| HOME | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|---|
| ||||||||||||||||||||||||
a The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin
b Department of Family and Community Medicine, The Chinese University of Hong Kong, Shatin
Correspondence: Diana T. F. Lee, PhD, RN, The Nethersole School of Nursing, Room 831, Esther Lee Building, Chung Chi College, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong. E-mail: tzefanlee{at}cuhk.edu.hk.
Decision Editor: Laurence G. Branch, PhD
 |
Abstract |
|---|
 TOP Abstract MethodsResultsDiscussionReferences |
|---|
Key Words: Long-term care • Grounded theory • Chinese elders
The dramatic change in both physical and social demands as a result of nursing home placement has been widely discussed in the literature as a stressful life event that challenges elderly people. Accordingly, researchers have attempted to untangle the challenges residents encounter in making the transition from life on the "outside" to life in a nursing home. Frequently identified are feelings of abandonment and loss of a home, lifestyle, autonomy, privacy, and the opportunities for contact with family and friends (Fiveash 1998
; Iwasiw, Goldenberg, MacMaster, McCutcheon, and Bol 1996; Nay 1995; Wilson 1997).
These different losses upon nursing home placement generate much suffering for the residents. The loss of privacy and of autonomy over activities of daily living, for example, create anxiety and stress (Thomasma et al. 1990) and lead to a devalued sense of individuality and self-determination (Kahn 1990; Nay 1995). These negative feelings are further intensified by the constraints encountered immediately after placement (Brubaker 1996; Fiveash 1998; Iwasiw et al. 1996; Wilson 1997). The problems associated with the public nature of nursing home life and with the restrictions involved in complying with the rules and regulations frequently cause major concerns to residents. The presence of sick and confused people is a constant source of threat to the newly admitted elders who feel their health may similarly deteriorate. Living in a nursing home is described as "alien, different and distanced from all other experiences which elderly people accumulate over a lifetime" (Willcocks et al. 1987, p. 134). The initial period of residence has even been labeled as the "first month syndrome," when they adjust to the idiosyncrasies of a roommate and life in a congregate environment (Tobin & Liberman, 1976).
Although a body of knowledge relating to elderly residents' post-placement challenges is identified in the literature, less is known about the actual process of how newly admitted elders handle these challenges and adjust after nursing home placement. Using data drawn from interviews with nursing home residents, Gubrium 1993 revealed that through continuing to be biographically active, residents were able, within the parameters of their situation, to construct and live in worlds of their own. This enabled them to forbear the unfamiliarities of the new nursing home. Groger 1995, on the other hand, found that through using their own home as a reference, elderly residents achieved a sense of home in the new home and came to terms with the "new life."
Using a grounded theory approach, Wilson 1997 explored the initial process of how residents made the transition to nursing home life in the first month after placement. In-depth semi-structured interviews were carried out 24 hours after placement, every other day for 2 weeks, and 1 month post-placement. This transition was found to occur in three phases: the overwhelmed phase when elderly residents were dominated by a negative emotional response to the placement; the adjustment phase when most residents began to develop a positive attitude toward the future and everyday living; and the initial acceptance phase when residents worked on accepting nursing home life. In a longitudinal qualitative study, Brooke 1989 described the elders' adjustment to living in a nursing home in four phases of progression: disorganization, reorganization, relationship building, and stabilization. Ninety-three percent of the newly admitted residents progressed through these phases in a period of 8 months. Newly admitted residents were typically disorganized during the first 2 months after placement, but gradually began reorganizing or problem-solving by the third month, building relationships during the third and fourth months, and stabilizing by the fourth through sixth months.
It is apparent that although the pattern of adjustment processes described by Brooke 1989 and Wilson 1997 are rather similar, the time that residents needed to progress through the different experiences was found to be vastly different. While residents in Brooke's study were disorganized for the first 2 months after placement, residents in Wilson's study had already established relationships and activities in the home at the end of the first month. Moreover, although both studies described the process of how adjustment was made, they did not address the question of why residents engaged themselves in these stages. More insight into the processes of how elders adjust after nursing home placement is needed in order that relevant caring practice can be identified to assist the older adults to go through the experience with dignity and success.
The purpose of this study was to describe the processes through which residents in Hong Kong adjust following nursing home placement. Various socioeconomic changes have resulted in an increasing number of elderly people moving into nursing homes. At present, about 5.7% of elders in Hong Kong are residing in nursing homes (Census and Statistics 2001). However, little is known about their lives after such placement, especially with regard to how they resolve the various issues related to the transition and stabilize in the nursing homes. Chinese people have been characterized as having family values that foster intense interdependent family ties, high filial expectations, and strong intergenerational cohesiveness (Bond 1996; Chow 1996). Because of these traditional family values, the majority of Chinese elders expect to be cared for at home by their children (Lui, Lee, and Mackenzie 2000). In exploring the perceptions of nursing home placement among community elders in Hong Kong, Lee 1997 found that they generally had mixed feelings toward such placement. Although they believed that this could be an unavoidable alternative to family care, it was an important source of conflict in their later years. There is a need to understand how Chinese elders adjust to living in nursing homes. The knowledge thus obtained is of great value in providing a sound theoretical basis to unravel how elders can be assisted to go through the nursing home experience with dignity and success.
|
Methods |
|---|
|
TOPAbstractMethodsResultsDiscussionReferences |
|---|
The grounded theory method was employed to achieve the aim of the study. It provides a means to guide the collection and interpretation of data, and to discover categories and concepts that can be linked to describe processes and build theoretical frameworks (Glaser and Strauss 1967). This is therefore the method of choice when the problem being examined is considered a dynamic process (Stern 1996), as in the case of adjustment to nursing home life. This methodology is hierarchical and recursive, requiring data collection, different levels of coding and constant comparative analysis of data and recycling of earlier steps directed by the emergent findings (Morse and Field 1996).
Setting
Informants were recruited from a 126-bed nursing home that provided personal and basic nursing care. Residents did not require a high level of medical supervision and nursing care. Ninety-eight percent of the beds were occupied throughout the 1-year study period. Social workers and nursing personnel (registered nurses, enrolled nurses, and personal care workers) were employed to provide care to the residents. As a common feature of nursing homes in Hong Kong, residents were living in their "bed-units" together with other residents. These bed-units were arranged along the walls of a big room. Eight to 10 residents of the same gender shared a room and there were three toilets and a bathtub in each room. Each floor was made up of four big rooms of this kind. There was also a sitting cum dining room on each floor where the nurses' station was located. Gardens, staff offices, meeting rooms, recreation and exercise rooms, and consultation and treatment rooms were located on the ground and first floors of the building. As is typical of all nursing homes, the activities and events in this home were scheduled routinely.
Participants
Newly admitted elders who could understand and speak Cantonese and were permanent residents of the home were invited to participate in this study. Characteristics of the participants are reported in Table 1 . A total of 18 elderly residents (9 men and 9 women) participated. They ranged from 70 to 86 years old, with a mean age of 79.2 years. Four elders lived alone before the admission whereas 11 others lived with their families. The remaining 3 elders were transferred from other nursing homes. Three of the elders who lived alone before admission had never married, 11 other elders were widowed, and 4 were still married. Admission into the home had been voluntary, except for 3 elders. Most elders had chronic health problems such as hypertension, diabetes mellitus, and heart failure, yet they were able to take basic care of themselves. The main reasons for admission were failing physical health and family members' anticipated inability to provide care at home.
|
). Obviously, the questions of the interviews could vary from participant to participant, depending on the disclosure of particular adjustment experiences. The themes that emerged from analysis of early interviews were also used to shape the line of inquiry of subsequent interviews.
Data Analysis
Data analysis was carried out manually using the constant comparative method (Glaser and Strauss 1967). The audiotape of each interview was transcribed verbatim. Open and axial coding were performed to identify relevant concepts and their relationships in the data to allow for creation of categories. Analysis of within-subject and between-subject patterns and variations in the data occurred next. Consistencies and contradictions as well as similar and negative cases were identified to further test and dimensionalize the emerging categories. This process was continuously validated through weekly discussions with the other two members of the research team who had experience using grounded theory. As the interrelationships among the different categories became more apparent, the core variable/category that explained how the different categories were linked was identified. As a result of this process of ongoing analysis, the process of how residents adjust to nursing home placement was identified.
|
Results |
|---|
|
TOPAbstractMethodsResultsDiscussionReferences |
|---|
). The purpose of this article is to illustrate the different stages involved in the process of regaining normality.
Regaining Normality
Following admission to nursing homes, elders adjust through a process that may last from 3–7 months. This complex process involves a struggle to regain normality, that is to regain a life that is as close as possible to that lived before nursing home admission. One elder said, "All I have on my mind is what it was like before I came here and how I am ever going to make it here." Regaining normality is therefore the basic social psychological process (Glaser 1978) through which newly admitted elders adjust to living in a nursing home. It is the core variable that explains the processes and activities involved when elderly people deliberately assess actual or potential threats to establishing normality and then plan and implement strategies designed to regain a sense of normality with respect to life inside the nursing home. This process is comprised of four stages: orienting, normalizing, rationalizing, and stabilizing. As noted by the double arrows in Fig. 1, there is a reciprocal relationship between the stages of normalizing and rationalizing. These four stages are described below in more detail.
|
Stage One: Orienting
Immediately after admission, newly admitted elders oriented themselves regarding life inside the nursing home. This stage began from the date of admission and lasted for 2 weeks to 1 month. Residents commented that the information provided by the home staff upon admission was rather standard and formal. They therefore used their own efforts to gain a realistic understanding of the dynamics of every aspect of nursing home life, both written and unwritten. They observed very closely how other residents acted, behaved, and spent their days. A mental picture of the home was formed when they were confident that both the written and unwritten rules and regulations had been understood and that they had identified those residents upon whose "toes" they did not want to "tread" (labeled as the "kings" and "queens"). Elderly residents also identified and "followed" a role model to help settle themselves into the home. They would sound out the role model for observations about the unwritten or informal regulations. One elder talked about what it meant to "sound out" her role model, Ah Mei:
Ms. Ho [the deputy superintendent] told me not to hang dry my clothes in the corridor. Yet, I saw a lot of others were doing this in the evening. I just informally checked this with Ah Mei. I now know that this rule is really not followed. The staff would "close one of their eyes" and just let us dry our clothes in the evening. We could not do this in the morning. They [the staff] say that this is too unsightly! This is good since I really want to wash my own underclothes and not send them for public laundry.
With the information thus gained, most newly admitted elders began to establish realistic limits that would be allowed in the home in their next task of normalizing. This marked the end of the orienting stage.
Stage Two: Normalizing
From around the third or fourth week to the fifth month after admission, most newly admitted elders began to use the knowledge gained from the first stage of orienting to plan and implement strategies for normalizing their lives inside the new home. This meant they tried to maintain a lifestyle close to that before admission. Findings of this study suggest that there is an interesting temporal sequence to elders' normalizing with the different aspects of nursing home living. Immediately after admission, all newly admitted elders were very eager to thoroughly work through the rules and regulations of the home. Getting through communal living was the next target for the elders, followed by establishing interpersonal relations with other residents and staff. Dealing with altered family relations came last in this sequence.
All residents regarded rules and regulations as the "laws of a country" and as necessary in maintaining harmony and order in the nursing home. They therefore obeyed these regulations and attempted to fit in by repatterning their lifestyles and daily routines as much as they could. With regard to communal living, elders expressed their understanding about meeting collective needs rather than individual needs in dealing with various issues arising from living together. Meeting collective needs was also discussed in relation to the Chinese culture of living and eating together as a big family. This, together with elders' past life experience of sharing a flat with many families, had helped them accommodate the present need of sharing common facilities with ease. Problems commonly discussed in the literature, such as shared common facilities, were therefore not regarded as important by the elders in this study. One elder said about the bathing schedule:
If there is a vacancy in the bathroom, you can go ahead to take a bath. If the bathrooms are fully occupied, you have to wait until others had finished. It is the same as living at home—you also have to take turns for bathing. Now, you just live in a bigger room with more neighbors.
Contrary to their accepting attitude toward communal living and the rules and regulations of the home, elders were very cautious in dealing with other residents and staff. They were guarded in establishing relations with residents and stories of "difficult" residents were abundant. "Walking on thin ice" was the strategy newly admitted elders used to avoid unpleasantness that resulted from unhappy transactions with difficult residents, whom they labeled as "kings" and "queens." This involved not saying or doing the wrong thing. It was evident that elders had a lot of unresolved turmoil and suffering resulting from these unhappy encounters. However, none of the elders attempted to inform the home staff of these unhappy incidents; as one elder said, "They [staff] should know of these problems, I really don't know how to tell them."
Indeed, newly admitted elders expressed that they did not know what the staff–resident relationship should be like. In the face of this uncertainty, a distant and superficial relationship was preferred because the home staff were seen as "rulers of a country." Elders claimed that it was very important to be cooperative and not be seen as "troublesome." They therefore did not actively seek to establish relations with staff and reveal their difficulties in settling in.
Of all the aspects of normalizing, working through the altered family relationship was considered by the elders as the most difficult. This was a result of Chinese cultural characteristics that strongly emphasized family ideology. In order to reestablish their lives inside the new home, elders rationally worked to let go of their emotional attachments to the families by discouraging their families from visiting them. They also disguised their feelings about problems of settling into the nursing home. This, however, raised intense feelings of ambivalence in the elderly residents.
Although all elders in this study progressed from the first stage of orienting to this second stage of normalizing, none of them attained full normality, that is, none were able to reestablish a life as "normal" as before admission. It was therefore important that elders came to accept living in this new, reestablished life inside the nursing home. This brought them to the third stage of the adjustment process.
Stage Three: Rationalizing
Rationalizing was the process elders used to come to terms with the reestablished life inside the new home. It involved engaging in tasks that helped elders gain insight into how to put their lives back together, within the normality that they had negotiated in the second stage of adjustment. Findings of this study suggested that there is a reciprocal relationship between the second and third stages of the adjustment process. The ability of the elderly person to normalize was affected by his progress in rationalizing this normalization process, and the strategies used in rationalizing, in turn, affected the process of normalization.
The strategies employed to rationalize include protecting the face, softening the blow, and defining the nursing home. Nursing home admission had undermined the family pride of upholding the virtues of filial piety, a very much treasured Chinese value, and resulted in "loss of face." Therefore throughout the adjustment process, elders had to struggle to protect their own "face" and that of their families. This was achieved by telling white lies about their "absence from the family." Elder H asked her son to tell a white lie:
I won't let others know that I have come and stayed here. I told my son to tell others that I was now living with my daughter. Only then will those people shut their mouths if they know that my son has not abandoned me.
To a certain extent, these white lies worked to pull the families together and protect them from having "shameful" feelings. Telling white lies also helped the elders to achieve the letting go of their emotional attachment to their families. This was an example of the reciprocal nature of the second and third stages of adjustment.
As newly admitted elders gradually came to realize that there were certain aspects of life that could not be managed in the way they would wish, they began to soften the blow by downplaying the negative so as to make day-to-day life easier within the limits of nursing home living. They attempted to validate their problems with other residents, relate them to old age, or simply ignore them. One elder explained this:
Hey, you can just sit over here for a while and you can hear how some of them [other residents] are talking about missing who and who. We are all like that. It is only abnormal if you don't miss someone or something. You are starting a new life here.
Once the blow was softened, the next task was to attempt to define what the nursing home was like for them. This was an important step in completing the process of rationalizing because it marked the beginning of a new life pattern in a place that was accepted by the elderly people. Most elders defined the nursing home as their "second home." The second home was almost like home except that in this second home elders were not living with their families.
At this stage, most residents were more able to understand the constraints of management and the difficulties of other residents. They also felt relieved that they were able to manage the different tasks brought about by their admission.
Stage Four: Stabilizing
At around 5–6 months after admission, most residents began to enter this final stage of the adjustment process as they put their lives back together after all the efforts directed toward regaining normality. They started to reconstruct what it should be like being old and in a nursing home. The central theme thus identified was resignation from previous life: to be simple, peaceful, take things easy, eat, and rest more. Chinese cultural values of tolerance, acceptance, and being thankful were seen as appropriate attitudes for them to continue their life inside the home. Reflecting on how he was being accused of not flushing the toilet by the "king" who had threatened to kill him, one elder remarked:
Maybe we were enemies in our lives previous to this. I might have treated him badly then and now it's his turn to take revenge. Maybe, it's just all what it is about. It's fate that brings us here—in this very same nursing home! I have to accept this.
Most residents also started to formally connect themselves to nursing home life. They began to join activities organized by the home and get more involved with the people around them. As they came to accept nursing home life, they no longer focused their attention solely on the nursing home. The admission was no longer the elderly residents' primary concern. This was a result of both the normality that had been re-established and the passage of time.
In summary, through the tasks achieved during the four adjustment stages, the majority of residents began to live a "normal" life again and nursing home issues were no longer their prime concern.
|
Discussion |
|---|
|
TOPAbstractMethodsResultsDiscussionReferences |
|---|
Despite the various ways in which elders respond to these stages, the goal is the same: to regain normality of a life as close as possible to that before admission. Indeed, regaining normality is all about maintaining an individual's "sense of biography, of self and of belonging" (Nolan et al. 1996, p. 271). Accordingly, elderly people's adjustment experiences and behavior were strongly influenced by their life experiences and sociocultural values. Hence, a number of adjustment experiences and behavior of Chinese elders as identified in this study were rather different from those described in the literature.
Chinese Sociocultural Values
Other longitudinal adjustment studies (Brooke 1989; Wilson 1997) have found that elderly people respond initially to nursing home placement with a great deal of emotional distress, feelings of loss, and fear. This is called the "disorganization phase" in Brooke's study and the "overwhelmed phase" in Wilson's study. The great differences in living arrangements before and after admission and the lack of previous life experience to relate to such situations are identified as major causes resulting in these painful transition experiences. The experiences of Chinese elders at this stage, however, are different. For Chinese elders, it is part of their culture to live and eat together as a big family. This, together with their past experiences of sharing common facilities and living in small spaces, helps them make the transition with ease. As they are not emotionally bothered by the constraints of nursing home living, they are able to remain "cool" and rational in their initial attempts to understand the new home.
It is evident that Chinese elders in this study were not unduly influenced by the problems of rules and regulations and communal living that are described in the literature as the major blocks to nursing home adjustment. Indeed, Chinese social interaction is to a great extent stereotypically collectivist. "Collectivism" refers to a conception of the person as deeply embedded in the group without legitimate autonomous interests (Schwartz 1994). Chinese elders, in particular, value the importance of collectivity over individuality (Kuo and Kavanagh 1994). They consider harmony and balance to be the keys to survival, peace, and happiness (Xingwu 1991). These values and norms seem to have influenced how elders in this study adjusted to the demands of rules and regulations and handled the difficulties arising from living together. Moreover, due to the crowded living environment in Hong Kong, most elderly persons live with their families in unpartitioned flats (Leung 1992). Some families in old public housing even have to share toilet and bathing facilities with other families on the same floor. For elders in this study, this past experience of living in such a crowded and "public" environment was seen to be important and relevant to their acceptance of the communal way of living in the nursing home. In fact, elders regard admission to nursing homes as opening the door to a better and secure living environment where basic care can be guaranteed. As the average waiting time for subsidized nursing home placement in Hong Kong is more than 2 years (Social Welfare Department 1999), the majority of the elders in this study considered themselves very lucky to have been "given" a place in a nursing home. They believed that they should therefore be thankful and tried to be compliant to nursing home life as much as possible.
However, these same values of harmony and balance created great tension as elders handled relations with other residents. Indeed, the problem of the tenuousness of relationships in nursing homes has been widely reported in the literature (e.g., Gutheil 1991; Kovach and Robinson 1996; Shield 1997). A variety of factors, including the physical and cognitive limitations of the elders, poor physical layout, and the emotional atmosphere of the nursing home, are suggested as explanations for this failure to develop relationships inside the nursing home (Bitzan and Kruzich 1990; Kovach and Robinson 1996; McGinty and Stotsky 1967; Wilson 1997). Findings of this study, however, revealed the influence of sociocultural values upon this process of relationship building. Harmony in social relationships is very important in Chinese societies. Being "modest" is a way to achieve harmonious social relationships (Gabrenya and Hwang 1996). Conflicts in social relationships are to be avoided whenever possible to prevent "loss of face," diminished confidence in the integrity of character (Kuo and Kavanagh 1994). These beliefs were described vividly by most of the elders in this study and were consistent with their use of "guarding" and "walking on thin ice" in the process of relationship building with other residents. Yet, it is worth noting that in most of the nursing home literature, willingness to become involved in relationships with other residents is still regarded as a desirable feature of adjustment to the new home. The fact that this overgeneralized expectation does not apply for every elder has been overlooked. Assisting residents with relationships also requires respect for residents' readiness to develop social relations, and staff should well be aware of the sociocultural values that come into play.
Elderly people's life experiences and sociocultural values also influence how they come to terms with and stabilize into nursing home life. "Protecting the face" is an interesting adjustment experience of the Chinese elderly residents in this regard. While concern about face is a universal phenomenon (Bond and Hwang 1986), what constitutes a desirable face is culturally specific. To "protect face" or preserve honor for oneself or one's family is important and worthy of great effort in Chinese society (Wong 1999). Admission to a nursing home signifies a defiance of moral standards, resulting in a loss of face for the whole family. Therefore, in order that the elderly residents can come to terms with their new life, they and their families have to first work to protect their face. This is achieved by telling white lies to relatives and friends about their admission. To a certain degree, these white lies bring the families together in this period of hardship and facilitate the letting go of negative emotions associated with loss of face. Without completing this task, elders will not be able to stand up and continue with their lives in the nursing home.
General Implications for Practice
The findings of this study suggest that the goal of nursing home practice in promoting elderly residents' adjustment is to assist with the process of regaining normality with the different aspects of nursing home living. This means that elderly residents should be assisted to maintain patterns of life and conditions of everyday living that are as close as possible to those before nursing home admission, despite the limitations under which they live. As indicated in this study, this has to be achieved through understanding and meeting the sociocultural needs of elderly residents. This necessitates the adoption of a biographical approach to needs assessment and care planning as well as a shift of the institutional focus inherent in the present nursing home care practice to a modality of practice that focuses on the elderly residents as unique individuals with distinct life histories.
The fact that elderly people experience different stages as they adjust to living in a nursing home also suggests that interventions to promote their regaining of normality should be dynamic in meeting the needs of the particular stage that the elder is experiencing. It is, however, important to note that an elder may struggle or rebound between stages with different levels of awareness. Therefore no set times should be set to begin and end adjustment. These stages are merely a convenient way to describe certain emotional-cognitive-behavioral patterns that are momentarily ascendant, depending on when in the total process one makes observations. Although these patterns do contribute to the development of criteria for assessing the different stages of adjustment (Table 2 ), nursing home staff must adopt an extremely flexible approach in noting elders' progress through these stages when helping them face the challenges. Caution should be exercised in expecting residents to adjust in a precise, step-wise sequence.
|
|
Acknowledgments |
|---|
Received for publication October 22, 2001. Accepted for publication April 15, 2002.
|
References |
|---|
|
TOPAbstractMethodsResultsDiscussionReferences |
|---|
| ||||||||||||||||||||||||
| HOME | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|---|
