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ORIGINAL ARTICLE

A model of event-generated dependence in older adults Kathleen L. Patusky

PhD, APRN-BC

Assistant Professor, School of Nursing, University of Medicine and Dentistry of New Jersey, Newark, NJ, USA

Submitted for publication: 2 June 2006 Accepted for publication: 13 December 2006

Correspondence: Kathleen L. Patusky School of Nursing University of Medicine and Dentistry 65 Bergen Street Newark NJ 07101 USA Telephone: þ1 973 972 9256 E-mail: [email protected]

P A T U S K Y K . L . ( 2 0 0 7 ) International Journal of Older People Nursing 2, 171–179 A model of event-generated dependence in older adults Aims and objectives. The proposed model of event-generated dependence characterizes dependence in older adults as an emergent phenomenon that may arise from interaction between the older adult with compromised health and the social environment, resulting in altered reciprocity. Background. Pejorative characterizations of dependence in older adults influence nursing care negatively. Concept analyses recommend the recognition that dependence is interactive in nature, not an inherent trait of the individual, and that dependence involves changes in interpersonal reciprocity. Conclusions. The model provides a testable causal path between dependence and psychological outcomes. Relevance to clinical practice. The event generated dependence model can sensitize nurses to an alternative view of dependence. It is important for nurses to recognize their role in determining the social environment of care, attend to the promotion of reciprocity with older adults as care is provided, and incorporate changes in their attitudes toward inequitable reciprocity.

Key words: ageing, dependency, reciprocity, relatedness

Introduction The health care of older adults is compromised when nurses and other health care providers label the patient as ‘dependent,’ then provide care that is influenced by this pejorative attribution. Older adults fear being dependent on others and see independence as important to their quality of life (Clark, 1991; Baltes, 1996; Mack et al., 1997; Grainger, 2004). The literature has addressed such issues as older adults’ desire to make a difference (Carlson et al., 2000), the influence of involvement in decision-making on older patients’ satisfaction with health care (Pipe et al., 2005), and the loss of motivation that can result from loss of autonomy and increasing dependence (Hazif-Thomas & Thomas, 2004). Yet despite the recognition that dependence has a negative influence on clients, and that nurses have the potential to mitigate it, the literature still notes that nurses and other

health care providers contribute to the development of dependence (Baltes, 1996; Flanagan & Holmes, 1999; Williams et al., 2004). At the root of the problem is a set of attitudes arising from entrenched beliefs about dependence. Particularly in Western society, adults are assumed to exercise the ‘optimal’ state of independence or autonomy, with dependence identified as a suboptimal or immature state (Munnichs & Van den Heuvel, 1976; Gurian & Gurian, 1983). Dependence has been regarded generally as a negative and inevitable consequence of ageing and chronic disability (Gignac & Cott, 1998). Older adults, viewed as non-productive because they are old (Klinefelter, 1984; Rowe & Kahn, 1999), have been stereotyped as ‘dependent.’ Yet the variability in the onset of dependence among the elderly, along with the potential for ‘successful’ ageing (Rowe & Kahn, 1999), should prompt us to re-examine our belief structure.

Ó 2007 The Author. Journal compilation Ó 2007 Blackwell Publishing Ltd

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Aims and objectives This article presents a model of event-generated dependence (EGD) that offers an alternative to traditional views of the phenomenon. In contrast to views that label dependence as a solely intrapersonal phenomenon, a personality style or character flaw, the model views dependence as an emergent phenomenon resulting from the interaction between the older adult and the social environment, residing within the interaction, not within the older adult. The EGD model does not presume behavioural or developmental inevitability, or pre-existing personality pathology; rather the EGD model addresses situational circumstances of the elderly that create the conditions within which dependence may emerge. Consistent with the above views, the EGD model is an application of the Theory of Human Relatedness (THR) (Hagerty et al., 1993), specifically the relatedness element of reciprocity.

Background In recent years, several authors have refuted the stereotype of the elderly as inevitably dependent (Munnichs & Van den Heuvel, 1976; Gignac et al., 2000), concluding that age and disability do not necessarily lead to a state of permanent dependence. Klinefelter (1984) argued that unless ‘dependent autonomy’ or ‘autonomous dependence’ is recognized as an inherent part of human experience, the elderly will be assigned to marginal social status. Rowe and Kahn (1999) noted that social biases regarding productivity based on paid labour should be replaced with an expanded definition of productivity that allows for recognition of the contributing activities of older adults. Movement away from a focus on older adults’ functional abilities, and toward recognition of the relational elements that influence both older adults’ experiences and the delivery of health care, has been encouraged (McCormack, 2001; Clark, 2002; MacDonald, 2002). Concept analyses of dependence (Munnichs & Van den Heuvel, 1976; Gurian & Gurian, 1983; Memmi, 1984; Bornstein, 1993, 1998) have refuted previous characterizations, specifically with regard to the valuation of dependence, interactivity and reciprocity. These concept analyses have concluded that dependence is neither ‘bad’ nor ‘good,’ but rather a natural phenomenon that is shaped by cultural, social and psychological norms. Bornstein (1993, 1995, 1998) concluded that dependence can be associated with positive, assertive traits, particularly in clinical settings, resulting in willingness to seek help when symptoms occur and to comply with treatment. A major theme in all the concept analyses has been the need to define dependence as a 172

social, interactive phenomenon, emphasizing the dependence unit as a dyad consisting of the dependent person and the provider as partners. Thus the nature of dependence is socially defined, not intrapersonally determined. Van den Heuvel (Munnichs & Van den Heuvel, 1976) was perhaps the first to categorize dependence as helplessness or powerlessness in a social/personal relationship involving unequal or non-reciprocal exchange. Gurian and Gurian (1983) expanded upon this concept, declaring dependence to be not a product, but a process of reciprocity requiring an external response. Life itself has been depicted as an ongoing process of ‘reciprocal dependencies that define and restrict the compass of our lives’ (Memmi, 1984, p.23), a process in which no one ever becomes completely adult in the sense that total autonomy or independence permits one to exist without relation to others. Mature dependence is distinguished from immature dependence by the presence of flexibility, reciprocity and situation-specific behaviour. Mature dependence has also been linked to connectedness and interdependence (Bornstein, 1998). Indeed, the act of receiving help need not be equated with dependence. For example, the exchange of services (e.g., housecleaning) for compensation (i.e., money), under conditions in which the person controls the amount and frequency of help, is not considered dependence (Gignac & Cott, 1998). Multiple studies have concluded that nurses have the choice of either inadvertently maintaining and fostering nursing home resident dependence, or supporting independence (Baltes, 1996). In one early study, comparing a traditional to an individualized approach in nursing care, Miller (1985) concluded that much of the dependence of geriatric in-patients could be iatrogenic, i.e., arising from environmental rather than physical or mental conditions, and could therefore be reversible. In fact, Bornstein (1995) proposed that future revisions of the Diagnostic and Statistical Manual of Mental Disorders reflect that the passive, submissive behaviour of dependent individuals currently described as ‘pervasive’ be characterized as situation specific. He later argued for lifespan developmental models that would ‘depathologize’ dependence (Bornstein, 1998). Thus, the conceptualization of dependence in older adults has moved from inevitable to multidimensional, multicausal and multifunctional (Horgas et al., 1996), and from the medical model of disability to a focus on the interaction between the older adult and the environment, including all elements that reinforce and perpetuate dependence (Gignac & Cott, 1998). The dependence of late life (when compared with childhood dependence) has been characterized as involving reciprocity that permits a greater capacity to request and accept assistance.


Event-generated dependence

Dependence has been reframed as a necessary part of family development, promoting mutual growth while providing the older adult with opportunities to exercise autonomy in decisions about the type and manner of assistance required (Motenko & Greenberg, 1995). The paradigm of selfregulated dependence has been posited to be an adaptive strategy for older adults in directing their own ageing process (Baltes, 1996; Horgas et al., 1996). Self-imposed reliance on others for some tasks may be characterized as a way to prevent pain or disability while conserving time and energy for other pursuits (Gignac & Cott, 1998; Gignac et al., 2000). In short, ‘Just as dependency on the caregiver in early life can be used to foster healthy development, dependency in late adulthood can, if conceptualized accurately and responded to appropriately, be an important part of successful ageing’ (Bornstein, 1998, p. 72). The importance of understanding dependence is highlighted by studies demonstrating a connection with negative psychological outcomes, particularly depression (Bornstein, 1993). The THR focuses on the individual’s perception of the quality of interface with relationships relative to the levels of involvement and comfort experienced. Four states of relatedness have been identified. Connectedness occurs when the relationship is experienced as high involvement and high comfort. Disconnectedness occurs with low involvement and low comfort. Enmeshment occurs with high involvement and low comfort, and parallelism occurs with low involvement and high comfort (Hagerty et al., 1993). Four primary elements have been identified as contributing to relatedness states: sense of belonging, mutuality, reciprocity and synchrony. Theorists posit that when levels of all four elements are high, individuals experience connectedness; when levels of all four elements are low, individuals experience disconnectedness. Varying levels of elements result in states of enmeshment or parallelism (Hagerty et al., 1993). The element of relatedness that appears most involved in dependence is reciprocity, defined as ‘the individual’s perception of an equitable, alternating interchange with another person, object, group, or environment that is accompanied by a sense of complementarity’ (Hagerty et al., 1993, p. 294). Two defining attributes of reciprocity have been identified: exchange and equity (Patusky, 2000). Dependence is posited to be a function of altered reciprocity, resulting in changes in relatedness states. Relatedness is thought to have a global and interactive influence on the human organism, such that biochemical alterations may occur in response to relatedness states (Perris, 1991). Direct and indirect support of links between relatedness phenomena, immunological and endocrinological status and psychopathology are found in the psychoneuro-

immunological literature (Hillhouse & Adler, 1991; Ur & Grossman, 1992). Theoretically, disruptions of reciprocity, resulting in dependence and changes in relatedness through an intermediate effect on biochemistry, may lead to conditions conducive to the appearance of psychopathological sequelae, including depression, anxiety and altered psychological adjustment.

Model of event-generated dependence Figure 1 depicts the model of EGD, with relationships shown among elements that operate around a major life event and may lead to an experience of dependence (Patusky, 2000). In the model, dependence is an alteration of interactional reciprocity resulting in an interpersonal system characterized by actual or perceived inequity or lack of exchange on the part of the recipient or the provider relative to a real or perceived recipient need. Specifically, a pattern emerges of perceived overbenefitting or underbenefitting by the recipient and chronic underbenefitting by the provider. This pattern, as a model element, is derived from exchange theory (Walster et al., 1978).

Event The model is activated when an event occurs within the everyday experiences of the older adult. This event may be any change in environment or functional level, any illness or injury with real or perceived residual, or any alteration of self-image that results in the destabilization of the individual and the contiguous social system. The event is experienced simultaneously by the individual and the social system, with the initial response of each determined by pre-existing influences. The occurrence of the event may not be evident to observers of the older adult. Onset may be rapid, as with the individual who breaks a hip, or insidious, as with the individual who has progressive diabetes or cardiac disease. The older adult’s perception that the ability to participate fully in interactions around self-care is compromised determines when the cascade of responses will be initiated. The response of the individual is shaped by elements of the individual’s intrapsychic experience and concurrent situation. Intrapsychic factors include such characteristics as hardiness, premorbid personality and cultural beliefs. The concurrent situation consists of all relevant external variables, including financial status and security, pre-existing interpersonal relationships and idiosyncratic stressors. Both intrapsychic factors and the concurrent situation will define an iterative response field of the individual, such that personality and situational elements are magnified.


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INTRAPSYCHIC FACTORS

CONCURRENT SITUATION

PREEXISTING ATMOSPHERE

EVENT

INDIVIDUAL SYSTEM

CONCURRENT SITUATION

SOCIAL SYSTEM

SOCIAL EFFECTS BIOLOGICAL COGNITIVE EFFECTS EFFECTS

EMOTIONAL EFFECTS

PRIMARY EVENT RESPONSE (Catastrophic Destabilization) Resolution of event

Nonresolution of event

Without sequelae: systems stabilize

With sequelae: systems seek restabilization

Systems remain destabilized

SECONDARY EVENT RESPONSE (Evaluation and Consolidation)

INDIVIDUAL SYSTEM RESPONSE

Agency

SOCIAL SYSTEM RESPONSE Response to agency

Withdrawal

Response to withdrawal Response to coping

Coping

RECIPROCITY

Underbenefitting

Parallelism

Disconnection

Equitable

Connection

Overbenefitting

Enmeshment

Disconnection

TERTIARY EVENT RESPONSE (Individual Emotional/Physical Symptoms) Figure 1 Model of event-generated dependence.

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A similar iterative relationship occurs within and among the biological, cognitive and emotional elements of the individual. Cognitive effects include changes in self-representation to accommodate real or perceived powerlessness, and lack of agency relative to both the event and the life trajectory that has been interrupted. Cognitive effects also include the belief that one needs to rely on others for temporary control or aid, imbuing others at least temporarily with a greater capacity for control or power. Emotional sequelae include such states as anxiety, helplessness, confusion, denial and fear. Potential biological effects are twofold, arising from the event itself (as with an injury) and from the body’s shock and stress responses. The social system’s response to the individual is shaped by elements of its own pre-existing atmosphere and concurrent situation. The social system includes the social network of prior importance to the individual, such as family or friends, and any professional network that becomes involved with the individual through the event. The pre-existing atmosphere consists of the tenor of the relationships and the environment within which the event evolves. The concurrent situation of the social system consists of such relevant variables as resource capacity and environmental restrictions. Social effects include social and professional networks’ efforts to meet the emotional and functional needs of the individual, as well as the networks’ internal responses to these demands. An example of the EGD model to this point might be the response of the older individual and relevant social networks to the event of a fall, resulting in transport to an emergency room. The older adult’s response will be influenced by his/her personality, elements of the concurrent situation (such as availability of insurance), physical status, cognitive abilities and emotional state. All of these components will interact and evolve in reaction to the event. At the same time, social systems contiguous to the individual will respond. Family members’ reactions will vary depending on their previous relationship with the individual, capacity for providing assistance and situational stressors. Preconceptions regarding the nature of illness in older adults will also play a role. The emergency room staff is another social system contributing to the event response. Pre-existing atmosphere refers to the milieu of the emergency room and the attitudes and behaviours of staff. Concurrent situational variables include such factors as staffing ratios, or the level of absenteeism on the day of the older adult’s admission. Social effects, such as rigid adherence to organizational regulations, will interact with atmosphere and situational variables in determining emergency room personnel’s reaction to the older individual’s event.

Primary event response The initial reactions of both individual and social system to a catastrophic destabilization of the status quo constitute a primary event response. Morse and Johnson (1991) have identified this period as a ‘stage of disruption’ within which the individual relinquishes control and significant others accept responsibility for the delivery of care. A catastrophe need not be extreme. In physics, catastrophe is a way of describing systems that exhibit discontinuity. In EGD, individual and social systems experiencing a transition from one state to another or from pre-event to primary event response do so through discontinuity. Previous behaviour undergoes a qualitative change similar to that described by Thom’s (1989) ‘cusp’ catastrophe, in which a system may be acted upon by two major influences and pushed in two different directions. We can construe these influences as the competing conditions of health vs. illness, or internal striving vs. external demands. In either case, catastrophe theory posits that the discontinuity or change between states need not result from a ‘great calamity;’ rather, a small change in the individual’s situation may result initially in little behavioural change. As the cusp is reached and exceeded, however, a critical point is passed beyond which abrupt behavioural change occurs. This is particularly relevant in explaining how progressive or seemingly minor (to the observer) behavioural responses of the older adult to chronic illness may result in sudden crisis events. Following the destabilization of systems, resolution or nonresolution may follow three possible paths. First, the event may resolve without sequelae, and all systems may restabilize. In the case of the older individual who falls, full resolution may be possible if an emergency room assessment reveals no injury. The older adult then returns home and resumes normal activities. Or the event may resolve with sequelae (e.g., minor injury or fear of injury), in which case all systems will persist in efforts to restabilize and will begin to experience, at least temporarily, a secondary event response. Cognitive processes will begin to assess the possibility that functional ability might not be fully restored, or that limitations may have to be incorporated into the older adult’s life style. Sequelae are not limited to actual changes in function; the older adult’s perception of change is sufficient. Such might be the case if the older adult develops a fearful attitude toward walking, and deliberately self-limits movement. Finally, the event may not resolve and all systems may remain destabilized. The older adult may be diagnosed as having a hip fracture, requiring hospitalization. Prior to this, it is posited that individuals will be focused on resolving the event and will perceive their reliance on others as


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contributing to a possible resolution. However, as systems remain destabilized with no end in sight, a highly individualized crisis point will be reached. This critical point might arise as a function of the tension resulting from disparities between self-image and inequities of reciprocity.

Secondary event response The result of persistent destabilization is a secondary event response. As the older individual faces a persisting disability, efforts begin at evaluating the current experience in terms of its expected duration and consequences. These efforts may include comparisons of the individual’s former functional level with the present level, and attempts at coming to terms with a new view of self. Likewise, the social system will evaluate its continuing role in and adjustment to long term or possibly permanent changes in the need level of the older individual. Morse and Johnson (1991) have described this period as a ‘striving to regain self.’ While the individual is attempting to make sense of what has happened, preserve the integrity of the self, renegotiate roles and look to the future, significant others are evaluating their commitment to the struggle, renegotiating their own roles and providing support. Taking an optimistic approach, Morse and Johnson (1991) describe the next stage as ‘regaining wellness.’ During this period, the individual takes charge and attains mastery while the social network relinquishes control. Within a dependence scenario, however, a more complex struggle occurs. In attempting to reconcile the need for care with the drive to maintain autonomy, the individual may struggle through responses of agency, coping, or withdrawal in efforts to accommodate and adapt. In the model, agency is defined as behaviour directed toward regaining control of one’s responses to the event as conditions permit. This involves accepting necessary assistance while seeking knowledge of one’s situation, assuming responsibility for self-monitoring, and becoming actively engaged in a recovery process. Coping is defined as a marshalling of resources that involves greater emphasis on strategies to adapt to the event and less emphasis on resumption of control of the situation. Necessary interdependence is accepted, but there is limited knowledgeseeking, self-monitoring, or engagement in the recovery process, as others are permitted to continue their efforts in these areas. Withdrawal is defined as a complete abrogation of personal responsibility, resulting in either symbolic or emotional disengagement from the situation. The older adult may experience one persisting response or may fluctuate between any of the three. 176

The social and professional networks that have been responding to the individual all along have their own struggles in responding to the individual’s agency, coping and withdrawal. For one thing, they may have difficulty accepting the individual’s responses. While agency might be considered the optimal individual response for the older adult, it may conflict with the expectations or requirements of family members or hospital staff. Withdrawal may create problems of its own, in that attempts to distance from others may foster greater unwanted involvement of others out of concern. The interaction of individual and social responses within this phase may result in an emergent state of dependence, i.e., disordered reciprocity between the participants. The levels of actual and perceived exchange are assessed by the participants as underbenefitting, overbenefitting, or equitable. Underbenefitting reciprocity results in a relatedness state of parallelism when the individual is content to receive a small amount of assistance. However, disconnectedness results when the individual is displeased, anxious, or worried about the same low amount of assistance. Overbenefitting reciprocity results in a relatedness state of connectedness if an individual’s needs are being met beyond his or her expectations and the degree of involvement is comfortable. However situations involving ‘imposed dependency’ (Gignac & Cott, 1998), in which physically capable adults receive care they do not need, can have other outcomes. A relatedness state of enmeshment results for the angry client who has not been permitted to participate in his/ her care. The withdrawn individual who is uncomfortable receiving unwanted care experiences disconnectedness. Equitable reciprocity results in an interdependent, connected state that is both involved and comfortable. Previous research on reciprocal and non-reciprocal support (Ingersoll-Dayton & Antonucci, 1988) has found that underbenefitting fostered negative responses when older adults failed to receive expected emotional support from children. While overbenefitting might seem to be a positive state, the valence of the response depended upon the nature and expectations of the relationship.

Tertiary event response The relatedness state achieved will influence the emergence of a tertiary event response in the individual, involving the appearance of emotional and physical symptoms of distress. Hagerty et al. (1993) warned that disruptions of the relatedness elements – in this case reciprocity or of the ability of the individual to move through relatedness states flexibly can contribute to biological, psychological and social



disturbances. Gignac and Cott (1998) identified depression and anxiety as possible outcomes of the powerlessness that dependence may engender. The EGD model acknowledges that certain states of relatedness, particularly enmeshment and disconnectedness, may result in physical or psychological symptoms that go beyond the effects of the initial event itself.

Discussion The elderly are often assigned a global dependence stereotype based on demonstrated need for specific assistance. Stereotyping results in limitations of medical treatments and other efforts to optimize older adults’ functional abilities. The problem is especially acute in institutional settings, such as nursing homes, where staff interactions have been shown to play a role in maintaining, if not fostering dependence. However, it is unreasonable for nursing staff to assume that previously independently functioning elders will suddenly become dependent on their own, without the intercession of an event and other forces. For too long we have acted on an unspoken assumption that older adults go through a natural and inevitable ‘transition’ from independence to dependence. Meleis et al. (2000) discussion of transitions suggests that the individual goes through an actual process of change, as with a woman experiencing menopause. However, the older adult responding to an event such as illness may not initially view the situation as a transition, certainly not to dependence. If reciprocity can be maintained at or near previous levels, the EGD model suggests that dependence need not emerge. Responses by the social environment that reinforce dependence will influence older adults’ perceptions of the situation. When and if they succumb to the label placed on them by caregivers, older adults may be said to have embraced dependence. The need for assistance or services need not be labelled as dependence. As nurses we do not claim that the young adult who breaks a leg and requires help with ADL’s is dependent in the way we consider the older adult. It is only when the social environment sees the situation as one that is likely to be prolonged indefinitely (even if a broken leg will heal with time), as we tend to presume with older adults, that we apply the label of dependence. Unfortunately, we may also be applying a self-fulfilling prophecy. The reciprocity of caregivers, whether family members or clinicians, plays a contributing role in the model of EGD. Caregivers who wish to provide services, but whose efforts are thwarted by older adults, are likely to experience their own frustration in response to the inequitable exchange. This frustration may lead to overzealous attempts to impose care

(representing enmeshment on the part of the caregiver and overbenefitting by the older adult), thereby increasing the older adults’ perception of dependence. Caregivers who prefer to avoid involvement in care (representing either parallelism or disconnectedness) may contribute to underbenefitting by the older adult. Attempts to elicit support from these caregivers may foster their resentment or sense of burden. Indeed, theorists have suggested that caregivers themselves experience a loss of independence while providing care, a loss that results in caregiver burden and stress (Gignac & Cott, 1998). The inequitable exchange of altered reciprocity, leading to caregiver burden, may illuminate problems of abusive or neglectful caregiving. Alterations in reciprocity may be both causal and inherent to elder abuse. Inequitable exchange is inherent in any process that involves unequal power or control between individuals, as found in abusive situations. While the outcomes of inequitable exchange may be relatively benign, as with employer to employee, the nature of the caregiving relationship and the affective elements between recipient and provider lend themselves to negative outcomes (Gignac & Cott, 1998). Thus reciprocity levels of caregivers toward older adults are important in the ability to provide safe, high quality nursing care and avoid promoting dependence. Application of the EGD model provides an opportunity to reframe our existing characterization of dependence. The nursing profession might be best served by avoiding use of the term ‘dependence,’ focusing instead on the specific areas of older adults’ need. However, ‘dependence’ in the form of altered reciprocity might also represent a form of adaptation to illness or disability, an adaptation that is active rather than passive (Gignac et al., 2000). Self-regulated dependence, interpreted as a means of self-care management, could serve to promote successful ageing (Baltes, 1996; Gignac & Cott, 1998; Gignac et al., 2000). Nurses, perhaps more than other professionals, are ideally placed to initiate and maintain appropriate reciprocity with older adults and to teach other caregivers to do the same. The THR can serve as a guide to promoting connectedness between nurse and client. Particular attention to reciprocity within the nurse–client relationship can have a direct effect on whether or not dependence will emerge. The EGD model can serve as a means of sensitizing nurses to an alternative view of dependence. It is important for nurses to recognize their role in determining the social environment of care, attend to the promotion of reciprocity with older adults as care is provided, and incorporate changes in their attitudes toward inequitable reciprocity.


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Conclusion The model of EGD incorporates a social-interactive perspective that does not presume all dependence to be negative and describes dependence as a function of altered reciprocity. A testable causal path between dependence and psychological outcomes is suggested. Identification of an event that initiates a cascade of responses leading to multiple outcomes, including the possibility of altered reciprocity and dependence, differentiates this model from characterizations of dependence as a personality disorder or an inevitable consequence of ageing. Dependence as an event-generated emergent function of reciprocity is posited to more accurately describe the actual experiences of older adults.

Acknowledgement The author wishes to acknowledge the assistance of Dr Marilyn Oermann and Elizabeth Tornquist in reviewing earlier versions of this article. Financial support for this work was provided partially by Sigma Theta Tau, Rho Chapter and by a Center for Education of Women Margaret Dow Towsley Scholarship at the University of Michigan.

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