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The one way trip of elderly people to the last living station
Abstract: Introduction: The promotion of health and economic status in all over the world is resulted in increasing the older population. It’s expected, that at least 40% of the population over 75 years need extensive health care services in the last years of their life. In Iran, like other parts of the world, the transferring elder people to the nursing home are increasing. Understanding elder’s emotional experiences is important for living in nursing home. The main aim of this study is to describe emotional experiences of elders living in nursing homes. Materials and method: The qualitative phenomenological approach and purposive sampling amongst elderly residents in private and public nursing homes in Esfahan, the second largest city in Iran, was applied. Sampling continued till data saturation and resulting sample size reached to 10 participants. The data was collected with in-depth interviews and field notes. Colaizzi's method was used for data analysis and the rigor was based on transferability and credibility. Findings: Three themes were extracted including: 'residents' emotional experiences in nursing home life', 'resident’s emotional experiences at the entrance in nursing home' and 'feeling of powerlessness'. Discussion: Older people have shown various emotions to relocation and residence in nursing homes. Every elder, with different context and different history in life, described its uniqueness experiences. Focusing on social, financial, health supports and mental, spiritual and physical needs of elders should be met through whole care. However, attention to physical needs may neglect hopeful, meaningful and purposive life in nursing homes. Keywords: elders, experience, emotions, nursing home.
Introduction: It was estimated that 10% of the world's population, 606 million people, were aged 60 or over in mid-2004 (Lee, 2005). The studies in Iran show that in 1996, 6.6% of population was over 60 years old. This figure is expected to increase in 2030 to over 10% of the population, about to 8.5 million (Nikfarjam, 2005). Almost 2 million Americans live in nursing homes, and the figure is expected to reach 5 million by 2030 (Theodos, 2003). In Iran, like other countries, the number of older people residency in nursing homes is increasing (Tajvar, 2004). It has been found that placement usually occurs at a time of distress and crisis, e.g. following an acute illness or period of hospitalization. Hence, the people need to adjust themselves to the new conditions; and the stress might be beyond the tolerance of the old people. Thus, ever increasing need to understand the old people's experiences in adjusting to such places should be observed. It is significant to understand why such placement is often regarded by elders as the 'final sign of failure'. These perceptions and fears have a negative influence on older residents' adjustment when they are faced with this challenge, and understanding these experiences for continuing their life in nursing home is important (Nikfarjam, 2005). In a study in Hong Kong, it was found that elders generally had mixed feelings towards such placement (Lee, 1999). In addition, the study on elders in Tehran, in responding to the question of 'what were your feelings, before admitting in nursing home?' was that more than 28 % of them claimed that they have had a sense of happiness (Tajvar, 2003). The other study suggested half of the female Chinese residents in geriatric wards verbalized their joy as the result of their relief from doing 'tedious' housework they said had been working very hard for their families in the past, and the residential home was a place for them to relax and enjoy. Furthermore, Of course, the Chinese values of balance, harmony and collectivism have made it easier to remain open and accept the communal way of living (Lee, 1999). Of course, transfer to the care and environment of a residential home has been identified in the literature as the most significant relocation affecting older people. However, little effort has been made systematically to review and synthesize the body of knowledge relating to older people's experiences with such placement. This has led to lack of concrete effort in the development of strategies to help elders adjust to such placement with dignity and success (Lee et al., 2002). However, admission to these homes poses much stress in relation to customary life styles in a community setting (Lee, 1999). Elders are confronted with not only a change in physical location of primary living space but also a change in daily life patterns, social networks and support. Therefore entering to residential home make the most stress and fear affect on elders (Lee, 2002) while, some of the residents have feeling at home in nursing home (Deveer & Kerkestra, 2001). Attitude is the only leading factor affects quality of aging (Haffman, 2003). There are myths and misconceptions about aging, differentiate these aging myths from realities, is the first step in understanding individual's feelings and developing positive attitude about aging (Farrel, 2004). Furthermore, the people in general do not have positive attitude towards living in nursing homes (Dorman and Rantz, 2000). Because the goal of resident- centered care is supporting opportunities for continuous growth, encouraging significant relationships with family and community, and attention to individual needs and each resident's tendency and respecting every person's life style and skills in this setting (Miller, 2004).
Method: Recognition of humankind's feelings with quantitative methods is relatively difficult. For assessing these feelings, many researchers carried out qualitative research for deep understanding of the concept (Wood & Harber, 2002). Phenomenological approach was used in this study for exploring and developing insight into the world 'as it is experienced' (Potter & Perry, 2005; Paton et al., 2004). Data was collected through deep interview with participants in nursing homes. Interview was unstructured and the researchers employed field notes to record observed cases, interactions, relations, environmental conditions and nonverbal communication. Sampling for the interview was based on purposeful approach, adherence to interview, have experiences, ability for recalling and defining daily near experiences. Data was collected from private, governmental and charity nursing homes located in Esfahan, the second largest city in Iran. Interview was done after getting permission from the nursing homes administrations. Each interview was proceeded after the participant's agreement. Ethical tips in research were intervened. Duration of interviews was between 20 to 30 minutes. The data were analyzed according to Colaizzi's method. First, the participants' recorded statements were played repeatedly, and their statements were transcribed. Next, to extract meaningful information, statements were underlined line-by- line. Further questions were included for the next meeting at the same time as transcribing and listening. The data was read several times to convert meaningful statements into universal and abstract statements. At the same time, efforts were made to find out whether the constructed meaning and theme groups were formed according to difficult themes and categorization or not. During this abstraction, meanings of statements were compared through phenomenological literature, and the similarities and differences were analyzed. After the identification of themes, they were written down and then statements on the interconnectivity of those themes were made along with statements for each theme, theme group, and categories. Efforts were made to describe phenomena as accurately as possible to get the essential structure. In order to confirm whether the final statement was appropriate for the emotional experience of the participants, validity of the essential structure was confirmed with the participants. The severity of the present study was grounded on the two criteria, credibility and dependability. Researchers for findings credibility referred extracted codes to participants with their confirmation, the findings were validated, also referred the findings and extracted codes to an expert in qualitative research, for further validation. Also for dependability of the findings, researchers explained the research process in details and the way of gaining to the results, to help other researchers to get the results.
Results: The codes were extracted after transcription and underlining, for example it could be understood the meaning of 'compulsory tolerance' from the underlined phase, "…here is not bad, I can't do any intervention, or feeling (satisfied or dissatisfied), everybody has to adapt him/her self…"(Interviewee 2). The meaning of 'taking shelter' could be attributed to the underlined phase, "… we have to stay, if we don't be here, there isn't anywhere else for us to live..."(Interviewee 8). However, the meaning of each significant statement spelled out, known as formulated meanings or codes (Burns & Grove, 2005). In this stage, 70 codes or formulated meanings were extracted. All of the extracted codes were listed and clustered into some categories. Sometimes it was necessary refer these clusters of themes back to the original protocols for validation. The stance of this stage include participant's low moral that could be found in the codes 1-6. These codes are sorted as subject category of 'low morale'. Thus all subject categories, as the same 'low moral' were formed, for example 'relocation stress', 'happiness' and so on. Then, results so far are integrated into an exhaustive description of the phenomenon under study e. g. subject categories such as 'low morale', 'relocation stress' and 'happiness' categorized under bigger subject categories. The subject categories such as 'compulsory tolerance', 'waiting for exiting permit constrained authority' also were formed as other bigger subject categories (Diagram 1). Finally three themes were extracted from the data (structural components of experience), including: 'residents’ emotional experiences in nursing home life', 'resident’s emotional experiences at the entrance in nursing home' and 'sense of powerlessness'.
Diagram 1: How categorization concepts
Discussion: One of the concepts was the sense of powerlessness. Some of the participants expressed inability to change the conditions and compulsory tolerance and/or they found themselves in constraint adaptation some of them have stated to be under constrained autonomy and waiting for exit permission. The concept named "powerlessness" was inferred from these statements. Sense of powerlessness could be resulted in the situation that somebody believes it's invariable, and sense of powerlessness increases depression feeling and inefficiency (Maas, 2001). As the participants of Lee's study believed that residential care was an unavoidable alternative to family care, it was an important source of fear in their last years of their life, and a sense of powerlessness, and adoption were their response. In this study two residents felt powerless and hopeless with a wish to die (Lee, 1999). Some of the participants expressed nursing home entry the source of helplessness and didn't see any future for themselves. Although the residents expressed the feelings such as loneliness, sadness, depression, etc. some of them expressed statements of convenience and happiness as the result of nursing home entry. For example one of the participants (no. 6) expressed a sense of happiness for being away from family problems, and the other one (no. 9) expressed a sense of happiness for having autonomy and freedom from family unfavorable problems. These findings could be found in other studies (e.g. Lee's study suggested that elders have different feelings about this setting) (Lee, 1999). As it was expressed, negative feelings also were stated by the participants. For example the interviewee no. 3 says 'I have a bad feeling… damaged morale!'. Another study conducted also indicated that the morale of the elderly in a geriatric day care institution was higher than that in a nursing home (Cited from Tseng & Wang, 2001). The participant no. 3 expressed a sense of worthlessness and absence of self-esteem. Sense of dignity and self-esteem were complementary to each other. Low self-esteem could result in depression and an elder person feels a loss of control in his life in this situation. Absence of control could result in a weaker justice, less activity level and decreasing physical health for elder persons (Maas, 2001). In the latter case, the researcher found she hadn't any visitors and her room mates suffered from mental disorder. However these findings are in line with the previous works in that social support provided by family members and relatives was an important predictor of quality of life in elders (Tseng & Wang, 2001). Some of the residents expressed sadness and grief. It is a very powerful feeling and comprises sorrow, loss and confusion, and it is caused when a worthy thing or person is lost. This reaction is caused in response to loss of a person, role, relationship, health or autonomy (Haffman, 2003). Some of them also expressed their own helplessness and anger destiny or expressed depression and hopeless feeling, ending life and lack of motivation. Feelings such as bad morale, lack of self-esteem, worthlessness and the like have mutual relationship with the sense of depression., depression rate in half of elders living in nursing home according to Geriatric Depression Scale (GDS), indicates probable depression and instances of depressing behavior including: loss of many activities, interests, lack of energetic feeling, worthlessness and helplessness (Kerber et al., 2004). Another study conducted by Teresi and colleagues (2001) found, among those nursing home residents who were capable of assessment, about one-fifth suffered from clinical depression syndromes; and it was concluded that prevalence of depression disorders among nursing home residents is high. German and colleagues found 6.5% of the residents to have major affective disorders (Cited from Teresi et al., 2001). While in another study, the moderately high level of hope was found in this population, and the finding that hope is not dependent on age, physical and mental health, or functional ability, dispels some myths that elders who live in nursing homes are hopeless (Touhy, 2001). In the present study, some of the participants expressed feeling of loneliness and others expressed to lack this feeling. On the other hand, one of them said that she is used to living in nursing home conditions and in general she is satisfied with living in the place. One of extracted concepts was fear of falling. Some of the participants after a fall had experienced fear of falling and were limiting their activities because of this feeling. Fear of falling ends loss of autonomy and other life styles are altered after a falling, thus, they are isolated physically and socially. This life style is associated with functional decline, loss of self-esteem, decreasing mobility and loss of autonomy (Roach, 2001). In the present study, most of the participants have experienced relocation stress after admission to nursing home or from other nursing home or other room in the same nursing home. Transfer to the care and environment of a residential home has been identified in the literature as the most significant relocation affecting older people (Lee et al., 2002). The elders might experience anxiety, stress, confusion and depression in the time of relocation from a place to another one. This form of relocation was named removal syndrome (it may be contain temporary confusion) and if they move from home to acute care hospital or from rehabilitation center to nursing center during a several weeks period, it's a fact (Hogstel, 2001). Every elder, with regard to the field where he before has lived had different attitude and unique experiences from nursing home residency, and expressed needs, expectations, feelings and emotional experiences. In varying degrees, admission to a residential care home has been found to evoke feelings of abandonment, stress an uncertainty, loss of a home and opportunities for contact with family and friends. Nay (1995) found that admission to a nursing home meant losing everything for these elders who felt to be worthless as individuals with no future (Lee, 1999). As it was explained before, elders suffering from chronic diseases or physical or mental deficits, and have no access to home care tend to reside in nursing homes. Participant no. 4, after an accident suffered from physical deficit, and had a compulsory reside in nursing home, and this intensifies his worthlessness and helplessness feelings. Tseng and Wang (2001) expressed healthy or independent elders were not sent to an institution unless they became sick or dependent. These elders separated from relatives and friends, are more probably at risk of the lack of self-worth. If elders feel that they are abandoned because of worthlessness, as a natural reaction suffer from negative feelings. These individuals often have feelings of worthlessness, unwillingness and unkindness (Haffman, 2003). The findings of Tseng and Wang's study also suggested that the elders who live longer in a nursing home may feel they are abandoned and thus get isolated from the society. In this study the elders who lived in a nursing home longer had a worse quality of life (Tseng & Wang, 2001).
Conclusion: The core concept 'emotional experience' was derived from the themes such as 'feelings in daily life in nursing home', 'feelings in nursing home entrance and sense of powerlessness'. Elders have different feeling to entrance and residency in nursing home and expressed their feelings. Physical inabilities, health, needy help others in doing activities that previously have been done independently, can cause loneliness and depression in elders. Amongst residents, depression, emotions such as sense of lack, feeling of abandonment, loneliness and hopelessness are important subjects that require emotional support. These negative feelings overlap each other and could aggravate each other. However, nursing home environment could be an environment where feel worthy and have active and innovative life. Participation in enjoyable activities in nursing home is away for making people prevent problems, and anxieties resulting in decreasing stress. Although, most focus is on the client's physical care needs, it is expected that nurturing body, mind and spirit should be met through general care, because only attention to physical needs of the client makes it impossible for the aged have opportunities for meaningful, purposeful and hopeful life.
Implications for practice: Such understanding from aging experience will help nurses in changing their attitudes about aging. Thus, the nurses should recognize residents' uniqueness regarding their needs, e.g. privacy, and preferences in nutrition. Concrete effort should be done in the development of strategies to help elders adjust to such placement with dignity and success. Mental health services may play a significant role in the matter of activity aging, should be attended as a leading part in long term care.
Acknowledgment: This study was supported by a grant from the Nursing and Midwifery Faculty of Esfahan. Researchers also thank the elders participated in this study, heads staff, and inmates of nursing homes.
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