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"' “1 13"33‘13' :3 «2313 ‘2; " L01' {'Ei‘ . ‘ Q’K‘i‘IL‘j -'.-‘ €3.11“, 11’ if: a 57:5,? . 2:3 :‘1 Lh‘IIn" ‘3 y‘.‘ '-" 1131‘ e] 855%:1‘ "if? -4 3‘1""; '3;wa 11.1%! ‘3? I11 1 :35 3'“: Isr‘ttln‘ I a}?! If" 3 K’ ‘1- $1151 11111.1 1 "3‘ , 012.11%: 933%? '.’4 {L13 1%‘33‘33; “£31630“. 1% . .1111111111‘131 ‘1111 1-11 5111 n "‘M 4': gig g: mxfig' 2.123 3&5} 1::4 :;:‘; 1 .1; ‘ u :‘1 I", THESYS This is to certify that the thesis entitled A DESCRIPTIVE STUDY OF DIFFERENCES IN OLDER WOMEN'S PERCEPTIONS OF TWO TYPES OF SOCIAL SUPPORT presented by Laurie Sefton Cojocel has been accepted towards fulfillment of the requirements for Master of Science degree in Nursing Major professor Date N 7 3’4 0.7639 MS U is an Affirmative Action/Equal Opportunity Institution MSU LIBRARIES ~— N-r RETURNING MATERIALS: Place in book drop to remove this checkout from your record. FINES will be charged if book is returned after the date stamped below. A DESCRIPTIVE STUDY OF DIFFERENCES IN OLDER WOMEN'S PERCEPTIONS OF TWO TYPES OF SOCIAL SUPPORT By Laurie Sefton Cojocel A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE IN NURSING College of Nursing 1984 Copyright by Laurie Sefton Cojocel ©1984 ABSTRACT A DESCRIPTIVE STUDY OF DIFFERENCES IN OLDER WOMEN'S PERCEPTIONS OF TWO TYPES OF SOCIAL SUPPORT BY Laurie Sefton Cojocel Elderly persons are often viewed as a homogenous group, with little effort made to identify differences. Recent interest in adult develop- ment focused attention on diversity among aged persons. A descriptive study was proposed to explore whether older women perceived social sup- port received, in emotional form, differently from tangible aid available. Age differences in perception of suport were examined between two age groups of women, 65 to 74 (n = 36) and 75 to 89 (n = 24). Data from a larger study, Active Participation: Health Care for the Elderly (Given, 1983), were analyzed using descriptive statistics and_£ tests. A significant difference was found within both age groups when mean perceived emotional support was compared with mean tangible aid. Subjects perceived less tangible support available tfluui emotional. Between the two groups a significant difference was found on tangible aid perceived to be available with the older group perceiving less. These findings contribute to Nursing assessment of social support avail- able to older women. To Constantin, Mom and Dad iii ACKNOWLEDGMENTS I would like to thank my committee members, Barbara Given, Rita Gallin, Bill Given, and Carol Garlinghouse, for their expertise and guidance. I am grateful for their contributions to this study. Special thanks to my committee chairperson, Barbara Given, for her guidance over this summer and for the opportunity to use data from her study, Active Participation: Health Care for the Elderly. I would like to express my heartfelt gratitude to Dorothea Milbrandt, R.N., M.S.N., for her mentorship over many years of growth in the profession. Without her support, encouragement and steadfast belief in my ability to succeed, completion of this Master's program in Nursing would have remained a dream. Special thanks to my long time friend, colleague and thesis partner, Carolyn Smith Adams, for her support (both emotional and tangible) over this difficult time. Through this thesis experience we learned collaboration, not just the skill, but the essence. A note of appreciation is extended to Brian Coyle for his invalu- able assistance in the data analysis, and for taking the time to help me understand statistics. Margaret McNivin's support and assistance with Chapter 5 is gratefully acknowledged. Sincere thanks to Jackie Bruinsma who patiently transformed this thesis from handwritten scribbles to right and left justified copy. Jackie's patience with me, tolerance for difficult deadlines, enthusiasm for a perfect copy and expert typing skills were much appreciated. There are many people whose direct or indirect assistance this summer assured completion of this project. The core of this group, and of my support network, is my family. My ongoing thanks and love to my parents, Beth and Bill Sefton. They have provided a strong base of family love and support, instilling in their children a deep sense of commitment to growth and joy in achievement. Their special understanding zuui help have lightened this summer's tasks with humor, creating treasured moments in the process. To all of my brothers and sisters, your sharing of life's changes and growth helped me maintain my perspective. Special thanks to Kathy and Sarah for their support and direct assistance this summer and to Amy for her help with library research. Most of all I thank.my husband, Constantin. liithout his love and encouragement, this project would not have been completed. Constantin's commitment to research, has provided a model for academic excellence. His support and pride in my endeavors have sustained me. With all my love I acknowledge my gratitude for his sacrifice and faith in me this summer. 1. 3. 4. 5. 6. 8. 9. 10. LIST OF TABLES Profile of Older Women in the U.S.A.: 1970, 1980, 1990, 2000 (from Uhlenberg, 1979)oooooooooo000000000000ooo00000000000000. 50 Number and Percent of Females 65 to 74 Years of Age by SGlECted Demographic Variables............................. 99 Comparison of the Group I (Younger) Educational Level Variable to Percent Distribution of Females Age 65 and and Older in the U.S. by Education (from Statistical Abstracts Of U.S., 1984)....ooooooooooooooooooooooo00.000.000.102 Selected Demographic Variables Concerning Group II Respondents (n = 24)....0.0000000000000000000000000000000.000.104 Comparison of the Group II (Older) Educational Level Variable to Percent Distribution of Females Age 65 and Older in U.S. by Education (from Statistical Abstracts Of U.S., 1984)ooooooooooo000000000000000000000000000107 Pearson Correlation Coefficients for 3 Emotional Items on NSSQ -- Data from Responses about 3 Significant Others............................................110 Pearson Correlaton Coefficients for 2 Tangible Aid Items on NSSQ -- Data from Responses about 3 Significant Others............................................111 Comparison of Composite Means for Emotional Support and Tangible Aid in Women Aged 65 to 74.......................ll3 Comparison of Composite Means for Emotional Support and Tangible Aid in Women Aged 75 t0 89000000000000000.000000.114 Comparison of Composite Means for Emotional Support and Tangible Aid Between Two Age Groups of Women..............115 vi CHAPTER II. TABLE OF CONTENTS List of Tables List of Figures THE PROBLEM Introduction.............................................. Background................................................ PurpOSEouooooooon0000000....coo...oooooooooooooooooooooooo Research Questions........................................ Definition Of the concepts................................ Age.................................................. Social Support....................................... Emotional Support.................................... Tangible Aid-coco...0000000000ooooooooooooooooooooooo Perception........................................... Significant Others...........o...................o... Theoretical and Conceptual Assumptions.................... Methodological Assumptions................................ Scope and Limitations..................................... Overview Of Chapters...................................... CONCEPTUAL FRAMEWORK Introductionooooooooooo0.0.0.0000.0...00000000000000.9000. Rogers‘ Conceptual System for Nursing..................... The Principle 0f Integrality......................... The Principle 0f Reasoncy....o....................... The Principle Of Helicy.............................. Rogers' Principles and Aging Phenomena............... Conceptual Framework and Definitions...................... AgeIOOOO0.0...00......OOOOCOCOOIOOOOIOIIOOOOOOOOUOOOO Social Support....................................... Support as Relational Provision................. Support as Information.......................... support as Structure............................ Support as Interaction.......................... Perception -- the Subjective Approach to Social Support......................................... The Function 0f Social Support....................... vii UVb-£~UJF— \I\I\I\IO*U 10 12 13 14 15 16 16 17 18 25 27 28 30 31 34 35 CHAPTER II. III. IV. PAGE Types Of Social Support.............................. 38 Nature Of the Situation......................... 38 Timing.......................................... 40 Personal resources.............................. 40 The Norbeck MOdeloooooooooocooooooooooooooooooooooooo 41 Integration and Summary.............................. 44 LITERATURE REVIEWOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO0.0.00.0... 47 Introduction.............................................. 47 Age and Individual Differences............................ 47 Social Support............................................ 59 Problems in Conceptualization and Operationalization.......o...................... 60 Development of the Concept of Social Support......... 62 Perceived Emotional Support.......................... 65 Perceived Tangible Aide...00000000000000.000000000000 73 Summary....................o....o.................... 80 METHODOLOGY AND PROCEDUREooooooooooooooooooooooooooooooooo 82 Introduction.............................................. 82 Design.................................................... 82 Research Questions........................................ 83 Independent/Dependent Variables........................... 84 Operational Definitions................................... 84 Age.................................................. 84 Significant Others................................... 84 Perceived Emotional Support.......................... 85 Perceived Tangible Aidooooooooooooo0.0000000000000000 85 Norbeck's Social Support Questionnaire.................... 86 Description Of the Instrument........................ 86 Administration and Scoring........................... 87 Pretest Of the Instrument............................ 87 Reliability and validity...oooooooooooooooooooooooooo 88 Sample.................................................... 90 Data Collection Procedure................................. 91 Sites..................................................... 91 Collection Of Data........................................ 92 Human SUbjGCC PfOtECtiOnoooooooooooooooooooooooooooooooooo 95 Statistical Analysis Of Data.............................. 95 Summary............................o...................... 96 viii c» CHAPTER PAGE V. DATA PRESENTATIONOOI...0......OOOOOOOOOOOOOOOOOOOOOOOIIOOO 97 Introduction.............................................. 97 Description Of the Study Sample........................... 97 Demographic Characteristics of Group I (Younger).......... 98 Age.................................................. 98 Marital Status....................................... 98 Ethnic Background....................................100 Employment Status....................................100 Head Of Household Status.............................100 Income........o...o..................................101 Education............................................101 Demographic Characteristics of Group II (Older)...........103 Age...00.0to...o.on...0.00.00.00000000000000000000000103 Marital Status.......................................103 Ethnic Background....................................103 Employment Status....................................104 Head Of Household Status.............................105 Income...............................................106 EducatiOHOOOOC'0.00....00......0000.000.00.0000000000106 Use of NSSQ on the Sample of Women Aged 65 to 89..........108 Description of Dependent Variable Creation................112 Presentation Of Findings.......o..........................112 Differences in perception of emotional support received and tangible aid available in a group or women aged 65 to 740o.so...0'00...cocooooooooooooollz Differences in perception of emotional support received and tangible aid available in a group Of women aged 75 to 89c0000000000000.0000000000000000112 Differences in perception of emotional support received and tangible aid available between two groups or elderly women..........................113 Discussion................................................117 Summary...................................................118 ix VI. SUMMARY AND CONCLUSIONSOOOOOOOOOOOOO0.0.0.0...00.0.0000000119 Increductionoo0000.00.00.00oooooooooooooooooooo...00000000119 ReView Of Chapters...’ 0 o o o o o o o o. 00 o o o o O O O 0.. o O O o o o o 0000 O o .119 Interpretation of Findings................................123 Descriptive Findings of the Study Sample.............123 Descriptive Findings Related to Research Questions 1 and 2...............................123 Description Findings Related to Research Question 3......................................125 Findings Related to the Definition of the Concept of Social Support.......................127 Additional Findings..................................129 Norbeck's Model of Social Support and Nursing Practice....130 Implications for Nursing Research and Recommendations.....135 Implications for Nursing Education........................140 Implications for Nursing Service..........................142 Dissemination of Results..................................146 References................................................149 Appendix AGO...0.0...0..O00....OOOOOOOOOOOOOOOOOOOOOOO0.0.168 Appendix BOOOOOOOOOO0.0.0.00.0.00...OOOOOOOOOOOOOOCOOOOO0.175 CHAPTER I THE PROBLEM INTRODUCTION The Clinical Nurse Specialist working with elderly individuals is aware that the perceptions of persons in their sixties differ from those of persons in their eighties. Identifying and describing per- ceptual, or other, age differences among the elderly, however, is complicated by little documentation in the literature, few empirical studies about age differences and developmental norms in older age groups, and by the pervasive ageism which is prevalent in our society. The term ageism was coined to explain the negative bias against people of advanced chronological age (Butler 1969). Ageism supports myths that most old persons are "all alike," a homogenous population, and are socially isolated. Martha Rogers' Theory of Unitary Human Beings (1980) provides the Clinical Nurse Specialist with a conceptual basis for viewing clients as unique individuals who become increasingly more complex as they age and interact with their environment. With this conceptual base of continuous development toward increasing complexity one would expect to identify age differences within and among aging persons. Just as an individual is ever changing in his/her personal evolu- tion, so is the individual's environment. This study concerns part of the social environment of elderly subjects, i.e., those persons iden- tified by the individuals as supportive. With aging, losses in role and interaction often lead to decreased opportunities for social sup- port, as well as the loss of support network members (spouse, siblings, l friends, co-workers) through death, relocation or retirement. How such losses affect an elderly person's capacity to cope is unclear, but there does appear to be evidence that social support functions to buffer or protect persons from the effects of many kinds of life stressors (Cassel, 1976; Cobb, 1976; Kaplan, Cassel and Core, 1977; Dean and Lin, 1977; Lowenthal and Haven, 1968, Wallston et al. 1983; Schaefer et al. 1981). Factors related to the availability of support are often not included in the nursing assessment of the elderly, even though they may be particularly at risk for deficits in support systems. Age is one factor that influences the amount and type of social support required for optimal functioning (Norbeck, 1981). The impor- tance of study in the area of age differences and perceptions concerning different types (fl? social support is ultimately related to nursing intervention. 11 model, developed by Norbeck (1981), which shows the elements and relationships that must be studied to incorporate social support into nursing practice, will be used as a framework for this study. The focus of this study will be on elderly women's perceptions of two types of social support: emotional and tangible. The theoretical framework will be based in Rogers' (1980) theory of unitary man which emphasizes differences and uniqueness of individuals. The clinical model for research and application of social support, developed by Norbeck will provide an operational framework for this study. Included in this chapter are the background of the problem, pur- pose of this study, research questions, definitions of the concepts, assumptions, and scope and limitations of the study. Data utilized in this study were collected as part of a funded research project, Active Participation: Health Care for the Elderly (1982), directed by B. Given. Additionally, a portion of this research was conducted in collaboration with Smith Adams (1984). Background As of July, 1982, the number of persons in the United States over 65 years of age was 26,824,000, or 11.6% of the total resident popula- tion of all ages. This age group has increased by 15% since 1970, compared to only 6% growth for the population as a whole. During this time the number of elderly women has increased more rapidly than men. In 1900, the total population of women aged 65 or older was 1.5 million, or two percent of the U.S. population. By 1982 the number of older women had reached 16 million, or 6.9 percent of the total U.S. popu- lation. For 1982, males over 65 numbered 10.7 million, or 4.6 percent of the total U.S. population. Since life expectancy is higher for women than men (in 1982, 78.2 years for women versus 70.8 years for men), a ratio of 70 males for every 100 females is reached by age 65. This ratio increases by age 85 to 50 males for every 100 females (U.S. Bureau of Census 1980 and 1976; Uhlenberg, 1979). Given the greater longevity of women, health care providers and researchers are only beginning to focus on the need for resources that promote the health of older women. Yet most of the literature tends to focus on disease processes in aging females, rather than on factors that promote health or delineate normal aging processes (Gelein, 1980). Awareness (fl? pathology and effective treatment is important to both physicians and nurses, but as Clinical Nurse Specialists, we need additional knowledge about factors that promote health. One such factor, present since the beginning of human existence, but only recently identified and examined as a mechanism that promotes health, is social support. For this study, the complex variable of social support is examined by comparing perceptions about the availa- bility of two types of social support: emotional and tangible. Women, ages 65 to 74, were chosen as study subjects because of their predomi- nance in the population of older people and because there is some evi- dence that females may use social support differently than males (Lowenthal and Haven, 1968). In collaboration with Smith Adams (1984), perceptions of the availability of emotional support and tangible aid are compared, to identify differences between two age groups of women (65 to 74 and 75 to 89). Purpose The purpose of this study, therefore, is to compare older women's perceptions of two types of social support, emotional and tangible, and, to identify differences in perception of the availability of emotional support and tangible aid between two age groups of elderly women. For the Clinical Specialist in advanced nursing practice with elderly clients, information of this type is essential for comprehensive assessment 0 Research Questions 1. Is there a difference in the mean value of perceived emotional support received and tangible aid perceived to be available among women ages 65 to 75? (Sefton Cojocel, 1984) 2. Is there a difference in the mean value of perceived emotional support received and tangible aid perceived to be available among women ages 75 to 89? (Smith Adams, 1984) 3. Is there a difference in the mean value of perceived emotional support received and tangible aid perceived to be available between two female groups, women age 65 to 74 and women age 75 to 89? (In collaboration with Smith Adams.) Definitions of the Concepts The study variables are age and perception of the availability of two types of social support: emotional support and tangible aid. 535 For the purposes of this study, age will be defined by needs and age norms, the basis of a sociocultural approach used by Neugarten (1981), to dichotomize older Americans into the young-old (65 to 75) and the old-old (75 years and older). The following are examples of the needs and age norms of each group of aging people. It is the young-old who now comprise the large majority of per- sons over 65. This trend is expected to continue. They are, for the most part, healthy and competent men and women, many of whom have retired or reduced their time in homemaking and/or in work outside the home, but remain integrated members of their families and communities. Whether they are working or retired, they play active roles in their churches, clubs, and organizations, and an increasingly large number perform volunteer roles. The old-old (75 years and older) are those persons who are likely to have undergone major physical and mental changes. While the members of this group are increasing as the population of older persons increases, they will likely remain a small proportion of aged Americans due to mortality. Nevertheless, this group, while frail, will expect to main- tain independent lives as long as possible (Neugarten, 1981). Neugarten's sociocultural age groupings of young-old (65 to 74), (Sefton Cojocel), and old-old (75+), (Smith Adams), will be utilized in this study. It might be expected that such a dichotomy will provide for similar needs and norms among the women in each age group, and that the perceptions and social support needs will be quite different between the two age groups (Smith Adams, 1984). Social Support Social Support is recognized as a multidimensional construct and has been described in various ways (Cobb, 1976; Caplan, 1974; Mitchell, 1969; Dean and Lin, 1977; Weiss, 1974). The conceptual definition used in this study was developed by Kahn (1979). He defines social support as "interpersonal transactions that include one or more of the following: the expression of positive affect of one person toward another; the affirmation or endorsement of another person's behaviors, perceptions, or expressed views; the giving of symbolic or material aid to another" (p. 85). Kahn's definition was chosen because it emphasizes three aspects of social support; affect, affirmation, and aid. Norbeck's Social Support Questionnaire, the data collection instrument used in this study, is based on the concepts in Kahn's definition. Analysis of data from the use of this instrument allows one to operationalize social support into two variables; emotional support and tangible aid (see Chapter IV). The ideas expressed in Kahn's definition of social support and Norbeck's Social Support Questionnaire (NSSQ) were used to develop the conceptual definitions of emotional support and tangible aid for this study. Emotional Support Emotional support is defined as a sense of warmth, of caring, and of concern expressed by significant others. The individuals know that others believe in them, love and respect them, and there is feedback which encourages self esteem. Emotional support implies the ability to confide. Tangible Aid Tangible aid is defined as material or behavioral assistance, provided by significant others. An individual may receive tangible aid in the form of money, services such as transportation and shopping, or actual assistance with the tasks of daily living. W Perception is defined as simply an individual's interpretation of reality. For the purpose of this study, the individual's subjective interpretation of two types of social support, received or available from significant others, was obtained. Significant Others Although this is not a study variable, significant others are an important part of the concept of social support and will be defined in this study as: those individuals "who help to mobilize psychological resources and master emotional burdens; share tasks; and provide extra supplies of money, materials, tools, skills, and cognitive guidance to improve handling of a situation" (Caplan, 1974, p. 6). Significant others for elderly persons are, very often, primarily family members. Shanas (1973) demonstrated that the majority of older persons live with or within 10 minutes of one of their children. From 70% to 80% of the elderly studied by Shanas had personal contact with at least one of their children within the previous week. A study com- pleted by Sussman (1979) demonstrated that the family of urban America is still an extended family with grandparents and often great-grand- parents. Summarizing two points from.the conceptual definitions demonstrates the focus of this study. 1). Social support is a multidimensional construct which has been defined and studied in various ways. By employing two distinct kinds of social support in this study, emotional and tangible, older women's perceptions of these types of social sup- port may contribute to clarifying the concept. 2) Aging is seen as an everchanging process that results in increasing diversity among the elderly. Perceptions of social support might be expected to reflect this diversity as age increases. For example, the old-old may have more need for, and therefore, experience with tangible aid, or the young-old might view tangible support as less available because their significant others may still view them as active, healthy, and involved people, i.e., not in particular need of increased support. In this study, perceptions of two types of social support, emotional support and tangible aid, are compared within a group of older women (65 to 74 years of age). Then, comparison of the same perceptions will be made between two groups of women of different ages. The study is based on the following assumptions and subject to the limitations presented in the next section. 1. 4. 5. 6. 7. Theoretical and Conceptual Assumptions Unitary Man is a four-dimensional, negentropic energy field iden- tified by pattern and organization and manifesting characteristics and behaviors that are different from those of the parts and which cannot be predicted from knowledge of the parts (Rogers, 1980, p. 332). Environment is a four-dimensional, negentropic energy field iden- tified by pattern and organization and encompassing all that is outside any given human field. Unitary man and his environment are in continuous, mutual, simul- taneous interaction, evolving ‘toward. increased, differentiation and diversity of field pattern and organization (Rogers, 1980, p. 333). Change is always innovative. There is no going back, no repeti- tion. The complexity and heterogeneity of man as he ages becomes more evident when he is viewed as an open system. He is greater than the sum of his parts. Man's interaction with his social environment has both direct and indirect effects on his behavior and his health. Social Support has a mediating or buffering affect that stimulates the development of coping strategies or provides direct aid. Lack of support can lead to decreased ability to cope and result in ill health. 8. 9. 10. 11. 12. 13. 10 Human beings need social support and receiving support contributes to their well being and ability to withstand stress. The need for social support persists throughout life. As people age, they lose significant others through death, reloca- tion, or retirement. These major losses can result in an inade- quate support situation for older adults. Man‘s perceptions depend on the conceptual model he holds of the world. His representation of reality is influenced by his past experiences and how he defines his situation. Methodological Assumptions Persons participating in this study will respond honestly according to their perceptions and understanding of the questions being asked. In the older age group studied, individuals may have more actual experience with receipt of tangible aid. Therefore, response of those in the older age group may be based on actual tangible aid received rather than hypothetical aid available. Scope and Limitations The scope of this study extends only to the sample that was studied. The sample was obtained from participants to a larger, pre- liminary study of the elderly's active participation in health care. The following are limitations of this study. 1. No attempt was made in the original study to obtain a random sample or typical group of elderly individuals. 2. 5. 6. 7. 8. 9. 11 This study uses secondary data obtained from the pre-test of instruments for the larger study. Therefore other pertinent data for this study are not available. Individuals who agreed to participate in the larger study may be different from those who refused and, therefore, the research findings may not be representative of all elderly women. Long-lived persons represent a select group. The well elderly, particularly those above age 75, could be considered elite sur- vivors. Therefore, generalization of findings will be limited. Various cohorts will have different historical and environmental exposures. A longitudinal study would be necessary to establish how perceptions within a cohort actually change over time. Rather than age changes, this cross sectional study will attempt to measure age differences. Individual perceptions of the meanings assigned to answer choices (represented in a.1dkert scale) may have differed, creating a problem in comparison of responses within the study group. The data were collected at one point in time. Several measure- ments over a period of time may have been more useful in repre- senting the perception of individuals. The sample sizes were small, 36 women aged 65 to 75, and 24 women aged 75 to 89. The small numbers may have been too limited to reflect true differences in perceptions of social support. The population studied is from one geographical area in Michigan and, therefore, may not be typical of the elderly in the United 8 tates o ‘ Overview of Chapters This thesis will be organized and presented in six chapters. The introduction, problem statement, purpose, research questions, defini- tions of the variables, assumptions and limitations of the study have been presented in Chapter I. In Chapter II, which was written in collaboration with Smith Adams, a more detailed discussion of the variables is presented. Martha Roger's theory of Unitary Human Beings is presented as an overall philosophy, and the relationship between the concepts and the nursing process are shown with a model developed by Norbeck (1981). The third chapter, also co-authored with Smith Adams, contains a review of the literature. In this chapter, both classical research in the area of social support and more recent studies with social support as a health conditioning variable are presented. Lit- erature and research on the aged American female and aging and indivi- dual differences are also reviewed. Limitations of currently available literature are also discussed in this chapter. In Chapter IV, methodology and procedure will be presented, including population, subjects, operational definitions, Norbeck's Social Support Questionnaire, data collection procedures, and scoring measures. Data and analysis are discussed in Chapter V. First the data specific to this study are examined. Then, data from the study by Smith Adams are summarized, and the results compared to answer the collaborative question of whether age differences in perceptions of emotional support and tangible aid are evident between the two study populations. In Chapter VI, implications of the findings for Nursing Research, Education, and Practice are discussed and recommendations are pre- sented. CHAPTER II CONCEPTUAL FRAMEWORK Introduction In this chapter, concepts of aging and the aging female will be related to dimensions of the complex ‘variable: of social. support. Advanced nursing practice, directed toward health promotion for the elderly, provides the overall orientation for this thesis. The discussion will begin with a general nursing theory proposed by Martha Rogers' (1971). Within Rogers' framework, broader concepts of holistic man, environment, and pattern and organization of human behaviors, will be presented as they relate to older women and the diversity and complexity of aging phenomena. A discussion of social support will follow, including related concepts from the literature on social networks. For this study, two dimensions of social support will be conceptualized, and operationally defined (Chapter IV): emo- tional support and tangible aid. In this thesis elderly women's perception of the emotional and tangible dimensions of social support are examined by analysis of five items on Norbeck's Social Support Questionnaire. A model developed by Norbeck (1981) In) incorporate social support into nursing practice will be presented in this chapter. We have chosen to utilize Norbeck's model because it provides the critical link between the complex concept of social support and the actual nursing process in clinical practice. We will now discuss the central nursing theory (mm which this study is based, incorporating age, social support, and Norbeck's model into Rogerian dimensions. This chapter was written in collaboration with Smith Adams (1984). 13 14 Rogers' Conceptual System for Nursing Rogers uses a dialectic method of reasoning in which nursing is explained in reference to broader principles that explain man. Man, in turn, is explained according to principles that, Rogers asserts, characterize the universe. The concept of evolution is central to Rogers' theory. The evolution of scientific thinking, the environment, and man as a species are presented in her discussion, as background information for describing the nature of development in the life pro- cess of individual man. Rogers states that the science of nursing is directed toward describing the life process of unitary man, and toward explaining and predicting the nature and direction of man's develop- ment (1981). The term "development" will be used as it focuses on an individual's evolution. Research in nursing, then, is the study of unitary man, while the practice of nursing is the use of this body of knowledge in service to people (Rogers, 1980). Four basic assumptions about human beings are proposed by Rogers. 1) Man is a unified whole and his oneness can be visualized as obser- vable phenomenon in the pattern and organization of unique energy fields. Man and environment do not have energy fields; they are energy fields. 2) Man and environmental fields are continuously exchanging matter and energy with one another and this interchange is the basis of man's growth and behavior. 3) The life process of humans evolves unidirectionally along a space-time continuum, thus involving continuous development of the individual and environment. 4) Man is characterized by the capacity for abstraction and imagery, language, thought, sensation and emotion. 15 Within this framework of man and environment, Rogers proposes three broad principles that postulate the nature and direction of uni- tary human development: Integrality, Resonancy, and Helicy. Definitions of these principles will be presented first, and then the concepts will be discussed as they relate to elderly women. The Principle of Integrality (formerly titled the Principle of Complimentarity) The interaction between human and environmental fields is con- tinuous, mutual and simultaneous. Man and environment are inseparable; they change together. The Principle of Resonancy The relationship between human and environmental fields is one of constant interaction and mutual change. The change of the pattern and organization in the fields of man and environment takes place by means of wave phenomena. The principle of resonancy proposes the nature of the change in stating that wave pattern and organization continually move from lower frequency, longer wave patterns, to higher frequency, shorter wave patterns. This principle provides the basis for explaining the creative unidirectional evolution of life, and implies predictability in some parameters where appropriate tools to measure wave frequency can be developed. 16 The Principle of Heligy The nature and direction of human and environmental development is continuously innovative, probablistic, and characterized by increasing diversity of the pattern and organization of human and environmental fields. This increasing diversity in man and environment is manifested in what Rogers terms "non-repeating rhythmicities." The principle of helicy, stated more simply, describes development as a constant, dyna- mic process which occurs through the continuous mutual interaction of man and environment. This interaction and repatterning is unique in time and therefore ever different. You can never be less than you are now, therefore, the life process is seen as a constantly evolving series of changes in which past experiences are incorporated and new patterns emerge. Rogers' Principles and Aging Phenomena The principle of helicy is a key frame of reference for viewing the elderly. In the past we have tried to place all older people into a group termed "the aged," making generalizations and predictions about the group (n1 that basis (Katch, 1983). iRogers' theory rejects that approach as implausible. Human development becomes more, not less, differentiated (Murray, 1979). As Neugarten (1979) states, ”with the passage of time, life becomes more, not less, complex; it becomes enriched, not impoverished." According to Rogers, integrality, resonancy, and helicy have validity only within the context of the conceptual system of unitary man. Man must be viewed as a whole, greater than the sum of the parts. The relationship within this conceptual system of unitary man 17 interacting with his environment, is very much in keeping with the ideas of several authors who have conducted research with aged popula- tions (Neugarten, 1974; Troll, 1977; Lawton, 1977). Aging is a con- tinuous process from birth to death. In Rogers' conceptual system, aging is considered a developmental process in which humans grow in diversity and complexity; biologically, socially, mentally, and spiri- tually. Rogers does not support a "running down" theory of aging. Her theory of increasing complexity and unidirectionality is evidenced in her statements about changing sleep patterns, taste patterns, and color preferences. Aging persons require less sleep per rest period, and the patterned frequencies of sleep and wakefulness are more diverse. Preference in taste is for sharp, distinct flavors, which implies appreciation of the complexities of the range of taste pheno- mena, rather than the often held premise of deteriorating taste buds. Color preference changes in the direction of higher wave frequencies with age. Conceptual Framework and Definitions Utilizing the conceptual framework proposed by Rogers, it is assumed that women become more diverse and complex each day they live, and that differences among age levels may be evident in their percep- tions of emotional support received and tangible support available from their social environments. This study will be based on three concepts from Rogers' conceptual system: 1) wholeness of unitary man/person as reflected in differences and uniqueness of individuals; 2) helicy, as reflected in changing social support patterns occurring as the 18 result of change in man/person and environment over time; and 3) inte- grality, the continu0us interaction between and among individuals and their environment (in this case the social environment). These con- cepts provide the background for the following discussion of age and aging women's perceptions of social support. Age Roger's theoretical base provides an optimistic view of aging but raises methodological problems in classifying age as a variable. Clearly, to lump everyone over 65 into a group is inappropriate as it denies the heterogeneity of the elderly. Norbeck (1981), states that age influences the amount and type of support required for optimal functioning. In examining elderly women's perceptions of social sup- port therefore, age is a critical variable. Appropriate and meaning- ful age categories that acknowledge the increasing complexity of older women must be determined. A review of the literature shows that four methods are currently used to classify age. The simple, objective way is to use chronological criterion, such as ages, 60, 65, 70. This criterion is used most often for administrative purposes, i.e. insurance programs and social security, etc. Gerontologists often use functional criteria rather than chrono- logocal age for classifying the older population. This method has been criticized as a minority position because it is representative of only portions of the elderly population, usually the dysfunctional (Troll, 1982). Functional assessment is usually done to determine 19 necessary treatment or staffing needs for those individuals unable to care for themselves. Although the concept of functional assessment for the well elderly and their environment is certainly appropriate, it is seldom used routinely with this population. A third method of classifying age is by cohorts. A cohort is a group of persons who share the common experience of the same historial events influencing them at similar ages. Troll (1982), defines the elderly cohorts as 80 to 90 year olds, 70 to 80 year olds, and 60 to 70 year olds, although these categories are not seen as mutually exclusive. Differences between cohorts may be seen in the following examples. The 80 to 90 year olds can be viewed as one cohort because time perception was less rapid in their youth, due to the relative simpli- city of society. For example, they grew up in rural surroundings. The world had narrower geographic boundaries, but individuals tended to knunv more about the space within their environments, i.e., neighbor- hood, town. Their youth was a time of close knit families and neigh- borhoods. This cohort might be expected to optimistically view social support in old age as a function of family members, however, they may be frustrated by their distance from family members at a time when support is needed. The 70 to 80 year olds were significantly influenced by two major historical events, the enormous immigration of Eastern Europeans after WW1, and the Great Depression. They were more pessimistic and more future-oriented. For example, these cohorts probably prepared finan- cially for their security in old age because they saw their parents or grandparents immigrate to the U.S. with hopes for a secure future, 20 only to suffer through the Depression. Today they are typified by retirees anxious for the pleasures of life. Their wary, more pessi- mistic viewpoint may influence their perception of social support. The 60 to 70 year old cohort, born around 1915, also were affected by the Great Depression which hit when they were in their adolescence. Many postponed marriage and children due to poverty. Both men and women in this cohort were actively involved in World War II efforts, either in industry or in the armed forces. This is the cohort that moved in umsses to the suburbs following the war, bringing about a trend toward nuclear, rather than extended, (i.e., multiple generations dwelling together) family units. Today this group is facing retire- ment as they move from middle to old age (Troll, 1982). The change from close knit families and neighborhoods to the relative isolation of the suburbs, and the movement of women into the work force, may have influenced this cohort to be more self reliant and more skilled at extending their support network outside the family. Classifying age by cohorts acknowledges the interaction of man and environment in time, and the influence that historical events have on life-span development. Historical influences also play a part in the schema developed by Baltes, Cornelius, and Nesselroade (1980). They identify three influences on development: normative age-graded influences, normative fdstory-graded (evolutionary) influences, and non-normative life events. Normative age-graded differences are the biological and environ- mental determinants of development that have a fairly strong relation- ship with chronological age. Examples are biological maturation and age-graded socialization events (Danish, 1980). 'These influences would support the classification of age by simple numerical ordering. 21 Normative history-graded influences are the biological and.environ- mental determinants associated with fdstorical time (Neugarten and Datan, 1973). They are normative if they occur to most members of a given cohort (generation) in similar ways. Examples of normative history-graded influences are economic depressions, wars, major epide- mics, and changes in the demographic and occupational structure of a given society (Danish, 1980). These influences would support classi- fication of age by simple cohorts. Non-normative life events are biological and environmental deter- minants that do not occur in any normative age-graded or history- graded manner for most individuals, such as divorce, heart attack, or other "stressful life events." Holmes and Rahe (1961); Danish, Smyer and Nowak, (1980); and Schlossberg, (1982), are among the number of authors who have discussed the role of such non-normative life events in life span development. Danish (1980), states that the joint impact of these three types of influences (normative age-graded, normative history-graded, and non-normative), mediated through the developing individual, account for the nature of life span development. In attempting to determine an appropriate, meaningful method of age classification, it is helpful to look, at. a 'prototypical. profile, postulated by Baltes, Reese and Lipsitt (1980), of the interaction among these three classes of influences. (See figure 1.) According to this figure, the effects of age-graded influences seen1tx> be most prominent during childhood; the effects of history- graded seem strongest in adolescence and early adulthood; and the non-normative events seem tx> increase iJI importance throughout the Relative Slrenglh 0! Influence 22 life span (Danish, 1980). An interesting observation of this prototy— pical profile is that both age-graded and history-graded influences have decreased impact in old age. One could speculate that the indi- vidual has integrated the personal impact of those influences into his/her unique pattern and organization and, in continuing his/her evolution innovatively, has diluted the effects of those events. Because of the increasing dilution of effect, Baltes, Reese, and Lipsitt's (1980) profile would appear to support the argument against using chronological age or cohorts for classification in elderly popu- lations. Figure 1 Life-Span Prolile ol Influences (Prololyplcal) J l I Childhood Adolescence Adulthood Old Age from the Annual Review ol Psychology. Volume 31. ©1980 by Annual Reviews. Inc. 23 For the purposes of this study, age will be defined by needs and age norms, the basis of a sociocultural approach used by Neugarten (1981), to dichotomize older Americans into the young-old (65 to 74) and the old-old (75 years and older). In using "needs" to group indi- viduals, Neugarten tries to distinguish what types of assistance are required at various ages. For example, Branch and Jette (1983), have clearly demonstrated that the risk of unmet needs for assistance with activities of daily living increases with age. An example of a "norm" that would help to distinguish similar groups within the elderly popu- lation is the culturally based age of retirement which falls within the young-old classification. The following are examples of some needs and age norms characteristic of each group of aging people. It is the young-old who now comprise the large majority of per- sons over 65. This trend is expected to continue. They are, for the most part, healthy and competent men and women, many of whom have retired or reduced their time in homemaking and/or in work outside the home, but remain integrated members of their families and communities. Whether they are working or retired, they play active roles in their churches, clubs, and organizations, and an increasingly large number perform volunteer roles. The old-old (75 years and older) are those persons who are likely to have undergone major physical and mental changes. While the members of this group are increasing as the population of older persons increases, they will likely remain a small proportion of aged Americans due to mortality. Nevertheless, this group, while frail, will expect to main- tain independent lives as long as possible. 24 Neugarten's sociocultural age groupings of young-old (65 to 74), (Sefton Cojocel), and old-old (75+), (Smith Adams), have been selected to define the study population for this thesis because the dichotomy acknowledges the heterogeneity of the elderly while providing a clear, logical method for delineating the study populations. It might be expected that such a dichotomy will provide similar groupings of needs and norms among the women in each age group, and that the perceptions and social support needs will be quite different between the two age groups (Smith Adams, 1984). While age classification by cohort or functional ability recognizes the heterogeniety of the elderly, the degree of overlap and somewhat arbitrary delineation in the case of the cohort classification, and the lack of established use with healthy elderly in the case of functional classification, make those methods less useful for this study. In summary, there are several means of classifying age as a study variable, but all present unique problems in addition to those caused by lack of research on real age differences. Chronological ordering is arbitrary. Because it fails to recognize the heterogeneity of the elderly and timing of aging phenomena, it defines the population either too narrowly or too broadly for meaningful results. The use of func~ tional criteria for classification has been established mainly with the disabled elderly. Cohort classification is appropriate with all elderly, because it recognizes heterogeneity while emphasizing the influence of historical events. Delineation of cohorts, however, is arbitrary. Additionally, at least one group of authors proposes that historical events are less influential to the elderly (Baltes, Reese and Lipsitt, 1980), and therefore may be unsuitable criteria for division. 25 Neugarten's categories for age classification within the elderly are also somewhat arbitrary, but seem to be the most logical grouping for this thesis because they provide clear, logical delineation of sub- jects while being consistent with the concept of increasing diversity in the elderly. Regardless of the method of grouping, age has been identified as important variable in determining the amount and type of social sup- port needed for optimal functioning (Norbeck, 1981; Branch and Jette, 1983). We now turn to a general discussion of social support and related concepts. Social Support Beginning with a general definition of social support such as helpful attitudes or acts communicated within a relationship, emphasizes that the idea of social support is certainly not new. Indeed, it has been included in nursing care planning and intervention for some time. What is new about social support is that researchers are beginning to accumulate an impressive amount of evidence documenting the beneficial effects of social support (Cassel, 1976; Cobb, 1976; Kaplan, Cassel and Gore, 1977; Dean and Lin, 1977; Lowenthal and Haven, 1968; Wallston et al., 1983; Israel, 1982). Unfortunately, social support has been defined in so many ways that comparison of studies is difficult and no one, clear definition seems possible. The following discussion is intended to present the variable of social support, emphasizing the complexity and difficulty in seeking one definition. 26 An in-depth review of the literature on social support makes it is evident that this concept is complex and multidimensional (Cassel, 1976; Nuckolls, Cassel, and Kaplan, 1972; Cobb, 1976). Generation of explicit and appropriate definitions of social support and translation of these definitions into operational measures for research, evaluation and practice are just beginning (House, 1981). Social support is generally understood to imply a helping rela- tionship. The word "support" is defined in Webster's New World Dictionary (1968) as: 1. To carry the weight of; keep from falling, slipping, or sinking; keep in position. 2. To give courage, faith, or confidence; to help, comfort or strengthen. 3. To give approval to, be in favor of, subscribe to, strengthen, uphold. 4. To maintain or provide for (a person, institution, etc.) with money or subsistence. It becomes evident that, even in this generally understood sense, sup- port implies both emotional caring and tangible assistance. Dimond and Jones (1983), summarized and organized the literature on social support into four major definitional categories: support as relational provisions; support as information; support as structure; and support as interaction. A presentation of the range of defini- tional categories within the domain of social support is useful for understanding the many, sometimes minute, distinctions within the con- cept. 27 Support as Relational Provisions Weiss (1974) conceptually defined social support as six types of assistance which can be individually associated with a particular type of relationship. These be defined as attachment, social integration, opportunity for nurturance, reassurance of worth, sense of reliable alliance, and the obtaining of guidance. 1. Attachment, a sense of security and place: provided by dyadic relationships of an intimate nature. 2. Social integration, provided by less intense, less intimate sharing; found in group relationships. 3. Opportunity for nurturance; provided by relationships in which an adult takes responsibility for the well being of a child. 4. Reassurance of worth; a sense that one is competent in a social role is provided by co-worker-type relationships. 5. Sense of reliable alliance; usually provided by kin relations in which continuing assistance is expected. 6. The obtaining of guidance, access to a trustworthy, authoritarian figure who can assist with strategies of action in time of crisis; found in relationships with professionals. Defining social support in terms of types of assistance which can be found in different types of relationships, has particular pertinence for elderly women. With aging comes a natural attrition of significant others from the elderly woman's support network. This attrition occurs through death, relocation, or increasing disability. Roles and rela- tionships change, leaving 'members of this population. at risk for problems with relational provisions. Long established attachments are 28 lost; isolation from members of the younger generation may reduce the opportunity to provide nurturance; and reduction in supportive others may lead to decreased self esteem. Kin relationships are more heavily depended upon for reliable alliance, and guidance may increasingly be sought from health professionals. Support as Information Social support has also been conceptualized as information, (Cobb, 1976). Information provides the supported person with feedback that he is esteemed, cared for, and a participant in a mutually obli- gated network. Cobb delineates information into three classes: 1. Information that the individual is loved and cared for, similar to Weiss' "attachment" dimension. 2. Information that creates the perception that the individual is esteemed and valued, similar to Weiss' "reassurance of worth" dimension. 3. Information that the individual is a participant in a mutually obligated network, as in Weiss' "social integration and reliable alliance" dimensions. By defining social support as information, Cobb focuses on the supported person's perception of the information he/she is receiving. One problem in using this definition is that it allows one only to measure social support from the supported person's subjective perspec- tive, i.e., information the individual received. Another problem unique to this definition is that tangible assistance is only included in the concept of social support in a peripheral way, i.e., by the act of 29 providing tangible assistance, you are giving the person information that you are supportive. Tangible aid, therefore, is not information. For the elderly, receiving supportive feedback is critical. Information that they are loved and respected assists the older person to cope with the multiple role changes and losses associated with aging. Information on assistive devices, safety measures, and home health services may be essential in maintaining independence. Addi- tional examples of informational support that may be important for the elderly, include health teaching, feedback on self management of chronic disease treatment regimens, and encouragement in activating the sup- port network. It is important to note that the elderly may have difficulty in receiving informational support, due to sensory deficits. Creative approaches in giving support as information may be essential, such as large print on health teaching resources, controlling the level of extraneous room noise when talking with elderly persons and speaking distinctly, at a moderate pace, when hearing is decreased. Defining social support as information focuses on yet another dimension of the concept and identifies particular problems, both for the researcher, in measurement, and for the elderly, in the potential for missing informational support as a result of sensory deficits. Information from the three areas described by Cobb; that one is loved and cared for, esteemed and valued, and is a participant in a mutually obligated network, is critical to an elderly woman's morale, confidence, and independence. 30 Support as Structure A third conceptualization of social support has been offered by J. Mitchell (1969), who views the social network as an indicator of the potentiality of support, i.e., the available social support oppor- tunities. Four structural characteristics of social support networks, identified by Walker et al. (1977), are relevant to the provision of social support. 1. Size: The number of people with whom the individual maintains some social contact, including those contacts that are renewable in case of need. 2. Density: The extent to which members of one's social network know and contact one another independently of the individual. 3. Homogeneity of membership: The extent of mutual sharing of social attributes between network members. 4. Dispersion of membership: The ease with which members of a net- work make face-to-face contact. The four structural characteristics of social support networks all concern one central idea; that people in a network must be available and in communication in order to provide social support. Robert Kahn's (1977) view of social networks as a "convoy" for the provision of social support is in keeping with this concept. In assessing an elderly woman's available support opportunities, one might ask questions related to each of the structural character- istics listed. For example: With how many people does the elderly person maintain contact? Are there others who could be called upon? 31 If one person, identified by the elderly person, was contacted, would he/she easily be able to notify others in the network? How alike are the network members, i.e., do they have similar interests or attri- butes? How quickly or easily could members of the network respond to a call by the elderly person? Questions such as those presented above are important tools in seeking assessment data about an elderly woman's potential opportunity for social support. The clinical specialist in advanced nursing prac- tice with the elderly recognizes that, because of normal attrition from an individual's network with aging, support network assessment is cri- tical to the client's data base. The assessment process itself may be an intervention in reactivating the network, by prompting the initiation of contact with dormant members. The structural properties of social networks, therefore, are important as indicators of the potentiality of support for the elderly. Structural properties, however, do not speak to the quality of relationships. As Mitchell (1969), has pointed out, it is the interactional characteristics which measure the quality of the relationship. Support as Interaction Mitchell (1969), summarized three aspects of interaction found within social networks. 1. Content: The meaning individuals give to their relationship. 2. Directedness: The amount of mutual sharing or reciprocity. 3. Intensity: The strength of the bond between two persons. 32 Defining social support as interaction is in keeping with Roger's theory of unitary man, when interaction is defined as the mutual exchange of energy and matter occurring between man and environmental fields. This broad definition of interaction would imply that social support as interaction includes: the intuitive sense of meaning that each individual (field) places on the interaction (content); the amount of energy exchanged, perhaps measured in time spent between individuals and types of support given, emotional and tangible (directedness); and the strength of the interaction, i.e., the interface of boundaries indicating the depth of involvement between individuals (intensity). Problems arise with this definition of support as interaction, however. Although Mitchell separates content, directedness and intensity, and examples of each may be given, it is obvious that the distinction between each aspect of interaction is not clear. For example, directedness and intensity, as defined by Mitchell, are cer- tainly overlapping concepts. While Mitchell's definitions overlap too much to be practical for this thesis, it does bring up an important point for the elderly. While attrition has been recognized in previous categories of social support, as risk factors for elderly individuals, support as interac- tion implies that a single relationship bond may be as important in the provision of social support as multiple network links (Dimond 1979, Hirsch 1979). Robert Kahn's definition of social support allows for the impor- tance of both single relationships and multiple network links. This definition, which we will utilize in this thesis, states that social support includes "interpersonal transactions that include one or more 33 of the following: the expression of positive affect of one person toward another; the affirmation or endorsement of another person's behaviors, perceptions, or expressed views; and the giving of symbolic or material aid to another" (1979). In addition to being consistent with Rogers' idea of interacting energy fields (interpersonal trans- actions), this definition emphasizes the two types of support studied, emotional (affect and affirmation) and tangible aid. Norbeck's Social Support Questionnaire, the data collection instrument for this thesis, includes the concepts of affect, affirmation and aid in items. Kahn's definition was chosen over the related, more comprehensive definition of social support provided by Robert Caplan (1979) because Caplan's definition is difficult to apply in all cases as it dictates the data collection procedure, i.e., it depends upon both the percep- tions of the elderly and of an "objective" observer. Caplan has specified two dimensions of social support, objective- subjective and emotional-tangible. Objective tangible support is "behavior directed toward providing the individual with tangible resources that are hypothesized to benefit his/her mental or physical well-being" (1979). Objective emotional support is "behavior directed toward providing the person with cognitions (values, attitudes, beliefs and perceptions) and toward inducing effective states that are hypothe- sized to promote well-being" (1979; p. 85). Objective support, tangible and emotional, are measured by an outside observer. Subjective tang- ible support and subjective emotional support are similar but are based on the individual's perception of the degree to which support is offered (Caplan, 1979). 34 Perception, the Subjective Approach to Social Support While objective assessment of social support is less prone to self reporting bias than subjective report, and would provide a more stan- dard comparison across individuals (DiMatteo and Hayes, 1981), social support is an) embedded in an individual's perception that objective measurement may be inadequate. For example, witnessing an interchange between a health provider and an elderly client, one might objectively determine that the interaction provided social support. If the elderly person did not adequately hear or understand the message, however, has support really been received? The subjective approach is valuable (Donald, et al., 1978; Kirity and Moss, 1974; Lipowski, 1969). Donald (1978; p.5) states "in favor of the more subjective approach is the argument that individuals have different needs and tastes; therefore, the nature and number of inter- personal contacts with friends, relatives, and others necessary to achieve social health vary greatly. These differences may not be ade- quately reflected in measures of objective social health constructs." Similarly, Kirity and Moss (1974, p.109) have suggested that " the most efficient predictor of a person's physiological behavior in a given environment may consist of how he perceives that environment." The sub* jective approach has also been supported with the argument that "what an individual experiences is directly known to him, and we may learn about it by obtaining his introspective reports" (Lipowski, 1969; p. 1198). In summary, the preceding sections have focused on defining social support and delineating its many aspects. The definition, formulated 35 by Kahn (1979), which emphasizes two consistent aspects of social sup- port, emotional support, and tangible aid is used in this study. A discussion on the objective/subjective dimensions of social support emphasized the importance of perception i.e. subjective measurement of the variable. We now turn to a discussion of the function of social support. The Function of Social Support While social scientists do not agree on one single definition, there is general agreement that social support functions to buffer stress and/or directly affect health (Kasl, 1978; McLean, 1979; House and Jackson, 1979; Thoits, 1982). House (1981, p.31), suggests that support can modify or counteract the effect of stress in three ways. First, social support can directly enhance health and well-being because it meets important human needs for security, social contact, approval, belonging, and affection (see arrow c of Fig. 2). That is, positive effects of social support appear to offset or counterbalance negative effects of stress. S()(:IAIL SLJPI’C)R'T .. 4. c . .5 Q5 t b c Q“ 5 I" m ‘3} Work Stress ; Health d. Figure 2. Potential effects of social support on stress and health (from House, 1981). 36 Second, social support may directly reduce levels of stress in several ways (arrow a), and therefore, indirectly improve health (via arrow d). The repatterning necessary after retirement is one example in which a supportive spouse, friends, or relatives may help reduce personal pressure and tensions by providing support that encourages self esteem. These two effects of social support are referred to as main or additive affects (House, 1981). A third type of effect has more recently been described as interactive or buffering (arrow 13 on Fig. 2). In this effect social support does not directly affect either stress or health, but rather modifies the relation between them. Despite the prominence of the buffering effect of social support, considerable confusion exists about what constitutes evidence of buf- fering vesus main effects. According to House (1981), "The need to distinguish main vesus buffering effects arises when considering how stress and social support may combine to effect health." Figure 3 (House, 1981) illustrates three possible ways in which the main and buffering effects of support may jointly effect health. Each graph depicts the linear relationship between stress and health for three different levels of social support: low (...), medium (---), and high 6___). Graph a illustrates a pure buffering effect. Here social sup- port has no beneficial effect on health among individuals with little stress, but the beneficial effects become increasingly apparent as stress increases. Graph b illustrates the main effect social support has on health. The slope of the relationship between stress and health is unaffected by levels of support, indicating no buffering. 37 Finally, Graph c illustrates the case where support has both main and buffering effects. The three lines are not parallel, indicative of a buffering effect, but when stress is low individuals with high levels of social support are healthier, indicating a main effect of support on health. Often these effects are not quite so clear, leading to much confusion in empirical testing. ‘5 . 35 . .. '5 ' , a = . ,/ .... g , /’ O 8 ’z” / gm tr” / m ‘ 43>Pfi LOW’ Shem a~—)>Phgh LOW’ Sue“ gh a. Buffering Only b. Support Improves Health Only ‘5 3% .......... LowSuppon 5 I ' —--- Medium Support 8- k .° ’ O ..' ”’ . gé ,,/ ——-- HrshSupport 62 LOW’ ~)>lfigh Shem c. Support Improves Health and Buffers Figure 3. Buffering versus Main Effects of Social Support (from House,(1981). 38 For the purposes of this study, however, the distinction between the main effects, buffering effects or effects of both is academic. Enough evidence has been accumulated to demonstrate the association of social support with health (Cassel, 1976; Cobb, 1976; Kaplan, Cassel and Core, 1977), and with positive outcomes for the elderly (Fuller and Larson, 1980; Lindsey and Hughes, 1981; Lowenthal and Haven, 1968). It will be the task of research to determine how social support exerts its effects and what dimensions of support are most helpful. Types of Social Support To suggest that one kind of support is appropriate in all stress- ful situations is to ignore the diversity of the needs that individuals can experience under stress (Walker, et al., 1977). Three factors influence the kind of support that is appropriate during periods of crisis: the nature of the stressful situation; the timing and the crisis period in which the support is provided; and the resources of the individual (Weiss, 1976). Nature of the Situation Discontinuity with the past is a common occurrence during stress- ful periods. A high degree of ambiguity is usually present for the individual and there is need for feedback from supportive persons that one's behavior is appropriate. Weiss (1976) identifies three forms of situational types of social support. 1. A crisis is a severe, upsetting situation of limited duration in which individual resources are quickly summoned to cope with emo- tional, social or physical instability. For older persons, this 39 might be death of spouse or close friend. It is likely that emo- tional support (empathy, understanding) would be the most useful type of support during a crisis. A transitions is a period of relational and personal change. Parkes (1971; p. 103) defines transitions as "major changes in life space which are lasting in their effects, which take place over a relatively short period of time and which affect large areas of the assumptive world." The key features of transitions are that they have lasting effects and involve major changes. For older persons, a move from their home to a retirement village or Senior Apartment Complex, bereavement or retirement from a life-long occupation can represent a major transition. It is likely during transitions that informational and tangible assistance would be appropriate types of social support. Weiss seems to imply that because of the intensity of the transition state, i.e., relatively short duration with major changes that must be dealt with, more action oriented types of support are needed. Therefore, in a transition emotional support could be less helpful than direct tangible aid. A deficit situations is a state in which relational provisions, important to well being, are unobtainable (Dimond and. Jones, 1983). An example of a deficit situation is a widow who becomes involved with family and church activities but remains profoundly lonely. Emotional support from a confidant would most likely be appropriate in deficit situations. 40 While there are other types of stressful situations, Weiss (1976) suggests crisis, transition and deficit situations are particularly important, as they represent loss. Crisis occurs on first awareness of loss; transition in which major changes take place follows, if the loss is unavoidable; and transition may lead to new ways of living that create deficit situations. Timing The needs of people are likely to change over time, particularly older persons and those experiencing distress. Timing is the second factor to be considered in determining the type of social support most appropriate in a situation. Support that provides relief and comfort initially in a situation may not be appropriate at later stages in the adjustment process. For example, emotional support that may "cushion" an individual in a crisis state may inappropriately shelter an indivi- dual in transition, stifling more productive endeavors towards change. Personal Resources A third factor determining the most appropriate type of support involves the individual's resources. Social support should "fit" the situation. Thus, a spouse or confidant can provide opportunities for intimacy and sharing; family and friends can provide assistance and a sense of security; professionals can provide information via education and counseling. Careful assessment of existing resources for social support will help to determine the appropriate kinds of interventions that may be necessary for a particular situation. 41 In summary, social support functions to buffer and protect per- sons in different situations. The extent to which this function occurs is likely to be based on the type of social support provided. It has been suggested that the kind of support appropriate to a par- ticular situation is based on the type of stressful situation, the timing of support, and the resources available to the affected indivi- dual. In the next section, a model developed by Norbeck (1981) will be presented to show the elements and relationships of persons, environment and social support within nursing practice. The Norbeck Model The link between social support and various outcomes has been established (Cassel, 1976; Cobb, 1976; Heller, 1979) but it needs to be refined, replicated and studied before it can be used to guide clinical applications. Norbeck (1981; p. 46-47) states, "the bulk of the social support research has explored relations between social sup- port and health.... Although these relations imply that interventions for persons with inadequate social support might reduce their risk for certain negative outcomes, serious gaps in knowledge exist that must be studied to provide a scientific basis for intervention." Norbeck proposed a model, therefore, to show the elements and relationships that must be studied to incorporate social support into nursing prac- tice. While the model was designed to guide research, it serves as a useful framework for incorporating the nursing concepts of person, environment, and nursing process, as it relates to outcome deter- mination. The Norbeck Model is presented in Figure 4. .Aiwmu .xuenuozv euro—cm _3_c:o 8E comma... Eco... mctecochUE 5.. 5:32 mEEam .8 {0.3895 :1 ma no 05850 339.. am uJ>¢—:sa.—-o'c 9:00.30 02:50: .0 305.95 .6820 3 Bandeau... conga» 300w 8030...» ”.20 600532 .3583 an 032.9.” 1 tongue 300a ¢> _a20< .883 300» to. 262 lthe sample selection and data collection for this study are presented. Design This section describes the research design for a preliminary test of seven instruments utilized in a larger general study, (Active Participation: Health Care for the Elderly), directed by B. Given and funded through a university supported research grant. “The purpose of the original study was to evaluate the quality of psychosocial measures when applied to an elderly population and to test the relia- bility and validity of measures of social support, self-esteem, and social stress upon active participation of the elderly in the manage- ment of their chronic disease. The seven instruments used in this study measured active participation, health habits, life events, self-esteem, medicine usage, social abilities, and social interaction. A socio-demographic questionnaire was also administered. A survey approach was used to pretest the seven instruments on a volunteer sample of elderly persons. The last instrument completed 82 83 by elderly subjects was the Norbeck Social Support Questionnaire (NSSQ). From the data collected in response to five items on the NSSQ, two theses are proposed to study differences in the mean values of perceived emotional support received, and tangible aid perceived to be available within a group of women aged 65 to 74 (Sefton Cojocel), and within a group of women aged 75 to 89 (Smith Adams). The metho- dology used in both studies is identical but data will be analyzed separately for each age group. In collaboration with Smith Adams, (1984), a joint analysis will be undertaken of age as a mediating variable in perceived emotional support received and tangible aid per- ceived to be available between the two groups of older women 65 to 74 and 75 to 89. Also presented in this chapter are the research questions, opera- tional definitions of the study variables, data collection procedures, discussion of the Norbeck Social Support Questionnaire, and human subject protection standards. Research Questions 1. Is there a difference in the mean value of perceived emotional support received and tangible aid perceived to be available among women aged 65 to 74? (Sefton Cojocel) 2. Is there a difference in the mean value of perceived emotional support received and tangible aid perceived to be available among women aged 75 to 89? (Smith Adams) 84 3. Is there a difference in the mean values of perceived emotional support received and tangible aid perceived to be available between two groups of women aged 65 to 74 and 74 to 89? (In collaboration with Smith Adams.) Independent/Dependent Variables The independent variable in this study is age. The dependent variables are perception of emotional support received and tangible aid perceived to be available. Operational Definitions The variables under study are operationalized in the following manner: ‘Agg_is classified according to Neugarten's categories of young- old (65 to 74), and old-old (75 to 89). Significant Others is operationally defined as the first three individuals a subject listed in response to instructions on the Norbeck Social Support Questionnaire (NSSQ). Only the first three individuals the respondent listed were selected for this study to narrow the focus from a possible twenty names requested on the NSSQ. The rationale for using only the first three of the selected twenty support persons was both theoretical and pragmatic. First, respon- dents were most likely to list their closest relationships first and, from a pragmatic standpoint, non-response rates rose rapidly after the third significant other named. 85 In utilizing the first three individuals named (people who are apt to be highly emotionally and tangibly supportive because of their close relationship), an inherent problem may be a halo effect. A halo effect in this instance refers to the range restriction that occurs when a limited range of responses out of five possible response response options are utilized. In other words, analyzing responses concerning the most supportive significant others (presumably the first few individuals listed) logically restricts the choice of responses to descriptors such as "a great deal" and “quite a bit," rather than "not at all" or "a little," when describing how suppor- tive those individuals are. Perceived Emotional Support is operationalized using three items on the Norbeck scale:' 1. How much does this individual make you feel liked or loved? 2. How much does this individual make you feel respected or admired? 3. How much can you confide in this person? Responses to these items, which the subjects made on a 5-point Likert scale, indicate the individual's perception of actual support received. The choices on each item were: "1) Not at all; 2) A little; 3) Moderately; 4) Quite a bit; 5) A great deal." Perceived Tangible Aid is operationalized using two items on the Norbeck scale: 1. If you needed to borrow $10, a ride to the doctor, or some immediate help, how much could this person usually help? 2. If you were confined to bed for several weeks, how much could this person help? 86 Both items are worded hypothetically, and responses indicate tangible aid perceived to be available. On both emotional support and tangible aid items, subjects were asked to respond on the 5-point Likert scale with descriptors "not at all," and "a great deal" as anchors. Norbeck Social Support Questionnaire The Norbeck Social Support Questionnaire (NSSQ) was used in this study as one of the seven instruments in the larger study Active Parti- cipation: Health Care for the Elderly, (1983). The NSSQ is a self- report questionnaire which is designed to measure multiple dimensions of social support. Kahn's (1979) definition of social support was utilized to develop the questionnaire, i.e., the dimensions of social support measured are affect (liked or loved), affirmation (respected or admired), and aid (borrow $10, help when sick). Kahn's concept of social networks as a "convoy" is measured by assessing the number of the network, duration of relationships, and frequency of contact with network members. Change in an individual's convoy over time, a sub- ject of secondary interest in the study of social support, is measured by questions regarding recent losses of network members (Norbeck, 1983). Of the items on the NSSQ, only questions 1, 2, 4, 5, and 6 (affect, affirmation and aid items) were used for this study. See Appendix A. Description of the Instrument The NSSQ consists of a series of half pages with two questions and number spaces for ratings that visually align with a full page, wherein the respondents list their personal network. After listing up 87 to twenty network members and their relationship to each (for instance, spouse or partner; family or relatives; friends; neighbors; health care providers; etc.), respondents are directed to turn the first half page and answer the questions. In each question, the respondent is asked to rate each of their network members on the Likert scale previously described. Administration and Scoring The NSSQ can be self-administered, to live groups or through mailings. The stated average length of time for completion is 10 minutes (range: 5-20 minutes). Modifications in administration for the study, Active Participation, will be presented in a later section on data collection procedures. Pretest of the Instrument To evaluate test-retest reliability for the Norbeck instrument, Norbeck (1981) administered the questionnaire to 75 graduate students in two grade levels; entering students and senior graduate students. Subjects were recruited in the classroom, and no class instructors were involved in the research or allowed to learn which students were parti- cipating. The first group of first-year graduate students numbered 75 (one male and 74 females), with a mean age of 30.3 years. These students were tested during their second week on campus, prior to developing extensive relationships with other peers. Group two was composed of 60 senior graduate students (six male and 54 female); mean age 27.3. The students had known each other for the past year. 88 The NSSQ was administered to all subjects, as well as several instruments to various subsets, i.e., the Marlowe-Crowne Social Desira~ bility Scale, The Social Support Questionnaire developed by Cohen and Lazarus, The Profile of Mood States and the Life Experiences Survey. Following the initial testing, a second testing was completed with sixty-seven of the subjects one week later (Norbeck, 1981). In this initial testing, a normative base was established for this population of nursing students. In a later phase of testing, a middle-aged group was used to evaluate the instrument with a working population. The NSSQ had not been tested, or utilized with a study population of aged Americans. Reliability and Validity In Norbeck's first phase of testing, means, standard deviations, range of scores, and test-retest Pearson correlations were completed on all items on the NSSQ. The mean scores represent the ratings on each item for the entire network list. The average ratings for the individual network members were calculated by dividing the mean scores by the number in the network. These average ratings were; affect, 4.14; affirmation, 3.81; aid, 3.07. Duration of the relationships were 4.30; and frequency of contact, 3.29. Each of the functional items and network items had a high degree of test-retest reliability (range .85 to .92). A Kendal Tau B correlation coefficients for test-retest scores on the number of categories of persons lost was .93 (p (.0001) and for the amount of support lost, .71 (p (.0001). 89 Internal consistency'was tested through intercorrelating all items. The correlation between the two affirmation items was .97 and between the two aid items, .89. The affect and affirmation items were also highly correlated (range: .95 to .98), suggesting, according to the author, that these two dimensions are not distinct. In evaluating validity, response bias was ruled out by comparison with the short form of the Marlowe-Crowne test, administered to all 76 subjects. None of the items of the NSSQ were significantly related to this social desirability measure, suggesting that responses to the NSSQ are relatively free from the influence of social desirability response bias. Concurrent validity was evaluated by testing with a similar questionnaire (Cohen and Lazarus, in press). Concurrent validity was demonstrated through moderately high correlations. Construct validity was tested initially by correlating the rela- tionship between the NSSQ and the theoretically relevant variable, i.e., social support to psychiatric symptomatology (Lin, et al. 1979; Schaefer, et al. in press). The Profile of Mood States was administered to 75 of the subjects. A weak relationship was found raising questions of whether the Profile of Mood States was sensitive enough for the popu- lation it was used with. A second testing phase was completed using the NSSQ with 500 staff employees at a large university medical center. Mailings were sent to a final sample of 136 (47 males, 89 females). The mean age was 35.8 years, 42% were married, and the mean number of years of education was 15.9 years. Final testing lent support to the earlier findings. A 90 small normative data base was established from males and females func- tioning in work roles. This provided a basis for comparison for the amount and type of support available between the two sample populations. Construct validity was supported by significant correlations between the NSSQ and two similar interpersonal constructs (need for inclusion and need for affection). Concurrent validity was tested again by cor- relating the PRQ instrument and was found to be significant. Evidence for predictive validity was found, reflecting the stress-buffering role hypothesized for social support. In Norbeck's follow-up study of the first sample of graduate stu- dents, the stability of the instrument over a seven-month period was found to be high, but lower than the test-retest results from the one- week interval. The functional support did not change over the seven- month period (Norbeck, 1983). Sample The sample in this study was selected by using all women between the ages of 65 and 89 frommwithin the larger study Active Participation: Health Care for the Elderly. In the original study, a convenience sample was selected for the pretest from groups of elderly individuals residing in or around two midwestern cities (Grand Rapids and Lansing, Michigan), during March, April, and May, 1983. ’There were 101 subjects, ages 59 to 95, (15 males and 86 females) in the original sample. Be- cause the sample was voluntary and not randomly selected, the results of this study can be generalized only to elderly women with charac- teristics similar to those of the sample. 91 Data Collection Procedure The Norbeck Social Support Questionnaire, described in the pre- vious section, was one of seven instruments utilized in the prelimi— nary study of Active Participation: Health Care for the Eldggbg (B. Given). Data for this pretest were collected and coded by four research assistants (graduate students in Nursing). Sites selected were based on the contacts these four individuals had in the community. This section describes the sites used for procuring the data, the method in which the data were collected, and procedure followed by interviewers. M Subjects were obtained primarily from senior nutrition sites, resi- dent centers and activity programs, in and around Lansing and Grand Rapids, Michigan. No attempt was made to randomize or obtain a typical group of older Americans. Approximately 1/4 of the study population (N=101) were volunteers from senior nutrition sites. Research assistants had visited these sites, requesting volunteers, and estimated that 16% of persons in attendance at 3 sites responded. No examination of the characteristics of those refusing to participate was attempted. Approximately 1/2 of the volunteers were solicited from various groups organized through both rural and urban senior citizen centers. The remainder of the volunteers were obtained through contacts with a local health depart- ment, senior residence center, and the research assistant's personal contacts with individuals in the community at large. 92 Criteria for inclusion in the pretest were based on age alone. Any individual over 59 years of age and willing to complete the ques- tionnaire was accepted into the study group. Sub samples for the pre- sent study were taken from the original study and were based on sex and age. Collection of Data A training session was held for each research assistant in which the procedure for administration of the questionnaire packet was empha- sized. The following protocol was the basis for the training procedure: 1. Interviewers contacted respondents by telephone to explain the research and make an appointment to administer the questionnaire. During the telephone interview (phone numbers obtained through personal contact at senior activity sites), the interviewer intro- duced herself and explained that she was a research assistant within the MSU College of Nursing. A brief explanation was given concerning the nature of the research and the purpose. Respondents were told that participation would require them to complete written questionnaires involving some personal opinion items, and would require about one hour of their time. Interviewers assured respondents that answers would be confidential and their names would not be on the questionnaire. Respondents were then asked if they had any chronic diseases. Potential subjects were then given the opportunity to ask questions, and appointments were made to administer the questionnaires. 2. 93 Interviewers were told to meet the respondents promptly and to supply pencils. Respondents were asked if they had any questions or concerns before testing 'began. Interviewers responded. to questions or concerns and told the respondents to open the packet and proceed. In the event that potential respondents decided not to participate, the interviewer was instructed to assure them of their right to decline and to thank them for their time and con- sideration. For those participating, the packet of questionnaires was administered in various settings, i.e., individually in homes, individually in senior activity sites and in small groups at activity sites. The time required to complete the packet of ques- tionnaires varied, ranging from 25 minutes to over two hours (the average time was estimated between 45 minutes to 1 hour. A. Consent Form: This was reviewed with the respondent and he/she was assured that the questionnaires would be kept anonymous and consent forms would not be kept with question- naires. Interviewer collected consent forms before proceeding. B. Socio-demographic: Interviewers reviewed the basic directions with the respondents. When the respondent finished, the interviewer provided the following questionnaires: Health Habits; How I Feel About Myself; Involvement in Health Care; Life Events; Social Ability; Medicine Survey; and Social Interaction. The "social interaction" survey, Norbeck's Social Sup- port Questionnaire, was the data collection instrument used for this study. Instructions for its administration are reviewed here. 94 First the respondent is asked to "list each significant person in your life on the right. Consider all the persons who provide personal support for you or who are important to you now." In listing these network members, the respon- dent uses only first names or initials. There is a space for the respondent to specify the category of relationship for each person from a list of categories presented in the instructions, including spouse or partner; family or rela- tives; friends; work or school associates; neighbors; health care providers; counselor' or therapist; minister/priest/ rabbi; and others. An example of a network list is provided in the instructions. After listing up to 20 network members, respondents are directed to turn the first half-page. On that and each suc- ceeding half-page, two questions are presented and numbered spaces for ratings correspond horizontally with the entries on the network list ... in each question, the respondent is asked to rate each of their network members on a Likert scale (Norbeck, 1981, pg. 265). With this study population of elderly individuals, the pro- cedure described above was modified in the following ways. The interviewers reviewed directions and assured respondents that their answers were confidential. In some cases the interviewer guided the respondent through the questions and entered their response. Respondents were given a 3 x 5 card with the response scale to refer to while answering questions. Questionnaires were administered both individually, and in a small group settings. Completion/Debriefing The interviewer was instructed to ask for and answer any questions or concerns that the respondents might have. The respondent was then thanked for his/her time and assured that their efforts would be of great value to this research project. 95 Human Subject Protection Specific procedures were employed to ensure the rights of the study sample participants. The right of the participants were pro- tected by following the standards from the University Committee on Research Involving Human Subjects (UCRIHS). A consent form was signed by each respondent (see Appendix B). Assurance of anonymity and con- fidentiality were provided as part of the data collection procedure. Statistiggl Analysis of Data Descriptive statistics were used to analyze sociodemographic data. The range, mean and percentage, along with tables summarizing distri- bution and percentages of subjects by demographic variables are pre- sented in Chapter V. Five items from the Norbeck Social Support Ques- tionnaire (three affect/affirmation items and two aid items) were used in this study. Correlations were done using the Pearson Product Moment coefficient. The values of the correlation range from -1.00 for a per- fect negative correlation, through 0.0 for no relationship, to +1.00 for a perfect positive relationship. Correlations were significant between all three affect/affirmations questions at the p = .001 level, and between the two aid related questions at the p = .001 level pro- viding statistical rationale for combining items into one emotional support score and one tangible aid score. Responses to these five items were made on a 5-point Likert scale ranging from "not at all" to "a great deal." The responses were c0m- bined and a mean value for perceived emotional support received and perceived tangible aid available was calculated. 96 Inferential statistics, i.e., Student's t-test, were utilized to answer the research question: Is there a difference between perception of emotional support received and perceived tangible aid available within each group of women? An additional t-test was computed for the mean values of perceived emotional support received and tangible aid perceived to be available between two groups of women aged 65 to 74 and 75 to 89. To provide a clearer picture of a possible relationship between age and perceived emotional support received and tangible aid perceived to be available, two sociodemographic variables, income and education, were evaluated for possible use as covariates. Analysis of co-variance controlling these two variables did not provide useful information to clarify the relationship between perceived emotional support received and tangible aid perceived to be available. Summary In this section the methodology for a preliminary survey data col- lection as part of Active Participation: Health care for the Elderly, and for use of a subset of this data to answer three research questions was presented. Data collection protocol and the Norbeck Social Support Questionnaire were discussed. Proposed data analysis procedures were outlined, and operational definitions presented. Chapter V contains the actual data analysis presentation. “ CHAPTER V DATA PRESENTATION Introduction In this chapter the demographic characteristics of the study sample are described, the analysis of data is presented, and the results are discussed. Demographic information on two groups of aged women is pre- sented first. A brief explanation of the statistical analysis utilized to obtain data for the research questions follows. Then data are analyzed to answer the question: "Is there a difference in the mean value of perceived emotional support received and tangible aid perceived to be available among women aged 65 to 74?" Data from a parallel study by Smith Adams (1984), are then summarized, and finally, the analysis of both data is presented to answer the question: "Is there a difference in the mean values of perceived emotional support received and tangible aid perceived to be available between two groups of women aged 65 to 74 and 75 to 89?" Description of the Study Sample The sample, selected from participants in the larger study Active Participatipp: Health Care for the Elderly, was composed of all women age 65 and over, who gave complete responses to the emotional support (affect and affirmation) and tangible aid (functional support) items on the Norbeck Social Support Questionnaire (NSSQ). From the total number of female participants over 65 (72 individuals), 12 were not included in the analysis because of missing data. The resultant sample (N = 60), was divided into two subsets, according to Neugarten's age 97 98 classification dichotomy of young—old (65 to 74), and old-old (75 and older). These subsets, "younger" (N = 36) and "older" (N = 24), were used as the study samples for two separate theses; the present study, and a parallel study by Smith Adams (1984), respectively. Data from the two groups are compared to answer a collaborative question con- cerning age differences in perceived support. Demographic Characteristics of Group I (Younger) The demographic variables utilized in the present study were age, marital status, ethnic background, employment status, head of household status, income and education. For this group of 36 women these variables are reported below. The frequency distributions and percent of the subjects in Group I responding to selected variables is presented in Table 2. All demographic data were obtained by self report. Age: The age of the younger participants ranged from 65 to 74 years. The mean age was 69.5 and the median age was 69. Marital Status: The majority of the younger sample, 20 individuals (56%), were widowed. Twenty-five percent (n = 9) were married, and 17% (n = 6) were divorced. One individual was single. The United States female population aged 65 to 74, in comparison, is 5.3% single, 51.3% married, 38.3% widowed and 5.1% divorced. 99 Table 2: Number and Percent of Females 65 to 74 Years of Age by Selected Demographic Variables (N = 36) Number of Variable Respondents Percent Marital Status Married 9 25 Separated O O Divorced 6 17 Single 1 3 Widowed 20 56 Ethnic Background White 34 94 Black 2 6 Mexican American 0 0 Indian 0 0 Oriental 0 0 Other 0 0 Employment Status Retired 32 91 Unemployed 1 3 Employed 2 6 Head of Household Status No 9 25 Yes 27 75 Income Level (in dollars): 0 - 4,999 5 15 5,000 - 9,999 10 29 10,000 - 14,999 5 15 15,000 - 19,999 5 15 20,000 - 24,999 7 21 25,000 - 29,999 1 3 30,000 - 34,999 1 3 35,000 and above 0 0 Missing Data 2 -- 100 Table 2 (continued) Number of Variable Respondents Percent Education: College graduate with professional training 4 11 College graduate 2 6 At least one year of college 8 22 High School graduate 16 44 Completed years 10-11 high school 3 8 Completed 7-9 years of school 3 8 Completed less than 7 years of school 0 0 NOTE: Percentages may not total to 100 due to rounding. Ethnic Background: In the younger group, 94% (34 individuals) were Caucasian. Six percent (2 individuals) were Black. Employment Status: Only two women (6%) were employed. Ninety-one percent (n = 32) were retired and one individual listed herself as unemployed. For the U.S. female population over 65, 7.6% list themselves as employed, 0.3% as unemployed and 92.1% as not in the labor force. Head of Household Status: Seventy-five percent (n = 27) of the women in Group I listed them- selves as head of the household. This characteristic is consistent with the response to the marital status item; i.e., 25% (n = 9) described their status as married, and not surprising, considering the sites from which volunteers were drawn; i.e., senior residence centers, and senior center programs catering to the elderly living alone. U.S. census data (1984) indicates that 42.4% of females over age 65 are "non- family householders." 101 Income: The frequency distribution of the women in Group I, by level of income, is included in Table 2. The incomes varied among the women in this group, with the largest percentage (29%, or 10 individuals), listing their income between $5,000 and $9,999. Comparison of the women in Group 1 with U.S. income averages for the age 65 and older female pop— ulation, reveals that the study sample has a higher mean income (x = 3.176 or between $10,000 and $14,999) than the national mean (x = $5.798). The medians for both the sample and the U.S. female population over age 65 were somewhat lower 2.900 (or between $5,000 and $9,999) and $4,226 respectively. On the income variable then, it appears that the younger sample is atypical for this age group. Nevertheless, because the U.S. statistics include all female individuals over age 65, and therefore include persons older than those in the sample, this atypical income finding may be explained by other dissimilarities in the two groups. Education: The frequency distribution of highest educational level attained for the women in Group I is included in Table 2. Eighty-three percent (n = 30), of the younger group report high school or greater educational levels. In comparing Group I to the U.S. female population over age 65 by highest educational level attained (see Table 3), again, there is evidence that this sample is atypical for this age group. In the national statistics one finds only 44.7 percent among over age 65 females reported high school or more education (compared to 83% of 102 Group I individuals). Again, the fact that U.S. statistics include individuals above age 75 as well, may explain some of this variance. Also, the U.S. census data collection was done with a slightly dif- ferent categorization to measure educational level, e.g., 8 years or less versus 7 years or less as the lowest education response available. Table 3: Comparison of the Group I (Younger) Educational Level Variable to Percent Distribution of Females Age 65 and Older in U.S. by Education (from Statistical Abstracts of U.S., 1984). Percent U.S. Female Over Age Percent 65 Population Education Group I by Education Four or more years of college 17 7.4 One to three years of college 22 9.1 Four years high school 44 28.2 One to three years high school 8 17.0 Eight years or less 8 38.3 NOTE: Percentages may not total to 100 due to rounding. In summary, demographic information describing the younger age group, Group I, reveals that of the 36 women, 94% were caucasian, 25% were married, 91% were retired and 75% listed themselves as head of the household. Comparison of income and educational levels of the sample with those of the U.S. female over age 65 population revealed that the sample may be atypical for that age group. There was, however, 103 some difficulty in comparing the two and this may account for the dif- ferences found. Differences may also be an artifact of the preponder- ance of Caucasians in the samples, or type of community from which the sample was obtained. Demographic Characteristics of Group II (Older) The second subset of the study sample was composed of women aged 75 to 89 (n = 24). The demographic variables utilized in the study (age, marital status, ethnic background, employment status, head of household, income and education) reveal the characteristics of the older group to be as follows. Frequency distributions and percentage of subjects in Group II on selected variables are presented in Table 4. All demographic data were obtained through self report. Age: The age of the older participants ranged from 75 to 89 years. The mean age was 79 and the median age was 77.5. Marital Status: Sixty-seven percent (n = 16) of the older group were widowed. Seventeen percent (4 individuals) were married. Three individuals (13%) listed themselves as single and one person was divorced. Ethnic Background: The women in the older group (Group II) were all Caucasian. 104 Employment Status: Ninety-six percent (n == 23), of the older women were retired. Only one individual listed herself as unemployed. For the U.S. Female population over age 65, 7.6% list themselves as employed, 0.3% as unemployed and 92.1% as not in the labor force. Table 4: Selected Demographic Variables Concerning Group II Respondents (n = 24) (marital status, ethnic background, employment status, head of household, income and education) Number of Variable Respondents Percent Marital Status: Married 4 17 Separated 0 O Divorced 1 4 Single 3 13 Widowed 16 67 Ethnic Background: White 24 100 Black 0 0 Mexican American 0 0 Indian O 0 Oriental 0 O Other 0 0 Employment Status Status: Retired 23 96 Unemployed 1 4 Employed 0 0 Head of Household Status: No 4 17 Yes 20 83 105 Table 4 (continued) Number of Variable Respondents Percent Income Level (in dollars): 0 - 4,999 0 0 5,000 - 9,999 12 57 10,000 - 14,999 3 14 15,000 - 19,999 2 10 20,000 - 24,999 2 10 25,000 - 29,999 2 10 30,000 — 34,999 0 0 35,000 and above 0 0 Missing Data 3 —~ Education: College graduate with Professional training 3 13 College graduate 4 17 At least one year of college 7 29 High School graduate 4 17 Completed years 10-11 high school 1 4 Completed 7—9 years of school 4 17 Completed less than 7 years of school 1 4 Note: Percentages may not total to 100 due to rounding. Head of Household Status: Eighty-three percent (20 individuals) of the older group described themselves as head of the household. The percentage of persons (17%) not listing themselves as the head of household corresponds perfectly with the marital status item. Again, this high percentage of persons listing themselves as head of household was not unexpected because the populatixnlwas drawn from independent living centers, or programs catering to elderly persons living alone. 106 Income: The frequency distribution and percentage of the older group pop- ulation in Group II, by income, is included in Table 4. The majority of respondents (12 individuals or 57%) listed their income as between $5,000 and $10,000. The mean response on the income variable of this older age group was 3.190, or between $10,800 and $15,000. The median was 2.375, or between $5,000 and $10,000. Comparing these Group II values to the national income statistics on females over age 65 (mean income = $5,798; median = $4,226) reveals, again, that individuals in the study sample are atypical for their age group. Education: The frequency distribution of highest educational level attained for Group II is included in Table 4. The largest percentage of persons in this group (29%, or 7 individuals) reported at least one year of college. Indeed, 76% (18 individuals) reported having a high school education or better. According to national statistics on women over age 65, only 44.7% of women report high school or better education (see Table 5). Therefore, on the variable of education, individuals in Group II are also atypical for their age group. 107 Table 5: Comparison of the Group II (Older) Educational Level Variable to Percent Distribution of Females Age 65 and Older in U.S. by Education (from Statistical Abstracts of U.S., 1984) Percent U.S. Female Over Age Percent 65 Population Education Group I by Education Four or more years of college 30 7.4 One to three years of college 29 9.1 Four years high school 17 28.2 One to three years high school 4 17.0 Eight years or less 21 38.3 Note: Percentages may not total to 100 due to rounding. In summary, a demographic description of Group II, composed of 24 older women, reveals that all were Caucasian, 17% married, 96% were retired and 83% listed themselves as head of household. The income and educational levels of the sample were higher than the national averages for women over age 65. Again, methodological problems in comparing Group II responses to the national statistics make conclu- sions difficult, but it would appear that Group II does not represent a typical older American group. 108 Use of the NSSQ on a Sample of Women Aged 65 - 89 Reliability of Norbeck's Social Support Questionnaire has been established in two sample populations: nursing students and working adults (Norbeck 1981, 1982). To establish its use with an elderly study population, the internal consistency of emotional and tangible support items on. NSSQ was evaluated using Cronbach's alpha. The Cronbach's alpha is a measure of the extent to which all items contri- bute to a single common dimension or factor. It is used to indicate the reliability or uniformity of scale items by comparing the obtained values with each item successively deleted. The data used to calculate Cronbach's alpha were obtained using Pearson Product Moment Correlations between 3 emotional items for 3 significant others and 2 tangible aid items for 3 significant others. These Pearson Correlation Coefficients are presented in Tables 6 and 7. The Cronbach alpha analysis of 3 emotional support (affect and affirmation) items for 3 significant others yielded a high reliability coefficient for the nine items (alpha = .87). The range of alpha values (.83 to .87) demonstrates consistently high correlation among the emotional items. Two impor- tant points are raised by this finding: 1) The items that Norbeck has developed to measure the conceptually distinct constructs of affect and affirmation appear not to distinguish between the items. It would appear that Kahn's definition may be "splitting hairs" by distinguishing between affect and affirmation, and 2) That the results of the Cronbach's alpha for the emotional support related items provided mathematical evidence in support of combining affect and affirmation items into one more robust emotional score. 109 Analysis of 2 tangible aid (functional support) items for 3 signi- ficant others yielded a reliability coefficient for the 6 items of .79 (range .73 to .79). This finding shows the consistency between the two items and provides the rationale for combining the tangible aid item responses into one more robust tangible aid score. In summary, evaluation of the NSSQ emotional support and tangible aid items by Cronbach's alpha provided statistical support for combining items into one score for each type of support. The major contribution of these findings, however is in the confirmation of internal consistency with an elderly sample. Previously, Norbeck had only determined relia- bility with two younger populations. The following section describes the process for combining items to get a mean emotional support score and a mean tangible aid score. 110 serum #00. um moo. um coo.q Nnmm. amen. serum moo. um ooo.~ momm. serum ooc.H m.o.m N.o.m H.O.m SEES m gonna #00. um memm. mNo. um mmmm. unxfi um omen. «sanm ooo.~ m.o.m ewe. um mmqw. moo. um oxen. #00. um «use. Lac. um eeem. «sanm ooo.~ N.o.m «RN. um ~30. mm“. um «Neg. Hoe. um mmme. Hoe. um owmm. Loo. um wmmc. seeum ooo.~ ~.o.m ABBMHBMV N 135:3 Hoe. um mwfie. moo. um mqmm. woo. um coon. Hoo. um woes. Moo. um omen. #00. um Nfiwm. m.o.m mofi. um ofiofi. see. "a $3. Hoe. um Gene. #00. um Nome. Hoo. um comm. Hoe. um fimwm. ~00. um efimm. serum ooo.~ N.o.m woo. um ooom. awe. um fimwfi. So. +m moan. Loo. um eNLm. #00. um coco. Hoe. um meow. Hoe. um «Noe. 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The Eftest shows this difference to be valid about 7 out of 10 times (p = .293) or 3 times out of 10 the dif- ference could occur by chance. Therefore, this trend toward the older group perceiving lower emotional support (i.e., having a lower mean value for perceived emotional support received) was found not to be significant at conventional probability levels. Comparing the composite means for tangible aid perceived to be available between the groups, however, shows a large difference between the means (.64) and much greater standard deviations (younger SD = 9.8; older SD = 1.2) than noted in the emotional support comparison. The 2-tail probability shows this difference in means to be valid about 97% of the time (p = .027). In other words, the magnitude of the dif- ference found between means would be due to chance only 3 out of 100 times. Therefore it would appear that subjects in the two groups really do perceive tangible aid differently, with the older women per- ceiving significantly less tangible support. Correlations between the mean emotional and mean tangible scores were .283 in the younger group, and .489 in the older group. The dif- ference in these correlations indicates that the older group was more likely to score their first 3 significant others similarly on both tangible and emotional related items. This may be an indication of the decrease in network size with age, i.e., those closest support members must be relied upon for both emotional and tangible support. 117 Another explanation may be that the older group does not distinguish between emotional support and tangible aid. as clearly' as in the younger group. Therefore, the halo effect of viewing these first 3 significant others as globally supportive is more evident in the older group. Discussion Three cautions must be considered in examining these results. The first is that a distinction must be made between age differences and age changes. Age differences simply implies that there are dif- ferences between two age groups. Age changes implies that a develop- mental change within individuals over time is being described. With this cross sectional study, only statements regarding age differences are valid. The second point for caution in interpreting results is that the study was drawn from a convenience sample of volunteers obtained for a larger study. Both groups of older women were found to be atypical, based on national comparisons, for their age group at least on income and highest educational level obtained. Findings from this study then can only be generalized to women having the same characteristics as the study population. The last caution in interpreting results has to do with the halo effect mentioned in Chapter IV. This range restriction caused by analyzing data only from the closest significant others (i.e., the first 3 named) in fact occurred. In other words on a five point Likert scale, responses 3, 4 and 5 ("Moderately," "quite a bit," and "a great 118 deal") were chosen most frequently to describe significant others. The three significant others from whom data were analyzed were seen to be globally supportive, leaving one with the essential question, in prac- tical use, of how significant is a difference in support perceived from overall supportive persons. No measure was undertaken of how adequate the subjects support was, or what actual support was needed. Further research including and clarifying these salient issues is needed. Summary In summary, the data analysis for this study revealed three major findings: 1) The reliability (internal consistency) of emotional support-related and tangible aid-related items on Norbeck's Social Support Questionnaire Instrument were confirmed with an elderly study population. 12) Significant differences were found within each age group between the mean of perceived emotional support received and the mean of tangible aid perceived to be available. 3) A significant difference was found between the younger and older group of women on the mean of tangible aid perceived to be available. In the next chapter interpretations of these findings and a dis- cussion of the contribution of these results to 3 areas of Nursing will be presented. The study will be summarized and recommendations for changes in research design will be discussed. Chapter VI SUMMARY AND CONCLUSIONS Introduction This chapter contains a brief review of previous chapters, a discussion of the study results and the relevance of the findings to Nursing, as well as recommendations for methodological changes for future researchers. In a final section, ideas for dissemination of research results are presented. Review of Chapters Chapter I contained an introduction to the problem and relevant background information for the study. Population trends in the United States indicate that the proportion of elderly is increasing rapidly, due tn) high birth rates in the late 19th and 20th centuries, high immigration rates prior to World War II, and dramatic increases in life expectancy in the United States (1984 United States Census Data). The number of persons in the U.S. over age 65, as of July, 1982, was 26,824,000, or 11.6% of the total resident population of all ages. In 1900, the total population of women aged 65 or older was 1.5 million, or 2% of the U.S. population. By 1982 the number of older women had reached 16 million or 6.9% of the total U.S. population. This trend toward increasing proportions of older women in the population is expected to continue. These population trends have implications for the Clinical Nurse Specialist. The elderly are a high risk population requiring a vast amount of health care resources and a specialized knowledge base, both 119 120 for treatment of health problems and for health promotion. This know- ledge base must be increased through research studies that dispel myths of aging, emphasize the heterogeniety of the elderly, and open avenues for the development of strategies to promote health. One area where research has already shown impressive preliminary evidence of health benefits is in the area of social support. That is, social support has been linked to various positive health related outcomes (House, 1981; Nuckolls et al., 1971; Core, 1978). The study of social support and related concepts such as social networks, using elderly populations, is still in its infancy. In addition, the dearth of research in the area of age differences within the elderly population points clearly to the need for beginning level studies about aging persons, differences within cohorts, sex differences and actual and perceived social support needs and resources. In this study an attempt has been made to con- ceptualize social support, study the perception of two types of sup- port in an elderly female sample and begin to describe age differences in the perception of these types of social support between two elderly age groups. In Chapter II, the theoretical basis for the study (i.e., Martha Rogers' Theory of Unitary Man), was presented and integrated with con- cepts from Norbeck's Model of Social Support and Nursing Process. Roger's theory describes the overall evolution of man over time. Both as a species, and as individuals, man evolves unidrectionally toward increasing complexity. This evolutionary developmental perspective provides the rationale for expected age differences. lflithin this frame- work, conceptual definitions for the study variables were developed. 121 In Chapter III, a review of relevant literature was presented that emphasized: various methods of categorizing age groups within the elderly population; difficulties in conceptualizing, defining, and measuring social support; the importance of two types of support (emotional support and tangible aid); and the lack of solid empirical studies on age differences within an older population. Problems with existent definitions of social support and lack of research studies to clarify the concept present a confusing picture of the aspects of social support. The review of the literature presented indicates the important contribution beginning level studies can make to clarify the concept of social support. Chapter IV contained the methods used in a larger study, Active Participation: Health Care for the ElderLy. Data collected in the pretest of instruments were used for this study and in a parallel study by Smith Adams, (1984). Literature supporting the use of one instrument, the Norbeck Social Support Questionnaire, was presented, because responses to five selected items on this instrument were analyzed to answer the research questions. The original impetus for this study stemmed from observations in a health maintenance clinic setting with well elderly clients. The research questions (presented in Chapters I and IV), evolved from a desire to empirically describe some of the age differences observed. The area of perception of two types of social support, emotional sup- port and tangible aid, was chosen for examination, as these types of support seem to significantly affect the elderly's ability to maintain their independence. 122 For this study older women's (65 to 74 years old) perceptions of two types of social support, emotional support and tangible aid, were examined using items front Norbeck's Social Support Questionnaire. Composite mean values of responses to emotional support-related items and tangible aid-related items were compared, using Students 5 tests. In a parallel study, Smith Adams examined the same variables in an older (75 to 89 year old) group of women. Data were then analyzed collaboratively to investigate possible age differences in perceptions of emotional support and tangible aid between the two groups. Chapter V contained the data analysis and presentation of results. Briefly stated, the results indicated that the women in both groups perceived the emotional support they received significantly differently from the tangible aid they perceived to be available to them. Their mean responses indicated a trend toward viewing a higher level of per- ceived emotional support received than tangible aid perceived to be available. Analysis of the combined data from both groups demonstrated a significant difference in tangible aid perceived to be available between the two age groups, with the older group (75 to 89) reporting less tangible aid available than the younger group (65 to 74). Addi- tionally, the reliability (internal consistency) of five items (three emotional and two tangible), on Norbeck's Social Support Questionnaire was established with a gerontological sample of women. Interpretation of these findings and this study's relevance to Nursing research, edu- cation and practice will be discussed in the following sections. 123 Interpretation of Findings Descriptive Findings of the Study Sample In interpreting results of this study, the characteristics of the study sample must first be considered. Population statistics from the U.S. Census Bureau were presented in the first chapter, supporting the need for research on aging females. ‘The study sample of females (n==60) with subsets 65 to 74 years of age (n = 36) and 75 to 89 years of age, (n = 24) was found to be atypical for their age group when compared to the U.S. female population over age 65. More specifically, the females in the study sample reported higher levels of income and education than their counterparts in the U.S. These sociodemographic findings, in addition.tx) the volunteer convenience sample from which participants in this study were drawn, clearly indicate that no generalization of findings to other populations is appropriate. Possible reasons for the atypical levels of income and education include the preponderance of Caucasians in the study sample and the limited geographical area from which participants were drawn. Descriptive Findings Related to Research Questions 1 and 2 The finding in both age groups that less tangible aid was perceived to be available than emotional support preceived to be received, demon- strates that both samples distinguished between these conceptually dis- tinct dimensions of social support. Possible explanations for the direction of these results (less tangible aid) include first, that indeed, in both subsamples, subjects perceived a lower level of tangible aid available than the level of emotional support they reported they 124 received. iFor example, study subjects may have perceived emotional support as easier to obtain than tangible aid, i.e., emotional support may be given over the phone, as a gesture or through actions requiring little time or cost. In any event, the study subjects certainly viewed emotional support and tangible aid as two separate types of support, i.e., their responses supported the idea that social support is not one global concept. A second explanation for the significant difference found between the mean for perceived emotional support received and tangible aid per- ceived to be available in both groups, is that the results may reflect differences in the wording of the questions. For instance, questions about emotional support asked the subject to indicate "how much" the significant other made her feel loved/respected, or, "how much" she 'was able to confide in this person (significant other). In other words, the questions asked an individual to respond on the basis of experience. The tangible aid questions, in contrast, asked the subjects to respond to two hypothetical situations; e.g., "If you needed $10, or a ride to the doctor ... how much could this person help?” Therefore, the sub- jects may have responded with more certainty in describing their per- ceptions of the emotional support they had received and with less con- fidence about hypothetical (untested) situations. In considering this explanation with the older group, however, one must be aware of studies that indicate that with increasing age more people have unmet support needs or are at greater risk of developing them (Branch and Jette, 1983; Jette and Branch, 1981; and Branch and Jette, 1981). Therefore, in the older sample of women, more of the 125 subjects may have had experience in the types of hypothetical situations described in the tangible aid items and may have answered based on their experiences for both items. Without further data, unavailable in this study, no further clarification can be made; i.e., clarification of these possible explanations could only be made after validation of findings in different populations and, perhaps with a change in the item wording to achieve consistency. At this point, it is only appro- priate to say that there is a significant difference between the mean for perceived emotional support received and perceived tangible aid available in this study population of women aged 75 to 89, and that this great a difference would have occurred by chance only one time in one thousand. Descriptive Findings Related to research Question 3 The second major finding of this study was that a significant difference (p. (.001) in the mean value of tangible aid perceived to be available was demonstrated between the young-old and the old-old groups of women. Overall, the comparison of both emotional and tangible means between the two age groups shows a trend toward consistently lower scores by the older aged group of women. One explanation for this trend could be that opportunities available for receiving support decrease with increasing age; i.e., there is increasing loss of sup- port network members with advancing age. Such an explanation implies that older women have more unmet support needs, (a view which is sup- ported by Branch & Jette, 1983 & 1981) and therefore have had more actual experience in not receiving tangible aid when it was needed. 126 These older women may have answered, therefore, a bit more conserva- tively, having had experience in needing more support; whereas the younger group may have responded optimistically, a view that may have been untested by experience. A third explanation for both the trend toward lower scores in the older group, and the significant finding of lower perceived tangible aid in the older group can be attributed to cohort effect. As the women in these two age groups belonged to different cohorts; findings could be attributed to the effect of different historical experiences (Troll, 1982; Baltes et al., 1980; and Danish, 1980). Again, although the finding of significant age differences cannot be generalized, two important points are made. The first is that it logically follows previous findings (Branch and Jette, 1981 and 1983) that the need for tangible support increases with age. The decrease in support persons through natural attrition with aging suggests that fewer support network members would be available to provide help. Therefore, it follows that older persons might perceive less tangible aid available. The second point is that by dichotomizing elderly women into two age groups according to Neugarten's concept of young-old and old-old, significant age differences were found in perception of tangible aid available. Therefore it is concluded that this finding supports Neugarten's dichotomy as a meaningful way to categorize age within this elderly sample. Certainly, there are other methods (such as cohort groupings) that could be used to categorize age, which would recognize the heterogeneity of the elderly, as well, but use of Neugarten's dichotomy in this study supports consideration of the method for future research. 127 Findings Related to the Definition of the Concept of Social Support Although findings of this study cannot be generalized because of the atypical sample, they do tend to provide support for dichotomizing social support into types, emotional and tangible. Literature on social support emphasizes the need for clear conceptual definitions, and con- sistent instruments to measure them (Thoits, 1982; Schaefer et al., 1981). In this study, the NSSQ was utilized for data collection. This instrument is consistent with the conceptual definition of social sup- port developed by Robert Kahn which emphasizes affect, affirmation, and aid. Statistical support for combining affect and affirmation into one construct (emotional support) was demonstrated in this study by the use of Cronbach's alpha. In beginning attempts to delineate clearly all of the complex constructs involved in social support, it is certainly appropriate to define each theoretical construct narrowly. If, however, strong correlations between supposedly distinct constructs continue to be demonstrated with many study populations, operational definitions of social support that combine related concepts (such as affect and affirmation), into a more encompassing constructs will evolve. In other words, theoretical distinctions of subtle dimensions of social support are appropriate at this stage in examining social support. As evidence accumulates, however, combinations of related concepts may provide better operational definitions for social support dimensions. The conceptualization of social support into two types, emotional support and tangible aid, is supported by various research studies that emphasize the importance of both types of support in the lives of older 128 people. In particular, the studies by Branch and Jette (1981 and 1983), and the study by Lowenthal and Haven (1968) demonstrate this point. Branch and Jette (1981 and 1983) measured disability in older populations and the use of informal support systems to provide long term care assistance. Their findings clearly demonstrate that the need for tangible support increases with age. In Lowenthal and Haven's classical work (1968), intimacy (ability to confide in someone) was evaluated as a variable in interaction and adaptation among an elderly sample. Their results showed intimate relationships to be more closely associated with good mental health and high morale than high social interaction or role status. Therefore, Lowenthal and Haven's findings would support the importance of emotional support in the daily lives of the elderly. In summary, although specific findings, such as the direction of the trend in different perceptions of emotional support and tangible aid cannot be generalized, a contribution is made by this study, in attempting to delineate the important aspects of the overall construct of social support. The conclusion which may be drawn is that measuring perceptions of two types of social sppport, emotional support and tangible aid, provides megpingful delineation of aspects of social support that are critical to the elderly. As empirical evidence accumulates, through replication of studies which correlate dimensions of social support to determine appropriate distinctions of the construct, better, more con- sistent definitions of social support will evolve. 129 Additional Findings The final contribution of this study is in validation of the relia- bility (internal consistency) of the NSSQ with a sample of elderly women. Research instruments must be tested with varied populations to determine the universality of their application. Norbeck (1981 and 1983) had previously tested her instrument with a sample of graduate and undergraduate nursing students and with a working population. Valida- tion of one aspect of the NSSQ's reliability in an elderly population is a contribution to the ongoing development of this instrument. In summary, two conclusions can be drawn from this study: 1) The significant finding of differences in perception of available tangible aid between two age groups supports the conclusion that Neugarten's dichotomy of young-old and old-old is a meaningful way to categorize age within this elderly sample. 2) Measuring perceptions of two types of social support, emotional and tangible, provides meaningful delineation of aspects of sup- port that are critical to the elderly. Discussion of the study's contributions and relevance to three areas of Nursing; research, education, and practice, will follow a review of Norbeck's Model for guiding research and incorporating social support into clinical nursing practice. 130 Norbeck's Model of Social Support and Nursing Practice A nwdel, developed by Norbeck (1981) for the purpose of incor- porating the concept of social support into nursing practice was pre- sented in Chapter II. A brief review of this model (see Figure 4, pagee 42) shows that properties of the person and of the situation jointly determine the need for social support. The need for social support and the actual support available must be compared during the assessment phase of the nursing process. If social support is adequate there is a greater likelihood of positive health outcome for the client. If social support is inadequate, planning and intervention are aimed toward increasing support. Evaluation of the actual outcome may indi- cate a need for reassessment and so the nursing process is cyclical in nature. Although Norbeck implies the importance of perception in her pro- perties of the person, it is not clearly illustrated in her model. A revised model, with greater emphasis on perception, is presented in Figure 5. This adaptation of Norbeck's Model provides a clearer picture of the focus of this study. The client's perception of the need for social support should be compared with an objective assessment of the need for support and the actual support available in the assessment phase of the process. The Family Clinical Nurse Specialist working with elderly clients uses the assessment phase of the nursing process to develop a comprehensive database. At this level of advanced prac- tice, accuracy and efficiency in assessment is recognized as critical to the success of planning and intervention. 131 This study contributes to accuracy and efficiency in the assess- ment phase of the nursing process by providing evidence to suggest that an appropriate way to assess social support, particularly among the elderly, is to look at two types of support; emotional support and tangible aid. The findings of the study, with support from the litera- ture, suggest that needs for support may be different with increasing age. Information such as this, although a minute part of a comprehen- sive assessment, could be important in the outcome of the nursing pro- cess for an elderly individual because deficits in either area of social support may be problematic. Superficial assessment of support, without delineating the concept for elderly clients may result in missing impor- tant information for planning. Therefore planning and implementation (intervention) are dependent on the assessment information. The type of social support deficit determined through assessment with a client, has implications for planning and intervention. For example, the CNS who determines an unmet need for tangible aid in an elderly client has many avenues for planning and intervention. These avenues include referral of the client to such services as a home care type of agency, meals on wheels, or a senior center which may provide transportation. Another option in intervention to correct a tangible support type deficit would be to explore options for receipt of tangible aid from available or potential support network members. An identified deficit in emotional social support, however, requires different planning and intervention strategies. Possible 132 strategies include working with the client to identify "dormant" Sup- port network members who may provide emotional support or assisting the client with interpersonal relationship skills that will help her to elicit emotional support from existing or potential network mem- bers. The study by Wentowski (1981) described elderly person's use of an exchange system to build supportive networks. Raising an elderly person's awareness of this type of reciprocal system of help could influence the individual to use such skills to increase ties with emo- tionally supportive network members. Another option for intervention in the area of an emotional support deficit is for the CNS to become an emotionally supportive member of the client's network. This option for planning must be considered carefully as it may foster client dependency rather than assisting the individual to develop skills which will help increase independence. The type of setting and practice will also determine the feasibility, and desirability of this strategy to augment an elderly client's support resources. To some degree, a CNS will develop a supportive relationship with clients who are seen over time. A distinction is made, however, in being emotionally supportive within the boundaries of a client/practitioner interaction and becoming a mutually obligated member of a client's support network. Use of Norbeck's Model to demonstrate the focus of this study in the overall nursing process provides an important contribution in con- ceptualizing the links that must be maintained between research, edu- cation and practice in Nursing. The nursing process is usually discussed in terms of dyadic interactions between nurse and client. The same 133 systematic process of assessment, planning, implementation and evalua- tion, however, can be used to demonstrate the link between research, education, and practice. The interaction between these areas of nursing guides the progression of nursing science. Research is the assessment phase for the nursing profession. Here nurse researchers test observations, searching for empirical evidence of observed phenomena. Establishment of a body of knowledge for nursing is, therefore, analogous to the assessment phase of gathering a database for a client. Results of research must then be disseminated for planning and implementation. Education is our planning for the future. Social- ization of students into theory and research based practice, with clear articulation of the realities of the health care climate and current trends, should be the primary focus of undergraduate education. Grad- uate education in nursing prepares leaders, who through their commit- ment to advanced practice, will guide the development of the profession. Through practice, nurses have the opportunity to implement the results of research. The quality of their socialization in part determines nursing's commitment to continuing the use of research to propel the development of the profession. Feedback from service and education, in part, dictates the evaluation and focus of further research, demon- strating the cyclical nature of the continuing process. With the ana- logy of the nursing process in mind, the relevance of the role of this study to the three areas of Nursing will now be discussed. 134 .xomnuoz Scum woummw< I wuwuowum Hmoficfiao can“ uuomnsm HmHoom wcwumuomuoucw wcm nouwmmmm wcwvfisu you Home: m.xomnuoz mo :ofiumuamc< < anomasw Hmfiuom Hw5u0< .m muswam m> wHAmHHm>< uuoaasm HmHoom wm>amuumm manawame cam Hmcofiuoam I uuoaaam Hmwoom now wmmz muomwmuum wmuusomwm mchEww mHoM “coauwsuam wcu mo mmwuuwaoum L anomasm Hmaoom pom vow: mo mcowuawouwm wmaufififin< wwwmz msumum Hmufiumz Now mw¢ "somumm mnu mo wwfiuuwaoum 135 Implications for Nursing Research and Recommendations The results of this study and the limitations of the methodology used have many implications for nurses in research. Three significant findings were reported. The first, validation of reliability (internal consistency) of 3 affect/affirmation items and two tangible aid related items on the NSSQ, with an elderly sample, is an important contribution. The continued development of research instruments, such as the NSSQ, depends on the use of the instrument with many different samples. It is only through continued study that instruments can be refined and reliability supported with data from other populations. For nurse researchers the task is clear; reliable and valid instruments for measuring social support must be developed that are consistent with the conceptual definition of social support. These instruments must be refined through use with various samples with widely different charac- teristics. The Norbeck Social Support Questionnaire was developed from the conceptual definition by Robert Kahn (1979) which emphasized affect, affirmation and aid as components of social support. Items on the NSSQ are consistent with that definition. As discussed in Chapter IV, the reliability and validity of the NSSQ had previously been established only in a sample of graduate students, senior undergraduate nursing students, and working persons. The results of the data analysis (Cronbach's alpha) in this study with elderly women supported the finding of internal consistency of five items on the scale. Further, work on the NSSQ and other instruments must be done. 136 Another contribution of the study, which can be used to demonstrate yet another area of need for nursing research, is in the conceptualiza- tion of affect and affirmation as one construct i.e., emotional support. The particularly strong correlation between affect and affirmation items, on the Cronbach alpha, raised the question of whether items intended to measure those dimensions were truly not measuring the same construct, emotional support. This question, as well as the obvious lack of con- census on one definition of social support (Cassel, 1976; Cobb, 1976; Kahn and Antonucci, 1981; Lin, Simeone, Ensel, Kuo, 1979), indicates a critical need for empirical studies to clarify the concept of social support. In conceptualizing social support by types, emotional and tangible, the results of this study would indicate that this dichotomy seemed to encompass important aspects of support for the elderly popu- lation. For nurse researchers, there is an obvious need for further work to systematically define the concept of social support. This can be accomplished by using instruments to measure social support as defined by various authors. By correlating items which measure similar dimensions of social support, those subtle distinctions in concept could be identified as part of an overall construct. If this process were completed for various definitions (e.g., relational provisions, inform- ation, etc.) of social support, a more consistent definition could evolve. A more consistent definition of social support, or at least a clearer idea of what dimensions of social support are important in the evolution of the construct, is critical information for the knowledge base of nursing practice. Nurses in research, therefore, can play a 137 crucial role in developing this knowledge base. The significant findings within each sample (i.e., each group of women perceived it received more emotional support than tangible aid), should guide researchers to inves- tigate further questions related to adequacy of support, both emotional and tangible, and the amount of emotional support and tangible aid necessary for satisfactory functioning. Nurse researchers, then, should focus their efforts on determining not only how much support is avail- able, but its adequacy. For example, this study described differences in perceptions of two types of social support in a sample of older women. In addition to replicating results with a representative random sample, measures that were not included in this study, such as determining actual need, actual adequacy of support available, etc., should be undertaken. Ultimately, research efforts must be focused on interven- tion studies. Because of their specialized knowledge of the elderly, and unique preparation for promoting health with elderly clients, nurses in advanced practice (FCNS, GCNS), must be leaders in designing and implementing intervention studies. Norbeck's Model to incorporate social support into practice (Figure 2) and the revised preassessment section of Norbeck's model (Figure 5) could be useful in designing such intervention studies. The finding for the two age groups of women, (i.e., tangible aid perceived to be available was significantly lower in the older age group [75 to 89] than in the younger age group [65 to 74]), has impli- cations for researchers as well. Efforts should be continued to distinguish age differences, age changes, and cohort variability. Age differences within the population of older adults is a clearly neglected area of research. 138 Methodological problems in data collection with an elderly sample must be addressed, and the design planned must be consistent with the variable being examined. Maddox and Douglass (1974) include problems with cross sectional studies, selective survival, sampling bias (i.e., frail elderly less likely to participate in research), and sex differ- ences as methodological stumbling blocks in working with the elderly. For example, cross sectional studies are intended to measure age differ- ences. Longitudinal studies attempt measurement of age changes over time in the same individuals. Time lag research (where persons of a certain age are studied and after a specified interval a different group of individuals at the same age of the first group when studied, are tested), is designed to distinguish change in behavior due to cohort effect (David, 1981). All of these designs have value, the problem is in determining the appropriate design for the variable being measured, e.g., you cannot measure age changes unless you use a longitudinal design. More complex research designs, involving combinations of cross sectional, longitudinal and time lag approaches, may be employed to reduce the limitations of a single method. Other methodological problems in the research reported here also have implications for nurse researchers. A convenience sample was used in this study. ‘The study should be replicated, using a stratified sample, i.e., truly representative of the older population on such parameters as sex, income, education, and race. The use of secondary data was limiting in that pertinent data, such as measurements of actual support were unavailable. 139 In general, the use of secondary data is convenient, expedient, and economical. The disadvantages, however, include restrictions in research questions because of lack of pertinent data, lack of control over the process used to select the sample and administer questionnaires and lack of information about modifications in the data collection procedures. Recommendations for future research to correct these methodological problems include: 1. 5. 6. Utilizing a stratified random sample representative of the elderly population. Evaluating the effect of wording differences in Norbeck's Social Support Questionnaire, i.e., some ask for responses from actual experience, others use hypothetical situations. This could be accomplished by changing emotional-related items to hypothetical situations and evaluating differences in response. Employing a longitudinal design to evaluate age changes. Including men in sample to examine sex differences in percep— tion of social support. Controlling for selective survival, was done in the Maddox and Douglass (1974) study. Evaluating sampling bias by attempting to determine charac- teristics of persons refusing to participate. Including a greater number of significant others in the analysis to reduce the halo effect which may occur when using the first (closest) significant others listed. 140 8. Including a measure of adequacy of social support perceived to be available. 9. Including a measure for external validation of perceived social support needs, i.e., survey significant others as well. In summary, it should be evident that specific results of this study are not generalizable land, therefore implications for’ future researchers include replication and refinement in methodology. These researchers play a critical role in the development offa sound know- ledge base for the nursing profession. The results of this study, if confirmed on replication with a representative sample, can contribute to the knowledge base for nursing. 'The role of researchers in developing this scientific base for nursing has been discussed. The next section will contain a discussion of the role of nursing education in linking three areas of nursing, research, education and practice. Although specific results of this study can not be generalized for use in edu- cation, implications of the conceptual framework used and perspective of viewing social support by types, emotional and tangible, will be discussed. Implications for Nursing Education Nursing educators have the critical responsibility to socialize students to theory and research based practice. To effectively accom- plish this objective, theory and research must be integrated into all student experiences. As this type of integration is most appropriately carried out at the BSN level of preparation, the discussion will be directed to that educational level. 141 The conceptual framework of Rogers (1980), is an important aid in providing students with a perspective for viewing clients holistically and individually. This holistic approach implies careful assessment of the client's interaction with her environment and recognition of the increasing complexity of individuals with aging. Results of this study indicate age differences exist between two groups of older women in perception of the tangible aid available to them, thereby emphasizing the heterogeneity of the elderly while focusing assessment on the critical area of support resources available. Practice with a gerontological population of patients is a routine part of the experience of all nursing students. The care of elderly clients provides an excellent springboard for discussion of topics such as Rogerian concepts of increased complexity with aging, the client's interaction (energy exchange) with her environment, and the nurse's role in assessment of social support for elderly persons. Along with this theoretical background and physiological and psychological changes of normal aging, content areas for students should.emphasize differences in perception of support, support resources, and needs over time. 'These content areas could be incorporated into the larger areas of family theory, social support, and interdisciplinary team support resources available. The clinical instructor acts as a role model by integrating results of research into practice through use of the nursing process. The present study contributes to the knowledge base of nursing by concep- tualizing support by types, emotional and tangible. This method of viewing social support adds to the accuracy of the assessment phase of the nursing process. By emphasizing assessment of older clients' needs 142 in the areas of emotional support and tangible aid, the clinical instructor assists students in assessing critical areas of potential support deficit. ‘By focusing (Hz the results of studies to provide information, such as what areas of support to assess, the clinical instructor assists students to develop commitment to research based practice. Through their own involvement in research, educators bring the research process into sharp focus for students. Ideally educators have contact, either directly or indirectly as consultants, with both research and service. In reality, educators are often unable to main- tain practice links and therefore, the connection between research, service, and education is not clear to new members of the profession. Implications for Nursing Service Nurses in the field of direct service to clients comprise the largest proportion of workers in the profession. Among these profes- sionals, those working in acute care settings are most numerous. Results of this research have general and specific implications for nurses in this setting. In general, results of this research, which support the concept of differences between two age groups of women, emphasize heterogeneity of the elderly and point to unsolved problems in traditional service settings. Adequate time for assessment is essential in working with older people. In-depth assessment of the individual with 80 years of history, development and complexity must logically take longer and possibly require more creativity to obtain a meaningful database. For 143 example, when the client is hard of hearing, sensitivity and creativity in providing quiet, uninterupted time for assessment is essential. In point of fact, little administrative support is provided for increasing professional nursing time with the elderly. Considering the traditional length of time for the work of admission assessment, the fatigability of an older individual under stress, and the confusing stimuli in the acute care setting, it is probable that accuracy of assessment suffers. Nurses in this setting, then, are apt to have a limited perspective on the older individual and her environment, including her support network. Yet, these nurses are strategically involved in discharge planning, where total assessment of the client, including emotional and tangible support resources is critical. Results of this study then, which indi- cate a trend toward a lower level of tangible aid perceived, particularly in the older age group, have implications for the process of discharge planning. Specifically, nurses in service should routinely assess the avail- ability of support resources and what opportunities the client has had to confirm the resources he/she perceives to be available (i.e., how likely are these support people to provide actual support). The actual items from Norbeck's Social Support Instrument could provide a method of asking the client about support available. Because of the high correlations (Cronbach's alpha) among the items, use of one item for emotional and one for tangible could be justified. Of course, valida- tion of actual support available would be essential in a service setting because discharge planning depends on such availability. 144 The value of research findings are perceived differently by indi- vidual nurses. Those socialized into research based practice, it is hoped, will seek out research information and incorporate it into their practice independently. This socialization is most likely to occur at the BSN level of preparation. In reality, nurses practicing in acute care settings have multiple levels of eduction. It is the role of Nursing administration to assist in bridging the gap between the various educational levels of nurses. Therefore, the general implications of research results for admin- istrators in nursing service include the need to assist in the dissemin- ation of findings that will improve the care of the elderly. In service education based on research results is one way to provide pertinent information to all levels of nurses involved in direct care. Commitr ment to facilitate development of formal links to those in education and researdh for consultation and collaboration must also come from administration. Creating or developing the role of a Gerontological Clinical Nurse Specialist in an acute care center can provide this critical link and assist in bridging the gap in educational levels of nurses. Administrators in nursing service have additional concerns related to care of the elderly client, i.e., discharge planning and assessment of support options. With pressure from federal legislation (TEFRA Act of 1983), involving a change to a prospective reimbursement system, the national trend toward shorter hospital stays will surely escalate. The elderly are at high risk to be caught in the triple vise of decreased 145 length of stay in acute care settings, lack of community facilities appropriate for post hospital stays, and lack of social support to maintain independence while recuperating at home. While it is beyond the scope of this thesis to discuss all the limitations and oppor- tunities possible within the new system, it is evident that resources for the elderly, and documentation of nursing time and effort in assess- ment and planning for these clients, are important parameters that administrators will watch closely. Therefore, in acute care settings administrators must provide time for professionals to complete an in- depth assessment of elderly clients and their support resources. Administrators must also make the commitment to provide in-service opportunities that disseminate research based information to help bridge the gap between the different educational preparation of nurses in their institutions. Additionally, they must formulate strategies to provide linkages with education and research, and establish com- munication with community facilities to assist in continuity of care. Development of the role of the Clinical Nurse Specialist (GCNS, FCNS) in acute care settings has been mentioned as a way to begin to meet these commitments. In any event it should be evident that documen- tation of the important role of nursing is crucial in this time of shrinking resources. The Clinical Nurse Specialist must assume a leadership role. She is commited to the larger View -- the development of the profession. Collaboration, role modeling, and consultation are methods of dissemi- nating results of research and assisting in integration of results into practice. Visibility of the Gerontological Clinical Nurse Specialist 146 in education, service, and research is essential. This provider must also be visible in the community, for example, by University Outreach programs or classes for support system members. Involvement of this type is another way of disseminating results and assuring that infor- mation is available for those who need it (i.e., the families and significant others of the elderly). Dissemination of Results The preceding recommendations for nurses and others in the area of education, service, and research serve as :1 guide to address the issue of dissemination of results. From the above discussion it is evident that there should be much more communication between nurses working in the different areas. A summary of the connection between these areas outlines the responsibility of each division. The researcher's ultimate responsibility'is to disseminate research findings in ways that make them available and understandable to other members of the profession. The responsibility of nursing educators is to socialize students to base practice on theory and research. Nurse educators have responsibility as well to maintain ties with those involved in research and service. The responsibility of nurses in service is to implement research findings into practice and create a climate in which the socialization of students can occur. Through communication links, service and education provide feedback to research for direction in the research process. 147 It is evident that a free flow of communication, consultation, and collaboration must exist between nurses in practice, education and research. Results of research must be available to others. iPublication in journals that appeal to nurses in each area is essential. 'The jargon of theory and research must be reduced in recognition of the differences in educational preparation of nurses. Clarity, communication and a bridge between nurses with various levels of educational preparation should be the goal in disseminating results. The educational preparation of Clinical.Nurse Specialists provides the basis for individuals at this level to take leadership roles in the nursing profession. Family and Gerontological Clinical Nurse Specialists must facilitate communication among professionals involved in research, education and practice in nursing. One way to accomplish this is to incorporate research findings into practice thereby serving as a role model to others. For example, by assessing for social support deficits in two areas, emotional and tangible, the Clinical Nurse Specialist (CNS) provides an example of the use of research results. By influencing others to recognize the heterogeneity of the elderly, the CNS helps to bridge the gap in educational preparation of nurses. Assisting other nurses to see that the needs of the elderly may differ depending on their age, decreases the impact of myths and ageism. Regardless of the type of setting (primary care, acute care or other), the Clinical Nurse Specialist can use the information and con- cepts presented in this thesis in practice with elederly clients. Nursing practice based on Roger's Theory of Unitary Man focuses the 148 CNS to approach each interaction with a client as a unique opportunity to influence, and be influenced in, the process of growth toward increasing complexity. Interaction with a: client regarding social support needs can be guided by the components of Norbeck's model for incorporating social support into clinical practice (Figure 2). With this framework as a base, the CNS uses the nursing process to direct the exchange of energy towards greater likelihood of 21 positive health outcome. In beginning the assessment phase, then, the CNS con- siders the factors which she must explore with the client in developing an accurate comprehensive assessment of social support needs and resources. Assessing potential support deficits by exploring two types of social support, emotional and tangible, may increase the accuracy of the assessment and decrease the potential for missing cri- tical areas of support deficit. In summary, the focus of this study has been on differences in perceptions of two types of support, emotional and tangible, among elderly women. One area of age difference (tangible aid perceived to be available) was described. Use of these findings will contribute to the accuracy of the assessment of elderly clients. The collaborators in this study also recognize the vital part this beginning research plays in the overall development of a knowledge base for nursing and the link it can provide to nurses in education, research and service. REFERENCES Ahammer, I., and Bates, P. (1972). Objective vs. Perceived age differences in personality: How do adolescents, adults, and older peOple view themselves and each other? Journal of Gerontology, 21(1), 46-51. American Nurses' Association (1981). Research priorities for the 1980's: Generating a scientific basis for nursing practice. American Nurses' Association Publication. Atchley, R. (1980). The social forces in later life (3rd Ed.). Belmont, California: Wadsworth Publishing Babchuk, N. (1978-79). Aging and primary relations. International Journal of Aging_and Human Development, 2(2), 137-151. Baltes, P. (1968). Longitudinal and cross-sectional sequences in the study of age and generation effects. Human Development, 11) 145-171. Baltes, P., Reese, H., and Lipsitt, L. (1980). Life-span developmental psychology. Annual Review of Psychology, 3;, 65-110. Bartlett, J., Till, R., Gernsbacher, M. and Gorman, W. (1982) Age related differences in memory for lateral orientation of pictures. Journal of Gerontology, 38(4), 439-446. Bengtson, V., Kasschau, P. and Ragan, P. (1980). The impact of social structure on aging individuals. In J. Birren and K. Schau (Eds.). Handbook of the Psychology of Aging, New York: Van Nostrand Reinhold Co. Berkman, L. and Syme, L. (1979). Social networks, host resistance, and mortality: A nine-year follow-up study of Alameda County residents. American Journal of Epidemiology, 109(2), 186-204. 149 150 Bigner, J. and Jacobsen, R. (1981). Models of developmental research: Individuals and families. The Personnel and Guidance Journal, June, 647-651. Billings, A. and Moos, R. (1982). Social support and functioning among community and clinical groups: A panel model. Journal of Behavioral Medicine, 5(3), 295-311. Binstock, P. and Shanas, E. (1976). Handbook of aging and the social sciences. New York: Van Nostrand Reinhold Co. Blazer, D. (1983). Impact of late-life depression on the social network. American Journal of Psychiatry, 140(2), 162-166. Blazer, D. (1982). Social support and mortality in an elderly com- munity population. American Journal of Epidemiology, 115(5), 684—694. Borg, W. and Call, M. (1979). Educational research. New York: Longman, Inc. Bott, E. (1957). Family and social networks. London: Travistock Botwinick, J. and Thompson, L. (1968). A research note on individual differences in reaction time in relation to age. The Journal of Genetic Psychology, 112, 73-75. Boyce, W. (1981). Comment: Interaction between social variables in stress research. Journal of Health and Social Behavior, 22(2), 194-195. Branch, L. and Jette, A. (1983). Elders' use of informal long term care assistance. The Gerontologist, 22(1), 51-56. Branch, L. and Jette, A. (1981). The Framingham Disability Study: 1. Social disability among the aging. American Journal of Public Health, 22(11), 1202-1210. Brandt, P. (1981). PRQ - A social support measure. Nursing Research, s955), 277-280. 151 Brody, E. (1981). ”Women in the middle" and family help to older people. The Gerontologist, 22(5), 471-479. Brody, J. (1982). Length of life and the health of older people. National Forum, 92(4), 4-5. Bomley, D. (1966). The psychology of human sging, Baltimore: Penguin Books. Butler, R. (1969). Ageism: Another form of bigotry. The Gerontologist, 2, 243. Cameron, P. (1968). Masculinity - feminity in the aged. Journal of Gerontology, 10, 63-65. Caplan, G. (1974). Support systems and community mental health: Lectures on concspt development. New York: Behavioral Publications. Caplan, G. (1981). The family as a support system. In B. Gottlieb (Ed.), Social networks and social support (vol. 4). Beverly Hills, California: Sage Publications. Carveth, W. and Gottlieb, B. (1979). The measurement of social sup- port and its relation to stress. Canadian Journal of Behavioral Science, 22(3), 179-188. Cassel, J. (1974). An epidemiological perspective of psychosocial factors in disease etiology. American Journal of Public Health, 22(11), 1040-1043. Cassel, J. (1974). Psychosocial processes and "stress": Theoretical formulations. International Journal of Health Services, 1 471-482. Cassel, J. (1976). The contribution of the social environment to host resistance. American Journal of Epidemiology, 101(2), 107-123. Chappell, N. (1981). Measuring functional ability and chronic health conditions among the elderly: A research note on the adequacy of three instruments. Journal of Health and Social Behavior, {22_(March), 90-102. 152 Cobb, S. (1976). Presidential address - 1976: Social support as a moderator of life stress. Psychosomatic Medicine, 22(5), 300-314. Cobb, S. and Kasl, S. (1977). Termination: The consequences of job loss. DHEW (NIOSH) Publication No. 77-244, Cincinnati: Department of Health, Education and Welfare. Cockerham, W., Sharp, K. and Wilcox, J. (1983). Aging and perceived health status. Journal of Gerontology, 22(1), 349-355. Cohen, C. and Sokolovsky, J. (1979). Health-seeking behavior and social networks for the aged living in single room occupancy hotels. Journal of the American Geriatrics Society, 22(6), 270-278. Comfort, A. (1968). Physiology, homeostasis and aging. Gerontologia, 22, 244-234. Conner, R., Powers, E. and Bultena, G. (1979). Social interaction and life satisfaction: An empirical assessment of late life pat- terns. Journal of Gerontology, 22(1), 116-121. Cumming, E. and Henry, W. (1961). Growiog old: The_process of disengagement. New York: Basic Books. Dacey, J. (1982). Adult development. Glenview, Illinois: Scott, Foresman and Company. Danish, S. (1981). Life span human development and intervention: A necessary link. The Counseling Psychologist, 2(2), 40-43. Davidson, T., Bowden, M., Tholen, D., James, M. and Feller, I. (1981). Social support and post-burn adjustment. Archives of Physical Medicine and Rehabilitation, §2_(June), 274-278. Dean, A. and Lin, N. (1977). The stress-buffering role of social support: Problems and prospects for systematic investigation. Journal of Nervous and Mental Disease, 165(6), 403-417. 153 Dean, A., Lin, N. and Ensel, W. (1980). The epidemiological significance of social support systems in depression. In R.G. Simmons (Ed.), Research in Community and Mental Health, Vol. 2. Greenwick: JAI Press. Decker, D. (1980). Social Gerontology: An introduction to the dynamics of sgiug. Boston: Little, Brown and Company. DiMatteo, M. and Hays, R. (1981). Social support and serious illness. In B. H. Gottlieb (Ed.), Social network and social support. Beverly Hills: Sage Publications. Dimond, M. (1979). Social support and adaptation to chronic illness: The case of maintenance hemodialysis. Research in Nursiug and Health, 2, 101-108. Dimond, M. and Jones, S. (1983). Social support: A review and theoretical integration. In P.L. Chinn (Ed.), Advances in Nursing_Theoty Development. Rockville, Maryland: Aspen Systems Corporation. Dohrenwend, B. and Dohrenwend, B. (Eds.) (1974). Stressful life events: Their nature and effects. New York: John Wiley and Sons. Dolen, L. and Bearison, D. (1982). Social interaction and social cognition in aging: A contextual analysis. Human Development, 22) 430-442. Donald, G., Ware, J., Brook, R. and Davies-Avery, A. (1978). Concsptualization and measurement of health for adults in the health insurance study: Vol. IV, social health. Santa Monica: The Rand Corporation. Ebersole, P. and Hess, P. (1981). Toward healthy sgiug: Human needs and nursiug response. St. Louis: The C. V. Mosby, Co. Elder, G., Jr. (1975). Age differentiation and the life course. In A. Fukelea (Ed.), Annual Review of Sociology. Palo Alto, California: Annual Review, Inc. 154 Erickson, E. (1982). Generativity and ego integrity. In B. Neugarten (Ed.), Middle age and aging. Monterey, California: Brooks/Cole Publishing Co. Ewing, E. (1984). Who cares about Mr. D.? Journal of Gerontological Nursing, 29(4), 16-25. Falco, S. and Lobo, M. (1980). Martha E. Rogers. In J. B. George (Eds.), Nursing_theories: The basis for professional nursing practice. New Jersey: Prentice-Hall, Inc. Ferraro, K. (1980). Self-ratings of health among the old and the old-old. Journal of Health and Social Behavior, 22(December), 377-383. Flaskerud, J. and Halloran, E. (1980). Areas of agreement in nursing theory development. Advances in Nursing Science, 2(1), 1-7. Freedman, D., Pisani, R. and Purves, R. (1978). Statistics. New York: W. W. Norton and Company, Inc. Fuller, S. and Karlson, S. (1981). Social support, personal autonomy, and the well-being of family-member care givers. In I. G. Mauksch, (Ed.), Primary care: A contemporary nursing perspective. New York: Grune & Stratton. Fuller, S. and Larson, S. (1980). Life events, emotional support, and health of older people. Research in Nursing and Health, 2, 81-89. Gallin, R. (1980). Life difficulties, coping, and the use of medical services. Culture,_Medicine and Psychiatry, 2, 249-269. Garrison, J. and Howe, J. (1976). Community intervention with the elderly: A social network approach. Journal of the American Geriatrics Society, 22(7), 329-333. Gelein, J. (1982). Aged women and health. Nursing_Clinics of North America, 21(1), 179-185. 155 Gelein, J. (1980). The aged American female: Relationships between social support and health. Journal of Gerontological Nursing, 2(2), 69-73. German, P. (1981). Measuring functional disability in the older population. AAmerican Journal of Public Health, 22(11), 1197-1199. Given, B. (1983). Active_participation: Health care for the elderly. College of Nursing, Michigan State University, East Lansing, Michigan. Goebel, B. (1979). Age preferences of older adults in relationships important to their life satisfaction. Journal of Gerontology, 2(4), 461-467. Gore, S. (1978). The effect of social support in moderating the health consequences of unemployment. Journal of Health and Social Behavior, 22 (June), 157-165. Gottlieb, B. (Ed.), (1981). Social networks and social support (vol. 4). Beverly Hills, California: Sage Publications. Hammer, M. (1983). "Core" and "extended" social networks in relation to health and illness. Social Science and Medicine, 22(7), 405-411. Hammer, M. (1981). Impact of social networks on health and disease. In B. Gottlieb (Ed.), Social networks and social support. Beverly Hills, California: Sage Publications. Havighurst, R. (1957). The social competence of middle-aged people. Genetic Psychological Monogrsphs, 22, 297-375. Hayter, J. (1983). Modifying the environment to help older people. Nursing & Health Care, May. Heller, K. (1979). The effects of social support: Prevention and treatment implications. In. A.P. Goldstein and F.H. Kaufos (Eds.), Maximizing treatment gains. New York: Academic Press. 156 Herzog, A. and Rodgers, W. (1981). The structure of subjective well- being in different age groups. Journal of Gerontology, 22(4), 472-479. Hill, R. (1970). Family development in three generations. Cambridge, MA: Schenkman. Hill, R. (1964). Methodological issues in family development research. Family Process, 2, 186- 206. Hirsch, B. (1980). Natural support systems and coping with major life changes. American Journal of Community Psychology, 2(2), 159-172. Hirsch, B. (1979). Psychological dimensions of social networks: A multimethod analysis. American Journal of Community Psychology, 2(3), 263-277. Hirsch, B. (1981). Social networks and the coping process: Creating personal communities. In B. Gottlieb (Ed.), Social networks and social support. Beverly Hills, California: Sage Publications. Holmes, T. and Rahe, R. (1967). The social readjustment rating scale. Journal of Psychosomatic Research, 22, 213-218. House, J. (1981). Work stress and social support. Reading, Massachusetts: Addison - Wesley Publishing Company. House, J., La Rocco, J. and French, J. (1982). Comment: Reply to Schaefer. Journal of Health and Social Behavior, 22(1), 98-101. Ide, B. (1983). Social network support among low income elderly: A two-factor model? Western Journal of Nursing_Research, 12(3), 235-244. Israel, B. (1982). Social network and health status: Linking theory, research and practice. Patient Counseling and Health Education, 2(2), 65-79. 157 Jaquish, G. and Ripple, R. (1981). Cognitive creative abilities and self esteem across the adult life-span. Human Development, 22, 110-1190 Jette, A. and Branch, L. (1981). The Framingham disability study: II. Physical disability among the aging. American Journal of Public Health, 22(11), 1211-1216. Job, E. (1983). Retrospective life span analysis: A method for studying extreme old age. Journal of Gerontology, 22(3), 369-374. Kahn, R. (1979). Aging and social support. In M. W. Riley, (Ed.), sging_from birth to death: Interdisciplinary_perspectives. Boulder, Colorado: Westview Press, 77-91. Kahn, R. and Antonucci, T. (1981). Convoys over the life course: Attachment, roles, and social support. In P. Baltes and 0. Brim, (Eds.), Life span development and behavior. New York: Academic Press. Kane, R. and Kane, P. (1981). Assessing the elderly - a practical guide to measurement, Lexington Books. Kaplan, B., Cassel, J. and Gore, S. (1977). Social support and health. Medical Care, 22(5), 47-58. Kasl, S. (1972). Physical and mental health effects of involuntary relocation and institutionalization of the elderly - a review. American Journal of Public Health, 62(3), 337-384. Katch, M. (1983). A negentropic view of the aged. Journal of Gerontological Nursing, 2(12), 656-660. Kim, H. (1983). Use of Roger's conceptual system in research: comments. Nursinngesearch, 22(2), 89-91. Kirity, S. and Moos, R. (1976). Physiological effects of social environments. Psychosomatic Medicine, 22, 96-114. 158 Kohen, J. (1983). Old but not alone: Informal social support among the elderly by marital status and sex. The Gerontologist, 22(1) 57’630 Langlie, J. (1977). Social networks, health beliefs, and preventive health behavior. Journal of Health and Social Behavior, 22_ (September), 244-260. LaRocco, J. (1983). Comment: Theoretical distinctions between causal and interaction effects of social support. Journal of Health and Social Behavior, 22(1), 91-92. LaRocco, J., House, J. and French, J. (1980). Social support, occupational stress, and health. Journal of Health and Social Behavior, 22 (September), 202-218. Larson, R. (1978). Thirty years of research on the subjective well- being of older Americans. Journal of Gerontology, 22(1), 109-125. LaRue, A., Bank, L., Jarvik, L. and Hetland, M. (1979). Health in old age: How do physicians' rating and self-ratings compare? Journal of Gerontology, 22(5), 687-691. Lawton, M. and Nahemow, L. (1973). Ecology and the aging process. In C. Eisdorfer and M. Lawton (Eds.), Psychology of adult development and aging. Washington, D.C.: American Psychological Association. Levinson, D. J. (1978). The seasons of a man's life. New York: Alfred A. Knapf. Lin, N. (1981). Comment: Causal interpretation of interaction effect. Journal of Health and Social Behavior, 22(2), 195-196. Lin, N., Dean, A. and Ensel, W. (1981). Social support scales: A methodological note. Schizophrenia Bulletin, 7(1), 73-89. Lin, N., Ensel, W., Simeone, R. and Kuo, W. (1979). Social support, stressful life events, and illness: A model and an empirical test. Journal of Health and Social Behavior, 22 (June), 108-119. 159 Lindsey, A. and Hughes, E. (1981). Social support and alternatives to institutionalization for the at-risk elderly. Journal of the American Geriatrics Society, 22(7), 308-315. Lipowski, Z. (1969). Psychological aspects of disease. Annals of Internal Medicine, 22, 1197-1206. Lowenthal, M. and Haven, C. (1968). Interaction and adaptation: Intimacy as a critical variable. American Sociological Review, 22, 20-30. Maddox, G. and Douglass, E. (1974). Ageing and individual differences: A longitudinal analysis of social, psychological, and physiological indicators. Journal of Gerontology, 22(4), 555-563. Maddox, G. and Douglass, E. (1973). Self-assessment of health: A longitudinal study of elderly subjects. Journal of Health and Social Behavior, 22, 87-93. Mancini, J. and Orthner, D. (1980). Situational influences on leisure satisfaction and morale in old age. Journal of the American Geriatrics Society, 22(10), 466-470. McCallister, L. and Fischer, G. (1978). A procedure for surveying personal networks. Sociological Methods and Research, 2(2), 131’1480 McCrae, R. (1982). Age differences in the use of coping mechanisms. Journal of Gerontology, 22(4), 454-460. McFarlane, A., Neale, K., Norman, G., Roy, R. and Streiner, D. (1981). Methodological issues in developing a scale to measure social support. Schizophrenia Bulletin, 2(1), 90-100. Minkler, M. (1981). Applications of social support theory to health education: Implications for work with the elderly. Health Education Quarterly, 2(2), 147-165. Mitchell, J. (1969). Social networks in urban situations. Manchester, Great Britain: The University of Manchester Press. 160 Mitchell, R. and Trickett, E. (1980). Task force report: Social networks as mediators of social support -- an analysis of the effects and determinants of social networks. Community Mental Health Journal, 22(1), 27-44. Moon, M. (1983). The role of the family in the economic well-being of the elderly. The Gerontologist, 22(1), 45-50. Murawski, B., Penman, D. and Schmitt, M. (1978). Social support in health and illness: the concept and its measurement. Cancer Nursing, October, 365-371. Murray, R., Huelskoetter, M. and O'Driscoll, D. (1980). The nursing process in later maturity. Englewood Cliffs, New Jersey: Prentice-Hall, Inc. Murray, R. and Zentner, J. (1979). Nursing assessment and health promotion through the life span (2nd Ed.). Englewood Cliffs, New Jersey: Prentice-Hall, Inc. Neugarten, B. (1964). A developmental view of adult personality. In J. E. Berrien (Ed.), Relations of development and aging. Springfield, Illinois: Charles C. Thomas Neugarten, B. (1974). Age groups in American society and the rise of the young-old. Annals of the American Academy of Political and Social Service, 415, 187-198. Neugarten, B. (1982). Age or need? National Forum -- The Phi Kappa Phi Journal, 22(4), 25-27. Neugarten, B. (1973). Developmental perspectives. In V. Brantl, and M. Brown (Eds.), Readings in Gerontology. Saint Louis: The C. V. Mosby Company. Neugarten, B. (1981). Growing old in 2020: How will it be different? National Forum -- The Phi Kappa Phi Journal, 22(3), 28-43. Neugarten, B. (1968). Middle Age and Aging. Chicago: The University of Chicago Press. 161 Neugarten, B. (1979). Time, age, and the life cycle. The American Journal of Psychiatry, 136(7), 887-894. Neugarten, B. (1973). Personality change in late life: A developmental perspective. In E. Eisdorfer and M. Lawton (Eds.), The_psychology of adult development and aging, Washington: American Psychological Association. Neugarten, B. and Datan, N. (1973). Sociological perspective on the life cycle. In P. Baltes and K. Schaie (Eds.), Life-span developmental,psychology: Personality and socialization. New York: Academic Press Neugarten, B., Moore, J. and Lowe, J. (1965). Age norms, age constraints, and adult socialization. American Journal of Sociology, 70, 710-717. New, P., Ruscio, A., Priese, R., Petritsi, D. and George, L. (1968). The support structure of heart and stroke patients: A study of the role of significant others in patient rehabilitation. Social Science and Medicine, 2, 185-200. Newman, M. (1982). Time as an index of expanding consciousness with age. Nursing_Research, 22(5), 290-293. Norbeck, J. (1981). Social support: A model for clinical research and application. Advances in Nursing Science, 3(4), 43-59. Norbeck, J., Lindsey, A. and Carrieri, V. (1983). Further development of the Norbeck Social Support Questionnaire: Normative data and validity testing. Nursinngesearch, 22(1), 4-9. Norbeck, J., Lindsey, A. and Carrieri, V. (1981). The development of an instrument to measure social support. Nursinngesearch, 22(5), 264‘269. Nuckolls, K., Cassel, J. and Kaplan, B. (1972). Psychosocial assets, life crisis and the prognosis of pregnancy. ‘American Journal of Epidemiology, 22, 431-441. 162 O'Brien, J. (1980). Help seeking by the frail elderly: Problems in network analysis. The Gerontologist, 22(1), 78-83. Obrist, W. (1953). Simple auditory reaction time in aged adults. Journal of Psychology, 22, 259-266. Palmore, E. (1968). The effects of aging on activities and attitudes. The Gerontologist, 8, 259-263. Palmore, E., Cleveland, W., Nowlin, J., Ramm, D. and Sielger, I. (1979). Stress and adaptation in later life. Journal of Gerontology, 22(6), 841-851. Parkes, C. (1971). Psychosocial transitions: A field for study. Social Science and Medicine, 2, 101-115. Perry, B. (1982). Validity and reliability of responses of the aged to surveys and questionnaires. The Journal of Family Practice, 22(1), 182-183. Peters-Golden, H. (1982). Breast cancer: Varied perceptions of social support in the illness experience. Social Science and Medicine, 22, 483-491. Petros, T., Zehr, H. and Chabot, R. (1983). Adult age differences in accessing and retrieving information from long term memory. Journal of Gerontology, 22(5), 589-592. Pilisuk, M. and Froland, C. (1978). Kinship, social networks, social support, and health. Social Science and Medicine, 222, 273-280. Pilisuk, M. and Minkler, M. (1980). Supportive networks: Life ties for the elderly. Journal of Social Issues, 36(2), 95-115. Pinneau, S. Jr. (1975). Effects of social support on psychological and physiological stress. Unpublished doctoral dissertation, University of Michigan. Pitman, E. (1939). Biometrika, 42:9, Summarized in G.W. Snedecor and W. G. Cochran, (1967). Statistical Methods. Ames: Iowa State Univeristy Press, 195-197. 163 Polit, D. and Hungler, B. (1978). Nursing research: Principles and methods. Philadelphia: J.B. Lippincott Company. Ragan, P. and Wales, J. (1980). Age stratification and the life course. In J. Birren and R. Sloane (Eds.), Handbook of mental health and aging. Englewood Cliffs, New Jersey: Prentice-Hall, Inc. Riegel, K. (1971). The prediction of death and longevity in longitudinal research. In E. B. Palmore and F. C. Jeffers (Eds.), Prediction of life span: Recent findings. Lexington, MA: Health Lexington Books. Riegel, K. and Riegel, R. (1972). Development, drop, and death. Developmental Psychology, 2, 306-319. Riegel, K., Riegel, R. and Meyer, G. (1967). Socio-psychological factors of aging: A cohort-sequential analysis. Human Development, 22, 27-56. Riley, M. (1980). Age strata in social systems. In J. Birren and R. Sloane (Eds.), Handbook of mental health and aging. Englewood Cliffs, New Jersey: Prentice-Hall, Inc. Rogers, M. (1970. An introduction to the theoretical basis of nursing, Philadelphia: F. A. Davis Company. Rogers, M. (1982, May). Lecture, panel discussion and interview. Michigan State University, College of Nursing, East Lansing, Michigan. Rogers, M. (1980). Nursing: A science of unitary man. In J. Riehl and C. Roy (Eds.), Conceptual models for nursing practice. New York: Appleton - Century - Crofts. Rossi, A. (1980). Life-span theories and women's lives. Signs: Journal of Women in Culture and Society, 2(1), 4-32. Sands, J. (1981-82). The relationship of stressful life events to intellectual functioning in women over 65. International Journal of Aging and Human Development, 22(1), 11-22. 164 Schaefer, C. (1982). Comment: Shoring up the ”buffer" of social support. Journal of Health and Social Behavior, 22(1), 96-98. Schaefer, C. Coyne, J. and Lazarus, R. (1981). The health-related functions of social support. Journal of Behavioral Medicine, 2(4), 381-405. Seelbach, W. (1977). Gender differences in expectations for filial responsibility. The Gerontologist, 17(5), 421-425. Seelbach, W. and Hansen, C. (1980). Satisfaction with family relations among the elderly. Family_Relations, 22, 91-96. Shanas, E. (1973). Family-kin networks and aging in cross-cultural perspective. Journal of Marriage and the Family, 22, 505-511. Shanas, E. (1960). Family responsibility and the health of older people. Journal of Gerontology, 22, 408-411. Shanas, E. (1980, February). Older people and their families: The new pioneers. Journal of Marriage and the Family, 9-15. Shanas, E. (1979). The family as a social support system in old age. The Gerontologist, 22(2), 10-17. Shanas, E. (1982). The family relations of old people. National Forum - the Phi Kappa Phi Journal, 22(4), 9-11. Shanas, E. (1979, February). Social myth as hypothesis: The case of the family relations of old people. The Gerontologist, 22(1), 3-9. Smith Adams, C. (1984). A descriptive study of the differences in perceived emotional support received andyperceived tangible aid available to elderly_women in two age_groups. Unpublished thesis, Michigan State University, East Lansing, Michigan. Snow, D. and Gordon, J. (1980). Social network analysis and intervention with the elderly. The Gerontologist, 22(4), 463-467. 165 Spradley, I. (1972). Culture and cognition. San Francisco: Chandler. Stearns, P. (1980). Old women: Some historical observations. Journal of Family History, Spring, 44-57. Stevenson, J. (1976). Issues and Crises Durinngiddlesence. New York: Appleton - Century - Crofts. Stoller, E. and Earl, L. (1983). Help with activities of everyday life: Sources of support for the noninstitutionalized elderly. The Gerontologist, 22(1), 64-70. Streib, G. (1976). Social stratification and aging. In R. Binstock and E. Shanas (Eds.), Handbook of aging and social science. New York: Van Nostrand Reinhold Co. Sussman, M. (1977). The family bureaucracy, and the elderly individual: An organizational/linkage perspective. In E. Shanas and M. Sussman (Eds.), Family, bureaucraoy and the elderly. Durham, N.C.: Duke University Press. Sussman, M. (1976). The family life of old people. In E. Shanas and R. Binstock (Eds.), Handbook of aging_and the social sciences. New York: Van Nostrand Reinhold. Syme, S., Hyman, M. and Enterline, P. (1964). Some social and cultural factors associated with the occurrence of coronary heart disease. Journal of Chronic Disease, 22, 277-289. Thoits, P. (1983). Comment: Main and interactive effects of social support: Response to LaRocco. Journal of Health and Social Behavior, 22(1), 92-94. Thoits, P. (1982). Conceptual, methodological, and theoretical problems in studying social support as a buffer against life stress. Journal of Health and Social Behavior, 22, 145-159. Thomas, P. and Hooper, E. (1983). Healthy elderly: Social bonds and locus of control. Research in Nursing and Health, 2, 11-16. 166 Tissue, T. (1972). Another look at self-rated health among the elderly. Journal of Gerontology, 22(1), 91-94. Treas, J. (1977). Family support systems for the aged - some social and demographic considerations. The Gerontologist, 22(6), 486-491. Troll, L. (1982). Continuations: Adult development and aging, Monterey, California: Brooks/Cole Publishing Company. Troll, L. (1971). The family of later life: A decade review. Journal of Marriage and the Family, 22, 263-290. Turner, R. (1981). Social support as a contingency in psychological well-being. Journal of Health and Social Behavior, 22, 357-367. Uhlenberg, P. (1977). Changing structure of the older population of the U.S.A. during the twentieth century. The Gerontologist, 22, 195-202. Uhlenberg, P. (1974). Cohort variations in family life cycle eXperiences of U.S. females. Journal of Marriage and the Family, 22, 284-292. Uhlenberg, P. (1979). Older women: The growing challenge to design constructive roles. The Gerontolpgist, 22(3), 236-241. Unger, D. and Powell, D. (1980). Supporting families under stress: The role of social networks. Family Relations, 22, 566-574. U.S. Bureau of the Census (1984). National Data Book and Guide to Sources: Statistical Abstract of the United States 104th Ed. U.S. Department of Commerce. U.S. Bureau of the Census, (1984). U.S.A. Statistics in Brief: A Statistical Abstract Summary, (1984). U.S. Department of Commerce. Walker, K., MacBride, A. and Vachon, M. (1977). Social support networks and the crisis of bereavement: Social Science and Medicine, 22, 35-41. 167 Wallston, B., Alagna, S., DeVellis, B. and DeVellis, R. (1983). Social suport and physical health. Health Psychology, 2(4), 367-391. Wandelt, M. (1970). Guide for the bsginning researcher. New York: Appleton - Century - Crofts. Webster's New Collegiate Dictionary (1968). Springfield, Massachusetts: G. and C. Merriam Company, 1979. Weeks, J. and Cuellar, J. (1981). The role of family members in the helping networks of older people. The Gerontologist, 22(4), 388-394. Weiss, R. (1974). The provisions of social relationships. In Z. Rubin (Ed.), Doing unto others, Englewood Clifs, New Jersey: Prentice- Hall, Inc. Weiss, R. (1976). Transition states and other stressful situations: Their nature and programs for their management. In G. Caplan and M. Killilea (Eds.), Support systems and mutual help. New York: Grune and Stratton. Wellman, B. (1981). Applying network analysis to the study of social support. In B. Gottlieb (Ed.), Social networks and social support: vol. 4. Beverly Hills, California: Sage Publications. Wentowski, G. (1981). Reciprocity and the coping strategies of older people: Cultural dimensions of network building. The Gerontologist, 22(6), 600-609. Winnubst, J., Marcelissen, F. and Kleber, R. (1982). Effects of social support in the stressor-strain relationship: A Dutch sample. Social Science and Medicine, 22, 475-482. Wood, V. and Robertson, J. (1978). Friendship and kinship interaction: Differential effect on the morale of the elderly. Journal of Marriage and the Family, (May), 367-375. APPENDIX A The Norbeck Social Support Questionnaire 168 Please list each significant person in your life on the LEFT. List their relationship to you on the RIGHT from the groups in the directions. FIRST NAME OR INITIALS RELATIONSHIP 1. 1. (16) 2. 2. (17) 3. 3. (18) 4. 4. (19) 5. 5. (20) 6. 6. (21) 7. 7. (22) 8. 8. (23) 9. 9. (24) 10. 1o. (25) 11. 11. (26) 12. 12. (27) 13. 13. (28) 14. 14. (29) 15. 15. (30) 16. 16. (31) 17. 17. (32) 18. 18. (33) 19. 19. (34) 20. 20. (35) 169 DO NOT OPEN UNTIL PAGE ON THE RIGHT IS COMPLETED. When the right page is completed, please open this booklet and match the lines on the right and left pages that are numbered 1-20. The questions you will answer on the left are about the people you listed on the right. Be very careful that the numbers of the lines match on both pages. Check them occasionally as you are completing the questions. PLEASE TURN THE PAGE AND BEGIN BY ANSWERING QUESTION 1. 170 For each person you listed, please answer the following questions by writing in the number that applies. 1 = Not at all 2 = A little 3 = Moderately 4 = Quite a bit 5 = A great deal Question 1: Question 2: How much does this person make How much does this person make you feel liked or loved? you feel respected or admired? 1. 1. (36) (56) 2. 2. (37) (57) 3. 3. (38) (58) 4. 4. (39) (59) 5. 5. (40) (60) 6. 6. (41) (61) 7. 7. (42) (62) 8. 8. (43) (63) 9. 9. (44) 44(64) 10. 10. (45) (65) 11. 11. (46) (66) 12. 12. (47) (67) 13. 13. (48) (68) 14. 14. (49) (69) 15. 15. (50) (70) 16. 16. (51) (71) 17. 17. (52) (72) 18. 18. (53) (73) 19. 19. (54) (74) 20. 20. (55) (75) GO ON TO NEXT PAGE End Card #10 171 For each person you listed, please answer the following questions by writing in the number that applies. 1 = Not at all 2 = A little 3 = Moderately 4 = Quite a bit 5 = A great deal Question 3: Question 4: How much can you confide in this How much does this person agree person? with or support your actions or thoughts? 1. 1. (16) (36) 2. 2. (17) (37) 3. 3. (18) (38) 4. 4. (19) (39) 5. 5. (20) (40) 6. 6. (21) (41) 7. 7. (22) (42) 8. 8. (23) (43) 9. 9. (24) (44) 10. 10. (25) (45) 11. 11. (26) (46) 12. 12. (27) (47) 13. 13. (28) (48) 14. 14. (29) (49) 15. 15. (30) (50) 16. 16. (31) (51) l7. 17. (32) (52) 18. 18. (33) (53) 19. 19. (34) (54) 20. 20. (35) (55) GO ON TO NEXT PAGE 172 For each person you listed, please answer the following questions by writing in the number that applies. 1 = Not at all 2 = A little 3 = Moderately 4 = Quite a bit 5 = A great deal Question 5: Question 6: If you needed to borrow $10, a ride If you were confined to bed for to the doctor, or some other several weeks, how much could immediate help, how much could this this person help you? this person usually help? Repeat 1 — 15 1. 1. (56) (16) 2. 2. (57) (17) 3. 3. (58) (18) 4. 4. (59) (19)‘ 5. 5. (60) (20) 6. 6. (61) (21) 7. 7. (62) (22) 8. 8. (63) (23) 9. 9. (64) (24) 10. 10. (65) (25) 11. 11. (66) (26) 12. 12. (67) (27) 13. 13. (68) (28) 14. 14. (69) (29) 15. 15. (70) (30) 16. 16. (71) (31) 17. 17. (72) (32) 18. 18. (73) (33) 19. 19. (74) (34) 20. 20. (75) (35) GO ON TO NEXT PAGE End Card 11 173 For each person you listed, please answer the following questions by writing in the number that applies. Question 7: Question 8: How long have you known this person? How frequently do you usually have contact with this person? (phone calls, visits, or letters) 1 = Less than 6 months 1 = Once a year or less 2 = 6 months - 1-1/2 years 2 = Every 3 - 6 months 3 = Between 1-1/2 years - 3 years 3 = Once a month 4 = Between 3 - 5 years 4 = Once a week 5 = 5 years or more 5 = Once a day 1. 1. (36) (56) 2. 2. (37) (57) 3. 3. (38) (58) 4. 4. (39) (59) 5. 5. (40) (60) 6. 6. (41) (61) 7. 7. (42) (62) 8. 8. (43) (63) 9. 9. (44) (64) 10. 10. (45) (65) 11. 11. (46) (66) 12. 12. (47) (67) 13. 13. (48) (68) 14. 14. (49) (69) 15. 15. (50) (70) 16. 16. (51) (71) 17. 17. (52) (72) 18. 18. (53) (73) 19. 19. (54) (74) 20. 20. (55) (75) GO ON TO NEXT PAGE End Card 12 174 Question 9: During the past year have you lost any important relationships due to moving, a job change, divorce or separation, death, or some other reason? (PLEASE CHECK ONE) Yes N0 Repeat 1-15 If yes, specify . 9a. 9b. If YES, indicate the category(ies) If YES, indicate how much support of persons no longer available to this person (or persons) has you. provided in the past six months. 1 = Spouse or partner 1 = Not at all 2 = Family or relative 2 = A little 3 = Friend 3 = Moderately 4 = Work or school associate 4 = Quite a bit 5 = Neighbor 5 = A great deal 6 = Health care provider 7 = Counselor or therapist 8 - Minister/priest/rabbi 9 = Other 1. 1. (17) (27) 2. 2. (18) (28) 3. 3. (19) (29) 4. 4- (20) (30) 5. 5. (21) (31) 6. 6. (22) (32) 7. 7. (23) (33) 8. 8. (24) (34) 9. 9. (25) (35) 10. 10. (26) (36) APPENDIX B Consent Form The Norbeck Social Support Questionnaire 175 CONSENT FORM The study in which we are asking you to participate is designed to learn more about how older individuals' life situations and support affect their ability to actively participate in their health care. It will take about 45 minutes to complete. If you agree to participate, please sign the following statement. 1. I have freely consented to take part in a study of patients being conducted by the College of Nursing at Michigan State University. 2. The study has been described and explained to me and I understand what my participation will involve. 3. I understand that if I withdraw from the study after originally agreeing to participate, the amount and quality of service pro- vided me will not change. I understand that I can withdraw from participating at any time. 4. I understand that the results of the study will be treated in strict confidence and that should they be published, my name will remain anonymous. I understand that within these restrictions results can, upon request, be made available to me. I, , state that I understand what (Print Name) is required of me as a participant and agree to take part in this study. Signed (Signature of Patient) Date H “'111111111111111113111111111117