Research in Gerontological Nursing

Empirical Research 

Incidents When Older Homebound Women Tried to Reach Help Quickly

Eileen J. Porter, PhD, RN, FGSA; Melinda Stafford Markham, PhD, CFLE; Lawrence H. Ganong, PhD

Abstract

During a longitudinal study of the experience of reaching help quickly, 34 homebound women (ages 85 to 97) who lived alone reported 106 reach-help-quickly incidents (RHQIs). The purpose of this study was to expand knowledge about RHQIs and intentions relative to them and to compare those facets of experience for subscribers to a personal emergency response system (PERS) and non-subscribers. We used a descriptive phenomenological method to analyze interview data, discerning six types of RHQIs, including finding myself down right here, realizing that I might not be alright after falling and getting up on my own, and realizing that something I cannot explain is or could be wrong with me. Intentions were focused on self-help before help seeking. The overall phenomenon was Handling a Situation When I Am Alone at Home and Probably Need Help Quickly. Practitioners should explore intentions about handling specific types of RHQIs and offer appropriate anticipatory guidance.

Abstract

During a longitudinal study of the experience of reaching help quickly, 34 homebound women (ages 85 to 97) who lived alone reported 106 reach-help-quickly incidents (RHQIs). The purpose of this study was to expand knowledge about RHQIs and intentions relative to them and to compare those facets of experience for subscribers to a personal emergency response system (PERS) and non-subscribers. We used a descriptive phenomenological method to analyze interview data, discerning six types of RHQIs, including finding myself down right here, realizing that I might not be alright after falling and getting up on my own, and realizing that something I cannot explain is or could be wrong with me. Intentions were focused on self-help before help seeking. The overall phenomenon was Handling a Situation When I Am Alone at Home and Probably Need Help Quickly. Practitioners should explore intentions about handling specific types of RHQIs and offer appropriate anticipatory guidance.

More than half of community-dwelling women 85 and older live alone (U.S. Administration on Aging, 2008), and half of women in that group are homebound or unable to leave home without help (Smith & Longino, 1995). Years ago, Butler and Lewis (1973) noted that older people who live alone must have “the ability to seek assistance when needed” (p. 189). However, little is known about incidents when older homebound women needed quick help and tried to reach help quickly. We use the term reach-help-quickly incidents (RHQIs) to refer to those unexplored situations. The purpose of this part of a longitudinal study of the experience of reaching help quickly (RHQ) was to expand knowledge about RHQIs that older homebound women experience, how they seek quick help in RHQIs, and from whom they seek it, while comparing those facets of experience for women who were subscribers to a personal emergency response system (PERS) and non-subscribers.

Background

Older women can face various problematic incidents in or around the home (Lau, Scandrett, Jarzebowski, Holman, & Emanuel, 2007), including unintentional injuries (Wyman et al., 2007), especially falls (Mack, 2004), and complications of chronic health problems (Wolff, Starfield, & Anderson, 2002). Although those typologies are well known to practitioners, there are few first-hand reports by older people who sought to RHQ in particular situations. There is a dearth of details about what it is like to experience a RHQI. Nonetheless, older people who experience such incidents are more likely to survive if they have quick help (Gurley, Lum, Sande, Lo, & Katz, 1996). This is an implication that intentions with regard to help seeking in RHQIs are particularly critical. Indeed, practitioners would find it useful to understand intentions of older homebound women relative to RHQIs.

However, little is known about what older homebound women are trying to do relative to RHQIs. The intentions of older people have been explored indirectly with regard to the decision to adopt (or not to adopt) a particular device designed to enable quick contact without moving to get to a telephone—the PERS (Dibner, 1992). A PERS subscriber can press a help button (worn on one’s person as a pendant or on a wristband) to send a telephone signal to a dispatcher. On receipt of signal, the dispatcher attempts to establish voice-to-voice contact with the subscriber, whom, if able, can ask the dispatcher to send a nearby first responder or an emergency vehicle. A dispatcher who fails to establish voice-to-voice contact sends emergency personnel to the scene (Dibner, 1992). Various forms of the PERS have been marketed for nearly 30 years. In a recent nationwide survey (N = 907, ages 65 to 94, mean age = 74), 84% of respondents had heard of a PERS. However, after those who were unaware were informed about it, only 54% of all respondents said they would use a PERS if it were available (Barrett, 2011). Another sample of older adults viewed the PERS more favorably than other devices for monitoring well-being at home (Mihailidis, Cockburn, Longley, & Boger, 2008). However, the percentage of subscribers 65 and older in nationwide surveys has ranged from 6% (Simmons Market Research Bureau, 1998) to 9% (Barrett, 2011). Thus, it is not necessarily the case that “the knowledge that a PERS has the potential to make a senior’s life simpler and safer might persuade some to incorporate a PERS into their health care routine” (Hessels, Le Prell, & Mann, 2011, p. 160).

Despite the potential benefits of being a PERS subscriber, intentions relative to RHQIs cannot be understood based solely on one’s status as a subscriber or non-subscriber. That is, being a subscriber is not synonymous with “using” a PERS. In one study, researchers asked subscribers about “situations when they used their PERS” (Mann, Belchior, Tomita, & Kemp, 2005, p. 85) in terms of possible events such as “risk of fall” (p. 86). They were not asked to report actual events. Therefore, little is known about how subscribers decide to use the PERS to contact help. Perhaps more important, there are few, if any, data about whether the help-seeking intentions of PERS differ from those of non-subscribers in particular types of RHQIs.

Furthermore, little is known about whom older women contact for help in RHQIs. In health-related crises, kin are the most responsive helpers (Hogan & Eggebeen, 1995; Hurlbert, Haines, & Beggs, 2000). However, older women rely on various “standbys” (Porter, Ganong, Drew, & Lanes, 2004, p. 750), including kin, friends, and neighbors, for help with daily tasks. Women might contact particular standbys for help in RHQIs, but such situations have not been explored.

Thus, for older homebound women, there is limited knowledge about four issues regarding RHQIs: (a) types of problems viewed as warranting quick help, (b) intentions regarding help seeking, (c) strategies used to reach help quickly and any differences between PERS subscribers and non-subscribers, and (d) characteristics of people from whom quick help is sought. We report data pertaining to those issues from a longitudinal study of the experience of RHQ for older homebound women. Our purpose was to address the study aims of comparing the experiences of PERS subscribers and non-subscribers and detailing the personal-social contexts of those experiences, such as the nature of RHQIs and types of helpers in RHQIs.

Method

When there is limited understanding about an experience and its personal-social context, descriptive phenomenology is the method of choice. We used Porter’s (1994, 1995, 1998) descriptive phenomenological method, which was influenced by Husserl (1913/1962). An initial activity of the method is the development of a “phenomenological framework” (Porter, 1998, p. 21) to establish potential sources of interview and observational data about the experience. Typical data sources include perceptions that people report, actions they take or report, and intentions they imply or directly report (Porter, 1994). After setting aside extant views about the experience, the researcher explores the experience with people who are living it. Drawing on data obtained over time, the researcher seeks to discern the essence of the experience. While discerning each participant’s intentions relative to the experience, the researcher compares data from all participants to grasp how “the phenomenon directly presents itself in experience” (Kohák, 1978, p. 9). Concurrently, data pertaining to the underlying personal-social context of the experience is explored in terms of life-world. Life-world is that “natural and social world, the arena, as well as what sets the limits, of my and our reciprocal actions” (Schutz & Luckmann, 1973, p. 6).

Analysis of data pertaining to experience and life-world is a recursive activity, involving participants and co-investigators in ongoing dialogue about data and emergent findings, affording continual opportunities to consider and enhance validity of findings (Porter, 1998). Findings should reveal a “faithful description of what we really see from our own point of view and after the most earnest consideration” (Husserl, 1913/1962, p. 259). Findings are stated in vernacular terms to illustrate their empirical origin and presented in the form of a leveled taxonomy (Porter, 1998). The taxonomy should reveal “essential connections” (Husserl, 1913/1962, p. 385) among (a) very specific, individualized findings; (b) mid-level findings for subgroups of participants; and (c) general findings for the sample.

Design

To gain an understanding of the RHQ experience over time, we used a prospective, longitudinal design for “the RHQ project,” the study from which we drew data for this report. We planned a data collection period of 18 months per participant with four in-depth interviews (during Months 1, 2, 9, and 18) and short telephone interviews (during Months 3–8 and 10–17). Due to staggered recruitment, data collection for all participants occurred over 3 years.

Sampling

The RHQ project was approved by the University Institutional Review Board as a minimal risk project requiring informed consent. We sought to recruit 40 women through newspaper advertisements and contacts with 13 rural and 14 urban service agencies in a six-county region. Volunteers who notified project staff of their interest were screened for these criteria: (a) being 85 or older, (b) living alone in a residential setting (home or apartment), and (c) being homebound (Smith & Longino, 1995) or unable to leave home without personal help, a walking device, or both. Project staff visited eligible women, read the informed consent aloud, and invited questions. Rights to privacy, confidentiality, and withdrawal for any reason were guaranteed. The 40 women (ages 85 to 98, mean age = 89.6) who gave written consent to participate included 21 PERS subscribers and 19 non-subscribers. The 6 women (ages 88 to 98, mean age = 90.5) who did not report a RHQI relocated to more supervised settings after one or two interviews for various reasons, including family influence.

This article pertains to the 34 women (ages 85 to 97, mean age = 89.3)—19 PERS subscribers and 15 non-subscribers—who reported at least one RHQI. Other demographic data are shown in Table 1. Three of the 4 Black women were PERS subscribers, and 16 of the 30 White women were PERS subscribers. Of the 34 women, 23 (67.6%) completed the 18-month study, whereas 11 women (32.4%) did not complete the study, due to relocating (n = 5), losing interest (n =3), declining health (n = 2), or death (n = 1). We report each woman’s data using an initial that does not correspond to her surname.

Demographic Data for ParticipantsReporting RHQIs (N = 34)

Table 1: Demographic Data for ParticipantsReporting RHQIs (N = 34)

Data Collection

We developed an interview guide to elicit data pertaining to perceptions, actions, and intentions associated with RHQ. Certain questions were specified for each in-person interview, and a protocol was devised for telephone interviews. Interviews were audiorecorded. On average, each woman had three in-person interviews (range = 1 to 5, total = 115) and eight telephone interviews (range = 0 to 12, total = 280). The first author (principal investigator) conducted or co-conducted all but one in-person interview. The second author co-facilitated two interviews; the third author reviewed interviews and took part in data analyses. Participants described RHQIs in response to routine questions such as: (a) “Since our last contact with you, have you tried to reach help quickly for any reason?” and (b) “Have you had an emergency at the house?” Such questions were closed, but the women had ample opportunity to relate details; we used probes to amplify understanding. To obtain data about helpers, we asked each woman at Interviews 2–4: (a) who helped her at home and with what tasks (standby helpers) and (b) whom she would prefer to contact if she needed to reach help quickly (preferred RHQ helper), if anyone. We asked PERS subscribers to name people on the “PERS list,” as first responders to be contacted by the PERS dispatcher.

Some women reported RHQIs from years earlier; others shared incidents that had happened hours before. Some women could not remember all details about recent RHQIs; others elaborated at length about historical RHQIs. We obtained data about: (a) types of problems viewed as warranting quick help, (b) intentions regarding help seeking, (c) strategies PERS subscribers and non-subscribers used to reach help quickly, and (d) characteristics of people from whom quick help was sought. Data reliability was bolstered because we asked about each RHQI more than once, either during the same interview, in ensuing interviews, or both. For example, if a woman mentioned a RHQI during a monthly telephone call, we continued to explore her perceptions and intentions about that RHQI at her next in-person interview.

Data Analysis

Data Pertaining to RHQIs. We viewed RHQIs as problematic facets of “life-world..., [that] taken-for-granted frame in which all the problems I must overcome are placed” (Schutz & Luckmann, 1973, p. 4). In contrast to “routine situations” (Schutz & Luckmann, 1973, p. 116) of daily life, we considered RHQIs as “problematic situations [that] are reciprocally determined by the partners in the situation” (Schutz & Luckmann, 1973, p. 116). To identify all RHQIs within the RHQ project database, the first two authors reviewed all interviews reporting attempts to reach help quickly. We labeled as an RHQI any incident that occurred when a woman was alone “in or around the home” (Nachreiner, Findorff, Wyman, & McCarthy, 2007, p. 1440). Next we categorized RHQIs as having occurred before or during study enrollment. We classified people whom the women had contacted in RHQIs (RHQI helpers) and determined whether the RHQI helpers were also standbys who were helping with daily tasks. We denoted RHQI helpers by role (such as kin) and classified them as (a) preferred RHQ helpers, (b) PERS list helpers, or (c) both. Finally, we counted frequencies of each RHQI category for the sample and for PERS subscribers and non-subscribers. Descriptive analysis of pertinent quantitative data is consistent with Husserl’s (1913/1962) view that “numbers themselves are essences” (p. 81). “The perfectly clear meaning of arithmetical speech...can at any time be perceived as valid” (Husserl, 1913/1962, pp. 81–82).

As noted earlier, we used Porter’s (1994, 1995, 1998) phenomenological method to analyze data about RHQIs, creating a taxonomy of three levels (“element, descriptor, and feature” [Porter, 1995, p. 35]) to characterize life-world pertaining to RHQIs. We labeled each RHQI as a life-world element with “nuances defined by the uniqueness of each life history” (Porter, 1995, p. 35). We used ordinary language to create labels for RHQIs, such as having a terrible sickness and pain in my right side. Some women also characterized a RHQI in diagnostic terms such as “pancrenitis [sic],” but we bracketed such terms (Porter, 1998) to avoid phrasing RHQIs in medical language. Next, we grouped similar life-world elements under broader descriptors. For example, we grouped having a terrible sickness...and finding that I couldn’t breathe when I went to lie down under the following life-world descriptor: realizing that something I cannot explain is or could be wrong with me.

Analysis of Data About Intentions Relative to RHQIs. Concurrent with analysis of life-world data, we analyzed data to understand intentions (Porter, 1998) relative to each RHQI. Analysis consisted of cyclical phases of “describing, comparing, distinguishing...and inferring” (Husserl, 1913/1962, p. 93). We used those strategies during interviews, while reading and rereading interview texts, and during ongoing dialogue while analyzing data.

Like the nature of life-world data, the structure of an experience emerges as a taxonomy (Porter, 1998; Spiegelberg, 1994). An intention, the most basic level of analysis, can be unique to one person. For example, when Ms. N. fell, her intention to seek quick help was evident in perceptions and actions she reported to us; knowing that she could not get up without help, she pressed her PERS button to summon her granddaughter, her preferred RHQI helper. The intermediate component phenomenon captures similar intentions across people or groups within the sample. To capture the overall intention of using some means to reach help quickly, we coined the phrase Seeking Quick Help in a Certain Way, viewing it as a component phenomenon. Accordingly, we discerned each woman’s intentions, grouped unique intentions into six component phenomena, and envisioned them as parts of a larger phenomenon—a pattern of the experience of the sample (Porter, 1998). Finally, we wove the taxonomies of life-world and intentions into a chronology exemplifying the nature of RHQIs. Validity of findings was bolstered by ongoing dialogue with participants and among team members.

Findings

Participants reported 106 situations that we viewed as RHQIs. In Table 2, participants are categorized as to when their reported RHQIs occurred: before the project only, during the project only, or both before and during the project. As a group, the 34 participants reported twice as many RHQIs as having occurred before the project as they reported during it.

Number of Participants Reporting RHQIs, Classified by Intervals of RHQI Occurrence and Retention in the Project

Table 2: Number of Participants Reporting RHQIs, Classified by Intervals of RHQI Occurrence and Retention in the Project

As shown in Table 3, we discerned six categories of RHQIs: (a) finding myself down right here, (b) realizing that I might not be alright after falling and getting up on my own, (c) realizing that something I cannot explain is or could be wrong with me, (d) knowing enough about this health problem to know what help I need now, (e) facing an unexpected urgent household problem, and (f) realizing that someone or something is disturbing my peace. In Table 3, the RHQI categories are classified by occurrence before or during the project and whether or not the woman was a PERS subscriber at the time. Compared with women who were subscribers when a RHQI occurred, non-subscribers reported approximately twice as many RHQIs. The six types of RHQIs occurred in combinations, illustrating marked variability. Finding myself down right here was the most common RHQI, appearing in combination with all other types.

Types of RHQIs by Timeline of Occurrence and PERS Subscriber Status

Table 3: Types of RHQIs by Timeline of Occurrence and PERS Subscriber Status

We viewed one overall phenomenon as the overarching category for all unique intentions in RHQIs: Handling a Situation When I Am Alone at Home and Probably Need Help Quickly. It was composed of five component phenomena: Taking Care of the Situation the Best I Could First, Giving Up on the Idea of Helping Myself, Seeking Quick Help for a Certain Reason, Seeking Quick Help in a Certain Way, and Seeking Quick Help from a Certain Person/Agency. PERS subscribers did not consistently use the PERS to reach help quickly. Although 13 of 19 subscribers had used the PERS to seek help, most had also used telephones in some RHQIs. The type of RHQI was implicated in whether subscribers used PERS to reach help quickly. Every subscriber who found herself down used the PERS to summon help. PERS use in other RHQI categories was markedly lower: (a) in 1 of 3 injuries after getting up from a fall, (b) in 2 of 5 unexplainable health problems, (c) in 2 of 7 explainable health problems, (d) in 1 of 8 household problems, and (e) in 2 of 4 disturbances of one’s peace. Ms. S. noted:

When people have fallen, they use it. They know they can’t get up. But when [a friend who was a PERS subscriber] had a heart attack, she waited 7 hours before she called for help. But I could sort of understand that. She wasn’t sure it was a heart attack. You wouldn’t want to call for help, unless you really needed it.

A key finding was that the realm of standby helper activity extended beyond assistance with daily tasks; in fact, standbys were the primary helpers in the majority of RHQIs. Participants viewed standby helpers as preferred RHQ helpers, and PERS subscribers asked standbys to serve as PERS list helpers. Indeed, instead of using the PERS to contact standbys who were PERS list helpers, some subscribers telephoned those people for help in RHQIs.

Although the goal of descriptive phenomenology is to capture the essence of an experience (Porter, 1998), engaging in dialogue about an experience can affect its nature. Participating in this study might have influenced intentions about handling RHQIs, but we believe that influence was minimal. Despite interacting with project staff about the PERS during monthly in-home or telephone interviews, 4 subscribers used telephones instead of the PERS to seek quick help for health problems and post-fall sequelae during the project.

A Chronology of the RHQI

In a RHQI, intentions were focused initially on Taking Care of the Situation the Best I Could First (component phenomenon). The bridge between self-help and help seeking was captured in Giving Up on the Idea of Helping Myself (component phenomenon). Ensuing intentions were focused on help seeking, grouped in these component phenomena: Seeking Quick Help (a) for a Certain Reason, (b) in a Certain Way, and (c) from a Certain Person/Agency. After helpers came, life-world was characterized by Having Quick Help From Them Here When I Needed It. These data are an exemplar of the chronology. After one woman had a “light stroke,” her children visited; a PERS was “part of our plan.” She had subscribed for a few weeks when:

I closed this finger in the latch of the storm door. That’s when I called it [the PERS], because a flap of skin was loose. They came and took care of it. [What came into your head when you caught your finger?] I wanted to stop the bleeding. I’m accustomed to doing things for myself, and I held off calling a little while. But I ended up pressing the button. [What led you to do that?] Well, that’s probably the sort of situation we had in mind when we decided to get it [PERS], that there might come a time when I needed someone to do more than I could do.

Basic Descriptions of RHQIs, Help-Seeking Strategies, and Helpers

In the descriptions below, details about RHQIs include when it occurred, device(s) used to reach help quickly, and the helper(s) involved. Exemplars are presented with associated intentions for PERS subscribers and non-subscribers.

Finding Myself Down Right Here. When women showed us their homes, they pointed out exact locations, “right here,” when they had found themselves “down” after falling to the floor from an upright position or in one case after “slithering down” while holding onto a walker. These 31 RHQIs were of three types: (a) unable to get up after trying, but able to move away from the site (21 RHQIs); (b) unable to try to get up, but able to move from the site (8 RHQIs); and (c) unable to get up after trying and unable to move from the site (2 RHQIs).

With regard to Taking Care of the Situation the Best I Could First, most intentions revolved around efforts to get up or to a telephone. However, some situations were more complex than finding oneself down on the floor. Ms. G. set the scene that preceded her RHQI:

I put some pork chops on the stove and was opening the ice box when I went down. I knowed right there and then, “I got to get that burner out.” I knew I broke the hip, because I couldn’t hardly move. So I just scooted ’til I got the burner out, and then I got to the telephone [on the wall] and pulled it down to where I could reach it.

Although the above two scenarios differed based on the ability to get up, both women could move on the floor. Most non-subscribers to PERS tried to reach a telephone, although Ms. C.C. moved to a location where she thought others could see or hear her. Ms. D., who fell in a bedroom, called out to passers-by on the sidewalk while scooting to get to the telephone. Passers-by heard both women and contacted emergency personnel. Both Ms. C.C. and Ms. D. subscribed to a PERS after these RHQIs, which occurred prior to the project. PERS subscribers reported 10 RHQIs of this type, all involving use of the PERS help button.

Two women could not move when they fell; both had an accessible RHQ device. Ms. S., the only non-subscriber who had a home security system with a remote device, had it with her when she fell: “I tried to get up and it hurt too bad, my shoulder and my hip. I really couldn’t move. So I thought, ‘Well, I need help.’ [What did you do next?] I pressed this button.”

Women who were on the floor used various strategies and devices to reach help quickly, but they tended to contact standbys who were also preferred RHQ helpers. Ms. G. knew that her rural town had recently activated 9-1-1 and that she could get an ambulance by dialing it. Yet, in “awful pain” with a broken hip, she dialed the sheriff’s office, because a deputy was her cousin:

I called up here to the law. When he come in, he put the pork chops in the ice box. They said, “What hospital?” He just up and said, “Central.” That’s where I had all my surgeries, first one thing and another. I think he knew that. Then he called my son and talked to him from the hospital. He just knew who he was taking care of.

Before that incident, Ms. G. had planned to contact her son in an emergency; however, he lived 45 minutes away. After that incident, “the law” became her preferred RHQ helper.

Several women who had frequent falls went through a process of determining which standby was a preferred RHQ helper for falls. For her first fall, Ms. Z. felt fortunate that her neighbor’s cleaning woman “had the training and didn’t have any trouble getting me up.” Those neighbors moved. When she fell again, she called her daughter and son-in-law, who lived nearby and helped her daily, but “He’s had back surgery, and he couldn’t lift me. She couldn’t get me up, ’cause she’s not very big. So she called a neighbor to help us.” The daughter encouraged Ms. Z. to consider a PERS and facilitated a subscription. However, Ms. Z. listed her granddaughter, who lived nearby, as the first responder: “She is strong and could help me get up”—perceptions that were borne out during two later falls. Although she relied on her granddaughter as a RHQI helper, Ms. Z. continued to view her daughter as her preferred RHQ helper.

Realizing that I Might Not Be Alright After Falling and Getting Up On My Own. These 15 RHQIs involved either finding that I am bleeding or having pain or swelling where I fell. Most of these RHQIs were reported by non-subscribers, including Ms. B.: “I had seven bad falls inside of probably 2 years, and I didn’t break a bone.” She had “hollered for help” by contacting her granddaughter, whose roommate was “an ex-nurse”: “They came and took me to emergency three times. I had stitches, and I’ve got one scar. Her roommate patched me up time and time again, at least four times.” Ms. B. telephoned for help a few times, but she did not want to bother her granddaughter at work. She often waited for her to drive by after work, leaving the porch light on as a signal: “That light was on for them to stop all the time.”

Ms. R., a rural non-subscriber, moved a chair from its usual position and fell while trying to sit in it to answer the telephone. Her son was calling, and he wanted to come when she told him she had fallen. She declined his help; she thought she was alright. But when “a knot came up on my head big as a lemon,” she called her nearby daughter, who came over immediately:

She wanted to take me to the hospital [medical center 25 miles away]. I said, “Sallie, there’s usually nobody going to the hospital at this time of night.” So I said, “I’m going to call Dr. B. [local physician].” She told me to press on it real hard for 5 minutes and put an ice pack on it and let it stay 30 minutes. Said, “I’m on call, but I be at my home number, too. If you need me, you call me.” So Sallie stayed here ’til I took the ice pack off. It [the knot] started going down a little bit. Dr. B. said, “Tell her she’s gonna have an awful headache in the morning.” And I did. I had a slight headache for 2 or 3 days.

Of the 3 PERS subscribers who reported a RHQI of this type, only Ms. A.A. used the PERS when she was in pain after a fall. Ms. B.B. said, “I hit my head on a brick and had a bump and a sore place.” She called her hired helper, who “came every day for 3 or 4 days to put ice packs on it.”

Realizing that Something I Cannot Explain Is or Could Be Wrong With Me. Participants reported 22 sudden health-related situations when they did not understand what was happening. PERS subscribers used the PERS help button in 2 of the 5 RHQIs they reported. Otherwise, both subscribers and non-subscribers used the telephone to reach help quickly. Non-subscribers reported 17 RHQIs of this type, and they contacted a family member or friend for help in 14 of those incidents. In 10 RHQIs, the helper took the woman to the emergency department (ED) or the physician’s office, whereas in 2 RHQIs, the helper called 9-1-1. Ms. U. called her son when she looked in the mirror and realized she had “a black eye.” He was distressed because they had agreed she would call 9-1-1 in an emergency, but she did not perceive it as an emergency:

I had no pain. I looked a mess, but it didn’t bother me. I thought it would go away. I didn’t think 9-1-1 could do anything. I wouldn’t have gone to the hospital if they [son and daughter-in-law] didn’t take me. He thought it was a stroke.

Ms. U. was hospitalized overnight for “high blood pressure.” Her son promised that in the future he would come to the hospital immediately if she went to the hospital by ambulance: “He enlightened me by saying, ‘Mom, they can help you quicker than I do.’ I answered, ‘You’re right. That’s the way we’ll do it.’” Later, when Ms. U. realized she had taken “an extra blood pressure pill,” she called 9-1-1. The medics “checked me over and said everything was fine.”

Aside from Ms. U., Ms. B. was the only other non-subscriber who contacted a health care provider about an unexplainable problem. She had a history of “that heart bit. It’ll bang real hard and feel like it’s going to stop.” One night, “I couldn’t breathe good when I went to lie down.” She called her physician: “He said it could be ‘congestive heart’. He said, ‘Go to the emergency room,’ so I did.” She drove to the ED instead of calling her granddaughter (preferred RHQ helper) to avoid “worrying her in the middle of the night.” After that, Ms. B. said that her granddaughter urged her to “‘call 9-1-1 to save time and call me, too. I’ll be there first.’ I suppose if something happens that I need to have help bad, I’d call 9-1-1. I never have had to.”

Ms. C., a PERS subscriber, explained that although she needed “help quickly” for several incidents after abdominal surgery, none was “an emergency” warranting use of the help button:

I’ve thought about you ladies down through this all. Every once in awhile, I think, “Well, there’s their famous question: Did you need help quickly?” And I thought, “Those [home care] nurses were a wonderful help-quickly.” If I worried about something, or something didn’t seem quite right, I called them. They were right here.

Knowing Enough About This Health Problem to Know What Help I Need Now. In addition to RHQIs they could not explain, participants reported 17 RHQIs with which they had some prior experience that suggested the need for specific treatments, involvement of a specific RHQ helpers, or both. During her first episode of atrial fibrillation, Ms. F. used her PERS “to reach my daughter” at work. The daughter called 9-1-1, according to Ms. F. When the problem arose again, Ms. F. called her daughter at home rather than using the PERS:

It was a Saturday; I knew I could get her. But I guess I didn’t think it was as serious, and we knew what to expect. We’d been there, done that before. So we just kind of did it ourselves.

Other women had lifelong problems that were usually minor but could get “out of hand,” such as too much “mucus,” “phlegm,” or “nosebleeds.” Others dealt with “flare-ups” (or potential flare-ups) of chronic “constipation,” “bile duct spasms,” “heart trouble,” or “high blood pressure.” Ms. Q. was the only woman who failed to contact a helper, but that did not trouble her. Her “heart was racing really bad,” but it began to “settle down.” Compared with prior episodes, “I was not that bad off, really. I’ve had those spells all my life.” Two women who were taking warfarin (Coumadin®) had “a bloody spell” due to a minor injury; they knew they were at risk for excessive blood loss. Ms. H.H. was connected to her nephew-in-law via a pager; she knew he was at home next door, when she “kicked off a toenail”: “I was able to get to the telephone...[while] grabbing up something to wrap around it.” Ms. V., a former paramedic, was dicing vegetables: “I cut my thumb a little bit. It bled, but I knew my pressure points, where I had to poke and to hold my arm up, and I did that.” She reached for the telephone and called a neighbor for help.

Facing an Unexpected Urgent Household Problem. These RHQIs included: (a) six problems with appliances or alarms, (b) five structural or access problems with the home, (c) three personal safety hazards, and (d) one pet-related problem. Ms. M. shared a RHQI story that had occurred the day before the interview. It illustrates these intentions: Taking Care of the Situation the Best I Could First; Giving Up on the Idea of Helping Myself; and Seeking Quick Help (a) for a Certain Reason, (b) in a Certain Way, (c) from a Certain Person/Agency. The narrative also illustrates the life-world descriptor of Having Quick Help From Them Here When I Needed It. Ms. M. shared:

That carbon monoxide thing just kept a-goin’, up high right next to the ceiling. I couldn’t get up there and get it down. I tried to knock it down with my cane, but I couldn’t do it. Betsey [daughter, preferred RHQ helper] was at the lake. I didn’t know what the heck I was going to do. I went out on the porch and if anyone was walking down the street, I was going to ask them to come in and tear the thing down. A woman was parked in front of my house, and I said, “I need help.” She just got in her car and rolled off. That’s when I thought, “I’m going to have some help from somewhere.” I hated to do it, but I called my son-in-law, Doug; he soon got here. He helped me a lot. Said, “You better call the fire department. Find out if there’s carbon monoxide.” They came and carried an apparatus around. Decided something was wrong with it. Doug went and bought one that plugs into the outlet. They said it was more safe.

Ms. M. was a PERS subscriber; if she realized that she could have used the PERS to contact emergency personnel, she did not say so. When the interviewer commented on the hesitancy with calling the son-in-law, she said, “I don’t like to bother anybody unless I have to.” For Ms. M., as for most women, life-world linked to RHQIs was characterized by coming to terms with bothering someone because I really had to do it.

Realizing That Someone or Something Is Disturbing My Peace. Four women reported 6 RHQIs when their serenity was disrupted. During a conversation with project staff the day after someone threw a brick into her picture window, Ms. D.D. said:

Things are pretty quiet around here, until I got that awful scare yesterday.... But things happen when you old, you feeble, and you Black. What else can you do about it? [Well...] You can’t answer that truthfully (shared laughter). [I can listen.] Well, it really upset me pretty much, at my age and in my condition. I couldn’t fight back.

Ms. D.D. had used the PERS to reach the police, as she had done for a similar RHQI prior to the project. During Interview 1, she described the PERS dispatchers as “the people in the know” and said they were her preferred RHQ helpers, especially “if someone frightened me badly.” When Ms. H. was still a non-subscriber, she called 9-1-1 when strangers knocked on her door. Later, when a neighbor’s visitors pounded on her house during the night, she called 9-1-1 again, despite the fact that she had a PERS by then. When presented with a similar incident a second time, both Ms. D.D. and Ms. H. used the RHQ device with which they had prior success.

Discussion

This work is the first to present empirical descriptions of RHQIs and intentions of older women who experience RHQIs. Although health professionals would not necessarily classify all 106 RHQIs as emergencies, the work fills a key gap in knowledge by detailing types of situations that warranted self-help and help seeking for this vulnerable group. Findings contribute to a developing understanding of the life-world of older women; the descriptors (including RHQI categories) are viewed as parts of “facing vulnerability” (Porter, 1995, p. 39), a previously discerned life-world feature. The phenomenon Handling a Situation When I Am Alone at Home and Probably Need Help Quickly is part of a broader phenomenon of “sustaining myself” (Porter, 1994, p. 19) at home indefinitely.

Indeed, because this work emanates from a longitudinal study, it clearly illustrates that for older homebound women, handling RHQIs is a basic facet of living alone over time. As is evident from Table 2, the 23 women who completed the 18-month study reported more RHQIs than the 11 women who did not complete it. Although that trend cannot be generalized, it is noteworthy. As older homebound women continue to age, practitioners should monitor RHQI incidence. As the population group of older women continues to grow, researchers should focus more directly on RHQI categorization and interventions. Accordingly, the findings from this study have useful clinical implications and represent unexplored parameters for research.

Clinical Implications

Issues underlying the RHQI categories, such as falls, pose critical challenges for clients, families, and care providers. Because nearly half of RHQIs were associated with falls or fall sequelae, practitioners should continue to emphasize fall prevention, in part by inquiring about intentions to use a walking device and to maintain proximity to it in the home (Porter, Matsuda, & Benson, 2010). However, findings contrast with the literature in two key ways. First, injurious falls have been defined as those “resulting in medical care” (Bergland & Wyller, 2004, p. 310). However, our findings show that injuries from falls do not always result in medical care. Women in this study took care of themselves first and tended to seek initial help from trusted non-professionals. Thus, although reports of the incidence of injurious falls are necessarily based on medical records, those reports could be low estimates. Second, there are ongoing efforts to define a fall (Zecevic, Salmoni, Speechley, & Vandervoort, 2006) and to develop alarm systems that recognize a static pose as a fall (Mihailidis et al., 2008). Yet, in this study, in 29 of 30 RHQIs involving falls to the floor, the women could move away from that location, even if they could not attempt to get up from the floor.

Health problems resulting in RHQIs were similar to conditions indicating the need for ED visits: heart disorder, visual problems, and respiratory diagnosis (McCusker, Karp, Cardin, Durand, & Morin, 2003). Researchers should explore interrelated factors that older adults consider “in relation to the decision to seek care in general and to use the ED rather than another type of service” (McCusker et al., p. 1369). Our findings are consistent with that view, while emphasizing the influence of standbys in such decisions. Some women discussed the problematic situation with standbys before deciding whether to seek care. Scholars should explore why older women seek guidance from (a) helpers about certain RHQIs, but not other RHQIs, and (b) some helpers, but not others.

Because nearly 90% of our sample reported at least one RHQI, we recommend that practitioners ask about recent RHQIs and offer post-event counseling and anticipatory guidance at every encounter with older adults. The RHQI categories are useful starting points for dialogue with older women about both self-help and help seeking. Practitioners should ask women (a) how they would plan to self-manage each type of RHQI before seeking help and (b) what device(s) they would use to reach help in each type of RHQI. Older women should be encouraged to have a help button or a portable telephone in hand (not just “at hand”), before the first RHQI occurs.

Research Implications

Researchers typically have asked PERS subscribers to report the situations when they pressed the help button (De San Miguel & Lewin, 2008; Mann et al., 2005). To obtain more accurate counts of RHQIs, researchers should inquire about situations when PERS subscribers and non-subscribers tried to reach help quickly by any means.

Researchers who study caregiver burden should consider expanding caregiver tasks from assisting with daily activities (Montgomery, Gonyea, & Hooyman, 1985) to responding to requests for quick help. Further work should be done to explore RHQIs from the helper’s perspective. Some people whom the women contacted might not have perceived the situation as urgent. Discrepancies between a woman’s perspective and those of other people who become involved in an RHQI contribute to the complexity of these incidents. Researchers should explore how availability and accessibility of standbys influence intentions about handling RHQIs.

Finally, it is noteworthy that these older women took time to try to deal with the situation alone before they tried to reach help “quickly.” We did not pose a standard definition of “quickly,” because we view it as context specific. Researchers should explore the variability of “quickly” across RHQIs and assess how variations in the time spent on self-help (before seeking help) influence health-related outcomes of RHQIs. Because dealing with RHQIs is a long-term problem for older women, further studies are needed over years instead of months to capture the impact of RHQIs on well-being.

Conclusion

In this study, similarities among intentions were not directly aligned with PERS subscriber status; some PERS subscribers used telephones to reach help quickly. PERS subscribers used the help button when they found themselves down and unable to get up, just as others have found (Mann et al., 2005). However, if our findings are typical, women might hesitate to use the PERS for an unexplainable health problem or a disturbance of one’s peace, possibly increasing risk from the incident. Practitioners should confer with new and continuing subscribers about plans for using the PERS in various situations. Finally, practitioners should ask women to name their preferred RHQ helpers and to identify some if they have not done so. Having standbys to contact might be as important as having a device with which to contact them.

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Demographic Data for ParticipantsReporting RHQIs (N = 34)

Characteristicn (%)
Age
  85 to 8922 (64.7)
  90 and oldera12 (35.3)
Race
  White30 (88.2)
  Black4 (11.8)
Residential locationb
  Urban21 (61.8)
  Rural13 (38.2)
Type of residence
  Home28 (82.4)
  Apartment6 (17.6)

Number of Participants Reporting RHQIs, Classified by Intervals of RHQI Occurrence and Retention in the Project

Intervals of RHQIs Reported by Participants
Duration of RetentionBefore Project OnlyBefore and During ProjectDuring Project Only
Retained for 18 months3164
Not retained for 18 months911

Types of RHQIs by Timeline of Occurrence and PERS Subscriber Status

Non-Subscribers (n = 15)PERS Subscribers (n = 19)
Type of RHQI (Life-World Descriptor)Before the StudyDuring the StudyBefore the StudyDuring the StudyTotal
Finding myself down right here1837331
Realizing that I might not be alright after falling and getting up on my own930315
Realizing that something I cannot explain is or could be wrong with me1432322
Knowing enough about this health problem to know what help I need now285217
Facing an unexpected urgent household problem434415
Realizing that someone or something is disturbing my peace20226
Total49202017106
Authors

Dr. Porter is Professor, School of Nursing, University of Wisconsin-Madison, Madison, Wisconsin, and Professor Emerita, Sinclair School of Nursing, University of Missouri, Columbia, Missouri; Dr. Markham is Assistant Professor, School of Family Studies and Human Services, Kansas State University, Salina, Kansas; and Dr. Ganong is Professor, Nursing and Human Development and Family Studies, University of Missouri, Columbia, Missouri.

The authors have disclosed no potential conflicts of interest, financial or otherwise. The project described was supported by grant 1 R01 AG021971 from the National Institute on Aging. The content is solely the responsibility of the authors and does not necessarily represent official views of the National Institute on Aging or the National Institutes of Health.

Address correspondence to Eileen J. Porter, PhD, RN, FGSA, Professor, School of Nursing, University of Wisconsin-Madison, K6/344 CSC, 600 Highland Avenue, Madison, WI 53792-2455; e-mail: hporter2@wisc.edu.

Received: March 25, 2012
Accepted: May 30, 2012
Posted Online: December 04, 2012

10.3928/19404921-20121127-01

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