In the Public Domain The Cerontologist Vol. 32, No. 4, 552-557
This study investigated treatment procedures for enhancing the self-esteem of older adult male nursing home residents. Twenty-one subjects were assigned randomly to either a control group meeting to discuss current news events or an experimental group receiving the intervention. Self-esteem significantly increased for the experimental subjects but not before they experienced a significant decrease in feelings of self-worth. The midtreatment observation of the dependent variable was a vital factor in determining the curvilinear relationship between time and the protocol. Key Words: Continuity theory, Counseling, Institutionalized elderly persons
Enhancing the Self-Esteem of Selected Male Nursing Home Residents1 Diane E. Frey, PhD,2 Thomas J. Kelbley, MA2, Lisa Durham, BS, RN,: and Jacqueline S. James, BS, RNCSelf-esteem is proposed by Hirst and Metcalf (1984) to be an important ingredient for the quality of life of institutionalized older adults. Long-term care for nursing home residents, however, often has a primary emphasis on the delivery of medical services (Chenitz, 1983). Neglecting the psychological aspects of care may create a condition that diminishes self-worth (Taft, 1985) and the significance of selfesteem in older adults is gaining attention in the literature (Cooper, 1983; Gielow & Hobler, 1986; Lappe, 1987; Perrotta & Meacham, 1981-1982). Most of these studies (Cooper, 1983; Gielow & Hobler, 1986; Perrotta & Meacham, 1981-82) found no change in self-esteem after a treatment, indicating that a theoretically valid counseling protocol appropriate for institutionalized elders is needed. The present research tested such a protocol and used the theory of continuity described by Atchley (1989) for theoretical validity. The major proposition of continuity theory (Atchley, 1989) is that older adults use already existing internal and external structures to adapt to life changes such as retirement, death of a spouse, or institutionalization. The internal structures may include an individual's personality and identity; external components involve social interactions and relationships with significant others. Individuals adapting to their changing lives are motivated toward inner psychological continuity and outward continuity of social behavior. This is a process of evolution and growth rather than an attempt to regain homeostasis after a loss or change. For inner psychological continuity, identity is the dimension included in a counseling protocol be-
1 This research was awarded the 1991 Mid-America Congress on Aging Student Award. Address correspondence to Diane E. Frey, PhD, Wright State University, 374 Millett Hall, Dayton, OH 45435. department of Human Services, Wright State University, Dayton, OH. 3 Veterans Affairs Medical Center, Dayton, OH.
552
cause Bengtson, Reedy, and Gordon (1985) describe personality as too broad for meaningful investigation. Identity is separate from social interaction (Bhatti et al., 1989) and serves as the foundation for integrating new information about the self. Social relationships make up the external component and usually continue from middle age (Covey, 1981). Intimate friendships may be difficult to establish in the nursing home (due to immobility, chronic illness, or depression) and a counseling intervention that nurtures interpersonal support is consistent with the external structure of continuity theory. Self-esteem is a multidimensional construct (Goldsmith, 1986) manifested through internal and external evaluations of the self (Kroner & Sinha, 1989; Mclntire & Levine, 1984). The internal evaluation is based on an individual's experience of efficacy and competence in the environment. The external evaluation consists of feedback from significant others in the form of social approval. According to Rosenberg (1965), the impact of this feedback depends on the centrality it is given in the individual's belief system. Both continuity theory and self-esteem share internal and external dynamics, lending face validity to the premise that continuity theory is an appropriate theoretical foundation to enhance the self-esteem of institutionalized older adults. Self-Esteem and the Older Adult
Among noninstitutionalized samples, self-esteem has been found to increase with age. Of 15 studies reviewed by Bengtson, Reedy, and Gordon (1985), eight reported a positive relationship between age and self-esteem. The seven other investigations found no age differences associated with feelings of selfworth. These authors conclude that self-esteem is at least maintained, if not increased, as individuals age. A dissenting view is expressed by Crouch (1983). The elderly must be considered a population that merits special attention regarding the enhancement The Gerontologist
of self-esteem. Negative labeling and elder stigmatization contribute to low self-esteem (Bulman & Marshall, 1982; Rodin & Langer, 1980); the title " o l d " may be disparaging in a society focused on the young. Seniors need increased opportunities for esteem building and self-appreciation because the environment may have a contributing influence, especially with elders living in a nursing home. Self-Esteem and the Institution
In a study with institutionalized and noninstitutionalized subjects (the institution examined was a prison), Jacques and Chason (1977) found age and institutionalization related to self-esteem. Older noninstitutionalized individuals maintained higher self-esteem than younger noninstitutionalized persons, although older institutional residents exhibited lower self-esteem than younger residents. Lower self-esteem with higher age is contrary to research findings (Bengtson, Reedy & Gordon, 1985), so the question of an institution's influence on self-esteem becomes significant. Elders reshape their life-style to the nursing home rather than the facility's nurturing any existing patterns of successful living (Dorsey & Purcell, 1987). This may deprive a resident of selfesteem due to a lack of control over the environment (Stensrud & Stensrud, 1981). Nursing home residency may threaten the selfesteem of its elder residents. This study tested a counseling protocol designed specifically for institutionalized older adults, described by Frey and Carlock (1989) and supported by a theory of continuity (Atchley, 1989). It was hypothesized that the experimental group would experience a change in their feelings of self-worth. Method Participants Gender has been identified as a research variable to be controlled in studies of self-esteem (Prescott, 1978). Consequently, the sample was limited to male residents of a Veterans Affairs Medical Center (VAMC) nursing home. Criteria for inclusion in the study consisted of (a) age of 60 years or more, (b) residing in the nursing home for at least 1 year, (c) competent for VAMC informed consent purposes, and (d) not exhibiting evidence of cognitive impairment as indicated by a score of at least 20 on the Mini-Mental State Examination (Folstein, Folstein, & McHugh, 1975). After random assignment to treatment conditions, but before the experiment began, three residents were unable to continue. Two men transferred to the inpatient acute care hospital with no return to the nursing home and the other man died. After the treatment began, but before the midtreatment observation of self-esteem, two additional subjects (one from each group) voluntarily withdrew from the experiment. After the midtreatment observation an additional member of the experimental group was unable to attend sessions due to his physiVol. 32, No. 4,1992
cian's orders for bedrest. Twenty-one participants completed the experiment. Treatment Conditions The experimental condition was a 12-week counseling intervention following the Frey and Carlock (1989) protocol to increase self-esteem. This protocol involves four phases: (a) the discovery of identity (the internal aspect of Atchley's [1989] continuity theory); (b) acceptance of personal strengths and weaknesses; (c) a nurturance of the identity and strength/weakness continuum through social interaction (the external structure); and (d) maintenance activities to sustain high self-esteem. The identity phase was begun by asking the participants to state a word or phrase that described themselves and this was recorded by the group leader. Each member then briefly elucidated on their choice of words. The second session focused on a positive aspect each member believed about the first session's self-description. The third session consisted of nonverbal expressions of identity through painting and clay. The strength/weakness phase has self-acceptance as its goal. The fourth session consisted of members discussing a skill or ability they are good at. During the fifth session each subject discussed a personal weakness and indicated either (a) "I'm working to change this" or (b) "I'm not ready to change this yet." The sixth session examined positive perceptions of the stated weaknesses and the group leader helped subjects reframe their beliefs. Nurturing self-esteem was the goal of sessions seven through nine. Session seven consisted of guided imagery where subjects created their own "inner room" as a place of safety and comfort. Session eight was a reminiscence time in which individuals related memories of people who nurtured them. Session nine was a group affirmation where each member made a positive statement to every other participant in the group. Continuing personal growth was the goal of the last three sessions. The tenth examined realistic goals that members could work for in the future. Session eleven looked at risk-taking behavior. Session twelve consisted of subjects making a commitment to a risk-taking goal with a discussion of gains made during the past 3 months. The control condition was a 12-week group session where members discussed current news events. Group Leaders The experimental group was led by a female VAMC Head Nurse assigned to the nursing home. Prior to beginning the first session, this individual was trained by the principal investigator in (a) the theory of continuity for successful aging, (b) group dynamics, (c) active listening techniques (Cormier & Cormier, 1990), (d) self-esteem enhancement procedures, and (e) goals specific to each phase of the treatment. The control group was led by another female VAMC Head Nurse who was trained in group 553
dynamics, active listening techniques, and leading discussion on current news events. Each session of each group was co-led by the principal investigator. Instruments The high prevalence of cognitive disorders in nursing homes suggests that any study within this environment establish cognition as intact (Rabins et al., 1987). The Mini-Mental State Examination (Folstein, Folstein, & McHugh, 1975) was used to screen potential subjects for memory and thought dysfunction with a score of at least 20 required for participation. Self-esteem is multidimensional (Goldsmith, 1986) and two instruments were used in this research. The Culture-Free Self-Esteem Inventory for adults (CFSEI; Battle, 1981) is an assessment instrument that measures four aspects of self-worth: total selfesteem, general self-esteem, social self-esteem, and personal self-esteem. The CFSEI is a 40-item forcedchoice (yes/no) questionnaire for which high scores are associated with high self-esteem. While the instrument is valuable because it includes several components, the norm group for test validity was college-age students and its validity for the elderly is unknown. For elder self-esteem, Hunter, Linn, and Harris (1981-1982) conducted a principal component factor analysis of the Rosenberg Self-Esteem Scale (Rosenberg, 1965) and the Coopersmith Self-Esteem Inventory (Coopersmith, 1967) with 120 elders to derive a 20-item self-esteem scale appropriate for older adults. The instrument is a 20-item Likert-type scale in which subjects assign numbers to their level of agreement with given statements (1 = strongly agree to 4 = strongly disagree). Lower scores are associated with higher self-esteem, so the instrument was reverse-scored for ease of interpretation. Assessment Times In addition to the mental status screening, subjects were assessed on the dependent variables prior to the experiment, 6 weeks into the experiment, and at the end of the study. The midtreatment observation was made because this is the time when the protocol shifts from internal structures of continuity theory to external. The final measurement was made to compare treatment effects between the two groups. Procedure Participants were provided the informed consent interview, the mental status examination, and individually completed the self-esteem measurements. The groups then met weekly. At the conclusion of the sixth session the self-esteem instruments were administered. After the groups completed 12 sessions, the posttreatment measurements were taken. The principal investigator co-led each group during the course of the study. Matched t tests were conducted for the control group at the 6-week and posttest intervals with no significant differences due to experimental bias.
Results
Sociodemographic Characteristics There were no significant differences at pretest between the experimental and control groups on the background characteristics described in Table 1. The men's mean ages were 71.3 in the experimental group and 73.36 in the control group. Most of the men were white, had a high school education, and had been married. Comparison of the Experimental and Control Groups Pretest analyses of subject scores on the selfesteem measurements revealed no significant differences between the experimental and control groups. However, a significantly lower score was found for the experimental group on mental status, f(1,20) = 3.17, p = 0.0048. A relationship has been found between self-esteem and cognitive ability or mental status (Brack, Orr, & Ingersoll, 1988). A MANCOVA and an ANCOVA were used to statistically account for variation due to mental status. All analyses were conducted with the Statistical Analysis System (SAS
Table 1 . Sociodemographic Characteristics (with Features Related to Continuity Theory) of Male Nursing Home Residents in Study of Self-Esteem
Conditions
Variable Age M SD Education M SD Marital status Single/never married Married Divorced/separated Widow Race White Other Subject's decision to live in nursing home Yes No Previous institutionalization Yes No Number of family visits per month 0 1-10 11-20 21-30 Years in residence at current facility 1-3 3-5 5-7
7-9 9+
554
Experimental (n = 9)
Control (n = 12)
71.30 9.10
73.36 7.70
12.70 3.13
11.45 1.86
0 6 2 1
0 5 3 4
8 1
8 4
4
5
6 6
4 5
6 6
1 5 2 1
1 8 0 1
4
5 3 3 0
3 1 1 0
t
X2
df
0.56
1,19
1.12
1,19
1.49
3
2.01
1
0.44
1
0.44
1
2.58
3
2.74
4
1
The Gerontologist
Institute Inc., 1985), the General Linear Model for MANCOVA and ANCOVA with the univariate program for descriptive consideration. At the 6-week measurement, the descriptive analysis revealed a very low self-esteem (outlier) score in the experimental group with both the Hunter and CFSEI instruments. Removal of the outlier score did not change the difference between groups on mental status, £(1,19) = 3.78, p = 0.001. The participant with this very low score completed the experiment and the outlier score continued to be observed on the CFSEI at the posttest. Table 2 presents the means, standard deviations, sample sizes, and tests of significance for each measure of the dependent variables during the three observations. A significant MANCOVA, as measured by the Wilks' Lambda test, suggested that an ANCOVA be conducted for each individual instrument. A significantly lower self-esteem score was found for the experimental group at the midtreatment measurement, on both instruments, in comparison to controls. When the outlier score was removed from the ANCOVA, significant differences between groups on total score ceased to be evident. Because the outlier score may have influenced group variation, an interpretation must be guarded pending further analysis. An ANCOVA conducted with the CFSEI subscales at midtreatment suggested that the experimental intervention was significantly interacting with the personal domain of self-esteem. When the outlier score was removed from this subscale analysis, there re-
mained a significant difference between the experimental and control groups. At the end of the study, the Wilks' Lambda test of the MANCOVA was significant for both analyses on total score and the multiple subscales of the CFSEI, suggesting the ANCOVA procedure. There were no differences between the experimental and control groups on total self-esteem scores at the end of the experiment. This represents a significant increase in the experimental group's self-esteem. On the Hunter instrument without the outlier score, the experimental group's mean was significantly higher than control's. An increase (but not significant) in self-esteem was also measured by the CFSEI. An ANCOVA conducted with the posttest CFSEI subscales revealed no significant differences between groups with or without the outlier score. The experimental group again experienced a significant increase in the personal domain of self-esteem. The midtreatment measurement of the dependent variables and the descriptive analysis finding an outlier score were vital observations. Without this data the posttest mean scores would have shown no significant difference between groups when in fact the experimental subjects experienced an increase in their self-esteem. Discussion
The results make a strong case in support of the Frey and Carlock (1989) model for influencing self-
Table 2. Means, Standard Deviations, and Sample Sizes at Pretest, 6-weeks, and Posttest with ANCOVA Tests of Significance Conditions
Pre Instrument Hunter M 61.3 SD 9.0 N 10 CFSEI total score M 21.2 SD 5.8 N 10 CFSEI subscales General M 11.0 SD 3.3 N 10 Social M 6.1 SD 1.6 N 10 PersonalI M 4.1 SD 2.3 N 10
ANCOVA df
Control
Experimental
F
Mid
Post
Pre
Mid
Post
Pre
Mid
Post
Pre
Mid
Post
Source
56.6 5.5 10
63.4 9.8 9
60.1 6.4 12
60.4 4.1 12
60.6 5.7 12
1 1 20
1 1 20
1 1 19
0.00 0.02
0.29 8.01*
0.22 0.53*
Covariate Between Within
21.0 7.8 10
23.2 7.4 9
23.8 4.5 12
23.8 4.0 12
25.1 4.7 12
1 1 20
1 1 20
1 1 19
2.69 2.56
2.85 7.48*
1.86 3.18
Covariate Between Within
10.8 4.5 10
12.0 4.0 9
11.9 1.6 12
11.7 1.9 12
12.4 2.4 12
1 1 20
1 1 20
1 1 19
2.65 1.41
2.42 3.73
4.32 3.25
Covariate Between Within
6.2 1.5 10
6.4 1.5 9
6.4 1.8 12
6.3 1.4 12
6.6 1.3 12
1 1 20
1 1 20
1 1 19
0.04 0.05
1.48 1.29
0.21 0.33
Covariate Between Within
4.0 2.7 10
4.8 2.8 9
5.3 1.9 12
5.8 1.7 12
6.1 1.6 12
1 1 20
1 1 20
1 1 19
0.21 4.32
1.59 13.5**
0.25 4.01
Covariate Between Within
Note. Significant Wilks' Lambda (WL) of the MANCOVA (for Hunter and CFSEI total score) at 6 weeks (p = .0286). Significant WL for CFSEI Subscales at 6 weeks (p = .0306). Significant WL at posttest for total score, both instruments (p = .0042) and at posttest on CFSEI subscales (p = .0137). "When the outlier score was removed from analysis, the experimental group's self-esteem was significantly higher than controls; F(2,17) = 4.73, p = .044.
*p
This study investigated treatment procedures for enhancing the self-esteem of older adult male nursing home residents. Twenty-one subjects were assigned randomly to either a control group meeting to discuss current news events or an experimental group receiving the intervention. Self-esteem significantly increased for the experimental subjects but not before they experienced a significant decrease in feelings of self-worth. The midtreatment observation of the dependent variable was a vital factor in determining the curvilinear relationship between time and the protocol. Key Words: Continuity theory, Counseling, Institutionalized elderly persons
Enhancing the Self-Esteem of Selected Male Nursing Home Residents1 Diane E. Frey, PhD,2 Thomas J. Kelbley, MA2, Lisa Durham, BS, RN,: and Jacqueline S. James, BS, RNCSelf-esteem is proposed by Hirst and Metcalf (1984) to be an important ingredient for the quality of life of institutionalized older adults. Long-term care for nursing home residents, however, often has a primary emphasis on the delivery of medical services (Chenitz, 1983). Neglecting the psychological aspects of care may create a condition that diminishes self-worth (Taft, 1985) and the significance of selfesteem in older adults is gaining attention in the literature (Cooper, 1983; Gielow & Hobler, 1986; Lappe, 1987; Perrotta & Meacham, 1981-1982). Most of these studies (Cooper, 1983; Gielow & Hobler, 1986; Perrotta & Meacham, 1981-82) found no change in self-esteem after a treatment, indicating that a theoretically valid counseling protocol appropriate for institutionalized elders is needed. The present research tested such a protocol and used the theory of continuity described by Atchley (1989) for theoretical validity. The major proposition of continuity theory (Atchley, 1989) is that older adults use already existing internal and external structures to adapt to life changes such as retirement, death of a spouse, or institutionalization. The internal structures may include an individual's personality and identity; external components involve social interactions and relationships with significant others. Individuals adapting to their changing lives are motivated toward inner psychological continuity and outward continuity of social behavior. This is a process of evolution and growth rather than an attempt to regain homeostasis after a loss or change. For inner psychological continuity, identity is the dimension included in a counseling protocol be-
1 This research was awarded the 1991 Mid-America Congress on Aging Student Award. Address correspondence to Diane E. Frey, PhD, Wright State University, 374 Millett Hall, Dayton, OH 45435. department of Human Services, Wright State University, Dayton, OH. 3 Veterans Affairs Medical Center, Dayton, OH.
552
cause Bengtson, Reedy, and Gordon (1985) describe personality as too broad for meaningful investigation. Identity is separate from social interaction (Bhatti et al., 1989) and serves as the foundation for integrating new information about the self. Social relationships make up the external component and usually continue from middle age (Covey, 1981). Intimate friendships may be difficult to establish in the nursing home (due to immobility, chronic illness, or depression) and a counseling intervention that nurtures interpersonal support is consistent with the external structure of continuity theory. Self-esteem is a multidimensional construct (Goldsmith, 1986) manifested through internal and external evaluations of the self (Kroner & Sinha, 1989; Mclntire & Levine, 1984). The internal evaluation is based on an individual's experience of efficacy and competence in the environment. The external evaluation consists of feedback from significant others in the form of social approval. According to Rosenberg (1965), the impact of this feedback depends on the centrality it is given in the individual's belief system. Both continuity theory and self-esteem share internal and external dynamics, lending face validity to the premise that continuity theory is an appropriate theoretical foundation to enhance the self-esteem of institutionalized older adults. Self-Esteem and the Older Adult
Among noninstitutionalized samples, self-esteem has been found to increase with age. Of 15 studies reviewed by Bengtson, Reedy, and Gordon (1985), eight reported a positive relationship between age and self-esteem. The seven other investigations found no age differences associated with feelings of selfworth. These authors conclude that self-esteem is at least maintained, if not increased, as individuals age. A dissenting view is expressed by Crouch (1983). The elderly must be considered a population that merits special attention regarding the enhancement The Gerontologist
of self-esteem. Negative labeling and elder stigmatization contribute to low self-esteem (Bulman & Marshall, 1982; Rodin & Langer, 1980); the title " o l d " may be disparaging in a society focused on the young. Seniors need increased opportunities for esteem building and self-appreciation because the environment may have a contributing influence, especially with elders living in a nursing home. Self-Esteem and the Institution
In a study with institutionalized and noninstitutionalized subjects (the institution examined was a prison), Jacques and Chason (1977) found age and institutionalization related to self-esteem. Older noninstitutionalized individuals maintained higher self-esteem than younger noninstitutionalized persons, although older institutional residents exhibited lower self-esteem than younger residents. Lower self-esteem with higher age is contrary to research findings (Bengtson, Reedy & Gordon, 1985), so the question of an institution's influence on self-esteem becomes significant. Elders reshape their life-style to the nursing home rather than the facility's nurturing any existing patterns of successful living (Dorsey & Purcell, 1987). This may deprive a resident of selfesteem due to a lack of control over the environment (Stensrud & Stensrud, 1981). Nursing home residency may threaten the selfesteem of its elder residents. This study tested a counseling protocol designed specifically for institutionalized older adults, described by Frey and Carlock (1989) and supported by a theory of continuity (Atchley, 1989). It was hypothesized that the experimental group would experience a change in their feelings of self-worth. Method Participants Gender has been identified as a research variable to be controlled in studies of self-esteem (Prescott, 1978). Consequently, the sample was limited to male residents of a Veterans Affairs Medical Center (VAMC) nursing home. Criteria for inclusion in the study consisted of (a) age of 60 years or more, (b) residing in the nursing home for at least 1 year, (c) competent for VAMC informed consent purposes, and (d) not exhibiting evidence of cognitive impairment as indicated by a score of at least 20 on the Mini-Mental State Examination (Folstein, Folstein, & McHugh, 1975). After random assignment to treatment conditions, but before the experiment began, three residents were unable to continue. Two men transferred to the inpatient acute care hospital with no return to the nursing home and the other man died. After the treatment began, but before the midtreatment observation of self-esteem, two additional subjects (one from each group) voluntarily withdrew from the experiment. After the midtreatment observation an additional member of the experimental group was unable to attend sessions due to his physiVol. 32, No. 4,1992
cian's orders for bedrest. Twenty-one participants completed the experiment. Treatment Conditions The experimental condition was a 12-week counseling intervention following the Frey and Carlock (1989) protocol to increase self-esteem. This protocol involves four phases: (a) the discovery of identity (the internal aspect of Atchley's [1989] continuity theory); (b) acceptance of personal strengths and weaknesses; (c) a nurturance of the identity and strength/weakness continuum through social interaction (the external structure); and (d) maintenance activities to sustain high self-esteem. The identity phase was begun by asking the participants to state a word or phrase that described themselves and this was recorded by the group leader. Each member then briefly elucidated on their choice of words. The second session focused on a positive aspect each member believed about the first session's self-description. The third session consisted of nonverbal expressions of identity through painting and clay. The strength/weakness phase has self-acceptance as its goal. The fourth session consisted of members discussing a skill or ability they are good at. During the fifth session each subject discussed a personal weakness and indicated either (a) "I'm working to change this" or (b) "I'm not ready to change this yet." The sixth session examined positive perceptions of the stated weaknesses and the group leader helped subjects reframe their beliefs. Nurturing self-esteem was the goal of sessions seven through nine. Session seven consisted of guided imagery where subjects created their own "inner room" as a place of safety and comfort. Session eight was a reminiscence time in which individuals related memories of people who nurtured them. Session nine was a group affirmation where each member made a positive statement to every other participant in the group. Continuing personal growth was the goal of the last three sessions. The tenth examined realistic goals that members could work for in the future. Session eleven looked at risk-taking behavior. Session twelve consisted of subjects making a commitment to a risk-taking goal with a discussion of gains made during the past 3 months. The control condition was a 12-week group session where members discussed current news events. Group Leaders The experimental group was led by a female VAMC Head Nurse assigned to the nursing home. Prior to beginning the first session, this individual was trained by the principal investigator in (a) the theory of continuity for successful aging, (b) group dynamics, (c) active listening techniques (Cormier & Cormier, 1990), (d) self-esteem enhancement procedures, and (e) goals specific to each phase of the treatment. The control group was led by another female VAMC Head Nurse who was trained in group 553
dynamics, active listening techniques, and leading discussion on current news events. Each session of each group was co-led by the principal investigator. Instruments The high prevalence of cognitive disorders in nursing homes suggests that any study within this environment establish cognition as intact (Rabins et al., 1987). The Mini-Mental State Examination (Folstein, Folstein, & McHugh, 1975) was used to screen potential subjects for memory and thought dysfunction with a score of at least 20 required for participation. Self-esteem is multidimensional (Goldsmith, 1986) and two instruments were used in this research. The Culture-Free Self-Esteem Inventory for adults (CFSEI; Battle, 1981) is an assessment instrument that measures four aspects of self-worth: total selfesteem, general self-esteem, social self-esteem, and personal self-esteem. The CFSEI is a 40-item forcedchoice (yes/no) questionnaire for which high scores are associated with high self-esteem. While the instrument is valuable because it includes several components, the norm group for test validity was college-age students and its validity for the elderly is unknown. For elder self-esteem, Hunter, Linn, and Harris (1981-1982) conducted a principal component factor analysis of the Rosenberg Self-Esteem Scale (Rosenberg, 1965) and the Coopersmith Self-Esteem Inventory (Coopersmith, 1967) with 120 elders to derive a 20-item self-esteem scale appropriate for older adults. The instrument is a 20-item Likert-type scale in which subjects assign numbers to their level of agreement with given statements (1 = strongly agree to 4 = strongly disagree). Lower scores are associated with higher self-esteem, so the instrument was reverse-scored for ease of interpretation. Assessment Times In addition to the mental status screening, subjects were assessed on the dependent variables prior to the experiment, 6 weeks into the experiment, and at the end of the study. The midtreatment observation was made because this is the time when the protocol shifts from internal structures of continuity theory to external. The final measurement was made to compare treatment effects between the two groups. Procedure Participants were provided the informed consent interview, the mental status examination, and individually completed the self-esteem measurements. The groups then met weekly. At the conclusion of the sixth session the self-esteem instruments were administered. After the groups completed 12 sessions, the posttreatment measurements were taken. The principal investigator co-led each group during the course of the study. Matched t tests were conducted for the control group at the 6-week and posttest intervals with no significant differences due to experimental bias.
Results
Sociodemographic Characteristics There were no significant differences at pretest between the experimental and control groups on the background characteristics described in Table 1. The men's mean ages were 71.3 in the experimental group and 73.36 in the control group. Most of the men were white, had a high school education, and had been married. Comparison of the Experimental and Control Groups Pretest analyses of subject scores on the selfesteem measurements revealed no significant differences between the experimental and control groups. However, a significantly lower score was found for the experimental group on mental status, f(1,20) = 3.17, p = 0.0048. A relationship has been found between self-esteem and cognitive ability or mental status (Brack, Orr, & Ingersoll, 1988). A MANCOVA and an ANCOVA were used to statistically account for variation due to mental status. All analyses were conducted with the Statistical Analysis System (SAS
Table 1 . Sociodemographic Characteristics (with Features Related to Continuity Theory) of Male Nursing Home Residents in Study of Self-Esteem
Conditions
Variable Age M SD Education M SD Marital status Single/never married Married Divorced/separated Widow Race White Other Subject's decision to live in nursing home Yes No Previous institutionalization Yes No Number of family visits per month 0 1-10 11-20 21-30 Years in residence at current facility 1-3 3-5 5-7
7-9 9+
554
Experimental (n = 9)
Control (n = 12)
71.30 9.10
73.36 7.70
12.70 3.13
11.45 1.86
0 6 2 1
0 5 3 4
8 1
8 4
4
5
6 6
4 5
6 6
1 5 2 1
1 8 0 1
4
5 3 3 0
3 1 1 0
t
X2
df
0.56
1,19
1.12
1,19
1.49
3
2.01
1
0.44
1
0.44
1
2.58
3
2.74
4
1
The Gerontologist
Institute Inc., 1985), the General Linear Model for MANCOVA and ANCOVA with the univariate program for descriptive consideration. At the 6-week measurement, the descriptive analysis revealed a very low self-esteem (outlier) score in the experimental group with both the Hunter and CFSEI instruments. Removal of the outlier score did not change the difference between groups on mental status, £(1,19) = 3.78, p = 0.001. The participant with this very low score completed the experiment and the outlier score continued to be observed on the CFSEI at the posttest. Table 2 presents the means, standard deviations, sample sizes, and tests of significance for each measure of the dependent variables during the three observations. A significant MANCOVA, as measured by the Wilks' Lambda test, suggested that an ANCOVA be conducted for each individual instrument. A significantly lower self-esteem score was found for the experimental group at the midtreatment measurement, on both instruments, in comparison to controls. When the outlier score was removed from the ANCOVA, significant differences between groups on total score ceased to be evident. Because the outlier score may have influenced group variation, an interpretation must be guarded pending further analysis. An ANCOVA conducted with the CFSEI subscales at midtreatment suggested that the experimental intervention was significantly interacting with the personal domain of self-esteem. When the outlier score was removed from this subscale analysis, there re-
mained a significant difference between the experimental and control groups. At the end of the study, the Wilks' Lambda test of the MANCOVA was significant for both analyses on total score and the multiple subscales of the CFSEI, suggesting the ANCOVA procedure. There were no differences between the experimental and control groups on total self-esteem scores at the end of the experiment. This represents a significant increase in the experimental group's self-esteem. On the Hunter instrument without the outlier score, the experimental group's mean was significantly higher than control's. An increase (but not significant) in self-esteem was also measured by the CFSEI. An ANCOVA conducted with the posttest CFSEI subscales revealed no significant differences between groups with or without the outlier score. The experimental group again experienced a significant increase in the personal domain of self-esteem. The midtreatment measurement of the dependent variables and the descriptive analysis finding an outlier score were vital observations. Without this data the posttest mean scores would have shown no significant difference between groups when in fact the experimental subjects experienced an increase in their self-esteem. Discussion
The results make a strong case in support of the Frey and Carlock (1989) model for influencing self-
Table 2. Means, Standard Deviations, and Sample Sizes at Pretest, 6-weeks, and Posttest with ANCOVA Tests of Significance Conditions
Pre Instrument Hunter M 61.3 SD 9.0 N 10 CFSEI total score M 21.2 SD 5.8 N 10 CFSEI subscales General M 11.0 SD 3.3 N 10 Social M 6.1 SD 1.6 N 10 PersonalI M 4.1 SD 2.3 N 10
ANCOVA df
Control
Experimental
F
Mid
Post
Pre
Mid
Post
Pre
Mid
Post
Pre
Mid
Post
Source
56.6 5.5 10
63.4 9.8 9
60.1 6.4 12
60.4 4.1 12
60.6 5.7 12
1 1 20
1 1 20
1 1 19
0.00 0.02
0.29 8.01*
0.22 0.53*
Covariate Between Within
21.0 7.8 10
23.2 7.4 9
23.8 4.5 12
23.8 4.0 12
25.1 4.7 12
1 1 20
1 1 20
1 1 19
2.69 2.56
2.85 7.48*
1.86 3.18
Covariate Between Within
10.8 4.5 10
12.0 4.0 9
11.9 1.6 12
11.7 1.9 12
12.4 2.4 12
1 1 20
1 1 20
1 1 19
2.65 1.41
2.42 3.73
4.32 3.25
Covariate Between Within
6.2 1.5 10
6.4 1.5 9
6.4 1.8 12
6.3 1.4 12
6.6 1.3 12
1 1 20
1 1 20
1 1 19
0.04 0.05
1.48 1.29
0.21 0.33
Covariate Between Within
4.0 2.7 10
4.8 2.8 9
5.3 1.9 12
5.8 1.7 12
6.1 1.6 12
1 1 20
1 1 20
1 1 19
0.21 4.32
1.59 13.5**
0.25 4.01
Covariate Between Within
Note. Significant Wilks' Lambda (WL) of the MANCOVA (for Hunter and CFSEI total score) at 6 weeks (p = .0286). Significant WL for CFSEI Subscales at 6 weeks (p = .0306). Significant WL at posttest for total score, both instruments (p = .0042) and at posttest on CFSEI subscales (p = .0137). "When the outlier score was removed from analysis, the experimental group's self-esteem was significantly higher than controls; F(2,17) = 4.73, p = .044.
*p
