In the last 5 years, there has been vast interest in the homeless population in America.1·2 Although much attention has been focused on the younger homeless, cohorts of men 65 years old or older without a permanent residence have not been ignored. The literature is replete with reports of physical and psychosocial problems of the homeless, including those of men 65 years old or older.3"18 Howevei; there is a paucity of literature on what homeless elderly men (aged 65 years or more without a permanent residence) identify as universal self-care requisites.
Orem suggested eight universal selfcare requisites that are common to all humans.19 The universal self-care requisites include: a sufficient intake of air, water, and food; elimination; a balance between activity and rest and solitude and social interaction; prevention of hazards; and normalcy. These requisites represent purposive actions that are required for humans to meet basic needs. The requisites are inter-related and vary in nature and quantity for individuals or groups in relation to age, sex, health state, sociocultural orientation, and resources. Thus, the varieties of practices used by individuals or groups must be considered when eliciting and describing reports of universal self-care requisites of any population.19
Meeting basic needs through selfcare or dependent care is an integral part of daily living of individuals and their social groups, but it tends to become visibly separated from the fabric of human life when certain conditions, such as homelessness, predominate. Subsequently, individuals as well as social groups focus attention on specific needs and act to bring about conditions under which they can be met.19 Based on this actuality, it was assumed that a unified description of the universal self-care requisites of homeless elderly men could be constructed. Furthermore, it was assumed that the description could provide information that would enhance understanding about the linkage between universal self-care requisites as identified by homeless elderly men and Orem's sets of actions for meeting basic needs.19 Moreover, obtaining information from various populations partially fulfills recommendations from Orem20 and the Nursing Development Conference Group to derive knowledge about human functioning from a variety of sources.
PURPOSE AND METHOD
The purpose of this study was to construct a unified description of the universal self-care requisites of homeless elderly men. The research question formulated for the study was: What are the universal self-care requisites as identified by homeless elderly men?
Qualitative methodologies, as used in this study, often have been selected as the research strategy of choice when investigating and subsequently describing a given event or action at a particular time.21 Characteristic of mis approach is the process associated with the participant's report of a need, action, or event. Therefore, the research and interview questions are framed to reflect human nature and the connectedness of humans with the environment.22 Data are analyzed inductively, and themes emerge as the data are grouped and categorized. It was the emphasis on constructing a unified description of phenomenon that made a qualitative approach the most appropriate choice of method for this study.
Ten homeless men, who were 65 years old or older, who used the services of a 90-bed shelter located in the southeastern United States on daily or as needed basis, and who could speak and understand English, agreed to participate in the study. Participants ranged in age from 65 to 70 (mean = 66). Six participants were white; four were black.
The sample size was consistent with recommendations by Glasser and Strauss23 and Wilson24 that 10 to 12 participants are sufficient to identify and describe phenomenon. Additionally, because the research phenomenon was homogenous to the subjects and data collection was conducted in the same manner, a large sample size was not necessary.23,24
Method and Materials
A semi-structured interview guide was constructed by the researchers and content analyzed by two judges. One judge was a certified gerontological nurse familiar with Orem's theory19 and who was enrolled in a doctoral program in nursing. The other judge was a certified adult psychiatric nurse familiar with Orem's theory and who provided nursing care for homeless persons at local shelters. The interview guide consisted of two parts: an introductory statement related to living, functioning, and being healthy; and open-ended items for eliciting reports of the self-care requisites of homeless elderly men. The interview guide was used to collect data during audiotaped interviews.
NUMBER OF DESCRIPTIVE THEMES BY CATEGORY OF OREM'S UNIVERSAL SELF-CARE REQUISITES
Procedures for Data Collection
Study participants were deemed not to be at risk, and approvals were granted by appropriate Institutional Review Boards to conduct the study. One researcher met with each of the participants to discuss the purpose of the study, audiotaping procedures, and option to withdraw at any time during data collection. Furthermore, the researcher informed each participant that he would collect all data, use corresponding codes to ensure confidentiality, and interview tapes would be destroyed after completion of the study.
A date and time was scheduled with each participant and interviews were conducted in a designated interview room at the shelter. The length of the interviews averaged 40 minutes. The interview sequence included signing an informed consent form, reading the introductory statement, eliciting reports of universal self-care requisites, and ascertaining participant's age and race.
Procedures for Data Analysis
A number of researchers (Glasser and Strauss,23 Miles and Huberman,21 and Turner25) have addressed the problem of handling the large amounts of data generated by qualitative approaches. Turner identified nine stages to handle volumes of descriptive data. For the purposes of data analysis in this study. Turner's stages were modified to form six steps:
* Verbatim transcription of each interview. The researcher who conducted the interviews was responsible for the transcriptions;
* Selection of 10 colors from a possible 64 for color coding the transcriptions;
* Review of each transcription by the researchers. During the review process, the question was asked, "what words or phrases best describe the universal self-care requisites of homeless elderly men?" A notation of the words or phrases was made in the margin of the color-coded transcript;
* The words or phrases were entered on corresponding, color-coded, 3X5 index cards in the event a specific paragraph of a transcription needed to be reviewed;
* Grouping and sorting the cards to establish a list of themes describing the universal self-care requisites as identified by homeless elderly men; and
* Review of the list and classifying themes in each of Orem's universal self-care requisite categories.19
The reliability of analyzing descriptive data using the six steps was established during a pilot study with other homeless elderly men from a different city.
To establish inter-rater reliability among the themes and classification into categories, a gerontological nurse, a program developer for the homeless, and an educator who teaches in a baccalaureate program based on Orem's theory each reviewed the data. A rating of .89 was obtained by the researchers and was recognized as a valid measure of reliability.26
Fourteen themes descriptive of the universal self-care requisites for homeless elderly men emerged from analysis of the data. The number of descriptive themes by category of Orem's universal self-care requisites are presented in the Table.19
No participants identified the maintenance of a sufficient intake of air as a self-care requisite. This was an interesting finding considering that sufficient air intake provides individuals with one of the materials required for metabolism and energy production.
Eight participants reported that finding clean water was essential to the maintenance of the integrity of human structure and functioning, and general well-being. As one participant stated:
I have to carry this old milk jug I found in the dumpster full of water so I will not be thirsty and to keep my kidneys flushed. But you know it is hard to find enough clean water around here. Folks do not want you stopping in their places and asking for water. I have had to catch me some water to drink from them fountains that spray up, like in the park.
Finding enough healthy food was identified by nine of the participants. According to one participant, "I find food, but it has got so much salt in it. The doctors say that is bad with my high blood pressure, so I have to hunt more." The detailed description is representative of the participants' statements that described a need to consume the quantity and quality required for normal human functioning with adjustments for internal and external factors.
The provision of care associated with eliminative processes of excrements was another requisite not reported by the participants. Although no participant reported the requisite, questions arise as to integrity of these processes and their regulation.
Two themes associated with the need to maintain a balance between activity and rest were reported. Adequate rest was reported by six of the participants, whereas five reported getting some exercise. As one participant stated, "I am getting older and they say I will not need as much rest, but they have not lived out here on the street. I know what I need. Otherwise, I have lost it." Another participant stated:
Folks are always telling me that I need to walk about so I will not get stiff and not have my feet swell up like old folk's feet do. I try and walk every day around the place so I can build up my strength 'cause I never know. I never know what day that I will have to get along on the streets at night without a place to sleep like here.
Two themes associated with maintaining a balance between solitude and social interaction also were reported by participants. Finding better ways to use time and finding people to trust and have as a friend were both reported by three participants. According to one participant, "I have so much time that I do nothing, just sit around here on the sidewalks without folks to talk with. I was not used to that." Another stated, "I wish for someone to trust and have as my friend. Friends are hard to come by here and when you are as old as me that is something you want." These descriptions were similar to other participants' statements that described the kinds of purposive self-care essential for developmental processes in which knowledge is acquired, values and expectations are formed, and a measure of security and fulfillment is achieved.
Five themes related to the need for preventing hazards to life, functioning, and well-being were reported. Seven participants reported being aware of health needs and finding help. As one participant stated:
I know I need to watch out for myself, especially with this high blood pressure. When my head hurts bad and spins, my pressure is up and I have to find some help. I have to watch it with my getting about 'cause I get out of wind quickly and my heart races and I know then I got to get help or do something.
Getting medicines and being treated was reported by six of the participants. According to one, "to stay alive I have to get my heart pills and water pills. I find that hard 'cause they do not want to treat you if you have no money."
Nine participants identified protecting self. "It gets so hot in the summer and cold in the winter that I have to find places so I can protect myself so not to die from the heat, cold, or get robbed," stated one of the participants.
Seven participants reported that having enough clothes for the winter was a requisite. As one participant stated, "It does not really matter what my clothes look like as long as I have enough, especially in winter. If I do not have enough, it is bad."
Having a safe place to stay at night was reported by all 10 participants. As one stated, "I need a place where I can close my eyes and believe that I will wake up unhurt. That is why I come here at night." Each of the themes related to hazard prevention contributes to the maintenance of human integrity and promotion of human functioning and development.
Finally, three themes associated with the need for promotion of normalcy were reported. Getting money was reported by 10 participants, keeping clean by 4, and having clean clothes by 4. Examples of participant responses include, "I do not have enough money to take care of myself and pay for medicine, so I come here, but I keep trying. I get money any way I can." Another participant stated, "There is just not a whole lot of places to wash up everyday, but I do not want to be smelly 'cause folks shun me." And another stated, "I want and need clothes that are clean and neat. It helps me keep some good feelings 'cause having to ask for everything brings me down." Each of the themes and participant examples are descriptive expressions of need expressed in terms of actions for maintaining and promoting human structure and functions.
When analyzing the findings of the present study with previous studies, similarities and differences can be seen. For example, Rueler, Bax, and Sampson suggested that adequate intake of air, water, and food are taken for granted by people.14 This was partially supported by the findings of the present study that a sufficient intake of air was not a theme descriptive of a universal self-care requisite. This finding was of interest to the researchers considering the incidence of chronic obstructive pulmonary disease among elders as reported in the literature.5 In contrast, a significantly high number of responses evidenced the need for finding clean water (8 of 10) and enough healthy food (9 of 10). The need for finding enough healthy food supported the report by Winick that a large number of homeless elderly persons describe health problems as a result of poor nutritional habits.17
Burnside reported that as individuals age, physiological changes in the gastrointestinal and urinary systems occur, resulting in problems with elimination of excrements.5 Bassuk27 and Mowbray13 reported that such problems are compounded when homeless elderly persons lack the available resources to eliminate excrements. The findings of the present study - that no themes emerged in the category of excrements - may be indicative of the effectiveness of self-care actions taken by homeless elderly men to meet the requisite, or they may reflect the relative severity of problems.
Susser, Struening, and Conover reported that the majority of homeless elderly focus on survival needs that are void of personal and appropriate patterns of activity and rest.16 It could be argued from the findings of the present study that the participants generally engaged in personal and appropriate patterns of activity and rest, given the prevailing conditions of homelessness, age, and shelter living.
Orem suggested that a balance between solitude and social interaction is required for normal human development.19 In the current study, themes descriptive of a need to balance solitude and social interaction were the least evident (3 of 10). Although the findings reveal that homeless elderly men have both solitude and social interaction needs, maintenance of a balance between the two is not evident. This may be explained by the findings of Sebastian that establishing and maintaining relationships are difficult for homeless elderly people due to shelter limits on length of stays and an individual focus on survival.15
Cohen6 and Zlotnick18 reported that the needs of homeless elderly men primarily concern day-to-day survival and are aimed at preventing conditions that constitute internal and external hazards. In this study, the themes were congruent with findings by Cohen and Zlotnick, for example, getting medication and treatment and having a sate place to stay at night.
In this study, promotion of normalcy was an identified need. Getting money to maintain human structure and functioning, keeping clean, and having clean clothes to maintain a positive self-concept were descriptive of normalcy. This was incongruent with findings by Sebastian that demands for normalcy are often unattended to by homeless elderly persons.15
According to Orem, meeting universal self-care requisites is an integral part of daily living.19 However, this tends to become separated from the fabric of human life when certain conditions exist, for example, homelessness. The findings of the current study suggest areas where nursing could be required. For example, nursing systems could be designed so that healthand situation-oriented needs are organized based on available resources, selfreports, and individual assessments. Furthermore, nursing actions could be directed toward assisting homeless elderly men attain desired states of health and development that are within their capabilities. Considering that the majority of themes included the categories of water, food, activity and rest, hazards, and normalcy, this suggests that a comparable amount of nursing action should be directed toward intervening and assisting homeless elderly men meet the requisites. However, an answer to the fundamental question of "Is self-care the proper object of nursing?" may be required initially.
Orem stated that the universal selfcare requisites are inter-related.19 Many of the participant's statements illustrate the nature of the interrelatedness of categories. For example, maintenance of sufficient intake of water and food and balancing activity and rest prevented hazards to human Ufe and functioning, and promoted conditions of normalcy.
The findings of this study lend support to the proposition that universal self-care requisites are common to all individuals regardless of age, sex, developmental level, health state, or internal and external conditions.19 Although the study is limited to a specific setting and sample, the researchers conclude the following.
* In descending order of overall themes, the categories were hazards, normalcy, food, water, activity and rest, and solitude and social interaction.
* The participant's gendei; lack of control over the environment, and survival actions could be directly related to specific themes and their order.
* A significant percentage of the themes (50% or greater) were related to the categories of water, food, activity and rest, hazards, and normalcy, which suggests the need for nursing intervention.
* A small percentage of the themes (30%) were related to solitude and social interaction, which suggests that few opportunities exist for homeless elderly persons to maintain a balance between solitude and social interaction.
* A number of the participants' statemente used to formulate themes suggested a relationship to more than one category of universal self-care requisites, which suggests that the categories are not mutually exclusive.
Implications and Recommendations
The implications of the study's findings extend across discipline and professional boundaries and involve anyone who is in the position of providing care and support to homeless elderly men. Because of the limited generalizability of the findings, only tentative nursing implications are presented.
For nursing practice, the findings underscore that homeless elderly men have self-care requisites. Furthermore, the findings expand areas of knowledge critical to understanding self-care requisites as identified by homeless elderly men. The availability of this knowledge to gerontological nurses suggests foci for professional nursing intervention to assist homeless elderly men in meeting universal self-care requisites. For example, as helping artists, nurses can contribute to the regulation of individual functioning by Unking homeless elderly men with available community resources that are appropriate to identified and mutually agreed upon needs. In addition, nurses can contribute to the self-care of homeless elderly men by aiding in overcoming limitations or disabiUties that cause them to be unable to act, to refrain from action, or to engage in ineffective actions.19 Such aid by nurses can facilitate therapeutic care demands and promote responsibility for self-care.
For nursing education, the findings suggest that nurses must be prepared to facilitate movement of the homeless elderly toward self-care. Therefore, a didactic approach coupled with clinical experiences are paramount so that students have opportunities to recognize and eUcit self-care requisites of the homeless elderly and associated actions. Students also should be helped to explore the meaning of homelessness to the elderly and others. In concert with other nurse educator actions, identification and analysis of interventions that reinforce self-care actions for meeting identified requisites should be encouraged by students and nursing peers.
More knowledge is vital to understanding the universal self-care requisites of homeless elderly men, intervention strategies that reinforce their involvement in self-care activities, and the role of gerontological nurses in the process. Also, knowledge is needed commensurate with the efficacy of interventions that reinforce the actions of homeless elderly men in self-care.
To enhance the generalizability of the findings, replication of the study in similar settings is recommended. Furthermore, additional research to identify the self-care actions associated with meeting identified self-care requisites is recommended. Additional research is needed to isolate the specific conditions that exist so that homeless elderly men may meet universal selfcare requisites.
As Duffy so cogently pointed out, using research to improve practice and to serve society's health-care needs is a mandate confronting nursing.28 Nurses clearly are in pivotal positions to engage in clinical research and translate the findings into practice so that needs of the homeless can be addressed.
- 1. Bassuk EL. The homeless problem. SdAm. 1 984; 251:4045.
- 2. Holden C. Homelessness: Experts differ on root causes. Science. 1986; 232:569-570.
- 3. Abdellah FG, Chamberlain JG, Levin IS. Role of nurses in meeting needs of the homeless: Summary of a workshop for providers, researchers, and educators. Public Health Rep. 1986; 101:494-498.
- 4. Brickner P, Filardo T, Iseman M. Medical aspects of homeless. In: Lamb HR, ed. The Homeless Mentally III. Washington, DC: American Psychiatric Association; 1984.
- 5. Burnside I. Nursing and the Aged: A SelfCare Approach, 3rd ed. New York: McGraw-Hill; 1988.
- 6. Cohen CI, Teresi J, Holmes D, Roth E. Survival strategies of older homeless men. Gerontoiogist. 1988; 28:58-65.
- 7. Doolin J. Planning for the special needs of the homeless elderly. Gerontologisi. 1986; 26:229-231.
- 8. Fischer PJ, Shapiro S, Breakey WR, Anthony C, Krammer M. Mental health and social characteristics of the homeless: A survey of mission users. Am J Public Health. 1986; 76:519-524.
- 9. Jones BE. Treating the Homeless: Urban Psychiatry's Challenge. Washington, DC: American Psychiatric Press; 1986.
- 10. Kroll J, Carey K, Hagedorn D, Fire P, Benavides E. A survey of homeless adults in urban emergency shelters. Hasp Community Psychiatry. 1986:37:283-286.
- 11. Long M. What are the health needs of the homeless? In: National Institute of Mental Health: The role of nurses in meeting the health/mental health needs of the homeless. Rockville, Md: National Institute of Mental Health. 1986; 57-61.
- 12. McMahon M. Loving the unlovabte. Journal of Emergency Nursing. 1987; 13(3):129130.
- 13. Mowbray C. Homelessness in America: Myths and realities. Am J Orthopsychiatry. 1985;55(1):4-8.
- 14. Rueler JB, Bax MJ, Sampson JH. Physician house call services for medically needy, inner-city residents. Am J Public Health. 1986;74:1097-1111.
- 15. Sebastian J. Homelessness: A state of vulnerability. Family and Community Health. 1985;8(3):11-24.
- 16. Susser E, Struening EL, Conover S. Childhood experiences of homeless men. Am J Psychiatry. 1987; 144:1599-1601.
- 17. Winick M. Nutritional and vitamin deficiency states. In: Bricker PW, Scharer LK, Conanan B, Elvy A, Savarese M, eds. Health Care of Homeless People. New York: Springer Publishing; 1985:131-150.
- 18. ZIotnick C. Pediculus corporis and the homeless. Journal of Community Health Nursing. 1987;4(1):43-48.
- 19. Orem DE. Nursing Concepts of Practice, 3rd ed. New York: McGraw-Hill; 1985.
- 20. Orem DE, ed. Concept Formulation in Nursing: Process and Product, 2nd ed. Boston: Little Brown & Co; 1979.
- 21. Miles MB, Huberman AM. Qualitative Data Analysts. Beverly Hills, Ca: Sage Publications; 1984.
- 22. Parse RR, Coyne AB, Smith MJ. Nursing Research: Qualitative Methods. Bowie, Md: Brady Communications; 1985.
- 23. Classer B, Strauss A. The Discovery of Grounded Theory: Strategies for Qualitative Research. Chicago: 1967.
- 24. Wilson HA. Limiting intrusion-social control of outsiders in a healing community. Nurs Res. 1977; 26:103-111.
- 25. Turner BA. Some practical aspects of qualitative data analysis: One way of organizing the cognitive processes associated with the generation of grounded theory. Qualitative and Quality. 1981; 15:225-247.
- 26. Waltz CH, Strickland OL, Lenz ER. Measurement in Nursing Research. Philadelphia: FA Davis; 1984.
- 27. Bassuk EL, Rubin L, Lauriat AS. Characteristics of sheltered homeless families. Am J Public Health. 1986; 76:519-524.
- 28. Duffy ME. Research in practice: The time has come. Nursing and Health Care. 1985; 6(3): 127.
NUMBER OF DESCRIPTIVE THEMES BY CATEGORY OF OREM'S UNIVERSAL SELF-CARE REQUISITES