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 o f the s t u d y , the nat u r e of t h e i r r e q u e s t e d i n v o l v e m e n t , the amount o f time r e q u i r e d , and the means of 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 they were f r e e t o withdraw from the st u d y a t any time w i t h o u t compromising t h e i r r i g h t s f o r any type of s e r v i c e . The taped i n t e r v i e w s were coded so t h a t the 38 c o n f i d e n t i a l i t y o f the s u b j e c t s was e n s u r e d . The d a t a was not s h a r e d w i t h anyone e l s e b e s i d e s the t h e s i s committee members. As w e l l , t h e r e was no mention o f any names i n d i s c u s s i n g the d a t a w i t h the t h e s i s committee members. In w r i t i n g the t h e s i s , t h e r e was no i n f o r m a t i o n r e p o r t e d t h a t c o u l d i d e n t i f y the s u b j e c t s . A l l t a p e s were e r a s e d once the t h e s i s was c o m p l e t e d . S e l e c t i o n o f P a r t i c i p a n t s S e l e c t i o n C r i t e r i a The s u b j e c t s were chosen f o r the s t u d y because they l i v e d the e x p e r i e n c e the i n v e s t i g a t o r was r e s e a r c h i n g . The c r i t e r i a f o r s e l e c t i o n d e s c r i b e d each i n d i v i d u a l i n the f o l l o w i n g manner: 1. Female, 75 y e a r s of age or o l d e r , and have e x p e r i e n c e d a f a l l which r e s u l t s i n a h o s p i t a l i z a t i o n or t r e a t m e n t i n an Emergency and/or O u t p a t i e n t Department. 2. L i v i n g a l o n e i n a house or apartment which i s not p a r t of a c a r e f a c i l i t y . 3. A b l e t o c o n v e r s e f l u e n t l y i n E n g l i s h . 4. L i v i n g i n the C i t y of Vancouver. 5. A l e r t and o r i e n t a t e d 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 p r i o r t o a d m i s s i o n or f o l l o w i n g d i s c h a r g e from h o s p i t a l . R e c r u i t m e n t P r o c e d u r e A s p e c i f i c p r o c e d u r e t o a c q u i r e p a r t i c i p a n t s was p l a n n e d 39 and f o l l o w e d . A p p r o v a l f o r the r e s e a r c h was o b t a i n e d from The U n i v e r s i t y of B r i t i s h C olumbia (UBC) B e h a v i o u r a l S c i e n c e s S c r e e n i n g Committee f o r Research and Other S t u d i e s I n v o l v i n g Human S u b j e c t s . A t the 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 the Vancouver H e a l t h Department was c o n t a c t e d t o o b t a i n p e r m i s s i o n f o r the s t u d y . As w e l l , the D i r e c t o r of N u r s i n g f o r the S h o r t Term Assessment and Treatment (STAT) U n i t a t Mount S a i n t Joseph (MSJ) was c o n t a c t e d t o o b t a i n t h i s agency's p e r m i s s i o n t o r e c r u i t s u b j e c t s f o r the s t u d y . P a r t i c i p a n t s were r e c r u i t e d from the community h e a l t h l i a i s o n n u r s e s (CHLNs) who f u n c t i o n as 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 r e c r u i t e d t h r ough the home c a r e c o o r d i n a t o r s a t the h e a l t h u n i t s o p e r a t e d by the C i t y of Vancouver H e a l t h Department. As 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 from the head nurse of the STAT u n i t a t MSJ. The CHLNs, home c a r e c o o r d i n a t o r s , and head nurse were p r o v i d e d 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 stud y and the sample s e l e c t i o n c r i t e r i a . These p r o f e s s i o n a l s i d e n t i f i e d p o t e n t i a l s u b j e c t s f o r the s t u d y . As w e l l , they gave a v e r b a l e x p l a n a t i o n of the stu d y and p r o v i d e d the 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 from t h i s r e s e a r c h e r (see Appendix B ) . 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 p e r m i s s i o n from the i n d i v i d u a l s f o r t h i s r e s e a r c h e r t o c o n t a c t them. 40 C h a r a c t e r i s t i c s o f the P a r t i c i p a n t s There were e i g h t women who p a r t i c i p a t e d i n the stu d y . They ranged i n age from 75 t o 102 y e a r s o f age. Of the e i g h t i n d i v i d u a l s who wished t o p a r t i c i p a t e i n t h i s s t u d y , f i v e were r e f e r r e d 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 . Three o f the f i v e women had s u s t a i n e d h i p f r a c t u r e s and were r e f e r r e d from a g e r i a t r i c r e h a b i l i t a t i o n u n i t w i t h i n an a c u t e c a r e f a c i l i t y . One woman who s u s t a i n e d i n j u r i e s t o her lower back was r e f e r r e d t o t h i s 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 her d i s c h a r g e from 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 . I n her f a l l , 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 t o both lower l e g s t h a t r e q u i r e d s k i n g r a f t i n g . 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 from the community. Two o f the t h r e e women were r e f e r r e d by the home ca r e s t a f f v i s i t i n g them. One woman f r a c t u r e d her w r i s t . The 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 t o her f a c e . The l a s t woman was r e f e r r e d by the nurse a s s e s s o r a t the STAT u n i t . She was b e i n g s c r e e n e d f o r a t t e n d a n c e a t the Day H o s p i t a l . Even though she d i d not have any s p e c i f i c i n j u r i e s , her f a l l s r e o c c u r r e d on a f r e q u e n t b a s i s . As s t a t e d i n the c r i t e r i a f o r the s t u d y , a l l the women l i v e d a l o n e a t home. Seven o f the e i g h t women l i v e d i n apartment or condominium complexes. The 1 0 2 - y e a r - o l d woman 41 was s t i l l l i v i n g i n her own home. Three o f the e i g h t women had e x p e r i e n c e d p r e v i o u s f a l l s . Two o f the 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 second f a l l . The t h i r d woman r e p o r t e d t h a t t h i s was her t w e l f t h f a l l . Four o f the e i g h t women were unable t o e x p l a i n the rea s o n f o r t h e i r f a l l . One of thes e women was p r e s e n t l y u ndergoing e x t e n s i v e m e d i c a l i n v e s t i g a t i o n s . The o t h e r f o u r women i d e n t i f i e d the reason f o r t h e i r f a l l . Three o f the f o u r women i d e n t i f i e d an e n v i r o n m e n t a l h a z a r d as p a r t of the e x t r i n s i c cause f o r t h e i r f a l l . F o r example, one woman r e p o r t e d t r i p p i n g on her bedspread. Another woman t r i p p e d on a sweater t h a t was t a n g l e d i n a c h a i r . One woman i d e n t i f i e d an i n t r i n s i c cause f o r her f a l l s . The woman who had f a l l e n t w e l v e t i m e s s t a t e d t h a t her f a l l s were due t o e p i s o d e s of weakness t h a t were due t o a neuro-muscular d i s o r d e r . Four o f the e i g h t women r e p o r t e d t h a t they had c h i l d r e n l i v i n g i n the Lower M a i n l a n d A r e a . Three o f these f o u r women had phone c o n t a c t or saw t h e i r c h i l d r e n on a f r e q u e n t b a s i s . Two of the e i g h t women r e p o r t e d t h a t t h e i r f a m i l y s u p p o r t c o n s i s t e d of n i e c e s and nephews. The o t h e r two women r e p o r t e d no f a m i l y w i t h i n the a r e a . T h e i r s u p p o r t s c o n s i s t e d of f r i e n d s . Data C o l l e c t i o n Since phenomenology was the chosen research design, the interview was the appropriate process for data c o l l e c t i o n . This writer a c t i v e l y engaged in the interactive process and thereby entered into the world of those people whose experiences were under study (Oiler, 1982). This allowed th i s writer to get as close as possible to the subject's experiences before attempting to interpret them. E f f e c t i v e l i s t e n i n g s k i l l s were used in the interview technique (Knaack, 1984). "The use of 'bracketing' was part of the e f f e c t i v e l i s t e n i n g s k i l l s . This s k i l l allowed this writer to put aside any preconceived thoughts about the phenomenon being studied" (Oiler, 1982). It allowed information from the experience to be understood pr e c i s e l y as i t was presented (Giorgi, 1986). The use of bracketing established the c r e d i b i l i t y or truth value of the study and, therefore, ensured that the study's findings were representative of the true phenomenon as described by the subjects. A l l interviews were conducted by th i s writer. The interviews ranged from 30 to 60 minutes in length, and were tape-recorded. As well, this writer made some written or f i e l d notes. A set of open-ended or trigger questions were used to guide the interview (see Appendix C). These questions helped the writer to avoid putting personal 43 i n t e r p r e t a t i o n s on the s u b j e c t s ' s t a t e m e n t s . However, as the d a t a a n a l y s i s proceeded, new t r i g g e r q u e s t i o n s were developed based on the p r e v i o u s d a t a a n a l y s i s from e a r l i e r i n t e r v i e w s . Four of e i g h t women p a r t i c i p a t e d i n second i n t e r v i e w s . The purpose of the second i n t e r v i e w was t o v e r i f y w i t h the p a r t i c i p a n t s t h a t the meaning of the e x p e r i e n c e was u n d e r s t o o d c o r r e c t l y by the r e s e a r c h e r (Knaack, 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 w i t h o u t t e l l i n g them what t o say. The v e r i f i c a t i o n of the d a t a h e l p e d t o e s t a b l i s h c r e d i b i l i t y of the s t u d y . Data A n a l y s i s The p r o c e s s of d a t a c o l l e c t i o n o c c u r r e d s i m u l t a n e o u s l y w i t h d a t a a n a l y s i s . A l l taped i n t e r v i e w s were t r a n s c r i b e d by a t y p i s t or t h i s w r i t e r . A l l t r a n s c r i p t i o n s were s u b s e q u e n t l y checked by the w r i t e r by l i s t e n i n g t o the tapes and r e a d i n g the t e x t s i m u l t a n e o u s l y . A l l m i s c o n s t r u e d words were then c o r r e c t e d t o ensure v e r b a t i m a c c o u n t s of the taped i n t e r v i e w s . Data a n a l y s i s was done f o l l o w i n g the s t e p s o u t l i n e d by G e o r g i (1985) . The f i r s t s t e p was t o read the e n t i r e d e s c r i p t i o n t o get a sense of the whole. The second s t e p was t o read the 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 the meaning u n i t s or themes. T h i s s t e p a l s o c o n s i s t e d of e l i m i n a t i n g r e d u n d a n c i e s i n the u n i t s , c l a r i f y i n g or 44 e l a b o r a t i n g the meanings of the r e m a i n i n g u n i t s by r e l a t i n g them t o each o t h e r and t o the whole. The meaning 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 viewed as c o n s t i t u e n t s . A c c o r d i n g t o G i o r g i (1985), a c o n s t i t u e n t was det e r m i n e d i n such a way t h a t i t was c o n t e x t - l a d e n . The t h i r d s t e p was the t r a n s f o r m a t i o n of the s u b j e c t ' s everyday e x p r e s s i o n s i n t o c o n c e p t s o f s c i e n c e . Here, the t r a n s f o r m a t i o n s took p l a c e b a s i c a l l y through a p r o c e s s of r e f l e c t i o n and i m a g i n a t i v e v a r i a t i o n . The l a s t s t e p was t o i n t e g r a t e and s y n t h e s i z e the i n s i g h t s i n t o an e x h a u s t i v e d e s c r i p t i o n o f the phenomena of 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 . The d a t a a n a l y s i s i n Chapter Four w i l l be a r t i c u l a t e d by the use o f a c l e a r d e c i s i o n t r a i l . T h i s w i l l h e l p t o e s t a b l i s h a u d i t a b i l i t y of the s t u d y . Summary Th i s c h a p t e r examined the p h e n o m e n o l o g i c a l r e s e a r c h d e s i g n used f o r t h i s s t u d y . The c r i t e r i a f o r e v a l u a t i n g q u a l i t a t i v e s t u d i e s was d i s c u s s e d . The p r o c e d u r e f o r the 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 i n t h i s c h a p t e r . F o l l o w i n g t h i s d i s c u s s i o n , the c r i t e r i a f o r s e l e c t i o n of p a r t i c i p a n t s and the 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 . T h i s c h a p t e r a l s o c o n t a i n e d a d e s c r i p t i o n o f the s t u d y ' s p a r t i c i p a n t s . L a s t l y , the p r o c e s s f o r the c o l l e c t i o n and 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 next c h a p t e r c o n t a i n s the r e s u l t s of the d a t a a n a l y s i s . 45 CHAPTER FOUR: DATA ANALYSIS I n t r o d u c t i o n The r e s u l t s of the d a t a a n a l y s i s are p r e s e n t e d i n t h i s c h a p t e r and d i s c u s s e d i n the next c h a p t e r , u s i n g the r e l e v a n t t h e o r e t i c a l l i t e r a t u r e and r e s e a r c h f i n d i n g s t h a t a re c u r r e n t l y a v a i l a b l e . T h i s c h a p t e r p r o v i d e s an i n d e p t h e x p l o r a t i o n o f the phenomenon t h a t s u r f a c e d d u r i n g the c o l l e c t i o n and a n a l y s i s of the d a t a . I t b e g i n s w i t h a d e s c r i p t i o n of the f a l l as a s i g n i f i c a n t e v e n t , and p r o g r e s s e s t o a d e s c r i p t i o n o f the tr e a t m e n t r e c e i v e d w i t h i n the H e a l t h Care System. F o l l o w i n g t h i s , the changes i n r o u t i n e upon t h e i r d i s c h a r g e home are d e s c r i b e d by the e l d e r l y women. T h i s i s f o l l o w e d by a d e s c r i p t i o n o f the t h r e a t t o t h e i r s e l f - e s t e e m as they responded t o the changes i n t h e i r r o u t i n e . A d i s c u s s i o n of how the women coped w i t h the f a l l and the subsequent t h r e a t s t o t h e i r s e l f - e s t e e m c o n c l u d e s t h i s c h a p t e r . Two predominant co n c e p t s emerged as the e l d e r l y women were asked t o d e s c r i b e t h e i r e x p e r i e n c e i n r e l a t i o n t o 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 they r e t u r n e d home a f t e r h o s p i t a l i z a t i o n f o r a f a l l . The f i r s t c oncept was s e l f - e s t e e m . From the a n a l y s i s and v e r i f i c a t i o n of the d a t a , i t appeared t h a t the f a l l and tr e a t m e n t w i t h i n the H e a l t h 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 consequences f o r the women as they r e t u r n e d home. These consequences r e s u l t e d i n a change of r o u t i n e a t home f o r them. As a r e s u l t , they viewed themselves d i f f e r e n t l y than they d i d p r i o r t o t h e f a l l . The themes of independence, 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 the s e l f - e s t e e m c o n c e p t . The a d a p t a t i o n p r o c e s s was the second concept t h a t emerged from the a n a l y s i s of the d a t a from the e l d e r l y women. 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 the changes i n r o u t i n e once they r e t u r n e d home. T h i s i n c l u d e d b e h a v i o u r s used t o cope w i t h the p e r c e i v e d t h r e a t s t o t h e i r s e l f - e s t e e m . Each woman coped w i t h the s i t u a t i o n i n her own unique way. However, t h e r e were common c a t e g o r i e s of b e h a v i o u r s used. As w e l l , the two major themes of problem-f o c u s e d and em o t i o n - f o c u s e d c o p i n g b e h a v i o u r s were i d e n t i f i e d . F a l l as a S i g n i f i c a n t Event The f a l l was a s i g n i f i c a n t event f o r a l l the women i n the s t u d y . Even though t h i s s t u d y d i d not f o c u s on the e x p e r i e n c e of a f a l l , d u r i n g the c o u r s e of the i n t e r v i e w s e v e r a l women asked i f they c o u l d d e s c r i b e t h e i r f a l l f o r t h i s w r i t e r . The d e s c r i p t i o n s of the f a l l event were r i c h i n d e t a i l . F o r example, some of the d e t a i l s i n c l u d e d the time of the e v e n t , a c t i v i t i e s p r e c e d i n g the f a l l , a d e s c r i p t i o n of the f a l l i t s e l f , and sequence of e v e n t s a f t e r the f a l l . The f o l l o w i n g d e s c r i p t i o n s from f o u r women i n the s t u d y i l l u s t r a t e t hese p o i n t s : I'd hung up, I was g o i n g over t o my d a u g h t e r ' s f o r d i n n e r and the d r e s s I was g o i n g t o wear was a 2-piece d r e s s and the s k i r t needed p r e s s i n g and I d i d t h a t and I wasn't r e a c h i n g up h i g h j u s t from the handle of t h a t door when I went down. The second d e s c r i p t i o n g i v e s d e t a i l s as t o how the i n c i d e n t happened: I opened the f r i d g e door and got something out and I t h i n k i t was supposed t o be a s p r i n g on the 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 because t h e r e was t h i s square v e g e t a b l e c o n t a i n e r s t i c k i n g out of the bottom s h e l f so when i t went back the next time i t wasn't c l o s e d . W e l l , I e x p e c t e d a l i t t l e r e s i s t a n c e so I grabbed t o p u l l , because you've got t o s o r t o f yank i t , and I j u s t swung back and went down, h i t the back of the k i t c h e n cupboards and the c o u n t e r ; I don't know i f I h i t the c o u n t e r , I h i t the back of the k i t c h e n — then I_^  got t o the phone and phoned my f r i e n d and she came o v e r . The next s u b j e c t d e s c r i b e d the sequence of events a f t e r the f a l l : T h i s time t h i s was a t e r r i f y i n g e x p e r i e n c e , i t r e a l l y was. I never f e l t so h e l p l e s s , and I l a y t h e r e . I t happened i n the bathroom, you see I had t h r e e s t i t c h e s i n here ( p o i n t s t o head). My head must of h i t one of the t a p s , f e l l , I l a y t h e r e on the f l o o r , b l o o d and water. How I ev e r , t o t h i s day, how I ever got up, grabbed the r a g , wiped my f a c e , p i c k e d me up and walked out of the bedroom. I don't know. But I d i d . Another woman d e s c r i b e d the ev e n t s a f t e r t he f a l l : W e l l , because I went out the back of the bus one day, and I landed up on the s i d e w a l k . You see, when I get down, I can ' t get up. So, I'm t h e r e on my hands and knees on the s i d e w a l k , and some woman came a l o n g and s a i d , "What are you d o i n g down t h e r e ? " I s a i d , " W e l l , I f e l l o f f the bus, and I c a n ' t g e t up." She s a i d , "You ca n ' t get up?" And I s a i d , "No." I would have t o c r a w l r i g h t a c r o s s the s i d e w a l k t o get t o something t o p u l l m y s e l f up, you know? At my age, i t ' s a b i t e m b a r r a s s i n g , r e a l l y . " H e a l t h C are System A l l the women t a l k e d about t h e i r e x p e r i e n c e w i t h i n the H e a l t h C are System. Treatment w i t h i n t h i s system i n c l u d e d the c a r e w i t h i n the i n s t i t u t i o n , as w e l l as the c a r e w i t h i n the community s e t t i n g . S i m i l a r t o the d e s c r i p t i o n o f the f a l l e v e n t , t h e i r s t o r i e s were a l s o d e t a i l e d . Most of the women were d i s s a t i s f i e d w i t h the c a r e they r e c e i v e d from the H e a l t h Care System. One woman d e s c r i b e d the events p r i o r t o her d i s c h a r g e . 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 , but the s t a f f a d v i s e d her t h a t she had t o w a i t u n t i l Monday. On Monday, her d o c t o r would be a v a i l a b l e t o d i s c h a r g e h e r : They d i d n ' t even want t o l e t me out o f t h e r e . They s a i d I c o u l d n ' t go out a t a c e r t a i n t i m e . I f e l t t h a t I was ready t o go but they d i d n ' t want t o l e t me go home. When asked how t h a t s i t u a t i o n made her f e e l , she r e p l i e d t h a t i t made her f e e l angry because she f e l t t h a t the s t a f f were not l i s t e n i n g t o h e r . Here, the woman ex p r e s s e d d i s s a t i s f a c t i o n w i t h the s t a f f r e g a r d i n g t h e i r i n a b i l i t y t o l i s t e n and i n v o l v e her i n the d e c i s i o n - m a k i n g p r o c e s s . T h i s i n c i d e n t was her f i r s t exposure t o the f a c t t h a t her wishes were not r e s p e c t e d . 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 w i l l o c c u r as the theme of autonomy i s d i s c u s s e d . Another woman d e s c r i b e d the e v e n t s s u r r o u n d i n g her d i s c h a r g e from the acute c a r e f a c i l i t y : The o n l y t h i n g t h a t s u r p r i s e d me . . . i s t h a t the o t h e r o p e r a t i o n s I have ever had a t the h o s p i t a l they always wheeled you out t o the t h i n g , you know, whatever . . . the c a r you were g o i n g home i n . B u t , l i s t e n , I c a l l e d a t a x i by mysel f and had t o take my own bag down ( l a u g h s ) . She s t a t e d t h a t she managed t o do i t . However, t h i s p r o c e s s r e p r e s e n t e d an i n c o n s i s t e n c y i n her c a r e : B u t , 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 . " You j u s t s i t t h e r e l i k e a s i l l y i n a w h e e l c h a i r r i g h t down and you d i d n ' t r e a l l y need i t . You c o u l d have walked down. Another woman d e s c r i b e d her t r i p t o an Emergency Department f o r back x - r a y s , t h r e e weeks a f t e r her o r i g i n a l f a l l : And, I went i n t o Emergency and they kept me a l l a f t e r n o o n . They d i d some t e s t s . They put me on i n t r a v e n o u s . And, a t 7:00 o ' c l o c k , they s a i d , "We're g e t t i n g you d r e s s e d . You can s i t i n the w h e e l c h a i r and the ambulance w i l l come." I was out t h e r e ; i t was c o l d and I wasn't d r e s s e d p r o p e r l y . I went up i n the ambulance, r o l l e d up i n a b l a n k e t . So, I was t h e r e f o r 3 1/2 h o u r s , i n PAIN. . . . I f i n a l l y went over and l a i d down on some c h a i r s and a woman t o l d me t h a t the bed I had v a c a t e d was made up and never o c c u p i e d . F i n a l l y , one o f her f r i e n d s p i c k e d her up and took her home s i n c e t h e r e were no ambulances a v a i l a b l e . Another woman t a l k e d about the b e d s i d e c a r e she r e c e i v e d : I l i k e i t a l o t i n the h o s p i t a l . B u t , t h e r e c o u l d be some improvements 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 t h e s e , F i l i p i n o n u r s e s (lowers v o i c e ) . My goodness, they are rough. They need more t r a i n i n g i n be d s i d e c a r e . Oh y e s , d e a r , oh y e s . I know, e s p e c i a l l y when the 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 c a n ' t push the pe o p l e around l i k e t h a t . That i s where the h e l p i s needed. When asked how t h a t type o f t r e a t m e n t made her f e e l , she r e p l i e d , "Oh, dependent on o t h e r s , which I don't l i k e . " Even though s t a t e d b r i e f l y , i t was the b e g i n n i n g o f the t h r e a t t o her s e l f - e s t e e m . More s p e c i f i c a l l y , t h i s was r e l a t e d t o the theme of independence. T h i s theme w i l l be d i s c u s s e d l a t e r i n the c h a p t e r . As w e l l , i t was p r o b a b l y the b e g i n n i n g of her a d a p t a t i o n t o her change i n r o u t i n e . Here, she was d e v e l o p i n g new c o p i n g b e h a v i o u r s , such as u s i n g s o c i a l s u p p o r t t o d e a l w i t h her s i t u a t i o n . T h i s theme w i l l a l s o be d i s c u s s e d l a t e r i n the c h a p t e r . Two women t a l k e d about t h e i r e x p e r i e n c e w i t h the Community Home Care Program. The f i r s t woman d e s c r i b e d her e x p e r i e n c e w i t h the homemakers who were sen t t o her home: Oh, y e s , t h e y ' r e h e l p f u l . The g i r l s a r e very n i c e . They've g i v e n me a [ s i c ] sponge b a t h s . They are a l l F i l i p i n o s , they are very hard t o make out and another t h i n g I r e s e n t i s f i r s t y o u ' l l get a d i f f e r e n t one eve r y [time] and you have t o t e l l them, h o l l e r from here i n the k i t c h e n , where t h i n g s a r e . W e l l now, the l i t t l e one t h a t came t h i s morning, she knows, she's been here about f i v e or s i x t i m e s . She knows where t h i n g s a r e , but they don't g i v e you one p e r s o n and they don't know; you have t o t e l l them every time a new g i r l comes; you 52 have t o go i n t o a b i g d i s c u s s i o n and they c a n ' t f i n d t h i n g s . When asked how t h i s made her 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 the problems i n terms of a c c e p t i n g h e l p from o t h e r s . I n u s i n g s o c i a l s u p p o r t s , the importance of c o n t i n u i t y of c a r e and communication were a d d r e s s e d . As w e l l , the work performance of t h e i n d i v i d u a l s was i m p o r t a n t . T h i s d i s c u s s i o n w i l l o c c u r l a t e r i n the c h a p t e r . Another s u b j e c t t a l k e d about her i n a b i l i t y t o o b t a i n home h e l p once she r e t u r n e d home: Not o n l y a l i t t l e but I am r e a l l y peeved about i t . I t r i e d s e v e r a l times and then they came over h e r e , what s h o u l d I say, from the o f f i c e , and they spoke t o me n i c e y - n i c e . To me, i t wasn't n i c e y - n i c e , i t was j u s t words t o get me t o make me f e e l b e t t e r towards them. Because I was wronged. She s t a t e d t h a t she was i n i t i a l l y a c c e p t e d and then t o l d t h a t her income was t o o h i g h and she d i d not q u a l i f y f o r home h e l p a s s i s t a n c e . She i n d i c a t e d : I have had no h e l p a t a l l . None, even a b a t h , which I beg [ s i c ] them t o do b e f o r e when I f e l l because I was s c a r e d the f i r s t t i m e . I begged them t o , j u s t t o g i v e me a bath but they d i d n ' t even do t h a t . I d i d i t on my own, t o o . When asked how she f e l t about the way she was t r e a t e d , she responded: Oh, I am r e a l l y d i s a p p o i n t e d . I guess I thought the system was b e t t e r than t h a t . And I heard from o t h e r p e o p l e t h a t they g i v e you h e l p , but I never got any h e l p at a l l which I thought was r e a l l y bad. Because, l i k e p e o p l e l i k e me need any h e l p . They c a n ' t do i t on t h e i r own. But we are expected t o . For t h i s woman, t h i s e x p e r i e n c e r e f l e c t e d a l a c k of r e g a r d f o r her autonomy. I t a l s o r e f l e c t e d a d e c i s i o n - m a k i n g p r o c e s s t h a t d i d not r e g a r d her r e q u e s t s f o r h e l p . A nother s u b j e c t ' s d e s c r i p t i o n of the c o n t a c t w i t h a n e u r o l o g i s t was d e t a i l e d i n the f o l l o w i n g a c c o u n t . T h i s woman was undergoing m e d i c a l i n v e s t i g a t i o n s t o determine the reasons f o r her f a l l s : They j u s t say the muscles are d y i n g ; t h i s clown over a t the 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 muscles and nerves were d y i n g , and when I s a i d , "What?" he s a i d , " N o t h i n g . " Very c h e e r f u l l y , he s a y s , "We don't know what causes i t , so we don't know what c u r e s i t , so come back and see me i n a y e a r . " You know, t h a t ' s n i c e , i s n ' t i t ? When asked how she f e l t about t h a t , her anger was r e f l e c t e d i n t he f o l l o w i n g s t atement: " I t made me f e e l l i k e k i c k i n g him." She commented f u r t h e r as t o how she coped w i t h t h i s s i t u a t i o n : I went back once more and then my d o c t o r s a i d t h i s time i t was time t o go back. I s a i d , "I'm not goin g back t o him. I want t o see someone e l s e . " I f e l t t h a t I j u s t had t o have a say i n t e l l i n g my d o c t o r t h a t I was not s a t i s f i e d w i t h [ t h a t ] type of t r e a t m e n t . T h i s d e s c r i p t i o n r e f l e c t e d the woman's a b i l i t y t o e x e r t her autonomy i n t r y i n g t o o b t a i n more m e d i c a l i n f o r m a t i o n about her c o n d i t i o n . Here, the woman used the be h a v i o u r of t r y i n g t o e x e r t some c o n t r o l t o cope w i t h the s i t u a t i o n . A l l o f the women t a l k e d about t h e i r change i n r o u t i n e s i n c e coming home from the h o s p i t a l a f t e r t h e i r f a l l . One woman d e s c r i b e d s u c c i n c t l y the change i n her r o u t i n e : " W e l l , you know v e r y w e l l you c a n ' t do the t h i n g s a f t e r you've had t h a t , t h a t you c o u l d do b e f o r e . " S e v e r a l women commented on t h e i r s i t u a t i o n i n terms o f meal p r e p a r a t i o n a t home. These d e s c r i p t i o n s were d e t a i l e d i n the f o l l o w i n g a c c o u n t s : Now she'd made a sandwich 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 she's got my soup made f o r t o n i g h t , because I ' l l be a l o n e but I w i l l have t o c r a w l , w e l l w i t h my w a l k e r r i g h t around t h e r e you know, i t ' s p r e t t y hard . Not t h a t g r e a t . I have t o make my own meals which i s h a r d . I have t o st a n d i n one spot because my l e g i s s o r e . Then i t g e t s s o r e and i t g e t s r e a l l y l i k e cramps. 55 When the l a s t woman was asked t o e x p l a i n more about why she f e l t i t was h a r d , she r e p l i e d : W e l l , j u s t t o get a meal, you have t o wander over here and o ver t h e r e and i t ' s not t h a t easy. We have t o wander back and f o r t h . You b r i n g t h i n g s from t h e r e , you miss something you have t o go back, t h i n g s l i k e t h a t which i s n ' t abnormal i n the k i t c h e n . F o r t h e s e women, the term "hard" seems t o r e f l e c t a degree of s t r u g g l e f o r them i n managing a t home. Both women r e p o r t e d t h a t they were independent i n th e s e t a s k s p r i o r t o the f a l l . One s u b j e c t e x p l a i n e d the change i n meeting her p e r s o n a l c a r e needs a f t e r the f a l l . 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 t o f e a r r e s u l t i n g i n a l o s s of c o n f i d e n c e . "They bathed me, showered me, because I was f r i g h t e n e d t o get i n the shower myself a t f i r s t w i t h t h i s funny c a s t — t h i s Hoffman t h i n g w i t h a l l the m e t a l i n i t . " A nother woman t a l k e d about her l o s s o f c o n f i d e n c e r e s u l t i n g i n a change of r o u t i n e . "You l o s e your c o n f i d e n c e , c e r t a i n l y a f t e r h a v i n g had a f a l l . I s t a y e d home a l i t t l e b i t more. I d i d n ' t f e e l l i k e g o i n g out on my own." S e v e r a l women r e p o r t e d a change i n t h e i r s t r e n g t h or f e e l i n g s o f f a t i g u e a f t e r the f a l l . The f o l l o w i n g two acc o u n t s a re d e s c r i b e d : Once you are h u r t , e s p e c i a l l y when you are h i t , i t t a k e s a l o t out of you. You f e e l weak. I t i s slow. R e a l l y 5 6 slow. I was s t r o n g a t one t i m e . B u t , now I am n o t . I c a n ' t s t a y up l o n g enough. I h u r t the upper p a r t of my back. The upper p a r t and I get t i r e d and I don't s t a y up l o n g enough. One woman developed o s t e o m y e l i t i s i n her w r i s t a f t e r b e i n g s e n t home. She was r e - a d m i t t e d t o h o s p i t a l f o r t r e a t m e n t . Upon her d i s c h a r g e from h o s p i t a l , the second t i m e , she s t a t e d : "Oh, I was v e r y , v e r y i l l . V e r y weak f o r a w h i l e . " 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 of the d a t a , i t appeared the 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 the 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 , the t h r e e themes were independence, p r o d u c t i v i t y or a c t i v i t y , and autonomy. S e l f - E s t e e m Independence A l l of the women i n the s t u d y p e r c e i v e d themselves t o be independent p r i o r t o the f a l l . Independence was seen as the a b i l i t y t o p r o v i d e f o r one's own p h y s i c a l and e m o t i o n a l needs. As d i s c l o s e d e a r l i e r , the change i n r o u t i n e a t home r e f l e c t e d a change i n t h e i r l e v e l of independence. T h i s theme i s i l l u s t r a t e d i n the s t o r i e s o f s e v e r a l women i n the s t u d y . Upon r e t u r n i n g home, the 1 0 2 - y e a r - o l d woman remarked t h a t e v e r y t h i n g i n her l i f e had changed. Her p e r c e p t i o n of 57 her s i t u a t i o n , p r i o r t o the f a l l compared t o a f t e r the f a l l , was c o n t a i n e d i n the f o l l o w i n g passage: "Very d i f f e r e n t . Because I hadn't been w e l l , n u r s e , p r e v i o u s l y but I had c a r r i e d on i n a m i n i m a l way and t h a t g i v e s you a sense of independence the o t h e r t a k e s from you." When asked t o e x p l a i n f u r t h e r about her s i t u a t i o n a f t e r the f a l l , she s t a t e d : " W e l l , f o r one t h i n g , I was h e l p l e s s , a b s o l u t e l y h e l p l e s s . " When asked how t h a t f e l t , she r e p l i e d : " A w f u l ! A w f u l , t o an independent o l d me. Not o n l y was I l e s s i n d e p e n d e n t , but I f e l t a w f u l . " For t h i s woman, independence was an i m p o r t a n t p a r t o f her s e l f - e s t e e m . When asked i f independence was an im p o r t a n t p a r t o f how she viewed h e r s e l f , she s t a t e d : "Yes, v e r y much so." The f a l l t h r e a t e n e d the e l d e r l y woman's s e l f - e s t e e m . When asked how t h a t f e l t , she responded: "Hard, a w f u l l y h a r d . I had no sense of d i r e c t i o n , and you wonder, i t i s a more a sense o f a n x i e t y wondering about the f u t u r e . " A n o t h e r woman t a l k e d about the f a l l i n terms o f i t s e f f e c t on her l e v e l o f independence: W e l l , I have never been not a b l e t o do f o r m y s e l f . I am very independent. And when I f e l l t h i s l a s t time by opening the f r i d g e door and s w i n g i n g on i t , w e l l , I have been h e l p l e s s more or l e s s ever s i n c e . And i t ' s t e r r i b l e . I c a n ' t s t a n d i t . When asked t o e x p l a i n f u r t h e r , about her f e e l i n g s , she 58 s t a t e d : " I t makes me f e e l angry. I t makes me f e e l angry t h a t I am not a b l e t o do f o r m y s e l f and have t o have h e l p i n . " S i m i l a r t o the o t h e r woman, independence was an i m p o r t a n t p a r t o f her s e l f - e s t e e m . From both women's a c c o u n t s , l o s s of independence was p e r c e i v e d as a t h r e a t t o t h e i r s e l f - e s t e e m . T h i s t h r e a t r e s u l t e d i n f e e l i n g s of anger, h e l p l e s s n e s s , a n x i e t y , and worry. 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 was an im p o r t a n t p a r t of her f e e l i n g s about h e r s e l f . She s t a t e d : "Oh, v e r y much. I have a n i c e f r i e n d t h a t would j u s t smother me t o d e a t h . B u t , I am v e r y independent." When asked what she l i k e d about b e i n g independent, she responded: Bu t , I l i k e my own way of d o i n g t h i n g s . And I j u s t l o v e and I t h i n k t h a t way you get more freedom back from the p e o p l e . They don't f e e l as i f t h e y ' r e very put upon, l o o k i n g a f t e r you i f you're independent. I t h i n k t h a t you have 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 asked i f she f e l t 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 image t o f a m i l y and f r i e n d s , she responded: "Oh, y e s . Very much so. Oh, y e s . I am not f r i g h t e n e d of g o i n g anywhere m y s e l f . You know, I do t h i n g s on my own." T h i s woman was asked about her f e e l i n g s r e l a t e d t o her l o s s of independence. She s t a t e d : I never f e l t h e l p l e s s , even i f I had t o c r a w l . I was j u s t g r a t e f u l f o r the w o n d e r f u l c a r e I r e c e i v e d . I knew 59 I was s i c k but I a l s o knew I would get b e t t e r . T h i s woman e x p e r i e n c e d dependency d i f f e r e n t l y from the o t h e r two women. A f o u r t h s u b j e c t a l s o d e s c r i b e d the f a l l ' s e f f e c t on her l e v e l of independence: I f e e l t h a t i t a f f e c t e d my whole e n t i r e system; what I can do, what I c a n ' t do; you c a n ' t move around t h a t much; you have t o keep y o u r s e l f l i m i t e d , i n what you can do! Her f e e l i n g s i n r e l a t i o n t o the l o s s of independence were: W e l l , i t wasn't t h a t g r e a t . I wanted more h e l p , but I d i d n ' t get any h e l p . So, t h a t r e a l l y I was peeved w i t h t h a t because I thought t h e r e was more h e l p coming t o S e n i o r s . T h i s p a r t i c u l a r woman f e l t t h a t r e c e i v i n g some s u p p o r t at home would have h e l p e d t o make her more independent, thereby l e s s e n i n g the t h r e a t t o her s e l f - e s t e e m . She was not p r o v i d e d w i t h homemaking or n u r s i n g a s s i s t a n c e once she r e t u r n e d home. Her anger, r e g a r d i n g her l o s s o f independence, was d i r e c t e d a t the system f o r not p r o v i d i n g adequate s u p p o r t s t o h e r . She agreed t h a t independence was i m p o r t a n t i n terms of her s e l f - e s t e e m or f e e l i n g s about h e r s e l f . When asked what she l i k e d about independence, she s t a t e d : " W e l l , j u s t t o be more a g g r e s s i v e and you know, f e e l f r e e , do as you p l e a s e , which you c a n ' t do now." When asked 60 t o c l a r i f y what she meant by a g g r e s s i v e , she s a i d : W e l l , say f o r i n s t a n c e , now I c a n ' t go out and weed i n the garden because I c a n ' t bend down and s t u f f l i k e t h a t . I am used t o hard work. I l o v e w o r k i n g around b e i n g l i k e , I say, independent. I c a n ' t do i t now. Even though t h i s woman was e x p e r i e n c i n g t h r e a t s t o her a b i l i t y t o be independent, she was h o p e f u l t h a t she would r e t u r n t o her p r e v i o u s l e v e l o f f u n c t i o n i n g . Another woman t a l k e d about l i v i n g a l o n e s i n c e her husband d i e d 15 y e a r s ago. She s t a t e d t h a t she: Managed my own t h i n g s and I always managed my own b a n k i n g , my own e v e r y t h i n g . I wasn't dependent on anybody and I don't want t o be dependent on my daughter because she's a very busy l i t t l e g i r l . A f t e r d i s c h a r g e from the h o s p i t a l , she 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 her a c t i v i t i e s o f d a i l y l i v i n g i n the community. She s t a t e d : " I f I d i d n ' t have t h i s l i t t l e g i r l , i t would be q u i t e hard 'cause I know my daughter c o u l d n ' t come any more than a c o u p l e of tim e s a week or t h r e e t i m e s . " She went on t o say t h a t her g r e a t e s t f e a r over the l o s s o f her independence was the dependence on her d a u g h t e r . Here, a g a i n , f e e l i n g s of f e a r were s t a t e d t o l o s s of independence. The l a s t d e s c r i p t i o n was from a woman who t a l k e d about her r e c o v e r y over a 6-week p e r i o d . I n i t i a l l y , she s t a t e d 61 that she was quite dependent but now was feeling as independent as she was prior to the f a l l . She stated that she was frustrated due to the fact that her friends s t i l l viewed her as dependent: I don't want to be treated l i k e a baby. Good heavens! Some of my friends have been over s o l i c i t o u s . They nearly died when I told them I went downtown yesterday. They said, "Why didn't you t e l l us and we would have driven you." But, as I say, I don't want to be treated l i k e a baby. If I can go out and do things for myself, I want to be able to do that. She stated that she recognized her own lim i t a t i o n s after this experience but i t was s t i l l important for her to s t r i v e for independence. She became frustrated when her friends became over-protective or treated her as i f she was dependent. A c t i v i t y Productivity or a c t i v i t y was another theme within the self-esteem concept that was i d e n t i f i e d throughout the interviews. A l l of the women stated that their a c t i v i t y in their l i f e changed after the f a l l . One woman described her l i f e p r ior to the f a l l . "Oh, going out and having fun and doing everything, yes, no trouble at a l l . " Later in the interview, she spoke again about her a c t i v i t y prior to the f a l l . She stated: "Going down to the golf club or going wherever I want. There was nothing wrong with me; I was just 62 as natural as you are." When asked to describe her l i f e a fter the f a l l , she commented on the length of the days. She r e p l i e d , "Well, I guess they could be shorter, just you know, i t i s not very nice, sometimes always alone." She stated that she had been home for about three weeks and had not been out of her apartment once. She was looking forward to Friday when her daughter's friend was taking her to a hair appointment. When asked how she f e l t about the change in her a c t i v i t y l e v e l , she responded: "Well, you know very well you can't do the things after you've had that, that you could do before." Another subject described her a c t i v i t y prior to the f a l l : "I was active before I had the f a l l . I was out every day, more or less. I went shopping, go downtown." This same woman was admitted to hospital and required skin grafting to the abrasions on her lower legs. After her discharge from ho s p i t a l , she described her l e v e l of a c t i v i t y : I stayed home a l i t t l e b i t more. I didn't f e e l l i k e going out on my own, but my friends would take me i f I wanted to go anywhere special in the car. I was quite content; I was t i r e d . It takes a l o t out of you. A c t i v i t y was an important part of these e l d e r l y women's perceptions of s e l f . As documented, a l l the women talked about their various a c t i v i t i e s prior to the f a l l . In analyzing the data, there were several d i f f e r e n t types of a c t i v i t i e s . Some o f the women t a l k e d about s o c i a l a c t i v i t i e s . Other women t a l k e d about a c t i v i t i e s t h a t were g o a l - d i r e c t e d , such as p r o v i d i n g s u p p o r t t o f r i e n d s or a s s i s t i n g w i t h the c a r e of o t h e r f a m i l y members. Other women t a l k e d about a c t i v i t i e s such as c r a f t work t h a t kept them busy a t home. S e v e r a l o f the women t a l k e d about t h e i r s o c i a l a c t i v i t i e s p r i o r t o the f a l l . One woman d e s c r i b e d the f o l l o w i n g : " I used t o l o v e d a n c i n g , but I can't do i t now. (Laughs). I l o v e music and d a n c i n g . I s t i l l do. J u s t b e f o r e I f e l l , I had been out d a n c i n g . " T h i s woman e x p e r i e n c e d a f r a c t u r e of her h i p and, a t the time of t h i s i n t e r v i e w , she was s t i l l w a l k i n g w i t h a w a l k e r . A n o t h e r s u b j e c t d e s c r i b e d some o f her s o c i a l a c t i v i t i e s w i t h i n the S e n i o r ' s complex where she r e s i d e d : We u s u a l l y , we go down f o r the m a i l , and u s u a l l y , you know, t h e r e a re two or t h r e e down t h e r e and we s i t and yap. B u t , and then we have a n i c e room u p s t a i r s where we go once a week f o r a f t e r n o o n t e a . A n o t h e r s u b j e c t who f r a c t u r e d her w r i s t d e s c r i b e d her s o c i a l a c t i v i t i e s p r i o r t o the f a l l . She s t a t e d : "You know, I have f un and I have a l o t o f p a r t i e s and go t o a l o t of d i n n e r s a t the c l u b , you know." She went on t o say t h a t she had t o c a n c e l a t r i p t o W h i s t l e r , B.C. because she was unable t o d r i v e her c a r , due t o the 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 the South Sea I s l a n d s i n September. B e s i d e s s o c i a l a c t i v i t i e s , t h i s woman a l s o d e s c r i b e d her a c t i v i t y i n terms o f p r o v i d i n g s u p p o r t t o o t h e r s . Here, t h e r e was some f e e l i n g of p r o d u c t i v i t y i n her l i f e . She had been a t e a c h e r and her husband had been a p s y c h o l o g i s t . They had no c h i l d r e n o f t h e i r own but s t a t e d t h a t they had p r o v i d e d s u p p o r t t o many c h i l d r e n through the y e a r s : "And t h a t was my husband's and my l i f e ; [we] have been h e l p i n g , h e l p i n g c h i l d r e n a d j u s t t o d i f f i c u l t i e s . R i g h t now, I am s u p p o r t i n g a n i e c e down i n C a l i f o r n i a . " A p p a r e n t l y , w h i l e i n the h o s p i t a l , she p r o v i d e d some s u p p o r t t o the woman i n the next bed: I f I can h e l p somebody e l s e . She was so n e r v o u s , t h a t l i t t l e woman, a b s o l u t e l y p a n i c k y ; i f I c o u l d g i v e her some s u p p o r t . A l t h o u g h i t was hard on m y s e l f . I do t h a t and I want t o do i t . When asked how i t f e l t t o g i v e s u p p o r t t o someone e l s e when she 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 . " S i m i l a r t o t h i s woman's g o a l - d i r e c t e d a c t i v i t y , a n o t h e r woman t a l k e d about her r o l e as a c a r e g i v e r t o an o l d e r s i s t e r : I was always a busy p e r s o n and on top of t h a t , I have an o l d e r s i s t e r t h a t d i d n ' t have, w e l l , she had a very f i n e husband, but he passed away and she never had any 65 children, so about 10 years ago she moved up here to be near me and my children. This 79-year-old woman was driving her own car prior to the f a l l . She stated that she v i s i t e d her s i s t e r on a dail y basis in the private care f a c i l i t y . Besides v i s i t i n g her, she also shopped for any clothes or t o i l e t r y items that her s i s t e r required. Another subject talked about her a c t i v i t y l e v e l in terms of the c r a f t work she did at home. She talked about completing a l l the c r o s s - s t i t c h and pet i t - p o i n t pictures in her apartment: But that way I keep myself occupied. I can s i t for hours and embroider and enjoy i t and watch the te l e v i s i o n and a l l the s i l l y s tuff on there, but s t i l l — you learn more. It was interesting to note that three of the women incorporated their past a c t i v i t i e s into t h e i r present s e l f -concept. One woman, in response to a question about the a c t i v i t y in her l i f e , responded: "I used to work every day." Upon further questioning, she indicated that she had worked up u n t i l a couple of years ago. When asked about the type of work, she stated: "Hard work. I worked in the f i s h market. I used to carry f i s h and a l l that s t u f f , i c e — I r e a l l y worked hard a l l my l i f e . " Even though she had not worked recently, t h i s past work had important meaning to her. 66 The second woman t a l k e d about her p a s t a c t i v i t i e s . These a c t i v i t i e s remained an i m p o r t a n t p a r t of her p r e s e n t s e l f - c o n c e p t and r e s u l t a n t s e l f - e s t e e m : " W e l l , t h a t ' s i f you s e e , p l a y i n g g o l f , w e l l not j u s t b e f o r e , but a l l my l i f e I p l a y e d , and bowled 1 0 - p i n s . " She went on t o say t h a t she j u s t l o v e d i t . A t one p o i n t , she had been a member of the E x e c u t i v e of a p r i v a t e g o l f c o u r s e i n Vancouver. She showed t h i s w r i t e r a p i c t u r e t h a t had been t a k e n of a l l p a s t members of the E x e c u t i v e : These are a l l the p a s t - p r e s i d e n t s and I'm t h e r e . I t h i n k i t ' s a l o v e l y p i c t u r e . We have the banquet once a year and he's g o i n g 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 every 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 about her y e a r s as a n u r s e . A t 83, she had not p r a c t i c e d f o r many y e a r s . Y e t , her d e s c r i p t i o n i m p l i e d t h a t t h i s p a r t of her l i f e remained an i m p o r t a n t p a r t of her s e l f - c o n c e p t : " I g r a d u a t e d i n 1930, so I am g e t t i n g t o be old-hand a t the j o b . I g r a d u a t e d from the Regina G e n e r a l [ R e g i n a , Saskatchewan]." She was l o o k i n g f o r w a r d t o 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: I t i s j u s t a w o n d e r f u l e v e n i n g . H o p e f u l l y , e v e r y t h i n g w i l l be okay and I w i l l be g o i n g . I s t a y e d on s t a f f a f t e r I graduated f o r 13 y e a r s so I know a l o t of the n u r s e s . And they know me. They remember me. 67 A l l o f the women c o n f i r m e d t h a t b e i n g a c t i v e or p r o d u c t i v e was an i m p o r t a n t a s p e c t o f t h e i r s e l f - c o n c e p t and r e s u l t a n t s e l f - e s t e e m . I t d i d not appear t h a t any one a c t i v i t y was judged t o be more i m p o r t a n t than the o t h e r s . The woman who p r o v i d e d s u p p o r t t o her f a m i l y s t a t e d t h a t t h i s was an i m p o r t a n t p a r t of her s e l f - e s t e e m . Another woman d e s c r i b e d the e v e n t s of the morning i n response t o the q u e s t i o n about the importance of a c t i v i t y f o r her s e l f - e s t e e m : W e l l , t h i s morning, I got up and made c o f f e e . I had some c o r n f l a k e s and then I put some c h i c k e n on t o o , bones on t o stew because I had some l e f t o v e r c h i c k e n , can of l e f t o v e r c h i c k e n soup. I took the meat o f f of t h a t and the b r o t h and put t h a t away. W e l l , I made d i s h e s . When asked about t h i s l e v e l o f a c t i v i t y , she responded: "But, I am more a c t i v e than I was and t h a t makes me f e e l b e t t e r about m y s e l f . " T h i s woman had spent t h r e e weeks i n bed a t home a f t e r r e t u r n i n g from the Emergency Department. The f i r s t i n t e r v i e w had been done w i t h her l y i n g i n bed. The above c o n v e r s a t i o n took p l a c e on the second i n t e r v i e w , a p p r o x i m a t e l y f i v e weeks l a t e r . D u r i n g the second i n t e r v i e w , she was d r e s s e d , and a b l e t o s i t on the couch f o r the e n t i r e l e n g t h of t i m e . The f a l l and the r e s u l t a n t change i n r o u t i n e had posed a t h r e a t t o her s e l f - e s t e e m i n terms of a c t i v i t y . 68 It was evident that even though her a c t i v i t y l e v e l had changed since the f a l l , she s t i l l placed value on the a c t i v i t y component of her self-esteem. Autonomy A theme of autonomy emerged from the data analysis as thi s writer t r i e d to determine the el d e r l y women's perceptions of their need for care and support at home. Matteson and McConnell (1988) stated that autonomy or s e l f -determination meant that individuals were respected as decision-makers about their own care. Within the theme of autonomy, the elderly women described three d i f f e r e n t decision-making processes. These processes were well-represented along a continuum. At one end, the women described decisions made solely by themselves in rel a t i o n to their medical care. In the middle were decisions made by the women in consultation with family, friends, and/or health professionals. The other end of the continuum was represented by decisions made for the el d e r l y women by health professionals and others involved in their care. The f i r s t process of decision-making was represented by those decisions s o l e l y made by the women regarding their care. One woman talked about the decision-making process involved in deciding whether to have surgery on her fractured wrist. The surgery option arose after the i n i t i a l treatment of putting her wrist in a cast was not successful: "I'm in charge of ray l i f e . I c e r t a i n l y decided that I wanted the operation and I decided that I wanted to go home as fast as I could." She decided to have the surgery and returned home. She was home for approximately three weeks and then was re-admitted to hospital with osteomyelitis. She described her discharge after t h i s h o s p i t a l i z a t i o n : Yes, in fact I probably shouldn't have been home alone, but I wanted to be home alone so much. I wanted to be in my own home that I put up with being alone. Here, again, this woman's a b i l i t y to make her own decisions regarding her care was evident. Another woman talked about her role in the decision-making regarding some type of abdominal surgery. This 102-year-old woman had experienced a f a l l related to dizziness due to anemia. She was experiencing a loss of blood through her bowel. She described the experience of seeing the surgeon: He examined me down here (points to lower abdomen). And I didn't ask him any questions because I had my mind made up. I was not having surgery. No, not me. No! And I had no desire when the c a l l comes for me, nurse, I am ready. That's a l l important. I don't want to do anything that would hasten i t . I couldn't see where this would help me; I haven't got what i t would take. When asked i f she f e l t her wishes were respected, she stated: " I don't t h i n k Dr. G. l i k e d i t but don't say a n y t h i n g . " She s t a t e d t h a t her wishes were r e s p e c t e d . "They [wishes] have t o be. I would never have gone on t h e n . No, I have had a l l t h a t , and i t remains w i t h the L o r d what the f u t u r e h o l d s f o r me. " In the middl e o f the continuum 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 h e a l t h p r o f e s s i o n a l s and/or f a m i l y members. One woman t a l k e d about the o c c u p a t i o n a l t h e r a p i s t ' s v i s i t t o her apartment p r i o r t o her d i s c h a r g e . She was r e t u r n i n g home a f t e r b e i n g h o s p i t a l i z e d f o r a f r a c t u r e d h i p : They d i d a l l t h a t from the G e n e r a l 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 because i t ' s t o o low t o get o u t , you know, and so they d i d , they got t h i s and, oh, they d i d a l o t of t h i n g s ; I t h i n k 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 , she i n d i c a t e d t h a t the t h e r a p i s t had d i s c u s s e d her recommendations w i t h her and t h a t she was i n agreement w i t h the equipment b e i n g o r d e r e d . T h i s same woman a l s o t a l k e d about her inv o l v e m e n t i n the d e c i s i o n - m a k i n g p r o c e s s r e g a r d i n g p e r s o n a l c a r e home placement. She d e s c r i b e d her i n i t i a l a m b i valence towards t h i s i d e a : "But I t h o u g h t , no, I can ' t go, I can't go and l e a v e my f r i e n d s , and I have a l o t of f r i e n d s i n Vancouver, you know, the 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 w i t h her d a u g h t e r : When I s t a r t e d t o t h i n k about i t how many f r i e n d s do come and v i s i t you i f you can never go o u t , you know, so I t h o u g h t , w e l l , gee, I'd r a t h e r be where my daughter i s . So, we've t a l k e d i t a l l out 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 the c o u r s e of the s t u d y , t h i s woman moved t o a p e r s o n a l c a r e home i n L a n g l e y , B.C. which was c l o s e r t o her d a u g h t e r . Another s u b j e c t t a l k e d about i n v o l v i n g f a m i l y members i n d e c i s i o n s r e g a r d i n g p e r s o n a l m a t t e r s such as f i n a n c e s . She made i t e x p l i c i t t h a t she d i s c u s s e d the matter w i t h them b u t , u l t i m a t e l y , i t was her d e c i s i o n : I have 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 , t h a t ' s made money f o r me and l o o k s a f t e r me t h a t way. And i f I , l i k e w i t h t h i s t r i p , I s a i d , "Do you t h i n k I s h o u l d go?" he s a i d , "By a l l means, because your time i s r u n n i n g o u t . Go and have fun now." And we d i s c u s s t h i n g s w i t h my aunt and t h i n g s l i k e t h a t . I d i s c u s s i t but i t i s my d e c i s i o n , v e r y much i n my l i f e . F i n a l l y , a t the o t h e r end of the continuum were d e c i s i o n s 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 i n c o n t r o l of the d e c i s i o n - m a k i n g p r o c e s s . One woman t a l k e d about wanti n g t o change her 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 l o c a l h o s p i t a l . She d e s c r i b e d her d i s c u s s i o n w i t h her p h y s i c i a n over t h i s m a t t e r : But I brought i t up t o him and he wasn't v e r y happy about i t . " She e x p l a i n e d 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, i s t h a t he does not p r a c t i c e a t any h o s p i t a l . And a t the back of my mind, I t h o u g h t , " I f I do f a l l and break my h i p or a n y t h i n g and get landed i n the h o s p i t a l , he c a n ' t come. I have t o j u s t t a k e whoever they d i s h out t o me. Which I don't t h i n k i s v e r y s a t i s f a c t o r y . She d e s c r i b e d her d o c t o r ' s r e a c t i o n t o her s u g g e s t i o n and her r e s u l t i n g f r u s t r a t i o n : So, I s a i d t h i s t o him, and he s a i d , " W e l l , I would come and see you," and I n e a r l y s a i d , " W e l l , I'd l o v e t o see you s i t t i n g b e s i d e my bed, but i f you c a n ' t do a n y t h i n g f o r me." She s t a t e d t h a t she p l a n n e d t o s t a y w i t h him u n t i l autumn and then she would t r y t o get him t o a c c e p t the i d e a and r e f e r her 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 her e x p e r i e n c e of not b e i n g i n v o l v e d i n the d e c i s i o n - m a k i n g p r o c e s s r e g a r d i n g her own c a r e . She t a l k e d about not r e c e i v i n g any home c a r e h e l p a f t e r her h o s p i t a l i z a t i o n f o r a f r a c t u r e d h i p : 7 3 They c o u l d have g i v e n me more h e l p , you know, t o get me up and g o i n g , but they d i d n ' t ; l i k e I s a i d , they d i d n ' t want t o even g i v e me h e l p f o r a b a t h . They c o u l d have come a c o u p l e of times and then I would have s a i d , "You don't have t o come any more." I would have but they d i d n ' t even say t h a t - - i t was j u s t , n o — t h a t was i t . When asked why she d i d not get any h e l p , she responded: " I t ' s j u s t more or l e s s because they t o l d me you have t o make so much money and i f you make t h a t much you have t o pay i t . " The o n l y s u p p o r t t h i s woman r e c e i v e d was the p h y s i o t h e r a p i s t t o a s s e s s her w a l k i n g . She d e s c r i b e d t h i s e x p e r i e n c e : "They send t h a t woman out here t o walk w i t h me. I can walk by m y s e l f ! That doesn't make sense, does i t ? " She s t a t e d t h a t she t r i e d t o go w a l k i n g f o r s h o r t d i s t a n c e s each day. She a d v i s e d the t h e r a p i s t s t h a t t h e i r v i s i t s were not n e c e s s a r y . She d e s c r i b e d the f o l l o w i n g e x p e r i e n c e : "I'm coming down t o take you out f o r a walk. I don't need t h a t . Who needs t h a t ? I don't. So I t e l l them." She d e s c r i b e d t h e i r response t o he r : " W e l l , they s a i d we have t o come. I can't see t h a t 'we have t o come.' I s t h a t what I s h o u l d say? R e g u l a t i o n or whatever l i k e t h a t . " At the time of the second i n t e r v i e w , a p p r o x i m a t e l y f o u r weeks l a t e r , she s t a t e d t h a t she had f i n a l l y been s u c c e s s f u l i n s t o p p i n g t h e i r v i s i t s : " I j u s t t o l d her t h a t I am not g o i n g . That was i t , because I d i d n ' t see the sense i t made." 74 In o r d e r f o r i n d i v i d u a l s t o be autonomous, they must be p r o v i d e d w i t h adequate m e d i c a l 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 . T h i s was another i m p o r t a n t theme i n the d a t a . S e v e r a l women d e s c r i b e d t h e i r a t t e m p t s t o i n c r e a s e t h e i r u n d e r s t a n d i n g about what was happening t o them. The woman who remained i n bed f o r t h r e e weeks a f t e r her d i s c h a r g e from h o s p i t a l t a l k e d about t r y i n g t o o r g a n i z e m e d i c a l f o l l o w - u p t o o b t a i n m e d i c a l i n f o r m a t i o n . T h i s d i s c u s s i o n took p l a c e on the second i n t e r v i e w : So, then today I phoned. I am not w e l l . I phoned Dr. C , he's a t the A r t h r i t i c C e n t r e . He's one of t h e , i f not the top d o c t o r s i n Canada on a r t h r i t i s . He's send i n g someone i n tomorrow t o do some b l o o d work. Tha t ' s r e l a t e d t o the d e r m a t i m y o s i t i s . My muscles are very po o r . Of c o u r s e , t h i s a w f u l r a s h on my head i s i n f l a m m a t i o n . I t drags you down. So anyway, we've got some wheels g o i n g . Another s u b j e c t t a l k e d about her t r i p back t o an Emergency department t o have her c a s t checked. T h i s c a s t had been a p p l i e d two days e a r l i e r : That was a j o k e . I went over t h e r e when I c r a c k e d i t , and one d o c t o r bound me up i n a c a s t , some new k i n d of c a s t , and s a i d , "Now t h a t ' s got t o s t a y on f o r one week and you see the d o c t o r t h e n . " And i n two days i t had worked l o o s e . So I th o u g h t , w e l l — s o I went back o v e r . 75 The nurse was r a t h e r p e r t u r b e d a t my coming back. I s a i d , " W e l l , I r e a l l y d i d n ' t know what t o do. I t ' s no good t h i s way." The woman who saw the n e u r o l o g i s t f e l t t h a t she had been t r e a t e d t o o i n d i f f e r e n t l y . She s t a t e d : I do f i n d i t r a t h e r a g g r a v a t i n g . I mean, i f you because you 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 t o get a m e d i c a l book and read i t . But you don't want t o end up i n a w h e e l c h a i r or what you're g o i n g t o do. As n o t e d , autonomy was a l s o p e r c e i v e d as an i m p o r t a n t p a r t of t h e i r s e l f - e s t e e m . I t appeared t h a t as the d e c i s i o n -making s h i f t e d from t h e i r own r e s p o n s i b i l i t y t o the r e s p o n s i b i l i t y of the h e a l t h p r o f e s s i o n a l s , the women e x p e r i e n c e d a t h r e a t t o t h e i r s e l f - e s t e e m . As w e l l , l a c k of m e d i c a l i n f o r m a t i o n p l a y e d an i m p o r t a n t r o l e i n t h e i r a b i l i t y t o make autonomous d e c i s i o n s . A d a p t a b i l i t y In the i n t e r v i e w s , the women t a l k e d about b e h a v i o u r s t h a t they used t o cope w i t h t h e i r change i n r o u t i n e and t h r e a t s t o t h e i r s e l f - e s t e e m . As d i s c u s s e d e a r l i e r , the t h r e a t s t o s e l f - e s t e e m changes were p r i m a r i l y r e l a t e d t o independence, a c t i v i t y , and autonomy. Each woman coped w i t h the s i t u a t i o n i n her own unique way. However, t h e r e were s t i l l common c a t e g o r i e s of 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 . As w e l l , t he two major 76 themes o f p r o b l e m - f o c u s e d and em o t i o n - f o c u s e d b e h a v i o u r s were i d e n t i f i e d . B oth b e h a v i o u r s were used by the women i n c o p i n g w i t h the f a l l event and r e s u l t a n t t r e a t m e n t w i t h i n the h e a l t h c a r e system. The c o p i n g b e h a v i o u r s or r e s o u r c e s t h a t were i d e n t i f i e d were the f o l l o w i n g : use o f p o s i t i v e b e l i e f s , m a i n t a i n i n g c o n t r o l , c o m p l i a n c e , p r e v e n t i o n , use of s o c i a l s u p p o r t s , and p l a n n i n g f o r the f u t u r e . Some o f thes e b e h a v i o u r s were i d e n t i f i e d as b e i n g used i n o t h e r s t r e s s f u l l i f e e v e n t s . Some of the o t h e r b e h a v i o u r s d e v e l o p e d i n response t o the f a l l e v e n t . Use o f F a i t h / P o s i t i v e B e l i e f s Most o f the women i n the stu d y spoke of the use o f f a i t h and/or p o s i t i v e 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 t h a t they used t o cope w i t h l i f e d i f f i c u l t i e s . In p a r t i c u l a r , they had used t h i s b e h a v i o u r t o cope w i t h the consequences of the f a l l . T h i s was c o n s i d e r e d t o be an example of an e m o t i o n - f o c u s e d c o p i n g b e h a v i o u r . The 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 d i f f i c u l t i e s a t home a f t e r her f a l l . Her bowel c o n d i t i o n r e s u l t e d i n p e r i o d s of d i z z i n e s s and weakness. She s t a t e d t h a t the f a l l had a f f e c t e d her l e v e l of independence. She 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 . When asked i f she f e l t the f a i t h h e l p e d her t o cope, she responded: I t 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 . I am persuaded t h a t He i s a b l e t o do e v e r y t h i n g f o r me and when the time comes, i f I d i d n ' t have t h a t , d e a r , I would be even more h e l p l e s s , h o p e l e s s . I am not h o p e l e s s , n u r s e . Another s u b j e c t t a l k e d about her a b i l i t y t o look on the p o s i t i v e s i d e of l i f e . She had f r a c t u r e d her w r i s t and had s t a t e d t h a t she was q u i t e dependent on her r e t u r n home from h o s p i t a l . When asked how she f e l t she coped w i t h the dependency, she s t a t e d : I'm l o o k i n g a t the p o s i t i v e . J u s t b e i n g as p a t i e n t as I can. I am s o r t of a p o s i t i v e t h i n k e r . V e ry much so w i t h mental h e a l t h and my husband's background and my own f e e l i n g s towards l i f e t h a t you have courage, march on. Throughout the two i n t e r v i e w s , she s t a t e d s e v e r a l t i m e s t h a t t h i s p o s i t i v e o u t l o o k p r o v i d e d s u p p o r t t o h e r . A t h i r d woman a l s o r e f e r r e d t o her p o s i t i v e o u t l o o k . She s t a t e d t h a t she was angry about b e i n g dependent a f t e r her f a l l . When asked how she coped w i t h t h i s f e e l i n g , she s t a t e d : " I was angry but I don't l e t t h i n g s get me down. I was mad a t myself f o r f a l l i n g . However, I t r y t o be o p t i m i s t i c and have a p o s i t i v e o u t l o o k . " Another woman t a l k e d about not be i n g a b l e t o d r i v e her c a r a f t e r her r e t u r n home. She d e s c r i b e d the e x p e r i e n c e of a l l o w i n g her daughter t o d r i v e the c a r w h i l e she s a t i n the 78 back s e a t : " I s i t i n the back and we have f un p r e t e n d i n g she's my c h a u f f e u r . " When asked about u s i n g humour, she s t a t e d t h a t she always t r i e d t o loo k on the p o s i t i v e s i d e of l i f e : Oh, s u r e , t h a t ' s what l i f e i s , you know, i f you're sour g r a p e s . I guess i t ' s r e a l l y d r e a d f u l i f you're i l l ; maybe you c o u l d n ' t h e l p i t . No, you've got t o laugh a t t h i n g s . I t h i n k the more you t h i n k you're f i n e you do get b e t t e r whereas i f you foc u s on a l l the bad t h i n g s , you w i l l f e e l worse. The l a s t i l l u s t r a t i o n of t h i s p o s i t i v e approach was from the woman who was de n i e d home c a r e s u p p o r t s upon her r e t u r n from h o s p i t a l . She t a l k e d about her p o s i t i v e approach i n r e c o v e r i n g from her f r a c t u r e d h i p : " I d i d n ' t do i t p u r p o s e f u l l y , but n e v e r t h e l e s s , you have t o l i v e w i t h i t ; you have t o come over the hump and get b e t t e r . " Compliance Another b e h a v i o u r p a t t e r n t h a t was used i n c o p i n g w i t h 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 was c o m p l i a n c e . T h i s b e h a v i o u r was c o n s i d e r e d t o be an example o f p r o b l e m - f o c u s e d c o p i n g . Most o f the women e x p e r i e n c e d some r e s t r i c t i o n s i n t h e i r a c t i v i t y l e v e l r e l a t e d t o t h e i r m e d i c a l c o n d i t i o n . F o r example, the women who f r a c t u r e d t h e i r h i p s were r e s t r i c t e d i n t h e i r w e i g h t - b e a r i n g and f l e x i o n o f the a f f e c t e d l e g . Other women were g i v e n 79 e x e r c i s e s o r o t h e r regimes such as d i e t s t o f o l l o w a t home. A l l o f the e l d e r l y women d e s c r i b e d t h e i r adherence or comp l i a n c e t o thes e r e s t r i c t i o n s or regimes. Most of the women t a l k e d i n an a c c e p t i n g manner about th e s e r e s t r i c t i o n . One woman's comment i l l u s t r a t e d t h i s p o i n t : "But I'm i n t e l l i g e n t enough t o know t h a t when you have t o do something, you have t o do i t and have t o do e v e r y t h i n g t h a t I had t o do t o get b e t t e r , which I've done." As mentioned e a r l i e r , some of the i n s t r u c t i o n s were r e l a t e d t o w e i g h t - b e a r i n g on the a f f e c t e d l e g . One woman d e s c r i b e d t h i s : I s t i l l am not supposed t o put my whole weight on t h i s when I walk. I put my weight on t h i s and my hand. I touch my f o o t down k i n d o f on my t o e s and put not the f u l l w eight on i t . I have t o w a i t u n t i l they t e l l me when I can put my f u l l weight on i t . S e v e r a l of the women who had e x p e r i e n c e d f r a c t u r e d h i p s t a l k e d about not b e i n g a b l e t o have a b a t h . They d e s c r i b e d the e x p e r i e n c e of s i t t i n g on a bath b o a r d and u s i n g a hand-h e l d shower: " S t i l l , j u s t s i t t i n g on t h a t s i l l y b o a r d . " When asked how t h a t f e l t , she s t a t e d : " A w f u l ! They haven't t o l d me y e t t h a t I can get i n t o the t u b . " Another woman d e s c r i b e d t h i s e x p e r i e n c e : " Q u i t e what s h o u l d I say, not l i k e a b a t h — n o t l i k e a good b a t h ; water s p l a s h e d on you, more or l e s s . " The woman w i t h the f r a c t u r e d w r i s t t a l k e d about e x e r c i s i n g her f i n g e r s of the a f f e c t e d hand: "He [ p h y s i c i a n ] t o l d me t o w i g g l e i t as much as I can. So, I c o u l d see ray muscles down t h e r e moving. I t h i n k i t i s almost b e t t e r than a c a s t f o r moving." As one woman p r o g r e s s e d from a wa 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 her c a r a g a i n . Here, a g a i n , her com p l i a n c e t o the h e a l t h p r o f e s s i o n a l ' s a d v i c e was e v i d e n t : I f e e l t h a t I c o u l d d r i v e because you see a l l me, l i k e the gas and the brake i s w i t h the r i g h t f o o t , t h e r e ' s n o t h i n g t o the l e f t . I've been warned by f r i e n d s , "Don't s t a r t u n t i l your d o c t o r or your p h y s i o t e l l s , says you can, because i f you had an a c c i d e n t , they say t h a t ' s the f i r s t t h i n g they do, i s check back on your h i s t o r y , so I wouldn't d a r e . She r e f r a i n e d from d r i v i n g u n t i l the d o c t o r gave her p e r m i s s i o n . I t was i n t e r e s t i n g t o note t h a t these e l d e r l y women d i d not e x p e r i e n c e any d i f f i c u l t i e s a d h e r i n g t o the r e s t r i c t i o n s . M a i n t a i n i n g C o n t r o l S e v e r a l o f the women d e s c r i b e d s i t u a t i o n s where they f e l t the need t o m a i n t a i n some c o n t r o l o v er t h e i r e n vironment. T h i s b e h a v i o u r appeared t o be r e l a t e d t o those s i t u a t i o n s where the women e x p e r i e n c e d t h r e a t s t o t h e i r autonomy. T h i s b e h a v i o u r was a l s o an example of pr o b l e m -f o c u s e d c o p i n g . As a l r e a d y mentioned, one woman f e l t the 81 need t o t e l l her p h y s i c i a n t h a t she wanted t o see another n e u r o l o g i s t : " I went back once more and then my d o c t o r s a i d t h i s time i t was time t o go back. I s a i d , 'I'm not g o i n g back t o him.' I s a i d , 'There's no way I'm g o i n g back t o him.' So t h e n , t h a t ' s when I went up t o U.B.C." A second s u b j e c t d e s c r i b e d her e x p e r i e n c e i n r e l a t i o n t o g i v i n g d i r e c t i o n s t o the home h e l p e r s : W e l l , I guess they get s o r t o f annoyed w i t h me. B u t , I go o ut i n the k i t c h e n and say, "Oh, heat t h i s l e f t o v e r c h i c k e n up i n t h i s package of b o u i l l o n , c h i c k e n b o u i l l o n . " I t r y t o t e l l them how t o do t h i n g s which I guess they don't a p p r e c i a t e . C o n t r o l w i l l a l s o be d i s c u s s e d f u r t h e r i n the c o p i n g b e h a v i o u r o f u s i n g s o c i a l s u p p o r t s . Another 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 she f e l t was making her s i c k . She made the d e c i s i o n a f t e r c o n s u l t i n g a m e d i c a l d i c t i o n a r y : I took some m e d i c i n e and I guess they gave i t t o me a l l the time I was i n h o s p i t a l , I don't know, but I know, then I read about t h i s m e d i c i n e and they s a i d i t makes you l o s e your a p p e t i t e ; 'be s u r e t o t e l l your d o c t o r i f t h i s i s happening.' I t o l d my d o c t o r t o o and i f you l o s e your a p p e t i t e and you're t h i r s t i s g e t t i n g a l i t t l e s t r o n g e r , and you do t h i s and I t h i n k I had e v e r y t h i n g t h a t they s a i d would happen w i t h t h i s p i l l . Prior to stopping the pill, she consulted her doctor about her loss of appetite. She was told that this happened with many medications. Ultimately, she stopped the medication. Prevention Previous falls had been experienced by 3 of the 8 women. The other five women coped with the physical and psychological consequences of their first fall. The data was rich in detail in relation to the women trying to determine why the fall occurred. Subsequently, the women talked about being more careful or taking preventative steps to protect themselves from another fall. Prevention was viewed as another problem-focused coping behaviour. There was considerable wory over the possibility of experiencing another fall. Some of the women talked about general safety measures such as putting the rubber mat down in the tub during a bath or shower. This example was from the woman who tripped on the sweater wrapped around the chair. Several of the women talked about being more careful in relation to all their activities. The woman who had fractured her hip after tripping on her bedspread described her wory over her first few outings outside the home: "There is no guarantee that it can't happen. It could happen any time. Even when I go out on the street it could happen." When asked how she coped with this worry, she stated: 83 Wel, you have to be more careful, watch out for everything that comes your way. For instance, you are walking on the street in case a bike comes along you wory because you are going to get hit or whatever. That could happen very easily. Several of the women described changing their approach to the activities in their life. For example, taking more time or not rushing all the time. This account was from the woman who tripped on her sweater and broke her wrist: "I am watching it better. I don't rush the way I usualy go. Maybe I will get over that." From these statements, slowing down may not be a permanent behaviour change. Several other women were more commited to the proposed change in lifestyle. One woman detailed the folowing account of her change: But I find one thing that I must not do is to leave anything to the last minute, and rush. I get very, very shaky and nervous if I have to push myself too far. And I usualy try, if I go out one day, to more or less rest up the next day. The above account was from the woman who had experienced 12 falls in the past. This woman had developed ways of balancing the activity in her life. Another woman also talked about a slower pace. She had experienced two falls in the last eight months. She did not 84 know the cause for her falls. As a result of her wory over more falls, she hoped that a slower pace would help to prevent them. She indicated that she had always moved fast to get all the things done that she had to do. She described the worry, and the slowing of her pace of activities: So, I keep on, but worrying, back in my mind, although the physio that came to the house said to just relax and don't rush; that might have a certain amount to do with it. When asked how it felt to slow down, she replied that she was learning to slow down. This woman viewed slowing down as a coping behaviour to prevent more falls. Ultimately, it was also a behaviour to protect her level of activity and independence : And so I just have to stop and think a little bit of myself. And it isn't only of myself, but my family, because if I, you know, I'm ill, it's more work for them. From the data analysis, it was also interesting to note that several women identified ways of walking that might prevent further falls. Here, problem-solving skills were quite evident. Besides slowing her pace, the woman who had fallen 12 times described her conscious approach to walking: If I remember to lead with this leg, you see my right leg is my weak leg and sometimes I step down on that and 85 then it just goes on me, and I just colapse, I don't have any warning; and that's what happened this last time on the bus. I went down on my right leg. But, if I remember to use this leg, then I usualy make it all right. So far, so good. The woman who fell while opening the fridge door also talked about reminding herself to walk in a certain way. Even though this behaviour was not specifically related to this fall, she had obviously been thinking about it: What I think is, I don't when I'm tired maybe raise this foot as high as I should and what I always say to myself is, "Raise your feet, raise your feet." I don't think I raise that left foot. It was evident, from these accounts, that prevention of further falls was an important issue for these elderly women. Plans for the Future As a result of the fall, several women in the study began to contemplate and make plans for the future. This planning was viewed as a new coping behaviour in response to their perceived need for care and support. This planning was clearly related to their loss of independence and their desire to not be a burden to family and friends. There were varying degrees of acceptance to placement as some of the women talked about their plans. One woman talked about planning a tour of the facilities 86 with some of the women in her Senior's Complex. She appeared to approach the issue of nursing home placement in a mater-of-fact way: "Wel, sometimes that's why I think that you know we've all got to face it; we'll probably end up in a nursing home." When asked if she had any feelings of what life would be like in a facility, she responded: Wel, I'm not too, a lot of people dread it. I don't really. I think if you get in a halfway decent place, you have to make your own way. I mean, have your own interests and just do the best you can. Realy, I wouldn't go with family. This woman had made no definite plans for placement. In contrast, two women talked about their plans for personal care home placement. One woman had her name placed on a list before she left the hospital to return to the community. The other woman was considering this option during the first interview with her. She had strained her back during her fall and had spent three weeks in bed after her discharge from hospital. During the second interview, she indicated that she had made some arangements for placement with the Long Term Care coordinator. Both of these women talked about moving to the facility once they were more independent. The folowing accounts illustrate this point: "I'm going—I am going into a nursing home when I get better; I've got my name in"; and: 87 I want t o get b e t t e r enough t o g a t h e r up what I want t o t a k e w i t h me and go i n t o a n u r s i n g home. I don't want t o go i n r i g h t now; I want t o get on my f e e t . The 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 the i n f o r m a t i o n t h a t p e o p l e e n t e r e d f a c i l i t i e s once they were no l o n g e r a b l e t o c a r e f o r t h e m s e l v e s . When t h i s was e x p l o r e d f u r t h e r w i t h the women, the second woman responded t h a t she wanted t o make the d e c i s i o n a t the r i g h t t i m e . She wanted t o see i f t h e r e was g o i n g t o be any improvement i n her f u n c t i o n a l s t a t u s . I t was a b i g d e c i s i o n f o r her as she had l i v e d i n her p r e s e n t apartment s i n c e 1964. D e s p i t e the f a c t t h a t the women t a l k e d about placement as i n e v i t a b l e , t h e r e appeared t o be some ambivalence about t h i s o p t i o n as the time f o r the d e c i s i o n drew n e a r e r . T h i s ambivalence may have 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 . I t may a l s o have been r e l a t e d t o the a d j u stment between t h e i r p e r c e p t i o n o f themselves as independent v e r s u s the f a c t t h a t b e i n g i n a f a c i l i t y meant t h a t they would now r e q u i r e some a s s i s t a n c e w i t h t h e i r c a r e . Use of S o c i a l Support In response t o t h e i r p e r c e p t i o n of t h e i r d e c r e a s e d independence, the l a s t c o p i n g b e h a v i o u r t h a t was d e s c r i b e d was the use o f s o c i a l s u p p o r t s . The s o c i a l s u p p o r t came from v a r i o u s s o u r c e s such 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, and homemakers. The homemakers were from the government Long 88 Term Care programs or p r i v a t e companies. One s u b j e c t a l s o t a l k e d about her p r i v a t e c l e a n i n g l a d y . The theme of s o c i a l s u p p o r t use was d i v i d e d i n t o two d i f f e r e n t c a t e g o r i e s . The f i r s t c a t e g o r y was the type of h e l p . The second c a t e g o r y was the e x p e c t a t i o n s f o r the h e l p t h a t was p r o v i d e d i n t h e i r homes. The f i r s t c a t e g o r y o f the type of h e l p was e a s i l y r e p r e s e n t e d on a continuum. The continuum ranged from 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 the o t h e r end where 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 f r i e n d s ) . At the end of the continuum where the main s u p p o r t was home c a r e , the women t a l k e d about not wa n t i n g t o burden f a m i l y or f r i e n d s . One woman t a l k e d about not b e i n g a burden t o her f r i e n d s : They are my f r i e n d s , okay, but I don't want t o c a l l . They have t h i n g s t o do w i t h t h e i r c h i l d r e n o r whatever. They have a l i f e t o l i v e t o o . I don't want them t o get i n v o l v e d i n t h a t . P l u s , they l i v e q u i t e f a r away from me, so I don't want t o get them i n v o l v e d i n t h a t or d i s t u r b them. Another woman t a l k e d about her f e a r of becoming a burden t o her f a m i l y : You know, I can get on because I've got the w a l k e r and I've got the g i r l i n and I've made m y s e l f a b l e t o do, 89 because I didn't want people to, I didn't want to have to go and live with my daughter and ruin her life up. On the middle of the continuum, several women talked about receiving home care and some help from their friends and family. One woman described this experience: Oh, I am helpless. There's a girl at the end of the hall; she's not well. I don't like calling on friends to wait on me. You know, I don't want to bring them in on my troubles. When exploring these feelings further, she stated that some of her friends had volunteered their help: A chap brings groceries. Another friend will be driving me to my doctor's appointments. I don't want them to do anything like helping me. I couldn't ask my friends to do what the homemaker's doing for me. I don't want my friends to have total responsibility for my care. Home care was then viewed as a compromise so that her friends could assist her, but, at the same time, not have total responsibility for her care. At the other end of the continuum were the women who relied solely on the help from their friends or family. One woman described her experience of relying on her daughter and cleaning lady after her discharge from hospital: I was so tired of people, as I told you. I never had a public ward, or a 4-bed, whatever you call it, in my 90 life before, and I was so tired of people — listening to them talk about their ailments and everything, that I couldn't put up with a homemaker and I happened to have a good cleaning woman, and so we coped. Reciprocity appeared to be an important determinant of whether to ask a friend for assistance. One woman stated that relying on her friends and family was part of their reciprocal relationship: "They just swamped me with their kindness and almost—I can't believe it. Oh, this is wonderful." Her friends had assisted her with numerous tasks such as household chores, meal preparation, shopping and personal care. When asked how she felt about her friends providing support to her, she stated: "I would do the same thing for them. They say it's time you got home care; you've been so good to us. So it is very mutual." Another woman described the reciprocity in her relationships with the neighbours in the block: There are people in the building that will help, you know; we help each other quite a bit. I've got two gals down the hall, Jehovah's Witnesses, and I've always been kind of leery of them, but you know, they're so nice, they'll do anything; if I want help, they'll do anything. We try to help each other. Another example of reciprocity was the woman who decided to accept home care to alleviate being totally dependent on her 9 1 friends. The theme of reciprocity was important as the women decided who to ask for assistance. It was interesting to note that the involvement of friends or family was dependent on the women's perception of their relationship with these different people. The elderly women's autonomy was important in the decision to involve family or friends. The second category within the use of the social support theme was defined as expectations of the help. Since 5 of the 8 women received home care, the expectations of the help was primarily related to this service. However, there were also some examples of expectations from the women who relied solely on family and friends. It was interesting to note that most of the women mentioned the race of the homemakers. For several women, this was an important issue because they had difficulty communicating with the homemakers. The woman who had laid in bed for three weeks after her discharge from hospital described this experience: "They are all Filipino; they are very hard to make out." This communication problem was complicated further due to the lack of continuity in sending the same homemaker to the woman's home. She described this experience: And another thing, I resent is first you'll get a different one every time and you have to tell them, holer from here in the kitchen where things are. Wel now, the little one that came this morning, she knows, she's been here about f i v e or s i x t i m e s . She knows where t h i n g s a r e , but they don't g i v e you one perso n and they don't know; you have t o go i n t o a b i g d i s c u s s i o n and they c a n ' t f i n d t h i n g s . Another woman t a l k e d about her communication problems w i t h her S p a n i s h c l e a n i n g l a d y . Even though l a c k of c o n t i n u i t y was not a problem i n t h i s p r i v a t e arrangement, the communication was a source of 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 c l e a n i n g g i r l . She's f r o m — I f o r g e t — n o t S p a i n , but some p l a c e s o u t h , and she's Span-ish and doesn't speak E n g l i s h v e r y w e l l . And so sometimes when she goes s h o p p i n g , she wouldn't b r i n g back the r i g h t t h i n g s . That's the o n l y f r u s t r a t i o n I had. The 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 problem f o r s e v e r a l of the o t h e r women i n the s t u d y . These comments were not s p e c i f i c a l l y r e l a t e d t o any communication i s s u e . One woman who was r e c e i v i n g homemakers on a d a i l y b a s i s d e s c r i b e d t h i s e x p e r i e n c e : "And they were n i c e t oo but I've got used t o L., and I l i k e R., and I hope s h e ' l l be a b l e t o s t a y w i t h me." When asked 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 have the same p e r s o n , she responded: " I t i s , f o r she g e t s t o know where e v e r y t h i n g i s and my way and her way. " From t h e s e a c c o u n t s , the women e x p r e s s e d f r u s t r a t i o n i n 93 receiving home care help from people whom they could not communicate with. As well, it was important to have continuity of homemakers. The continuity of homemakers was also important for communication and ensuring some familiarity with the elderly women's routines in the home. Another important expectation of the homemakers was that they be good housecleaners. Here, the women commented that they were nice girls but they remained critical of the girls' housekeeping skills. The 102-year-old woman described her homemaker: She's a nice person but she leaves much to be desired on housework the way I do it myself, but then, I am a fussy old duck. I like things done right (whispers) and I like to work. Here, this woman's expectations for herself were passed on to the homemakers. One woman commented on their lack of training which she believed to be the major problem. As a result, they were poor housekeepers: I have this girl, comes in once a week and does the vacuuming and a few other jobs, and I have everything to put away when she goes. They don't train them, you know. I don't know why, I don't know why they don't train them properly. She's a very nice little girl, very willing to do things, but when they're finished, 94 they j u s t drop e v e r y t h i n g and then i t ' s up t o you t o go and s t r a i g h t e n t h i n g s up, and put t h i n g s away. I t was apparent t h a t the homemakers' l a c k of s k i l l s was ano t h e r s o u r c e o f f r u s t r a t i o n f o r the women i n the stu d y . Another e x p e c t a t i o n of the h e l p r e c e i v e d was t h a t they show some r e s p e c t f o r the women's way of managing her household a c t i v i t i e s . From the i n t e r v i e w s , t h e r e appeared t o be e v i d e n c e of the 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 m a i n t a i n some c o n t r o l . T h i s maintenance of c o n t r o l was r e f e r r e d t o e a r l i e r i n t h i s paper. One woman d e s c r i b e d her o r g a n i z a t i o n of the t a s k s t h a t r e q u i r e d c o m p l e t i o n . She was r e l y i n g on her f r i e n d s and f a m i l y f o r s u p p o r t : The g i r l s a l l phone, a s k i n g can they h e l p ? And I have e v e r y t h i n g l i n e d up. C o r n f l a k e s box t h a t needs o p e n i n g , t o b u t t e r t h a t needs c u t t i n g , and i t i s a l l l i n e d up and they go r i g h t t o i t . Another woman d e s c r i b e d her e x p e r i e n c e w i t h the homemakers from a p r i v a t e agency: W e l l , I guess they get s o r t of annoyed w i t h me. B u t , I go out i n the k i t c h e n and say, "Oh, heat t h i s l e f t o v e r c h i c k e n up i n t h i s package of b o u i l l o n , c h i c k e n b o u i l l o n . " I t r y t o t e l l them how t o do t h i n g s which i guess they don't a p p r e c i a t e . D u r i n g the c o u r s e of the i n t e r v i e w w i t h t h i s woman, she had 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 r y i n g t o f i n d the 95 m a r g a r i n e . She had s t a t e d t h a t t h i s p l a c e no l o n g e r seemed l i k e her own. When asked how i t f e l t t o have p e o p l e come i n and do t h i n g s f o r you t h a t you were used t o d o i n g on your own, she responded: But my k n i f e drawer, I have one drawer f o r s i l v e r , my s i l v e r and the o t h e r drawer f o r u t e n s i l s , and I have got a l o t of k n i c k - k n a c k s or u t e n s i l s . Some of them are never used but they were a l l mixed i n w i t h the s i l v e r . That annoyed me. My t o w e l s i n my h a l l , f o l d e d j u s t s o , j u s t l i k e they are i n the s t o r e or shops. W e l l , they j u s t f o l d them and throw them up. When asked i f she wanted the homemakers t o r e s p e c t her ways, she r e p l i e d : W e l l , t h e y ' r e a l l n i c e g i r l s , r e a l l y , but t h e y ' r e young. They're a l l n i c e g i r l s . I haven't any c o m p l a i n t about them. B u t , I am f u s s y , I guess; f u s s y o l d maid. (Laug h s ) . B u t , you know, I w i l l be 80 next week and you are s e t i n your ways. Here, the woman d e s c r i b e d how she t o l d the homemakers how t o do t h i n g s but she was r e l u c t a n t t o admit t h a t t h i s was the way she wanted t h i n g s done. A l s o , t h e r e was a f e e l i n g of not w a n t i n g t o c o m p l a i n about the s e r v i c e because she r e q u i r e d the s e r v i c e : " I am v e r y t h a n k f u l t h a t they come i n ; someone t o come i n . " 96 Summary In summary, this chapter has presented the results of the data analysis. Both the fall and treatment within the Health Care system resulted in a change of routine for these women, upon their return home. The change in the routine was due to the physical and psychological consequences of the fall. The change in routine resulted in threats to the elderly women's self-esteem. The themes that were identified as part of the self-esteem concept were independence, activity, and autonomy. All of the women in the study described how their degree of independence was affected after the fall. The ability to meet one's physical and emotional needs was valued highly by all the women. Some women reported a loss of confidence after the fall. Other women reported that they required assistance with their personal care or in the management of household tasks. All of the women described their activity level prior to the fall. Activity was an important component of their self-esteem. Despite the different types of activity, the women perceived them all to be important. The women's level of activity changed after the fall. This was a source of concern for the women in the study. Autonomy was the last theme that the elderly women described. Autonomy, or self-determination, was important to these women. The data 97 revealed three different processes of decision-making that the women encountered after their fall. As well, it was important for the women to have adequate medical information about their health status. The second concept was adaptation. The women used coping behaviours in order to cope with the threat to their self-esteem. Some of these behaviours were emotion-focused coping, while other behaviours were problem-focused. There was a wide range of behaviours that were used by the elderly women. The different categories of behaviours included the folowing: (a) use of faith/positive beliefs, (b) compliance, (c) maintaining control, (d) prevention, (e) planning for the future, and (f) use of social support. Some behaviours were used in past life-events. Other behaviours were learned in response to the fall and change in rout ine. This chapter has presented the findings of this study. In the next chapter, these findings are discussed and related to the current research and theoretical findings that are currently available. 98 CHAPTER FIVE: DISCUSSION OF THE FINDINGS I n t r o d u c t i o n T h i s c h a p t e r p r e s e n t s a d i s c u s s i o n o f the s t u d y ' s f i n d i n g s . Here, the f i n d i n g s w i l l be more f u l l y e x p l o r e d i n c o n j u n c t i o n w i t h the t h e o r e t i c a l l i t e r a t u r e and r e s e a r c h f i n d i n g s c u r r e n t l y a v a i l a b l e . The l a s t c h a p t e r w i l l d i s c u s s the 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 p r a c t i c e t h a t a r i s e from the s t u d y ' s r e s u l t s . C h a p t e r S i x w i l l a l s o i n c l u d e the s t u d y ' s summary and c o n c l u s i o n s . K leinman's H e a l t h Care Systems Model (1978) p r o v i d e d the framework f o r e x p l o r i n g the 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 . As mentioned i n Ch a p t e r One, the e x p l a n a t o r y models c o n t a i n e d i n t e r p r e t a t i o n s o f 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 consequences o f a f a l l . These 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 the women's p e r c e p t i o n s of the need f o r c a r e and su p p o r t as they r e t u r n e d home from the h o s p i t a l t o l i v e a l o n e . S e v e r a l major themes emerged from the d a t a a n a l y s i s as the e l d e r l y women d e s c r i b e d the need f o r care and s u p p o r t . F a l l as a S i g n i f i c a n t Event Each woman p e r c e i v e d the f a l l as both a s i g n i f i c a n t and unexpected event i n t h e i r l i v e s . They d e s c r i b e d the changes i n r o u t i n e a t home r e s u l t i n g from the f a l l and i t s p h y s i c a l and p s y c h o l o g i c a l consequences. One major consequence was the d e s c r i p t i o n o f the t h r e a t t o t h e i r s e l f - e s t e e m a f t e r the f a l l e v e n t. In t h e i r own unique ways, the women adapted t o the changes i n r o u t i n e a f t e r the f a l l e v e n t . The p r o c e s s of p e r c e p t i o n and adjustment t o l i f e events i s well-documented i n the l i t e r a t u r e . Hanley and B a i k i e (1984) p r o v i d e d a breakdown o f s t r e s s f a c t o r s t h a t were r e l e v a n t t o the f i n d i n g s from the e l d e r l y women. The f o u r c a t e g o r i e s o f a t t a c k , r e s t r a i n t , l o s s , and t h r e a t were b e l i e v e d t o be u s e f u l i n h e l p i n g t o un d e r s t a n d the r e l a t i v e d i f f i c u l t y o f a d j u s t i n g t o d i f f e r e n t l i f e e v e n t s . A t t a c k was viewed as an e x t e r n a l f o r c e which produced d i s c o m f o r t (Hanley & B a i k i e , 1984). In t h i s s t u d y , the f a l l was i n c l u d e d i n the a t t a c k c a t e g o r y . R e s t r a i n t c o n s t i t u t e d 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 which were n e c e s s a r y f o r the s a t i s f a c t i o n o f b a s i c human needs. From the e l d e r l y women's d e s c r i p t i o n s , the change i n r o u t i n e , upon t h e i r r e t u r n home, was r e l e v a n t t o t h i s c a t e g o r y . Loss was d e f i n e d as the removal o f e x t e r n a l c i r c u m s t a n c e s 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 t h e i r needs. An example of l o s s , from t h i s s t u d y , was the l o s s o f a c t i v i t y the women e x p e r i e n c e d a f t e r the f a l l . T h i s a c t i v i t y or p r o d u c t i v i t y was viewed as an i m p o r t a n t way t o s a t i s f y t h e i r need f o r s e l f - e s t e e m . F i n a l l y , Hanley and B a i k i e (1984) d e f i n e d the t h r e a t as any event which warned of p o s s i b l e f u t u r e l o s s , a t t a c k , or r e s t r a i n t . Here, the p o s s i b i l i t y o f more f a l l s and t h e i r 100 p h y s i c a l and p s y c h o l o g i c a l consequences posed a t h r e a t t o the e l d e r l y women i n t h i s s t u d y . The importance o f the f a l l event to the women was a l s o congruent w i t h L a z a r u s and Folkman's (1984) s t u d i e s on c o p i n g . T h e i r work on the c o p i n g p r o c e s s r e v e a l e d t h a t i t s d u a l g o a l s of p r o b l e m - r e s o l u t i o n and e m o t i o n - r e g u l a t i n g brought i n to p l a y the c o g n i t i v e , a f f e c t i v e , and b e h a v i o u r a l response systems of the i n d i v i d u a l . The c o g n i t i v e system was the f i r s t to be engaged when the person was exposed to the s t r e s s o r , such as the f a l l e v e n t . The i n d i v i d u a l attempted to d i s c e r n the s i g n i f i c a n c e of the s t r e s s o r in terms of h i s or her w e l l - b e i n g . As a r e s u l t , the s t r e s s o r was i n t e r p r e t e d i n one of f o u r ways: as a t h r e a t , as a source of harm, as a l o s s , or more as a c h a l l e n g e . A g a i n , the p e r c e p t i o n of the f a l l event was im p o r t a n t i n d e t e r m i n i n g the women's a d a p t a t i o n to the r e s u l t a n t changes i n t h e i r l i f e . S e l f - E s t e e m S e l f - e s t e e m was one o f the major concepts i d e n t i f i e d d u r i n g the data a n a l y s i s . As d i s c u s s e d , the e l d e r l y women d e s c r i b e d t h r e a t s t o t h e i r s e l f - e s t e e m r e s u l t i n g from the f a l l e v e n t. Independence, a c t i v i t y , and autonomy were i d e n t i f i e d as i m p o r t a n t themes w i t h i n the s e l f - e s t e e m c o n c e p t . These are 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 the t h e o r e t i c a l work on s e l f - e s t e e m . B e f o r e d i s c u s s i n g these i n d i v i d u a l themes, i t i s i m p o r t a n t t o p r o v i d e a d e f i n i t i o n f o r the concept due t o a m b i g u i t i e s i n the l i t e r a t u r e . S e l f - e s t e e m has been the fo c u s o f t h e o r e t i c a l w r i t i n g s i n p s y c h o l o g y and s o c i o l o g y s i n c e the 1930s (Mead, 1934). A r e v i e w of the l i t e r a t u r e h i g h l i g h t s 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 the d e f i n i t i o n . S e l f - e s t e e m i s a dynamic f e e l i n g t h a t r e f l e c t s the degree t o which 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 , and/or v a l u e s him or her s e l f (Mead, 1934; Rosenberg, 1985). S e l f - e s t e e m i s i n f l u e n c e d by the r e f l e c t e d a p p r a i s a l s o f s i g n i f i c a n t o t h e r s ( C o o l e y , 1964; S u l l i v a n , 1953), and by the i n d i v i d u a l ' s f e e l i n g s o f competence and worth r e l a t e d t o h i s e f f e c t i v e n e s s i n s o c i e t y ( F e l k e r , 1974; T a f t , 1985). Independence, a c t i v i t y , and autonomy were i m p o r t a n t components of the e l d e r l y women's s e l f - e s t e e m . These f i n d i n g s r e l a t e d t o s e l f - e s t e e m were s u p p o r t e d i n the l i t e r a t u r e . Kaufman (1986), i n her work, found t h a t 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 the e l d e r l y i n d i v i d u a l s . Her sample c o n s i s t e d of 60 men and women over the age of 70. She c o n c l u d e d t h a t t h e s e themes were based on i m p o r t a n t v a l u e s f o r t h a t g e n e r a t i o n or b i r t h c o h o r t . A b i r t h c o h o r t r e f e r r e d t o a l l i n d i v i d u a l s born d u r i n g a c e r t a i n time-frame. She s t a t e d t h a t these v a l u e s emphasized 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 and f a i r l y e x p l i c i t i n d i c e s of s o c i a l w orth. The i n d i v i d u a l s w i t h i n the c o h o r t s t a r e d common i d e a l s d e r i v e d from common e x p e r i e n c e s . These 102 v a l u e s were e v i d e n t i n the women i n t e r v i e w e d i n t h i s s t u d y . Independence was viewed as the a b i l i t y t o p r o v i d e f o r one's own p h y s i c a l and e m o t i o n a l needs. From the r i c h d e s c r i p t i o n s , i t was e v i d e n t t h a t 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 posed a t h r e a t t o the women's p e r c e p t i o n s o f themselves as independent. The women d e s c r i b e d the 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 a c t i v i t i e s upon t h e i r r e t u r n home from h o s p i t a l . Examples i n c l u d e d s h o p p i n g , meal p r e p a r a t i o n , and p e r s o n a l c a r e . T h i s s t u d y c o n c l u d e d t h a t independence was an i m p o r t a n t component of the women's s e l f - e s t e e m . T h i s was a s i g n i f i c a n t f i n d i n g and was su p p o r t e d by the l i t e r a t u r e ( H i r s t & M e t c a l f , 1984; Kaufman, 1986). I n f a c t , independence was viewed as the most i m p o r t a n t aim o f the m a j o r i t y of the e l d e r l y p o p u l a t i o n r e g a r d l e s s o f t h e i r s t a t e of h e a l t h ( C u l b e r t & Kos, 1971). A c t i v i t y was the second theme i d e n t i f i e d d u r i n g the d a t a a n a l y s i s . The e l d e r l y women viewed a c t i v i t y as another i m p o r t a n t component of t h e i r s e l f - e s t e e m . S e v e r a l women d e s c r i b e d t h e i r p a s t w o r k i n g l i v e s . A l l the women d e t a i l e d t h e i r p r e s e n t - d a y a c t i v i t i e s . These 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 the p r o v i s i o n of sup p o r t t o o t h e r s , s o c i a l f u n c t i o n s , and s o l i t a r y c r a f t work. A s i g n i f i c a n t f i n d i n g was the p e r c e p t i o n t h a t a l l a c t i v i t i e s were m e a n i n g f u l . A n o t h e r i m p o r t a n t f i n d i n g was t h a t the women e x p e r i e n c e d d e c r e a s e d 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 103 p s y c h o l o g i c a l consequences of the f a l l . As a r e s u l t , they p e r c e i v e d t h r e a t s t o t h e i r s e l f - e s t e e m . The importance of a c t i v i t y t o the women's s e l f - e s t e e m was s u p p o r t e d by the l i t e r a t u r e . R e search on a c t i v i t y has been on-going s i n c e the e a r l y 1960s. D u r i n g t h i s t i m e , i m p o r t a n t l i n k s have been e s t a b l i s h e d i n the r e l a t i o n s h i p between a c t i v i t y and s e l f - e s t e e m (Neugarten, H a v i g h u r s t , and T o b i n , 1968). Today, a c t i v i t y remains an i m p o r t a n t v a l u e i n s o c i e t y . The tendency remains t o d e s c r i b e a p e r s o n ' s i d e n t i t y i n terms of h i s or her work r o l e (Kaufman, 1986; Stahmer, 1986). I t remains an a c c e p t a b l e measure of human worth and t h e r e b y a f f e c t s f e e l i n g s of s e l f - e s t e e m . The f i n d i n g t h a t a l l a c t i v i t i e s , not j u s t w o r k - r e l a t e d ones 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 s u p p o r t e d i n the l i t e r a t u r e . P e r c e p t i o n s r e l a t e d t o m e a n i n g f u l n e s s are s h i f t i n g away from t r a d i t i o n a l work a c t i v i t i e s (Coleman, 1990). S o c i e t y i s now a p p r o a c h i n g a time i n human h i s t o r y where l e i s u r e time p u r s u i t s , v o l u n t a r y community work and c r e a t i v e e x p r e s s i o n are becoming more i m p o r t a n t . Autonomy was the l a s t i m p o r t a n t theme t h a t emerged as the women d e s c r i b e d t h e i r e x p e r i e n c e s a f t e r the f a l l e v e n t . T h i s was the l a s t component of t h e i r s e l f - e s t e e m t h a t was i d e n t i f i e d i n t h i s s t u d y . Autonomy, or 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 d e c i s i o n - m a k e r s about t h e i r own c a r e (Matteson & M c C o n n e l l , 1988). There 104 were s e v e r a l s i g n i f i c a n t f i n d i n g s i n t h i s s t u d y r e l a t e d t o autonomy. F i r s t l y , the women d e s c r i b e d s i t u a t i o n s where d e c i s i o n s about t h e i r m e d i c a l c a r e were made s o l e l y by h e a l t h p r o f e s s i o n a l s . Examples from the d a t a i n c l u d e d not r e c e i v i n g any f o r m a l s u p p o r t s upon d i s c h a r g e home and unwanted v i s i t s from a p h y s i o t h e r a p i s t . Here, the women's autonomy was t h r e a t e n e d by t h e i r l a c k o f in v o l v e m e n t i n the d e c i s i o n -making p r o c e s s . The second s i g n i f i c a n t f i n d i n g was t h a t the women f e l t t h a t they l a c k e d adequate m e d i c a l 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 . S e v e r a l women arr a n g e d t h e i r own m e d i c a l f o l l o w - u p f o r the purpose of o b t a i n i n g more i n f o r m a t i o n . T h i s l a c k o f m e d i c a l knowledge was p e r c e i v e d as a t h r e a t t o t h e i r autonomy. These f i n d i n g s were congruent w i t h the l i t e r a t u r e r e v i e w on autonomy. W r i g h t ( c i t e d i n McElmurry & Z a b r o c k i , 1989) d e s c r i b e d autonomous d e c i s i o n s a s : (a) those based on the i n d i v i d u a l v a l u e s , (b) u t i l i z i n g adequate i n f o r m a t i o n and u n d e r s t a n d i n g , (c) f r e e from c o e r c i o n or r e s t r a i n t , and (d) based on reason and d e l i b e r a t i o n . Based on these c r i t e r i a , a l l i n d i v i d u a l s need t o be i n v o l v e d i n the d e c i s i o n - m a k i n g p r o c e s s about t h e i r m e d i c a l c a r e . D e c i s i o n s about h e a l t h c a r e a re no l o n g e r 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 ( R e i l l y , 1989). I n s t e a d , t hey must i n v o l v e the i n d i v i d u a l , s i g n i f i c a n t o t h e r s , and h e a l t h p r o f e s s i o n a l s . 105 Several studies also supported the importance of the rel a t i o n s h i p between autonomy, perceived control, and s e l f -esteem (Berkowitz, Waxman, & Yaffe, 1988; Langer, 1983; Rodin, 1986) . Langer (1983) studied perceived control in a group of nursing home residents. One group of residents was addressed by an administrator who emphasized their autonomy. This group was encouraged to make decisions for themselves, given decisions to make, and given r e s p o n s i b i l i t y for something outside of themselves. A second group of residents received a d i f f e r e n t speech from the same administrator. This speech stressed the s t a f f ' s r e s p o n s i b i l i t y for their care and management in the home. Of the f i r s t group, 93% f e l t happier, became more active, and experienced a feeling of competence. In contrast, 70% of the second group became more d e b i l i t a t e d within a 3-week period. Langer (1983) concluded that increasing environmental control, thereby fostering autonomy, was related to increases in self-esteem for the study's pa r t i c i p a n t s . Berkowitz et a l . (1988) made similar conclusions. Here, community-residing individuals who participated in decision-making, and advocating for their own needs, scored higher on tests measuring self-esteem. Once again, lack of involvement in decision-making resulted in lower scores on the s e l f -106 esteem t e s t s . T h e r e f o r e , these two s t u d i e s supported the f i n d i n g s t h a t the women e x p e r i e n c e d t h r e a t s to t h e i r autonomy when not i n v o l v e d i n t h e i r m e d i c a l c a r e d e c i s i o n s . The second f i n d i n g , r e g a r d i n g the importance of m e d i c a l i n f o r m a t i o n i n making autonomous d e c i s i o n s , was a l s o s u p p o r t e d by the l i t e r a t u r e . L e s s - i n f o r m e d i n d i v i d u a l s were p a r t i c u l a r l y v u l n e r a b l e t o engaging i n h e a l t h d e c i s i o n s i n which i n f o r m a t i o n d e f i c i t s were a s e r i o u s concern (McElmurry & Z a b r o c k i , 1989). Here, an i n d i v i d u a l ' s autonomy was t h r e a t e n e d by t h i s type of p r o c e s s . As d e s c r i b e d i n the l i t e r a t u r e , the i s s u e of ageism i s i m p o r t a n t i n d e t e r m i n i n g many of the a f o r e m e n t i o n e d c o n d i t i o n s f o r autonomous d e c i s i o n s (French, 1990; Matteson and M c C o n n e l l , 1988) . As w e l l , ageism has a p o w e r f u l impact on the l a r g e r concept of s e l f - e s t e e m . Ageism i s d e f i n e d as the p r o c e s s of s y s t e m a t i c s t e r e o t y p i n g and d i s c r i m i n a t i o n a g a i n s t p e o p l e because they are o l d ( B u t l e r , 1975). O l d e r p e r s o n s are o f t e n s t i g m a t i z e d as b e i n g l o n e l y , absent-minded, s e n i l e , dependent, i r r i t a b l e , and p o s s e s s i n g poor h e a l t h ( T e r p s t r a , T e r p s t r a , P l a w e c k i , & S t r e e t e r , 1989). Ageism remains a problem i n our s o c i e t y , and because n u r s e s r e f l e c t the views of s o c i e t y i n which they l i v e , they may h o l d n e g a t i v e views about the aged ( B u r n s i d e , 1990). One study by Knowles and S a r v e r (1985) documents t h a t b a c c a l a u r e a t e s t u d e n t s i n a u n i v e r s i t y program l e a s t 107 p r e f e r p a t i e n t s over 75 y e a r s o f age. Even though, n u r s e s have not been found t o be any more n e g a t i v e than o t h e r groups (Maddox & T i l l e y , 1988), i t remains d i f f i c u l t t o a s s e s s an e l d e r l y 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 are h e l d . S e l f - e s t e e m o f the e l d e r l y i s then a f f e c t e d by s o c i e t y ' s view toward them. T h i s comment p e r t a i n s t o the a s p e c t o f the d e f i n i t i o n t h a t r e f e r s t o the r e f l e c t e d a p p r a i s a l s o f s i g n i f i c a n t o t h e r s . These a p p r a i s a l s a re i m p o r t a n t s i n c e a l l the women i n t h i s s t u d y r e c e i v e d t r e a t m e n t w i t h i n the H e a l t h Care System. A d a p t a t i o n A d a p t a t i o n was the second concept t h a t emerged from the d a t a a n a l y s i s . T h i s concept has a l s o undergone e x h a u s t i v e r e s e a r c h . Due t o i t s magnitude, the d i s c u s s i o n o f a d a p t a t i o n w i l l be r e s t r i c t e d t o the d i f f e r e n t methods of c o p i n g t h a t were i d e n t i f i e d i n t h i s s tudy on e l d e r l y women. The p r o c e s s of a d a p t a t i o n or c o p i n g was d e f i n e d as the " 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 and/or i n t e r n a l demands t h a t are a p p r a i s e d as t a x i n g or e x c e e d i n g the r e s o u r c e s o f the p e r s o n " ( L a z a r u s & Folkman, 1984, p. 141). In t h i s s t u d y , the women used a v a r i e t y of b e h a v i o u r s t o cope w i t h the f a l l event and r e s u l t a n t change i n r o u t i n e . Examples of c o p i n g b e h a v i o u r s from the f i n d i n g s were use o f 108 p o s i t i v e b e l i e f s , m a i n t a i n i n g c o n t r o l , c o m p l i a n c e , p r e v e n t i o n , p l a n n i n g f o r the f u t u r e , and use of s o c i a l s u p p o r t s . As d e s c r i b e d i n the l i t e r a t u r e , c o p i n g b e h a v i o u r s were det e r m i n e d by the p e r s o n ' s r e s o u r c e s ( L a z a r u s & Folkman, 1984). There were s e v e r a l major 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 ( h e a l t h and e n e r g y ) , p s y c h o l o g i c a l r e s o u r c e s ( p o s i t i v e b e l i e f s ) , competencies ( 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 ) , s o c i a l s u p p o r t , and m a t e r i a l r e s o u r c e s . I n h e r e n t i n the s t u d y ' s f i n d i n g s were two d i f f e r e n t t y p e s of c o p i n g . Use of p o s i t i v e b e l i e f s r e p r e s e n t e d one type of c o p i n g . In c o n t r a s t , the second type o f c o p i n g 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 . 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 as the women d e s c r i b e d t h e i r c o m p l i a n c e t o m e d i c a l regimes, p r e v e n t a t i v e s t e p s taken t o p r e v e n t the r e o c c u r r e n c e of another f a l l , and p l a n n i n g f o r the f u t u r e . T h i s d i s t i n c t i o n between c o p i n g b e h a v i o u r s was su p p o r t e d i n the l i t e r a t u r e . The two ty p e s o f c o p i n g were pr o b l e m - f o c u s e d and e m o t i o n - f o c u s e d (Folkman & L a z a r u s , 1980) . Problem-focused c o p i n g b e h a v i o u r s were s i m i l a r t o 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 ( L a z a r u s & Folkman, 1984). These i n c l u d e d d e f i n i n g the problem, g e n e r a t i n g a l t e r n a t i v e s o l u t i o n s , w e i g h t i n g the a l t e r n a t i v e s i n terms of t h e i r c o s t and b e n e f i t s , c h o o s i n g among them, and a c t i n g . As 109 well, problem-focused coping also included strategies that were directed inward, such as motivational or cognitive changes. Examples encompassed learning new s k i l l s , finding alternative 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 directed at lessening emotional distress and involved strategies, such as distancing, 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 pos i t i v e b e l i e f s , and seeking s o c i a l support (Lazarus & Folkman, 1984). The findings from the study concluded that the elderly women used more problem-focused than emotion-focused coping. This finding was s i g n i f i c a n t in that i t was related to the perception of the women regarding the changeability of the si t u a t i o n . Research has been conducted to determine the extent to which individuals used these d i f f e r e n t types of coping (Folkman & Lazarus, 1980; Folkman, Lazarus, Drunkel-Schetler, Delongis, & Gruen, 1986). The results concluded that the type of coping depends f i r s t l y on the primary appraisal or the personal significance of the encounter. The importance of primary appraisal of the stressor was already discussed in the e a r l i e r section on the f a l l as a s i g n i f i c a n t event. Secondly, the type of coping was also contingent on the secondary appraisal of the event. This involved options for changing the person-environment r e l a t i o n . 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 amenable t o change (Folkman, L a z a r u s , P i m l e y , & Novacek, 1987). T h e r e f o r e , the f i n d i n g s from the e l d e r l y women were congrue n t w i t h the l i t e r a t u r e . The use o f s o c i a l s u p p o r t was a c o p i n g b e h a v i o u r d e s c r i b e d by a l l the women i n t h i s s t u d y . As a r e s u l t , the s t u d y ' s f i n d i n g s , i n r e l a t i o n t o t h i s b e h a v i o u r , w i l l be d i s c u s s e d i n d e t a i l . S o c i a l s u p p o r t encompassed the " e m o t i o n a l s u p p o r t , a d v i c e , g u i d a n c e , and a p p r a i s a l , as w e l l as the 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 e d from t h e i r s o c i a l r e l a t i o n s h i p s ( E l l , 1984, p. 134). The two c a t e g o r i e s of su p p o r t were i n f o r m a l and f o r m a l . As w e l l , i t s h o u l d be noted t h a t use of s o c i a l s u p p o r t was i n c l u d e d i n both e m o t i o n - f o c u s e d and pr o b l e m - f o c u s e d b e h a v i o u r s ( L a z a r u s & Folkman, 1984). One f i n d i n g from the stu d y was t h a t the women d e s c r i b e d a s s i s t a n c e 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 such as f a m i l y and f r i e n d s . S e v e r a l women d e s c r i b e d t h e i r r e l u c t a n c e t o a c c e p t f o r m a l s u p p o r t s such as homemakers. The l i t e r a t u r e s u p p o r t e d t h i s f i n d i n g t h a t e l d e r l y p e r s o n s drew i n i t i a l l y on a i d from 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 from 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 ( C h a p p e l l , 1985; O'Brien & Wagner, 1980) . Another i n t e r e s t i n g f i n d i n g was t h a t the women d e s c r i b e d I l l t h e i r f e a r of becoming a burden t o f a m i l y members or f r i e n d s . Due t o t h i s f e e l i n g , they a c c e p t e d f o r m a l s u p p o r t s . As i t p e r t a i n e d t o f a m i l y members, t h i s f i n d i n g was not s u p p o r t e d i n t he l i t e r a t u r e . C o n t r a r y t o the women's b e l i e f t h a t a c c e p t i n g h e l p would d e c r e a s e the burden f o r f a m i l i e s , s t u d i e s have shown t h a t the p r o v i s i o n of home c a r e does not l e s s e n the f a m i l y ' s i n v o l v e m e n t i n t h e i r c a r e ( C h a p p e l l , 1985; S h a p i r o , 1986). A c c e p t i n g s o c i a l s u p p o r t from f r i e n d s was another d e c i s i o n . One s i g n i f i c a n t f i n d i n g r e l a t e d t o t h i s d e c i s i o n was the importance o f r e c i p r o c i t y i n the women's r e l a t i o n s h i p s . T h i s p a r t i c u l a r f i n d i n g was s u p p o r t e d by the l i t e r a t u r e (Rook, 1987; T i l d e n & W e i n e r t , 1987). R e c i p r o c i t y was a s i g n i f i c a n t f i n d i n g from t h i s s t u d y . Due t o the importance of r e c i p r o c i t y , the e l d e r l y women knew the type 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 from c e r t a i n i n d i v i d u a l s . A l t h o u g h t h i s f i n d i n g was r e l a t e d t o the d i s c u s s i o n on autonomy, i t was a l s o s u p p o r t e d by the l i t e r a t u r e . Rook (1987) s t a t e d t h a t r e c i p r o c i t y was dependent on the p r e v i o u s r e l a t i o n s h i p w i t h the f r i e n d , and the type o f s u p p o r t or s o c i a l exchange r e q u i r e d . Exchange r e f e r r e d t o any o f the f o l l o w i n g t y p e s : companionship, i n s t r u m e n t a l s u p p o r t such as 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 . A n o t h e r s i g n i f i c a n t f i n d i n g from the st u d y was the 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 the home h e l p e r s . I n h a v i n g the homemakers come t o t h e i r homes, the women e x p e r i e n c e d problems w i t h communication, due t o language b a r r i e r s . As w e l l , the s e r v i c e l a c k e d c o n t i n u i t y , i n t h a t the women d e a l t w i t h s e v e r a l homemakers throughout one week. The women were a l s o d i s s a t i s f i e d w i t h the homemakers' work performance. These were i m p o r t a n t f i n d i n g s . R e search was found t h a t d e a l t w i t h home n u r s i n g i n terms of 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 of n u r s e s , and c l i e n t s a t i s f a c t i o n ( K i n g , 1986; McNeese, 1988). However, t h e r e appeared t o be a p a u c i t y o f r e s e a r c h on homemakers. T h i s was i n t e r e s t i n g s i n c e the homemakers were the p r i m a r y care workers f o r s e v e r a l of the women who r e c e i v e d f o r m a l s u p p o r t s . The l a s t i m p o r t a n t f i n d i n g was r e l a t e d t o the women's responses t o the homemakers. They began t o e x e r t some c o n t r o l and t o l d the homemakers how t o complete t a s k s i n t h e i r home. I t appeared t h a t the women's autonomy and independence were f u r t h e r t h r e a t e n e d by the homemaker's a c t i o n s . T h i s f i n d i n g was s u p p o r t e d by the l i t e r a t u r e . A g a i n , Langer's (1983) s t u d y on autonomy and c o n t r o l was r e l e v a n t h e r e . Rowe and Kahn (1987) s t a t e d t h a t s o c i a l s u p p o r t appeared t o e i t h e r i n c r e a s e or decrease the autonomy and 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 enc 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 of s u p p o r t . 113 Constraining, "doing f o r , " and warning beyond the requirements of the sit u a t i o n conveyed caring but they taught helplessness. Again, there was a dearth of research on the types of support provided by homemakers. Summary This chapter provided a summary of the major findings of the study. The findings were discussed and supported by current research and the o r e t i c a l findings. This chapter began with a discussion of the significance of the f a l l event. It was followed by the discussion on self-esteem. The findings related to the themes of independence, a c t i v i t y , and autonomy within the self-esteem concept were then presented. A brief discussion on ageism was also included in the discussion of self-esteem. The process of adaptation was presented as i t related to the study's findings. The d i f f e r e n t types of coping resources were reviewed. This was followed by a discussion on the problem-focused and emotion-focused coping behaviours that were used by the elderly women. The use of s o c i a l support was discussed in d e t a i l since a l l the women used this behaviour. This discussion was followed by a presentation on the importance of rec i p r o c i t y in s o c i a l relationships. F i n a l l y , the women's experiences with the homemakers from formal programs was discussed. 114 CHAPTER SIX: SUMMARY, CONCLUSIONS, AND IMPLICATION FOR NURSING Summary C o n c l u s i o n s T h i s study i s de s i g n e d t o d e s c r i b e the need f o r c a r e and supp o r t as 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 h o s p i t a l i z a t i o n f o r a f a l l . F a l l s are a s i g n i f i c a n t problem f o r these women who c o n s t i t u t e the f a s t e s t growing segment o f the Canadian e l d e r l y p o p u l a t i o n . F a l l s have numerous p h y s i c a l and p s y c h o l o g i c a l consequences. In many c a s e s , t h e s e women r e t u r n home t o l i v e a l o n e a f t e r h o s p i t a l i z a t i o n f o r a f a l l . A r e v i e w o f the l i t e r a t u r e i n d i c a t e s t h a t the 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 . There a re no s t u d i e s t h a t 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 consequences o f f a l l s 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 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 . I n many s i t u a t i o n s , the 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 i s not o n l y m i s u n d e r s t o o d , but the p e r c e p t i o n s a re not even a d d r e s s e d . S t u d i e s on s o c i a l s u p p o r t i n d i c a t e t h a t e l d e r l y p e r s o n s draw i n i t i a l l y on a i d s from i n f o r m a l s u p p o r t s . As w e l l , i n c r e a s e d age 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 i n the use of f o r m a l s u p p o r t s . Kleinman's H e a l t h Care System Model (1978) p r o v i d e s the d i r e c t i o n f o r the purpose and methodology o f the s t u d y . T h i s 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 c o n s i s t i n g o f t h r e e d i s t i n c t but i n t e r r e l a t e d a r e n a s : the p o p u l a r , the p r o f e s s i o n a l , and f o l k a r e n a s . The arenas are where s i c k n e s s i s " e x p e r i e n c e d and r e a c t e d t o " (Kleinman, 1978, p. 8 6 ) . The p o p u l a r arena i s composed of the f a m i l y c o n t e x t of s i c k n e s s and c a r e , as w e l l as the s o c i a l network and community a c t i v i t i e s . The p r o f e s s i o n a l arena i s composed of m e d i c i n e , 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 arena c o n s i s t s o f n o n - p r o f e s s i o n a l h e a l i n g s p e c i a l i s t s . K leinman (1978) s t a t e s t h a t e x p l a n a t o r y models (EMs) can be e l i c i t e d from i n d i v i d u a l s i n the t h r e e d i f f e r e n t a r e n a s . The EMs a r e used t o u n d e r s t a n d the e t i o l o g y , symptoms, p a t h o p h y s i o l o g y and t r e a t m e n t o f the i l l n e s s e v e n t . 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 a s p e c t s o f s i c k n e s s . In c o n t r a s t , the EMs i n the p o p u l a r arena are more l i k e l y t o i n c l u d e the e x p e r i e n c e of the i l l n e s s e v e n t . As a r e s u l t , the EMs used by i n d i v i d u a l s i n the d i f f e r e n t arenas may not agree w i t h each o t h e r . T h i s may r e s u l t i n c a r e c o n s i s t i n g o f i n c o n g r u e n t o b j e c t i v e s and outcomes as the i n d i v i d u a l e n t e r s the p r o f e s s i o n a l arena f o r t r e a t m e n t . I n c o n c l u s i o n , K l e i n m a n 1 s Model p r o v i d e s d i r e c t i o n i n d e s c r i b i n g the EMs o f e l d e r l y women as they r e l a t e t o 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 i n the community 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 event. In o r d e r t o d e s c r i b e the EMs, the r e s e a r c h d e s i g n of 116 phenomenology was chosen. In the attempt t o u n d e r s t a n d the l i v e d e x p e r i e n c e , e i g h t women s u b j e c t s were r e c r u i t e d who had e x p e r i e n c e d a f a l l event r e s u l t i n g i n a h o s p i t a l i z a t i o n . A l l the s u b j e c t s were r e c r u i t e d t h rough the Vancouver H e a l t h Department. The women were 75 y e a r s o f age and o l d e r , l i v i n g a l o n e i n a house or apartment which was not p a r t of a c a r e f a c i l i t y i n the C i t y of Vancouver. As w e l l , they were a l e r t and o r i e n t e d 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 p r i o r t o a d m i s s i o n or f o l l o w i n g d i s c h a r g e from h o s p i t a l . Data were c o l l e c t e d through the use of u n s t r u c t u r e d t a p e - r e c o r d e d i n t e r v i e w s . The i n t e r v i e w s took p l a c e i n the s u b j e c t ' s home. F i v e of the 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 , and 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 f o r a t o t a l of 14 i n t e r v i e w s . S e v e r a l t e l e p h o n e c a l l s were a l s o made t o the s u b j e c t s throughout the co u r s e o f the s t u d y . Four t r i g g e r q u e s t i o n s were used t o g u i d e the i n i t i a l i n t e r v i e w s . As the d a t a a n a l y s i s proceeded, the t r i g g e r q u e s t i o n s were r e v i s e d , based on the common themes emerging from the 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 v e r b a t i m t o ensure an e x a c t account o f the phenomenon. Data a n a l y s i s was done f o l l o w i n g the s t e p s o u t l i n e d by G i o r g i (1985). Common themes were noted and coded a c c o r d i n g l y . S u b s e q u e n t l y , the themes were c l a r i f i e d , v a l i d a t e d , and d i s c o u n t e d i n subsequent i n t e r v i e w s w i t h the s u b j e c t s . In t h i s p r o c e s s , the p e r c e i v e d need f o r 117 care and support from the elderly woman's experience was described. The perceived need for care and support once the women returned home to l i v e alone was ultimately influenced by the f a l l event and treatment within the Health Care System. The findings are complex and inter-related and summarized in the following manner: 1. The elderly women in thi s study perceived the f a l l as both a s i g n i f i c a n t and unpredictable event in their l i f e . The f a l l event resulted in a change of routine at home once they returned home to l i v e alone. After returning home, the women described threats to their self-esteem. 2. Autonomy, a c t i v i t y and independence were important components of self-esteem that were threatened by the f a l l event and resultant change in routine. 3. The women i d e n t i f i e d a c t i v i t y as an important part of t heir self-esteem. After the f a l l , the women experienced decreased opportunities for a c t i v i t y due to the physical and psychological consequences of the f a l l . This was perceived as a threat to their self-esteem. 4. The women wanted their autonomy respected. They experienced threats to their autonomy. They had decisions about their care made for them by health professionals. As well, they wanted more information about their health status. 5. The elderly women used behaviours to cope with the threats to their self-esteem. According to the appraisal of 1 1 8 the s i t u a t i o n , d i f f e r e n t t ypes of b e h a v i o u r s were used. These i n c l u d e d use o f p o s i t i v e b e l i e f s , c o m p l i a n c e 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 the f u t u r e , and use of s o c i a l s u p p o r t . These s p e c i f i c b e h a v i o u r s encompassed both p r o b l e m - f o c u s e d and emot i o n - f o c u s e d c o p i n g s t r a t e g i e s . 6. The use of s o c i a l s u p p o r t was a c o p i n g b e h a v i o u r used by a l l the women i n the s t u d y . R e c i p r o c i t y o f exchange was i m p o r t a n t i n the women's use o f s o c i a l s u p p o r t from f r i e n d s . 7. The women i n t h i s s t u d y encountered d i f f i c u l t i e s w i t h the s o c i a l s u p p o r t from the f o r m a l programs. The women e x p e r i e n c e d problems w i t h (a) communication due t o language b a r r i e r s , 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 the a b i l i t y t o send the same homemaker t o them on an ongoing b a s i s . As w e l l , t h e r e were problems w i t h the women's e x p e c t a t i o n s f o r the homemaker's perf o r m a n c e . These problems 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 autonomy and 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 once they r e t u r n home has numerous 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 , p r a c t i c e , and e d u c a t i o n . These i m p l i c a t i o n s w i l l be addressed i n the f o l l o w i n g s e c t i o n s . 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 d e s c r i b e d t h r e a t s t o t h e i r s e l f - e s t e e m upon t h e i r r e t u r n home. U l t i m a t e l y , t h e s e 119 t h r e a t s a f f e c t e d t h e i r p e r c e p t i o n o f the need f o r c a r e and s u p p o r t i n the 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 the homemakers from the f o r m a l s u p p o r t programs. I t was o b v i o u s t h a t t h i s s e r v i c e d i d not 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 the community. Homemakers are the lo w e s t p a i d and l e a s t e d u c a t i o n a l l y -p r e p a r e d members o f the h e a l t h c a r e team. Y e t , t h e s e 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 the 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 s t u d y . There remains a p a u c i t y o f r e s e a r c h t h a t d e a l s w i t h 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 , and e d u c a t i o n needs of t h e s e w o r k e r s . As w e l l , r e s e a r c h i s l a c k i n g on t h e i r assessment and communication s k i l l s . F u r t h e r m o r e , r e s e a r c h i s r e q u i r e d on the r e l a t i o n s h i p between the i n d i v i d u a l ' s need f o r s u p p o r t ( o b j e c t i v e and p e r c e i v e d ) , the sup p o r t r e c e i v e d from the homemakers, and the e f f e c t t h a t s u p p o r t has on o t h e r p r e d i c t o r s of s u c c e s s such as c o n t r o l and autonomy. The f i n d i n g s from t h i s s t u d y c o n c l u d e d t h a t the 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 independence and autonomy r e s u l t i n g from the homemaker's a c t i o n s . C o n s e q u e n t l y , the 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 t h e s e t h r e a t s . Research i s r e q u i r e d i n the a f o r e m e n t i o n e d a r e a s , s i n c e t h e r e 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 f r a i l , e l d e r l y i n d i v i d u a l s u s i n g homemakers i n the community 120 s e t t i n g . T h i s i n f o r m a t i o n would have s e v e r a l p o l i c y i m p l i c a t i o n s . F i r s t l y , t h i s i n f o r m a t i o n would have i m p l i c a t i o n s f o r p l a n n i n g the type and amount of s u p e r v i s i o n t h a t i s r e q u i r e d 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 . S e c o n d l y , the e d u c a t i o n a l needs of these w o rkers would be documented, t h e r e b y e n s u r i n g t h a t a p p r o p r i a t e e d u c a t i o n a l programs a r e e s t a b l i s h e d f o r them. As a r e s u l t , homemakers may be p e r c e i v e d as meeting an e l d e r l y p e r s o n ' s need f o r c a r e and s u p p o r t i n the community, r a t h e r than p o s i n g a f u r t h e r t h r e a t t o i t . The l a s t i m p l i c a t i o n f o r r e s e a r c h r e l a t e s t o the a r e a of autonomy and s t e r e o t y p i n g of the e l d e r l y . S t e r e o t y p i n g of the 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 been documented i n the l i t e r a t u r e (Maddox & T i l l e r y , 1988; Penner,' L u d e n i a , & Mead, 1984). However, nurses working i n l o n g - t e r m c a r e s e t t i n g s have been the major f o c u s o f t h i s type of r e s e a r c h . S i n c e a l l the women were a s s e s s e d i n an Emergency department, i t i s c r u c i a l t o conduct r e s e a r c h on these n u r s e s ' a t t i t u d e s towards e l d e r l y i n d i v i d u a l s . T h i s r e s e a r c h may h e l p t o expose a hidden s o u r c e of n e g a t i v e s t e r e o t y p i n g o f the e l d e r l y . In c o n c l u s i o n , f u r t h e r r e s e a r c h i s r e q u i r e d on the e d u c a t i o n and t r a i n i n g of homemakers as they c o n t i n u e t o p l a y an i m p o r t a n t r o l e i n c a r e of the e l d e r l y i n the community s e t t i n g . As w e l l , f u r t h e r r e s e a r c h i s r e q u i r e d on the 121 attitudes of the nurses working in Emergency Departments towards the el d e r l y . Implications for Practice In order to understand the perceived need for care and support of elde r l y women after a f a l l event, i t is important to gather information on their value systems. In p a r t i c u l a r , i t i s important for nurses to learn about an individual's values as they relate to feelings about f a l l s , acute and chronic i l l n e s s , loss of functional a b i l i t y , and expectations for health care. In this study, the women's values reflected aspects of their self-esteem. These values were fundamental in understanding the elderly women's perceived need for care and support in the community. In the present Health Care System, most patient information is gathered on patient assessment and history forms. However, most of this information i s focused on the physical and functional aspects of ind i v i d u a l s . Information about an individual's values also needs to be documented and communicated to a l l nurses involved in the c l i e n t ' s care. The inclusion of this information has implications for the formulation of health assessment forms within both i n s t i t u t i o n a l and community settings. In order to provide care that promotes the autonomy of elderly women after a f a l l event, the nurses must ensure that adequate medical information i s provided to these 122 individuals. As well, a l l health professionals need reminding that decisions involving the c l i e n t s ' health care are no longer the sole prerogative of health professionals. The aforementioned are two important conditions for autonomous decisions-making by individuals. Nurses and other health professionals require inservices on the e t h i c a l p r i n c i p l e of autonomy. As well, nurses require education about the concept of advocacy in the practice setting. In many sit u a t i o n s , the nurse may need to assume the role of patient advocate to ensure that autonomous decision-making occurs. This promotion of autonomy for e l d e r l y women w i l l help to meet their perceived need for care and support as they return home after a h o s p i t a l i z a t i o n for a f a l l . Nurses need to be aware of the importance of reci p r o c i t y in the s o c i a l relationships of elderly women. This r e c i p r o c i t y was important as the women described their perceived need for care and support in the community. Therefore, i t is a c r u c i a l point to remember as nurses discuss with elderly women the decision to involve t h e i r friends as a support in the discharge plan. The women need to be consulted about who to phone and what to request of that person. This finding may have important policy implications for the provision of formal supports to those women who do not want their friends involved in the discharge plan. 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 o f t h e i r a c t i o n s i n s u p p o r t i n g the s e l f - e s t e e m o f e l d e r l y women. The importance o f autonomy has a l r e a d y been d i s c u s s e d . N u r s e s , i n t h e i r i n t e r a c t i o n s w i t h the e l d e r l y , are a b l e t o p r o v i d e the r e f l e c t e d a p p r a i s a l of s i g n i f i c a n t o t h e r s . As d i s c u s s e d i n Chapter 5, t h i s i s one s o u r c e f o r s e l f - e s t e e m f e e l i n g s . Nurses can p r o v i d e acknowledgement f o r accomplishments o r n e w l y - r e g a i n e d s e l f -c a r e t a s k s . As w e l l , they can a s s i s t i n d i v i d u a l s i n i d e n t i f y i n g s t r e n g t h s and p o s i t i v e a s p e c t s o f t h e i r s e l f -c o n c e p t . B e s i d e s p r o v i d i n g v e r b a l feedback, unspoken a c t i o n s a r e a l s o i m p o r t a n t i n p r o v i d i n g the r e f l e c t e d a p p r a i s a l s . 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 f a c i a l e x p r e s s i o n s , body language, and v o i c e tone when i n t e r a c t i n g w i t h the e l d e r l y . I t i s i m p o r t a n t f o r nur s e s t o l e a r n the meanings o f ev e n t s t o e l d e r l y women. From t h i s s t u d y , the meaning of the f a l l event had a tremendous i n f l u e n c e on the 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 as they r e t u r n e d home alo 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 meaning t r a n s c e n d s the reasons f o r the f a l l o r the r e p o r t o f the f a l l from an o u t s i d e o b s e r v e r . An u n d e r s t a n d i n g o f the f a l l event i s i m p o r t a n t i n the p r o c e s s o f assessment and the f o r m u l a t i o n of n u r s i n g c a r e o b j e c t i v e s i n the c a r e o f e l d e r l y women. In c o n c l u s i o n , the i m p l i c a t i o n s f o r p r a c t i c e i n c l u d e 124 f o u r recommendations f o r n u r s e s . F i r s t l y , t h ey must a s s e s s and document the v a l u e s of e l d e r l y i n d i v i d u a l s . S e c o n d l y , nurses must remember the importance of r e c i p r o c i t y i n 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. T h i r d l y , the r o l e of nurses i n pr o m o t i n g the s e l f - e s t e e m o f e l d e r l y i n d i v i d u a l s i s a d d r e s s e d . L a s t l y , n urses must b e g i n t o i n c r e a s e t h e i r u n d e r s t a n d i n g o f the f a l l event as e l d e r l y women r e t u r n home a l o n e . I m p l i c a t i o n s f o r E d u c a t i o n Over the l a s t 15 y e a r s , t h e r e has been i n c r e a s i n g emphasis on the s t u d y of G e r o n t o l o g y by the n u r s i n g p r o f e s s i o n . D e s p i t e t h i s f o c u s , t h e r e remain many n e g a t i v e s t e r e o t y p e s o f 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 c u r r i c u l u m s i n n u r s i n g s c h o o l s p r o v i d e o p p o r t u n i t i e s f o r s t u d e n t s t o c a r e f o r the e l d e r l y . However, many of thes e s i t u a t i o n s i n v o l v e c a r i n g f o r the e l d e r l y w i t h many p h y s i c a l and 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 community s e t t i n g s . A g r e a t e r f o c u s on the w e l l e l d e r l y i s r e q u i r e d w i t h i n the n u r s i n g s c h o o l c u r r i c u l u m . Here, b e g i n n i n g p r a c t i t i o n e r s would b e g i n t o l e a r n about the v a l u e s o f t h i s g e n e r a t i o n . T h i s would h e l p t o e l i m i n a t e some o f the 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 e x p e r i e n c e i n c a r i n g f o r the w e l l e l d e r l y would h e l p t o promote more p o s i t i v e a t t i t u d e s toward the a g i n g p r o c e s s . B e s i d e s 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 is important that there be adequate faculty prepared at the master's l e v e l in gerontological nursing. Here, the students would benefit from the expanded knowledge and s k i l l levels of the gerontological c l i n i c a l nurse s p e c i a l i s t within the practice s e t t i n g . As well, the students would observe role-models on which they could pattern their own behaviours in learning se n s i t i v e care to the e l d e r l y . In conclusion, there needs to be more emphasis on wellness in order to eliminate negative stereotypes of the elderly among beginning p r a c t i t i o n e r s in the nursing profession. As well, nursing students require more opportunity to learn and work with masters-prepared c l i n i c a l nurse s p e c i a l i s t s in gerontology. 126 Ref e r e n c e s 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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Advances i n  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. , T e r p s t r a , T e r r y L., P l a w e c k i , H. M., & S t r e e t e r , J . ( 1 9 8 9 ) . As young as you f e e l : Age i d e n t i f i c a t i o n among the e l d e r l y . J o u r n a l of G e r o n t o l o g i c a l N u r s i n g , 1_5(12), 4-10. T i d e s i k s a a r , R. ( 1 9 8 6 ) . G e r i a t r i c f a l l s i n the home. Home  H e a l t h c a r e Nurse, 4(2), 14-23. T i l d e n , V. R., & W e i n e r t , C. ( 1 9 8 7 ) . S o c i a l s u p p o r t and the c h r o n i c a l l y i l l i n d i v i d u a l . N u r s i n g C l i n i c s of No r t h  A m e r i c a , 22(3), 613-620. T i n e t t i , M. E., Richman, D., & P o w e l l , L. ( 1 9 9 0 ) . F a l l s e f f i c a c y as a measure o f f e a r o f f a l l i n g . J o u r n a l o f  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 , J 5 _ ( 6 ) , 239-243. 132 T i n e t t i , M. E., & Sp e e c h l e y , M. (1989). P r e v e n t i o n o f f a l l s among the e l d e r l y . New England 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). R i s k 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 the community. New England J o u r n a l o f M e d i c i n e , 319(26), 1701-1707. V i c t o r , C. R., & V e t t e r , N. J . (1988). 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 a s p e c t of p a t i e n t c a r e . Age and A g i n g , 17, 155-163. W i l s o n , C., & N e t t i n g , F. E. (1987). Comparison of 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 the 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 Aging and Human  Development, .25(1) , 11-25. Woods, N. F., & C a t a n z a r o , M. (1988). N u r s i n g r e s e a r c h :  Theory 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). Human v a l u e s i n h e a l t h c a r e : The  p r a c t i c e o f e t h i c s . New Yo r k : McGraw H i l l . Appendix A 133 Consent Form T i t l e o f the Study: H o s p i t a l t o Home: What i s 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 of 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 ? P u rpose: The purpose o f t h i s s tudy i s t o d e s c r i b e the need f o r c a r e and s u p p o r t as 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 f a l l . I n v e s t i g a t o r : Sharon G a l l o w a y The purpose of t h i s s tudy has been e x p l a i n e d t o me by Sharon G a l l o w a y and I agree 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 p r o j e c t . 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 of 30-60 minutes d u r a t i o n i n my home and t h a t the 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 in v o l v e m e n t i n the study w i l l be c o n f i d e n t i a l and t h a t my name and any 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 from 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 answer any q u e s t i o n s and may withdraw my consent a t any time 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 about the 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 Sharon Gallo w a y a t xxx-xxxx 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 the s u p e r v i s o r o f the p r o j e c t (Jo Ann P e r r y ) a t xxx-xxxx w i t h q u e s t i o n s a t any ti m e . I acknowledge r e c e i p t of a copy of t h i s consent form. S i g n a t u r e Date 1991 134 Appendix B L e t t e r of I n f o r m a t i o n My name i s Sharon G a l l o w a y . I am a R e g i s t e r e d Nurse 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 the M a s t e r of 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 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 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 you t o p a r t i c i p a t e i n my s t u d y . You are under 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 you choose t o p a r t i c i p a t e you may withdraw from the study 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 your d e c i s i o n t o p a r t i c i p a t e o r not p a r t i c i p a t e . I f you are i n t e r e s t e d i n t a l k i n g w i t h me about your e x p e r i e n c e upon d i s c h a r g e from h o s p i t a l , I would l i k e t o meet w i t h you i n your 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 the 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 about your 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 . Subsequent 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 expand on the 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 hared w i t h me. Each 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 so t h a t I may l i s t e n t o what you are 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 n o t e s . 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 ; the tapes w i l l be numbered so t h a t your name w i l l not appear on them and a code w i l l be used when the tapes are t r a n s c r i b e d . A ccess t o the tapes and typed 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 taped i n f o r m a t i o n a t any time and a t the c o m p l e t i o n o f the s t u d y , a l l tapes 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 s tudy 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 n u r s e s t o b e t t e r u n d e r s t a n d the need f o r c a r e and s u p p o r t i n the community 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 the s t u d y . I f you are 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 the 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 your nurse g i v e s me your 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 you have and t o 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 f o r w a r d t o s p e a k i n g w i t h you. S i n c e r e l y , Sharon Gallo w a y Appendix C Trigger Questions 1. How do you f e e l you are managing at home since the hos p i t a l i z a t i o n ? 2. How has the f a l l affected your d a i l y l i f e ? 3. How has the f a l l affected your need for assistance or help at home? 4. How do you f e e l the f a l l has affected your need for care at home? 

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