The in-depth, open-ended formal interview is a mainstay of qualitative nursing research. The formal qualitative interview is an unstructured conversation with a purpose that usually features audiotaping and verbatim transcription of data, and use of an interview guide rather than a rigid schedule of questions (Fielding, 1994; Rose, 1994; Swanson, 1986). The interview guide consists of a set of general questions or topical outline, and is used early in the encounter to provide structure, particularly for the novice. The general rule in qualitative interviews is to refrain from imposing an agenda or framework on the respondent - instead, the objective is to follow the respondent's lead. The purpose of this format is to capture the respondents' perspectives, allowing for definition of the world or phenomenon under study in their own way and emergence of issues that the interviewer may not think of or know about (Domarad & Buschmann, 1995; Fielding, 1994).
Difficulties with collection of data through formal qualitative interviews have been reported with institutionalized elderly individuals (Bray, Powell, Lovelock, & Philp, 1995; MacPherson, Hunter, & McKeganey, 1988; West, Bondy, & Hutchinson, 1991). The physical status of the older person, including poor hearing, impaired vision, pain, fatigue, or urinary urgency, can challenge both respondent and interviewer. Cognitive problems, such as disorientation or poor memory, also make interviewing difficult, if not impossible. Poverty of facial expression and body language, relatively common among institutionalized elderly individuals, can make nonverbal cues difficult to pick up. In addition, responses from this population can be insufficient, unclear, or emotionally extreme. Artificial responses caused by a desire to be socially acceptable are also common. Finally, older adults who reside in institutions often fear that speaking up will jeopardize their care or personal welfare.
Interviewing difficulties arising from extensive physical and cognitive frailty are often impossible to overcome. However, meaningful responses can be elicited from institutionalized elderly individuals who are willing and able to be interviewed. Experienced investigators suggest that efforts to steer conversation, tune in to stories, provide a frame of reference for recall, convey empathy, and socialize with the respondent will enhance the richness of data obtained from older adults (MacPherson et al., 1988; West et al., 1991). These approaches were used during the formal interview phase of a qualitative study of urinary incontinence (UI) among nursing home residents (Robinson, 2000). As data collection and analysis proceeded, it became apparent that six distinct and sequential phases of the formal interview occurred with every resident. Described in this article are phases of the research interview discovered in this study and recommendations to facilitate the conduct of qualitative research interviews with institutionalized older adults.
SAMPLE AND METHOD
The study was conducted during a 17month period in three nursing homes located in the metropolitan area of a major East Coast city. Approval was obtained from the administrator of each facility following institutional review board procedures at a major university. To qualify for a formal interview, residents were required to be 65 years of age or older, cognitively intact, and English speaking. In addition, those interviewed were required to acknowledge either actual or potential UI and provide written or audiotaped informed consent.
Six women and four men, ranging in age from 69 to 93 years, provided formal interviews. Most were White, widowed, and confined to a wheelchair. Formal education ranged from 7 to 1 8 years - half did not complete high school. Length of stay ranged from 10 days to 8 years.
Interviews occurred by appointment at times and in places convenient and comfort - able for the resident. Most were conducted in the resident's room during afternoon hours. Interviews ranged from 30 to 90 minutes in duration, with the majority lasting approximately 1 hour. The data collection plan stipulated use of an interview guide and a funnel approach to interviewing (Swanson, 1986), with questions and prompts in each category that proceeded from the general to the particular and personal. For example, the interview guide called for an initial question about concerns that most nursing home residents have about bladder control, followed by a question about the importance of those concerns to the respondent, and finally questions about specific concerns of the respondent regarding their own bladder control status. However, this approach was abandoned after two interviews when it became apparent that respondents quickly, naturally, and decisively assumed control of the agenda, and data gleaned in this manner were far more comprehensive and rich than data obtained by adhering to the interview guide. Thus, for the remaining eight interviews, the investigator (JPR) provided an introduction of herself and the study, and then followed the respondent's lead.
Data regarding the research interview were found in verbatim transcriptions of formal interviews, field notes pertaining to these interviews, and procedural and theoretical memos of the investigator. Content analysis of this data set revealed six distinct and sequential phases of the research interview:
Each phase of the interview is described, illustrated, and discussed in further detail.
Introducing and Personalizing
Formal interviews typically began with brief introductory remarks by the investigator about herself and the study (introducing phase). The investigator always provided information about her professional background, what the study was about, and unless interrupted by the respondent, why the study was important. Without prompting, respondents then offered comments that placed the research question in a personal context (personalizing phase). Most launched immediately into a description of their own continence status and individual efforts to prevent or manage leakage. The transition from introducing to personalizing is particularly apparent in the following dialogue between the investigator QPR) and Mrs. H, age 77, who had right hemiplegia following a cerebrovascular accident and had been a resident for 9 months:
JPR: What I'm interested in is the kinds of things that nursing home residents do for bladder control, and why they do what they do, and how they do what they do.
Mrs. H: Well, I can just tell you, since I can't walk at night, they put a diaper on me, and then they change me three times a night.
JPR: And how did that come about?
Mrs. H: I have to do it [that way] here because it takes too much time to put my brace on. To help me, it takes about a half-hour to do it. So... but during the day I go myself.
Another example of the spontaneity and speed of transition from introducing to personalizing is illustrated in opening dialogue with Mrs. O, age 84, whose right leg was amputated below the knee and who had been a resident for 1 month following hospitalization for dehydration, depression, and renal insufficiency:
JPR: People come into the nursing home with different types of [problems]. Some have bladder control problems; some don't have a problem, but they have to do back flips in order not to have one [because] it's really hard for them to control their urine. So I'm interested in...
Figure. Phases of the qualitative research interview.
Mrs. O: Well, I can't control mine.
JPR: You can't control yours?
Mrs. O: I dribbles [sic]... And when I go, I have to go right then.... When it comes down, I have to go right then or else I'll wet myself.
Thus, interviews progressed from the introducing phase to the personalizing phase quickly and spontaneously, usually yielding an overview of objective features of the problem (i.e., UI signs, symptoms, management strategies). Probing by the investigator for greater clarity, specificity, or additional information from the respondent generally triggered transition to the reminiscing and contextualizing phases of the interview.
Reminiscing and Contextualizing
During the reminiscing phase, respondents engaged in selected life review. Focusing on critical life episodes, respondents shared vivid descriptions and stories about challenges such as growing up in poverty, coming to America, raising a family, coping with life-threatening health problems, retiring, caring for chronically ill or dying family members, becoming disabled, and living in a nursing home. Ultimately, each respondent articulated a philosophy of life linked to acquired wisdom, longstanding values, life experience, and endured hardships. Reminiscing is evident in the following passage between the investigator and Miss N, age 82, a resident for more than 3 years following amputation of her left leg. Miss N speaks initially about efforts to become independent in toileting (personalizing), and then reminisces about her lifelong independence and assumption of caregiving roles:
Miss N: I was getting therapy.... Then they stopped it. And I don't know why. I have to get more strength. My strength I need. I wheel this chair around myself. Some of them ask, "Push me to my room. Push me here." I do everything for myself.
JPR: I noticed that.
Miss N: You know... some people come into a place like this and they think they're paying for it and they should get waited on hand and foot. I don't think that because I took care of my mother.
JPR: Uh huh.
Miss N: And my older sister was a nurse. My mother would rather have me!
JPR: Uh huh.
Miss N: So, that's all about her... you know. I'll tell you another thing that'll make you laugh (laughs). I was a midwife to a dog.
JPR: You were a midwife to a dog?
Miss N: My mother was sick and the dog was going to have pups and it was only a stray dog that followed my brother in a cab, behind a cab in South Philly. And the dog followed the cab. And [my brother] said to the cab driver, he said, "Stop and let that poor little thing in." So the dog came in and they took him home. And it was having pups. Somebody put her out.... And it was a nice dog and we had just had a dog, a fox terrier (begins to cry); [it] died. We had it put away 'cause it was old. So anyhow, here the next thing the dog was going crazy... going to have pups.
Miss N then told the story of how she delivered the pups independently. More stories followed about independence, caregiving, and risk-taking, including deciding not to marry, wanting to be a nurse, coming to America, being robbed, traveling extensively, caring for her terminally ill mother and brothers, having her leg amputated, declining treatment for a lump in her breast, and entering a nursing home.
With, and sometimes without, gentle probing by the investigator, the interview then progressed to the contextualizing phase. During this phase, respondents discussed their UI problem in greater detail within the context of information presented in the reminiscing phase. For example, Miss N, who reminisced about being a midwife to a dog, caring for multiple family members, taking risks throughout life, and prizing her independence, eventually spoke about the impact of UI on her life in the following way:
Miss N: Well, I've got a diaper on.... Just like a baby. It's awful.... It's very embarrassing having two people to lift you and sitting you [on the commode]. One time I was sitting [on] the commode and the doctor came in. You felt like a nickel, you know, it's awful... sitting there on the toilet. Some people don't care, but I'm... I don't like it.
Probing for greater clarity or depth of information than was presented during the personalizing phase usually triggered the reminiscing and contextualizing phases of the interview. In addition, reminiscing and contextualizing were cyclic in the way respondents moved back and forth between the two until closure began. Reminiscing and contextualizing produced the meat of the interview, which, in this study, consisted of the respondent's unique experience with UI and its personal meaning and impact.
Transition to the final two phases of the interview was precipitated by the investigator, respondent, or environmental factors. When conversation became redundant or when the respondent appeared tired or uncomfortable, closure was initiated by the investigator. Alternately, respondents initiated closure by expressing a desire to stop talking or attend an activity. Environmental factors, such as turning over the tape, dropping the tape recorder, or staff interruptions for care, prompted closure when the induced distraction was impossible to overcome.
Closing and Reciprocating
During the closing phase of the interview, respondents were asked to validate demographic information retrieved from their health care record and to permit return visits by the investigator for participant observation and informal interviews. Closure also furnished a natural opportunity for the investigator to summarize the respondent's identified strengths and philosophy of life, affirm the respondent's wisdom and contribution to the study, and answer questions or address needs of the respondent. Most respondents took advantage of the latter offer, which triggered the reciprocating phase. During this phase, the investigator was typically asked to provide information or services to the respondent (e.g., listen to additional stories about respondents' past and present lives, perform errands, escort respondents to meals or activities, answer general questions about health concerns, admire art and needle work, view photographs, read cards, answer personal questions, provided comfort measures such as positioning, setting up for bed, and emptying urinals).
CONCLUSIONS AND RECOMMENDATIONS
The Figure depicts the process by which the qualitative research interview typically unfolded with this sample of institutionalized older adults. Although a few respondents did progress through each phase in a linear pattern, most proceeded as depicted in the Figure. In addition to the cyclic patterns observed between reminiscing and contextualizing, and be-tween closing and reciprocating, most respondents also revisited reminiscing during the final phases of the interview. For example, Reverend R, a 76-year old short-stay resident of 10 days, was recovering from emergency surgery and had also recently experienced mandatory retirement from the priesthood. As a means of reciprocating, the investigator listened as he reminisced about previous role transitions, good times with members of his nuclear family, and achievements during a long, gratifying career.
Although findings reported in this article were derived from a very small sample, the importance of reminiscence as a research tool with institutionalized elderly individuals cannot be overlooked. Reminiscing is necessary and valuable for individuals of this age group, and for those wishing to understand their point of view. Life review and integration of past events with current situations are universal concerns and developmental tasks of older adults. Thus, one question in an interview may lead to a long chain of thoughts, which often cannot and should not be broken. Allowing for reminiscence will usually pay off in terms of gaining better understanding of respondents, their value systems, and data that are reported (Mezey, Rauckhorst, & Stokes, 1993; Newbern, 1992).
Successful accounts of interviewing institutionalized older adults are scarce in the literature. Further study of the process of interviewing members of this group is recommended for three important reasons. First, input from nursing home residents is often sought to define and evaluate quality of care and quality of life in nursing homes. Thus, an effective method for accessing these data is needed. Second, nursing home residents are generally willing to participate in research (Williams, 1993). Addi-tionally, a variety of therapeutic benefits are associated with participation in research interviews, including (Bray et al., 1995; Hutchinson, Wilson, & Wilson, 1994; McHaffie, 1988; Morse, 1991):
* Catharsis and healing.
* Intellectual stimulation.
An empirically derived framework to guide the qualitative interview process with institutionalized elderly individuals would facilitate research with this population as well as allow more members of this group to reap these benefits. Third, findings from qualitative research interviews with institutionalized older adults have the potential to inform nursing staff and other health care providers about life in an institution from the residents' perspectives. Staff who understand, appreciate, and respect these perspectives are in a better position to collaborate with residents to design and deliver care that is individualized rather than driven by institutional routines.
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