In the present study, we sought to understand how hospitalized older adults cope with FOF. The analysis showed that, to confront FOF, three types of coping strategies were developed by hospitalized older adults: primary confrontation, in terms of explaining the reason of falls; secondary confrontation of fear; and tertiary confrontation of the consequences of falling.
The first level of confrontation refers to the attribution of the cause of falls. The attribution style ranged from a globalized, inner attribution to normal ageing to specialized, external attributions for isolated accidents. When older adults perceived falling as a social identity of stigma and shame, which might bring the cruel fact of “getting old and fragile” to the forefront of their awareness, they preferred to find external reasons for their falls to overcome the feelings of anxiety and helplessness associated with their awareness of falling risk. Their attribution of the cause of the unfortunate falls from a special temporal perspective can be hopeful for the prevention of future falls.
Meanwhile, others perceived ageing as a normal part of the life course, and falling was not surprising as their physical function deteriorated with the ageing process. Although the falling event might sound inevitable and uncontrollable, their acceptance of ageing allowed them to be more aware of the potential risk of falling and better prepared to protect themselves from falling, which also provided a cushion against the development of FOF. The attribution style was taken as an important and effective strategy for hospitalized older adults to minimize the impact of the falling event. It seemed that the two opposite attribution styles played the same role in preventing FOF, suggesting that no matter what attribution style they adopted, the essence was to regain a sense of control by interpreting the falling event in a positive manner.
For the secondary confrontation, cognitive adjustment was taken as the main strategy to overcome FOF. Over two thirds of participants in this study had fallen more than once: some of them were quite familiar with the accident and positive about the consequence. Some older adults without falling experience could also be inspired by the recovery stories of their friends. Their own previous recovery experiences as well as those of their friends were taken as a source of comfort to alleviate anxiety and FOF, the results of which were partially supported by a previous study suggesting that FOF was influenced by their own falling experiences[27]. Meanwhile, some older adults felt blessed and grateful when witnessing the worse consequence experienced by other hospitalized patients, which helped them to fight their fear in the present moment.
It was interesting to find two opposite ways of dealing with fear – distraction from it or confronting it – both of which were chosen by older adults with FOF at the back of their minds. They were overwhelmed by fear soon after the falling event, and somatic symptoms like insomnia, headache and trembling often haunted them. Nevertheless, some of them chose to control their fear by doing more interesting and delightful things like watching TV, playing on a mobile phone, gardening or thinking about their responsibilities of taking care of grandchildren after leaving hospital, which was in line with previous studies suggesting engagement in pleasant activities is an effective way to handle FOF[15] and sustain quality of life [28]. From their point of view, FOF led nowhere but was a waste of time: they would rather prioritize sense of value and accomplishment over consistent concern with FOF.
Other older adults, however, believed that “the only way to conquer fear is to face it”. They went through the whole process of falling to find solution to prevent falling or avoid serious consequences. For instance, they examined their physical limitations and acted within their abilities in the future. They also learnt how to fall without severe injury. A study conducted by Roe et al. (2008) [29] in British elder care institutions showed that older people who reflected on their own falling experiences were more likely to develop strategies to prevent future falls. Ballinger and Payne (2000) [30] also suggested that it might be more important to reflect on the impact of risk status on lifestyle and identity than to take immediate action to reduce risk. No matter which strategies older adults pursued, the ultimate goal was to take the initiative and overcome FOF through cognitive adjustment.
Tertiary confrontation was primarily concerned with taking actions to deal with the possible consequences of FOF. Rehabilitation exercise and food therapy were universal and essential actions taken by the hospitalized elderly adults in China to recovery from surgery[26]. This is not only beneficial for physical recovery [16] but is also helpful for the alleviation of anxiety and fear. Previous findings have proposed that FOF appears when elderly adults do not trust their physical body[9]. Therefore, the recovery of physical function is crucial evidence for them to regain trust and reduce FOF. Meanwhile, social support was also essential for rehabilitation in terms of providing encouragement, hope and motivation to recover when hospitalized elderly adults feel vulnerable and insecure[31–32]. Common preparatory strategies such as auxiliary equipment and environment modification were prominent for older adults to avoid potential risk of falling. Similar results found that older adults concerned about the social consequences of falling – that is, the embarrassment of being seen to lose control[9, 15] – and emergency alarm devices or mobile phones were necessary when they fell without anyone around. In addition to arming themselves with facilitating devices when they went out, environment modification inside the house was also indispensable for elderly adults to resume their daily activities and regain their independence without relying on others.
Clinical implications
The obvious fact that the frequency of falls increases with age and frailty highlights the importance of taking preventive measure to avoid FOF. The results of this study provide several valuable clinical suggestions for health social workers to prevent and intervene in FOF. First, it is imperative for health social workers to invite hospitalized patients to interpret the cause of falling from their own perspectives, which serves the dual purpose of understanding the impact of falling as well as empowering their sense of control over the event by reconstructing it. Post-modern constructionist theory suggests that the interpretation of the fact, rather than fact itself, might play a more crucial role in empowering people and buffering the negative impact of the fact[33].
Second, a variety of cognitive coping strategies could be explored with hospitalized older adults to deal with the emotion of fear. For instance, facilitating the exploration of their own or others’ previous successful recovery experience among hospitalized patients to gain confidence in their own rehabilitation, as well as discussing with them how to deal with fear in an appropriate manner, such as oscillation between distraction by focusing on their hobbies and confrontation through reflecting the lessons they can learn from falling.
Last but not least, actions speak louder than words. The potential consequences of FOF can be dealt with by taking a series of actions. Health social workers can provide trainings in physical exercises and lectures containing nutrition information, giving a psycho-social education in the importance of social support as well as suggestions to enhance a sense of security by environment modification and taking assistive devices.
Limitations and future research directions
This study had several limitation. First, the inclusion of participants with the experience of FOF was only based on a single question: “Are you afraid of falling?” This measurement was not as rigorous as the standardized scales such as the Short Falls Efficacy Scale-International[33]. Second, the participants in this study included single-fallers as well as frequent fallers, while coping with FOF among older adults without falling experience in the community was not examined. Future research might compare the different experiences of FOF and coping strategies between older adults with falling experience with those without falling experience but with FOF. Finally, the focus of this study was mainly on the confrontation path of FOF, and the detailed delineation of avoidance path as well as the dynamic shift between the two paths in different contexts could be further explored in the future.