Illuminating Meanings of Thriving for Persons Living in Nursing Homes

Abstract

Background and Objectives

Thriving has been described as a multidimensional concept that can be used to explore place-related well-being; however, there has been limited research into the meaning of thriving in aged care. This study aimed to illuminate meanings of thriving as narrated by persons living in nursing homes.

Research Design and Methods

Narrative interviews were conducted with 21 persons residing in a rural Australian nursing home. The interviews were audio-recorded, transcribed, and interpreted using a phenomenological hermeneutic approach.

Results

Meanings of thriving could be understood as: Striving toward acceptance of being in a nursing home while maintaining a positive outlook; Feeling supported and cared for while maintaining a sense of independence; Balancing opportunities for solitude and company while living with others; and, Feeling a sense of home while residing in an institutional environment. The meanings of thriving, as presented through the interpretive lens of Gaston Bachelard’s “Poetics of Space,” encompassed having access to literal, metaphorical, and symbolic doors, as well as having the freedom to open, close, and use these doors however the person wishes.

Discussion

Exploring meanings of thriving in nursing homes could contribute towards understanding and implementing positive life-world constructs in research and practice. These findings could be used to inform and enhance person-centered care practices by maximizing opportunities for persons residing in nursing homes to have options and choices, and the agency to make decisions where possible, in relation to their everyday care and living environment.

Exploration of the concepts, measures, and outcomes for persons residing in nursing homes have traditionally focused on negative aspects of ageing and health (i.e., cognitive and physical decline, illness, depression, anxiety, behaviors, isolation, use of medication, and dependence on others) (Bradshaw, Playford, & Riazi, 2012). However, there is growing interest in the utilization of positive life-world concepts in nursing homes. Thriving is one such concept which has been described as a multidimensional phenomenon that encompasses elements of subjective well-being, environmental adjustment, and life satisfaction (Bergland & Kirkevold, 2001; Bergland & Kirkevold, 2006). Thriving has been said to differ in comparison to other concepts such as Quality of Life (QoL) or health-related QoL as it acknowledges that a person’s abilities or disabilities are only one component of overall well-being (Bergland & Kirkevold, 2001). Instead, persons residing in nursing homes are thought to focus less on the limitations related to institutionalization and physical and/or cognitive decline, and more on the life that they have lived and the things that they can still do despite dependence on others for activities of daily living (ADL) and everyday care needs (Bergland & Kirkevold, 2001). Therefore, a strengths-focused approach may provide opportunities to explore positive life-world perspectives for persons living in this environment, despite potentially experiencing suboptimal health or function (Bergland & Kirkevold, 2001).

Knowledge surrounding the concept and dimensions of thriving in nursing homes has been primarily informed through several studies by Norwegian and Swedish researchers. Bergland and Kirkevold (2005) interviewed 26 persons residing in a Norwegian nursing home to describe experiences and perceptions of resident–caregiver relationships and their importance in relation to thriving. Three distinct groups emerged, with one group reporting that personal relationships with caregivers were integral to thriving, another group reporting that nonpersonal relationships contributed to thriving, and a third group stating their preference for distant relationships with caregivers (Bergland & Kirkevold, 2005). Interestingly, relationships with individual caregivers were not found to influence thriving for all persons. Bergland and Kirkevold (2006) went on to describe contributing aspects to thriving in Norwegian nursing homes, outlining two core dimensions: the residents’ mental attitude towards living in a nursing home, and the quality of care and caregivers; and five peripheral dimensions: relationships with family, positive relationships with other residents, qualities in the physical environment, participation in meaningful activities, and opportunities to go outside of the ward/nursing home. In their subsequent study, Bergland and Kirkevold (2008) explored the significance of peer relationships to thriving in nursing homes. Their findings revealed that personal relationships with other persons residing in the nursing home were not essential to experiences of thriving. Recently, Ericson-Lidman (2019) interviewed six persons residing in a Swedish nursing home to describe experiences of living in a residential care facility. This study identified one overall theme: struggling between a sense of belonging and a sense of alienation; and two main categories: feelings of thriving, and feelings of loneliness. Here, feelings of thriving were abstracted into five subcategories: the significance of visits from loved ones, a functional communication with care providers, the pleasant physical care environment, being secure and met with respect, and, to be satisfied with one’s life (Ericson-Lidman, 2019). Findings from these previous studies emphasize the importance of the psychological, psychosocial, and environmental focus of thriving for the life stage of the person living in the nursing home, which has been said to differ from the components of thriving reported in other life stages (i.e., infancy, adolescence, adulthood) (Bergland & Kirkevold, 2001; Haight, Barba, Tesh, & Courts, 2002). In this way, thriving could be viewed as a situational, adaptive, and adjustive indicator for persons residing in nursing homes that could inform care practices and interventions to promote a sense of well-being relative to a person’s life context and lived experience.

Previous empirical research has explored factors related to thriving in the nursing home context. Björk et al.’s (2017) study involving 4,831 proxy-rated persons residing in 172 nursing homes throughout Sweden reported positive associations between thriving and engagement in everyday activities such as involvement in an activity program, dressing well, and spending time with others. Strong associations have also been reported between thriving and a positive psychosocial climate within the nursing home (Björk et al., 2018). Other environmental characteristics, such as access to newspapers, the care level of the unit, and whether the unit was locked or unlocked, were also found to be associated with thriving (Björk et al., 2018). Patomella, Sandman, Bergland, & Edvardsson’s (2016) proxy-rated survey of 191 persons residing in a Swedish nursing home reported that persons with higher thriving scores also had higher levels of functioning in relation to ADL and QoL. This study recommended that persons with low thriving scores could benefit from initiation of interventions to encourage thriving, such as, supporting participation in everyday activities and promotion of independence in ADL (Patomella et al., 2016). However, these studies were based on cross-sectional data collected from proxy-raters, not self-reports; hence, illuminating the meanings of thriving from the perspective of persons residing in nursing homes may enhance the ways in which these findings can be utilized and optimized to promote thriving in the nursing home environment.

Recently, Sullivan and Willis (2018) put forward a definition of thriving in long-term care (LTC) after reviewing the literature and conducting interviews with six nursing home staff, and six persons residing in an American nursing home. Their definition states:

“Thriving in LTC is an older adults’ situational response manifested by a pattern of satisfying social interactions and connection with others, freedom from pain and physical stressors, appetite and weight maintenance, regular physical activity for benefits of health and as a means to maintain independence, purposeful communication, self-advocacy, autonomy, and contribution, within an environment that is supportive to one’s needs and personhood. Thriving was a conscious choice; an acceptance, and willingness to do well.” ( Sullivan & Willis, 2018 , p. 395).

Notably, the inclusion of seemingly negative qualifiers in this definition seems to conflict with Bergland and Kirkevold’s (2001) previous work which stated that the concept of thriving should be separated or disconnected from the concept of concept of failure to thrive. Perhaps, this has emerged as a result of amalgamating resident and staff descriptions of different aspects of the phenomena (i.e., observations versus experiences) (Baxter, Björk, & Edvardsson, 2019). The existing ambiguity in the current thriving literature appears to emphasize the importance of illuminating subjective experiences of thriving to inform both theory and practice.

It seems necessary to further explore contemporary temporal concepts related to the health and well-being of persons living in nursing homes that extend beyond the traditional mind-body/attribute-deficit dichotomies. To the best of our knowledge, no previous studies have explicated the meanings of thriving for persons residing in nursing homes, and there is limited research regarding the exploration of thriving in nursing homes beyond the Scandinavian context. Exploring meanings of thriving in nursing homes could contribute towards supporting the bourgeoning paradigmatic shift towards understanding positive life-world constructs in research, and subsequently, practice.

Aim

To illuminate meanings of thriving as narrated by persons living in nursing homes.

Research Design and Methods

Context, Setting, and Participants

In Australia, residential aged care services are delivered by both public and private providers and may be funded by contributions from both the government and the individual. The Aged Care Funding Instrument (ACFI) is used to calculate the care needs (i.e., ADL, health care) of persons residing in nursing homes, where higher estimated care needs result in higher overall care subsidies for individuals (Grove, 2019). Under the current regulations, individuals pay a basic daily fee of 85% of the age pension and may pay an additional means-tested aged care fee depending on their assets and income. So, while the total cost of nursing home care may be covered in full by the government for some, others may pay more as determined by the services and regulations set out by different providers (i.e., payment of accommodation bonds/refundable accommodation deposits) (Grove, 2019). The socioeconomic status of participants in this study was not explored.

The study was undertaken over a 4-week period in March 2018 at a public nursing home facility providing residential aged care, palliative care, respite care, and secure dementia care in rural Victoria, Australia. This single-level building was situated in a residential neighborhood close to both the local hospital and the town center. The nursing home was separated into three wings, each of which contained their own day room, nurses’ station, and access to outdoor courtyards and gardens. In addition, several rooms could be used for relaxation, meetings, or booked for functions. Within the nursing home, there were single rooms with a private bathroom, single rooms with a shared bathroom, or double rooms with a shared bathroom. Care needs for individuals varied depending on their reason for admission (i.e., general aged care, palliative care, respite care, or dementia care), and mobility ranged from requiring full assistance, requiring some assistance (i.e., two/four-wheel frame, walking stick, wheelchair), to being able to ambulate independently. A registered nurse was available on-site at all times.

The inclusion criteria outlined that eligible persons would (a) be aged 65 years or older; (b) have been residing in the nursing home for a minimum of 3 months; (c) have been assessed as not having a cognitive impairment by nursing staff; (d) be able to read, speak, and comprehend English; (e) be able to provide informed consent; and (f) be assessed by nursing staff as able to participate in an interview. Two of the authors (R. Baxter and D. Edvardsson) presented information about the aim and purpose of the study at the monthly meeting for persons living in the nursing home. Those who were interested in participating were encouraged to contact a member of the nursing staff who could ascertain whether they met the criteria for inclusion. Nursing staff also approached eligible persons who were not present at the meeting and invited them to participate. The final convenience sample consisted of 21 participants (13 females; 8 males) aged between 72 and 97 years (mean, 85.4 years) who had resided in the nursing home between 4 months and 5 years (mean, 23.1 months).

Data Collection

Data were collected through narrative interviews which were guided by the aim of the study (Brinkmann & Kvale, 2015). A single open-ended question was used to commence the interview and orientate the conversation toward the phenomenon of interest. Participants were first asked to describe their understanding of the concept of thriving (i.e., Could you tell me what you understand thriving to mean?). Follow-up questions were guided by participant responses and were used to stimulate descriptions and examples (Brinkmann & Kvale, 2015). This included questions surrounding how the participant experienced living in the nursing home, their relationships with others (i.e., staff, other persons residing in the nursing home, family, and friends), and what they believed contributed to positive or negative experiences of thriving in the nursing home setting.

A private interview room was available for use; however, all participants elected to have the interview take place in their personal bedroom space. To minimize interruption, interviews took place during daytime hours (0900–1630) and were negotiated around the participants’ daily schedule (i.e., hygiene attendance, medication administration, activities, visitors, and meal times). Participants were offered refreshments throughout the interview for their comfort. Interviews lasted between 15 and 55 min and were audio-recorded and transcribed by the first author (R. Baxter) for analysis. After 21 interviews, no new information emerged and we reached what we considered to be saturation (Saunders et al., 2018). The transcribed text was confirmed against the audio to verify accuracy.

Data Analysis

This study utilized a phenomenological hermeneutical methodology inspired by Ricoeur’s (1976) theory of interpretation, and developed as a method for researching lived experience by Lindseth and Norberg (2004). According to Ricoeur (1976), meanings of lived experience can be conveyed through the interpretation of narratives. The narratives are viewed as texts through which the meaning of the utterance (i.e., intended meaning in the text) can be identified (Ricoeur, 1976). The analysis and interpretation of the text encompasses a dialectic process that moves between parts of the text and the text as a whole over three methodological phases (naive understanding, structural analysis, and comprehensive understanding) (Lindseth & Norberg, 2004). This movement back and forward between understanding (inductive method) and explanation (scientific method) distinguishes the hermeneutic circle (Lindseth & Norberg, 2004; Ricoeur, 1976). First, the whole text was read through several times and a naive understanding was formed. Our naive understanding was that thriving could be understood as a dynamic phenomenon with context specific considerations relative to the person, their relationships, and their environment. This appeared to encompass achieving a sense of balance between the needs of the individual person and possibilities in the environment to meet these needs.

Next, the structural analysis examined the text as a whole, and line by line, to identify meaning units related to the overall study aim and the naive understanding. Meaning units were long or short sections of text that conveyed a single meaning related to thriving. Similar meaning units were compared, condensed, and grouped to form themes. The themes were not developed as abstract concepts, but instead as “condensed descriptions” to convey the lived experience within the text (Lindseth & Norberg, 2004) (Table 1). Moving back and forward between parts of the text, and the text as a whole, six structural analyses directed by the naive understanding were performed to identify meaning units and themes. First, we identified units expressing literal meanings of thriving, and then we identified units expressing figurative meanings of thriving. Following this, meaning units were distinguished in relation to thriving and the person, their interpersonal relationships, and their environment. The sixth analysis focused on identification of metaphors within the text as these are said to be important conveyers of meaning within language systems (Lakoff & Johnson, 1980).

Table 1.

Example of the Structural Analysis Process for One Theme

Meaning units from transcribed text	Condensation	Theme
I think you just accept. That’s a great big thing, to accept that you are here and that nothing is going to change, definitely not for the better (P 1; F).	Accepting life in the nursing home.	Striving toward acceptance of being in a nursing home while maintaining a positive outlook.
I can’t thrive anywhere else if I didn’t have here to go. I couldn’t manage anywhere else but here, or another nursing home of course. It is not where I want to be, but it is where I have got to be really (P 11; M).	Acknowledging that one must live in the nursing home.
Well, all I can say is that I have settled in and that I am not just going to put up with it, I am going to do the best I can and be the happiest I can be here (P 6; F).	Settling in and being the happiest one can in the nursing home.
I think it is purely myself. Some people are very needy with everything aren’t they? You have to keep it positive… I think it is a lot to do with yourself and the way you look at life (P 5; M).	Maintaining a positive outlook in the nursing home.
I think that thriving is what you make it yourself. You can make yourself very unhappy, or you can just accept what it is. No, you don’t have to accept it, but you can try hard (P 19; F).	Trying hard to accept life in the nursing home.

Finally, a comprehensive understanding of the text as a whole was forged between the naive understanding, the structural analysis, and the existing knowledge. This has been interpreted through the philosophical lens of Gaston Bachelard’s (1958/1964) Poetics of Space, which challenges us to consider our lived environments and how they are experienced. This recontextualization encourages us to widen and deepen our understanding of the text and themes to provide further insight into the meanings of thriving (Lindseth & Norberg, 2004).

Ethical Considerations

Ethical approval was obtained from the La Trobe University Human Research Ethics Committee (S17-228). All participants received a hard-copy information statement outlining the study aims and method. The information statement emphasized the voluntary nature of the study, and reiterated that all contributions would remain anonymous. Informed consent was obtained via a signed and dated written consent form.

Results

Structural Analysis

The narratives revealed several meanings of thriving in nursing homes presented as four themes: Striving toward acceptance of being in a nursing home while maintaining a positive outlook; Feeling supported and cared for while maintaining a sense of independence; Balancing opportunities for solitude and company while living with others; and, Feeling a sense of home while residing in an institutional environment. These themes are described in detail below and supporting quotations have been provided in italics with the participant number (1–21) and gender indicated in brackets (Female/Male; F/M). As the participants are from a relatively small nursing home in a rural town, it is not possible to link the supporting quotes with each individual’s demographic information (i.e., age, length of stay) without risking the anonymity of those involved.

Striving Toward Acceptance of Being in a Nursing Home While Maintaining a Positive Outlook

One meaning of thriving was described as striving toward a sense of acceptance and a positive view of living and being in a nursing home. The narratives spoke of acceptance as being important to finding a sense of balance between living the life one wants, and living the life one can in the nursing home. For example, one man spoke of the nursing home being the only possible place for him to live, stating “I can’t thrive anywhere else if I didn’t have here to go. I couldn’t manage anywhere else but here, or another nursing home of course. It is not where I want to be, but it is where I have got to be really” (P 11; M). This was described as a process where the person acknowledged a sense of loss of their previous life, or the “ideal” life, followed by a period where they could strive toward accepting life the way that it is now, or not. Inability to adjust and/or accept the life situation within the nursing home was understood as a barrier to thriving. One female participant described her understanding of thriving as comprising of acceptance and attitude, she explained “I think that thriving is what you make it yourself. You can make yourself very unhappy, or you can just accept what it is. No, you don’t have to accept it, but you can try hard” (P 19; F).

The meaning of thriving also encompassed striving for a sense of positivity toward living and being in the nursing home, described as happiness, contentment, and fulfillment. This was narrated as being both an active decision, and an ongoing process. Participants acknowledged that it could take time to adjust to living in a different environment, with one person stating “well, all I can say is that I have settled in and that I am not just going to put up with it, I am going to do the best I can and be the happiest I can be here” (P 6; F). A negative outlook toward life in the nursing home was understood as a barrier to both acceptance and thriving. One male participant reflected “I think it is purely myself. Some people are very needy with everything aren’t they? You have to keep it positive… I think it is a lot to do with yourself and the way you look at life” (P 5; M). However, the narratives described that it was possible for a person’s outlook toward life in the nursing home to evolve over time (i.e., positive to negative, or negative to positive). This was often characterized as being a choice, as persons could make an active effort to be positive. As recounted by one participant, “I do what I want to do virtually, but then again that depends on your own character. I could raise it up or knock it down, it is just a living place. But I like it” (P 17; M). This dynamic process was described in terms of comparing thoughts of past, present, and future experiences to determine how to best survive and thrive in the current situation.

Feeling Supported and Cared for While Maintaining a Sense of Independence

Another meaning of thriving was expressed as an experience of feeling supported and cared for while also having opportunities to maintain a sense of independence and make decisions for oneself. Feeling supported and cared for was described in relation to provision of functional and physical cares, such as medication administration or help getting dressed. Knowing that someone would be there if required seemed to provide a sense of comfort and safety, as one participant explained “you have got a bell, and they never ignore it. They might take a little bit of time to get to it, but you never get ignored” (P 1; F). This also encompassed emotional and psychosocial support, such as having an enjoyable conversation. Interactions with staff were largely described in positive terms, with one participant recounting “I can’t fault them [the staff]… They have got one here and she is a real comedian. You could get up feeling lousy, and within half an hour she will have got you going” (P 13; M). Descriptive imagery from the text highlighted staff “going the extra mile,” “doing the little things”, or “bend[ing] over backwards” to make life more comfortable in the nursing home had a positive influence on feeling supported and cared for.

The importance of maintaining a sense of independence despite potentially being dependant on others was also emphasized in this meaning. This included being offered opportunities for involvement in making everyday decisions such as, what to eat, when to shower, or what to wear. Opportunities to exercise independence emerged in relation to deciding what one wanted to do during the day and the level of involvement one had with others or activities within the nursing home environment. This was narrated by one female participant in terms of having the freedom and ability to make decisions for oneself, “if I wanted to join in I would, and if I didn’t then I wouldn’t. I don’t like anyone saying ‘do this’ or ‘do that’. I am quite happy with what we have got and what is on. If you want to join in you can, but you aren’t forced to join in” (P 19; F). The narratives described being offered opportunities for involvement in decisions relating to the individual person, and the nursing home as a whole, as supportive to this meaning, with one participant outlining “…If there is any deciding what the [nursing] home is going to do I think well, perhaps I should go to those because, you know, you would grizzle afterwards because they are doing things you don’t like. You have been given a voice so… I do things like that” (P 1; F). Acknowledging values, beliefs, and cultures, and incorporating these in everyday care, were described as ways that staff could promote feeling supported and cared for while recognizing individual preferences.

Balancing Opportunities for Solitude and Company While Living with Others

This theme expressed the meaning of thriving as having opportunities to be alone, or with others, and balancing these preferences around formal and informal interactions in the nursing home. Interactive activities such as baking, gardening, craft, bingo, church services, and movie screenings were advertised in a monthly activity schedule and persons could choose whether they wanted to attend, or not. Planned activities offered some participants opportunities to interact with others either directly or indirectly, with one person relating “you can make it isolating if you don’t get into things. But they have got everything up on the chart there each day of what is going on. They have baking classes and then they come around with their fresh wares you know… There is always someone with a birthday, they have a big cake and they cut it up so everybody can have a bit of birthday cake… They make a big fuss over everybody. You always know it is a birthday when the cake comes in” (P 12; F). Being informed about what was happening in the nursing home, having something to look forward to, and being able to plan one’s own level of involvement was described as supportive to thriving. Within the nursing home, interactions among other persons were said to facilitate a sense of fellowship, comfort, and comradery. However, not feeling forced to interact with others was understood as being part of this meaning. One female participant emphasized that “I just like to be on my own. Talk to people if we were doing stuff, you would talk to whoever is sitting beside you, but other than that I just prefer my own company” (P 2; F).

Staff–person interactions were also narrated as important to this meaning, requiring a level of consideration and negotiation to balance personal and professional relationships depending on the individual person and their preferences. Knowing that a member of staff would be there if needed provided a sense of security and safety. While it was not always possible for persons to choose which staff member they interacted with, it was possible for them to direct the depth of the interaction (i.e., superficial or significant). The narratives identified how staff–person interactions could develop into more meaningful relationships over time. One participant recalled that building relationships with staff took time, but that once those connections had been made they often had things in common, she shared “you only get told their first name here, but then once you have known them for a while you think ‘oh, she belongs to so and so’ and then we get talking and you knew her mum and dad and grandma and grandpa… It is all of those little stories” (P 6; F).

Thriving also encompassed opportunities for interactions with persons external to the nursing home, such as family, friends, and the wider community (i.e., face to face, phone calls, text messages, and letters). Face to face interactions were described as being supported through having access to areas outside of the bedroom that could be used to host family or friends, as well as help to leave the nursing home if the person wished (i.e., provision of a wheelchair). Persons who received visits from family and friends described them in terms of providing a sense of social support and connection with the individual person’s identity. These visits were described as something to look forward to, with one female participant stating “my daughter takes me out once a week. Sometimes she has cooked for me, sometimes we have a lunch somewhere. I am very lucky” (P 18; F). Being involved in decisions around the frequency and type of interactions with persons from outside the nursing home was understood as important to this meaning.

Feeling a Sense of Home While Residing in an Institutional Environment

Living in an environment that meets the needs of the person as both a home and an institution was described as another meaning of thriving. Features of the nursing home environment were narrated in relation to physical characteristics, such as access to staff and specialized equipment; as well as in relation to abstract characteristics of the atmosphere, such as feeling welcoming, warm, and comfortable. One participant detailed their first impressions of the nursing home, articulating “it is warm and inviting… It is just comfortable. The people, the nurses, they are all so kind… When I walked in the doors and everybody was welcoming me, that was an invitation – we are glad that you are here. It was comfortable yes, because I could look up the corridors and it all just looked warm and cozy and home-like” (P 4; F). Being given opportunities to exercise control over the nursing home environment, in both a physical and atmospheric sense, was one way to make the living environment feel less like an institution, and more like home. While there are constraints that come with living in an institution, one participant described how they negotiated these limitations, stating “I am quite happy with everything, all of their rules and regulations. It isn’t jail! I am quite happy with my room, I can do what I want with it. It is your own and you can have it how you want, within reason” (P 20; F).

The narratives spoke of the environment as consisting of more than the physical boundaries of the nursing home, and emphasized the importance of feeling at home while maintaining a connection to the outside world, both in relation to the physical outdoors, and the wider community. While it was not possible for all participants to physically go outside, connecting visually seemed just as important to this participant who had a window looking out onto a colorful garden, she asserted “I am happy in my room. I can look outside and I don’t feel enclosed. I can see out and see what is going on” (P 19; F). This was supported by having opportunities to look outside, go outside, or to be outside. Visits from volunteers, school children, sports teams, and church groups were described as important aspects of the broader nursing home environment. One female participant spoke of how she looked forward to being visited by a volunteer and his dog, she explained “There is a man who comes in with his dog, he always comes to see me. He says whether he [the dog] has had a bath today or is behaving. He takes his dog to anyone here who likes dogs” (P 1; F). These connections were described in relation to “bringing the outside world in,” and helped persons residing in the nursing home to maintain connections with the wider community.

Comprehensive Understanding and Discussion

These four themes conceptualize the participants narrated experiences of the meanings of thriving. This included elements of acceptance, balance, and contentment in relation to ones living situation and care provision, as well as ones social and physical environment. Meaningful experiences of thriving were narrated in both active and passive terms, and as manifesting within oneself, and in relation to external factors. The meanings of thriving were interpreted through the lens of Gaston Bachelard’s (1884–1962) Poetics of Space (1964). By presenting our comprehensive understanding through this lens, new possibilities may be revealed in relation to the world in front of the text (Ricoeur, 1976). Bachelard, a philosopher and phenomenologist, reflected on the meaning, memory and imagining of lived spaces. He illuminated that geometric places are rational and tangible until they are inhabited by persons, after which they are transposed into lived spaces of intimacy where people can experience, feel, dream, and imagine. In this way, doors are opened between the geometric and the lived, and between places and spaces. Bachelard’s (1964) theorizing on literal, metaphorical, and symbolic doors acting as facilitators or barriers to the inside and outside spaces that exist within us and around us will be used to interpret meanings of thriving in nursing homes.

Bachelard (1964) discusses the dialectic of inside and outside spaces as being illustrative of both a simple division, and a complex interpretive construct; with the image of the door presented as the interpretative portal that can separate or unite these seemingly opposing, yet complementary, parts of the universe. The symbolism of the door encompasses boundless possibilities in that it may open or close; lock or unlock; provide entry or exit; be old or new; present as visible or hidden; or represent a beginning or an ending. In this way, going through a door, literally or metaphorically, may not only alter one’s lived or imagined environment, but potentially alter the person themselves; as Bachelard (1964) himself questioned, “is he who opens a door and he who closes it the same being?” (p. 224). The concept of the door opens up rich analytical possibilities through Bachelard’s writings that can be applied to thriving in nursing homes. For one person, what lies beyond the physical, metaphorical, or symbolic door is of no interest. They may choose to remain in their current reality, content to leave the mystery of the other side unknown. For another, what lies beyond the door is the promise of something more, and may represent opportunity, temptation, or adventure. Thus, the meanings of thriving in the nursing home context can be interpreted to mean remaining inside a space, not seeking to open other doors, as one may feel a sense of balance or contentment within oneself and the environment without wanting more or less than what one has in the present. However, the meanings of thriving can then also be interpreted to mean having the possibility to expand one’s space by choosing to open a door to explore and potentially change oneself or one’s environment despite not knowing what may lie on the other side. For example, one person may open a door to seek out company, while another may close a door to find solitude. This illustrates two central elements to the meaning of thriving—having options (different doors to open), and having choices (opportunities to open or close doors as one wants). Accordingly, the meanings of thriving, as interpreted through this Bachelardian lens, is to have access to the literal, metaphorical, and symbolic doors that one wants or desires; and, to have the freedom to open, close, and use these doors whenever and however one needs and wishes.

In line with previous research (Bergland & Kirkevold, 2006; Bjork et al., 2018; Ericson-Lidman, 2019; Sullivan & Willis, 2018), personal, relational, and environmental aspects were identified as important to the meanings of thriving. As described by Bergland and Kirkevold (2001), attitudinal and care-related dimensions were meaningful to experiences of thriving in the nursing home. In addition, living within a pleasant and home-like physical environment (Ericson-Lidman, 2019), with a positive psychosocial climate (Björk et al., 2018) was described as essential to thriving. Our findings emphasize the importance of acknowledging the ubiquitous influence of the unique nursing home environment on experiences and meanings of thriving. It is only once this has been realized that it can become possible to balance the needs of the individual with possibilities to meet their needs in this context. In contrast to the definition put forward by Sullivan and Willis (2018), bodily experiences of pain and other features such as weight maintenance were not recognized as part of the meanings of thriving. Perhaps, this is because the present study focused solely on exploring the experiences of persons residing in nursing homes, and did not incorporate staff perspectives. This could indicate that the meanings of thriving as understood by persons residing in nursing homes may not necessarily align with assessments of thriving in practice.

Inactivity, boredom, and social isolation have been documented in past research as being obstructive to positive experiences and thriving in nursing homes (Thomas, 1996; Tremethick, 1997). However, insisting upon participation in interactions or activities may cause distress if the person does not enjoy connecting in this way. Our findings illustrate that one size does not fit all, and individual preferences must be taken into account. This seemingly highlights the significance of consultation and collaboration between persons residing in nursing homes, and persons caring for them. Previous research involving older persons in the community setting has stressed the importance of partnership in care-planning and care delivery, as health care providers’ goals and priorities may not necessarily be in alignment with those of the individual (Jobe, Engstrom, & Lindberg, 2019). With this in mind, staff and managers could use the findings from the present study to inform and enhance person-centered and person-directed care practices by maximizing opportunities for persons residing in nursing homes to be given options and choices, and the agency to make decisions where possible, in relation to their everyday care and living environment. In doing so, the doors to thriving may be revealed and opened in this context.

Methodological Considerations

The phenomenological hermeneutic approach used in this study requires consideration. The narrative interviews were unstructured and participants were not asked identical questions or follow-up questions; however, by interpreting the narratives as a whole we can hope to understand meanings that are common to the phenomena itself (Ricoeur, 1976). The researchers come from nursing and occupational therapy backgrounds, hence, we must acknowledge that this interpretation is but one of many possible interpretations that may be influenced by any number of personal or external factors, known or unknown. It should also be noted that this study was undertaken in a single rural nursing home in Australia, thereby situating it within a specific sociocultural context. Repeated studies in different settings and within other cultural contexts may further explicate these findings. Research is also required to further elucidate the meanings of thriving among persons with cognitive impairment. These findings are not intended for generalization, rather, this interpretation is intended to contribute an initial understanding of the meanings of thriving to the limited body of literature related to thriving in nursing homes.

Conclusion

Our study has interpreted the meanings of thriving as described by persons residing in nursing homes. These findings could assist persons living in nursing homes, staff, managers, and policy makers in gaining a deeper understanding of what contributes to thriving in this context; particularly in relation to providing opportunities to make decisions around person-centered care practices, needs fulfillment, and the lived environment. To further extend and expand the existing knowledge and understanding of thriving in nursing homes, and how it can be promoted and supported in practice, there is need to explore the concept of thriving from the healthcare providers’ perspective.

Funding

This work was supported by The FORTE: The Swedish Research Council for Health, Working Life, and Welfare (Forskningsrådet för hälsa, arbetsliv och välfärd) [2014–4016]; The Swedish Research Council (Vetenskapsrådet) [521-2014-2715]; and, The Medical Faculty, Umeå University [311-839-13].

Conflict of Interest

None reported.