The role of older patients in acute care settings has not been explored from the perspective of the patient. A review of the literature revealed research focused on nurses' practice, patients' satisfaction with care, and services used by patients. There was little available information on what patients do to affect the outcome of their hospitalization.
In the grounded theory research presented in this article, the meaning of acute hospitalization was explored for older adults and the activities they engaged in to affect those meanings. The goal of the research was to develop a theory that explained how the behavior of hospitalized older adults affected their hospitalization. Analysis of the data revealed autonomy was a central feature of being in the hospital, especially as discharge approached (Jacelon, 200 1 , 2004). For this study, autonomy was described as having two components: independence (the physical ability to engage in activities) and control (the ability to make decisions on one's own behalf). This article describes the research process and the findings in relation to the autonomy of older adults who are hospitalized in an acute care setting.
The Committee on Protection of Human Subjects at both the university and the hospital approved the research design. All participants were informed of the aims of the study and voluntarily agreed to participate.
Five older adults (two men and three women) ranging in age from 77 to 85 years composed the convenience sample for this grounded theory research study (Hutchinson, 1993; Strauss & Corbin, 1998). Inclusion criteria were:
* Being age 75 or older.
* Living independently in the community prior to hospital admission.
* Being admitted for medical, not surgical reasons.
* Being English-speaking.
The opportunity to participate in the study was presented to individuals by the hospital admitting clerk during admission. Participants who expressed interest were then approached and informed consent was obtained.
All of the participants were White. One of the men was married and one was recently widowed, while two of the women were widowed and one was divorced. All of the women lived alone, and the man who was recendy widowed lived with a daughter.
Three of the participants were admitted to the hospital with a medical diagnosis of chest pain, one with pneumonia, and one with deep vein thrombosis. For all of the participants, hospitalization was directly related to an underlying chronic health problem.
In-depth interviews were conducted with each participant on admission, at discharge, and within 2 to 4 weeks after discharge. Interviews also were conducted with a family member of each participant and with a registered nurse who had provided care for each participant. All of the interviews focused on the meaning that the older adult attributed to being in the hospital.
In addition to the interviews, participants also were observed by the researcher for at least 2 hours per day during their hospital stay. The length of stay for participants ranged from 2 to 25 nights. The average length of stay for the participants in the study matched the national average of 7 nights (Graves & Kozak, 1999).
In qualitative research, researchers often use small samples that emphasize the depth rather than the breadth of an experience (Mariano, 1995; Patton, 1990). Participants are purposively recruited until data saturation occurs, which is when all new information can fit into the categories developed through data analysis. For this study, saturation occurred after the fourth participant, and data from the fifth participant were used to ensure the saturation.
The database for this research contains transcripts of a total of 25 interviews (5 admission, 5 discharge, 5 follow up, 4 family members, and 6 nurses), approximately 40 participant observation logs, 5 medical record transcriptions, and numerous reflective and methodological logs regarding the process of data collection. In addition, there is an extensive collection of dated memos on development of the theory.
The constant comparative method was used for data analysis. In this method, each new piece of data is compared with all previous data, and similar items are labeled with codes. The codes or groups of data are then grouped by themes that are eventually connected to the central idea.
During theory development, statements were developed to explain the relationships among the themes. Prolonged engagement, member checks, the researcher's reflective journal on the process and findings, peer debriefing, and an audit of the process by an expert researcher enhanced trustworthiness.
The purpose of grounded theory research is to develop substantive theory grounded in the experience of the participants. Such theory is designed to have predictive power within a specified context (Strauss & Corbin, 1998). The merit of such a theory is "to speak specifically for the populations from which it was derived" (Strauss & Corbin, 1998, p. 267). The findings presented in this article explain the development of the concept of autonomy for this study.
Managing Personal Integrity
The theory developed from the research is entitled Managing Personal Integrity (Jacelon, 2001, 2004). Personal integrity is a dynamic, intrinsic quality of the self with the properties of health, dignity, and autonomy. Managing personal integrity is a dynamic process in which older adults use certain strategies to enhance their personal integrity.
Each property was the focus of the behavior of the older adults in one of three phases during their hospitalization. During the stabilizing phase, which occurs early in the hospitalization, the older adults focused primarily on their health. During the repairing or second phase, they focused on dignity. In the reintegrating phase prior to discharge, older adults were most concerned with regaining autonomy.
The Concept of Autonomy
Autonomy is the freedom and ability of older adults to act on their own behalf. It consists of independence (the physical ability to act) and control (self-perceived power). In the hospital, autonomy was diminished by acute illness, by consenting to treatment, by decisions made by health care workers (based on their expertise and the urgency of the health crisis), and by decontextualization in the alien and inflexible hospital environment. There was little flexibility in the hospital schedule for individuality.
Independence as an attribute of autonomy. Early in their hospitalization, the independence of the participants was severely limited. Most required assistance to meet their basic hygiene needs, and several were too ill to get out of bed. Prior to admission, all had lived independently in the community. Regaining their independence was of paramount importance. The daughter of one of the participants explained how important independence was to her mother:
Being able to resume independence [is her biggest concern]. ..I can just tell in her manner that she wants to be very independent. Coming into the hospital has been pretty scary for her in terms of this independence issue.
In addition to their health problems, the hospital schedule and routine restricted the older adults' independence. One of the participants commented that she did not "like to be confined." Her nurse noted that this participant was "very independent" and "willing to let someone else take control for the present," but expected the participant was "going to go and get right back to what she was doing previously" after being discharged.
Another nurse expressed a similar point of view regarding another participant:
...here in the hospital, she has lost some of her independence. Maybe at home she would have to deal more - here she doesn't have to. She can just pass it right on to us and...we take care of it.
The staff's expectations for older adults' independence were often lower than that of the older adults. One nurse considered one of the participants, an 85-year-old woman, to be independent if she could feed herself. The nurse noted that older adults with very limited self-care skills were the norm on her unit, and her standard called for considerably less independence than the participants had while living at home or than they expected to have in the hospital.
In reflecting on the meaning of dependence for older adults, one nurse remarked:
It must be awful to lose your independence, to all of a sudden be dependent, and even to want to be dependent, be afraid that you will never get it [independence] back. I can't imagine ever being dependent on someone like that.
Figure. The attributes of autonomy are positively related, with improvement in one attribute positively affecting the other attribute.
Hospitalization threatened the older adults' independence and ability to return home.
Control as an attrìhute of autonomy. Control is a mental process. Most individuals feel in control when they can exert their will over a given situation. One nurse explained her ideas about the importance of control to older adults:
They need to feel like they still do have some control. When they know what's going on, it helps them feel a little bit better, mentally if not physically.
The hospital's routine was alien to the older adults. The older adults' ability to control their activities was curtailed by their health status and by the structure of the hospital. One participant explained what being in the hospital was like for her:
I can't even explain what I mean...It just seemed like they [staff] took away everything. It was just like you were at everybody's mercy, and you didn't count... When I was good and sick, it didn't matter, I guess. Their word was law.
Diminished control was evident in the older adults' inability to schedule their activities while in the hospital. One participant expressed her lack of control over her schedule, saying "Everything had to be done on schedule - their schedule, not mine." One of the nurses agreed, noting that:
In the hospital, one of the major problems is that all of their routine is taken away from them. We tell them when to take their medications, when to go to the bathroom - they even have to ask for a drink.
Participants' schedules were not only beyond their control, but also unpredictable. One participant explained:
You go into the bathroom to wash up because something was going to happen in an hour and a half. No sooner do you get in there, and bang, they were there to take you. They say, "You're going to do that at 11 o'clock." Well, then they come and say, "I can take you in at 9 o'clock." Whenever they were ready, you had to be ready.
Older adults were scheduled for procedures without being informed. For example, while one participant was waiting for discharge, an aide came into the room with a wheelchair and said, "I'm ready to take you downstairs for your test." The participant replied, "I'm not going for any test. I'm being discharged." The older adult experienced a loss of control because his morning had been reorganized without his knowledge.
Poor or absent information led participants to feel they had no control over their situation or their health. In addition to an inability to control their schedule in the hospital, some had difficulty obtaining accurate and timely information about their condition. One participant noted:
I was angry that they didn't come and tell me what was happening with each test. Finally, my primary physician came in and told me. Up to that point I was worried because they didn't tell me. I thought that maybe something really bad was wrong with me. I didn't know what was going on.
Relationships between independence and control. Control and independence were in a positive mutual relationship (Figure). An increase in participants' ability to complete functional activities had the effect of improving their control. A decline in physical ability required an increase in the amount of assistance needed, thereby reducing the ability to control a situation. An increase in the amount of control older adults had over their situation did not necessarily improve their physical ability, but it did allow greater freedom in problem solving about functional activities. Situations that enhanced one attribute of autonomy helped make deficits in the other attribute easier for elderly individuals to endure.
Autonomy and the Process of Hospitalization
The process of managing personal integrity included a pre-hospital stage, three phases in the hospital, and a post-hospital stage (Jacelon, 2004). Although autonomy was important in each stage, it became participants' central focus during their last phase in the hospital.
Autonomy and the pre-hospital stage of managing personal integrity. All of the older adults who participated in this research had lived autonomously in the community prior to being hospitalized. To support their various levels of autonomy, all participants had support either from their families or the health care system. One of the women had help from a visiting nurse, one of the men collaborated with his wife in making decisions, and one man lived with his daughter who made many health decisions with him; the remaining two women lived alone but were in regular contact with their children.
Each of the older adults who participated in the study made the decision to come to the hospital for health care, usually with the help of a family member. On entering into the health care system, the older adults willingly suspended their autonomy by relying on the health care providers for treatment.
Autonomy and managing personal integrity in the hospital. During the hospitalization stage, participants went through three phases: stabilizing, repairing, and reintegrating.
* Autonomy during the stabilizing phase. During the initial or stabilizing phase of hospitalization, older adults were physically dependent for at least some of their needs and were willing to give up control for the security of being in "the best place to be." The older adults were often too ill to want or be able to exert much independence. Moreover, the hospital routine placed restrictions on the older adults.
One of the nurses described the restrictions placed on the elderly individuals in the hospital:
One of the major problems that they have is that all of their routine that they're used to doing is taken away from them. We're telling them when they can go to the bathroom...A lot of them are used to taking their medications on their own schedule at home and we're telling them, "No, you have to take your medicines on an every 12-hour basis." I think it's frightening, I think it's frustrating, I think every patient does [feel this] on some level. I think it's more overwhelming for some, but I think on some level they all do.
The strategy used by the older adults in relation to autonomy during the stabilizing phase was to rely on the authority of the health care workers. During this phase, the loss of autonomy was outweighed by the anticipated improvement in their health.
* Autonomy during the repairing phase. During this second phase of hospitalization, the older adults' independence began to improve. Although activities of daily living may have taken longer than usual, been modified in some way, or still required some assistance, the participants were able to accomplish more by themselves. As their independence increased, the older adults tried to "do it my own way." During this repairing phase, one participant's independence had improved enough so that she could walk into the bathroom and tend to her own needs, and then organize and straighten her half of the room.
Worrying, the predominant strategy for improving control during this phase of hospitalization, had both positive and negative effects. Worry served the positive purpose of "doing something" when participants could not take actions to enhance their control. A negative effect of worry was to disturb sleep patterns.
One participant's concern about his health problems exemplifies the lack of control the older adults felt over their situation:
So that's what I worry about most. It's how long I'll livc.Can't they do something to give me a couple of years without any health problem?
The longer this participant waited for information, the more he tried to gain control by worrying:
In the hospital, you worry more about your illness, and then you worry about being in the hospital. The worry just increased until they found out what the problem was.
During the reparative phase, participants began to feel well enough to increase their autonomy by reasserting their control over their lives. They insisted on more participation in decision-making and in the plan of care. They questioned the nurses about which medications they were given and made decisions about which medications they took.
For example, one of the participants routinely examined each of her medications when they were brought to her and questioned the nurse about any medications she thought were missing:
I know everything that I am taking. I never take anything unless Fm sure it's the right stuff. I always ask [the nurse] what needs to be taken or if there is something missing or if something doesn't look right to me.
Independence also began to improve during this phase. Participants no longer had to rely on the staff for assistance to meet most of their basic hygiene needs. Personal care still might take longer than usual or might require modification, but the need for assistance had diminished. The repairing phase of managing personal integrity came to a close when discharge from the hospital was scheduled.
* Autonomy during the reintegrating phase. This phase of hospitalization marked the time when the older adults began to reassert their autonomy. The health crisis that brought them to the hospital was resolving, and they gained more control over their situation. This did not mean the underlying cause of the health crisis had been resolved, but the exacerbation that precipitated hospitalization was resolving. During this phase, the older adults participated in planning for discharge and prepared to resume independent functioning at home.
Participants continued to worry while taking more responsibility for self-care and decision-making, although the focus of worrying changed from the current situation to what would happen on return home. One participant commented:
I wonder how I'm going to be when I get home - how I'm going to do everything, like cook my meals and clean my house and all that stuff.
Independence continued to improve. The older adults took more responsibility for both their activities of daily living and their health. One participant spoke about resuming management of her medications:
[The doctor] had my medications all written out yesterday when she came in. Then she went over them with me, the nurse went over them with me again, so I know what to do when I get home.
The strategies participants used to increase their independence and feelings of control while they were in the hospital included worrying, maintaining health, taking action, and taking responsibility.
Autonomy and post-hospital stages of managing personal integrity. All of the participants were able to return to their previous living situations. Initially on returning home, two participants required increased support from their families and the health care system. By 4 weeks after discharge, four of the five older adults had returned to their previous levels of function. The participant with the longest length of stay continued to require more support than she had prior to her hospitalization, but she continued to Uve independently in her own apartment.
At home, the older adults were responsible for their health. They acted to ensure their supplies and medications were available and then implemented the health care plan that they had been taught while hospitalized. Their autonomy increased as their health continued to improve.
The Meaning of Altered Autonomy During Hospitalization
The older adults perceived being in the hospital as representing a loss of autonomy and worried that hospitalization might herald a change in their ability to be autonomous on returning home. One participant was very articulate about the threat that hospitalization represented to her autonomy:
Anything that is a threat to my independence is very scary. Being in the hospital is somewhat of a relief, but it has also raised many issues about my ability to take care of myself.
One nurse explained the effect that hospitalization had on one participant s autonomy:
For some elderly patients, it is very difficult for them to come in here. They lose their independence. We do things terribly differently than they're used to doing for years and years at home.
One participant summarized the significance of being in the hospital with respect to autonomy:
I saw the difference in a woman who lived in my apartment house between when she was 84 and 85 years old. I thought, geez, I wonder if when I turn 85, I'll be like that too? Well, I didn't change, but now, since I've been in the hospital, I can see a difference in myself. Now I feel weak and old, and I don't feel in control.
These older adults were worried that being in the hospital would permanently diminish their autonomy. In most cases, the threat to autonomy was temporary; as the older adults recovered and were discharged, their autonomy increased.
After developing a grounded theory, the researcher compares the theory to the existing literature. Independence in terms of functional ability has often been used as a variable in studies of hospitalized older adults (Hirsch, Sommer, Olsen, Mullen, & Winograd, 1990; Jarren, Rockwood, Carver, Stolee, & Cosway, 1995; Rudberg, Sager, & Zhang, 1996; Sager, Franke et al., 1996; Sager, Rudberg et al., 1996), but control has rarely been used.
Autonomy, as defined in the current research, has both physical and psychological attributes and is conceptualized as elderly individuals' freedom and ability to act on their own behalf. Autonomy has two attributes: independence, or the individual's ability to act in a given situation, and control, or the individual's power in a given situation. This definition of autonomy is similar, but not identical to that found in the literature.
Ramsay (1997) identified autonomy as "necessary" for an individual to have integrity and defined autonomy as "the capacity to reflect, deliberate, judge, and form self-constituting choices" (p. 88). Ramsay's definition of autonomy included ideas similar to the attribute of control in the current study. For individuals to feel powerful in a given situation, they must be able to reflect on the situation and make choices on their own behalf. Autonomy, as derived in the current research, also included the physical ability to act on the choices that were made. Physical ability was beyond the scope of Ramsay's definition.
The definition of autonomy proposed in this article is more in keeping with the definitions proposed by Hertz (1996) and Collopy (1988), who defined autonomy as control over behaviors, decisions, and courses of action. Although these definitions suggest a physical component to autonomy, the definition arising from this research clearly identifies both cognitive and physical attributes.
While some research suggests staff actions to increase the reciprocity in relationships between staff and elderly patients increased patients' feelings of control, the current study found increased participation in decisionmaking and increased information had a positive effect on older adults' control. In a study of participatory control in long-term care settings, Stirling and Reid (1992) found older adults' feelings of control increased through reciprocal interactions with their environment. They based their work on the cognitive social learning theory of control, which
emphasizes that the sense of personal control is optimized when the people feel they have a clear grasp of how much...they can influence their situation, (p. 206)
The researchers proposed nurses would feel more effective and patients would be more adjusted with increased feelings of control when the nurses acted to enhance patients' feelings of control. Using a quasi-experimental design, the researchers used education to change the attitudes of nurses in the intervention group, and these changes had a positive effect on patients' feelings of control. Stirling and Reid (1992), like much of the literature regarding hospitalized older adults, investigated the behavior of the staff.
Changes occurring during the process of older adults managing their autonomy over the course of hospitalization are supported by recent findings in a study exploring autonomy in individuals with stroke. In a grounded theory study of the autonomy of individuals who had strokes, autonomy was found to change over the course of rehabilitation (Proot, Abu-Saad, Esch-Janssen, Crebolder, & Meulen, 2000). The current study examines older adults' role while in acute care; nonetheless, participants in both studies used similar strategies with respect to taking responsibility for their care. The participants in this study were much older (mean age, 82 years) than participants in the Proot et al. (2000) study (mean age, 72.5 years).
Although many studies have been conducted using functional ability as a variable in relation to hospitalization, only a few studies address the older adults' control over their situation. The current study is unique in that the theory proposes control and functional ability are integrally related within the concept of autonomy. Further research is needed to explore the relationship between control and functional ability.
IMPLICATIONS FOR NURSING
The hospital in which this study was conducted has no identified geriatric care program and is in a rural, middleclass area of New England with few minority patients or staff. In addition, all participants in this study were cognitively intact. The validity of transferring this theory to ottier contexts and other patient populations therefore is dependent on the similarity of the new context to the one described in this article. Lincoln and Guba (1985) suggest a period of testing the theory in another setting prior to application.
In this research, hospitalization posed a significant threat to the autonomy of older adults. During the prehospital stage, older adults made autonomous decisions to seek health care. During the hospitalization stage, older adults willingly gave up control to improve their health and were often dependent related to their illness. Particularly during the stabilizing phase, the older adults were often too ill and weak to engage in independent self-care. As hospitalization progressed toward discharge, they began to engage in increased independence and control. This process continued during the reintegrating phase of hospitalization when increasing autonomy was important in preparing for discharge. After discharge, the older adults' autonomy continued to increase.
One area of nursing practice that was found to be a problem for older adults was the disparity between their expectations and the expectations of the nurses in relation to the older adults' independence. Several researchers (Congdon, 1994; Cremin, 1992; McCauley, Lowery, & Jacobsen, 1992; Reiley et al., 1996) have illustrated this gap between nurses' and patients' expectations of themselves. Activities for staff that educate and reinforce the importance of promoting independence may help older adults survive the hospitalization with fewer deficits and less difficulty adjusting to the return home.
The results of this research suggest redesigning acute health care settings in which hospitalized older adults have more control would enhance their autonomy and might reduce the need for post-discharge services. Implementing some long-standing traditions of rehabilitation in acute care settings could enhance control for older adults. For example, improved patient participation in scheduling might increase their sense of control. Nurses could facilitate this process by meeting with hospitalized older adults regularly to assist them in organizing their schedule and provide information about the plan of care. A predictable schedule would allow older adults to set aside periods where they could rest or receive visitors. In addition, such meetings would provide a regular opportunity for nurses to explain any changes in their plan of care.
Another possibility for enhancing older adults' autonomy is described by Hertz (1996) in her description of health and nursing. In this model, nurses working with older adults strive to build trust; enhance patient control; promote cognitive orientation to person, place, and time; affirm and promote patient strengths; and mutually set health goals. This type of nursing practice would encourage patients to act as a partner in the process of improving health rather than as a recipient of health care.
The failure to receive adequate information in a timely manner was identified as a problem by the hospitalized older adults in this study. One of the issues raised was who should be authorized to discuss patients' cases with them. Nurses are ideal candidates to provide information and can schedule regular times to meet with older adults to discuss their case. On some occasions, meetings may be held in conjunction with physicians or other members of the health care team. In this way, nurses would have comprehensive information about patients' cases and could explain and reinforce information given by others as well as provide education. Rehabilitation units provide evidence that such a system can work.
Finally, providing a less restrictive environment could enhance independence. Units such as the Acute Care for the Elderly (ACE) units create environments that encourage independence and control while decreasing decontextualization for older adults (Palmer, Landefeld, Kresevic, & Kowal, 1994). Perhaps general hospitals could begin to consider creating such environments.
Conceptualizing autonomy as a combination of independence and control provides a new way for health care workers and older adults to think about the needs of hospitalized older individuals. Although promoting independence is well ingrained in gerontological nurses, developing strategies to assist hospitalized older adults improve their control over their situation is a challenge for all health care providers. This research helps illustrate the experience and actions of older adults during hospitalization. While the usual portrayal of hospitalized older adults is as care recipients, this research portrays older adults as engaged in a dynamic process to enhance their autonomy.
- Collopy, BJ. (1988). Autonomy in long term care: Some crucial definitions. The Gerontologist, 2í(Suppl. 3), 10-17.
- Congdon, J.G. (1994). Managing the incongruities: The hospital discharge experience for elderly patients, their families, and nurses. Applied Nursing Research, 7(3), 125-131.
- Cremin, M.C. (1992). Feeling old versus being old: Views of troubled aging. Social Science and Mediane, 34(\2), 1305-1315.
- Graves, E.J., & Kozak, LJ. (1999). National Hospital Discharge Survey: Annual summary, 1996. Vital and Health Statistics, Data From the National Health Survey, /J(HO), 1-46.
- Hertz, J.E. (1996). Conceptualization of perceived enactment of autonomy in the elderly. Issues in Mental Health Nursing, 17,261-273.
- Hirsch, C.H., Sommer, L., Olsen, ?., Mullen, L., & Winograd, CH. (1990). The natural history of functional morbidity in hospitalized older patients. Journal of the American Geriatrics Society, 38(12), 1296-1303.
- Hutchinson, S.A. (1993). Grounded theory: The method. In P.L. Munhall & CO. Boyd (Eds.), Nursing research: A qualitative perspective (pp. 180-212). New York: National League for Nursing.
- Jacelon, CS. (2001). Managing personal integrity: A grounded theory of elderly people surviving hospitalization. Unpublished doctoral dissertation, New York University, New York.
- Jacelon, CS. (2004). Managing personal integrity: The process of hospitalization for elders. Journal of Advanced Nursing, 46(5), 549557.
- Jacelon, CS. (2001b). Managing personal integrity: A grounded theory of elderly people surviving hospitalization. Unpublished doctoral dissertation, New York University, New York.
- Jarrett, P.G., Rockwood, K., Carver, D., Stolee, R, & Cosway, S. (1995). Illness presentation in elderly patients. Archives of Internal Medicine, /55(10), 1060-1064.
- Lincoln, Y.S., & Guba, E.G. (1985). Naturalistic inquiry. Beverly Hills, CA: Sage.
- Mariano, C (1995). The qualitative research process. In L.A. Talbot (Ed.), Principles and practice of nursing research (pp. 463-491 ). St. Louis, MO: Mosby.
- McCauley, K.M., Lowery, B.J., & Jacobsen, B.S. (1992). A comparison of patient/nurse perceptions about current and future recovery status. Clinical Nurse Specialist, 6(3), 148-152.
- Palmer, R.M., Landefeld, CS., Kresevk, D., & Kowal, J. (1994). A medical unit for the acute care of the elderly. Journal of the American Geriatrics Society, 42, 545-552.
- Patton, M.Q. (1990). Qualitative evaluation and research methods (2nd ed.). Newbury Park, CA: Sage.
- Proot, I.M., Abu-Saad, H.H., Esch-Janssen, W.P.D., Crebolder, H.F., & Meulen, R.H.T. (2000). Patient autonomy during rehabilitation: The experiences of stroke patients in nursing homes. International Journal of Nursing Studies, 37(3), 267-276.
- Ramsay, H. (1997). Beyond virtue, integrity and moraUty. New York: St. Martin's Press.
- Reiley, P., lezzoni, L.L, Phillips, R., Davis, R.B., Tuchin, L.I., & Calkins, D. (19%). Discharge planning: Comparison of patients' and nurses' perceptions of patients following hospital discharge. Image, 28(2), 143-147.
- Rudberg, M. A., Sager, M. A., & Zhang, J. (1996). Risk factors for nursing home use after hospitalization for medical illness. Journal of Gerontology, 51A(5), Ml 89- Ml 94.
- Sager, M.A., Franke, T., Inouye, S.K., Landefeld, CS., Morgan, T.M., Rudberg, M.A., Siebens, H., & Winograd, CH. (19%). Functional outcomes of acute medical illness and hospitalization in older persons. Archives of Internal Medicine, 156(6), 645-652.
- Sager, M.A., Rudberg, M.A., Jalaluddin, M., Franke, T., Inouye, S.K., Landefeld, S., Siebens, H., & Winograd, CH. (1996). Hospital admission risk profile (HARP): Identifying older patients at risk for functional decline following acute medical illness and hospitalization. Journal of the American Geriatria Society, 44(3), 251-257.
- Stirling, G., & Reid, D.W. (1992). The application of participatory control to facilitate patient well-being: An experimental study of nursing impact on geriatric patients. Canadian Journal of Behavioural Science, 24(2), 204-219.
- Strauss, A., & Corbin, J. (1998). Basics of qualitative research: Techniques and procedures for developing grounded theory (2nd ed.). Thousand Oaks, CA: Sage.