Elderly peoples' experiences of nursing homes in Bam city: A qualitative study.

BACKGROUND: With the increasing number of elderly, especially in recent decades, transfer to nursing homes and the number of centers has also increased but experiences and problems of elders in these centers is less considered. So, the goal of this study is to explore the Elderly peoples' experiences of nursing homes.
METHODS: The current research was performed using a phenomenological approach in 2016. Participation in the study is comprised of the elderly residents in a nursing home in Bam city who were selected based on an objective-oriented approach. The sampling was done until data saturation. Data collection methods were observation and an unstructured and in-depth interview. Data were analyzed using seven-stage Colaizzi process.
RESULTS: In total, fifteen 68 - 82 years old people participated in our study and 52 primary and conceptual codes that were eventually categorized in five main themes (sense of rejection, sense of daily routine, impaired of communications, sense of hardship and mental obsession) and ten sub-themes emerged.
CONCLUSION: Overall, most of the elders were not satisfied with the conditions. It seems that helpful, community and family education to acculturate respect for the elderly in the community, teach proper coping strategies, use the elderly's experiences, and consultation with them could be a way to maintain a sense of usefulness, independence and to prevent them from sensing monotonous and routine rhythm of life.

1. Introduction

Distribution of the population aged 65 years and over, especially in recent decades has rapidly increased and it is expected that this trend will continue until the end of the twenty-first century (1). Population of this group has doubled from 1950 to 1980; namely 12.3 million individuals in 1950 has increased to 25.5 million individuals in 1980 (2). For the time being, it is expected that the trend of the doubling population of 65s and over will recur in 2050 (from 841 million in 2013 to almost 2 billion in 2050) (3). Given that the growth of elderly people in developing countries is more than that of developed countries, it is expected that by 2050, eight out of ten elderly people will live in these areas (1). In Iran, according to the official statistics, the population under 14 years has almost halved from 1976 to 2006 (45.5% to 25.1%). But in the same period of time, the population of 65 years and above has increased 2% (4). Although the current population of Iran is relatively young the aging process is growing two times that of the last two decades (5). Recent factors such as marital status, having a job and salary, healthy lifestyle, having a social support system, and religious commitment affect successful aging (6). New reports show that at least one chronic disease such as arthritis, diabetes or heart disease is common in elderly people that results in limited mobility, pain and the need for self-management among this population (7). The elderly gradually lose their ability to perform daily affairs due to the incidence of greater rates of physical and cognitive disability (1), mental and physical diseases and consequences; they require more and more support from family and acquaintances (8). On the other hand, change in family structures, the increasing number of older people, the prevalence of disease in the elderly (1), change from extended families to nuclear families (9), divorce, and remarriage and blended and step family relations (10), together with social change such as industrialization, urbanization and migration have forced elderly people to live alone and change their lifestyles (9). Almost all are widowed and without assistance with Activities of Daily Living. Decreasing family size and increasing employment among women may reduce the traditional caregivers in the family (11) or no one in the home may be able to spend time with them or take care of them, or the family may suffer from other relevant factors such as family and economic problems, inability to hire private nurses, etc (11). Under this condition, the elderly situation in the modern household is on an exasperating trend increasingly. Perhaps, it could be said that the old people in such situations or the ones with other conditions such as weak physical and mental conditions are required to be maintained in specialized caring institutions such as nursing homes (8). Nursing homes provide services and assistance to elderly people. Professionals in nursing homes offer care and assistance for residences (11, 12). Admission to nursing homes has a substantial effect (12) and is a stressful event (13, 14) in the life of an elderly person, that can evoke negative mental consequences such as sense of rejection, mental tension, depression or insecurity (15). Also, social status and interaction will be affected and a decrease of regular activities reported (14), along with loss of home, privacy, personal lifestyle, and the chance of living with family and friends (13). Accordingly, among the various relocations, transfer to nursing homes is considered in the literature as the most important relocation affecting elderly people (16). Since the transition to these places happens during the period of suffering and crisis, for instance following acute illness or a period of incapability, the elderly under this condition are required to adapt themselves to new conditions (13). The experience of being a resident of a nursing home is different for everyone, but they usually adapt within 3–6 months (14). This is because the environments where the elderly live constitute a very important dimension of their life quality (17); comfort and mental health. The significance of physical space and the appearance of the place differs from one person to another person but many of the elders like to live in their own home late in life, and some of them openly insist that they want to die in their own home (16). They are deeply attached to the home as a place where past memories are recollected for them because it is a place to be independent and to have autonomy and social support like relatives and friends (18). In addition, there has been much recent emphasis on the role of social relationships in our physical health. The structure of our social networks, the support receives from others, the quality and quantity of our social interactions, and our feelings of isolation and loneliness have all been identified as predictors of health and wellbeing (19). Mental and physical health and health behavior, as well as mortality risk, are affected by quantity and quality of social relationships (20). The results obtained from a research conducted by Joghtae and Negate on elderly people living in Kashan city showed that the most common health problems reported among them include skeletal-muscular and cardiovascular diseases (41.7%), however, 81.7 % of them were independent in daily activities. Of the elderly under study, 78.3 and 82.5% reported varying degrees of depression and cognitive impairment (21). Furthermore, compared to the quality of life and mental health among the resident and non-resident elderly in Shiraz city, the results showed the quality of life has significant difference with mental health in the two groups (16). Therefore, several years of work experience with nursing students in nursing homes and elderly care, the special problems faced by the elderly residing in nursing homes and despite the advances in medical science and emergence of specialized subfields in the area of geriatrics, different dimensions of personality and psychological and mental health of this group still remain unknown and are indeed unresolved. Given the limited volume of the research performed in this field, the current research seeks to explore the participants’ tangible experiences through revealing their own verbal articulations using a phenomenological methodology. This is because, to take any action for this group, deep understanding and knowledge of their life experience is a necessity.

2. Material and Methods

The current research was performed using a hermeneutic phenomenological approach. In the present study, the phenomenon under study is the experience of elderly residents in nursing homes who describe their experiences, in the same way that has occurred in real life (15, 22). The participants under study are comprised of the elderly residents in Bam nursing home, who were selected based on an objective-oriented approach. The sampling was done until data saturation when the number of participants rose to fifteen. Data collection methods were observation and interview. Type of interview was unstructured and in-depth. Interviews continued from February to June 2016. The participants were selected based on inclusion criteria (at least 6 months living in nursing homes and also a degree of their awareness and consciousness), then they received the necessary explanations and announced consent to participate in the study and interview. Time and place of interview were determined by the participants. Seven people preferred their own room and 6 people preferred the yard for interview. In terms of the time of the interview, before noon was chosen by the participants. Before the beginning of the interview, the participants were asked permission to record interviews, and written informed consent was received from them. Accordingly, accurate notes of conversations and all non-verbal gestures were also recorded. The duration of each interview lasted 30–45 minutes. Although the researcher explained that, any time the subjects became tired, they could continue the interview the following day, no repeated interview occurred. To initiate the interview and to reach a comprehensive understanding of the elderly experience of living in the nursing home, the questions were started with this open question: “How did you feel the first time you attended this place?” And, “How do you feel right now?” Other questions on the elderly experience of living in a nursing home were asked along with probing questions such as “Can you explain a little more?” “Do you have any suggestions or comments?”

At the end of each day, interviews were carefully listened to, typed and written verbatim. Data were analyzed using seven-stage Colaizzi process. First, the descriptions of all participants were read several times to create a sympathetic atmosphere (the involvement of the researcher in the data). Then, each of the notes were referred to and the key phrases were extracted (extract important sentences). In the third stage, the meaning of each important phrase and passage (named of adjusted terms) was specified. At the fourth step, the adjusted concepts were organized into thematic categories (organize concepts or main themes). In the fifth stage, the findings combined to give the overall expression of the phenomenon under study (incorporate results). In the sixth stage, an overall expression of the studied phenomenon in the form of an explicit statement was formulated and presented (structure of subject or phenomena). The seventh stage was data validation (23, 24),was assessed through Lincoln and Guba method (25) to ensure the accuracy credibility, the results relevant to the reports and hand writings were presented to the subjects who were inclined to cooperate in the research to be able to amend and rectify the results (member check), and in the six cases of the elderly who were not willing to analyze the results, the interviews and extracted codes were delivered to the second researcher for approval or completion of the themes (peer check). In order to prolong engagement with data, the researcher reviewed each document many times, and continued sampling until data saturation. In transferability, she used of maximum variation in sampling. Therefore, data analysis was started after the first interview, and proceeded with the continuation of data collection. Finally, to ensure the accuracy, and confirm ability of the data and codes, they were reviewed and checked by a team of experts (external check).

3. Results

In total, fifteen people aged 65 to 82 years old (73±2.82 years) participated in our study and whose duration of stay in the nursing home was 7 months to 5 years. There were 52 primary and conceptual codes that were eventually categorized in the form of five main themes (sense of rejection, a sense of life monotony, disruption of communications, sense of hardship, and mental obsession) and ten sub-themes emerged (Table 1).

Table 1

Sub-themes and main themes derived from the primary and secondary data

Main Theme	Sub-Theme	Code
Sense of Rejection	Feeling oblivion (feeling forgotten)	Lack of companionship and conversation; Being away from family; Feeling forgotten and neglected
	Feeling of being neglected	Not to opening the door to the elderly; Transferring to nursing home; Not answering the elderly’s phone call; Children’s failure to visit the elderly
Monotony & life routine	Lack of motivation	Sense of Depression and malaise; Indifference to any activity and nap; Sitting aimlessly
	Monotony	Repetitive/monotonous; Days; Bound to a daily schedule; Inability to go outdoors; Excessive TV watching; Smoking
Preoccupation	Mental involvement with people	Thinking of children; Thinking of grandchildren; Thinking of one’s parents
	Mental preoccupation with events	Thinking of death; Thinking of the reasons for the presence in the nursing home; Thinking of the personal mistakes in life
Disruption of communication	Communicative problems of the elderly people with others	Lack of trust in others; Lack of a cultural peers
	Others’ lack of adaptability with others	Mental and emotional problems in others
Sense of hardship	Physical pain and suffering	Pain in leg; Loss of vision; Skin dryness; Difficulty in walking
	Mental pain and suffering	Dependency and lack of independence; Regretting the efforts of the past; Sense of sorrow

3.1. Sense of rejection

Rejection is the result of acquaintances’ disregard for the elderly, and includes two sub-themes including sense of oblivion (sense of being forgotten) and sense of neglect (sense of being neglected).

3.1.1. Sense of being forgotten

Some elderly people believed that as they were away from the family, the relatives had forgotten them, and there was no one to resolve their problems in this place. In this regard, one old woman, an illiterate housewife states that: “My daughter’s husband is dead, and we could live together but as she is very wicked, she relocated me here, and I think she has forgotten me” (p3). One old man, a retired teacher, stated that: “Since I have been here, nobody has visited me, even my children do not reply to my phone calls. Nobody understands me here; there is neither sympathy nor talking” (p7).

3.1.2. Sense of being neglected

Some of the elderly made complaints of relocating to nursing homes and caretaker’s disregard for them. They even expressed that not only did their children not visit them but also, they avoided replying to calls, and even when they were allowed to leave the nursing home and attend home to visit their children, the children did not allow them to go indoors. In this regard, one old man, a 45-year-old farmer who replied with a loud sigh and a few seconds of silence stated that: “Some days ago I demanded caregivers helped me to visit my son’s home, yet as soon as the grandchildren saw me, they closed the door”. (p4). One of the elderly women who had a stroke two years ago and was afflicted with hemiplegia had tears in her eyes while stating: “A couple of the years after my husband died, I had a stroke and half of my body was paralyzed, and then I was relocated to here. It was difficult for them to take care of me”. (p10).

3.2. Sense of daily routine

A sequence of actions regularly followed and included two sub-themes: lack of motivation and sense of monotony.

3.2.1. Sense of monotony

Most participants did refer to their monotonous and repetitive daily life. One of the elders that looked younger than her age alluded to the subject: “Although the place has a green and pretty courtyard, our days are so repetitive and monotonous and this green space is of no avail to us. Even some days I do not like to come here and see the yard. I prefer to watch TV or I browse the newspapers or magazines that my visitors and nurses bring me”. (p1) Another elderly that lost all her relatives to an earthquake in 2004, stated: “We have no work to do here; we must stay here without any hope to be relocated to another place. Once a year we have a camp which has been subjected to conditions: we must not be sick, we must have ID cards and our number must not be limited”. (p2).

3.2.2. Sense of lack of motivation

This was the second sub-theme. Sense of monotony and repetition had reduced the passion for the life and led to lack of motivation and reluctance and boredom. The elderly underwent this emotion in the form of reluctance, sitting aimlessly, daily nap, and smoking a cigarette. This is an example of one of the elderly women in this regard: “Every day here is repetitive and exactly the same. I sit on the chair and look around aimlessly, I do not even think, and it will not work”. (p11).

3.3. Mental obsession

Mental obsession is mind conflict with issues of the past, the future, persons, stressful factors and daily events that take a lot of energy from elderly people. This theme consisted of two subthemes including mental preoccupation with individuals and preoccupation with events.

3.3.1. Mental preoccupation with individuals

When the elderly have more free time, and sense more loneliness due to lack of activity, then they ruminate on their situation more and more. In this regard, the elderly have referred to their mental preoccupation in relation to individuals and acquaintances. One of the female subjects who had come from another city said: “I constantly think about what my children are doing now and where my grandchildren are”(p14).

3.3.2. Preoccupation with events

Some of the elderly refer to their mental preoccupation with past events, the mistakes that they have done up to now, the reasons why they are here now, and death. In this regard, one of the participants said: “I think too much, I always say I suffered too much in life to have a better life, and why I am here? I do not know; I say maybe I was not a good daughter to my father.”(p7). One of the women who had married twice and her first husband was no longer alive and she had divorced from the second one, sadly shook her head and said: “I constantly think if I had not married for the second time, my situation would not be like this right now, and I think, I made many mistakes”. (p12). Some of the subjects also spoke of death, and one of them who had high blood sugar stated that: “I do not want to continue treatment, because I do not think of improvement at all, and I know that death is my only solution”. (p15).

3.4. Impaired communication

This theme refers to the communication difficulty the subjects have with each other, which leads to further loneliness, and two sub themes of it include difficulty in establishing relationships with others and others’ incompatibility with older people.

3.4.1. Difficulty in establishing communication with others

Some subjects narrated the sufferings that they had undergone to raise the children to make them grown up and educated, and they talked of having a sense of distrust of others. Some others considered the presence of the elderly from different cities (in the setting of research), and individual and cultural differences between themselves and others as detrimental factors to communication. One woman, a spinster who had lived there for almost 6 years, and, because of aggression, addiction, and some psychiatric disorders, according to the caregivers, who’s mental problems were treated to some extent, stated: “Here, all of the elderly people have a problem, one of them yells, one is rude and impolite, some of them suffer from severe obsession, look at the hand of that one! Her hand’s skin is fragmented because she washes them repeatedly with washing powder. How can I find a friend here or somebody to talk to?”(p1). One of the elderly people said: “Caretakers behave politely and warmly, yet I cannot trust anyone any longer. My children who I spent all my love and life on abandoned me, now these strangers can show mercy to me?”(p10).

3.4.2. Others’ incompatibility with older people

Given the fact that our center takes care of the people with physical and mental disabilities (regardless of whether they are elderly or not) and the elderly are also present at the same time, the presence of physical and mental problems and incompatibility with older people were considered to be as an obstacle to proper communication. In this regard, one of the old men sadly said: “There is no one here to talk to him, I have a roommate that is not conscious, and he thinks everyone wants to steal his possessions”. (p3).

3.5. Sense of hardship

This theme means chronic pain and suffering and can be divided into two sub-themes including physical and mental pain and suffering.

3.5.1. Physical pain and suffering

Physical problems relevant to elderly people are the most common complaint that can lead to sleep disorders and mental problems among the elderly. Many of the elderly people under study made complaints of pains in legs, loss of vision, difficulty in walking, dry skin, nocturnal insomnia. One of the old women considered the main reason for her insomnia as pain and stated that: “I feel pain in my entire body, hands, chest, knees, and I recite prayers until morning, and I can fall asleep almost at daybreak.”(p7). One of the elderly people, a 67-year-old, army retiree, in this regard stated that: “I really like walking for pleasure some hours in a day, because I feel better in this way, yet I have problems in walking, and when I walk for almost fifteen minutes, I feel pain in my legs.”(p9).

3.5.2. Mental pain and suffering

The suffering of the elderly in many cases has a psychic psychological origin. According to some participants, factors such as regretting the efforts of the past, nostalgia, boredom and lack of independence can cause pain and discomfort in elderly people. In this regard, one of the elders said: “I feel pain in my heart when I see I am hungry yet I must wait to the hour specified, to eat some food, or when I become dirty and I cannot take a bath unless it is at its specified time, I get so embarrassed”(p9). One of the elderly referred to this point and stated that: “Although every morning we have a schedule, I am so depressed and sad and feel lonely that I do not like to attend these classes” (p2).

4. Discussion

The present article sought to explore the experiences of elderly people residing at a nursing home. The themes emerged from the study were consistent with the concepts extracted from other studies. The first theme extracted from the elderly’s experience in the current research was “sense of rejection”. Transfer to nursing homes can cause change in mental and physical balance of elderly people and subsequent feelings of worthlessness and uselessness among them (26). Similar research performed by Salarvand on the nursing homes affiliated to the governmental, private and charitable sectors in Isfahan (15, 27), Haji Adib’s research on Kashan nursing homes (27), and Hamid Hassan’s research performed in Bahrain (28) have also approved the feeling of rejection in older adults. Thus, it seems that the elderly’s involvement and satisfaction and opportunity to visit family and friends are critical factors in reducing the feeling. Reverence and paying special attention to the elderly is deeply rooted in Iranian culture and our religious rules. This important matter should be repeated in official and non-formal education to families regardless of the specific circumstances of urbanization, modernization and change in traditional values. On the other hand, studies have shown that the quality of relationships between the elderly with family and friends and acquaintances is one main factor to improve the elderly’s satisfaction with living in a nursing home, and the elderly expect to have an intimate environment and others consider them as family (15). Bland Lewinson, in his research, underlined the importance of having a regular schedule to meet friends and even attend home (12, 29). The next issue is sense of daily routine and monotony. In similar studies conducted in Ireland, Korea, and Taiwan, boredom with routine life (30), loss of past programs (30, 31), structured lifestyle and restricted activities were extracted themes (32). Unfortunately, in the nursing home under analysis, cigarettes were distributed and often, elderly people welcomed it as a way to relieve themselves. Though, numerous studies have concluded that smoking is associated with most diseases, depression and physical symptoms, and is strongly associated with mortality and poor health among the elderly (33). On the other hand, sense of daily routine and worthiness affect a person’s sense of control (26). Excessive monotony is associated with some factors such as lack of participation in the matters relevant to the nursing home and also lack of positive and family relations, and can progress the elderly toward waiting for the termination of life due to low self-esteem, reduced sense of helpfulness and depression (27). Thus, given the conditions underlying the elderly, and the presence of occupational therapists and psychologists in the center, a variety of entertainment, business, cultural, and short-term camping programs are recommended to be adopted (if possible accompanied by elderly relatives). Mental preoccupation is another theme addressed by the elderly. The elderly that live alone spend much of their thinking on the children and feel remorse for their late spouse. This isolation can easily lead to depression (15). For many residents of nursing homes, this place is the place of their death (34). In this regard, Warren and Williams stated that the option of nursing homes is better than death, while the elderly residing in this place believed that death is better than such type of lifestyle and the elderly believe that staying in a nursing home, gets them one step closer to death (35). Thus, upgrading and maintaining the elderly’s health status requires paying special attention to their health care throughout the life course and protection of their lifestyle changes, of which such objectives can be fulfilled with a variety of vocational, cultural, sporting, social and rehabilitative collaborations, and also possibility to take advantage of a proper environment. This is because personal, sport and cultural activities can actualize the elderly’s hidden potentials, which in turn, their emotional, mental, and health functioning can be actualized (36). Disruption of communication was another theme raised in the current research. Most of the elderly had a negative attitude towards the rest of the people, and considered them as irrational and inconsistent people, perhaps due to mental health problems and physical or cultural differences and sense of distrust. Though similar research performed in the Netherlands and Ireland nursing homes is indicative of the fact that sometimes, the elderly sit with each other and talk (37, 38), drink coffee and read journals (37) and share their daily hours in this way (12, 39). Perhaps the main reason for the difference between the relevant research and the research presented, is that the people with physical and mental problems in Iran, whether they are young or old, are maintained along with the elderly. This situation is inconvenient for visitors as well, and can reduce the social interaction of the elderly, create more sense of loneliness, depression and cognitive impairment (40). Studies have shown that by 2050, 115.4 million people in the world will be afflicted with dementia, and nearly “half of them live in nursing homes” (41). On the other hand, elderly people who have mental problems are usually afflicted with verbal aggressive behavior, and cause nuisance to others (15). Distrust of others is also prevalent among the elderly in the current research, and the finding was corroborated in a similar research performed in Norway (42). People’s and government’s attention paid toward the elderly can create more positive results for the elderly and visitors, and contribute to the improvement of their relations.

Another issue raised in the study was sense of physical and mental hardship. New reports show that at least one chronic disease such as arthritis, diabetes or heart disease is common in elderly people that results in limited mobility, pain and the need for self-management among this population (7, 43). The results obtained from the research carried out by Afzali and Etemadifar in the Sharked Organization of Welfare reported the percentage of the relevant problems to be 13.8 and 13.9%, respectively, and these problems were considered to be the most common complaints reported by the elderly (44). A research performed in England indicated that 75% of the residents suffer from a type of mediate to severe incapability (45). Forjaz et al. performed a research on the Spanish elderly and came to the conclusion that inability resulting from chronic diseases is associated with inappropriate quality of life, and chronic articular diseases (59.5%) have the maximum prevalence among the elderly (46). A research performed by Smalburgge in the Netherlands indicated that 40.5% of them had complaints of severe pain (44). In a similar research, Hoss came to the conclusion that the prevalence of chronic pains in nursing home residents is high and, this has led to some problems including the reduced quality of life (33), sleep disorders, reduced mobility, and loss of leisure activities, depression and anxiety (47). Thus, it is recommended to caregivers working in these centers to diagnose and treat health problems in older people early, and prevent unwanted complications of these problems. The participants in the research reported mental distress and feelings of impatience, boredom and lack of independence in many cases. In the research performed by Haghighatian in Iran (48) and Hamid Hassan in Bahrain, the elderly made complaints of feelings of impatience, boredom and fatigue (28). Impatience and boredom occur in the elderly followed by sense of loneliness. Although the findings obtained from the previous studies indicate that loneliness is not synonymous with living alone, living alone can exacerbate the feeling of loneliness. Similar studies have shown that there is an association between loneliness and lack of social networks in the elderly with reduced physical activity (49). Among the elderly, there is a negative correlation between the elderly’s sense of loneliness and their physical and mental health (50). The research conducted by Derajest indicates that loneliness is a deep and painful feeling among the elderly that its prevalence is 40% in society and 56% in nursing homes, and the main reason underlying it, is lack of satisfaction with social relations or the lack of sense of belonging (51). Hemmati et al., in their research indicated that the elderly living in nursing homes away from their families feel more loneliness than the elderly living at home along with their families (52, 53). Lack of independence is another factor in creating a sense of mental suffering among the subjects, and it can cause anxiety, stress and a sense of worthlessness (13). In this regard, Bradshaw Siobhan writes that the lack of privacy, repetitive days and the feeling of emptiness can influence the sense of control among these individuals (26). This study had several limitations. First, it was restricted to a nursing home in Bam city and has not represented all Iranian nursing homes, thus, the results cannot be generalized to all Iranian nursing homes. Second, in some participants, after explaining that their voice is recorded, they withdrew from the study and did not feel comfortable in expressing their experiences. Third, in order to complete the study, the researcher was expected to continually return to participants for final approval, which, at times, would be over a long waiting period. But talking with the elderly gave a feeling of satisfaction, and after results were delivered to the stakeholders of nursing homes; they decided to make changes for increasing elderly satisfaction in planning for the next six months.

5. Conclusions

Based on the findings of this research to achieve more favorable conditions, some helpful suggestions can be presented, including: community and family education through the media and information campaigns to acculturate respect for the elderly in the community, use of experiences of the elderly to improve hygiene and health status, teach proper coping strategies, and consultation with them in terms of planning and execution of appropriate activities in order to maintain a sense of usefulness, independence and a sense of ownership for reducing the sense of powerlessness and dependency among them and to prevent them from sensing a monotonous and routine rhythm of life.