The Lived Experience of Nursing Home Residents in the Context of the Nursing Home as their 'Home'

ulster.ac.uk
‘The lived experience of nursing
home residents in the context of the
nursing home as their ‘home’.
Dr Kevin Moore

Structure of the Presentation
Background and Rationale for study
Pertinent Literature
Broad Aim and Research Questions
Methodology – Grounded Theory
Project Preparation & Ethical Considerations
Data Collection/Analysis & Preliminary Results
Future Work Plan & Dissemination & Final Report

An Introductory Quote & Thought
“If I could run out through the door now…..believe
me I would…….. (Resident Pauses).
………..Not because there is anything wrong with
the nursing care that I receive as this is second to
none…… (Further Resident Pause)
…… Well, it’s just that whilst it might be my home
now, it’s not really my home, and I’d prefer to be
in my own wee corner, in my own home, with my
wife……but the reality is….that can’t happen as
neither of us can cope!” (Tears and silence!)

Background & Rationale for Study
• The proposed study is designed to explore and
extrapolate on the lived experience of nursing
home residents in the context of the nursing
home as their ‘home’. Further, the study will also
explore how staff employed within the nursing
home sector in Southern Ireland, enable and
maximise the nature and meaning of home for
their residents.
• Transition to long-term care can be an emotional
and stressful occasion for older people as well as
their families (Cheek et al, 2007; Ellis, 2010).

• A worldwide demographic trend elucidates
significant global transitions to an older
population as people are living much longer and
are in effect ageing in place (Want et al., 2008;
Gitlin et al., 2009).
• The UN reports that approximately 20 countries
in 2000 had over one-fifth of their total population
aged 65 years and over. Population projection
figures suggest many of these countries will have
well over 35% of their total population aged 65
years and over by 2050.

• There are clearly significant implications for
Governments in the provision of services and
more importantly for the recipients of such
complex aspects of care (McClimont and Grove,
2004; Health Information and Quality Authority,
[HIQA], 2012).
• Additionally, the need to explore the perspectives
of older people receiving such care and their
perceived quality of life remains high on the
research agenda (Ehrenfeld, 1998; Hellström and
Hallberg, 2001).

• Moreover, the need to explore and extrapolate on
the nature of the lived experience of ‘home’ will
be central to the effectiveness of such care
provision.
• A workforce that is strategic and responsive to
individual, societal and Government demands,
and one that enables and supports independent
living, wherever this may be in the person’s own
home or in the nursing home, is an essential and
important component to any Government
strategy.

• The Livindhome Report (2011) provides
important insights into home care identifying the
drivers for change in each European country.
• However, it did not explore the context and
nature or meaning of ‘home’, nor does it offer a
sufficient operational definition. No clear or
unequivocal contrasts are presented
• Moore and Ryan (2014) have outlined the
importance of exploring the roles of home care
workers and have identified a disconnect in the
centrality of such roles and its recognition within
the wider health and social care contexts.

• HIQA (2012) reported on the need for greater
reliability and less variation in the quality of Irish
healthcare and the need for the setting and
implementation of standards and monitoring
compliance with them as important levers in
driving improvements in quality and safety in
healthcare.
• HIQA (2012) also suggested that such standards
in healthcare were instrumental in providing
professional expectations, ensuring safeguarding
patients and delivering continuous improvement
in the quality of care provided.

Aim of Study
The aim of this study is to explore the
context and nature of the lived
experiences of nursing home residents
as their current ‘home’; and to evaluate
the importance and role that nursing
home staff play in enabling and
maximising a ‘homely’ experience for
their residents.

Research Questions
• To identify the current context and meaning of ‘home’
from the residents and nursing staff perspective.
• To identify, compare and contrast the residents’
previous context and meaning of ‘home’ prior to
admission to this nursing home.
• To examine current levels of nursing home practice
that determines a ‘typical day’, thus enabling
identification of the factors that may maximise or
minimise the lived experience of ‘home’.
• To explore the factors that influence current practice
and service provision that promotes or inhibits a
‘homely’ experience.
• To make recommendations to NHI that will inform
future planning, policy provision and educational
provision to staff.

Methodology
Grounded Theory Approach
Why Grounded Theory? “Grounded Theories,
because they are drawn from the data, are likely to
offer insight, enhance understanding and provide a
meaningful guide to action” (Strauss & Corbin,
1998, p12). Further, Cutcliffe (2000) contends that
where the researcher is aware that there is a lack of
substantial knowledge in the given area, then a GT
methodology is most suitable.

Core Elements of GT Approach
• Constant comparative
analysis
• Theoretical sampling
• Theoretical sensitivity

Methodology
1. Semi-structured interviews using focus groups
with a sample of nursing home residents in
both an urban and rural setting, who are
willing to participate in a tape-recorded
discussion for about 1 hour.
2. Semi-structured interviews using focus groups
with a sample of nursing home care staff (all
staffing groups), in both an urban and rural
setting, who are willing to participate in a tape-
recorded discussion for about 1 hour.

Project Preparation
• Letters of introduction circulated from NHI and
Ulster University in advance of project.
• Participant Information Sheets & Focus Group
Topic Guides & Consent Forms designed for both
residents and staff groups.
• Random sampling of urban and rural split of
nursing homes registered on the NHI data base
• Random sampling technique from this listing for
Co Dublin and Co Donegal to capture: private,
voluntary and group homes registered.

Ethics
•Ulster University INHR Ethics Filter Committee
Application. Ethical Approval from UU.
•Enquiries made to some HEI’s in ROI regarding
ethics. Ethics application to NHI Management
Committee following UU Approval & Permission
also granted from NHI prior to any contact with NHI
Registered homes.
•The main ethical issues relate to the protection of
vulnerable adults, participants information, consent,
autonomy and confidentiality.

Focus Group Topic Guide Residents
• Exploration of reasons/nature of stay in this
nursing home?
• Exploration of your initial impressions of nursing
care in this nursing home?
• Changes between your experiences of your ‘own
home’ life, prior to admission, and the
experiences of your ‘home life’ now?
• Exploration of the current context? What are
your personal experiences of ‘home’ in the
context of this nursing home?
• The future context?

Focus Group Topic Guide Staff
• Exploration of reasons/nature of stay for your
residents in this nursing home?
• Exploration of the context of the Nursing Home
as Home for the residents?
• What are your thoughts/impressions/meanings of
this nursing home as the residents ‘home’ at this
stage of their lives?
• How does the nature of the resident’s day to day
experiences maximise the nature and meaning
of home?
• The future context?

Data Collection
• Total Homes Registered with NHI data base
(n=443): City of Co Dublin (n=42); Co Donegal
(n=12)
• Total Homes selected at random for inclusion in
study from Co Dublin (n=7) and in Co Donegal
(n=3).
• Total Focus Groups with Residents and Staff in
Co Dublin (n=6) & in Co Donegal (n=6).
• NHI Nursing Committee group (n=1)
• Total participants (n=75)

Breakdown of Participants
Nursing Home Staff Nursing Home Residents
NHI Committee (n=10)
NH 1: (n=6) 9 months – 25 yrs. NH 1. (n= 7) Range 35-84 Ave 62.42
NH 2: (n=4) 2.5 months – 8 yrs. NH 2: (n=6) Range 74-98 Ave 84.5
NH 3: (n=6) 4yrs.-8yrs. NH 3: (n=6) Range 74-85 Ave 80.0
NH 6: (n=5) 2yrs. – 40 yrs. NH 6: (n=4) Range 60-94 Ave 76.0
Totals (n=42) Totals (n=33) Range 35-98
Average Age =93

Data Analysis
• A content analysis will be conducted using the QSR
(Qualitative Solutions and Research) Nvivo qualitative data
analysis programme. This programme facilitates the
organisation, management and retrieval of transcribed
interviews and field notes and provides tools for coding,
categorising and linking qualitative data.
• Time of residency in nursing home (or accumulated time)
ranged from 4 months to over 11.5 years.

Data Analysis
• Core reasons for admission, particularly in urban area was
directly from acute hospital sector and related to either
physical health deterioration or falls at home.
• The younger residents were admitted due to RTC & severe
physical illness/immobility issues.
• Whilst this was also prevalent in the rural sector, other
reasons such as loneliness and feelings of isolation/inability
to cope with life changes/spousal death are high on the
reasons for admission to NH sector.

Preliminary Results (Residents)
• “I had a stroke and couldn’t stay at home.”
• “Was in hospital for 2 weeks for some treatment and the
consultant said it would be good to go for respite and this
one was recommended. I always stayed another
fortnight and another fortnight, and I have a driver and he
takes me down home when I want to go but getting more
seldom.”
• “My husband was dead, I had 4 boys so I had to sell the
house to come here.”
• “I’m 85, I have 4 children and they all drifted away, so I
had to sell the house.”
• “I fell at home and went into hospital, then from there to
here, apparently for respite, but I never got to go back
home.”

• “I was living with my sister who was born in 1919 and died at
the age of 91, and I wasn’t myself, little nervous and upset
about different things, so they thought it would be better to
come to a nursing home so I came here.”
• “It's really hard to go into detail, it’s too upsetting to talk about
it as I came in for respite and never got to go back to my own
wee home, I’m sorry but it’s not right, is it?”
• “I came here because I can’t manage myself at home so my
sister who can’t take care of me brought me here. I stayed
about a year in the hospital after a bad fall at home.”
• “I came here from St James hospital, I had 2 bad legs,
couldn’t look after myself at the time. They said I had to come
to a nursing home, which is one thing I never wanted to do. I
don’t think about it, 2 years already here.”

Preliminary Results (Staff)
• “This nursing home is quite a relaxed atmosphere and
that is something you want in your own home. So when
patients come it's very welcoming. Obviously they can
be quite anxious if the family has asked them, finding
difficult to cope, if they can't meet their needs anymore.
Here would be suitable for their needs.”
• “I would feel much the same for families that are
struggling at home and for choosing this one here I do
feel that residents that come would be local and they
would know a lot of people in here.”
• “Most residents are here because they might not have
been able to cope or the family might not have been able
to cope.”

• “People obviously come to nursing homes maybe through
illness, they might not be able to cope at home any more, they
could be living alone, family may not be able to provide the 24-
hour care that they may need. There are many different
reasons why people come to a nursing home. Maybe they
choose to come, they feel that they cannot do it themselves
and the best choice for them and those involved is to come to
a nursing home where there is 24-hour care provided.
• “I suppose for some it could be isolation & loneliness. I've one
lady who could be living at home and maybe see two people a
day whereas living here she has numerous friends and staff to
talk to, put her at ease.”
• “I think the people come to us for a variety of reasons. There
are medical needs that they are no longer able to stay in an
unsupervised environment.”

• “I had decided that I would stay in my own house until I was
90 but I got a severe pain in my leg last year and was less
able to do things. I lived alone and didn’t have many relatives
in the area and didn’t want to impose on them or my
neighbours.”
• “I just had nieces in the area, my siblings are all dead. I found
the responsibility of a house too much for me and it didn’t
seem necessary to maintain a property for an 89 year old.”
• “All my family are married and gone from home and my
husband is dead. I fell and broke a bone and had to go to
hospital. I got on OK in hospital and when I came home I
couldn’t walk very well and couldn’t do very much, and my
family couldn’t be with me all the time and I got nervous and
depressed. I then decided to come here.”
• “Well I could never manage at home on my own, I wouldn’t be
able. I can do nothing with my hands. I can hardly hold a
cup.”

“I am 89 years of age and I have buried all of my relatives,
my husband, my sister and my brother. I have been living
alone for many years and the only human contact I have
had was when the postman would call with me. I
experienced sadness, loneliness, anxiety and despair. So I
decided to come here and give up my beautiful home and
my life as I knew it to be! Life is strange and funny you
know, but if I can accept that it needs to change, which is
what I have done. Then my day to day living here is just
not all that bad really. It’s the acceptance of this new way
of living in this home, that is the hardest thing to accept.
But, alas, it is the most important thing to do, and then life
becomes so much easier you see!”

“My life has changed a lot. I was in a steady job for
over 20 years, I worked as a manager in Dublin
and at the start, going through all this, they told me
I couldn’t live on my own any more, all I wanted to
do was curl up in a ball and die. I made my
feelings clear to my sisters, I wanted them to get
a gun and shoot me, I felt so depressed. As
time went by you learn to look at things differently.
This is the path that was chosen for me and a path
I have to walk,…….. And like, you see other people
who are worse off, it gives me great courage.”

• “I wouldn’t like to sit in that day room all day with a
television going, that would upset me.”
• I’ve lost my independence being here.”
• “I had difficulty accepting, I had to get accustomed to
the fact that the staff had other people to look about
and that somebody might come to shower me at
9.10 but might not come the next week to 10.10 and
as well as that, I’m not being critical of the staff, they
have responsibilities here and crisis can arise for
them, but sometimes my medication does not arrive
until 10.30 and other days would arrive at 9.15, but
just had to reconcile myself. I had to adjust.”

• “I would like more activities. We had music in the
past and trips, but due to staff shortages, we’ve
not been out the door in months. The staff, of
course, well…..they’ll tell you a different story
entirely.”
• “I knew nobody and I felt I was just sitting there
and I used to actually go up to bed as soon as I
had my tea at 4 o’clock and I spent the evening
in my room and I did feel very lonely until I got to
know everybody then it became more like
home.”

“No day is the same. But a typical day would be, I
need assistance to get up, they wash and dress
me and help me into my chair. Then breakfast. It
depends what kind of day it is. A lady comes in to
do a little bit of aerobics, always something to do,
but a typical day is what you make of it. Some
days we could be feeling a bit down, other days
you feel great, going round everybody, having fun.
Just day by day. See how you feel that day. Get
out for the day. Music and bingo on days. They do
their best to keep you occupied.”

• “I like the staff, couldn’t say a bad word about any of
them. Lost for words now.”
• “No, I was glad to shed the responsibility living alone
at 89, all the little things that come along, and your
helper isn’t there 24 hours a day. If I fell no one
would get me for a good while. I knew that when I
came here if I needed someone they were available.
I am very happy.”
• “You can go in and out as you please. I have joined
the active retirement and I go to that every week and
I go on outings and day trips and I can come and go
as I please and I feel I'm living an independent life as
well as being in a nursing home and having the
comfort of a nursing home and people around me.”
•

• “I came in on my own time to do a resident’s hair,
because it gives them that wee bit of friendliness
and that we are always there for them, try to help
them out. That would be just one thing I would
say about here, because everybody goes above
their duty. I think that one of the good things as
well is that the residents are able to personalise
their rooms to whatever extent they want, they
can bring furnishings, bed clothes etc., so it is a
home from home.”
• “We offer a wide range of therapy which is
substantial for this home compared to other
homes.”

• “My role here is to promote independence and for
the residents to live a meaningful life, and I suppose
independence would have been something they
would have valued at home in terms of their self
determination and that would be something that I
would value very much in my role.”
• “It's their choice, it's like home. Also they go to bed
late or whatever suits, it's their choice.”
• “Every resident is really valued here, we are all very
aware of how they like to spend their day, be in their
room or amongst the rest of us, but we would never
force anyone to go along with our own pace.”

• “Personally I see my role as enhancing whatever
I can in their lives. All we can bring is assistance
and support, we can't live the life they live but we
can try to identify with it.”
• “But the way is as I see it, the word
enhancement for me and close support where
possible and it's like giving something back.”
• “We would say to family we are here to support
that person to live their life and to live it in the
same manner as they would have done at home
and that families should do that as well.”

• “Not really much that I would like to change,
everything.... great areas to go and sit, outdoor
patio. If you want to go out ……. arranges it.
• “Not only is this our home, our families are made so
welcome when they come, it's like it's their home as
well. My sister has her dogs with her and nobody
tells her to take them out.”
• “I never worry much about the long day. I just like
the place so well that I am quite happy to go with the
flow.”
• “But the staff that are here are lovely and they do
what they can but they really do need more staff.”

• “Well I lived alone and I see more people here during
the day than many a day at home and I like doing
my own thing and I'm allowed to do it. I still come
back to the thing that old age changes things and
that home is not what it was when we were
younger. Life changes and you change with it.”
• “While we would all prefer our home, things have
changed and we have to change with it.”
• “Well they listen to anything I say to them and they
treat me like a civil person, which I think I am still,
and anything I ask for they do their best, I don’t feel
I'm being walked over or anything like that.”

“I have my bedroom set out with a lot of my own
things, furniture, paintings, I have my bedroom set
out like as if I was at home. I am independent
and that's what makes it home for me. But even
with all of this, it’s not really the home that I want
to remember; the home that I raised my children
in; the home I waked my husband in; the home I
loved so well with my dog. But this is it now for me,
so I have to make the best of it, but if I could, and
I’m sure we all would, we would go back to our
own wee home in the morning to be sure.”

Recurrent Themes & Categories
• Dependency levels.
• Connectivity – Families – Normalcy.
• Communication – Choices.
• Transitions – From home to home!
• A ‘disconnected’ & ‘reluctant’ acceptance of
current reality.
• Perceptions & Attitudes, both staff and residents.
• Training – Skills – Staffing levels.
• Cultures – Urban – Rural.
• Loneliness.
• A social environment – ‘A new lease of life’.

Next Steps
• Conduct 1 or 2 more resident groups in Dublin to
determine theoretical saturation of data.
• Complete analysis using the paradigm model &
operationalise open, axial and selective coding
for all categories (Corbin & Strauss, 2008).
• Draw up executive summary and complete final
report for NHI by December 2016.
• Prepare papers for academic publications &
present study findings at further conferences at
International level.

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