Relocation Decisions and Constructing the Meaning of Home: A Phenomenological Study of the Transition into a Nursing Home

Abstract

The transition from community dwelling to a nursing home is a common, though idiosyncratic, experience in the United States. This study employed an interpretive phenomenological approach to uncover how eight older adults in nursing homes in the Midwestern U.S. constructed the meaning of home shortly following the relocation and again approximately two months later. The degree to which the individual had been involved in the decision making process was also explored as it related to the meaning of home within the nursing home setting. The majority of individuals did not consider the facility to be “home,” but actively changed their attitudes toward the facility and themselves to better adjust to the setting. The findings demonstrate the importance of autonomy in older adults’ definitions of home.

One and a half million people in the United States live in nursing homes(institutions which provide 24-hour nursing care focused on the physical and mental health needs of residents) (U.S. Department of Health and Human Services, Centers for Disease Control [CDC], 2010). Individuals who do not qualify for governmental assistance (i.e. Medicaid) must pay for their care on a per-month, or fee-for-service basis. This payment either comes from the older adults’ own resources, or from private insurance policies. People over the age of 65 make up 88% of all nursing home admissions in the U.S. (CDC, 2010). The majority of new nursing home residents transfer from another type of care facility (e.g. skilled nursing facilities where older people go to recuperate after a catastrophic illness or injury, hospitals, assisted living residences where older people must be able to take care of themselves, or other nursing homes). Less than thirty percent of nursing home residents move from a private or semi-private residence (CDC, 2010). Therefore the decision making process of moving into a nursing home can range from a carefully planned move to an immediate response to an acute health crisis which resulted in hospital admission.

Decision Making and Adjustment to a Nursing Home

The process of moving into a nursing home (also referred to as long-term care) requires a great deal of decision-making involving multiple decision making domains (e.g. financial, health, legal) regardless of its duration (Kao, Travis, & Acton, 2004). Maintaining a feeling of control over the decision to move into a long term care facility has been positively associated with greater psychological well-being following the transition (Street & Burge, 2012). Forced admission has been shown to lead to anger in new residents (Mikhail, 1992) and an increase in mortality rate over a one year period (Laughlin, Parsons, Kosloski, Bergman-Evans, 2007). Qualitative studies of the decision making process have illustrated the complexity and importance of the decision for older adults. Individuals who felt excluded from this process reported a decrease in psychological well-being (Bekhet, Zauszniewski, & Wykle, 2008). Interviews with new residents in a long-term care facility showed that taking part in the decision making process, having to admit dependence upon others, and being able to maintain a connection to the past while becoming a part of the new setting were salient themes for older women who had relocated into long-term care (Saunders & Heliker, 2008). The perception of being supported, as opposed to directed, by family caregivers has been found to be more important to older adults than the actual ability to participate in the decision making process (Johnson, Popejoy, & Radina, 2010). Experts suggest that health care providers and families establish a careplan for relocation and that the relocating adult be included in this process as early as possible (Johnson, 2013).

The Meaning of Home

Due to space limitations, the transition into a nursing home requires that older adults dispose of many personal belongings, and necessarily be removed from the physical structure of their home. In qualitative studies of older adults, home has been viewed as both a place and a quality which develops over time and across domains such as the personal, social, and physical (Molony, 2010). A study of elderly women in the Midwest found that the most salient meaning of home was as the center of self, such that where one resided was equated to who one was (Swenson, 1998). Older adults’ self-identity and personal history have been found to be intertwined with their dwellings and physical possessions (Shenk, Kuwahara, & Zablotsky, 2004). The home may also serve as a symbol of previous physical health and autonomy, qualities which are often left behind when entering a nursing home (Groger, 1995). Separation from the physical home and its possessions can disconnect individuals from their self-identity and lived previous experience (Rowles, 1983). These connections to meaning of the physical home are likely to make the transition into a nursing home a difficult process for older adults (Molony, 2010).

Establishing a sense of home and meaning have been shown to be central processes for older adults recently admitted into nursing homes. The process of establishing or finding home within a facility is likely a core process in adjustment to life in a long term care facility (Cooney, 2011). The process may be especially salient in a nursing home where the environment is focused on the healthcare process and residents are dependent upon the staff in contrast to the focus in assisted living facilities on maintaining independence and creating a home-like environment. Residents of nursing homes often share a room with a stranger while in assisted living facilities the residents have their own private apartments. Strict adherence to routine by staff and a lack of individual privacy have been associated with residents feeling less at home in a nursing home (de Veer & Kerkstra, 2001).

Qualitative studies have explored whether and how individuals create a sense of home within the nursing home setting. Adapting to a nursing home environment has been shown to be an active process. Kahn's (1999) ethnographic study of adapting to a nursing home found that the phrase “making the best of it” embodied the ambivalence felt by older adults moving into a nursing home, along with the conscious coping mechanisms they employed to accept the situation and perceived lack of alternative options. The study revealed the older adults’ efforts to focus on positive as opposed to negative features of the relocation, revealing ultimately, their choices to frame the situation in the most positive way in order to adapt to the environment where they would spend the remainder of their lives.

Phenomenological Insight into Home and Nursing Home Adjustment

Phenomenological studies explore how people make meaning of their world and experience (Porter & Cohen, 2012; van Manen, 1997). A study of three individuals’ transitions into a long-term care facility found that socialization into the institution occurred at both an institutional and interpersonal level; the institution did not come to define the entirety of the individuals’ sense of self (Wiersma & Dupuis, 2010). New nursing home residents were found to progress through three similar stages of transition beginning with the loss of home immediately following the transition, getting settled, relational transitions, and learning the ropes. The latter occurred one to two months after relocation, and the last stage of adjustment was getting settled in the facility which began to take place two to three months following the relocation (Heliker & Scholler-Jaquish, 2006). Adapting to a new living arrangement requires an older adult to establish a sense of place which entails new physical care routines, maintaining values activities, maintaining and establishing new social relationships, and managing personal belongings (Hersch, Spencer, & Kapoor, 2003). The themes of privacy, respect, affection, security, autonomy, a sense of community, and a continuing significance to one's life were themes associated with home in a phenomenological study of older adults in long-term care facilities (Hammer, 1999). The same study found the themes of intrusion (lack of privacy), disrespect, disdain, fear, dependency, discordance, and disrespect to be associated with the feeling of not being at home when living in a long-term care facility.

Research Questions

The findings of the preceding studies elucidated the process aspect of relocation. The present study used interview data immediately following the transition into a nursing home and again six to eight weeks later in order to better understand the experiences of older adults. Specifically, the following questions were posed: How does the concept of home emerge in older adults who have recently relocated into a nursing home? To what extent does the concept of home change following a period of potential adjustment? In what way does the degree of perceived control over the decision making process seem to be related to the sense of home developed in a nursing home?

Methods

Participants

Participants were part of a larger longitudinal study investigating the transition into nursing home facilities in the Midwest. The purpose of the complete study was to evaluate the decision making process of entering a nursing home for older adults across three ethnic groups, African-Americans, European-Americans, and Latinos, with the aim of understanding the factors (e.g. instrumental and social support) and sequelae (e.g. side effects and/or complications) of the relocation. Six participants from each ethnic group were randomly selected to take part in more detailed interviews through computer-generated selection of participant identification numbers out of the 95 individuals in the larger study. Eligibility requirements were that the participant be admitted to the facility within the previous two weeks and have a minimum score of 18 on the Mini Mental State Examination in order to assure cognitive functioning. The study had relevant institutional review board approval and informed consent was obtained from all participants. Each interviewee has been provided with a pseudonym to protect anonymity.

Interviews were conducted by the primary investigator or a research assistant in the participants’ respective nursing home settings. Two separate semi-structured interviews took place; the first within two weeks of the older adult's transition into the nursing home and again six to eight weeks following the first interview. The present study included participants who completed both interviews (n=8). The other eligible-participants (n=10) did not complete the second interview for a variety of reasons including illness, hospitalization, transfer to another facility, or unwillingness.

Instruments

Participants completed a brief demographic questionnaire by verbally answering questions and having their answers recorded by the interviewer. The demographic questionnaire included 11 items addressing basic demographic information (age, race, marital status, and highest level of education completed) along with information about current residence (e.g. How long have you lived at your current residence?) and recent moving history (e.g. How many times have you moved in the last 5 years?). One open-ended item asked the purpose for the move into the nursing home and the other asked, “Is there anything else you'd like to tell us to help those who move?”

Interview Guides

An interview guide was developed for each semi-structured interview. The guides served as a framework for the interviewer who allowed participants to direct the conversation and speak freely in order to reveal their thoughts and experiences. The guide for the first interview addressed the topics of the previous residence, reason for the transition, who had assisted in the move, along with the decision making process. The guide also included concerns about moving into a nursing home, the move's effect on interpersonal relationships, and what a nursing home meant to the participant.

The guide for the second interview again included questions about the move into the facility, including who had helped and how the decision-making process unfolded. Questions were included that specifically addressed the positive and negative aspects of living in a nursing home and how the move had affected the participants’ emotional support and social life. Participants were also asked whether and how their life had changed since they moved and to what extent they felt that they had come to the right place to live.

Data Analysis

Phenomenology did not guide the larger study, but was employed in the retrospective analysis of the interview data. Phenomenology is a descriptive method of inquiry which focuses on the subjective experience (van Manen, 1990). The method assumes individual's perceptions create their lived experience and that meaning is dependent on context; qualities which may be of special importance to people in medical settings who may feel voiceless, such as those in a nursing home (Carel, 2012). Context is comprised of four existentialisms of time, space, body, and human relations (van Manen, 1990). Conceptualizing perceptions and meaning as a combination of experience and context allows for exploration into the creation of an individual's personal and interpersonal existence. The present analysis employed interpretive phenomenology to uncover how the meaning of home was created by new residents in nursing homes in the Midwestern U.S.

The aim of interpretive phenomenology is to uncover shared meaning of the lived experience (Benner, 1994). The method has also been referred to as Heidggerian hermeneutics due to the philosopher's focus on meaning of the lived experience and its development through retrospective interpretation. The method involves interviewing participants within their environments and using the text generated through transcription to reveal the meaning of the subjects’ lived experience. The method has been found to be comparable to a quantitatively based methodology to analyze interviews of and build theory around the experiences of older adults (Mitzi, 1999). The method is not intended to predict behavior; instead the intention is to understand the human experience.

Phenomenologists work to establish an accurate portrayal of the meaning of the lived experience through bracketing and the iterative process. Bracketing is the process of recognizing the a priori information a researcher has and holds on a given subject and then actively setting that information outside of her consciousness (Porter & Cohen, 2012; Giorgi, 1985). Bracketing is done in order to allow the experience and meaning to emerge from the data without being filtered through beliefs, expectations, and assumptions. Previous research used in the development of the study's purpose (cited above) was bracketed throughout the analysis of the data. The bracketed literature was later employed to compare the themes, categories, and conclusions of the present study to assess whether a shared experience could be established across studies.

The iterative data analysis began with the participant's own language which was then interpreted and reinterpreted by the researchers. Coding was a three step process which began with in vivo coding, progressed to thematic coding, and finally the categorization of those themes. The codes developed through in vivo coding are taken verbatim from the data (Corbin & Strauss, 2008). This process preserves the participant's language and maintains the context provided within the data. Codes were assigned to words and phrases which captured the experiences which appeared to be most salient.

Analytic memos noting saliency and meaning of statements were produced throughout the analytic process of the transcribed interviews. Each round of coding began a new document and each new document was analyzed by the researchers along with the previously recorded memos in the formation of the latest analytic memo. Memos were used to organize and clarify ideas and information, as well as to extract meaning, maintain a bracketed perspective, and develop the themes which emerged from the data.

Thematic analysis is employed in interpretive phenomenology in order to uncover unique and shared experience(s) (Benner, 1994). The in vivo codes were analyzed along with the transcribed interviews to identify the salient themes for each participant. These themes were then evaluated as a whole to understand which themes applied across individuals. Themes were consolidated to expose the underlying concept and/or subject of the varying themes (e.g. the themes of food and less worry were consolidated into the “cared for” theme which emerged in the second interview). This process was done separately for the first and second interviews. The themes which emerged from the first and second interviews were then classified into categories which reflected area of adjustment (i.e. the self and the facility) and the meaning of home.

Results

The sample's demographic characteristics are presented in Table 1. The sample was evenly split by gender and had a wide range of age, number of children and marital status. There was little variation in education, with a trend to less years of education (ranging from 8^th grade or less to Master's degree).

Table 1.

Participants' Demographic Information

Characteristic	N = 8
Age (years)
X̄	80.88
Range	68 - 97
Children
X̄	1.88
Range	0 – 8
Characteristic	n
Gender
Male	4
Female	4
Ethnicity
Caucasian	5
African-American	2
Latino	1
Marital Status
Married	1
Never Married	2
Widowed	4
Divorced/Separated	1
Education
8th Grade or Less	3
Some High School	1
Graduated High School	0
Some College	1
Bachelor's Degree	2
Master's Degree	1

Degree of Decision-Making Choice

The perceived degrees of choice ranged along a continuum from having a choice, having some choice, having no choice, having no control, and no control paired with deception in the decision-making process. These degrees were based on the participants’ retelling of why they moved and the process of transitioning into the nursing home. Having a choice was defined as the perception of being included in and having an autonomous voice in the decision making process. Participants Megan and Penelope reported having a choice in moving to the nursing home (“I knew it was up to me.”). Penelope spoke of the importance of information in the decision making process (“. . . make sure you pick one that you know something about.”). Bea had some choice, meaning she had not been included in the decision making process but did not report the decision had been made for her (“My niece set it up.” [The decision to move] was not made for you? “No.”) Jane, Marvin and Sam reported having no choice, meaning they had no active role in decision making process (“I had no choice. … They just told me I was coming here and that was it.”; “They [my son and his wife] made the decisions already.” and “I had no choice.”).

Charles had no control over the decision making process (“I didn’t have nothing to do with it.”). No control implied being forced into the situation without any degree of autonomy or inclusion in the decision-making process; while no choice implied inclusion without perceived autonomy. Luis had no control and reported deception, (active deceit) in the decision making process (“She lied to me like a kid.” “Well, I don’t know anything. I ended up here like a mouse in a trap.”).

The majority of participants (with the exception of Marvin who had no choice and Charles and Luis who reported having no control) did not focus on the decision making process to enter the nursing home in the second interview. Instead, the content of the second interviews tended to focus on the logistical matters of moving (e.g. what was brought to the nursing home, where to place possessions) and daily life within the facility which will be further discussed below.

Lived Experience at First Interview

The themes which emerged described a self-driven process of adjustment in which the participants made explicit choices about how to manage both internal and external changes. Themes addressed the processes of acceptance and coping. Two categories of adjustment became apparent in the analysis: the self and the facility. Self adjustment was self-directed endogenous change which took place within the individual; specifically his or her cognitive processes directed at adjusting to life in the nursing home. Facility adjustment was also self-directed but was the process of adjusting to exogenous forces found within the nursing home.

Self Adjustment

The themes of “acknowledgement of need,” “making the best,” and “a place to die” were categorized under “the self” because they had emerged from a conscious self-guided decision-making process. The theme of “acknowledging need” came out of language which recognized requiring assistance in daily living, and/or no longer being capable of living on one's own. Megan specifically stated she was living at the facility due to, “My health.” Marvin, Penelope, Bea, and Sam all expressed needing help (“I need help,” Marvin; “I knew I needed help,” Penelope). Penelope, Bea, and Sam were explicit in the cause and effect of requiring assistance and transitioning into the nursing home (“Yeah, I think it's the thing to do, if you, if you're at the point where you can't do for yourself anymore,” Bea). These statements depicted an explicit self-awareness and honesty regarding the discrepancy between level of care participants needed and that which they could provide for themselves. The acknowledgement of need must not be conflated with an acceptance of need; this theme captured the candid recognition for assistance, not the approval of it. Jane was the only participant to deny any need of assistance (“I don't really think I need to be here.”).

The theme of “making the best” was based on Jane, Megan, and Penelope's description of the need to make the best of the current situation. This theme echoed Kahn's (1999) findings which demonstrated new residents consciously worked to accept and cope the best they could in a situation they could not change. These women described having to change their attitudes and perspectives in order to adjust to their new living situation. Megan also spoke of the importance of becoming involved in the facility (“Make up your mind it's going to work out, play the games, go to the meetings, enjoy meeting people.”).

The theme “a place to die” came from residents’ recognition that they would die within the facility. Jane, Megan, and Luis openly spoke of the nursing home being their final residence before death. Jane acknowledged that this would be her final residence (“I'll be here forever.”) which moved her to tears, while Jane felt she had no choice and was “stuck” (“So I'm stuck here for the rest of my life.”). Luis spoke of the inevitability of death in the facility in more generalized terms (“They will die here because they are very old.”). The participants’ identification of the nursing home as a place to die also spoke of their own impending mortality and being in the final stage of their lives.

Facility Adjustment

Adjusting to the facility brought out themes which contrasted life in the community and within the nursing home. The themes of “restriction” and “safety” emerged from residents’ description of their experiences within the facilities. The theme of “restriction” represented having one's actions within the facility or access to the outside world restricted and/or controlled by the staff. These are consistent with known characteristics of institutional life (de Veer & Kerkstra, 2001). Participants spoke about the lack of choice in daily activities and not being allowed to travel outside of the nursing home (“Can't do what I wanna do. Can't do anything I used to. All that bad,” [sic] Sam). Sam and Charles expressed frustration with the restriction due to being adults capable of making decisions; while Luis was the most emphatic stating, “I would say to my friends, don't go there, go to jail instead.”

Conversely, the nursing home was experienced as a place of “safety” by Sam, Charles, and Marvin who found protection and/or security at the facility. Marvin spoke about the facility being a safer living situation than his previous residence with his son's family. Sam and Charles addressed the physical safety the nursing home provided; Charles’ previous residence was being condemned due to its physical instability and Sam spoke of both problems with their home's physical structure and of the danger of being robbed as an older adult in the community (“Be safer in this home than we was by ourself.” [sic]). The theme of safety expressed the vulnerability of older adults in the community and the influence of neighborhoods on their physical functioning (Balfour & Kaplan, 2002) and emotional well-being (Wight, Cummings, Karlamangla, & Aneshensel, 2009)..

Home

The themes which emerged under the category of home were “being an ideal,” the “desire to return,” and “possessions.” These themes captured the stories of the participants’ lives and how they defined themselves. Charles was the only participant to speak of home in a negative way (“I see everything wrong with it.”) which was most likely due to having lived in a now condemned residence. Home as an ideal meant the participant felt home, which they defined as their previous community residence, being the best possible place to reside. Despite the safety issues, Sam expressed home as being the ideal place to reside while the nursing home did not qualify to the ideal of home (“Just stay where you're at.”). Marvin expressed home as a place to be close to family and Luis described home as a calm refuge (“Yes, a tranquil place.”). These aspects of home (e.g. family, sanctuary) illustrated the importance of the participants’ lives constructed throughout their previous decades living in the community.

The “desire to return” to a previous residence which was considered to be home overlapped with the ideal of home as expressed by Sam, “Well ... right now I think it be best to head home.” The desire to return was also expressed by Luis and Jane who simply stated, “I'd like to go back, but I can't.” During the first interview no one spoke of the nursing home as having any quality of home or being considered to be their home. Home was not a quality contained within the nursing homes; instead it was defined by the relationships and places outside of the facilities.

“Possessions” were the physical items owned by the participants. Jane, Marvin, Sam, and Luis spoke of the importance of possessions and not being able to bring all that they wanted with them to the facility. “Possessions” also overlapped with the “desire to return” (“I wanted to go back to my apartment ... Cause that's where my things are, where all my paperwork and stuff is,” Jane). The theme of possessions also overlapped with the theme of restriction from the facility (“They wouldn't take us back home to pack up nothing . . . there's nothing here, no nothing,” Sam).

Lived Experience at Second Interview

Participants continued to consciously adapt to their new environment. Themes from the first interview carried into the second, as participants engaged in coping strategies to “make the best” of their situations. The processes of acknowledgement and acceptance, as well as weighing the costs and benefits (e.g. restriction versus safety) of life in the nursing home compared to the community persisted. The benefit of “being cared” for and ambivalence about “interpersonal interactions” emerged in the second interview. Home continued to be a self-defining place, though not by possessions and past experiences, but through autonomous decision making.

Self Adjustment

”Acknowledgement of need,” “making the best,” and “a place to die” continued to emerge in the second interview. Penelope, Bea, and again Sam acknowledged their need to be in a nursing home (“I like being here on account of . . . I couldn't help myself and too much [my wife] couldn't help herself,” Sam) while Jane continued to deny she required assistance (“I think I'm in better shape than a lot of them here.”). Jane, Megan, Penelope, and Bea were explicit about making a conscious effort to adjust to life at the nursing home. Jane repeatedly spoke of “making the best” of the situation. Megan spoke of learning how to do essential tasks such as eating and sleeping at the facility (“I still haven't learned to sleep here. But I've learned to eat here. And ... eventually I'll learn to sleep here.”). Jane, Penelope and Bea addressed having to make a conscious decision to adjust to the nursing home and do their best to be happy in the situation (“Make up your mind you're going to be content,” Bea). The words participants chose and their descriptions of how they were redefining happiness showed they had personally changed their behaviors and thoughts to adjust to the institution. These participants had made a conscious effort to find meaning in what some acknowledged to be their final home.

For Jane, Megan, and Luis, the nursing home continued to be understood as the place where people would die. Megan's outlook on the fact had changed and reflected her effort to “make the best” (“. . . and now I think I am, so I don't worry about it”). Jane and Luis continued to feel respectively stuck (“I just feel like you just come here to die. That's the way I feel about it right now.”) and angry (“This is a place for seniors who are dying already.”) in their living situation.

Facility Adjustment

The themes of “restriction” and “safety” continued to define experiences while the themes of “being cared for” and “interpersonal interactions” were described in the second interview. Penelope, Sam, and Charles compared the lack of mobility and choice within the facility to the autonomy they had previously experienced while living in the community (“Well before you did what you pleased, you know and I enjoyed it. And here, you do what you please (inaudible) but still you know, they have rules and regulations,” Penelope). The rules and regulations set by the facilities were viewed as restrictive by all four, but both Penelope and Sam spoke of them being necessary. These residents had redefined their autonomy within the context of the facilities.

Jane, Sam, and Charles described the facilities as being places of “safety” in the second interview. Charles continued to speak of the physical condition of his previous home while Jane and Sam spoke of the danger in their previous neighborhoods and personal safety within the facility. Jane told a story of having a stroke while alone in her apartment and contrasted the experience with the security of having people to check in on her at the nursing home. Residents clearly felt safer in their new homes and viewed this positively.

The theme of “being cared for” expressed the quality of being provided with care from and having needs taken care of by facility staff. The participants described a sense of relief in not having to ask family and/or friend for help. Assistance was now available which would not place an additional burden on somebody and participants were secure they were being cared for. Megan, Marvin, Penelope, Bea, Sam, and Charles all spoke of the nursing home as a place in which they were cared for. The nursing home was seen as a place where you could ask for help without “the feeling that you were putting them out by asking to help” (Megan). Basic necessities such food and a clean place to live were provided which lead Megan, Penelope, and Sam to experience less worry than while living in the community (“And now there's someone to physically and mentally take care of me,” Jane. “Feel safe, don't have to be goin’ out there, worryin’ about getting bopped in the head,” Sam).

Participants expressed gratitude for being in a place with others despite the differences in participants’ previous and current levels of autonomy. The nursing home was revealed as a place with a great deal of “interpersonal interactions,” both positive and negative and with staff and other residents. Jane, Megan, Marvin, and Charles described interpersonal interactions as being positive in providing social support and new friends, and assistance when necessary (“I have more people to talk to here,” Jane. “At least you're not by yourself,” Charles). Megan, Marvin, and Charles also described interpersonal experiences negatively, by being intrusive (“I don't want to know these people,” Charles) and not allowing for privacy (What's the worst part about living here? “Well (inaudible) there's three of us in here together,” Marvin).

Home

The previous themes of a “desire to return,” “ideal,” and “possessions” were not as salient in the second interviews which indicated that participants had made significant adjustments between the interviews. Instead the themes of “autonomy” and degree of experiencing the qualities of home at the nursing home came out of these interviews. Jane and Luis were the only individuals to express the desire to return to their previous residences. Luis was the sole individual to express the previous residence as an ideal. He also reported no positive qualities of the nursing home and stated, “I can't wait to leave here.” Possessions continued to be important to individuals. Sam continued to speak of possessions left behind (“They don't allow you to bring anything you wanna bring in here.”) and each of the women spoke of arranging things in order to make the residence their own space.

Home was no longer expressed as a desired ideal to return to (with the exception of Luis), but as a place where individual autonomy could be expressed. The theme of “autonomy” described the experience of having freedom and/or choice in daily living. The theme overlapped with the theme of “restriction” but differed in that it was a quality which defined home for Megan, Penelope, Sam, and Charles (“See, when I was in my home, nobody sign ya in and out”).

While the interview did not directly address whether the nursing home was considered to be home by each resident, many of the participants expressed the degree to which they felt the nursing home was home. Bea and Luis explicitly expressed the nursing home itself was not home (What advice would you give someone moving to a nursing home? “If they got a home, stay,” Bea). Sam stated that he was fortunate to sometimes feel as if he were home (“. . . sometime I feel like I was home, thank God He likes me, but not all.”). Megan was the only participant to express that she was home at the facility, “And I'm not a patient, I'm a resident.”

Megan also described having had a choice in moving to the nursing home. Indeed, the overall satisfaction with the current lived experience at the time of the second interview appeared to be related to the degree of choice in decision-making of the new resident. Penelope also had had choice and like Megan described the nursing home as a place where she was “cared for” though there were “restrictions.” Home remained a place of autonomy for Penelope as it was for Sam, who had had no choice and for whom possessions remained a salient aspect of home missing from the nursing home. Bea described having some choice in the decision making and was explicit that the nursing home was not her home, but she continued to “make the best” of the situation. Marvin and Jane, like Sam, had had no choice; Marvin did not consider himself to be living at home and Jane expressed a “desire to return.” Charles had no control over his transition while his previous home was now condemned. He spoke of his situation in ambivalent terms; he felt “safe” but “restricted” and enjoyed the “interpersonal interactions” but did not want to get to know the people. Luis had had no control and described being deceived in the decision-making process. Luis remained adamant that he was not at home and a yearning to return to his previous residence.

Discussion

Findings from this study are consistent with those of others depicting the importance of place, possessions, safety, and autonomy in older adults’ definitions of home. It is logical to assume that experiences described by participants during the first interview were similar to those that anyone would experience shortly after moving. However, these participants, unlike the general population of people who move, had experienced loss of personal belongings, and an initial recognition that they could not manage their lives at home. In general, people who move are able to take the majority of their belongings with them and could be expected to remain able to take care of themselves in their new homes. Thus, the relocation experienced and described by our participants was implicitly more complex and potentially more disturbing.

Statements of our participants differed between the first interview and the second in the ways in which they applied the concepts of place, possessions, safety, and autonomy to their new setting. While still feeling strong loyalties to their previous homes, they had by the second interview begun to meet people, and in particular to attach the concept of safety and availability of care to their new residence.

The lack of space for their possessions remained a theme through both interviews. This problem has not been adequately addressed in long-term care facilities in the U.S. in which older adults often only have very limited space in which to store their belongings. When this is considered with very small areas on which to put their cherished possessions, it is apparent that in the U.S. this concept of home has not been adequately addressed for this population despite several decades of findings demonstrating the importance of possessions to older adults’ definition of home.

Participants continued across the two interviews to make statements about wanting to return to their previous homes, not belonging in the nursing home, and being “better off” than most of the residents surrounding them. It was clear that the nursing home was not the ideal home to any of them, however by the second interview, they did begin to recognize that they needed care which could not have been provided in their previous residences. Even with participation in the decision-making, they would have preferred not to move. But it is evident from the findings that participants were beginning to come to resolution about the permanence of their new location and to most, the benefit of having needed care provided. This reorganization of their thinking was apparent in statements about “making the best” of it which may be indicative that the participants were beginning to assign the definition of home, albeit a different one, to the nursing home. This phenomenon may in part be a cohort effect given that the participants were all from a generation that had experienced the Great Economic Depression in the U. S. which was associated with creative strategies devised by families to conserve and stretch very limited resources to “make do.” Another cohort effect in this population that is commonly recognized in American society is the notion of “putting your mind to it,” which involves deciding to make the best of one's situation and to adjust to change irrespective of the challenges that this presents. These findings supported previous evidence that new residents actively change their interpretation of the situation in order to adjust to life in a nursing home (Kahn, 1999).

Inability of the participants to have much control over their daily lives was an impediment to their assigning the label of “home” to their respective facilities. This is consistent with others findings showing that having some degree of control over their daily routines was important (Harnett, 2010). It may be that having this control could enhance adjustment to relocation. This may be particularly important in situations in which older adults have little choice in the decision to move to a nursing home (Iwasiw, Goldenberg, MacMaster, McCutcheon, & Bol, 1996). Our participants seemed to separate personal adjustment from adjusting to the nursing home facility. Personal adjustment seemed to be connected with finding a degree of autonomy even within the limits of an institution with rules and processes which did not per se facilitate autonomy.

The nursing home as a place to die has been reported previously in the literature (Tuckett, 2007), and our findings are consistent with this. Our participants stated that this was to be their final home which demonstrated that they were assigning a different dimension to their meaning of home. None of the participants described their previous residences as places to die. The more institutional nature of the nursing home and the finality of their relocation may have brought to the forefront of their awareness the certainty of death and the likelihood that it would occur in this setting.

Expressed presence of deceit and lack of participation in the relocation decision-making among our participants was disconcerting. This area is one needing further investigation as to older adults’ ability to adjust to their new homes. It is clear that further research is needed into the phenomenon of relocation of older adults. While our findings show that participants had begun to redefine home, they do not identify what interventions could facilitate this process. This remains particularly important given the large numbers of older adults who will enter nursing homes and need to be assisted to feel at home.

Limitations: While our data analysis used a phenomenological perspective, the interviews were not specifically conducted with the intent of defining the meaning of home to the participants. Using this perspective to conduct the interviews would have provided us with more direct statements about the meaning of home. So while we are inferring this meaning from the data, participants provided a rich description of their relocation process and adjustment in which they in essence led us to explore the meaning of home.

The use of extant data limited the verification processes of the codes because participants could not be contacted to validate the themes which emerged. Another limitation is that only two interviews were conducted. While the timing of the interviews was consistent with intervals accepted as indicative of older adults’ adjustment to relocation to a nursing home, it may be that a third or fourth interview conducted later in the process could shed further illumination on participants’ emerging reconstructions of their meanings of home. Further research would do well to explore this process in the longer term.

Highlights.

• Older adults take an active role in changing their attitudes and beliefs to facilitate their transition into a nursing home.

• Involvement in the decision-making process and the preservation of autonomy are imperative for maximizing the likelihood of an older adult having a positive perception about the transition and the facility.

• The meaning of home is complex and involves emotions, possessions, and the sense of autonomy.