Interviewing Institutionalized Elders: Threats to Validitv

d

Mary West, Elizabeth Bondy, Sally Hutchinson

In the course of an ethnographic study of an intergenerational Geriatric Remotivation Program in a Southeastern US. nursing home, we encountered dvjculties in interviauing institutionalized elders that threatened the validity of the data. The purpose of this paper is to explicate the difficulties and to recommend strategzes f i overcoming them. Four main clusters of elder characteristics threat- ened the validity of data: (1) phjsical characteristics; (2) cognitive characteristics; (3) affective characta’stics; and (4) personal char- acteristics. Probhatic data were categmied as “insufficient, ” “unchar, ’’ “nice and “emotionally charged. ’’ Strategzes fi increas- ing validity when interviewing impaired institutionalized elders included increasing the sample size, returning to the settingfie- quently, lengthening observation periods, recognizing the value of stories, recognizing the value of socializing, using videotapes, collecting both intmiew and obseruation data, and having elders view and respond to videotaped recordings.

people being studied may not be aware of their mental constructions of reality, the constructions are expressed in what they say and do. By observing and talkingwith individu- als, a researcher can gain access to their reality. However, observing and interviewing pose problems for researchers who are concerned with the validity of their findings, and these problems have been widely discussed (LeCompte & Goetz, 1982; McCall & Simmons, 1969; Schwartz &Jacobs, 1979). Dobbert (1982) summarized the following charac- teristics of “good” informants; that is, those participants who are likely to provide valid data:

They appear comfortable and unstrained in interactionswith the researcher; they are generally open and truthful although they may have certain areas about which they will not speak or where theywill cover up; they provide solid answerswith good detail; they stay on the topic or related important issues; they are thoughtful andwilling to reflect on what they say. (p. 263)

* * *

A fundamental assumption of qualitative re- search is that reality is “a multiple set of mental constructions” (Lincoln &Guba, 1985, p. 295). The researcher’s goal is to represent reality as

‘ i t has been constructed by the individuals being studied. In short, the researcher strives for valid findings, which means “to understand a situation as it is seen by the participants” (Dobbert, 1982, p. 260). Although

Mary G. west, R.N.. M.s.N., Alpha Theta is Associate Chief, Nursing Service, Extended Care, V.A. Medical Center, Gainesvllle, FL.

tion, Unlversityof Florida, Gainesvllle. Sally HutchinSon, R.N., Ph.D.. F.A.A.N., Beta Epsilon, is Professor, College of Nursing, university of Florida, Gainesville. ThlS study was funded by veterans Affalrs Health Services Research and Development Project IIR #85-020, Principal Investigator, Mary West; Co-Prlnclpal Investigators - Elzabeth Bondy, sally HUtChinSOn, Marguerite Warner,Rodman Webb. The authors thank the staff of the Gainesvllle VA Nursing Home Care Unit and the P.K. Yonge Laboratory School of the University of Florida who made this project possible. A special thanks to Barry Murphy and Walter carr, Recreation Therapists at the VA NHCU and all the children and resldents who participated in the P.K. Pal program. correspondence to MS. west, VA Medical center, Nursing Home care unit (11881, Archer Road, Gainesvllie, FL 32608.

Elizabeth BOndy, Ph.D. IS Assistant Professor, College Of Educa-

1

Accepted for publication January 8,1991.

Volume 23. Number 3, Fall 1991 171

When studying the institutionalized elderly, few infor- mants can be found who display Dobbert’s characteristics of good informants. In fact, the characteristics of impaired, institutionalized elders threatens the validity of studies which seek to uncover elders’ views of reality. The purpose of this paper is to explicate the difficulties encountered when interviewing institutionalized elders and to recommend strategies for overcoming these difficulties.

Background and Literature Review The preponderance of research on institutionalized el-

ders has relied on quantitative methods of study. In an exhaustive review of elders’ responses to instruments used in quantitative studies of social functioning of elders, Kane and Kane (1981) conclude: “The consistently positive responses of institutionalized patients to awide range of experimental interventions suggest that the attention and stimulation itself may produce the change as much as the specific independent variable” (p. 139). This summary of the state of research on institutionalized elders underscores the need to adopt alternative approaches to learn about this popula- tion.

Qualitative research methods provide an alternative a p proach by offering institutionalized elders the opportunity to define their feelings about interventions designed to affect their lives; unhappily, these same methods introduce major problems for the researcher. With informant inter- viewing and participant observation the major data collec- tion tools, qualitative researchers face significant challenges when studying frail, impaired elders in institutional settings, a fact recently discovered in the course of an ethnographic study of an intergenerational Geriatric Remotivation Program in a Southeastern U.S. nursing home.

The program under study involved 15 volunteer, middle- school children who were transported by van after school for twice-weekly, one-hour sessions in the nursing home. Each child was paired with an elder who became his or her “Pal.” In many cases these partnerships continued for two or three years. Activities planned by program coordinators were games and crafts chosen to promote certain outcomes in the elders such as physical stimulation or reminiscence. Occa- sionally, there were special programs, such as picnics, nursing home festivities or visits to the school. In all cases, the elder- child partners participated together during activities. The research questions relevant to the present paper were:

How do elders experience the program? Do they value the program? Do they hear, see and understand program activities? Do they actively participate in the program and value their participation? Do they find their relationships with their middle-school partners satisfjmg? Does the child- elder relationship contribute positively to the life satisfac- tion of the elders? Are these relationships satisfying to children?

Data were collected during three week periods in the fall, winter and spring of two consecutive school years. The three methods of data collection were audicwisual documentation, participant observation and informant interviewing. Many interviewswere taped; otherswere hand-written anddictated into a tape recorder immediately after the interview. We took field notes and later dictated our notes into a tape recorder. This paper focuses on difficulties with interview- ing the elder.

Interviewing Institutionalized Elders: Threats to Validity

IMAGE: Journal of Nursing Scholarship

We approached this study of social interaction between institutionalized elders and middle-school children in fun- damentally the same way we would approach the study of subjects of other ages in other settings. Literature that provides direction for qualitative study, such as Spradley’s (1979, 1980) texts on ethnographic methodology, did not prepare us for the particular problems of interviewing im- paired elders with multiple functional disabilities: hearing loss, memory impairment or communication deficits. Fur- thermore, methodologists provided no strategies for de- coding impaired elders’ behavior during participant ob- servation. Profound poverty of movement, gesture or ex- pression was the rule. Low volume voices, difficult to hear in close proximity, let alone on videotape, were the norm. We came to expect “thin” data and were overjoyed when snip- pets of rich data emerged from time to time.

A search of the literature for reports of methodology difficulties encountered by other investigators conducting similar studies was non-productive. Powers (1988) used participant observation and informant interviews in a study of institutionalized elders’ social networks; however, no mention was made of methodologic difficulties. The inves- tigator acknowledged that elders with physical, cognitive or communication deficits were excluded from the study-the very subjects least able to muster or sustain social support and presumably most in need of being studied. The recently released Qualitative &search Methods Series and Applied Social &searchMethods Series (Sage Publications, 1989) suggest that differences exist in populations at the extremes of the life cycle by including a volume about problems using qualita- tive methods to study children (Fine & Sandstrom, 1988). Yet no author in these 33 volumes contributed a similar perspective about elders, in particular those who reside in institutions.

The bulk of the literature addresses issues about quantita- tive methodology in aging research. One problem discussed extensively in the medical and sociological literature is the validity and reliability of elders’ responses to data collection instruments (Jackson, Ramsdell, Renvall, Swart, and Ward, 1989; Perry, 1982; Ebrahim, Morgan, Dallosso, Bassey, Harries, and Terry, 1987). Another methodology problem described by a number of authors (Berkowitz, 1978; Butler, Vestal, Lawton, et al. 1977; Duffy, Wyble, Wilson, and Miles, 1989; Herzog and Rodgers, 1988; Hoffman, Marron, Fillit, and Libow, 1983; Mercer and Butler, 1967; Norris, 1985; Robb, 1983; Todd, Davis and Cafferty, 1984) is getting and keeping elders in studies; that is, obtaininginformed consent, avoiding recruitment bias and recognizing the causes for and outcomes of subject attrition.

Although the abundant literature about recruitment and retention of elderly subjects focused solely on the entry or exit point of the research process, the problems described by these authors mirror those we experienced during data collection. Hoffman etal. (1983) enumerated these obstacles in an article about obtaining informed consent from elderly subjects: timeconsuming interviews; need for repetition; vision and hearing deficits; memory and cognitive impair- ment; aphasias and language barriers; limited education; poor vocabulary skills; and the lonely elder’s desire to chat with a captive listener.

~~~

Sample and Method Nursing home staff identified elders in need of social

stimulation and referred them to the therapeutic program under study. In order to understand whether the therapy worked, all elders in the program were studied. Conse- quently, our sample included elders with varying degrees of psychological and physical impairment. Diagnoses included Parkinson’s disease, stroke and a variety of dementias. The all-male sample ranged in age from 58 to 100.

Findings Our findings came from a search of our field notes that

documented our difficulties in interviewing these men. Four main clusters of elder characteristics threatened the validity of interview data: (1) physical characteristics; (2) cognitive characteristics; (3) affective characteristics; and (4) personal characteristics. Essentially, elders’ impairments often made it difficult for us to collect and interpret data.

Physical characteristics included such things as being in pain; being unable to see and hear; urinary urgency; and being unable to move small and large muscles. All of these factors affected elders’ ability to communicate clearly. Al- though all the elders did not experience all of these condi- tions, many of them experienced several. Elders frequently were difficult to understand because they spoke so quietly and/or did not articulate clearly. The meaning of their restricted movements was often difficult to interpret. And, data often were nonexistent due to an elder’s physical condition; that is, an elder in extreme pain or suffering from a distressing physical ailment was likely to remain in bed or leave a program session early.

Cognitive factors also threatened the validity of data gathered from some elders. A number of the men were frequently disoriented to time and place, had difficulty remembering people and events (long and short term memory deficits) and failed to recognize others. Often elders could not remember what happened only a few minutes earlier. Because some of the elders were disoriented during the sessions, we had difficulty interpreting their actions or lack of activity.

Affective characteristics of elders refer to the ways in which elders expressed their feelings. Generally, elders displayed flat affect-blank faces and unexpressive eyes. For some thiswas due to aphysical condition, such as Parkinson’s Disease. Others appeared to be depressed or unhappy with their circumstances at the nursing home. Although facial expression and body language normally provide a researcher with clues to participants’ thoughts and feelings, these clues were unavailable from a number of participants.

Finally, elders’ personal characteristics threatened data validity. The elders in this institution represented a range of socioeconomic, educationa1,career and ethnic backgrounds. As a result, although they all spoke English, their language reflected their backgrounds and life experience. In at- tempting to understand the elders, we had to tune in to many dialects spoken in the nursing home. Differences phonological, syntactic and semantic features of language were evident. For instance, often we were not sure what an elder meant when he used familiar words in ways which were unfamiliar to us. Attempts to clarify meaning were frequently unsuccessful, due to the elder’s cognitive and physical im- pairmen ts.

The four main characteristics-physical, cognitive, affec- tive, and personal-directly affected interview data. We categorized problematic data as insuSfibent, unclear, nice and emotionally charged. Recommendations for researchers studying institutionalized elders follow a presentation of types of problematic data.

Inslggcient or “thin” data were the norm. Many elders responded to standardized, open-ended, evaluative ques- tions about the program with patterned, minimized re- sponses.

Int: What do you talk to your pal about? Elder: Different things. Int: Like what? Elder: Different things. Int: Are the kids coming today? Elder: Yeah. Int: What do you think you’ll be doing? Elder: I don’t know what they’ll be doing today. Int: What do they do most times? Elder: Different things. Int: Do you remember what those things are? Elder: Not off hand. After numerous difficult interviews like the ones above,

we erroneously concluded that the length of time between the end of that day’s activity and the interview itself directly affected the quality of the data. However, alterkg the time of thzintmiew, as in the following example of an interview done less than 10 minutes after the activity had ended, often proved unsuccessful.

Int: Were the kids here today? Elder: The boy was, I know. (His partner was a girl) Int: The boy was. Un-huh. Elder: Uh-huh. Int: What does the boy look like? Elder: I couldn’t tell you, he’s a little dark skinned boy.

Int: A little dark skinned boy. Were you at the program

Elder: I was there. Int: What did they do? Elder: I don’t know. I don’t pay them too much attention

(Partner was fair with very light brown hair)

today?

cause it wasn’t so hot to me.

Although we had been schooled in the use of open-ended questions, our lack of success in acquiring meaningful data led us by trial and error to use probing questions. As the following example demonstrates, this too did not guarantee success.

Int: When you were talking about autumn with the children, I’d like to know whether you had any memories about autumn and what you used to do when you were younger.

Elder: No Int: When you think about it right now, when you think

about the fall of the year, do you have any memories of what you used to do as a young man during the fall?

Elder: No. I don’t remember anything particular. Int: If you had a choice, let’s say between spending an hour the way you did yesterday when you saw baby

pictures and made some crafts, or spending an hour

Interviewing Institutionalized Elders: Threats to Validity

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Interviewing Institutionalized Elders: Threats to Validity

just talking with your pal, what do you think that you would enjoy the best of those two activities?

Elder: I just can’t say, I just don’t know. Int: I guess what I’m getting at, is there anything you

would rather be doingwith the children than what you are presently doing?

Elder: I can’t think of nothing.

For some elders, waiting for t h response for several minutes occasionally paid off.

Int: What do you like about the program? Elder: Everything, everything. Int: Tell me what you like. (several minutes of silence

Elder: It brings us much closer together. elapsed)

Unclear data refers to data that simply did not make sense to the interviewer. Sometimes the answer did not fit the question being asked. Note the following examples:

Int: Are there other things here in the nursing home that make you laugh, or is the kid’s program the most laughable one?

Elder: Well, laughable one. It is not foolish though. Int: I don’t understand. Elder: A lot of them school show that senior citizens can

Int: Tell me about that. Elder: Well, like you shouldn’t throw them away. Int: Hmm? Elder: You shouldn’t throw those things away. Keep them

Int: Throw what things away? Elder: What the kids do and what they say. I should only

Int: I don’t think I understood what you said. Elder: Well, there is a lot of senior citizens that don’t

follow the rules and they stay in a group. Int: They stay where? Elder: They stay in one place. They are afraid to move

take up.

in the back of the noodle.

said some of them.

from one place to another and they don’t say really what they mean.

In other examples, of unclear data elders used words and

“Not really they can’t talk the past far enough for me.” (translation: The kids are too young to be able to talk about the old days or historical events.)

syntax that required translation by the investigator.

“She doesn’t put up any conversation.” (translation: My pal doesn’t talk to me.)

“I’ve sat at the Judge’s Bench and don’t know what a child or children might construe.” (translation: I don’t talk to my pal because she might misunderstand me.)

(When asked if he thought the kids were the right age for this type of program) “They can say all the conversations when they are a bit smaller, but to get meaning on it should be 10 until 12.” (translation: Younger kids can talk but they have to be older to really carry on a good conversation.)

“It’s hard for me to say, because this one will say one thing and another one another, and you got it hard to get it together to where you understand it yourself. (translation: Sometimes it’s hard for me to follow the kid’s conversations.)

(When asked how he knows his pal doesn’t like to be corrected) “It takes her breath away from her.” (translation: She acts surprised.)

In other situations, listening for a theme, interp-eting it, and stating it in the form of a question helped the researchers un- derstand the elder’s meaning:

Int: What about the older men? What do they get out of the Program?

Elder: They get to, with the children, younger children, every, they won’t ever, they have somebody, some old man, some like me or somebody else, they have a pal and they, whatever ... ah, I don’t know.

Int: So you think the men get friendships out of it? Elder: Yeah. Friendships. They have somebody to, the

little girls, they have little girls and the little girls have the person and when they come and she does talks to him in that way.

Nice data refer to socially acceptable comments that a p pear interview after interview, contributing little to the purpose of evaluating the program. Elders who provided nice data did not seem to be actively involved in the conver- sation with the researcher. Probing questions or waiting for responseswere unsuccessful in acquiring rich data. Following is an example of nice data:

Int: Hi. I’m interested in knowing how you felt about the program and finding out if you have any suggestions about how we might be able to improve it.

Elder: Oh, I can’t tell you, I like it so well.

Emotionally churged refer to data gathered during inter- views in which the elder expressed strong emotions such as sadness, anger, fear, or pain.

sadness: Int: What would be your general analysis of the kid’s

Res W: Well, I think it’s a great thing. Int: And why do you think that? Res W Well, it does us good and the kids good. (Starts

Int: Does you good. Res W. (still crying) Yeah. Int: Tell me why it does you good or how would you

Res W: (still crying) Well, being around kids. Int: What about being around kids is good? Res W: It just makes me feel good. Int: Happiness. ResW Yeah. Int: Huh. Well that’s great. So you think being around

Res W (laughs through tears) No, it ain’t.

program?

to cry).

describe the good it does you.

‘us old folks’ isn’t near as much fun, huh?

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Interviewing Institutionalized Elders: Threats to Validity

Volume 23, Number 3, Fall 1991 175

Anger: Int: Un-huh. What do you do with Debbie? Elder: We just talk and converse back and forth and do

Int: Can you tell me what you talk about? Elder: Well, about school and activities and ... Int: So what she’s doing you talk about. Elder: What she’s doing and I tell her what I’m doing. Int: Un-huh. What are you doing? Elder: Well, what I’m doing every day, like now talking to

Int: Um-hum. So you might tell her about that, today. Elder: Yeah. And what I make in OT, occupational

Int: Oh, you do. Great. Elder: Yeah, well, keep her interested in me. Int: That keeps her interested in you by giving her gifts.

Is that right? Elder: Yeah ... Not exactly, I’m not buying ... You’re kinda

irritating me. Int: I’m so sorry. Elder: I’m not buying her friendship. Int: No, I’m sorry. That isn’t, I thought I was repeating

backwhat yousaid. I didn’tmean to read anything into that. Okay. I apologize. Would ...

things together.

you and ...

therapy, and then I make her things.

Elder: I’m kinda irrational, I... Int: Would you like to, would you rather that I not

interview you, because I don’t want to make you un comfortable.

view me. Elder: Well, yes, I would rather that you wouldn’t inter

Int: Okay. That’sjustfine. I’m glad that you told me that. Elder: I’m kinda touchy on a couple subjects.

Fear: Int: What do you think of the program? Elder: I’d rather not talk about it. Int: You’re uncomfortable talking about it? Elder: Yes. Int: Do you mind telling me why? Elder: I just can’t talk about it. In t: Are you afraid if you tell me you might get in trouble? Elder: Yes. (shakes his head yes.)

Pain: Int: What do you think about while the program is going

on? Elder: Well, I’ll tell ya, I hurt so bad I don’t know. I don’t

know what’s going on. I’m hurting right now so bad I can hardly stand it.

Int: Do you think that the more active you are or the more involved you are with life around you, do you think it makes you feel better if you can get involved?

Elder: No. I tell ya, like I’ve tole ya before, if I didn’t suffer all the time like I do, I’d enjoy it a whole lot better. I’d enjoy those kids better being with them, but I hurt all the time and suffer. I don’t enjoy nothing much.

Insufficient, unclear, nice, and emotionally charged data were problematic for us since we were trying to determine how elders perceived the geriatric remotivation program. These data were the direct result of elders’ physical, cognitive, affective and personal characteristics. Elders who could not

hear well or who were in constant pain (physical character- istics), had memory deficits or were disoriented (cognitive characteristics), displayed flat affect (af€ective characteris- tics) and used language unfamiliar to researchers (personal characteristics) provided data which were difficult to inter- pret.

Strategies for Increasing Validity in Studies of Impaired Institutionalized Elderly

Our experience working with this population provided some clues to strategies which can improve a researcher’s chances of drawing valid conclusions about elders’ sense of reality.

Increase sample sire. Due to the difficulties inherent in collecting data from this population, researchers should consider focusing on a larger sample than they might in a different population. With a larger sample the researcher is more likely to get enough data to be able to piece together an interpretation of elders’ perspectives. It is difficult to reach saturation when studying impaired elders; that is, patterns do not emerge and repeat themselves as quickly as they can in an unimpaired population. By increasing the sample size, researchers increase their chances of achieving saturation, thereby increasing their confidence that their findings are valid.

Return to settingfrequatly. The purpose of this strategy is to insure that a researcher gets enough rich data on which to base interpretations. Although qualitative researchers typically spend a lot of time in the setting they are studying, they should allow for even more visits to a nursing home. Because data are hard to get and interpret, many opportu- nities to collect data are necessary. Also, if researchers hope to build rapport with elderly participants, they must make frequent contactwith them. Although some elders are quick to respond to strangers, others are very guarded. Finally, frequent visits are necessary to overcome the problems posed by elders’ memory deficits and disorientation. It is common for impaired elders to forget people and events or to be confused about time and place.

Lengthen obseruation periods. Researchers hoping to get useful data from impaired elders must be prepared to spend time with those elders. It is common for elders to fall asleep, become disoriented, cry, and have to leave for therapy sessions while researchers are interviewing and/or observ- ing them. In order to gain insight into elders’ views, researchers need flexible schedules and long blocks of time €or “hanging around.”

Recognize thevalue of stmies. Frequently, impaired elders do not seem to provide a direct answer to an interviewer’s question. In fact, at first glance it appears that many elders go on to talk about an entirely different subject than that presented to them. Rather than dismissing these apparently irrelevant stories, we recommend that researchers tune in to elders’ stories. While they may appear to be off the subject, they often provide insight into the elders’ opinions and concerns. In addition, elders are grateful to have someone listen to their stories. By listening patiently, researchers may receive helpful data while providing reciprocity.

Recognize the value of socializing. In many settings partici- pant observers achieve insights into the view of the people under study through casual socializing. This is true for researchers studying the institutionalized elderly, too. We

Interviewing Institutionalized Elders: Threats to Validity

found that by chatting with the elders on the floors, in their rooms, in the television room, in the lobby, and in the dining room we were able to gather data that helped us understand their views. Restricting data collection to the remotivation therapy sessions and the periods directly preceding and following those sessions resulted in a much “thinner” body of data.

Use videotapes. Because elders’ movements are often re- stricted, their behavior can be difficult to detect and inter- pret. Note the following example:

An elder was videotaped ramming the table with his wheelchair while awaiting the arrival of the children for the program. Under other circumstances this behavior might have been interpreted as confused, antisocial or even belligerent. Because the incidentwas captured on videotape, we were able to discover that the elder was actually trying to move the table to allow a table mate to negotiate his wheelchair around a table leg-a very sociable act indeed!

Videotapes capture the details of elder behavior and preserve them for repeated analysis. We found that it was essential to have videotapes to study elders’ participation in and responses to remotivation therapy sessions. There are, of course, difficul ties inheren t in usingvideotapes. Although a stationary camera is less obtrusive than a roving camera, it captures activity within a narrow range. The researcher is not guaranteed to capture all of the activity, even among a small group of participants. The quality of the audio record- ing is also a concern, particularly for elders with low volume voices. We addressed these problems by using two stationary cameras and conference microphones. In addition, at least one researcher recorded field notes during remotivation therapy sessions.

Colkct interuiew and obsmation data. We are not the first to recommend that qualitative researchers should collect more than one kind of data. Because the elders’ words and actions can be so difficult to interpret, it is essential to have a large quantity of data and more than one kind of data. Although the videotapes and the field notes helped capture elders’ actions, the interviewsprovidedinsightinto meaning behind those actions. Interviews alone, however, would have been difficult to interpretwithout observations to ground them in specific events. Looked at together, then, observation and interview data create a more thorough and interpretable picture of the phenomenon under investigation than either of the data sources alone. Also, each source of data provides a means of checking the meaning and validity of data collected via the other method.

Have elders view and respond to videotaped recordings. Many impaired elders cannot remember events for more than a few minutes. To enable elders to talk about their experiences in an earlier activity, researchers should consider showing them a videotape of the activity. While we do not have extensive experience with this technique, we found some success in conducting interviews while elders viewed them- selves participating in a remotivation therapy session. Al- though use of videotape addresses the elders’ memory problems, it can pose other problems. For instance, elders can become confused by what they see on the screen. Additionally, some elders have trouble seeing the screen at all. Despite the problems this strategy can present, we think

it isworth the attention ofresearcherswho are wrestlingwith the problem of elders’ memory deficits.

All qualitative researchers must take steps to insure that their findings represent the world as seen through the eyes of the participants. Researchers interested in studying the elderly should be alerted to the special challenges involved in gathering and interpreting data from this population. It is important for researchers to spend a lot of time with elders, to value their stories and to collect different kinds of data. By adjusting research methods to be sensitive to the characteristics of the elderly, researchers can address the many threats to validity inherent in studying this population. a

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