Introduction

Transitioning into a new environment, particularly an aged care facility, is one of the main challenges for older adults and their family members [1]. Transition into an aged care facility includes making the decision to move, making a move, and settling into the new facility [2]. Transition is also defined as “The passage or movement from one state, condition or place to another” [3], which must be accomplished with efficiency to adjust successfully [2]. It is suggested by Meleis et al. [4] that transitioning could impact on well-being and make an individual become more vulnerable because of adjustment behaviors within a new environment [4]. There are several reasons for entry into an aged care facility such as, loss of physical function, chronic illness, frailty, and family factors [5]. These circumstances hinder an older person’s capability to look after themselves, which resulted in them making an informed decision and subsequently accepting to move [6]. Therefore, pre-planning can assist older adults in adjusting more swiftly.

The primary factor in aging is to maintain the quality of life of older adults, which means maintaining well-being in terms of both physical and mental health. However, this can be challenging for older adults, who moved from their place and live in a new environment where policy and regulation must be adhered to [7]. Aged care facilities in Australia have a complex regulatory framework. Thus it is necessary to understand that an increase in life expectancy in the aging population is one of primary health demand, which must be considered in policy reforms [8]. However, the social environment also plays a significant role in maintaining well-being and quality of life, which is highlighted in an Australian study [9]. Similarly, a UK report found that older adults in long-term care perceived meaningful relationships and control over their lives as one of the important factors in maintaining a good life [10]. Furthermore, it is noted that adhering to regulations in the aged care facility [11] and having difficulty with connecting other residents [12], adds additional challenges for older adults to adjust to a new environment.

Limited attention has been given to the perceptions and experiences of Australian older adult’s perspectives within their first six months of arrival into an aged care facility. It is well understood that an issue to providing effective nursing care comes from a lack of understanding of an older adults’ needs within this period. Previous studies in Taiwan and Canada identified the needs of older adult residents, through care provided and family members [13,14], and one study in Taiwan explored the older adults’ care needs from their own perspectives [15]. One Australian study that was conducted in the Eastern States explored the lived experiences of older adults in residential aged care which found that loss of autonomy, dignity and control the most important factors that have experienced by older adults [16].

Most importantly, older adults require 6-12 months to adopt themselves to the changes in an aged care facility [17], however no studies explored the perception of older adults’ transitioning within the first six months of their arrival yet. Therefore, this study has the potential to provide experiences and perceptions of older adult’s experiences of older Australians entering an aged care facility. The Knowledge gained will identify strategies to support older Australians entering a residential aged care facility.

Methods

A qualitative descriptive albeit with phenomenological overtones, approach was used [18]. This approach was adopted because it was deemed to be appropriate to explore the perceptions and experiences of older Australians who moved into permanent aged care facilities. The study was conducted in an aged care facility in the Perth metropolitan area during April and May 2019. Purposive sampling was used to recruit the participants [19]. The inclusion criteria were older adults who had entered the aged care facility within the previous six-month period (February 2018 to February 2019), and who had no cognitive impairment. The exclusion criteria were an older adult unable to engage in an interview. The sample size of 10-15 participants was suggested, based on previous studies which explored a similar phenomenon [20]. A total of ten participants were recruited. Data saturation was considered when eight interviews were completed however, two further interviews were conducted to confirm data saturation.

Data Collection

Semi-structured interviews were used for data collection. The researchers developed an interview guide through reviewing information from the literature and from consultations with three experts in qualitative research and gerontology nursing. The Residential Manager first screened for potential participants based on criteria identified by the study team. Then the second and third authors approached potential participants in the aged care facility, and the study details were explained clearly to them. Information and consent forms were presented to participants prior to the interviews. After the consent form had been signed, the second author obtained permission to record the interview digitally. Interviews were conducted by the second author in the presence of the third author to ensure accuracy of the interview process. The interviews took place in a quiet room that offered comfort, privacy, and proper ventilation in the aged care facility on a date and time convenient to the participants. Interviews took approximately 20-45 minutes.

Data Analysis

Thematic analysis was used in this study to explore the essence of phenomenon, and to identify and interpret the pattern or themes that emerged in the data [21]. The audio-recorded interviews were transcribed verbatim by the third and fourth authors. To ensure the accuracy of the analysis process, the first and second authors independently read and re-read the transcriptions and color-coded line by line, to compare emerging codes and to classify theses codes into potential themes. Incongruence was discussed between the first and second authors, and any discrepancy was also further discussed with the third and fourth authors, who did not analyses the transcripts until a consensus was reached.

Rigour

The rigour of this study was guided by Lincoln and Guba [22], who considered the four criteria to establish the rigour in the qualitative study. The first criteria of credibility were achieved by building a trusted relationship with the older adults before conducting the interview. The second criteria of dependability were obtained by selecting potential participants. The third and fourth criteria of transferability and confirmability were established by using direct quotations from the participants to support the findings, as well as maintaining an audit trail of systematic documentation of the research process respectively.

Ethical Consideration

The study was reviewed by Edith Cowan University’s Human Research Ethics Committee (Reference Number: 2019-00097). Permission was also sought from the aged care facility. The second author described the objectives, procedures, and implications of the study to the participants who had expressed their interest in undertaking the interview. The information sheet and consent form were also given to the participants. The second author also offered provision of independent counselling, as support to participants who may have been emotionally affected by speaking about their experience. However, independent counselling was not used by any of the participants.

Results

The total of ten participants consisted of four women and six men who had moved into the aged care facility. Participants’ age ranged between 66-95 years, with a median age of 88 years; with half of the participants being born overseas. The three main themes which emerged from the analysis are presented here and include: ‘acceptance of moving’, ‘maintaining participation in activities and social interaction’, and ‘challenges associated with adjustment’.

Theme 1: Acceptance of Moving

This theme includes some of the reasons for and decisions behind accepting to become a nursing home resident. The decision process commences with the identification of a need, importantly underpinned by the loss of physical function. When a need was identified, participants appeared to accept and accommodate their needs, with many of them reflecting on the natural process of transition to the changed lifestyle with advanced age, and particularly their reduced privacy and rights. One participant commented:

“I accepted that I needed to be cared and to go to a nursing home, as I am no longer able to look after myself because I am too old. I needed to be here where people can look after me even though I don’t have my own privacy and my own rights that I used to have it. This is normal and part of our life, as we get older, we need someone to look after us” (participant 5, female, 93 years old).

Some participants who had a chronic condition, such as arthritis, diabetes, and vision problems believed that they were unable to cope with their condition alone and they required higher support:

“Uhm, I got diabetes, I kept falling over at home and my wife could not lift me up anymore and I had 12 falls in one day. I accepted the fact that I need to move to aged care, where I can be cared by nurses’’ (participant 3, male, 83 years old).

However, three participants reported that they moved into aged care because of the burden on their family members:

“I used to live with my daughter, and I reached to the point it is hard to her to constantly look after me plus her own family I didn’t want to make their life harder because of myself” (participant 1, female, 89 years old).

Theme 2: Maintaining Participation in Activities and Social Interaction

The second theme focused on the importance of maintaining participation in activities and social interaction. In the nursing home, peers enabled participants to engage in meaningful activity, social interaction, and a connection to life outside. This networking reinforces the meaningful relationship and close bonds with other residents, which repeatedly surfaced:

“I have a good relationship with the residents, keep me busy to get involved in some activities. For example, in the morning, some residents, including myself, play mind games and, in the afternoon had a fun quiz that led to discussion and makes our brain to work. There’re other functions here - happy hour on a Friday afternoon, that allows us to have a fellowship. We also have some social event outside, which depends on the occasion” (participant 1, female, 89 years old).

This participation also provided an opportunity to remain active and maintain their physical independence. Subsequently, they valued being able to maintain their regular exercise:

“Here, gives me more freedom to be able to have fun, I am so grateful that I can engage with other residents to do some physical activity like stretching, I mean light exercise, like when I used to do it in my own place. After lunch, I will go down the physio gym and use the equipment to keep the muscles working” (participant 4, male, 88 years old).

Importantly, building relationships with residents who are both more socialised and active had a significant impact on the physical and mental health of participants. The feeling of both having fun and being fully engaged in any game and physical activity encouraged them to maintain a healthy social life:

“I believe having interaction with residents who are more socialised and more physically active help you to be happier, healthier mentally, physically and emotionally” (participant 9, male, 88 years old).

Theme 3: Challenges Associated with Adjustment

This theme highlights the challenges faced by participants in adjusting to the changed lifestyle. These challenges refer to difficulties that participants experienced in communicating and connecting with other residents due to mental illness or age difference. Participants reported that some residents have a diagnosis of dementia, which made adjustment more challenging:

“My difficulty was when I came across a resident who have memory loss, and I started talking to him and try to be friend, but I didn’t know that he had dementia. I would say it was hard when you don’t know about the resident condition and try your best to make friend’’ (Participant 2, female, 82 years old).

The age gaps of around ten to fifteen years between residents made it hard to connect with others. A younger participant described his experience:

“You know it was hard for me to share my interest with someone older than me, like 20 years, you know for me was a challenge to share my common interest and build a relationship or make a friend with someone older than myself” (Participant 6, male, 66 years old).

Another challenge was adjusting into a new environment that was different from their own. The lack of individual autonomy to take control over personal habits, daily routine and their preferences surrounding their every day schedule, lead to feelings of being restricted. One participant commented:

“Of course, here is not like my home, I had freedom, I used to do whatever want at any time, I didn’t have rules to follow such as eating or watching TV at a certain time. Now I feel more limited or restricted, for example I can’t go anywhere on my own, I have to ask - I need permission. I can’t to stay up, I can’t wake up too late. I mean I don’t choices” (participant 7, male, 71 years old).

Discussion

This qualitative study was conducted to explore the perceptions and experiences of older adults undergoing the transition from home to an aged care facility. This study describes the positive and negative perceptions and experiences of older adults who moved into an aged care facility. To our knowledge, the previous studies focused on the needs of and experiences of older adults in residential aged care without considering the first 6-12 months of their arrival, which is considered to be a crucial period. This study is the first to explore the perception of older adults’ transitioning within the first six months of their arrival. A decision to move into an aged care facility is usually proceeded by a loss of physical function or a chronic condition, and a desire not to burden family members. Once the participant made the decision, it provided a better opportunity for participants to have greater control and choice in their transition, which also could improve their adjustment. This finding seems to be consistent with the view of a sense of control over the transition to an aged care in contributing to a successful transition [23], increased autonomy [24] and mental health and emotional stability [10]. However, in Australia, most of the care provided to older adults is driven by the community, in allowing them to stay in their home for as long as possible [16].

It was clear from the findings that living within an aged care facility provided residents with a warm, friendly environment that encouraged a high level of social engagement. The participants described developing relationships, as they engaged in interactions in the activity room or dining room at mealtimes, which encouraged them to be more physically active and more social than their previous circumstance. Engaging in social interaction and meaningful activity enabled participants to connect to life outside of the aged care facility, particularly helping newly admitted residents to adjust quickly. This is supported by a previous study, which reported that such an interaction was important to staff, including nurses and carers in an aged care facility [25]. This could be related to the permanency of residents who may share a common interest, making it easier to form meaningful relationships with other residents, which would benefit both carers and residents. The importance of the relationship with other residents is evident in improving quality of life and well-being [26]. Other studies established a link between high levels of activity and more social interaction among residents within the facility [27], while some had emphasized less on nurturing social interactions between older adults and more on the provision of care services [28,29].

However, in this study, there were a few participants who faced challenges with building relationships with other residents, which were associated with the age of the residents or mental illness. Communicating with residents who had a mental illness or those who had twenty years of age difference between the youngest and oldest residents, can also pose a significant challenge. These participants reflected on feeling that there is a lack of consistency of resident, which could affect their ability to form an intimate relationship with the other residents and can be a significant barrier to sustaining the relationship. This finding has not yet been reported in studies, therefore further investigation is needed to determine the association between an age gap or memory loss and building relationships with others. Indeed, the problems of connecting to other residents in an aged care facility have been associated with adjustment [12]. Loss of personal autonomy of control over daily routines and habits makes the participants feel that they are being restricted. Not having choices over mealtime and social or physical activities pose a challenge.

Similarly, it is stated by Johnson and Bibbo [11] that “Strict adherence to the routine by staff and a lack of individual privacy have been associated with residents feeling less at home in an aged care facility” [11]. This reflects the older adults’ concerns about the challenges with adjusting to living in aged care. The lack of control and autonomy expressed among these participants was disconcerting. Therefore, further research, using a large cohort study is required to investigate the phenomenon of privacy of older adults within an aged care context. It is important to examine the different style of coping with adjustment, particularly within their first six months of arrival, and to precisely record and better understand the pattern of coping strategies. Also, further quantitative studies are also required to verify and enrich the results of the study.

Limitations

This study being a single site study and the exclusion of older adults with mild to severe cognitive impairment, which represents a significant proportion of older adults in aged care, might limit the transferability of findings into other settings. However, the results of this study are not intended to generalize to other experiences of older adults who moved into an aged care facility. Member-checking to ensure the credibility of the participant’s word was also not conducted.

Conclusion

In conclusion, it appears that older adults acknowledged a reduction in physical function and the need for additional care and support as being their reason for moving into an aged care facility. The process of their relocation decision, seemed to involve a willingness to accept to move and relinquish certain accepted rights, such as privacy. However, lack of control and autonomy remains a significant issue, given that a large number of Australian older adults enter an aged care facility. It is important that similar problems have been identified in other studies, reflecting the challenges associated with adjustment. The implication of this study is also essential to improve the quality of life of an older adult resident in an aged care facility. The results of this study will be used to recommend strategies for supporting older Australians entering a residential aged care facility. Further exploration is needed into the reasons why older adults find it important to build friendships and engage in social and physical activity in the aged care facility. Also, it would be interesting to investigate whether older adults use different coping strategies to adjust to their new environment.

Acknowledgement

We would like to acknowledge Juniper a Uniting Church Community for their support with this publication.

References

1. Ellis J (2010) Psychological transition into a residential care facility: Older people’s experiences. Journal of Advanced Nursing 66: 1159-1168.
2. Davies S (2005) Meleis's theory of nursing transitions and relatives' experiences of nursing home entry. Journal of Advanced Nursing 52: 658-671.
3. Chick N, Meleis AI (1986) Transitions: a nursing concern. In: Nursing Research Methodology: Issues and Implementation. Chinn PL (Editor), Aspen Rockville. Pg No: 237-257.
4. Meleis AI, Sawyer L, Im E, Messias D, Schumacher K (2000) Experiencing transitions: An emerging middle-range theory. Advances in Nursing Science 23: 12-28.
5. Buhr GT, Kuchibhatla M, Clipp EC (2006) Caregivers' reasons for nursing home placement: Clues for improving discussions with families prior to the transition. The Gerontologist 46: 52-61.
6. Barredo RDV, Dudley TJ (2008) A descriptive study of losses associated with permanent long-term care placement. Lancet 31: 87-92.
7. Brownie S, Horstmanshof L (2012) Creating the conditions for self-fulfilment for aged care residents. Nurse Ethics 19: 777-786.
8. Government of Australia (2011) Productivity Commission. Caring for Older Australians: Productivity Commission. Report overview no. 53. Canberra: Government of Australia.
9. Harris N, Grootjans J, Wenham K (2008) Resident identified issues shaping wellbeing in retirement and aged living and care facilities. Geriaction 26: 5-13.
10. Bowers H, Clark A, Crosby G, Easterbrook L, Macadam A, et al. (2009) Older People’s Vision for Long- Term Care. York: Joseph Rowntree Foundation.
11. Johnson R, Bibbo J (2014) Relocation Decisions and Constructing the Meaning of Home: A Phenomenological Study of the Transition into a Nursing Home. Journal of Aging Studies 30: 56-63.
12. Lee G (2010) Predictors of adjustment to nursing home life of elderly residents: A cross-sectional survey. International Journal of Nursing Studies 47: 957-964.
13. Li Ic, Yin TJc (2005) Care needs of residents in community based long-term care facilities in Taiwan. Journal of Clinical Nursing 14: 711-718.
14. Milke DL, Beck C, Danes S (2006) Meeting the needs in continuing care of facility-based residents diagnosed with dementia: Comparison of ratings by families, direct care staff, and other staf. Journal of Applied Gerontology 25: 103-119.
15. Chuang YH, Abbey J, Yeh YC, Tseng IJ, Liu M (2015) As they see it: A qualitative study of how older residents in nursing homes perceive their care needs. Collegian 22: 43-51.
16. Walker H, Paliadelis P (2016) Older peoples’ experiences of living in a residential aged care facility in Australia. Australasian journal on ageing 35: E6-E10.
17. Mavromaras K, Knight G, Isherwood L, Crettenden A, Flavel J, et al. (2016) National Aged Care Workforce Census and Survey - The Aged Care Workforce.
18. Sandelowski M (2000) Whatever happened to qualitative description? Research in nursing and health 23: 334-340.
19. Plays T (2008) Purposive sampling. In L. M. Given (Ed.), The Sage encyclopedia of qualitative research methods Los Angeles: Sage 2: 697-698.
20. Lao S, Low LP, Wong KK (2019) Older residents’ perceptions of family involvement in residential care. International journal of qualitative studies on health and well-being 14: 1-11.
21. Braun V, Clarke V (2014) What can “Thematic analysis” offer health and wellbeing researchers? International journal of qualitative studies on health and well-being 9.
22. Lincoln YS, Guba EG (1985) Naturalistic inquiry. Beverly Hills: Sage.
23. Johnson R, Popejoy LL, Radina E (2010) Older adults’ participation in nursing home placement decisions. Clinical Nursing Research 19: 358-375.
24. Mallers MH, Claver M, Lares LA (2013) Perceived Control in the Lives of Older Adults: The Influence of Langer and Rodin’s Work on Gerontological Theory, Policy, and Practice. The Gerontologist 54: 67-74.
25. Park NS, Zimmerman S, Kinslow K, Shin HJ, Roff LL (2010) Social Engagement in Assisted Living and Implications for Practice. Journal of Applied Gerontology 31: 215-238.
26. Robison J, Shugrue N, Reed I, Thompson N, Smith P, et al. (2011) Community-based versus institutional supportive housing: perceived quality of care, quality of life, emotional well-being, and social interaction. Journal of Applied Gerontology 30: 275-303.
27. Nordin S, McKee K, Wallinder M, Koch Lv, Wijk H, et al. (2017) The physical environment, activity and interaction in residential care facilities for older people: a comparative case study. Scandinavian journal of caring sciences 31: 727-738.
28. Bellis AD (2010) Opinion piece: Australian residential aged care and the quality of nursing care provision. Contemporary Nurse 35: 100-113.
29. Tuckett A (2005) Residents’ rights and nurses’ ethics in the Australian nursing home. International Nursing Review 52: 219-224.