“Holding on to What I Do”: Experiences of Older Slovenians Moving into a Care Home

“Holding on to What I Do”: Experiences of Older Slovenians Moving into a Care Home Abstract Purpose of the Study This qualitative study explored Slovenian older people’s experiences of transition into a care home and the influence on their everyday engagement in meaningful occupations. Design and Methods A longitudinal, phenomenological approach was employed. Semistructured interviews with six Slovenian older adults were conducted at three time intervals: before the relocation, 1 month after, and 6 months after the relocation into a care home. Interpretative Phenomenological Analysis was used for the study design and analysis. Results One overarching theme from the research findings Holding on to what I do is presented in depth. Although the participants’ everyday occupations were challenged throughout the transition, they tried to maintain their most meaningful occupations that were an important part of their identity. Three superordinate themes underpinned this overarching theme: This is who I am, Adjusting my daily occupations, and The value of health. Implications The study indicated the need to develop programs and services for older adults transitioning from home into a care home environment. Focusing on enabling older people to maintain their engagement in meaningful occupations as an important part of their identity is imperative. This study brings a better understanding of older people’s experiences of transition into a care home from an occupational perspective. It has the potential to influence how elder care is planned and implemented in Slovenia and further afield. Transition, Meaningful occupation, Identity Leaving home and relocating into a care home can pose a threat to older people’s physical and psychological health. It can have a negative impact on their choices and self-direction to engage in meaningful activities (Marshall & Mackenzie, 2008). Although the term relocation refers to a person moving from one place of residence to another (Komatsu, Hamahata, & Magilvy, 2007), transition refers to “changes in status that are discrete and bounded in duration, although their consequences may be long-term” (George, 1993, p. 358). Slovenian older adults often choose to relocate into a care home because of the lack of noninstitutional alternatives and a fear of becoming a burden to their families (Ramovš, Hvalič Touzery, Vusilović, & Ramovš, 2009). Slovenian care homes are large, the largest having capacity for more than 600 residents (Habjanič, Saarnio, Elo, Turk, & Isola, 2012). Types of residencies are combined by integrating residents with no care needs and those with differing levels of care need (e.g., residents who need nursing care or residents with dementia) in different parts of the same building (Mali, 2008). This is unlike Western European homes where institutional care is often differentiated according to need, with nursing homes offering higher levels of care than residential homes (Mali, 2008). Internationally different terms are used to describe settings that provide care for older people, the term care home will be used for the purpose of this article. Transitioning into a care home can impact on the ability of the older person to maintain occupations that were central to their previous life (McIntyre & Atwal, 2013). Occupations refer to “the ordinary and familiar things that people do every day” (Clark et al., 1991, p. 300). Although activity and occupation are often used interchangeably (Creek & Hughes, 2008), the term occupation will be used throughout this article. Occupational science is an academic discipline, studying humans as occupational beings (Yerxa et al., 1990). It postulates that all people have the right to engage in meaningful occupations that contribute to health and well-being of both individuals and communities (Townsend & Wilcock, 2004). It was developed to support occupational therapy practice that uses occupations as part of occupational therapy interventions (Pierce, 2014). From an occupational perspective, the key factor in the context of health is the person’s experience of meaning through engagement in occupation (Hasselkus, 2011). Meaningful occupations are defined as “chosen, performed and engaged in to generate experiences of personal meaning and satisfaction” (Canadian Association of Occupational Therapists, 2002, p. 181). Research has suggested a link between meaningful occupations and older people’s health and well-being. Lifestyle Redesign investigated the effectiveness of a preventive occupational therapy program using meaningful occupations as part of the intervention (Clark et al., 1997, 2012). The study highlighted that engagement in personally meaningful occupations resulted in significant improvement across various health, function, and quality of life domains (Clark et al., 1997, 2012). In addition, several qualitative studies reported older people’s positive sense of health and well-being when engaged in occupations that were meaningful to them (Bedding & Sadlo, 2008; Liddle, Parkinson, & Sibbritt, 2013). The living environment may support or constrain the everyday lives of older people (Golant, 2014). A study by Eyers, Arber, Luff, Young, and Ellmers (2012) highlighted that everyday occupations in care homes were dominated by the prioritization of activities of daily living. Furthermore, studies indicated that engagement in meaningful occupations may be restricted within care homes due to the constraints and routines of the institutional environment (Mali, 2008; Harnett, 2010). The importance of maintaining engagement in meaningful occupations after relocation was highlighted in a qualitative study with newly admitted hostel residents (Marshall & Mackenzie, 2008). There is limited evidence exploring older people’s perspectives of the impact of transitioning from a home environment into an institution from an occupational perspective (Cutchin, Marshall, & Aldrich, 2010; Marshall & Mackenzie, 2008). A quantitative longitudinal study by Cutchin and colleagues (2010) explored the role of occupation in the lives of 116 older adults transitioning to a Continuing Care Retirement Community. Results indicated that although levels of occupation did not change, patterns and frequency of engagement changed in the course of the move with some occupations increasing in frequency (e.g., social and cultural occupations) and others decreasing (e.g., grocery shopping and e-mail correspondence). A study by Lee, Simpson, and Froggatt (2013) indicated that the process of transition may not be time bound and linear. Eight older adults reported the importance of maintaining their self-identity throughout their transition (Lee et al., 2013). The value of continuity between past and present roles was also indicated by Minney and Ranzijn (2015). The importance of identity and its links with occupation was reported in a study by Cooney (2012) where 61 residents valued the opportunity to continue with their normal everyday activities that gave them a sense of security and familiarity. Leaving a home environment to move into a care home can be a stressful event for older people as they have to adjust to a new lifestyle and a different living environment. One Slovenian study by Kornhauser and Mali (2013) explored the experiences of relocation into a care home for 10 care home residents. Findings indicated that declining health forced the residents to relocate and some participants were concerned that their daily occupations may alter once relocated (Kornhauser & Mali, 2013). The limitation of the study was that it was conducted retrospectively, therefore not tracking the participants’ transition experiences. With an increase in older people moving into care environments and a growing awareness of the positive impact of meaningful occupations on well-being, the aim of the current study was to explore Slovenian older people’s experiences of transition into a care home and how it influenced their everyday engagement in meaningful occupations. Methods This study was designed using an Interpretative Phenomenological Analysis (IPA) approach for both data collection and data analysis (Smith, Flowers, & Larkin, 2009). The study focused on older people’s lived experiences and interpretation by both the participants and the researchers. This indicates the influence of the philosophical underpinnings of phenomenology and hermeneutics within the research (Finlay, 2011; Smith et al., 2009). Furthermore, the research team was committed to idiography, aiming to understand a particular individual’s experiences in a particular context (Finlay, 2011). A longitudinal research approach was employed (Patton, 2015). Data were collected at three time points in order to capture the participants’ lived experience of transition as the move between home environments evolved. Ethical approval for the study was obtained from the National Medical Ethics Committee in Slovenia and from the Plymouth University Health Human Ethics Sub-Committee. Consent was sought from the participants, and pseudonyms were used to ensure their confidentiality. Participants Participants were recruited via a gatekeeper who was a social worker in one Slovenian care home. The first six older people approached, aged 74–92 years old, who met the inclusion criteria of having decided to relocate to a care home and currently living independently in their home environment, consented to participate in the study. These purposefully selected “information-rich cases” allowed for an in-depth exploration of the phenomenon of interest (Patton, 2015). The sample size was considered appropriate according to the recommendations on IPA sample size by Smith and colleagues (2009) (Table 1). Table 1. Participant Information Participants Age Gender Living situation—first interview Living situation— second interview Living situation— third interview Janez 92 M Lives independently in a flat In a care home In a care home Widower Single room, shared bathroom Single room, shared bathroom Bor 82 M Lives independently in a house In a care home In a care home Married Single room Single room Miha 90 M Second day in a care home, previously lived independently in a house In a care home In a care home Widower Single room, shared bathroom Single room, shared bathroom Dora 90 F Lives independently in a house In a care home In a care home Single Double room (sharing room) Single room Jelka 74 F Lives independently in a rented flat In a care home In a care home Married Double room (sharing room with her husband) Double room (sharing room with her husband) Elza 89 F Lives independently in a house In a care home In a care home Widow Single room, shared bathroom Single room, shared bathroom Participants Age Gender Living situation—first interview Living situation— second interview Living situation— third interview Janez 92 M Lives independently in a flat In a care home In a care home Widower Single room, shared bathroom Single room, shared bathroom Bor 82 M Lives independently in a house In a care home In a care home Married Single room Single room Miha 90 M Second day in a care home, previously lived independently in a house In a care home In a care home Widower Single room, shared bathroom Single room, shared bathroom Dora 90 F Lives independently in a house In a care home In a care home Single Double room (sharing room) Single room Jelka 74 F Lives independently in a rented flat In a care home In a care home Married Double room (sharing room with her husband) Double room (sharing room with her husband) Elza 89 F Lives independently in a house In a care home In a care home Widow Single room, shared bathroom Single room, shared bathroom View Large Table 1. Participant Information Participants Age Gender Living situation—first interview Living situation— second interview Living situation— third interview Janez 92 M Lives independently in a flat In a care home In a care home Widower Single room, shared bathroom Single room, shared bathroom Bor 82 M Lives independently in a house In a care home In a care home Married Single room Single room Miha 90 M Second day in a care home, previously lived independently in a house In a care home In a care home Widower Single room, shared bathroom Single room, shared bathroom Dora 90 F Lives independently in a house In a care home In a care home Single Double room (sharing room) Single room Jelka 74 F Lives independently in a rented flat In a care home In a care home Married Double room (sharing room with her husband) Double room (sharing room with her husband) Elza 89 F Lives independently in a house In a care home In a care home Widow Single room, shared bathroom Single room, shared bathroom Participants Age Gender Living situation—first interview Living situation— second interview Living situation— third interview Janez 92 M Lives independently in a flat In a care home In a care home Widower Single room, shared bathroom Single room, shared bathroom Bor 82 M Lives independently in a house In a care home In a care home Married Single room Single room Miha 90 M Second day in a care home, previously lived independently in a house In a care home In a care home Widower Single room, shared bathroom Single room, shared bathroom Dora 90 F Lives independently in a house In a care home In a care home Single Double room (sharing room) Single room Jelka 74 F Lives independently in a rented flat In a care home In a care home Married Double room (sharing room with her husband) Double room (sharing room with her husband) Elza 89 F Lives independently in a house In a care home In a care home Widow Single room, shared bathroom Single room, shared bathroom View Large Data Collection Semistructured, in-depth interviews in the Slovenian language were conducted by the principal researcher at three time points: before the relocation, 1 month, and 6 months after the relocation. At the time of the first interviews, four participants were in their home environment; however, one participant was in hospital and one participant had already relocated into a care home 5 days prior to the interview. All second and third interviews were conducted in the care home. Interview guide questions covered topics relating to daily routines, meaningful occupations, and relocation. Examples of questions included Can you start by telling me how you spend your day? Which occupations do you enjoy the most? How did the relocation into a care home influence your engagement in (named occupation)? Interviews lasted approximately 1hr and were recorded and transcribed verbatim. Data Analysis Transcripts were analyzed by the principal researcher in the Slovenian language and translated into English at the theme stage. In line with IPA guidelines created by Smith and colleagues (2009), during the initial analysis, recordings and transcripts were reviewed several times. This stage involved initial noting of descriptive comments focused on content, linguistic comments focused on the use of language, and conceptual comments (Smith et al., 2009). The emergent (codes) themes and superordinate (initial) themes were developed for each individual interview of one participant. A master table of themes was then developed for each individual participant by looking across all three interviews; each master table contained three or four themes. The final stage of analysis involved the emergence of three overarching themes with superordinate themes drawn from looking across the master themes of all six participants, which highlighted convergence and divergence of participants’ experiences. Because IPA is committed to idiography (Smith et al., 2009), it was important to analyze each transcript of one participant individually, bracketing, that is attempting to set aside the ideas from the previous interview and preconceptions of the phenomenon under review. The same process was employed between individual participants. Emergent, superordinate, and master themes for all 18 interviews were translated into English for the purpose of checking the coding and presenting the findings. Ensuring Trustworthiness of the Study Three interviews (one from each time-point of data collection) with the entire data analysis process were translated from Slovenian into the English language by the principal researcher (native speaker of Slovenian language). This strategy was employed in order to check and confirm the data analysis process with the rest of the research team. The remaining transcripts were analyzed in the original language as recommended by van Nes, Abma, Jonsson, and Deeg (2010) with codes and themes translated afterwards. The analysis in the Slovenian language was additionally checked by a second bilingual Slovenian researcher to confirm the decisions made during the data analysis process (Santos, Black, & Sandelowski, 2015). The principal researcher was reflexive by using a reflective diary to highlight preconceptions during the research process that were regularly discussed within the research team. As stated by Clarke (2009), reflexive strategies are particularly important throughout the data analysis process. Findings The following overarching themes were developed from interviews with the six participants as they transitioned into a new living environment: “Holding on to what I do,” “The significance of others through transition,” and “The time of loss and acceptance.” One overarching theme Holding on to what I do with superordinate themes of This is who I am, Adjusting my daily occupations, and The value of health will be discussed in detail. Presenting one theme facilitates greater depth to the discussion of particular participants’ experiences and nuances inherent in those experiences. The remaining two themes will be presented in future publications. Holding on to What I Do All six participants expressed the importance of holding on to their usual everyday occupations. It was especially important to maintain their engagement in those occupations that were most meaningful to them and represented a significant part of their identity. Occupations, which were especially valued by the participants, were evident in their narratives at the time of the first interview and throughout their experience of transitioning into the care home. Maintaining health was a high priority that became even more important following their move when they became aware of how declining health could influence their everyday life. Participants also expressed a willingness to accept a certain level of adjustment especially if this allowed them to keep their independence and hold on to their meaningful occupations. This Is Who I Am During the interviews, it seemed important to the participants to introduce their personal background, giving a brief summary of themselves and their lives. It soon became evident they were telling their life stories, focusing on what they enjoyed doing and how that had changed over time. Each participant had certain occupations that they valued and defined them. For example, Janez was trying to hold on to his regular visits to his weekend cottage after he relocated; something he had independently achieved for several decades. It was interesting to note that his decision to move coincided with his decision to stop driving and that had an impact on these visits. His decision to move into a care home may suggest he perceived this as the end of a certain period of his life. It was at the time of the third interview that he acknowledged that the two occupations were interconnected. Although still determined not to drive, he expressed regret at losing the freedom and independence driving had given him. He explained: That is the only reason why I miss my car. If I was bored, I just sat in my car and went up there [to his weekend cottage] for a few days. (Janez, third interview) Jelka used a Slovenian saying to illustrate who she was, she considered herself “made of a farmer’s dough.” Although Jelka was never a farmer herself, she was influenced by her parents who were hardworking farmers. Jelka therefore valued productivity, financial stability, and enjoyed nature. She maintained productive roles also after her retirement. These roles included the occupations of taking care of her home and caring for her husband after he had a stroke until he moved into a care home. One of her main reasons for following her husband to the care home was to get back at least some of her previous responsibilities. Jelka’s self-perception was expressed through her most valued occupations; therefore, her decision to move meant she was able to hold on to her sense of productivity and her role as carer. Bor had a strong professional identity that influenced his entire life. From working in the music industry, he considered himself an artist, belonging to a highly respected peer group. He was not able to talk about his relocation experience without introducing his professional background. His transition was informed by the reminiscence of his professional pathway and the awareness of his strong professional identity. This became even more evident at the time of the second and third interviews, which showed that his sense of self linked to his professional engagement became even stronger after he relocated. He was especially careful about engaging in any kind of musical occupations in the care home and which he thought could potentially jeopardize his professional reputation. I was always very precise and I would usually give them a hard time…so I said…I can’t work with these people, and I won’t listen to them singing out of tune… (Bor, second interview) This may sound as if he felt superior to other residents but it was more an expression of fear about being unsuccessful at occupations linked to his professional background. Instead, he decided not to engage in these occupations. Bor also became more conscious of his professional legacy that was probably triggered by this transition. For example, when he moved his equipment and records, it sometimes made him nostalgic and he expressed that by telling several anecdotes from his professional life, these reflected who he was and what he valued. Adjusting My Daily Occupations The participants were aware of the changes not only being related to the transition into an institution but to old age in general. These changes brought several adjustments of their everyday engagements, the decision to relocate being one of them. When Elza was asked about how she spent her days, she illustrated this by saying: That’s…that’s very much related to health…and age. Very much…and of course it’s declining. It doesn’t improve…everything is going down. And even if you had a wide range of responsibilities and friendships and all of this…life goes on, and then this circle, you don’t even realize how it narrows…everything…and it narrows. Yes…it narrows into this phase between before and what’s going to happen next. (Elza, first interview) This circle may be interpreted as everything she was involved in throughout her life. This may be linked to her previous roles, occupations, and the social networks around her. Elza’s circle narrowed until she reached the point where she felt trapped in this space between the past and the future, and this may have triggered her decision to move into the care home. After the relocation, all six participants experienced a process of adjusting their daily occupations due to the new living environment or their health issues. Their everyday routines changed according to institutional timetable and routines. Janez mentioned how his morning routine changed after he relocated. That’s why I said I feel lost. I’m lost in a way that I just can’t find anything…I had a sequence for instance…I made myself breakfast in the morning, I took my medicine, then self-care, you know. And so on. That’s the case now. And I have to get used to it and that’s the hardest. (Janez, second interview) Although talking about feeling lost, Janez did not refer to the unfamiliarity of the physical environment. Instead, he expressed his distress about the change of his daily routines. Institutional timetables made him change his usual order of morning occupations and gave him a sense of loss, the loss of his previous morning routine. In contrast, Miha found the new physical environment challenging because of his disability resulting from his blindness. He felt that his living space was reduced to only his room because he was not able to navigate the environment outside of his room. This expression of distress is evident from his quote. “I got used to a bit…so I can go out…here [outside the room]…and by the wall rail you know…” “…It was easy at home,…I could walk by myself…and I knew certain paths…I took my stick and went…” (Miha, second interview) This may indicate that Miha prioritized independence whereas other participants prioritized different aspects. Therefore, his priorities were different from other participants for whom the new physical environment represented fewer obstacles. The process of adjustment was especially difficult for those who had to share their bedrooms and/or bathrooms with coresidents. For example, at the time of the second interview, Dora was sharing her room until a single room became available. After relocating to a single room, she described her experience: I found it difficult to live because I didn’t have my own life…but I had to adjust to the extent…that it wasn’t possible [to live her own life]. And now it is, and that’s what matters. (Dora, third interview) Dora felt that she had lost her life by adjusting her everyday routines to her roommate’s routines. Adjusting to this extent may only have occurred as she anticipated that a single room would become available soon and therefore it was a temporary adjustment. The Value of Health All participants perceived health as a high priority. Although some were already dealing with health issues, they all perceived old age as the time of health decline. Maintaining a healthy lifestyle became more important throughout transitioning into a care home. Dora and Elza both experienced health issues while still living at home that had interrupted their daily routine and dominated their everyday life. That was also one of their reasons for moving. Elza’s issues with her urinary incontinence developed further after she relocated. It began to occupy most of her time as she felt she was constantly busy looking after herself. …I usually don’t have breakfast because I have too much work with myself…so that I can at least sleep until 7 then… (Elza, second interview) As evident from the quote, her health issues sometimes prevented her from acclimatizing to the new living environment. Another example is Dora who was admitted into a care home from the hospital where she had an operation for cancer. She purposefully decided to look after her health by being conscientious regarding healthy ways of living. She therefore prepared her own breakfast in her room or purposefully walked the stairs to maintain her daily physical activity. She sometimes criticized the care home services and thought she could only trust herself in terms of having a healthier lifestyle. Both Elza and Dora were willing to sacrifice their other occupations in order to have the time to look after their health. This may be because they could see other care home residents struggling with different health challenges and they feared they would lose their independence. Janez was also engaged in his regular morning exercise that he believed helped maintain his health and independence. Interestingly, most of them preferred looking after their health on their own, avoiding making new social contacts. Looking after their health became a new meaningful occupation for them. In contrast, Jelka and Bor were the least preoccupied with their health. They both moved to the care home to join their partners who had their own health issues. Consequently, they both took over the role of carer, which helped them to stay engaged throughout their own adjustment period. Bor explained: …my daughters said to leave the work to the nursing staff…but I said…by the time I find the nurse, I’m already done, ha ha…I’m done…and then I…the only time that gets lonely is in the evening… (Bor, second interview) Taking care of his wife helped him fill his time after he relocated. It was not until after his wife died that he began to engage in other care home occupations, which became evident at the time of the third interview. The participants also perceived that some occupations influenced their health as they enjoyed engaging in them. For example, Janez felt that the surroundings of his weekend cottage had positive health effects for him. at [the weekend cottage] I have pine trees, I have greenness around me and I can really say that I can see better. That air influences my eyesight. (Janez, first interview) Similarly, Jelka described the significance of occupations for her soul every time she faced life challenges. She perceived these occupations as significant for her well-being and she also maintained them after she relocated. …when I was sad…I went and bought a cassette…so that I took care of my soul. I had over 400 cassettes and records; I took care of my soul if something was wrong. Researcher: What About Now…? I have my radio on all the time…silently…for my soul you know…yes, I do take the time for that. (Jelka, second interview) Most participants identified the link between having an opportunity to engage in their meaningful occupations and feeling healthier. Discussion The findings of this study illustrated how six Slovenian older adults experienced the process of transition from their home environment into a care home. Consistent with previous evidence older adults in this study expressed the importance of maintaining their identity throughout the time of this transition (Cooney, 2012; Lee et al., 2013; Minney & Ranzijn, 2015). The concept of identity is considered a “powerful construct” (Vignoles, Schwartz, & Luyckx, 2012) although critiqued within the literature for not being clearly defined (Rattansi & Phoenix, 2005). Social science literature defines identity at a personal, relational, collective, and material level, reflecting the complexity of who one is (Vignoles et al., 2012). The participants in this study expressed their identities through their experiences of engagement in occupations. They all valued and tried to maintain particular occupations, which gave meaning to their life and a sense of self. Existing evidence demonstrates that meaningful occupations influence older people’s health and well-being (Bedding & Sadlo, 2008; Clark et al., 2012; Liddle et al., 2013). Honoring the everyday preferences of nursing home residents can contribute to improved satisfaction with the care they receive (Bangerter, Heid, Abbott, & Van Haitsma, 2016). Enabling older people to maintain their meaningful occupations after relocating into a care home was shown to be of paramount importance to the individuals concerned (Marshall & Mackenzie, 2008), and this is reflected by the experiences of participants in this study. These findings are in line with Christiansen (1999) who suggested that a person’s unique identity is built through what they do, enabling them to create meaningful lives and remain well. This argument developed into the concept of occupational identity that has been defined as “a composite sense of who one is and wishes to become as an occupational being generated from one’s history of occupational participation” (Kielhofner, 2008, p. 106). The importance of occupational identity was echoed by these participants who attempted to maintain who they were through their experience of engagement in occupations that were meaningful to them (e.g., driving a car, caring for the family, being involved in profession-related occupations). Furthermore, these findings indicated the paramount importance of maintaining meaning throughout challenging life events (Frankl, 2006), which in this case was the significance of retaining meaningful occupations throughout the transition into a care home. While trying to maintain their unique identities throughout the transition, the participants also faced changes in their everyday engagement in occupations. Changes in their everyday roles and routines were expressed as challenging by all participants, especially those who shared the facilities with other residents. The issue of older people adjusting to institutional orders and routines has been acknowledged in previous research (Harnett, 2010; Mali, 2008). A study by Harnett (2010) demonstrated that any special requirements by the residents were considered as disruptions or disturbances to staff working routines. In contrast, adjusting to staff routines was expressed less than anticipated by participants in the interviews; this may be due to the fact that they were still independent in self-care. However, they did recognize the impact of institutional timetables on their occupations, for example, meal times influenced all of their daily routines. Interestingly, the findings by Mali (2008) who compared Slovenian care homes to Goffman’s (1961) concept of total institution described that although care home rules and routines were present; there was a possibility of adapting them to meet individual residents’ needs. However, this study did not concentrate on the transition period and data were collected also with staff and relatives, which may have influenced the findings. A study by Cooney (2012) indicated that keeping older people’s continuity in terms of their daily routines helped them develop a sense of home in their new living environment because it gave them a sense of security and predictability. Although expressed by all participants in this study, one participant illustrated the impact of change on his daily routine by saying he felt lost when addressing his new morning routine. Gamliel and Hazan (2006) argued that care home residents may focus on rigidly following daily routines and hobbies as these are the only activities that they can still control. Although this may be the case later in the process of transition, the present study focused only on the first 6 months of adjustment and more time may be required to fully adjust old routines to new ones. Previous studies have indicated the importance of continuity between past and present roles (Minney & Ranzijn, 2015); therefore, time may be needed for older people to readjust their roles throughout the transition. Losing several roles simultaneously may have an impact on their identity as was the case with most of the participants in this study (e.g., losing their role as housekeeper and driver at the same time). Social psychologists suggest that people’s identity changes according to the context in which they find themselves (Vignoles et al., 2012). Furthermore, Goffman (1961) argued that despite being rigid, total institutions represent a place of identity construction and Mali (2008) did find some similarities between Slovenian care homes and Goffman’s concept of total institution. In addition, the Theory of Selective Optimization with Compensation (Baltes & Baltes, 1990) describes a process of adaptation in old age by older people optimizing their general abilities and compensating for lost ones. Although the participants in this study found the process of adjustment challenging, it was evident at the time of the last interview that most of them had started to readjust their previous roles and develop new daily routines to replace the old ones. Nevertheless, they still tried to maintain engagement in those occupations that were most meaningful to them. This fits with findings from previous research (Marshall & Mackenzie, 2008) and with the Theory of Selective Optimization with Compensation (Baltes & Baltes, 1990), which proposes that older adults selectively concentrate on those domains that are of a higher priority and importance to them. All participants valued maintaining their health and independence although not all of them relocated due to health issues. Some participants perceived they had better health when engaged in their most enjoyable occupations. This links to occupational science evidence linking engagement in meaningful occupations with perceived health and well-being (Bedding & Sadlo, 2008; Liddle et al., 2013). Furthermore, the participants were purposefully engaged in health-promoting occupations such as physical activity, healthy eating, and going outdoors, which they believed helped them maintain their health. A study by Minney and Ranzijn (2015) similarly highlighted that the residents purposefully engaged in organized activities that promoted active ageing within a care home. This reflects the philosophy of the active ageing policy (World Health Organization, 2002, p. 17), which encourages older adults to make “personal efforts to adopt positive personal practices at all stages of life.” Interestingly, only one participant actively engaged in organized activities, whereas others preferred looking after their health in their own time and in their own way. This may be due to participants still being in the process of transition as they had only lived in a care home for less than 6 months. The participants mostly mentioned independence in the context of maintaining it for as long as possible and not wanting to be a burden to their families, which was one of the reasons for their decision to move into a care home. The importance of not being a burden was similarly expressed in previous studies (Stenner, McFarquhar, & Bowling, 2011). The value of independence was especially emphasized by one of the participants who was visually impaired and faced several barriers in his new living environment. Although he relocated to increase his support, he perceived the care home environment as limiting his abilities and therefore spent most of the time in his room. The Theoretical Model of Residential Normalcy (Golant, 2014) suggests that in order to achieve residential normalcy an older person needs to feel both residential comfort and mastery over their living environment. When there is a lack of congruence between their living environment and mastery in the setting, they decide to relocate. Although this was the case with this participant, the new living environment did not offer enough support to achieve a state of residential normalcy. Interestingly, all participants shared their experience of transition through reflection, by introducing their past life stories, linking them to the present events, and making predictions for the future. Similarly, eight older adults in a study by Lee and colleagues (2013) described their transition into a care home as part of their life story as opposed to the transition being a stage-based process (Brandburg, Symes, Mastel-Smith, Hersch, & Walsh, 2013). This links well with the work of McAdams (2012) who proposed the concept of narrative identity where an individual constructs a life story with the purpose of making sense of their life. It could be suggested that the participants in this study introduced their unique identities by interlinking their past events with the current period of transition, emphasizing their most valued occupations and the importance of carrying these throughout the transition into the future. The researchers acknowledge that as with any research there are limitations to this study. Although methods for ensuring trustworthiness of the study were employed, the findings were translated from Slovenian into the English language; therefore, some cultural meanings and nuances may be lost in translation. This research highlighted that the transition into a care home is a continuous process with older people striving to maintain their identities through engaging in their previously enjoyed occupations. The transition into the care home was shown to be challenging for the participants and support should be provided for older people going through this period of their lives. Löfqvist and colleagues (2013) emphasized the need to develop counseling services to support older people with the process of moving from home environment to care homes. Occupational therapists with their emphasis on enabling older people to stay engaged in their meaningful occupations have a valuable contribution to make during this transition period. There is also a need to evaluate the impact of the care home environment on the individual’s ability to engage in their meaningful occupations. Further longitudinal studies are necessary to address the concerns of older people transitioning to a care home over a longer time frame and in different cultural contexts. References Baltes B. B. , & Baltes M. B . ( 1990 ). Successful aging: Perspectives from the behavioural sciences . Cambridge, UK : Cambridge University Press . doi: 10.1017/CBO9780511665684 Google Scholar CrossRef Search ADS Bangerter L. R. Heid A. R. Abbott K. , & Van Haitsma K . ( 2016 ). Honoring the everyday preferences of nursing home residents: Perceived choice and satisfaction with care . The Gerontologist . doi: 10.1093/geront/gnv697 Bedding S. , & Sadlo G . ( 2008 ). 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“Holding on to What I Do”: Experiences of Older Slovenians Moving into a Care Home

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© The Author(s) 2016. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
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Abstract

Abstract Purpose of the Study This qualitative study explored Slovenian older people’s experiences of transition into a care home and the influence on their everyday engagement in meaningful occupations. Design and Methods A longitudinal, phenomenological approach was employed. Semistructured interviews with six Slovenian older adults were conducted at three time intervals: before the relocation, 1 month after, and 6 months after the relocation into a care home. Interpretative Phenomenological Analysis was used for the study design and analysis. Results One overarching theme from the research findings Holding on to what I do is presented in depth. Although the participants’ everyday occupations were challenged throughout the transition, they tried to maintain their most meaningful occupations that were an important part of their identity. Three superordinate themes underpinned this overarching theme: This is who I am, Adjusting my daily occupations, and The value of health. Implications The study indicated the need to develop programs and services for older adults transitioning from home into a care home environment. Focusing on enabling older people to maintain their engagement in meaningful occupations as an important part of their identity is imperative. This study brings a better understanding of older people’s experiences of transition into a care home from an occupational perspective. It has the potential to influence how elder care is planned and implemented in Slovenia and further afield. Transition, Meaningful occupation, Identity Leaving home and relocating into a care home can pose a threat to older people’s physical and psychological health. It can have a negative impact on their choices and self-direction to engage in meaningful activities (Marshall & Mackenzie, 2008). Although the term relocation refers to a person moving from one place of residence to another (Komatsu, Hamahata, & Magilvy, 2007), transition refers to “changes in status that are discrete and bounded in duration, although their consequences may be long-term” (George, 1993, p. 358). Slovenian older adults often choose to relocate into a care home because of the lack of noninstitutional alternatives and a fear of becoming a burden to their families (Ramovš, Hvalič Touzery, Vusilović, & Ramovš, 2009). Slovenian care homes are large, the largest having capacity for more than 600 residents (Habjanič, Saarnio, Elo, Turk, & Isola, 2012). Types of residencies are combined by integrating residents with no care needs and those with differing levels of care need (e.g., residents who need nursing care or residents with dementia) in different parts of the same building (Mali, 2008). This is unlike Western European homes where institutional care is often differentiated according to need, with nursing homes offering higher levels of care than residential homes (Mali, 2008). Internationally different terms are used to describe settings that provide care for older people, the term care home will be used for the purpose of this article. Transitioning into a care home can impact on the ability of the older person to maintain occupations that were central to their previous life (McIntyre & Atwal, 2013). Occupations refer to “the ordinary and familiar things that people do every day” (Clark et al., 1991, p. 300). Although activity and occupation are often used interchangeably (Creek & Hughes, 2008), the term occupation will be used throughout this article. Occupational science is an academic discipline, studying humans as occupational beings (Yerxa et al., 1990). It postulates that all people have the right to engage in meaningful occupations that contribute to health and well-being of both individuals and communities (Townsend & Wilcock, 2004). It was developed to support occupational therapy practice that uses occupations as part of occupational therapy interventions (Pierce, 2014). From an occupational perspective, the key factor in the context of health is the person’s experience of meaning through engagement in occupation (Hasselkus, 2011). Meaningful occupations are defined as “chosen, performed and engaged in to generate experiences of personal meaning and satisfaction” (Canadian Association of Occupational Therapists, 2002, p. 181). Research has suggested a link between meaningful occupations and older people’s health and well-being. Lifestyle Redesign investigated the effectiveness of a preventive occupational therapy program using meaningful occupations as part of the intervention (Clark et al., 1997, 2012). The study highlighted that engagement in personally meaningful occupations resulted in significant improvement across various health, function, and quality of life domains (Clark et al., 1997, 2012). In addition, several qualitative studies reported older people’s positive sense of health and well-being when engaged in occupations that were meaningful to them (Bedding & Sadlo, 2008; Liddle, Parkinson, & Sibbritt, 2013). The living environment may support or constrain the everyday lives of older people (Golant, 2014). A study by Eyers, Arber, Luff, Young, and Ellmers (2012) highlighted that everyday occupations in care homes were dominated by the prioritization of activities of daily living. Furthermore, studies indicated that engagement in meaningful occupations may be restricted within care homes due to the constraints and routines of the institutional environment (Mali, 2008; Harnett, 2010). The importance of maintaining engagement in meaningful occupations after relocation was highlighted in a qualitative study with newly admitted hostel residents (Marshall & Mackenzie, 2008). There is limited evidence exploring older people’s perspectives of the impact of transitioning from a home environment into an institution from an occupational perspective (Cutchin, Marshall, & Aldrich, 2010; Marshall & Mackenzie, 2008). A quantitative longitudinal study by Cutchin and colleagues (2010) explored the role of occupation in the lives of 116 older adults transitioning to a Continuing Care Retirement Community. Results indicated that although levels of occupation did not change, patterns and frequency of engagement changed in the course of the move with some occupations increasing in frequency (e.g., social and cultural occupations) and others decreasing (e.g., grocery shopping and e-mail correspondence). A study by Lee, Simpson, and Froggatt (2013) indicated that the process of transition may not be time bound and linear. Eight older adults reported the importance of maintaining their self-identity throughout their transition (Lee et al., 2013). The value of continuity between past and present roles was also indicated by Minney and Ranzijn (2015). The importance of identity and its links with occupation was reported in a study by Cooney (2012) where 61 residents valued the opportunity to continue with their normal everyday activities that gave them a sense of security and familiarity. Leaving a home environment to move into a care home can be a stressful event for older people as they have to adjust to a new lifestyle and a different living environment. One Slovenian study by Kornhauser and Mali (2013) explored the experiences of relocation into a care home for 10 care home residents. Findings indicated that declining health forced the residents to relocate and some participants were concerned that their daily occupations may alter once relocated (Kornhauser & Mali, 2013). The limitation of the study was that it was conducted retrospectively, therefore not tracking the participants’ transition experiences. With an increase in older people moving into care environments and a growing awareness of the positive impact of meaningful occupations on well-being, the aim of the current study was to explore Slovenian older people’s experiences of transition into a care home and how it influenced their everyday engagement in meaningful occupations. Methods This study was designed using an Interpretative Phenomenological Analysis (IPA) approach for both data collection and data analysis (Smith, Flowers, & Larkin, 2009). The study focused on older people’s lived experiences and interpretation by both the participants and the researchers. This indicates the influence of the philosophical underpinnings of phenomenology and hermeneutics within the research (Finlay, 2011; Smith et al., 2009). Furthermore, the research team was committed to idiography, aiming to understand a particular individual’s experiences in a particular context (Finlay, 2011). A longitudinal research approach was employed (Patton, 2015). Data were collected at three time points in order to capture the participants’ lived experience of transition as the move between home environments evolved. Ethical approval for the study was obtained from the National Medical Ethics Committee in Slovenia and from the Plymouth University Health Human Ethics Sub-Committee. Consent was sought from the participants, and pseudonyms were used to ensure their confidentiality. Participants Participants were recruited via a gatekeeper who was a social worker in one Slovenian care home. The first six older people approached, aged 74–92 years old, who met the inclusion criteria of having decided to relocate to a care home and currently living independently in their home environment, consented to participate in the study. These purposefully selected “information-rich cases” allowed for an in-depth exploration of the phenomenon of interest (Patton, 2015). The sample size was considered appropriate according to the recommendations on IPA sample size by Smith and colleagues (2009) (Table 1). Table 1. Participant Information Participants Age Gender Living situation—first interview Living situation— second interview Living situation— third interview Janez 92 M Lives independently in a flat In a care home In a care home Widower Single room, shared bathroom Single room, shared bathroom Bor 82 M Lives independently in a house In a care home In a care home Married Single room Single room Miha 90 M Second day in a care home, previously lived independently in a house In a care home In a care home Widower Single room, shared bathroom Single room, shared bathroom Dora 90 F Lives independently in a house In a care home In a care home Single Double room (sharing room) Single room Jelka 74 F Lives independently in a rented flat In a care home In a care home Married Double room (sharing room with her husband) Double room (sharing room with her husband) Elza 89 F Lives independently in a house In a care home In a care home Widow Single room, shared bathroom Single room, shared bathroom Participants Age Gender Living situation—first interview Living situation— second interview Living situation— third interview Janez 92 M Lives independently in a flat In a care home In a care home Widower Single room, shared bathroom Single room, shared bathroom Bor 82 M Lives independently in a house In a care home In a care home Married Single room Single room Miha 90 M Second day in a care home, previously lived independently in a house In a care home In a care home Widower Single room, shared bathroom Single room, shared bathroom Dora 90 F Lives independently in a house In a care home In a care home Single Double room (sharing room) Single room Jelka 74 F Lives independently in a rented flat In a care home In a care home Married Double room (sharing room with her husband) Double room (sharing room with her husband) Elza 89 F Lives independently in a house In a care home In a care home Widow Single room, shared bathroom Single room, shared bathroom View Large Table 1. Participant Information Participants Age Gender Living situation—first interview Living situation— second interview Living situation— third interview Janez 92 M Lives independently in a flat In a care home In a care home Widower Single room, shared bathroom Single room, shared bathroom Bor 82 M Lives independently in a house In a care home In a care home Married Single room Single room Miha 90 M Second day in a care home, previously lived independently in a house In a care home In a care home Widower Single room, shared bathroom Single room, shared bathroom Dora 90 F Lives independently in a house In a care home In a care home Single Double room (sharing room) Single room Jelka 74 F Lives independently in a rented flat In a care home In a care home Married Double room (sharing room with her husband) Double room (sharing room with her husband) Elza 89 F Lives independently in a house In a care home In a care home Widow Single room, shared bathroom Single room, shared bathroom Participants Age Gender Living situation—first interview Living situation— second interview Living situation— third interview Janez 92 M Lives independently in a flat In a care home In a care home Widower Single room, shared bathroom Single room, shared bathroom Bor 82 M Lives independently in a house In a care home In a care home Married Single room Single room Miha 90 M Second day in a care home, previously lived independently in a house In a care home In a care home Widower Single room, shared bathroom Single room, shared bathroom Dora 90 F Lives independently in a house In a care home In a care home Single Double room (sharing room) Single room Jelka 74 F Lives independently in a rented flat In a care home In a care home Married Double room (sharing room with her husband) Double room (sharing room with her husband) Elza 89 F Lives independently in a house In a care home In a care home Widow Single room, shared bathroom Single room, shared bathroom View Large Data Collection Semistructured, in-depth interviews in the Slovenian language were conducted by the principal researcher at three time points: before the relocation, 1 month, and 6 months after the relocation. At the time of the first interviews, four participants were in their home environment; however, one participant was in hospital and one participant had already relocated into a care home 5 days prior to the interview. All second and third interviews were conducted in the care home. Interview guide questions covered topics relating to daily routines, meaningful occupations, and relocation. Examples of questions included Can you start by telling me how you spend your day? Which occupations do you enjoy the most? How did the relocation into a care home influence your engagement in (named occupation)? Interviews lasted approximately 1hr and were recorded and transcribed verbatim. Data Analysis Transcripts were analyzed by the principal researcher in the Slovenian language and translated into English at the theme stage. In line with IPA guidelines created by Smith and colleagues (2009), during the initial analysis, recordings and transcripts were reviewed several times. This stage involved initial noting of descriptive comments focused on content, linguistic comments focused on the use of language, and conceptual comments (Smith et al., 2009). The emergent (codes) themes and superordinate (initial) themes were developed for each individual interview of one participant. A master table of themes was then developed for each individual participant by looking across all three interviews; each master table contained three or four themes. The final stage of analysis involved the emergence of three overarching themes with superordinate themes drawn from looking across the master themes of all six participants, which highlighted convergence and divergence of participants’ experiences. Because IPA is committed to idiography (Smith et al., 2009), it was important to analyze each transcript of one participant individually, bracketing, that is attempting to set aside the ideas from the previous interview and preconceptions of the phenomenon under review. The same process was employed between individual participants. Emergent, superordinate, and master themes for all 18 interviews were translated into English for the purpose of checking the coding and presenting the findings. Ensuring Trustworthiness of the Study Three interviews (one from each time-point of data collection) with the entire data analysis process were translated from Slovenian into the English language by the principal researcher (native speaker of Slovenian language). This strategy was employed in order to check and confirm the data analysis process with the rest of the research team. The remaining transcripts were analyzed in the original language as recommended by van Nes, Abma, Jonsson, and Deeg (2010) with codes and themes translated afterwards. The analysis in the Slovenian language was additionally checked by a second bilingual Slovenian researcher to confirm the decisions made during the data analysis process (Santos, Black, & Sandelowski, 2015). The principal researcher was reflexive by using a reflective diary to highlight preconceptions during the research process that were regularly discussed within the research team. As stated by Clarke (2009), reflexive strategies are particularly important throughout the data analysis process. Findings The following overarching themes were developed from interviews with the six participants as they transitioned into a new living environment: “Holding on to what I do,” “The significance of others through transition,” and “The time of loss and acceptance.” One overarching theme Holding on to what I do with superordinate themes of This is who I am, Adjusting my daily occupations, and The value of health will be discussed in detail. Presenting one theme facilitates greater depth to the discussion of particular participants’ experiences and nuances inherent in those experiences. The remaining two themes will be presented in future publications. Holding on to What I Do All six participants expressed the importance of holding on to their usual everyday occupations. It was especially important to maintain their engagement in those occupations that were most meaningful to them and represented a significant part of their identity. Occupations, which were especially valued by the participants, were evident in their narratives at the time of the first interview and throughout their experience of transitioning into the care home. Maintaining health was a high priority that became even more important following their move when they became aware of how declining health could influence their everyday life. Participants also expressed a willingness to accept a certain level of adjustment especially if this allowed them to keep their independence and hold on to their meaningful occupations. This Is Who I Am During the interviews, it seemed important to the participants to introduce their personal background, giving a brief summary of themselves and their lives. It soon became evident they were telling their life stories, focusing on what they enjoyed doing and how that had changed over time. Each participant had certain occupations that they valued and defined them. For example, Janez was trying to hold on to his regular visits to his weekend cottage after he relocated; something he had independently achieved for several decades. It was interesting to note that his decision to move coincided with his decision to stop driving and that had an impact on these visits. His decision to move into a care home may suggest he perceived this as the end of a certain period of his life. It was at the time of the third interview that he acknowledged that the two occupations were interconnected. Although still determined not to drive, he expressed regret at losing the freedom and independence driving had given him. He explained: That is the only reason why I miss my car. If I was bored, I just sat in my car and went up there [to his weekend cottage] for a few days. (Janez, third interview) Jelka used a Slovenian saying to illustrate who she was, she considered herself “made of a farmer’s dough.” Although Jelka was never a farmer herself, she was influenced by her parents who were hardworking farmers. Jelka therefore valued productivity, financial stability, and enjoyed nature. She maintained productive roles also after her retirement. These roles included the occupations of taking care of her home and caring for her husband after he had a stroke until he moved into a care home. One of her main reasons for following her husband to the care home was to get back at least some of her previous responsibilities. Jelka’s self-perception was expressed through her most valued occupations; therefore, her decision to move meant she was able to hold on to her sense of productivity and her role as carer. Bor had a strong professional identity that influenced his entire life. From working in the music industry, he considered himself an artist, belonging to a highly respected peer group. He was not able to talk about his relocation experience without introducing his professional background. His transition was informed by the reminiscence of his professional pathway and the awareness of his strong professional identity. This became even more evident at the time of the second and third interviews, which showed that his sense of self linked to his professional engagement became even stronger after he relocated. He was especially careful about engaging in any kind of musical occupations in the care home and which he thought could potentially jeopardize his professional reputation. I was always very precise and I would usually give them a hard time…so I said…I can’t work with these people, and I won’t listen to them singing out of tune… (Bor, second interview) This may sound as if he felt superior to other residents but it was more an expression of fear about being unsuccessful at occupations linked to his professional background. Instead, he decided not to engage in these occupations. Bor also became more conscious of his professional legacy that was probably triggered by this transition. For example, when he moved his equipment and records, it sometimes made him nostalgic and he expressed that by telling several anecdotes from his professional life, these reflected who he was and what he valued. Adjusting My Daily Occupations The participants were aware of the changes not only being related to the transition into an institution but to old age in general. These changes brought several adjustments of their everyday engagements, the decision to relocate being one of them. When Elza was asked about how she spent her days, she illustrated this by saying: That’s…that’s very much related to health…and age. Very much…and of course it’s declining. It doesn’t improve…everything is going down. And even if you had a wide range of responsibilities and friendships and all of this…life goes on, and then this circle, you don’t even realize how it narrows…everything…and it narrows. Yes…it narrows into this phase between before and what’s going to happen next. (Elza, first interview) This circle may be interpreted as everything she was involved in throughout her life. This may be linked to her previous roles, occupations, and the social networks around her. Elza’s circle narrowed until she reached the point where she felt trapped in this space between the past and the future, and this may have triggered her decision to move into the care home. After the relocation, all six participants experienced a process of adjusting their daily occupations due to the new living environment or their health issues. Their everyday routines changed according to institutional timetable and routines. Janez mentioned how his morning routine changed after he relocated. That’s why I said I feel lost. I’m lost in a way that I just can’t find anything…I had a sequence for instance…I made myself breakfast in the morning, I took my medicine, then self-care, you know. And so on. That’s the case now. And I have to get used to it and that’s the hardest. (Janez, second interview) Although talking about feeling lost, Janez did not refer to the unfamiliarity of the physical environment. Instead, he expressed his distress about the change of his daily routines. Institutional timetables made him change his usual order of morning occupations and gave him a sense of loss, the loss of his previous morning routine. In contrast, Miha found the new physical environment challenging because of his disability resulting from his blindness. He felt that his living space was reduced to only his room because he was not able to navigate the environment outside of his room. This expression of distress is evident from his quote. “I got used to a bit…so I can go out…here [outside the room]…and by the wall rail you know…” “…It was easy at home,…I could walk by myself…and I knew certain paths…I took my stick and went…” (Miha, second interview) This may indicate that Miha prioritized independence whereas other participants prioritized different aspects. Therefore, his priorities were different from other participants for whom the new physical environment represented fewer obstacles. The process of adjustment was especially difficult for those who had to share their bedrooms and/or bathrooms with coresidents. For example, at the time of the second interview, Dora was sharing her room until a single room became available. After relocating to a single room, she described her experience: I found it difficult to live because I didn’t have my own life…but I had to adjust to the extent…that it wasn’t possible [to live her own life]. And now it is, and that’s what matters. (Dora, third interview) Dora felt that she had lost her life by adjusting her everyday routines to her roommate’s routines. Adjusting to this extent may only have occurred as she anticipated that a single room would become available soon and therefore it was a temporary adjustment. The Value of Health All participants perceived health as a high priority. Although some were already dealing with health issues, they all perceived old age as the time of health decline. Maintaining a healthy lifestyle became more important throughout transitioning into a care home. Dora and Elza both experienced health issues while still living at home that had interrupted their daily routine and dominated their everyday life. That was also one of their reasons for moving. Elza’s issues with her urinary incontinence developed further after she relocated. It began to occupy most of her time as she felt she was constantly busy looking after herself. …I usually don’t have breakfast because I have too much work with myself…so that I can at least sleep until 7 then… (Elza, second interview) As evident from the quote, her health issues sometimes prevented her from acclimatizing to the new living environment. Another example is Dora who was admitted into a care home from the hospital where she had an operation for cancer. She purposefully decided to look after her health by being conscientious regarding healthy ways of living. She therefore prepared her own breakfast in her room or purposefully walked the stairs to maintain her daily physical activity. She sometimes criticized the care home services and thought she could only trust herself in terms of having a healthier lifestyle. Both Elza and Dora were willing to sacrifice their other occupations in order to have the time to look after their health. This may be because they could see other care home residents struggling with different health challenges and they feared they would lose their independence. Janez was also engaged in his regular morning exercise that he believed helped maintain his health and independence. Interestingly, most of them preferred looking after their health on their own, avoiding making new social contacts. Looking after their health became a new meaningful occupation for them. In contrast, Jelka and Bor were the least preoccupied with their health. They both moved to the care home to join their partners who had their own health issues. Consequently, they both took over the role of carer, which helped them to stay engaged throughout their own adjustment period. Bor explained: …my daughters said to leave the work to the nursing staff…but I said…by the time I find the nurse, I’m already done, ha ha…I’m done…and then I…the only time that gets lonely is in the evening… (Bor, second interview) Taking care of his wife helped him fill his time after he relocated. It was not until after his wife died that he began to engage in other care home occupations, which became evident at the time of the third interview. The participants also perceived that some occupations influenced their health as they enjoyed engaging in them. For example, Janez felt that the surroundings of his weekend cottage had positive health effects for him. at [the weekend cottage] I have pine trees, I have greenness around me and I can really say that I can see better. That air influences my eyesight. (Janez, first interview) Similarly, Jelka described the significance of occupations for her soul every time she faced life challenges. She perceived these occupations as significant for her well-being and she also maintained them after she relocated. …when I was sad…I went and bought a cassette…so that I took care of my soul. I had over 400 cassettes and records; I took care of my soul if something was wrong. Researcher: What About Now…? I have my radio on all the time…silently…for my soul you know…yes, I do take the time for that. (Jelka, second interview) Most participants identified the link between having an opportunity to engage in their meaningful occupations and feeling healthier. Discussion The findings of this study illustrated how six Slovenian older adults experienced the process of transition from their home environment into a care home. Consistent with previous evidence older adults in this study expressed the importance of maintaining their identity throughout the time of this transition (Cooney, 2012; Lee et al., 2013; Minney & Ranzijn, 2015). The concept of identity is considered a “powerful construct” (Vignoles, Schwartz, & Luyckx, 2012) although critiqued within the literature for not being clearly defined (Rattansi & Phoenix, 2005). Social science literature defines identity at a personal, relational, collective, and material level, reflecting the complexity of who one is (Vignoles et al., 2012). The participants in this study expressed their identities through their experiences of engagement in occupations. They all valued and tried to maintain particular occupations, which gave meaning to their life and a sense of self. Existing evidence demonstrates that meaningful occupations influence older people’s health and well-being (Bedding & Sadlo, 2008; Clark et al., 2012; Liddle et al., 2013). Honoring the everyday preferences of nursing home residents can contribute to improved satisfaction with the care they receive (Bangerter, Heid, Abbott, & Van Haitsma, 2016). Enabling older people to maintain their meaningful occupations after relocating into a care home was shown to be of paramount importance to the individuals concerned (Marshall & Mackenzie, 2008), and this is reflected by the experiences of participants in this study. These findings are in line with Christiansen (1999) who suggested that a person’s unique identity is built through what they do, enabling them to create meaningful lives and remain well. This argument developed into the concept of occupational identity that has been defined as “a composite sense of who one is and wishes to become as an occupational being generated from one’s history of occupational participation” (Kielhofner, 2008, p. 106). The importance of occupational identity was echoed by these participants who attempted to maintain who they were through their experience of engagement in occupations that were meaningful to them (e.g., driving a car, caring for the family, being involved in profession-related occupations). Furthermore, these findings indicated the paramount importance of maintaining meaning throughout challenging life events (Frankl, 2006), which in this case was the significance of retaining meaningful occupations throughout the transition into a care home. While trying to maintain their unique identities throughout the transition, the participants also faced changes in their everyday engagement in occupations. Changes in their everyday roles and routines were expressed as challenging by all participants, especially those who shared the facilities with other residents. The issue of older people adjusting to institutional orders and routines has been acknowledged in previous research (Harnett, 2010; Mali, 2008). A study by Harnett (2010) demonstrated that any special requirements by the residents were considered as disruptions or disturbances to staff working routines. In contrast, adjusting to staff routines was expressed less than anticipated by participants in the interviews; this may be due to the fact that they were still independent in self-care. However, they did recognize the impact of institutional timetables on their occupations, for example, meal times influenced all of their daily routines. Interestingly, the findings by Mali (2008) who compared Slovenian care homes to Goffman’s (1961) concept of total institution described that although care home rules and routines were present; there was a possibility of adapting them to meet individual residents’ needs. However, this study did not concentrate on the transition period and data were collected also with staff and relatives, which may have influenced the findings. A study by Cooney (2012) indicated that keeping older people’s continuity in terms of their daily routines helped them develop a sense of home in their new living environment because it gave them a sense of security and predictability. Although expressed by all participants in this study, one participant illustrated the impact of change on his daily routine by saying he felt lost when addressing his new morning routine. Gamliel and Hazan (2006) argued that care home residents may focus on rigidly following daily routines and hobbies as these are the only activities that they can still control. Although this may be the case later in the process of transition, the present study focused only on the first 6 months of adjustment and more time may be required to fully adjust old routines to new ones. Previous studies have indicated the importance of continuity between past and present roles (Minney & Ranzijn, 2015); therefore, time may be needed for older people to readjust their roles throughout the transition. Losing several roles simultaneously may have an impact on their identity as was the case with most of the participants in this study (e.g., losing their role as housekeeper and driver at the same time). Social psychologists suggest that people’s identity changes according to the context in which they find themselves (Vignoles et al., 2012). Furthermore, Goffman (1961) argued that despite being rigid, total institutions represent a place of identity construction and Mali (2008) did find some similarities between Slovenian care homes and Goffman’s concept of total institution. In addition, the Theory of Selective Optimization with Compensation (Baltes & Baltes, 1990) describes a process of adaptation in old age by older people optimizing their general abilities and compensating for lost ones. Although the participants in this study found the process of adjustment challenging, it was evident at the time of the last interview that most of them had started to readjust their previous roles and develop new daily routines to replace the old ones. Nevertheless, they still tried to maintain engagement in those occupations that were most meaningful to them. This fits with findings from previous research (Marshall & Mackenzie, 2008) and with the Theory of Selective Optimization with Compensation (Baltes & Baltes, 1990), which proposes that older adults selectively concentrate on those domains that are of a higher priority and importance to them. All participants valued maintaining their health and independence although not all of them relocated due to health issues. Some participants perceived they had better health when engaged in their most enjoyable occupations. This links to occupational science evidence linking engagement in meaningful occupations with perceived health and well-being (Bedding & Sadlo, 2008; Liddle et al., 2013). Furthermore, the participants were purposefully engaged in health-promoting occupations such as physical activity, healthy eating, and going outdoors, which they believed helped them maintain their health. A study by Minney and Ranzijn (2015) similarly highlighted that the residents purposefully engaged in organized activities that promoted active ageing within a care home. This reflects the philosophy of the active ageing policy (World Health Organization, 2002, p. 17), which encourages older adults to make “personal efforts to adopt positive personal practices at all stages of life.” Interestingly, only one participant actively engaged in organized activities, whereas others preferred looking after their health in their own time and in their own way. This may be due to participants still being in the process of transition as they had only lived in a care home for less than 6 months. The participants mostly mentioned independence in the context of maintaining it for as long as possible and not wanting to be a burden to their families, which was one of the reasons for their decision to move into a care home. The importance of not being a burden was similarly expressed in previous studies (Stenner, McFarquhar, & Bowling, 2011). The value of independence was especially emphasized by one of the participants who was visually impaired and faced several barriers in his new living environment. Although he relocated to increase his support, he perceived the care home environment as limiting his abilities and therefore spent most of the time in his room. The Theoretical Model of Residential Normalcy (Golant, 2014) suggests that in order to achieve residential normalcy an older person needs to feel both residential comfort and mastery over their living environment. When there is a lack of congruence between their living environment and mastery in the setting, they decide to relocate. Although this was the case with this participant, the new living environment did not offer enough support to achieve a state of residential normalcy. Interestingly, all participants shared their experience of transition through reflection, by introducing their past life stories, linking them to the present events, and making predictions for the future. Similarly, eight older adults in a study by Lee and colleagues (2013) described their transition into a care home as part of their life story as opposed to the transition being a stage-based process (Brandburg, Symes, Mastel-Smith, Hersch, & Walsh, 2013). This links well with the work of McAdams (2012) who proposed the concept of narrative identity where an individual constructs a life story with the purpose of making sense of their life. It could be suggested that the participants in this study introduced their unique identities by interlinking their past events with the current period of transition, emphasizing their most valued occupations and the importance of carrying these throughout the transition into the future. The researchers acknowledge that as with any research there are limitations to this study. Although methods for ensuring trustworthiness of the study were employed, the findings were translated from Slovenian into the English language; therefore, some cultural meanings and nuances may be lost in translation. This research highlighted that the transition into a care home is a continuous process with older people striving to maintain their identities through engaging in their previously enjoyed occupations. The transition into the care home was shown to be challenging for the participants and support should be provided for older people going through this period of their lives. Löfqvist and colleagues (2013) emphasized the need to develop counseling services to support older people with the process of moving from home environment to care homes. 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The GerontologistOxford University Press

Published: Nov 17, 2016

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