A total of 2066 records were retrieved through the electronic database search and a further 9 articles were identified by hand searching in a snowball fashion, these were reviewed against the inclusion and exclusion criteria and all will be systematically reviewed following the process outlined in Figure1. The study selection process resulted in 12 articles being included in the meta-synthesis.
Included studies were completed in several countries including China (N=3) UK (N=2), Switzerland (N=1), USA (N=3), Australia (N=1), Philippines (N=1), Canada (N=1). Of the 12 studies, results noted phenomenological (N=5), ground theory (N=5), narrative research (N=1), and one that did not describe the research method. Purposive sampling was the most commonly used sampling strategy, semi-structured interviews were the primary method of data collection, and phenomenological content analysis was a common method of data analysis. Table 3 details the methodology and sample characteristics of the included studies. When considering the hierarchical structure of the evidence classification system[18](Table 4).
Key Findings
The majority of the included articles reported in a descriptive manner on matters related to the adaptation of older people relocating to a residential care facility, listing and exploring the process of adaptation of older people after moving to a residential care facility, according to the participants. Thus, three overarching themes include: (1) the loading phase, (b) the adjustment phase and (3) the acceptance phase.Then,the three categories were integrated into two synthesized findings: synthesized finding1: the transition process.(Table 5). Each major theme contains a number of sub-level themes representing constituent factors. Based on the results of the included studies, we consider the three main themes identified in this meta-synthesis and underlying structure to be recursively related (Figure 2).
Synthesized finding 1
The transition process consists of three stages: the loading process, the adjustment process and the acceptance process.
Load phase
Undeniably,moving from a home to an institution can be a huge shock to older people as it is one of the most daunting and difficult challenges they can face in their later years[19,24,25,30].
A very big shock. A younger person wouldn't understand it. I can't say that I ever felt worse in my whole life time. Really, I don't recall ever feeling this way before[25].
At the same time, changes in the environment, family relationships and life style can lead to a range of physical, psychological and psychological changes in older people, starting with crying and feelings of loneliness as the most common reactions[19,26,27].
I’ve got to get use to it, but I can’t… I just can’t. I’m homesick, it’sjust being here. I’m so lonesome[26].
It’s probably nicer when you’re home, talking to your child. Unlike now, you don’t have any idea where she is or ...sometimes, I cry (long pause)[27].
The psychological burden of moving into an institution for older people can be enormous, with some showing strong resistance. Some older people even place themselves in a state of confusion; and are forced to give up what they have, expressing a sense of loss and discontinuity with their previous social environment and identity[19,21,25,26,29].
I get awful lonely and depressed.. I go to a room and forget why I went there.I’m afraid if I leave my room.I don’t want to be a burden to my daughter and her husband[26].
I am so lost here, it’s not me, it’s not home and it’s so big, I don’t really know where I am at now. It is very hard to find your way[25].
Some older people find the decisions to leave home and go to an institution were not happy because they have lost themselves, their friends, their families, their neighborhoods, and their familiar stories no longer exist and new ones have not yet begun, leaving them with the sadness of being 'homeless'[20,22].
I want to go back to my apartment; it’s a whole house full of memories. The only thing I’ve regretted is falling and being where I am now [nursing home]。You see the whole story is that if you can’t do for yourself, they have different places for you[20].
Adjustment phase
Individuals expressed their own sense of self-efficacy, personal resilience and ways of coping with adjusting to life in the care home. This includes continuous reinforcement of self-awareness. Secondly, an important part of the adjustment phase for older people is to enable them to instil a sense of themselves in their rooms and in many cases to establish a degree of continuity with their previous home[23,25,28].
Well I always take it one day at a time and thank god it’s been good so far. It’s the best way to take it, you know, because I wouldn’t be doing as well as I’m doing otherwise, you see, I would miss things from home. Well I do a lot of thinking but sure that’s no harm[25].
I wanted to make it as much like home as I could you know, that’s why I’ve got so much around me[23].
The elderly making the new home meaningful by bringing in possessions and photographs to symbolise their identity. Continued identification with such meaningful symbols helped to sustain identity[25,30].
Woman arranged for her piano to be moved from home to a lounge in the facility. She wanted to continue her musical hobby and also wanted other residents to enjoy and use the instrument[30].
Certain benefits such as food, donations and other free services escalate the likelihood of the elderly becoming attuned with their new milieu.In addition, some older people continue to learn the rules, to be able to do the things they love, to learn about others and to try to make connections with others to gain a sense of satisfaction[20,27].
“There are folks there. I like people; I like to talk to folks. I don’t like sitting here.Just be friendly to these people, and they’ll be friendly to you. Just be good to them, and they’ll be good to you[20].
However, older people felt very limited control of themselves in the process of adapting themselves to the institution. When older people are restricted, they report little involvement in decision-making in nursing home institutions. And older people are less able to make their own decisions, and when they are less involved in their homes, they are less likely to organise their new homes[21,27].
It was only when I arrived here that I realised that I couldn’t cope anymore. I used to like to cook, to invite friends. I could no longer do any of that[21].
Acceptance phase
Some older people have been helped to express tolerance and acceptance and to understand their lives through their own faith[30].
It's God's will", "You can't have it all"; "Life is what you make of it"; "I'm a firm believer in God's plan" "You have to go halfway"; "I have a lot to be thankful for and will make the most of it”[30].
Most residents also began to formally associate themselves with life in the nursing home. They began to join in activities organised by the family, to become more involved with the people around them and they saw participation in meaningful and productive activities as essential to achieving a successful adjustment and sense of well-being[21,23].
I think one should give it a try and do at least something independently. I try[21].
I feel like I'm still doing normal things in life ...... it's kind of like what I used to do, life hasn't changed that much - it's just slowed down a bit[23].
Older people continue to gain confidence and realize that "I can do it." Secondly, it gives new meaning to pension institutions by developing new memories, new friends, new neighbors and creating new stories[20,26,28].
No one can help me except myself. You have to pick up your boots and do it. As long as I can keep my sense of humor. Walking should be good. It's starting to look more like home[26].
I’ve met a lot of people here...they treat you right.”[20].
In addition, most elderly people mentioned that they want to spend the rest of their life here. They prefer the current nursing home than before. With adaptive acceptance, the elderly find the meaning of life in the nursing home[20,22,24,25,27,29].
If no one can bring me here, I can spend the rest of my life here "," yes, I think I will stay here for a long time "," indeed. " I even told others that I ate here (laugh)[27].