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JAN

JOURNAL OF ADVANCED NURSING

ORIGINAL RESEARCH

Resident strategies for making a life in a nursing home: a qualitative


study
Gloria L. Brandburg, Lene Symes, Beth Mastel-Smith, Gayle Hersch & Teresa Walsh
Accepted for publication 26 May 2012

Correspondence to G.L. Brandburg:


e-mail: gbrandburg@southuniversity.edu

Gloria L. Brandburg PhD RN GNP-BC


Associate Professor
College of Nursing, South University,
Savannah, Georgia USA
Lene Symes PhD RN
Associate Professor
College of Nursing, Texas Womans
University, Houston, Texas USA
Beth Mastel-Smith PhD RN
Associate Professor
College of Nursing & Health Sciences,
University of Texas at Tyler, Tyler, Texas
USA
Gayle Hersch PhD OTR
Professor
School of Occupational Therapy, Texas
Womans University, Texas USA
Teresa Walsh PhD RN
Assistant Professor
College of Nursing, Texas Womans
University, Texas USA
[Correction added after online publication
23 October 2012: The affiliated institute of
Gayle Hersch and Teresa Walsh have been
corrected from University of Texas at
Tyler to read Texas Womans
University.]

862

BRANDBURG G.L., SYMES L., MASTEL-SMITH B., HERSCH G. & WALSH T.


( 2 0 1 3 ) Resident strategies for making a life in a nursing home: a qualitative
study. Journal of Advanced Nursing 69(4), 862874. doi: 10.1111/j.13652648.2012.06075.x.

Abstract
Aim. To identify strategies that older adults use to adapt to live in long-term
care.
Background. The use of long-term care services has risen and this trend is
expected to continue as the population reaches old age. Moving into a long-term
care setting has been documented internationally as an overwhelming life change
for many older adults. It has been observed that residents adjust differently over
time, but the basis for these differences needs further exploration.
Design. A qualitative design using grounded theory method was employed.
Methods. A total of in-depth interviews were conducted in October 2008
February 2009 with a sample of 21 participants. Participants ranged in age from
6593 years, 81% women and 19% men; mainly Caucasian with one African
American and one Hispanic. Length of stay ranged from 3 days to over 9 years
living in long-term care so that all stages of adjustment were included in the
study. Ground theory method was used to analyse the data.
Findings. The results of this study yielded 21 facilitative strategies. The core
category identified was personal resiliency, which served as the underpinning for
the strategies used by the participants. Strategies were identified in making the
decision to move into long-term care and in day-to-day living.
Conclusion. Understanding the strategies that facilitate residents to make a
successful transition to long-term care life will assist nurses to intervene in ways
that are supportive. The strategies identified in this study may be used to develop
interventions for residents that are having difficulty living in long-term care.
Further exploration of how resiliency has an impact on strategies used by
residents is clinically relevant, but further research is needed.
Keywords: gerontology, grounded theory, long-term care, nursing home, psychosocial nursing

2012 Blackwell Publishing Ltd

JAN: ORIGINAL RESEARCH

Introduction
Most people move into a nursing home out of necessity not
desire. Adjusting to nursing home life is often a complex
and difficult process for older adults; marked by emotional
upheaval, personal losses and feelings of abandonment
(Chenitz 1983, Brooke 1989). However, despite the negative view that many people have of nursing homes, the
demand for long-term care services is expected to rise dramatically due to the unprecedented ageing of the global
population. The United Nations Programme on Aging predicts that by 2050 people over the age of 60 will grow from
759 million in 2010 to 2 billion worldwide (Sciegaj & Behr
2010). Another important factor that has impacted the need
for long-term care services is the lack of traditional family
carers. Women from all cultures continue to move into the
workforce at higher rates, which leaves a void in the traditional care giving role for ageing family members (Johnson
et al. 2007). Moving into a nursing home has been documented internationally as a major life change for many
older adults (Chenitz 1983, Brooke 1989, Nay 1995,
Iwasiw et al. 1996, Fiveash 1998, Lee et al. 2002).
Researchers have focused on describing the experiences of
older adults as they adjust to nursing home life and factors
that influence their adjustment; however, less research has
been dedicated to exploring adjustment processes (Lee et al.
2002). There is a need to increase our understanding of
how older adults are able to transition successfully into
long-term care environments. This study presents findings
on strategies used by older adults that have helped them
adjust to nursing home life.

Background
Research studies have described the experience of moving into
and living in a nursing home. Residents reactions and experiences were categorized into stages of adjustment with the defining end of adjustment usually occurring within 1 year of living in
the nursing home (Chenitz 1983, Brooke 1989, Young 1990,
Wilson 1997, Lee et al. 2002, Heliker & Scholler-Jaquish 2006).
For example, Brooke (1989) identified four phases of adjustment: disorganization, reorganization, relationship building and
stabilization. Disorganization was described as feeling displaced,
vulnerable, or abandoned during the first weeks after admission.
Reorganization usually occurred 23 months after admission
and was identified by older adults as becoming more involved in
their care and coming to grips with why they were living in a
nursing home. The third phase, relationship building began
about the third month, involved making new friends in the nursing home and rebuilding old relationships with friends and fam 2012 Blackwell Publishing Ltd

Resident strategies

ily outside the nursing home. The last phase, stabilization was
seen most often in residents 36 months post admission and
could best be described as settling in and having a sense of home
(Brooke 1989, p. 68).
Another group of studies in the area of nursing home
adjustment has focused on factors that influence how well
residents adjust to nursing home life. These factors include
whether or not the move was planned or unplanned, the
amount of social support received and the residents coping
abilities (Porter & Clinton 1992, Patterson 1995, Wilson
1997, Groger 2002). Adjustment approaches were identified
by Porter and Clinton (1992) as cognitive-behavioural strategies used by residents to help them cope with living in the
nursing home. Passive strategies such as getting used to it,
going along, keeping quiet and obeying were also frequently
described (Porter & Clinton 1992, Kahn 1999, Groger
2002). It is not clear from these studies how well these strategies facilitated adjustment.
More recently researchers have focused on the influence of
culture on resident adjustment to nursing home life (Kahn
1999, Groger 2002, Lee et al. 2002). Groger (2002) described
the experiences of African-American nursing home residents
and their former carers as they coped with nursing home
placement. Psycho-emotional and behavioural coping strategies were identified, which included praying, being content,
distancing oneself, living by the rules of the nursing home and
participating in social activities. Older Jewish nursing home
residents were found to frequently use the phrase making the
best of it to describe their adaptation to the nursing home
(Kahn 1999). Lee (2001) found that Chinese sociocultural
values were influential in adjustment to the nursing home.
Chinese elders did not have much difficulty with rules and
regulation and communal living; which are usually cited as
problems to adjustment because the Chinese culture value
collectivism over individualism.
Resiliency in older adults has been studied, but no work was
found specifically to the long-term care setting. The sources of
strength model by Janssen et al. (2011) included individual, contextual and interactional domains that explained how resiliency
could be identified and how it operated in the lives of older people. The location of where older adults live (rural, suburban, or
urban) does not impact resilience levels, but strong social ties and
good mental health do have an impact (Wells 2010). Nygren
et al. (2005) found that resilience was a driving force for handling adversities such as declining health. Women and immigrants have been studied in regard to their ability to overcome
adversities related to minority and gender status. Self-efficacy
and optimism were found to be important factors that predicted
resiliency in overcoming oppression (Cohen et al. 2006, Lee
et al. 2008, Browne et al. 2009, Alex & Lundman 2011).
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G.L. Brandburg et al.

In following the tenets of the grounded theory method,


no theoretical framework was used to guide the study. The
literature review was used to develop a clinically relevant
research question with the exception of the literature on
resiliency. The literature review on resiliency was conducted
after the development of the grounded theory to better
understand its relevance to the current literature.

The study
Aim
This study addressed the question: What are the strategies
used by older people that contribute to adaptation to nursing home life?

Design
A qualitative research design, using a grounded theory
approach guided this study undertaken 20082009.
Grounded theory is a method for analysing processes
(Glaser 1978) and has several approaches that can be
employed for analysing data. The techniques and procedures
for data analysis described by Charmaz (2006) were used.

Participants
The participants were a purposive sample of 21 participants
that consisted of 17 women and four men (Table 1). The
participants were recruited from three nursing homes in a
large metropolitan area. Participants were recruited with
assistance from the nursing home staff and nurse practitioner. A designated staff person or the nurse practitioner
approached the potential participant and read a recruitment
script. Those potential participants who were interested in
being part of the study were evaluated against the inclusion
criteria and those who were eligible were provided with
project information and details of informed consent. The
inclusion criteria were: (1) Residents 65 years or older; living in long-term care; (2) English-speaking; and (3) capable
of conversing by scoring 4 or less on the Short Portable
Mental Status (Pfeiffer 1975) were invited to participate in
the study. A total of 25 participants were recruited, but 4
did not meet the eligibility criteria and were excluded from
the study.
Theoretical sampling methods were employed as the data
were collected and analysed. Glaser (1978) defined this type
of sampling as a process where data are analysed as they
are collected and the researcher decides what data to collect
next, based on the analysis. For example, some participants
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recalled conflicts with fellow residents in the first few weeks


of living in the nursing home; which prompted interviews
with participants recently admitted to explore this issue further. Also, attempts were made to seek participants with a
variety of ages, gender, length of stay and cultural backgrounds as the study progressed in an attempt to obtain
diverse perspectives. Sampling was completed when theoretical saturation was reached (Strauss & Corbin 1998). Theoretical saturation is the point in category development at
which no new properties, dimensions, or relationships
emerge during analysis (Strauss & Corbin 1998, p. 143).

Data collection
Written informed consent was obtained from all participants.
Twenty-one initial interviews using an interview question
guide (Table 2) were conducted over 18 months. Interviews
were audio taped and transcribed verbatim. Nine participants
were interviewed a second time for the purpose of member
checking (Lincoln & Guba 1985). Member checking was conducted by the principal investigator through a second interview where the analysis from initial interview including any
identified facilitative strategies was discussed. Additional
questioning based on the analysis was done to clarify and validate findings. Participants were chosen for member checking
on the basis of participant willingness to be interviewed and
for those whose interviews were rich with data. Initial interviews lasted 4560 minutes and follow-up interviews lasted
2030 minutes. All interviews took place in the participants
private room focusing on past, present and future events
related to moving into and living in the nursing home. Interview questions were modified when indicated by the findings
to complete the emerging categories fully. All interviews were
conducted by the principal investigator who has spent 2 years
in the participating nursing homes prior to the start of the
study as a nurse practitioner.

Ethical considerations
The study was approved by the institutional review board
from the university and approved by the administration of
each nursing home.

Data analysis
Analysis was conducted by the principal investigator and the
other research team members served as independent readers of
the study and performed audit trails of the analysis throughout the study. Data analysis occurred in three stages: (1) open/
initial coding to categorize meaningful segments of data in the
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Resident strategies

Table 1 Characteristics of participants.

Code no.

Age/
Gender

A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U

93/Female
81/Female
86/Female
65/Male
87/Female
88/Female
87/Female
67/Female
71/Male
68/Female
82/Female
87/Female
68/Male
82/Female
86/Female
89/Female
91/Female
66/Male
79/Female
74/Female
87/Female

Race

Marital
status

Previous living
arrangement

Length of
stay

Do you feel
settled in to
live your life here?

Black
Hispanic
White
White
White
White
White
White
White
White
White
White
White
White
White
White
White
White
White
White
White

Widowed
Widowed
Widowed
Divorced
Widowed
Widowed
Widowed
Widowed
Married
Married
Single
Widowed
Divorced
Widowed
Widowed
Widowed
Widowed
Single
Widowed
Widowed
Widowed

Home-alone
Home-w/spouse
Home-alone
Nursing Home
Home-alone
Home-alone
Home-alone
Home-alone
Sons Home-w/spouse
Sons home-w/spouse
Home-alone
Home-alone
Home-alone
Nursing Home
Home-alone
Home-alone
Nursing Home
Home-w/mother
Home-w/daughter
Home-alone
Home-alone

1 year 2 months
8 years
9 years 10 months
4 months
1 year 2 months
11 months
4 months
6 months
3 days
3 days
9 months
18 months
5 years 3 months
2 years 1 month
14 months
1 month
9 months
2 years 3 months
8 years 2 months
2 years 5 months
3 years 4 months

Yes
Yes
Yes
Ambivalent
Yes
Ambivalent
No
Yes
No, too soon
No, too soon
Yes
Yes
Yes
Yes
Yes
No
Yes
Ambivalent
Yes
Yes
Yes

participants own words that focused on conditions related to


being a nursing home resident; (2) focused coding to further
develop and validate the emerging categories; and (3) theoretical coding to conceptualize the relationships among the categories (Charmaz 2006). Line by line analysis using the
constant comparison method was performed. The constant
comparison method involves comparing statements and incidents within and between interviews; analysing for similarities
and differences in data leading to the development of categories (Charmaz 2006). Initial coding of the data provided the
categories of who made the decision to move, feeling the
move was necessary, gains and losses related to nursing home
life, supportive relationships, being positive and feeling ones
needs are being met. During focused coding the initial code
categories were collapsed into fewer categories and some were
renamed for better clarity. After focused coding, theoretical
sampling methods were employed to ensure that the categories
were fully developed (Charmaz 2006). The researchers
memos, the literature and diagramming were used to guide the
theory development. The core category of personal resiliency
emerged from the final analysis. The facilitative strategies
were derived from the participants descriptions of their
thoughts, feelings and behaviours as they discussed their past,
present and future lives in the context of nursing home environment (Table 2).
2012 Blackwell Publishing Ltd

Validity and reliability/rigour


The strategies that were used in this study to demonstrate
scientific rigour were based on the criteria set forth by Lincoln and Guba (1985). The criteria of credibility, dependability, confirmability and transferability are considered the
gold standard for establishing trustworthiness in qualitative
research (Polit & Beck 2004). Credibility and dependability
were established by prolonged engagement in the field and
the persistent observation that occurred in this study over
time. Analysis methods and findings were reviewed and discussed during the study with a group of professionals with
expertise in long-term care and/or grounded theory methods
and this was used to establish confirmability of the findings.
It is not necessary that the qualitative researcher show
transferability, but should give thick description for the
reader to do so if they wish (Lincoln & Guba 1985,
p. 316). Theoretical sampling was completed until categories were saturated in depth by variation and dimension.
Member checking using a second interview was completed
with some participants in the study to obtain their feedback
on the researchers interpretations and conclusions drawn
from the data. Demographics of the participants and
descriptions of the settings were provided to aid in describing the participants and their setting.
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G.L. Brandburg et al.

Table 2 Interview guide.


Past
1. What happened in your life that you came here to live?
a. How was it decided that you should come here to live?
2. Moving to a nursing home is sometimes a big change in
ones life, how did you handle the move from your home
to here?
a. How did you feel, what did you do?
3. How has it been to live here?
a. What do you like about it?
b. What do you not like about it?
4. Do you feel you have settled in to live your life here ok?
a. If no,
i. What is it that keeps you from being settled?
ii. What do you think you could do to help yourself get
settled here?
iii. What do you think the nursing home could do to help?
Can anyone else help? If yes, what could they do to help
you?
b. If yes,
i. What did you do to help yourself to get settled?
ii. What did you think about?
iii. Did anyone help you? If yes, who and what did they do?
How did that help?
5. How did/will you know when you were settled in?
(what did/will it feel like?)
6. Looking back over when you came here to livewhat would
have made it easier for you to move into this new place
and get settled?
a. Having gone through this moveWhat would you do
differently? What might the nursing home (family,
friends) do differently?
Present
7. What is it like to live here?
a. Tell me about a typical day for you here
b. How has your day been today?
8. What has changed for you in your life or in your activities
since you came here to live?
9. Whats important to you now?
10. Do you consider this place your home?
a. If yes, what makes this home?
b. If no, what needs to happen to make this place home
for you?
Future
11. If I were coming here to live, what would be important
to know?
12. If I were building a new nursing home, what suggestions
do you have?
13. How do you see your future?

Results
A total of 30 interviews were completed with a sample of
21 participants (21 initial and 9 follow-up interviews)
(Table 1). Follow-up interviews were completed with nine
of the participants to clarify understanding and/or validate
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conclusions drawn from data analysis and also provided an


opportunity to ask more in-depth questions. The participants length of stay ranged from 3 days10 years. They
ranged in age from 6593 years. Most participants were
Caucasian, one was African American and one was Hispanic. Only two participants were married, two divorced,
one single and all others were widowed. Education level
ranged from less than elementary education to college graduate.
The final analysis revealed strategies that supported adaptation to the nursing home for these participants. The strategies were identified from the interviews and were
confirmed with the participants as being helpful to adjustment or to the quality of daily life. Participants were asked
directly what was helpful to them in the past and present;
and what would be helpful in the future in the context of
living a satisfactory life in the nursing home. Personal resilience was identified as the core variable for the facilitative
strategies (Figure 1).

Personal resiliency: becoming and being a nursing home


resident
There were a total of 21 facilitative strategies identified
from the participant interviews (Table 3). These facilitative
strategies assisted the participants to accept and adapt to
nursing home life and also revealed characteristics of resiliency as they faced challenging situations. Resilience refers
to a persons ability to adapt successfully challenges in life
that are often described as negative, traumatic, or stressful
(Cohen et al. 2006). A post analysis literature review was
conducted and support was found that suggests a relationship between the strategies identified in this study with
resiliency attributes in the literature (Table 4). It is proposed here that personal resiliency may play a role in the
participants insight and ability to develop these facilitative
strategies. The strategies were grouped into two main categories: (1) making the move to a nursing home; and (2)
day-to-day living in the nursing home.
Strategies to support making the move to a nursing home
Even though the move to the nursing home was years past
for some participants; all discussed the move with great
clarity: I remember it like it was yesterday, which reveals
in part the impact the move had on their lives. Two subcategories were identified: (1) agreement vs. disagreement
about the move; and (2) support in making the decision to
move. The facilitative strategies were grouped in these subcategories. Facilitative strategies for agreement vs. disagreement about the move:
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Resident strategies

Day to day living


In the nursing home
Gains and losses
Relationships
Coping with the living
situation
Core category:
Personal
resilience

Facilitative
strategies

Making the move to the nursing home


Agreement versus disagreement
about the move

Figure 1 Relationships among the categories and sub-categories.

Support in making the decision to


move

Be honest when reflecting on capabilities, needs and

expressed an abiding hope that one day it might happen. Partici-

options to meet those needs.


Believe that the move to the nursing home is necessary.
Have an attitude of hope that the nursing home will
improve quality of life.
Keep hope that someday you may return home in the
future.

pant K stated: I would rather be home and maybe someday I will

For most participants the driving force behind the decision to move into the nursing home was a decline in physical health. Concerns about being a burden to family and an
increasing struggle to do self-care were described by many
participants. It was important to believe that the nursing
home was the better place to live; otherwise there was
doubt that the move was necessary. Participant G spoke
about moving for other people saying:
I was staying [here] for someone else, for the family. And mainly because
she was pushing me; she was pressuring me to go there, to stay there and
give it a chance. I dont want to be here because I dont need to be here.
Recognizing the need for help and having hope that the move will
make a positive difference in their lives was germane to agreeing to
the move. For example, Participant I explained his reasons for
moving:
Im going to have to have a whole lot of help. Problem is Im here
because of me, but if Im going to do any of that at all, I got to be
better than what I am today. They may help me with my stamina
and with strength, to get me where I feel like living again.
Viewing the move as temporary was prevalent among the participants and this view was not related to length of stay. There were
participants who had hope to one day return home that had lived
in the nursing home several years. Even for those participants who
felt it was unlikely that they would ever return home, they
2012 Blackwell Publishing Ltd

return there, but in the meantime I accept living here because this
is the best place for me right now.

Facilitative strategies for having support in making the


decision to move:
Become familiar with facilities that will meet needs in the

least restrictive environment.


Plan for the need to someday move into a nursing home.
The physician or family in many instances played an
important role in initiating the move by suggesting that the
nursing home would be a safer environment. Participant A
recalled: I couldnt walk very good and so I came here.
The doctors say I have to be supervised. Family was the
primary resource for finding potential nursing homes. Decisions on where to move were usually made with the family
and participant. But in some cases the participant was too
ill at the time and this required the family to make the decision without the participants input. Many participants
agreed with the familys choice, but not all. Almost all
reported that they should have planned better for the move.
Some participants discussed having prior experiences with
nursing homes and they believed that helped them make the
move. Participant C explained: My mother lived in this very
home about 20 years ago. I know the family that owns this
place. Others had not thought about the need to be in a nursing
home and found that they were not able to make the decision on
where to live when it was needed. When asked what they would
do differently if they could; most participants stated they would
have planned for the need by talking it over with their families
and visiting places near their family.
Many participants complained about the rules and regulations of the nursing home, which often lead them to feel

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Table 3 The frequency and distribution of the strategies among the participant sample.

Facilitative strategies
Category: Making the Decision to Move
1. Plan for the need to someday move into a
nursing home

2. Be honest when reflecting on capabilities,


needs and options to meet needs

3. Believe that the move to the nursing


home is necessary
4. Become familiar with facilities that will
meet needs in the least restrictive
environment
5. Have an attitude of hope that the nursing
home will improve quality of life

6. Keep hope that someday you may return


home in the future
Category: Living Daily in the Nursing Home
7. Use losses to prepare for the more
restrictive nursing home environment

8. Rely on survivor mentality to


cope with losses associated and to
live with the nursing home rules
9. Take it one day at a time

10. Trust in the Lord


11. Seek supportive relationships with
family, friends, fellow residents
and staff
12. Get along with others
13. Be good to others
14. Be patient and flexible in getting
your needs met

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Frequency
of the
strategy

Distribution
by participant
code

I knew these places were all around and my son did the leg
work and filled out a lot of the papers to get in here.
I was familiar with this place because I had family here at
one time, so moving here was ok.
We knew about it here and after my son visited, we wanted
to come.
I told my daughter I would like to go to the nursing home
to live and she was not for it at first, but I thought it was
best.
I could not walk very good, so I came here to get the help I
needed.
I need a whole lot of help.
I just couldnt take care of my husband anymore and I
needed help myself.
I had no other place to go.
This was the best place for me.
I didnt want to live with family, so I came here.
I didnt know I would not know that there would be so
many rules here and that I would not be able to do things
for myself.
They have what I need here.
They [nursing home staff] may help me with my stamina and
with strength, to get me where I feel like living again.
This place had what I needed to feel safe and cared for.
I am better off living here.
I hope to be well enough to go back home.
I would like to go home, but I probably die here.
I would like to live with family if I cant go home.

B, C, I, S

B, C, D, I, R,
S

16

AE; HP; S
T

D, I

B, H, I, S, T

D, F, G, I, J
R,

I had to give up driving and so I didnt go anywhere without


someone to take me, so I dont mind being here [in the
nursing home].
I could not cook or take care of myself, since my eye sight
has gotten so bad, so this is ok. I have to wait for help, but I
did anyway before.
Ive faced harder times than this.
Im a survivor, baby, I do what I have to do.

I, J

A, B, D, T

I have my good days and my bad days, but I take it one day
at a time.
I try to live for today and not worry about tomorrow.
I put my trust in the Lord every day.
You know, the closeness, like beingtalking to them [the
nursing home staff] and stuff like that. It seems like they are
sisters, or family, you know.
I look out for her [roommate] and she looks out for me.
There are all kinds here. Some dont have a good mind and
you just have to over look them and just go along.
I just try to get along and help others when I can.
You have to realize you are not the only one here.

13

AH; KM,
T, U

3
13

A, G, P
AC, E, H,
K, L, NQ,
S, U

C, M, S

2
8

K, S
AD, I, K, N,
R

Sample of participant quotes

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Resident strategies

Table 3 (Continued).
Distribution
by participant
code

Facilitative strategies

Sample of participant quotes

Frequency
of the
strategy

15. When there is nothing that can be done,


let it go
16. Talk about losses and seek solutions to
lessen those losses as much as possible
17. Seek out people to help with difficulties
that are causing dissatisfaction

If I cant help it, I just let it go as best I can.

D, F, K, O

I am here to get back some of what I lost [strength,


abilities]. I am to get back to doing my music.
It is always changingyou just ask people and see the ones
that help and the ones that dont. It is a process of
elimination.
Dont hold up in your room, there is always something
going on here to do.
Youve got to figure out who youre suppose to talk to when
you need something.
Leave the outside world where you left it. You cant go back
to what it wasyou cant stay here and think about what
might have been. Its what it is today.
No place is perfect, no even home, so I accept that and make
the best of it.

I, J, P

BD, I, J, S

15
7

BF, KM,
O, P, RU
AD, E, I, N

D, I, R

19

AI, KO, Q
U

18. Engage in enjoyable activities


19. Learn the nursing home system and how
to get what you need
20. Dont dwell on the past and what might
have been, live for today
21. Make the best of it

more dependent than they liked. For example Participant D


reports:
They dont let me get to the coffee pot. I can understand why they
dont want you to get burned, but they dont like getting you coffee
either. I dont like that because I can do it and they wont let me.

Another common issue that these participants faced was


dealing with fellow residents who had dementia: It is hard
to find good minded people here (Participant D). When
asked about other living options that might be available;
many participants were not aware of the different levels of
care such as assisted living and to their knowledge these
options had not been explored by their families.

Take it one day at a time.


Trust in the Lord.
When there is nothing that can be done, let it go.
Do not dwell on the past and what might have been, live

for today.
Make the best of it.
Participants weighed the gains and losses of nursing
home life. Gains unanimously involved having the needs
met that they viewed as the reason for nursing home care.
Participant B stated:
A place like this is wonderful because they take care of you in
every wayyour diet, your activities, you know and personal
things like bathing and all that. Our medications are given to us.

Strategies to support day-to-day living in the nursing


home
Daily life in the nursing home was described as filled with
rules, regulations and routines. A paradox to the routine was
the high turnover of staff and administration, which some
participants said made their daily lives feel unsettled. Subcategories identified in this category were: (1) gains and losses,
(2) relationships and (3) coping with the living situation. The
facilitative strategies were grouped in these subcategories.
Facilitative strategies for coping with gains and losses:
Use losses to prepare for the more restrictive nursing
home environment.
Talk about losses and seek solutions.
Rely on survivor mentality to cope with losses and
changes.
2012 Blackwell Publishing Ltd

And they live up to what they say they do.

Losses were frequently mentioned. Losses were more


individualized and varied among the participants, but commonly involved loss of privacy and independence issues.
Participants spoke of how they coped with not living in
their own homes and generally used strategies that helped
them focus on the present. Participant R advised:
Yeah, leave the outside world where you left it. You cant go back
to what it was. When you come in here, its a different ballgame
you cant stay here and think about what might have been. Its
what it is today.

For most the loss of independence had occurred gradually


over time prior to the move to the nursing home. Some

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G.L. Brandburg et al.

Table 4 Facilitative strategies supported by resiliency attributes.


Resiliency attributes
Decisive risk taking: The ability to assume personal responsibility
by making some crucial decision even if the decision carries
personal risk (Mrazek & Mrazek 1987, pp. 339362)
Information seeking: The desire to learn as much as possible
about the hazards in the environment (Mrazek & Mrazek
1987, pp. 339362)
Optimism: Positive attitudes about the world in general and an
individuals life specifically, currently and in the future
(Weiss 2008, pp. 129)
Optimism and Hope: The disposition to take a positive view of
events that will happen in the future (Mrazek & Mrazek 1987,
pp. 339362)
Formation and utilization of relationships for survival: The ability
to create relationships that result in critical help and support in
times of crisis (Mrazek & Mrazek 1987, pp. 339362)

Self-efficacy: A persons belief about his or her ability to execute


a specific course of action (Bandura 2000)
Cognitive restructuring of painful events: The ability to reprocess
negative events in a way that will make them more acceptable
or congruent with ones view (Mrazek & Mrazek 1987,
pp. 339362)
Transcending adverse events through spirituality (Cohen et al.
2006)
Altruism: The ability to gain pleasure from giving to others
(Mrazek & Mrazek 1987, pp. 339362)
Rapid responsivity to situations: The ability to recognize and
adapt to the requirements of an immediate social setting to
avoid harm* (Mrazek & Mrazek 1987, pp. 339362)

Facilitative strategies
1. Be honest when reflecting on capabilities, needs and options
to meet personal needs
2. Believes that the move to the nursing home is necessary
3. Become familiar with facilities that will meet needs in the
least restrictive environment
4. Plan for the need to someday move into a nursing home
5. Have an attitude of hope that the nursing home will
improve quality of life
6. Keep hope that someday you may return home in the future
7. Take it one day at a time
8. Seek supportive relationships with family, friends, fellow
residents and staff
9. Get along with others
10. Seek out people to help with difficulties that are causing
dissatisfaction
11. Rely on survivor mentality cope with losses and changes
12. Talk about losses and seek solutions
13. Engage in enjoyable activities
14. Use losses to prepare for the more restrictive nursing home
environment
15. Dont dwell on the past and what might have been, live
for today
16. Make the best of it
17. Trust in the Lord
18. When there is nothing that can be done, let it go.
19. Be good to others
20. Be patient and flexible in getting your needs met
21. Learn the nursing home system and how to get what
you need

*Harm not limited to physical harm, but psychological, social, emotional and/or mental stress.

participants viewed becoming more dependent as preparation for the move and for living in the nursing home. Participant I explained:
I didnt do much at home anymoreI gave up driving and it was
difficult for me to cook and manage things. My son worked all
day. So being here [the nursing home] doesnt bother methere
are people here to talk to and help me.

Other losses identified by participants included loss of


privacy, possessions and hobbies. It was particularly difficult for the female participants to cope with the loss of personal possessions that had occurred during downsizing to
their nursing home room. Participant Q recalled: I brought
what I thought I couldnt live withoutit was hard to give
things away, but that is what I needed to do. In some
cases, solutions were found to combat the losses. One participant was an artist who sometimes splashed paint on the
870

walls. The nursing home administrator said she could not


paint in her room, but would need to use the activity room.
After some discussion a solution was proposed to use
removable coverings placed on the walls and floor of her
room so that she could continue to paint in her room.
Many participants discussed how they had faced many
hardships and difficulties throughout their lives and viewed
the nursing home as another challenge that they would overcome as well. The death of their spouse, the great depression,
wars and serious illness were commonly expressed experiences they had survived. Several female participants attributed their ability to persevere difficulties to their faith:
Participant A stated: I put my trust in the Lord everyday.
Facilitative strategies for relationships:
Seek supportive relationships with family, friends, fellow

residents and staff.

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JAN: ORIGINAL RESEARCH


Get along with others.
Be good to others.
Engage in enjoyable activities.

Relationships inside and outside the nursing home were discussed as being a source of support for participants. Having
family close by, even if they could not visit, was comforting,
but regular family visits were desired by most. Participant C
viewed the nursing home staff as family and stated: You
know, the closeness, like being with them, talking to them
about their families and stuff like that. It seems like they are
sisters, or family, you know. The loss of a favourite staff
member or a fellow resident was among the most distressing
problems for the participants. Participant M said: I dont get
too close to people here because they leave. Advice that was
often given by the participants to help with relationships was
to follow the golden rule of treating others like you would
want to be treated. Others talked about the need to get
involved in activities to pass the time and meet people. Participant E advised to Get out and move arounddont just hold
up in your room all day! Facilitative strategies for coping with
the living situation:
Be patient and flexible in getting your needs met.
Seek out people to help with difficulties that are causing

dissatisfaction.
Learn the nursing home system and how to get what you
need.
Participants often made reference to learning the ropes of
nursing home life. Participant D explained, Youve got to figure out who youre supposed to talk to when you need something. It is always changingyou just ask people and see the
ones that help and the ones that do not. It is a process of elimination. Being flexible was another adaptive strategy for complying with the nursing home routines as Participant D
pointed out, You have to get used to how they do things and
so you have to be pretty flexible. You got to remember youre
not the only here who needs something.

Discussion
A pivotal point in an older persons successful adaptation to
nursing home life is the decision-making process surrounding
the move. Those participants who were involved in the decision to move and had explored their options of where to live
were less ambivalent about living in the nursing home. Previous studies revealed that unplanned nursing home admissions
are associated with a more difficult transition to nursing
home life (Nay 1995, Iwasiw et al. 1996, Wilson 1997). We
found that those who had limited or no involvement in the

2012 Blackwell Publishing Ltd

Resident strategies

decision to move were often resentful about being in the


nursing home and were unhappy in their day-to-day life.
Another important element to the decision-making process
was recognizing the need to move. If the move was necessary
in the eyes of the participants; they were more positive about
living in the nursing home (Chenitz 1983). The findings from
this study suggest that while older adults do not welcome the
move to a nursing home; some possess the ability to adapt in
a positive way to this environment. Adaptability was revealed
in the cognitive-behaviours strategies participants employed
as they faced the challenges of nursing home life. Some of the
strategies identified in this study have been discussed in previous studies. For example, strategies such as making the best
of the situation, going along with it and trying to get along
(Kahn 1999, Porter & Clinton 1992, Groger 2002). A review
of the literature post data analysis which is in keeping with
the grounded theory method (Charmaz 2006) provided direction to explore the concept of resiliency. The results of this
study suggest that personal resiliency may be foundational to
developing strategies that facilitate positive adaptation to the
nursing home. Further study is needed to test this possible
relationship between resiliency attributes and the strategies
identified in this study.
The strategies used in day-to-day life were ways the participants coped with the challenges of institutional living and
these strategies are consistent with previous studies (Porter &
Clinton 1992, Kahn 1999, Groger 2002). When participants
spoke of the difficulties they faced living in the nursing home;
they often recalled how they dealt with other difficult situations in the past. Those participants who were able to maintain a positive outlook despite challenging circumstances
expressed being generally satisfied with life (Cohen et al.
2006, Schneller & Vandsburger 2008, Weiss 2008). Those
participants who were dissatisfied with nursing home life discussed having little or no control over their lives, focused on

Table 5 Implications for practice.


Identify indicators of resiliency in the resident by asking about
other challenging life events that he/she was able to overcome
Assess for positive coping patterns used by the resident
Recognize the residents ability to deal with past challenges as
a way to recognize their strengths
Build on past successes to empower the resident to deal with
current challenges
Help the resident to identify what areas he or she can control
Support the resident to engage in active problem-solving
Assist the resident in letting go of what he or she cannot
control
Support the resident to build relationships
Provide opportunities for the resident to express spirituality
Support the residents expression of hope for the future

871

G.L. Brandburg et al.

that is often associated with emotional upheaval and


personal loss.
Typically residents move through an adjustment period
during the first year of living in long-term care that
has been categorized into phases/stages on the basis of
reports of residents emotional reactions and experiences.
An unplanned move to long-term care, lack of social
support during and after the move and poor coping
abilities are factors that interfere with successful adaptation to long-term care.

they recalled and discussed. Similarity in language used to


describe a strategy does not necessarily mean the same
approach was used. For example, global responses like
being good to others, getting along could incorporate a
range of cognitive-behavioural responses. Approximately
90% of the sample was White and approximately 80%
were women. These limitations are related to the nursing
home locations and the typical profile of nursing home residents. Generally there is a much greater population of
women than men (He et al. 2005) and the location of the
nursing homes in this study were in predominately White
populated areas. The findings represent the participants of
the nursing homes in this study and should not be generalized outside this context.

What this paper adds

Conclusion

Introduces personal resiliency as a factor related to the

Nurses and other healthcare team members play a pivotal


role in assisting residents to adapt to nursing home life. The
facilitative strategies identified in this study may be useful
in developing interventions that support resiliency in older
adults as they adapt to long-term care. Future research is
recommended to more clearly understand the relationship
between personal resilience and facilitative strategies used
by residents to adapt to long-term care.

What is already known about this topic


Moving into long-term care is a major life adjustment

development of facilitative strategies that may support


adaptation to long-term care.
Identified facilitative strategies that residents use to
adapt to situations in long-term care.

Implications for practice and/or policy


Healthcare providers should be supportive of facilita-

tive strategies used by residents because they may be


instrumental to their adaptation process.
The facilitative strategies identified in this study may
be useful in developing interventions to support quality of life in long-term care.

their losses and often had negative relationships with those in


the nursing home (Nay 1995, Fiveash 1998). People who take
losses and other hardships that occur in life with optimism
and hope tend to experience higher levels of well-being (Seligman & Csikszentmihalyi 2000). Nurses and other healthcare
providers are in key positions to support residents as they
adapt initially and day-to-day living (Table 5). There are a
variety of settings where adaptation occurs as older adults
transition along the care continuum moving from various levels of formal care (home health care, assisted living, nursing
homes) and informal care (assistance from family and friends
at home) (Roe et al. 2001a, 2001b). How adaptation may be
similar or different in these settings is worth exploring.

Study limitations
Because the participants were asked to recall past events
and present situations, memory may be a factor in what
872

Acknowledgement
I would like to express my gratitude to Sue Tanner, MS,
FNP-BC for her assistance in this research project.

Funding

Texas Womans University Research Grant Award


amount $100000
Carter Small Research Grant Award amount $90000

Conflict of interest
No conflict of interest has been declared by the authors.

Author contributions
All authors meet at least one of the following criteria (recommended by the ICMJE: http://www.icmje.org/ethical_1author.html) and have agreed on the final version:

substantial contributions to conception and design,


acquisition of data, or analysis and interpretation of
data;
2012 Blackwell Publishing Ltd

JAN: ORIGINAL RESEARCH

drafting the article or revising it critically for important intellectual content.

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