Introduction
Injurious falling by older people continues to be constructed as one of the most important public health concerns facing contemporary Western health systems, as researchers and policy makers cite the many economic, social and personal burdens that are associated with ‘fall-related injuries’ (Fletcher and Hirdes Reference Fletcher and Hirdes2004; Scheffer et al. Reference Scheffer, Schuurmans, Van Dijk, van der Hooft and de Rooij2008; Scott Reference Scott2005; Stevens et al. Reference Stevens, Corso, Finkelstein and Miller2006). Public health-care organisations are continually engaging in efforts to prevent falls (Edwards Reference Edwards2011), with the dual challenge of maintaining older peoples' independent living and reducing expenditures related to the consequences of falling. As such, health service providers are increasingly expected to understand fall risk and fall prevention and be able to implement fall prevention programmes that help older people to prevent falls in their daily lives (Brown et al. Reference Brown, Gottschalk, van Ness, Fortinsky and Tinetti2005; Fortinsky et al. Reference Fortinsky, Baker, Gottschalk, King, Trella and Tinetti2008).
While a great deal of research has explored strategies for fall prevention among older people living in the community, less attention has been devoted to the experiences and views of older people that shape their motivations to engage in fall prevention activities. These experiences and views of older people represent the meaning and significance of ‘risky’ or ‘preventive’ behaviours related to falling, and thus represent essential insights for public health practitioners seeking to improve population health by preventing falls among older people. Moreover, the ways in which these experiences and views are approached in research seeking to inform public health and health care have an important impact on the kinds of insights uncovered. After summarising some key studies in this important domain, we will introduce the perspective from which we are approaching this phenomenological study of the experience of anticipating falling. We will then introduce a possible framework through which the implications of our study may be interpreted in order to provide some context for its application to public health and health care.
A number of qualitative studies have explored older people's perspectives of living with fall risk and their experiences with and reactions to fall prevention initiatives (McInnes, Sears and Tutton Reference McInnes, Seers and Tutton2011; McMahon, Talley and Wyman Reference McMahon, Talley and Wyman2011). In what has become an important study informing the critical analysis of fall risk among older people, Ballinger and Payne (Reference Ballinger and Payne2000) used an ethnographic approach to gain insight into the social construction of risk by older people using the services of a day hospital in the United Kingdom. Through their 50 hours of observation, 15 semi-structured interviews and policy document analysis, the authors found that older people considered their entire social situation and context in their understanding of fall risk. Older people embedded the experience of fall risk in the context of broader personal and social risks, such that study participants at times prioritised their portrayal of independence even if this put them at risk of falling. These findings suggest that health-care practitioners must look beyond their typically biomedical and reductionist notions of fall risk in order to consider the broader meanings and contexts that shape older peoples' actions more generally.
The perspectives of older people regarding fall risk and fall prevention were also explored in a study by Yardley et al. (Reference Yardley, Donovan-Hall, Francis and Todd2006). These authors conducted focus groups with 66 older people from a variety of European countries to better understand their views regarding advice about falls. Older participants considered a much broader perspective in self-reflection about risk and felt that admitting the self-relevance of fall prevention information might constitute a threat to their autonomy and identity. Building upon a broadened perspective of risk-taking, Horton and Arber (Reference Horton and Arber2004) and Horton (Reference Horton2007) investigated the understanding of fall risk by older people specifically in relation to their identities. These authors found that older peoples' gender, fundamental to identity, influenced their decisions and perceived level of control in risk-taking behaviour. Older men believed themselves to exercise rational decision-making processes and control over risky behaviour, and women discussed their perception of risk in terms of external factors and pressures. Furthermore, participants' gendered relationships impacted the ways in which they related to family members regarding support and encouragement to engage in fall prevention activities.
More recently, Berlin Hallrup et al. (Reference Berlin Hallrup, Albertsson, Tops, Dahlberg and Grahn2009) conducted an interpretive phenomenological study of 13 frail older women's experiences of living with fall risk. These authors found that study participants experienced a changing body and focused on recognising their social value to others despite their perceived need to take caution in their activities on a daily basis. The body and its meaning in and through the lives of the older women in this study figured prominently in the meanings they attributed to fall risk and falling, suggesting that the meanings of an ageing body should be built into approaches to fall prevention that seek to resonate with the experiences of older people. The broadened perspective of ‘risk-taking’ supported by these studies suggests that older people appear not to think about their behaviour specifically with respect to fall risk, but with respect to their self and social experience in general.
Together, these findings suggest that older people think about and experience fall risk in ways that are very different from the biomedical understandings of risk that inform health professional practice (Ballinger Reference Ballinger2002; Ballinger and Payne Reference Ballinger and Payne2000; Ward-Griffin et al. Reference Ward-Griffin, Hobson, Melles and Kloseck2004). While we cannot review every study in the literature addressing subjective perspectives and experiences of older people related to falls and falling (for a comprehensive review, see McMahon, Talley and Wyman Reference McMahon, Talley and Wyman2011), we interpret three key themes from previous research in this area as informing our approach to this study. First, efforts to understand older peoples' experiences of fall risk and falling must explicitly recognise the variety of social relationships and contexts that shape the meanings of self and ageing through social interaction. These social contexts include the home, family, community day programmes and the many other social situations through which meanings are exchanged on a daily basis in the life of an older person (Ballinger and Payne Reference Ballinger and Payne2000; Breheny and Stephens Reference Breheny and Stephens2012; Dollard et al. Reference Dollard, Barton, Newbury and Turnbull2012). Second, the body is what is most clearly affected by falling and fall risk, and it is in reference to the body that older people understand and experience fall risk (Berlin Hallrup et al. Reference Berlin Hallrup, Albertsson, Tops, Dahlberg and Grahn2009; Katz Reference Katz, Casper and Currah2011). The body must thus be considered as a clear focus in studies seeking to understand the meaning and significance of fall risk in older peoples' lives. Finally, the qualitative study of perceptions and experiences of older people related to fall risk and falling should be integrated into a broader understanding of how health-care practitioners might approach their practice in meaningful ways. This practical import of qualitative studies exploring fall risk is not always made clear.
In this study we sought to answer the question: what is the meaning of the experience of anticipating falling for older people living independently in the community? We chose to focus specifically on ‘anticipation’ because it reflects the experience of looking towards the future in everyday life. As the work of Martin Heidegger might suggest, our pre-reflective (non-conscious) experience of anticipation is central to our being ‘thrown’ into the world, to our experience of living and ageing in time (Heidegger Reference Heidegger1962). The experience of growing older in time provides a context for understanding the experience of living with fall risk as both an individual and socio-cultural phenomenon. As such, a phenomenological focus on the experience of ‘anticipation’ helps to integrate the key themes identified above, permitting a focus on the phenomenological (non-conscious) meaning of the body in understanding fall risk in relation to the social interactions and cultural constructions of risk that inform older peoples' experience of living with the risk that they might fall.
In a 2011 book chapter, Stephen Katz suggested,
we have bodies, which age, but we also have embodied lives whereby we create subjective phenomenological dimensions of meaning and identity. As embodied subjects, we are reflexively bound to make intelligible the physical changes and passages of life through which we experience living in time. (2011: 188)
This quotation reflects the importance of integrating understandings of phenomenological dimensions of embodied subjects with the symbolic social and cultural meanings that help to frame the experience of living with fall risk. Studying the intersection of these dimensions of meaning in the experience of older people may be understood as a cultural phenomenology (Csordas Reference Csordas, Weiss and Fern Haber1999), seeking to inform public health practitioners about the ways in which fall risk is experienced in order to help enact a more understanding and person-centred approach to fall prevention.
Before introducing the methodology for this study in more detail, a few comments are warranted about how the study findings might be interpreted to inform health professional practice. Discourses of patient-centred or consumer-centred care have been dominating the health-care delivery literature for some time, raising questions about the unintended consequences of such dominant ideas (Todres, Galvin and Dahlberg Reference Todres, Galvin and Dahlberg2007). Specifically, these discourses of patient or consumer-centredness take the meanings of issues such as health, illness and wellbeing for granted within the traditional framework of the biomedical model, creating complications for issues related to everyday meaning and activity such as fall risk and fall prevention. As the literature summarised above suggests, older people do not understand fall risk and fall prevention in traditional biomedical, reductionist ways. As such, an approach to health-care delivery that can understand and address the meaning of fall risk for older people likely needs to embrace the subjective social and contextual interpretations of fall risk and falling as expressed by older people themselves.
Lifeworld-led care is an approach to health services delivery that seeks to take the existential meanings of peoples' everyday experiences as the starting point for care (Todres, Galvin and Dahlberg Reference Todres, Galvin and Dahlberg2007). Practitioners working within a lifeworld-led approach thus first and foremost make the effort to interpret and understand the meaning of peoples' everyday experiences in order to address more fully and authentically those experiences in care. This moves beyond a patient or consumer-centred approach to care by viewing the person engaging in care existentially as a person, not as a ‘patient’ or ‘consumer’ that exists purely in relation to the health-care system. Such a perspective means that health-care practitioners make greater effort to ‘meet people where they are’ in their everyday activities, understanding the needs and wishes that help to construct meaning in their lives. Our phenomenological study of the experience of anticipating falling fits within this lifeworld-led approach to care, encouraging practitioners to understand the meaning of living with fall risk and falling for older people in the community when engaging in efforts to prevent falls.
Methodology
Max van Manen's phenomenology of practice (1990, 2007) formed the methodological orientation for this study, and insights from social and cultural phenomenology were integrated into the analysis and interpretation (Csordas Reference Csordas, Weiss and Fern Haber1999; Schutz Reference Schutz1953). Specifically, we emphasised the socio-cultural nature of meaning in the common-sense way of living in the world for our participants. Our interview questions and analysis sought to illuminate the taken-for-granted meanings underlying the experience of anticipating falling, focusing on the ‘natural attitude’ of the everyday lifeworld (Schutz and Luckmann Reference Schutz and Luckmann1973). These taken-for-granted meanings provide structure and order to our everyday experiences, and were thus the focus of our phenomenological inquiry (Schutz and Luckmann Reference Schutz and Luckmann1973).
In order to interpret reflexively the meaning of the (social) lived-experience of anticipating falling, a hermeneutic orientation was explicitly adopted (van Manen Reference van Manen1990). van Manen's hermeneutic approach to phenomenological research suggests that researchers must pay attention to more than the objective, rational knowledge which is typically sought during scientific research. Instead, his hermeneutic approach seeks pathic knowledge, that is, the embodied ‘lived dimension: our “moods” or ways of being in the world’ (van Manen Reference van Manen, Madjar and Walton1999: 31) described by study participants in order to interpret the meaning of the experience in question. From a hermeneutic perspective the essence of the lived-experience can be re-presented in phenomenological writing, but can never be considered absolute or complete. As such, the goal of phenomenological inquiry in this study was to describe as best as possible the evocative accounts of participants' experience of anticipating falling, in order to inspire a more sensitive, empathetic approach to professional practice.
Ethical considerations
The context of this phenomenological inquiry was a naturally occurring retirement community within a medium-sized Canadian city. This study was approved by the Research Ethics Board of The University of Western Ontario. We ensured that all participants provided prior informed consent for audio-recorded interviews and use of anonymous data for analysis, interpretation and dissemination. Pseudonyms have been used in reporting the findings.
Participants and sampling strategy
The purposeful sample recruited for this study included nine older people over the age of 65 living independently in the community (Coyne Reference Coyne1997; Patton Reference Patton1990). We purposefully recruited participants through a local senior's community centre who maintained their engagement in physical and social activities. In so doing, we sought to explore the meaning of anticipating falling in the context of efforts to maintain physical mobility and social relationships and functioning. While all participants were involved in recreational activity maintaining physical and social participation, we sought a diversity of ages (65–94 years) and both genders (seven women, two men) in order to explore the meaning of the experience across these diverse participants. We sought to achieve such diversity in participant characteristics to encourage the interpretation of shared meaning by seeking commonalities amongst the narrative experiences of diverse participants (van Manen Reference van Manen1990).
All participants had completed high school education. All participants lived independently in the community. One participant, an 84-year-old man, was living with Charcot-Marie-Tooth Disease, a neuro-degenerative condition that affected his mobility, but maintained his functional independence with the use of assistive devices (a single point cane and a standard walker). A total of three participants used either a single point cane or walker for independent community mobility. Four of the nine participants had experienced at least one injurious fall within the past five years, and all had experienced a non-injurious fall within the past three years. The lived-experiences of these falls and their consequences were explored in each interview.
Data collection
A single in-depth individual interview ranging in length from 50 to 90 minutes was conducted with each participant between August 2009 and April 2011. All interviews were completed by the first author and took place in participants' homes. The initial ‘phenomenological’ interview (van Manen Reference van Manen1990) focused on open-ended questions eliciting stories and descriptions of concrete lived experiences representative of older adults' experience of anticipating falling, seeking participants' thoughts and feelings about falling; the potential impact of falling; and what the risk of falling meant to them. Participants were also asked about their social context during the interview, including their social network (friends and family support), social and physical activities, living environment, work life/retirement and general health. All interviews were audio recorded and transcribed verbatim.
In accordance with phenomenological methods, a follow- up ‘hermeneutic’ interview (van Manen Reference van Manen1990) was completed with two participants after all initial interviews had been completed. Two particularly insightful participants were asked to participate in these second interviews. These collaborative interviews provided an opportunity to reflect in conversation with the participants on the findings of past interviews, creating a deeper understanding in order to achieve further interpretive insight (van Manen Reference van Manen1990). Hermeneutic reflection in conversation with participants helps to provide a reflective understanding of the experiences described during initial interviews, which were focused on eliciting daily lived-experiences without encouraging any critical reflection (van Manen Reference van Manen1990). The goal of the second interview was to determine whether select themes that had emerged throughout the interviews resonated with select participants and whether any new phenomenologically meaningful themes would emerge through further discussion. As these two participants conveyed that the interpretation resonated with their own lived-experience and no new themes emerged, no further data were collected.
Data analysis
Data were analysed using both the holistic/sententious approach and the selective/highlighting approach as discussed by van Manen (Reference van Manen1990), in conjunction with mind mapping methodology (Burgess-Allen and Owen-Smith Reference Burgess-Allen and Owen-Smith2010; Northcott Reference Northcott1996). In the holistic/sententious approach, we interpreted the meaning of the interview as a whole. In the selective/highlighting approach we interpreted particular stories and phrases that were emphasised as meaningful by participants. Immediately after each interview was conducted the interviewer listened to the entire interview and made reflective notes on details of the conversation and any immediate interpretations. Reflexive memos were written to identify explicitly which assumptions may be influencing interpretations of the data, recognising the inherently practical orientation of the researchers, who belong to the disciplines of physiotherapy and nursing (van Manen Reference van Manen1990). Participants' descriptions of experiences, behaviours, decisions, thoughts and feelings were initially coded on printed transcripts as a simple, common-sense interpretation of what was being said. As common interpretations emerged within and between transcripts, themes were established to characterise phenomena that appeared to be a part of the experience of anticipating falling.
A third level of analysis was conducted using the mind mapping methodology. That is, a ‘mind map’ or ‘cognitive map’ was created for each interview individually, providing a visuo-spatial depiction of the inter-relationships between the themes present in the interview (Buzan and Buzan Reference Buzan and Buzan2002; Northcott Reference Northcott1996). To synthesise themes into hermeneutic interpretations of the lived-experience of anticipating falling, recurring themes from the written analysis and the mind maps were brought together in a written phenomenological description (van Manen Reference van Manen2006). While the interpretation of the meaning of the experience in question may never be considered satisfactorily complete, the final interpretation of this study was created in the writing of the findings (van Manen Reference van Manen1990). Each step of this comprehensive analysis strategy was completed with peer review by the co-authors, who suggested refinements promoting coherence and cogency.
Rigour
We pursued consistency and coherence between the philosophical underpinnings of the selected research methodology and the interpretive knowledge claims arising from this research as the primary indicators of rigour (Caelli Reference Caelli2001; Holloway and Todres Reference Holloway and Todres2003). Our paradigmatic position suggests that hermeneutics is a fundamental element of all social inquiry, as all experience and knowledge are based upon interpretation (van Manen Reference van Manen1990). As such, we chose to apply van Manen's (Reference van Manen1990) approach to phenomenological human science for its resonance with our interpretive paradigmatic position. We drew upon van Manen's discussions of pathic ways of knowing (1999), phenomenological writing (2006) and the phenomenology of practice (2007) to guide our interpretations and presentation of the findings. In so doing, we have made every effort to integrate the interpretive language into the data collection, data analysis and implications derived from this study. By seeking to re-present the findings as a meaningful gestalt of the experience of anticipating falling within the social context in which the inquiry was situated, we have sought to emphasise the interactive and social co-constitution of lived-meaning for the experience in question (Schutz and Luckmann Reference Schutz and Luckmann1973). To promote the attainment of these attributes of rigour (consistency and coherence), we applied two general principles: transparency, or the reflexive disclosure of all decisions made within the study, and systematicity, involving the regular and reflective returning to the data and our interpretations to better understand the emerging findings (Meyrick Reference Meyrick2006).
Findings: the meaning of anticipating falling
For older participants residing in the community, the experience of anticipating falling meant confronting their embodied lived-identity in the context of ageing. The essence of confronting embodied lived-identity was composed of three major themes. The first major theme was the centrality of embodied lived-identity to the experience of anticipating falling, understanding lived-identity as the performance of meaningful activities (sub-theme one) and the inter-subjective portrayal of self-image (sub-theme two). Participants sought to strive continually for health and independence (sub-theme three) in order to enable themselves to enact embodied lived-identity continually. The second major theme was experiential learning of the meaning of anticipating falling, as participants tacitly learned how falling may disrupt the body and thus lived-identity through their own personal experiences or by witnessing the experiences of others. The final major theme was preserving embodied lived-identity through caution, which was constituted by two additional sub-themes. The first sub-theme was fear of falling, describing how participants understood their fear of falling in relation to their embodied lived-identity. The final sub-theme was modifying meaningful activities, as participants altered activities in order to take caution in their lives while continuing to perform activities that were central to their embodied lived-identity.
Major theme one: the centrality of embodied lived-identity to the meaning of anticipating falling
For older people in this study, the experience of anticipating falling meant confronting their lived-identity. Lived-identity was conveyed as an embodied phenomenon that was central to their life-world, and confronting lived-identity through anticipating falling encouraged participants to enact ways to strive continually for health and independence. Such continued striving for health and independence in turn enabled participants to enact their embodied identities continually by performing meaningful activities and inter-subjectively portraying self-image. The following sub-sections illuminate the interpretation of performing meaningful activities and inter-subjectively portraying self-image in terms of their constitution of lived-identity, and then recounts the means by which participants described striving for health and independence in order to enable their enactment of these two inter-related elements of embodied lived-identity.
Sub-theme one: performing meaningful activities
When asked about their experience of anticipating falling, participants talked about their embodied lived-identity, conveying an urge to maintain the lived experience of self throughout and despite advancing age and any accompanying anticipation of falling. Lived-identity was understood by participants in part through the continued performance of activities that provide their lives with meaning. One participant described what it meant to enact her lived-identity by constantly keeping herself busy and active despite her advancing age:
Even this morning working out there, I can't do anything slow, I sweat fiercely doing it. Why don't I slow down, I'm 80 years old? All I can explain is, it's my nature. I don't know how else to, and I think once in a while, even if I sit down for a few minutes, I'll sit down and [get] right back up again [and] I'm doing where I left off. How do you explain that? (Wendy)
This participant conveyed pride in her identity, or nature, as someone who is always doing things, thereby reinforcing her re-presentation of identity in terms of the way in which she enacted it, the way in which she performed her self through bodily movement. Her discussion recounted being someone who is active; active with physical activity, with errands and with social involvement, emphasising the important contribution of performing meaningful activities to the constitution of her lived-identity. Through her emphatic discussion of meaningful activities, she portrayed embodied lived-identity as central to her life-world in the context of ageing.
Confronted with questions of anticipating falling, another participant also emphasised the importance of being able to perform her identity through activities considered to be defining features of her self:
I don't want to hinder my ability to walk and drive and live the way I do because I think I'd be devastated. (Shirley)
As participants discussed their selves in relation to the meaning of anticipating falling, they illuminated the importance of self-affirming experiences and thus enacting lived-identity through the embodied performance of meaningful activities that would be undermined by the perceived consequences of falling or fear of falling. As such, the continued performance of meaningful activities, contributing to the constitution of lived-identity, was confronted by participants in the experience of anticipating falling as they felt their performance of meaningful activities (and thus embodied lived-identity) was disrupted in the experience of living with fall risk or the consequences of falling.
Sub-theme two: inter-subjectively portraying self-image
The meaning of anticipating falling was also understood by participants in terms of defining self by the experience of portraying ones' bodily self-image to those around them, and how this inter-subjective experience was felt and perceived in the context of anticipating falling. The ability to inter-subjectively portray self-image as desired was essential for older participants' enactment of embodied lived-identity, and participants confronted their ability to portray self-image in their experience of anticipating falling. In discussing how she had decided not to use a cane while out shopping in the community, another participant stated:
You have to learn. I have to learn to accept everybody to know that I need help [with walking] … And when [my daughter and I] go places I know how slow I am. So sometimes [she'll] take me by the arm, and given the extra security I know I can go faster. And here [in the retirement community], I'm better and faster than a lot of people so that's a bit deceiving, because I begin to feel I'm okay, I can go, I can go quicker. And so there are two worlds that you're living. The slow one, and everybody knows you're slow, and here, some people think you are fast. (Rachel)
This participant storied the meaning of anticipating falling by relating her experience of self as social, presenting her lived-identity as someone who wants to protect the way she is perceived by others despite her awareness of her potential for falling. For her, being able to perform the things she needed and wanted to do was important, but she tacitly recognised that alongside the need for the experience of enacting one's self is the need to have others recognise her as a person who can do so. Her understanding of the perceptions of others seemed to underpin her construction of what she felt she could and could not do in relation to those around her, reflecting a profound and recognised dependence on her social environment. She did not seem upset by this, but embraced it as a part of her life, further conveying the centrality of embodied lived-identity to participants' life-world in the context of ageing.
Yet another participant portrayed how her self-image in relation to anticipating falling was co-constructed by those around her:
Well [my daughter] gets mad at me because I won't use a cane, but I feel so self-conscious with a cane [that] I just use it when I go shopping. (Paula)
Participants often discussed how important it was to them to present their embodied identity as capable, independent and youthful. Their feelings of being different from others around them reflected their experience of the meaning of anticipating falling by their rejection of aids for walking to convey their feeling of pride in the way they are perceived to be able. This finding further suggests that participants confronted their continued abilities to enact embodied lived-identity, here through their continued portrayal of self-image, in the experience of anticipating falling.
Participants constructed images of their embodied identities that emphasised different elements of a dynamic or performative concept of self in the context of ageing. A rudimentary image of the experience of embodied lived-identity in anticipating falling seemed to raise a spectrum of accounts of identity, with one end emphasising actions and behaviours that reinforce a sense of self, and the other end emphasising the images and constructions of self that are reflected back towards someone by others in their surroundings. As embodied lived-identity was central to the life-world in the context of ageing, the lived-experience of anticipating falling was understood by participants through a confrontation of their embodied lived-identities, as they sought to establish ways to enact continually lived-identity along with and despite the experience of living with fall risk.
Sub-theme three: continually striving for health and independence
Participants felt that they were enabled to continue enacting their embodied identities when they maintained their health and independence, as these were understood as essential to performing the activities participants found meaningful and inter-subjectively portraying their self-image as desired. As such, participants constructed the continual achievement of health and independence as the means by which they could ensure their bodily capabilities to enact their lived-identity continually. One participant discussed the centrality and importance of maintaining health and independence, reflecting her felt desire to maintain the ability to enact her lived-identity:
I want to be healthy. I have an 87-year-old aunt who I say [is] failing … She fell in the doctor's office and those things just make me think more cautiously. I want to live healthy, I don't care if I don't live a long time but I don't want to live depending on somebody. (Maurine)
For this participant, the experience of being healthy and independent was essential for her ability to continue enacting her embodied lived-identity. Without the ability to be independent, and thus perform her identity and enact those aspects of self that provide her life with meaning, this participant conveyed that she would feel her life might be devoid of meaningful quality. In this way, participants described continually striving for health and independence as a means of actualising embodied lived-identity in daily life; as a means of overcoming their confrontation of lived-identity. With embodied lived-identity as the focal point of the life-world, participants strove to achieve health and independence in order to enact their embodied lived-identity continually.
Major theme two: experiential learning of the meaning of anticipating falling
Study participants portrayed the meaning of anticipating falling as situated within their tacit experiential learning about falling, either personally or indirectly through the experiences of others in their social lives. Participants pathically integrated the derived self-referential meaning of these experiences into their present experience of anticipating falling, conveying their experiential learning in reference to embodied lived-identity. By so doing, these study participants created a personal understanding of the meaning of falling with respect to both the ability to perform meaningful activities and to uphold their sense of dignity and worth through the continuous projection of self-image. In discussing her own experience of a fall, one participant stated:
And then, of course, I had to accept the fact that I couldn't get my shoes on, I couldn't go places, and then I had to start support hose. It was a nuisance! So I think from that time on, I've been more careful and more aware of the fact that [a fall] could happen, and so suddenly. (Shirley)
This participant reflected on the most immediate bodily limitations in her ability to engage in meaningful activities after experiencing a fall, discussing generally how it was difficult to get out into the community. She continued her thought by stating that she had become more careful and aware, reflecting the integration of the meaning of the consequences of falling into her experience of anticipating falling. In order to support and enable her continued experience of lived-identity, she had internalised the experience of the consequences of falling through the construction of self-referential meaning regarding how her activities are limited after experiencing a fall. She connected this lesson learned experientially with being more careful and aware.
Another participant discussed the experience of falling in front of others:
Well, in front of other people, other seniors, falling is loss of dignity, in my experience anyway. (Doug)
This participant, a man with a neuro-degenerative disease that affected his mobility, discussed falling in reference to its impact on his ability to portray his self-image. As a sub-theme of lived-identity, participants' continual striving for health and independence included seeking to portray themselves in certain ways that were socially constituted to reflect their embodied lived-identities. For this man, the lived experience of falling meant not being able to enact his embodied lived-identity through the portrayal of self-image in a satisfactory way, creating a loss of dignity and a detriment to his efforts in achieving quality of life. This participant's experience re-presents the impact of experientially learning the consequences of falling, not only in terms of performing meaningful activities, but also in terms of the ability to inter-subjectively portray oneself as one desires.
Participants also drew on their observations of the experiences of others in constructing understanding of the meaning of anticipating falling. One participant explained how it was not just her own experience of falling, but the experiences of family and neighbours that impacted her understanding of the consequences of falling:
Oh, I guess it's all kind of a muddled picture and all these other factors kind of going on at the same time. And, well, maybe from my experience at [work in a hospital], you know, and another experience I remember, not of me falling but just the neighbour and another neighbour had a big dog, a nice friendly dog, but the dog was too friendly, and I can remember my mother saying ‘That dog is going to knock over [the neighbour]’…. This was when I was in high school and that happened and she broke her hip or something and she did not recover. So that was, [pause], gosh, break a hip and you die? (Nancy)
Through personal experiences of falling and observing the experiences of others, participants integrated the meaning of experiencing a fall into their experience of anticipating falling.
Major theme three: preserving lived-identity through caution
Participants expressed an implicit understanding of the consequences of falling in terms of its impact on their embodied lived-identity, discussing a fall for its potentially devastating impact on their ability to live their lives as desired. The meaning of the experience of anticipating falling was constructed pathically in the context of a tension between understanding the potentially severe consequences of falling and yet continually striving to engage in activities that provided meaning for their lives.
Participants who had salient fall-related experiences (either personally or socially) discussed the importance of continuing to perform meaningful activities regardless of perceived risk or vulnerability with respect to falls. Participants who had not had salient fall-related experiences did not construct vulnerability, anxiety or fear as meaningful aspects of their experiences of anticipating falling, and thus described lived experiences of anticipating falling that did not reflect anticipation in its traditional definitional sense. Conveying an effort to enable themselves to enact their embodied lived-identities continually, participants who did recognise their vulnerability to falling and/or the potentially devastating consequences of falling described the adoption of implicit lived-caution in daily activities.
Sub-theme one: fear of falling
Participants who described having salient personal experiences of falling varied in terms of whether and how they expressed being fearful of falling. While certain participants denied any fear of falling, others described their efforts to continue engaging in meaningful activity despite their fear that a fall might occur. One participant who denied a fear of falling, despite being cautious with mobility, stated:
It's not a fear, I just wouldn't want to [fall]. My concern is that I would be, my living would be curtailed, my lifestyle, but, you know, I don't have a fear. I don't think I worry about [falling]. You know what, I don't worry about anything really, you know. (Maurine)
This participant suggests that while she understands the meaning of the consequences of a fall in terms of limiting her ability to engage in meaningful activities, she does not experience any fear in her lived experience of anticipating falling. Despite her understanding that she might be vulnerable to experiencing another fall in the future, she denies the experience of fear that might otherwise arise from this understanding. This reflects the non-rational nature of anticipating falling, in that a gnostic knowing of the self-risk of falling does not necessarily translate into the pathic knowing or feeling of fear related to that risk. Rather, the tacit and implicit negotiation of gnostic or rational knowledge of fall risk with pathic or emotional experience seems to be embedded within a continual process of achieving oneself while ageing, that is, a process of enacting embodied lived-identity.
Another participant described the omnipresence of her fear of falling, which she attributed to multiple salient experiences with falls leading to fractures. She elaborated that even though she is fearful, she will not allow this to prevent her from engaging in those activities that she finds meaningful in her life, similarly revealing the negotiation between gnostic and pathic modes of constructing the self.
No nothing will stop me. I take a chance to do anything. [Fear of falling] doesn't bother me. This morning I got up and I thought I could hardly walk. But I still got up and went and swam for an hour … I won't let anything come between me [and my activities]. If I have to do something, I will do it. (Paula)
The meaning of her experience of anticipating falling focuses on her capacity to continue enacting her identity through bodily action in the face of her profound fear of falling, as she presents herself as a brave, independent and capable woman who can accomplish the tasks she believes she ought to do. Her fear seems to provide her with an opportunity to express her identity, to perform her self-image of self-determination towards those around her, despite her lived-fear and fall risk.
Other participants denied any self-understanding of vulnerability to falling, in which case no fear or anxiety with respect to falling was discussed.
I never think about [falling] … It never occurred to me that I would fall and break my neck or something … I think that I kept walking and I think that my muscular system is in better shape than most of the older people here [at the retirement community] certainly, because I notice they have an awful time walking or doing, moving around, and I think it's a shame. (Nell)
Without any salient experiential learning to draw from in understanding the self as vulnerable to experiencing a fall, this participant had never considered the notion that susceptibility to falling is something that might be considered as she ages. Instead, she achieved her embodied lived-identity in ageing without consideration of vulnerability, anxiety or fear regarding anticipating falling.
Sub-theme two: modifying meaningful activities
Participants who understood themselves as vulnerable to experiencing a fall discussed minor modifications to engaging in meaningful activities in order to continue performing these activities and their embodied lived-identities. These participants portrayed their adoption of generalised cautious habits in daily life, or lived-caution, as a way-of-being that was compatible with their lived-identities and would enable their continued participation in self-affirming activities. Other participants who did not seem to understand themselves as vulnerable to falling, but who have had salient experiential learning regarding falling and its consequences, also discussed lived-caution in daily activities:
Well, like, [the chance of falling is] there anyway in my mind and I see [falls] happening many times [at retirement homes]. So I don't have to make a conscious effort at all … I think safety has always been a factor I've considered … I just try to be sensible and, you know, make sure that I am doing things that are safe and things like that as much as possible. I mean, if things happen beyond my control, then I'll deal with that at the time and I will try and keep the right frame of mind and handle things as they happen. (Robert)
Integrating safe habits through cautious actions was discussed by participants as the primary way to enable the continued experience of embodied lived-identity. Participants did not discuss this explicitly as a strategy to prevent falls, even though it has this potential. Participants discussed caution in terms of what it enabled them to do in their daily lives, as opposed to what it prevented from occurring (i.e. a fall).
Discussion
Confronting embodied lived-identity in the context of ageing composed the central theme in this phenomenological study, suggesting that identity and how it is lived-through in everyday life is essential to understanding the meaning of the lived-experience of anticipating falling (and is therefore essential to enacting a lifeworld-led approach to fall prevention care). Specifically, older participants discussed two conceptually distinct aspects of embodied lived-identity emerging as essential elements. The first element of identity, the performance of meaningful activities, re-presented the inner experience of self which acts and reacts towards the world. The second element of identity, the inter-subjective portrayal of self-image, re-presented participants' understanding of the self in relation to significant others in social contexts, or their self-understanding derived from how others act towards them. It is important to emphasise that these two elements of identity are only conceptually or analytically distinct, and that they cohere through the body and bodily action in a gestalt ‘whole’ in the actual lived-experience of identity. Participants sought to continually enact this gestalt experience of embodied lived-identity as a central element of their life-world.
Analyses of identity found in much contemporary theory and philosophy have been derived from the pioneering work of George Herbert Mead, whose distinction between personal and social types of identity have pervaded sociological explorations of identity (Aho Reference Aho1998; Jenkins Reference Jenkins2008). Mead ([Reference Mead1934] 1962) provided the conceptual or analytic distinction between the ‘I’ and the ‘Me’ aspects of identity, roughly corresponding to the two aspects of identity found in this phenomenological study. The ‘I’ aspect refers to the inner monologue, the inner experience of the continuity of self, resonating with the performance of the meaningful activities element of lived-identity found in this study. The ‘Me’ aspect refers to the way people understand and see themselves through the imagined eyes of others, resonating with the inter-subjective portrayal of the self-image element of lived-identity found in this study. While these are perhaps rough comparisons, they are intended to have analytic benefit as opposed to ontological similarity.
Importantly, it is in the relationship between these two strictly analytic categories (the ‘I’ and the ‘Me’) that self emerges (Jenkins Reference Jenkins2008), co-constituting the essence of embodied lived-identity as a gestalt experience that is enacted in and through the body. As the participants in this study revealed, it is through the convergence of both their meaningful actions and their inter-subjectively constructed self-image that an understanding of their embodied lived-identity is established. Furthermore, these participants portrayed this construction as dynamic, that is, as a continual process of enacting the self in the context of ageing. Thus, it may be more apt to interpret lived-identity in terms of this continual process of constructing one's identity: as identification, denoting a process, as opposed to identity, denoting a static state (Hockey and James Reference Hockey, James and Tulle2004; Jenkins Reference Jenkins2008). Such an interpretation of the notion of identity coheres with a phenomenological concept of embodied experience, in that we are always changing and thus always becoming as our bodies interact with our environmental context in meaningful ways (Heidegger Reference Heidegger1962; van Manen Reference van Manen1990). Overall, this continual process both shaped and was shaped by the experience of anticipating falling for the older people who participated in this study.
Issues of identity have been raised previously as primary concerns for older people in the context of fall risk and prevention (Berlin Hallrup et al. Reference Berlin Hallrup, Albertsson, Tops, Dahlberg and Grahn2009; Hanson, Salmoni and Doyle Reference Hanson, Salmoni and Doyle2009; Yardley et al. Reference Yardley, Donovan-Hall, Francis and Todd2006). A recent meta-ethnography of nine qualitative studies exploring older peoples' experiences and perspectives of living with fall risk found life change and identity to be a central theme across studies (McInnes, Sears and Tutton Reference McInnes, Seers and Tutton2011). In the context of ageing, the risk of experiencing a fall has been found to be an important signifier of unwelcome changes to a person's sense of self (Ballinger and Payne Reference Ballinger and Payne2000), reflecting the potential labelling of a person as a ‘faller’ and indicating their lack of control over how they are identified (labelled) by family, peers and professionals alike (Hanson, Salmoni and Doyle Reference Hanson, Salmoni and Doyle2009; Katz Reference Katz, Casper and Currah2011). Often this new label is bound up with meanings of loss of independence and autonomy, amounting to the perceived loss of personal agency amongst older people in determining the way they are understood by others (Hanson, Salmoni and Doyle Reference Hanson, Salmoni and Doyle2009; Jolanki Reference Jolanki2009). The finding of our phenomenological study that older people enact and enable embodied lived-identity as a central element of their life-world, as both the performance of meaningful activities and the inter-subjective portrayal of self-image, suggests added emphasis and attention to their continued identification is warranted in fall prevention programmes.
The findings of our phenomenological study related to embodied lived-identity inform three specific recommendations that resonate with a lifeworld-led approach to fall prevention care. First, our study suggests that older people understand their lived-experience of anticipating falling in reference to their embodied lived-identities as being a continual process, always being performed in everyday life. When health-care practitioners interact with older people they are thus inserting themselves into older peoples' processes of performing identity in everyday contexts. Simple advice to avoid activities that health-care practitioners might view as putting older people at risk, such as gardening, shovelling snow, decorating the home with throw rugs, etc., thus have the potential to interfere significantly with how older people understand themselves. Health-care practitioners' efforts to limit the risky activities undertaken by older people could thus include some alternative less risky activities that might enable them to continue performing their identities in other ways. By suggesting a new ‘safer’ activity to replace a current ‘risky’ one, health-care practitioners have greater potential to contribute to older peoples' lifeworlds in meaningful ways. However, this contribution requires a sensitive understanding of what is meaningful in each client's life, and thus requires practitioners to remain attuned to what is meaningful and why for each older person with whom they work (Todres, Galvin and Dahlberg Reference Todres, Galvin and Dahlberg2007).
Second, health-care practitioners can emphasise the ways in which particular activities might contribute to older peoples' abilities to continue enacting their lived-identities. Exercise and training programmes oriented to preventing falls might instead be oriented to active healthy living or improved functional mobility, thus enabling older people to understand how such programmes contribute to enabling their continued performance of meaningful activities (Yardley et al. Reference Yardley, Donovan-Hall, Francis and Todd2006). As opposed to emphasising what these programmes prevent (i.e. falling), such messaging would emphasise what these programmes can enable (i.e. continuing the activities that are important to you). An important caveat here is that such programmes ought to be targeted to older people of all functional capabilities, not only those who can already perform a variety of physical mobility-related tasks. When older people are excluded from such programmes due to lack of physical capabilities, their abilities to enact lived-identity are likely further damaged, leading to further detriments to quality of life (Katz Reference Katz, Casper and Currah2011; Layborne, Biggs and Martin Reference Laybourne, Biggs and Martin2008).
Finally, a fundamental aspect of older peoples' performance of embodied lived-identity is portraying themselves to others in meaningful ways. One important means by which health-care practitioners can more sensitively consider older peoples' embodied lived-identities during fall prevention efforts is to avoid displaying their tacit or explicit labelling of older people as ‘being at risk’ in front of others. This awareness of how service providers' actions affect older peoples' abilities to inter-subjectively portray self-image can avoid negatively affecting how older people are able to influence the ways in which they are perceived by others. Laybourne, Biggs and Martin (Reference Laybourne, Biggs and Martin2008) point out that most fall prevention intervention trials do not account for effects of participation in fall prevention activities on participants' quality of life. Further attention to embodied lived-identity as an ongoing process of identification during the provision of fall prevention activities can ensure that service providers are taking the quality of life of their older clients into account while encouraging mobility and safety in preventing falls.
Experiential learning and anticipating falling
As is illuminated by the findings of this study, the meaning of the experience of anticipating falling is derived from self and social (vicarious) experiences of falling. It was through a process of making meaning out of these experiences that the study participants arrived at diverse experiences of fear of falling and modifying meaningful activities accordingly.
Qualitative studies by Tischler and Hobson (Reference Tischler and Hobson2005) and Lee, MacKenzie and James (Reference Lee, MacKenzie and James2008) suggest that older people develop fear of falling primarily through directly experiencing a fall. The embodied experience of the fall itself and the consequences of fall-related injuries are integrated into the lived-knowledge of older people, leading to an implicit understanding that falls should be avoided. Some older people have reported feeling that they are not in control of preventing falls, but that falling is a natural symptom of ageing (Evron, Schultz-Larson and Fristrup Reference Evron, Schultz-Larson and Fristrup2009; Lee, MacKenzie and James Reference Lee, MacKenzie and James2008). Older persons who have not experienced a fall themselves, but have seen others live through a fall and its consequences, have also reported this perspective (Evron, Schultz-Larson and Fristrup Reference Evron, Schultz-Larson and Fristrup2009). Waiting for, or anticipating, an event that may dramatically alter one's life might elicit emotions of anxiety and fear. In our phenomenological study, older people who perceived themselves to be vulnerable to falling reported the internalisation of a tacit awareness of the consequences of falling into their daily embodied experience. While this did not necessarily lead to a fear of falling, it did lead to a heightened caution in daily activities; importantly, this did not mean a limitation in daily activities, but rather a modification of them.
A key implication of this insight resonating with a lifeworld-led approach to fall risk assessment is that risk factors such as ‘history of falling’ might be transformed from a simple quantitative risk factor into a conversation about the pathic, non-cognitive meaning and significance of a fall experience. Such a conversation would address the implications of the fall experience or other ‘risk factors’ for risk-taking activity and lived-caution in the older person's life. Framing fall risk assessment as understanding the pathic meaning and significance of the interplay of ‘fall risk factors’ in the lived-experience of older people may help health-care practitioners to carefully see older people situated within their life contexts, seeking a deeper understanding of the meaning of fall risk and fall prevention in their everyday lives. Such a deeper understanding may be essential to gaining insight into how an older person views their enactment of embodied lived-identity, thus providing a starting point for fall prevention dialogue that seeks to affirm lived-identity in ageing while helping to mitigate unnecessary risk of falling.
Limitations
One limitation in particular should be mentioned to contextualise interpretations of our phenomenological study. First, we recognise that the ability to recall events related to falls and falling might have been affected by cognitive decline in our participants. We did not administer any kind of cognitive assessment in order to determine eligibility, but simply included the ability to converse in English as our inclusion criteria. Understanding our participants' levels of cognitive functioning may have contributed to our ability to interpret the findings of the study with greater confidence. Future research might examine phenomenologically how the meaning of events such as a fall experiences change over time and vary over a range of levels of cognitive functioning.
Despite the potential benefits of a lifeworld-led approach to fall prevention for promoting embodied lived-identity, an important caveat and area of further investigation must be raised. Older people tend to glorify youthful accounts of identity in ageing, creating ideals of ‘successful ageing’ that are impossible to achieve (Gilleard and Higgs Reference Gilleard and Higgs2010; Jones and Higgs Reference Jones and Higgs2010; Katz Reference Katz, Casper and Currah2011; Twigg Reference Twigg2006). By over-emphasising function, mobility, independence and autonomy, fall prevention programmes may contribute to reifying a contradictory account of identity in ageing that older people will inevitably be unable to perform, leading to disappointment and depression in the future. The ways in which fall prevention programming may help to prevent falls and encourage embodied lived-identity while nonetheless attending to the inevitable bodily decline of the “fourth age” in very late life warrants much more consideration.
Conclusion
In keeping with van Manen (Reference van Manen1990), the implications of our study regarding the relevance of embodied lived-identity to older people at risk of falling raise important questions regarding how health service providers might tactfully approach fall prevention with older clients. While many older people and health service providers understand the potentially devastating consequences of falling and wish to prevent them (Mackenzie Reference Mackenzie2009; Salkeld et al. Reference Salkeld, Cameron, Cummings, Easter, Kurrie and Quine2000), the ways in which fall prevention programmes are enacted requires critical re-consideration. Specifically, adopting an approach to fall prevention that emphasises lifeworld-led care (Todres, Galvin, and Dahlberg Reference Todres, Galvin and Dahlberg2007) may encourage health service providers to understand better the impact of fall prevention initiatives on older peoples' embodied lived-identities and quality of life. Future research in this area might explore further the enactment of fall prevention initiatives informed by a lifeworld-led approach to care.
This paper has presented original phenomenological research that explored older persons' experiences of anticipating falling. This work raises the importance of embodied lived-identity to this experience, and hence, to health and social services and care aimed at risk reduction and fall prevention. Health service providers concerned about falling in later life confront the challenge of recognising how they may impact upon the health and quality of life of older clients for whom embodied lived-identity is a continuous priority. By fostering open critical reflection about the meaning of falling, fall risk and fall prevention with older people, health-care practitioners may succeed in working with older people to achieve fall risk education and health promotion. Further inquiry into the implications of a lifeworld-led approach to fall prevention with older people will continue to provide insight into fall prevention strategies that affirm embodied lived-identity in ageing.
