Description:

This is an individual assignment which requires you to conduct a detailed and

systematic critical appraisal of a research article. This critical appraisal will require you

to examine a research article, evaluate it according to what you have learned in this

unit, and consider how the results might inform practice.

Instructions:

You have two articles to choose from for this critique (found in the assessment folder in LEO). One

is a report of quantitative research and the other is a report of qualitative research. Select the one

that most appeals to you. In particular, you are required to:

1. Present the assignment as a scholarly/academic essay with an introduction, body and

conclusion.

o The introduction should present the overall topic and purpose of the essay, how you will

address it, and why it is important to be able to assess a research study.

o The body will follow the research process set out in the article and will include all aspects

of your appraisal and critique.

o The conclusion should be a brief overview of the main points you have made in the body.

No new information should be included.

2. During your appraisal:

o consider both the strengths and weaknesses of the article, and

o discuss how the recommendations from the article could be used in evidence-based

clinical practice (EBP)

3. Students are strongly advised to use the Marking Guide and detailed instruction in LEO as a guide when writing the essay.

4. This essay should be approximately ± 10% of 1800 words, 1.5/double spaced, 1” margins, 12

point font, with a range of relevant scholarly references and using APA referencing. The format

follows the research process

Weighting: 45%

Length and/or format: 1800 words

Purpose: This assessment task gives you the opportunity to demonstrate

your understanding of the principles for critiquing evidence. By

demonstrating capacity to appraise evidence at a beginner level

you will have demonstrated an appreciation for the principles of

reporting research as well as how research can be used as

evidence for practice.

This is the article;

”This is the Report Qualitative research”

‘Getting Up from Here’: Frail Older

Women’s Experiences After Falling

Eileen J. Porter, PhD RN

Few researchers have explored older persons’ experiences of

falling. As part of a descriptive phenomenological study of older

widows’ experience of home care, 25 interviews were conducted

with nine frail women who had fallen at least once at

home. Some women were able to get up on their own or tried to

do so. For them, the phenomenon of “getting up from here” and

its component phenomena, such as “finding something solid [on

which to pull upI,” were primarily focused on maximizing the

opportunities afforded by the home’s environmental features.

When the women needed help to get up, the phenomenon of “getting

up from here” was understood as an exemplar of the home

care experience; the women’s intentions were focused on contacting or interacting with people who were already assisting

them as they lived alone at home. Understanding the variability

in the experience of falling is an essential basis both for sensitive

interaction with elders who have fallen and for appropriate

assessment of frail elders who are at risk of falling in their

homes.

For frail older people, falling is an all too common, potentially

devastating event that can lead to death (Commodore,

1995) or precipitate the need for emergency health care and extensive

rehabilitation (Tideiksaar, 1993). Yet the experiences of

older people who fall while alone at home have been given minimal

consideration. Nursing research designed to explore this

experience is crucial to appropriate preventive and restorative

care of elders. Through empirical knowledge of frail older persons’

experiences of falling, home care and rehabilitation nurses

can find direction for specific assessment of elders who are

at risk for falling at home. Furthermore, rehabilitation nurses

who understand the experience of falling can intervene with

greater sensitivity and compassion as they bolster elders’ positive

adaptation after a fall.

This study, which is part of an ongoing longitudinal investigation

of older widows’ experiences of home care, addresses an

important gap in the rehabilitation literature. It is a description

of the variability in the phenomenon of “getting up from here”

as experienced by nine frail older widows who fell at least once

in their homes. Findings are presented as a basis for new approaches

to the nursing assessment of frail women who are likely

to fall at home.

Eileen Porter is an assistant professor of nursing at the University

ofMissouri-Columbia. Address correspondence to Eileen

J. Porter, S424 School ofNursing, University ofMissouri-Columbia,

Columbia, MO 65211.

Keywords

aging, accidental falls, women, physical environment

Review of the literature

From a theoretical perspective, the older person’s effort to

get up from the floor after a fall can be understood in terms of

personal control or “the desire to make decisions and affect outcomes”

(Rodin, 1990, p. 1). The exercise of personal control over an event has been linked to competence, or “the capacity to

manifest the behavior on which the intended event is contingent”

(Weisz, 1990, p. 105). The concept of control has multiple

subconcepts, including the polarities of internal and external

control (Rotter, 1966) and of primary and secondary control

(Weisz).

Research relevant to these subconcepts has produced certain

generalizations about older persons’ control. For example, Gatz

and Karel (1993) concluded that in each of four generations

studied, the oldest females reported higher levels of external

control than did any other group. Some life-span developmental

theorists have argued that because age-related constraints influence

primary control behaviors (Heckhausen & Schulz, 1992),

older people rely chiefly on secondary control processes (Schulz,

Heckhausen, & Locher, 1991). Older people may target primary

control behaviors to the external environment in order to mold

it to their needs, and direct secondary control efforts at internal

processes in order to maintain or expand primary control or to

minimize losses (Heckhausen & Schulz, 1995).

Accordingly, based on findings of-research relevant to control,

an exploratory study of older women’s experience of falling

could be framed in terms of external (rather than internal) control

and secondary (rather than primary) control. However, concepts

such as primary and secondary control are difficult to put

into operation in research with older adults. According to Weisz,

Rothbaum, and Blackburn (1984), these concepts “are defined

partly in terms of the aims or intent of the individual actor, and

intent is often difficult to discern.

Falls Among Elderly Women

Compared with dichotomous interpretations of control, such

as primary and secondary control, Gibson’s (1977,1979/1986)

ecological psychology represents a very different perspective.

Ecological psychological research is focused on environmental

information gleaned through perception. Adopting the premise

that the environment or situation affords opportunities to an agent

(Gibson, 1977), Gibson (1979/1986) proposed that control incorporates

perceiving, moving about in, and manipulating the

environment. Key concepts are “affordances,” defined as environmental

features that contribute to the nature of the interaction,

and “abilities,” defined as characteristics of the agent

(Greeno, 1994).

”Practitioners who understand

the experience of falling should be

better equipped to assesselders

who are at risk for falling” …

Thus, Gibson’s (1977,1979/1986) ecological perspective on

the psychological construct of control is a potential springboard

for investigating environmental perceptions associated with

falling. However, to understand what it is like for persons to experience

falling, it is necessary to move beyond Gibson’s focus

on perceptions about environmental information. Gibson’s

(1979/1986) ecological thesis, grounded in the centrality and directness

of the human’s perceptions of the environment (Reed,

1996), is clearly consonant with the core tenet of Husserl’s

(1913/1962) descriptive phenomenology. Rather than aiming to

advance generalizations about the elderly’s psychological makeup

(their control or their competence), Husserl’s phenomenology

enables researchers to show the intentions of a “human Ego

who experiences, thinks, and acts naturally in the world” (p. 9).

Purpose of the study:

To intervene with sensitivity and compassion when older persons

have fallen, rehabilitation nurses and healthcare providers

need to know what it is like to fall and to try to get up from the

floor while at home alone. Practitioners who understand the experience

of falling should be better equipped to assess elders

who are at risk for falling, to help older persons prevent further

falls, and to interact compassionately with elders who fall. Accordingly,

this descriptive phenomenological study was designed

to explore a neglected realm of frail older womens’ experience that

of falling to the floor and trying to get up while at home

alone.

Method:

The study reported in this article is derived from a larger study

of the home care experience. In the larger study, 25 women participated

in at least seven tape-recorded interviews with the investigator

over a 3-year period. All the interviews took place in

the women’s homes. The study was considered exempt from review

by the Health Sciences Institutional Review Board of the

University ofMissouri-Columbia. To enroll women 80 years of

202 Rehabilitation Nursing> Volume 24, Number 5 • Sep/Oct 1999

age or older who lived alone at home, convenience sampling

was done in six counties of central Missouri. Social service agencies,

such as county care coordinators, churches, and senior centers,

were contacted. The agencies dispersed brochures about

the project to eligible women, and those who wanted to participate

mailed pre-addressed postcards to project staff to declare

their interest. Articles about the study appeared in local newspapers,

and some women telephoned to express interest. The eligibility

of each volunteer was screened during a telephone call.

Each participant’s informed consent was secured during an initial

home interview.

For the study reported here, data from a specific subsample

of nine women were analyzed. These women, who ranged from

83 to 96 years of age, were those who spontaneously reported

at least one fall during the first year of project enrollment. Each

woman also had the following characteristics of frailty (Arfken,

Lach, Birge, & Miller, 1994): an inability to walk 10 blocks,

need of assistance to climb stairs, and need of an assistive device

to ambulate. Five of the women resided in rural communities

of fewer than 2,500 people, and four women lived in larger

communities ranging from 10,000 to 80,000 people. On the basis

of their self-reports that they fell frequently (such as having

fallen “so often it’s pitiful”), five of the nine women are referred

to as veteran fallers.

Data gathering and analysis were guided by a descriptive phenomenological

method developed by the principal investigator

(Porter, 1994a, 1998) from Husserl’s (1913/1962) book Ideas.

With regard to data gathering, major research activities included:

(a) exploring the diversity of one’s consciousness, because

consciousness is the primary analytic tool; (b) reflecting on experiences

relevant to the phenomenon of interest; (c) bracketing

or setting aside relevant scientific evidence such as findings concerning

personal control and competence; and (d) exploring the

participants’ experience world by spending time with them in

their homes during interviews.

To study the home care experience, the interviews were focused

on aspects of living alone at home that are particularly relevant

to seeking and having help. During each interview, the participant

was given at least two opportunities to spontaneously

report major events such as falls. Each interview was initiated

with an invitation to share “what has happened since the last visit”;

near the end of the visit, the participant was asked to report

“any changes” in her situation at home. When a fall was reported,

the woman was asked to explain what it was like and what she

tried to do; women who reported a fall were asked to discuss

any previous falls. Although these interview strategies may not

have solicited every relevant remark that the women could have

reported, the open-ended atmosphere of the interviews enabled

the women to speak at length, without restriction. Data reported

here were drawn from 25 interviews, consisting of more than

750 single-spaced pages in length, which were conducted during

the first year of each woman’s 3-year period of participation.

The fundamental activity of data analysis is to intuit the

women’s intentions, or what they are trying to do with their experience

(Kohak, 1978). When a woman’s remark suggested an

intention to the investigator, this idea was discussed with her

during that same interview whenever feasible, or during the next interview. The credibility of findings, in tenus of integrity and accuracy

(patton, 1990), is supported through the investigator’s discussions

about the intentions with participants and other members

of the research team. In line with Husserl’s (1913/1962) position

that “Each has his place whence he sees the things that are present”

(p. 95), the author also invites readers to appraise the credibility

of findings on the basis of their own practice experiences.

As is explained in the findings, a three-tiered taxonomy of

the intentions was developed to describe the experience of falling.

The purpose of the taxonomy is to elucidate the complexity of

the experience of each woman and to demonstrate the variability

of the intentions across the sample. In the taxonomy, each

woman’s unique intentions are at the basic level, similar intentions

are grouped to comprise a component phenomenon, and

similar component phenomena are combined to comprise a phenomenon.

These sets of intentions are proposed as the structures

of the experience of falling, as revealed through descriptive phenomenological

analysis. Finally, the structures of experience

were compared with those in the literature, as illustrated in the

discussion.

Results:

“I was standing at the sink, and I just went down. And I never

suffered so bad in all my life. And I was on the floor. I had

some stuff on the stove. And I thought maybe it will dry and

burn, and I’d choke on the smoke. I just thought of every way I

was gonna die. It’s a terrible thing to think that you might

not. .. nobody [will] find you.” For these frail older women, the

experience of falling began with “finding myself falling” or

“landing on the floor.” “I just fell and threw the cane here in the

doorway. And I was in the kitchen; oh, I got the hardest fall. Oh,

I [sic] scared the life out of me.” Although they were scared or

shocked by the fall, veteran fallers were not particularly surprised.

When she realized that she was falling, one woman said

that she thought to herself, “Oh, here I go again.”

Variations in the circumstances associated with getting

up after a fall: After “landing,” the experience of falling was

structured by the phenomenon of “getting up from here.” The

nine women differed in their ability to get up from a particular

fall and in the focus of their intentions with regard to getting up.

Some women’s intentions were focused on the home’s environmental

features, whereas other women’s intentions were focused

on seeking help from another person. The sample’s variability

in the phenomenon of “getting up from here” can be

characterized in three scenarios that contrast the differences in

the women’s abilities and their intentions.

1. For some women, “getting up from here” was hard, but

they were able to do it alone, without another’s assistance.

They relied on the features of their homes, such as their

floors and chairs, as props in getting up from the floor.

2. These women found that they could not get up alone after

they fell, and they tried to get someone to come to help

them.

3. These women knew before they fell that they would be unable

to get up alone. When they fell, they did not try to get

up but instead focused their intentions primarily on getting

a helper to come or on waiting for a helper.

Focus of the women’s intentions: the home’s

environmental features

Moving myself along: Depending on where the fall occurred,

some women had to move themselves elsewhere by “pulling

myself along,” “scooting,” or “bouncing.” One study participant

said, “Well, you just scoot on your rear end, you know, until you

get to where you want to go. I just put my hands on the floor,

you know, and work myself a ways forward.” A veteran faller

explained how the attributes of the floor (carpet or wood) could

enable her to propel herself along on the floor. “But a carpet,

you kind of stick to it, you know, when you pull yourself along.

It’s a way you get where you want to go. It isn’t slick, you know.

You have more control of yourself. You’re not just sliding like you

would on a hardwood floor. And when you’re sliding along like

that, I think it would be harder.”

Finding something solid: Several women described falls in

which they found themselves “sitting down close to something

solid.” The experiences of other women were structured by scooting

or bouncing to “something that may be solid” and “deciding

if it is solid enough.” A woman who slipped on the invisible

ice at her back door one “freezing-cold” day managed to pull

herself back inside the house because she was holding on to the

screen door. Once inside the house, she was “bouncing along,”

trying to find something solid to pull up on. “And I thought,

‘Well, I’ll go into the little back bathroom…and I’ll pull by the

tub, or something, you know.’ Didn’t work. I have a bed there

in the dining room…and I couldn’t climb up; I didn’t have the

strength. And I came in here [front room]. Everything seemed to

move around a little bit. But the piano bench [in the entry hall]

has so many heavy books and things in it, it was solid. And I

didn’t slip around trying to get up.”

According to veteran fallers, testing pieces of furniture for

their solidity involved the intentional actions of “turning over on

my knees,” “reaching up and grabbing hold of it,” and “putting

some weight on it.” During the interviews, some women spontaneously

pointed to various pieces of living room furniture, rating

their solidness. Two veteran fallers spontaneously rated the

solidness of major fixtures in other rooms. “I’ve found that I can

do that…when I’min the bedroom; I can grab hold of the bedpost:’

Pulling myself up into/onto something solid: Once the

woman decided that a piece of furniture was solid enough, she

went on to pull herself up into it (a chair) or onto it (a bed). As

one veteran faller said, “Sometime I can get the chairs and pull,”

but pulling was difficult. “I just gave it all the strength I had…and

it was an effort.” As described by two veterans, this involved

“turning over on my knees” (or “scrambling around”), “reaching

up and grabbing hold of it,” and “putting some weight on it.”

Then,they went on to “dig my feet in,” “balance myself,” and

“throw myself up on it.” As one woman explained it, “I can go

to that chair over there, and hang onto it and dig in my feet and

pull myself up.”

Some women were successful in getting up after some falls,

but on other occasions, they were unable to carry out an intention

that was vital to pulling themselves up. One woman, who

fell to the kitchen floor as her hip broke, said, “I would reach,

try to reach, thinking I’d get hold of something. I couldn’t get

hold …because I was hurt so bad; I just had to give it up.”

Rehabilitation Nursing> Volume 24, Number 5· Sep/Oet 1999 203

Falls Among Elderly Women

Some pieces of furniture that were not especially good for

sitting were effective for pulling up. One veteran faller did not

like to sit in a particular chair in her living room; it was hard to

get out of because it was low to the floor and soft. Yet this was

her preferred chair for pulling up, because it felt soft when she

pulled up on it and “flopped on her stomach.”

Focus of interaction:

Helpers Checking myself out: Except in situations when they were

bleeding, the women who got up on their own did not evaluate

the extent of their injuries until they had gotten themselves up.

One veteran faller said, “Oh, I never do that [check myself] until

I’m sitting. My first thought is to get up from here.” Once in

a chair, the women reported, they began to tell themselves that

they were all right (or not).

Letting them know: After checking themselves out, the

women sometimes informed family or friends about the fall.

They did this at the risk of “worrying them,” which is a risk that

older widows who live alone try to minimize (Porter, 1994b). A

veteran faller, age 94, chose not to tell her older sister about her

falls. “I didn’t hurt myself, and she worries about me over here.”

The experiences of some women who let others know about the

fall were structured by “deciding whether to go along with what

they want to do.” One woman, who did not feel “just right” after

getting up from a harrowing fall, called a friend, and then

agreed with the friend’s plan to call 911.

Mobilizing them to help with it: Two women reported

events in which the fall itself mobilized a helper. “It just so happened”

that someone was with one of the women when she fell.

The other woman “blacked out [and]fell on the kitchen floor”

one moming when her son “just happened to be [staying] here.

[He] carried me in here and laid me down…. If he hadn’t been

here, I don’t know….”

Getting them here right away: When there was no one immediately

available, the women who needed help to get up reported

“pressing the Lifel.ine” or “scooting to the telephone.”

When the women had to have help to get up, the fall event was

part of the overall experience of home care. Helpers included

kin, friends, and neighbors who already were providing other

help, such as shopping or transportation.

One veteran faller, who reported four falls during a l-year

period, also had suffered five previous falls, including one associated

with a hip fracture. “I just plunk backwards…, and I

just don’t have enough strength to get myself up.” To contact her

two sisters quickly, she wore a LifeLine on a cord around her

neck. One Sunday morning before church, she took off the LifeLine

because “it showed so bad” under her dress. “I thought,

‘Well, I can get along an hour without it.’ I went over to the closet

to get my shoes, and .. .1 fell right there. I had to lay on the

floor [for about an hour] until my sister came after me for Sunday

School.” She vowed to never again “get along” without the

LifeLine.

Letting them in: Some women called potential helpers who

did not have keys. One woman scooted to the telephone to call

her children and then scooted to the door to unlock it. Other

women who fell tried to open the door when someone came unexpectedly,

as did a woman whose friend coincidentally stopped

204 Rehabilitation Nursing > Volume 24, Number 5· Sep/Oct 1999

by much earlier than he was expected. “One Sunday morning I

was coming out of the kitchen and fell in the dining room, and

I was scooting around there trying to get up. And this fellow,

Ralph, came, and he knocked on the door. And I scooted up to

the door, and my arm’s long; I turned the knob. And when he

saw me on the floor, he said, ‘Sister, what’s wrong?’ I said, ‘I’ve

fallen.’ I said, ‘Just try to help me up.’ I was just helpless. I got

up, and he helped me up.”

Sequelae of the falls:

Some falls precipitated immediate contacts with healthcare

providers, including physician’s office or emergency room visits.

One rural physician made a post fall house call. A veteran

faller sustained a serious abrasion, requiring visits by the home

health nurse for dressing changes. Another veteran faller broke

her hip and after rehabilitation at the hospital was released home

to the care of a home health team. One woman began leasing a

LifeLine after her post fall hospitalization,and another veteran faller

cited frequent falls as the main reason for leaving her home

to go to live with a daughter.

Discussion:

On the basis of personal control theories (Rodin’s, 1990) and

research findings (Gatz & Karel, 1993; Heckhausen & Schulz,

1992; Schulz, Heckhausen, & Locher, 1991), the subconcepts

of external and secondary control would be expected to comprise

a theory of explanation for older women’s effort to get up

after a fall. Specifically, older women would be expected (a) to

rely primarily on others rather than themselves (external control)

and (b) to engage in internal psychological efforts to change

how they perceive the external environment rather than try to

modify the environment itself (secondary control).

However, the findings of this study are not consistent with

Rodin’s theory of personal control (1990). Instead, after they

fell, the women relied primarily on themselves. Whether they

focused on trying to get up or trying to seek help, the women

were much more involved in trying to manipulate the environment

than in trying to change how they perceived the environment.

Thus, compared to dichotomous interpretations of control

such as primary and secondary control, the findings of this

study are more consistent with Gibson’s (1977,1979/1986) interpretation

of control as perceiving, moving about in, and manipulating

the environment.

In this study, frail older women’s experience of falling was

structured in terms of intentions carried out in the uniquely personalized

environment of the home. Further study of the experience

of falling in different populations of frail elders is warranted

to describe more variations among elders’ experiences

with regard to their intentions. The nature of these intentions depends

on many factors, a prime influence being the extent to

which a frail woman is able to bring about the desired intentions,

such as pulling herself up onto something solid.

To extend Gibson’s (1979/1986) line of reasoning, an older

woman is afforded particular opportunities by the uniquely personal

environment of her home; control (understood as perceiving,

moving about in, and manipulating the environment) is

exercised in the context of those opportunities. For example, a woman who falls on a hardwood floor and a woman who falls on

shag carpet are each afforded different opportunities for perception,

movement, and manipulation. The woman who falls on

hardwood must scoot, whereas the woman who falls on carpet

can pull herself along.

When they fall, frail older women do not approach their familiar

furniture from the customary, standing position; they do

not elect to use a chair because it offers the best view of the television.

By the standard of the supine, aging person, environmental

fixtures are viewed from a new perspective-as potential

aids in “getting up from here [on my own].” “Sometimes I can

get the chair and pull.”

Even when the woman must have a helper to get up, the environmental

features of the home are more than tangential. To

admit the helper to the home, she must measure certain environmental

fixtures by her own body’s standards and then manipulate

those fixtures: “And I scooted up to the door, and my

arm’s long; I turned the knob.” According to Gibson (1977),

“Perception of the environment is inseparable from proprioception

of one’s own body. A man can bite into an apple but not

a rock; he can get a grip on a handle but not on a wall. He measures

these features of the environment by the standard of his

body” (p. 79).

Clinical Implications

Laura C. Heard,MSRN CRRN

Rehabilitation Nursing Editorial Board Member

The occurrence of a fall in a frail elder can be loaded with

significance-for the person herself, for concerned family

members and friends, and for health professionals. Because

the consequences of falling can be so drastic, efforts to prevent

them are well worth our time. Rehabilitation nurses practicing

in all kinds of settings have opportunities to influence

risk factors for falling and the environments in which our patients

often fall.

I was struck by these study participants’ emotional reactions

to falling: from the resignation of, “Oh, here I go again;’

to the acknowledgment of inadequate physical capability to

get up–“You wouldn’t think it would take that much to get

up, but I guess I’m weak.” I suspect many nurses have had

discussions with their patients that span an acute fear of

falling, worry about loss of independence, reluctance to use

adaptive aids (the “trappings of disability”), amazing resourcefulness

in solving the problem of getting up/getting

help, and being demoralized by a fall. So how can the rehabilitation

nurse be helpful in the arena off all prevention?

Relationship building before plunging into problem solving

is key. As the author writes, part of the trust development

in that relationship includes fostering the “telling of the story.”

From that could come assessment of factors that might

contribute to falling, such as orthostatic hypotension; poor

safety judgment; inadequate strength, endurance, or dynamic balance; a “hostile” environment, to name only a few. What

characteristics of the person can be modified to reduce risk?

What is the person willing to modify? What strengths does

the person bring to solving/managing the fall risk problem?

What characteristics of the person’s environment can be modified

to reduce hazard? What change is the person willing/able

to make? What positive attributes in the physical/social environments

contribute to the goal of no falls?

Interventions would follow then via discussion, rehearsal

of new strategies, contingency planning (“what would you

do if__T), and environmental adaptation. Specific plans

might be developed for maintaining balance, strength and endurance

building, practicing ‘getting up from different surfaces,

identifying possibilities for summoning help, rearranging

kitchen supplies to avoid the need for climbing or

squatting, removing hazards (e.g., scatter rugs, the home care

nurse’s favorite), adjusting medication regimes, using a tub

bench, and so on. The basic tenets of our practice-controlling

or modifying impairment, restoring function, reducing

secondary disability, and preserving dignity-are reflected

in this kind of caring.

Reference

Neal, L.1. (Ed.). (1998). Rehabilitation nursing in the home health setting.

Glenview, 11: Association of Rehabilitation Nurses,

As the human ages, the standards of the body necessarily

change, but the degree to which these standards have changed

may not be known until a fall precipitates an intense self-awareness

in those elders who retain consciousness. In this study, the

women reported the urgency with which they evaluated whether

they could make their bodies work to do their will. “You wouldn’t

think it would take that much to get up, but I guess I’m weak.

So, I just didn’t have the strength or the power to get up at the

time I wanted to.” During this activation of intense self-awareness,

the woman takes stock of opportunities for movement and

environmental manipulation while simultaneously appraising her

abilities to undertake the desired movements and manipulations.

Just as an older woman who has fallen takes stock of her abilities

and her opportunities to control her environment, so too

must home care and rehabilitation nurses take stock of the older

woman’s abilities and ecological control opportunities in relation

to falls. Because assessment through Medicare’s Outcome

Assessment Information Set (OASIS) (Shaughnessy, Crisler, &

Schlenker, 1997) has become mandatory for home health agencies

(Stoker, 1998), home health nurses can use the OASIS data

set to assess abilities essential in getting up after a fall.

In particular, the sensory and perceptual components of the

neurologic assessment (Neal, 1998) and the walking component

of the activities of daily living/instrumental activities of daily

living assessment are both crucial and consistent with the recommendation

that nurses should watch for fall-related factors

such as confusion, dizziness, weakness, and difficulty in ambulating

(Fortin, Yeaw, Campbell, & Jameson, 1998). In addition

to enabling assessment of frail elders’ abilities to get up after a

fall, the OASIS data set includes a thorough environmental assessment,

which is undertaken from the perspective of the client’s

safety. For instance, if stair railings cannot support the client’s

weight (Neal), they will be of little use when a frail woman attempts

to pull herself up from the floor.

However, in appraising the extent to which an elder’s home

affords opportunities to get up after a fall, it is recommended

that the nurse move beyond the parameters of OASIS. For instance,

OASIS requires an assessment of the Durable Medical

Equipment (DME) elders “must use in their daily living” (Sitzman,

1998, p. 561); DME includes equipment such as walkers

and canes. However, a frail elder may consider her “wall-to-wall

furniture” as much an asset in helping her move about in her

home. As is evident in the findings of this study, women who

fall to the floor seek a sturdy chair to pull themselves up. Fortunately,

they do not rely on a walker, knowing that it would not support

them in that effort.

When assessing frail elders’ environments, the definition of

DME could be expanded to incorporate environmental affordances

(Gibson, 1977), such as the sturdy, solid pieces of fumiture

that afford an elder the opportunity to get up after a fall. Veteran

fallers, in particular, may have concluded that certain pieces

of furniture are indispensable because of their solidness; if so,

this is important information for the nurse to obtain. In this study,

one of the veteran fallers noted that she had considered giving

away her soft living room chair because it was uncomfortable

to sit in and hard to get out of-until she realized that the chair

was her best prop in the living room when she needed to get up

from the floor. Thus, it is important to assess the environment

not only from the standpoint of safety, but also from the perspective

of affordances-environmental features that support

opportunities to move around in and manipulate the environment

in the event of a fall.

Above all, in assessing a frail elder’s abilities to get up after

falling and the opportunities the home environment affords in

this regard, the nurse should remember Neal’s (1998) precept

that “in measuring function, the patient’s ability to conceptualize

an activity is just as important as the patient’s physical ability

to perform the activity” (p. 672).

Because frail older women who have fallen are at increased

risk for falling again (Graafmans et al., 1996), prevention must

be a key element of rehabilitative intervention. Any efforts by

rehabilitation professionals to improve a woman’s ability to get

up after a fall must be individualized, devised in concert with

the “standards of her body” and in relation to the unique affordances

within her home. Furthermore, interventions designed

to activate intense self-awareness may be useful adjuncts to interventions

designed to teach elders how to fall and get up safely.

Designing interventions grounded in empirical knowledge is

an important thrust of rehabilitation. Hence, suggestions are

needed for interventions focused on training frail elders to get

206 Rehabilitation Nursing> Volume 24, Number 5·Sep/Oct 1999

up after a fall (Lanes & Porter, 1998).

Finally, it must be underscored that the difficulties of older

frail women who fall to the floor are far removed from the experiences

of most health professionals-a fact well known to

one veteran faller. “They used to have on television a woman

that just screamed out, ‘I’ve fallen and I can’t get up’ in that

squeaky voice. And you could imagine that people were laughing

about it. And I don’t like that. Because I tell you, until anybody’s

fallen and can’t get up, they don’t know what it’s like.”

Although phenomenological studies of the experience of falling,

such as this study, are an essential base for sensitive intervention-with

elders who have fallen, professionals must remember

that each elder’s experience of falling is unique. Accordingly,

every frail elder needs the opportunity to explain “what it was

like” for her when she fell at home and tried to get up.

References

Arfken, CL, Lach, H.W., Birge, S.1., & Miller, J.P. (1994). The prevalence and

correlates of fear of falling in elderly persons living in the community. American

Journal ofPublic Health, 84,565-570.

Commodore, D. (1995). Falls in the elderly population: A look at incidence, risks,

healthcare costs, and preventive strategies. Rehabilitation Nursing, 20, 84-89.

Fortin, J.D., Yeaw, E.M., Campbell, S., & Jameson, S. (1998). An analysis of risk

assessment tools for falls in the elderly. Home Healthcare Nurse, 16,624-

629.

Gatz, M., & Karel, M. J. (1993). Individual change in perceived control over 20

years. Special issue: Planning and control processes across the life span. International

Journal ofBehavioral Development, 16,305-322.

Gibson, J. J. (1977). The theory ofaffordances. In R. Shaw & J. Bransford (Eds.),

Perceiving, acting, and knowing: Toward an ecologicalpsychology (pp. 67-

82). Hillsdale, NJ: Lawrence Erlbaum Associates.

Gibson, J. J. (1986). The ecological approach to visual perception. Hillsdale, NJ:

Lawrence Erlbaum Associates. (Original work published 1979)

Graafmans, W.e., Ooms, M.E., Hofstee, M.A., Bezemer, PD., Bouter, L.M., &

Lips, P. (1996). Falls in the elderly: A prospective study ofrisk factors and

risk profiles. American Journal ofEpidemiology, 143, 1129-1136.

Greeno, J.G. (1994). Gibson’s affordances. Psychological Review, 101,336-342.

Heckhausen,J.,& Schulz, R. (1992). Shiftingpreferencesfor primary and secondary

control across the life course: A new conceptualization. Ceskoslovenska Psychologie,

36 (1), 1-9.

Heckhausen, J., & Schulz, R. (1995). A life-span theory of control. PsychologicalReview,

102,284-304.

Husserl, E. (1962). Ideas: General introduction to pure phenomenology (W.R.

B. Gibson, Trans.). New York: Macmillan. (Original work published 1913)

Kohak, E. (1978). Ideas and experience. Chicago: The University of Chicago

Press.

Lanes, T.!., & Porter, E.1. (1998). Enablingfrail elders to get up after falling:

Suggested interventionsfor home care nurses. Manuscript in preparation. University

of Missouri-Columbia, Columbia, MO.

Neal, L.1. (1998). Functional assessment of the home health care client. Home

Healthcare Nurse, 16; 670-677.

Patton, M.Q. (1990). Qualitative evaluation and research methods (2nd ed.).

Newbury Park, CA: Sage.

Porter, E.1. (1994a). Older widows’. experience of living alone at home. Image:

Journal ofNursing Scholarship, 26, 19-24.

Porter, E.1. (1994b). “Reducing my risks”: A phenomenon of older widows’ lived

experience. Advances in Nursing Science, 17 (2),54-65.

Porter, E.1. (1998). On “being inspired” by Husserl’s phenomenology: Reflections

on Ornery’s exposition of phenomenology as a method for nursing research.

Advances in Nursing Science, 21 (1), 19-28.

Reed, E.S. (1996). The necessity ofexperience. New Haven, CT: Yale University

Press.

Rodin, J. (1990). Control by any other name: Definitions, concepts, and processes.

In J. Rodin, e. Schooler & K.W. Schaie (Eds.), Self-directedness: Cause

viving traumatic brain injuries every year as a result of advances

in medical technology. Additional treatment approaches need

to be developed to facilitate the long recovery many must face.

This case study presents a multimodal treatment approach that

may be helpful in this process and that may be of particular interest

to nurses and other rehabilitative specialists who provide

service for such adolescents. Further research is necessary to

determine if these and similar interventions are truly effective

in treating adolescent aggressive and noncompliant behavior

following a traumatic brain injury.

References

Ayllon, T:, & Azrin, N.H. (1968). The token economy: A motivational system

for therapy and rehabilitation. New York: Appleton-Century-Crofts.

Burke, W.H., & Wesolowski, M.D. (1988). Applied behavior analysis in head

injury rehabilitation. Rehabilitation Nursing, 13, 186-188.

Crane, A, & Joyce, B. (1991″). Brief report: Cool down: A procedure for decreasing

aggression in adults with traumatic head injury. Behavioral Residential

Treatment, 1,65-75.

Frisch, M., Elliott, C., Atsaides, J., Salva, D., & Denney, D. (1982). Social skills

and stress management training to enhance patients’ interpersonal competencies.

Psychotherapy: Theory, Research, and Practice, 19,349-358.

Hogan, RT. (1988). Behavior management for community reintegration. Journal

ofHead Trauma Rehabilitation, 3, 62-71.

Horton, AM., & Howe, N.R (1981). Behavioral treatment of the traumatically

brain-injured: A case study. Perceptual and Motor Skills, 53, 349-350.

Kendall, P.C., & Braswell, L. (1982). Cognitive-behavior self-control therapy

for children: A component analysis. Journal ofConsulting and Clinical Psychology,

50,672-689.

Kendall, P.e., & Braswell, L. (1985). Cognitive-behavioral therapy with impulsivechildren.

New York: Guilford Press.

Lira, F.T., Carne, W., & Masri, AM. (1983). Treatment of anger and impulsivity

in a brain damaged patient: A case study applying stress inoculation.

International Journal ofClinical Neuropsychology, 5, 159-160.

Falls Among Elderly Women

continued/rom page 206

and effects throughout the life course (pp.l-17). Hillsdale, NJ: Lawrence

Erlbaum Associates.

Rotter, lB. (1966). Generalized expectancies for internal versus external control

of reinforcement. Psychological Monographs, 80 (1, Whole No. 609).

Schulz, R., Heckhausen, J., & Locher, J.L. (1991). Adult development, control,

and adaptive functioning. Journal ofSocial Issues, 47, 177-196.

Shaughnessy, P.W., Crisler, K.S., & Schlenker, RE. (1997). Medicare’s OASIS:

Standardized Outcome and Assessment Information Set for Home Health

Care, OASIS-B, Center for Health Services and Policy Research, Denver.

Sitzman, K. (1998). Tips for using OASIS. Home Healthcare Nurse, 16,561.

Stoker, J. (1998). OASIS as a mandatory Medicare requirement. Home Healthcare

Nurse. 16, 595.

Tideiksaar, R (1993). Falls in older persons. The Mount Sinai Journal ofMedicine,

60, 515-521.

Weisz, J.R (1990). Development of control-related beliefs, goals and styles in

childhood and adolescence: A clinical perspective. In J. Rodin, e. Schooler,

& K.W. Schaie (Eds.), Self-directedness: Cause and effects throughout

the life course (pp. 103-145). Hillsdale, NJ: Lawrence Erlbaum Associates.

Weisz, JR, Rothbaum, F.M., & Blackburn, T.e. (1984). Swapping recipes for

control. American Psychologist, 39, 974-975.

Acknowledgments

This work was supported by Project R29 NR04364-01,

Mehr, J.J, & Holi, T.C. (1984). Behavioral treatment for aggression in residents

of institutions for the emotionally disturbed and the mentally retarded. In S.

Saunders, A Anderson, & C. Hart (Eds.) Violent Families and Individuals:

A Handbookfor practitioners. Springfield, IL: Charles e. Thomas.

Miller, L. (1994). Traumatic brain injury and aggression. Journal ofOffender

Rehabilitation, 21 (3-4),91-103.

Patterson, G.R, Chamberlain, P., & Reid, J.B. (1982). A comparative evaluation

of a parent training program. Behavior Therapy, 13, 638-650.

Turner, J.M., Green, G., & McMorrow, D.B. (1990). Differential reinforcement

of low rates of responding (DRL) to reduce dysfunctional social behaviors

of a head-injured man. Behavioral Residential Treatment, 5, 15-27.

Wesolowski, M.D., & Zenicus, AH. (1992). Treatment of aggression in a brain

injured adolescent. Behavioral Residential Treatment, 3, 205-210.

Wood, RL. (1987). Brain Injury Rehabilitation: A Neurobehavioral Approach.

Aspen, CO: Rockville.

Zenicus, A.H., & Wesolowski, M.D. (1991). Reducing verbal aggression in

adults with brain injury. Behavioral Residential Treatment, 6,155-164.

This continuing education offering (code

number RNC 154) will provide 1 contact

hour to those who read this article and

complete the application form on page

226. This independent study offering is

appropriate for all rehabilitation nurses.

By reading this article, the learner will

achieve the following objectives:

1. Describe strategies that can be included in a multimodal approach

to treating aggression and noncompliance after traumatic

brain injury.

2. Describe the design and implementation of a contingency

management system.

3. Compare the use of a multimodal treatment approach with a

comprehensive integrated behavioral program following a

TBI.

NIHININR. The author is grateful to Tracy I. Lanes, MSN RN,

who is a doctoral student at the University ofMissouri-Columbia

and a graduate research assistant on the NINR study, and to

Dr. Lawrence H. Ganong, co-investigator.

This continuing education offering (code

number RNC-153) will provide 1 contact

hour to those who read this article and r

complete the application form on page

226. This independent study offering is

appropriate for all rehabilitation nurses.

By reading this article, the learner will

achieve the following objectives:

1. Identify abilities essential to getting up after a fall.

2. Describe how environmental features within the home are

used by elderly women when they fall.

3. Describe interventions that could be used with elderly

women living at home to use after a fall.