Elderly Health Journal

Elderly and Care Givers’ Experiences of Transfer to Nursing Homes in Bam City: A Qualitative Study

Mohammad Ali Rezaei ¹, Neda Mohammadinia <sup>2*

1.</sup> Department Medical Surgical Nursing, School of Nursing and Midwifery, Bam University of Medical Sciences, Bam, Iran
^2. Department of Community Health Nursing, School of Nursing and Midwifery, Bam University of Medical Sciences, Bam, Iran

Article history
Received 12 Feb 2018
Accepted 29 May 2018

A B S T R A C T

Introduction: The elderly population has increased rapidly in recent decades, and consequently, admission to nursing homes is growing, but their experiences of this transfer have not been paid adequate attention. The aim of this study is to explain the elderly and care givers’ experiences of transfer to nursing homes in Bam city, Kerman Province, Iran.
Methods: This study was conducted using a phenomenological approach in 2017. Participants were the elderly residents in the nursing homes in Bam city and their care givers. Sampling was done till data saturation. Sixteen elderly people and 6 their care givers were participated in the study by purposeful sampling. Data collection methods were unstructured in-depth interview and field-notes. Data were analyzed by seven-stage Colaizzi's method.
Results: The data analysis identified 47 initial and conceptual codes that categorized the causes of transfer in 2 categories from the viewpoint of the care givers and of the elders and 4 sub-categories (the elders' problems, the family problems, compulsory transfer andvoluntary transfer).
Conclusion: Participants' statements indicated that most elderly people were not happy with their transfer to nursing homes, although some are satisfy with their transfer. Therefore, formal and non-formal education should be offered regarding respect for the elderly, the use of their experiences, getting their satisfaction before transferring to the nursing homes, and regulating, meetings programs with them by their family, friends, and even all sections of society as much as possible.
Keywords: Qualitative Research, Nursing Homes, Iran, Aged

Introduction
Old age is one of the most critical stages of life, which has been referred to the ages upper 60-65 in various studies. It has been reported that one-third of the population of Iran is projected to be aged in 2050 (1). The elderly gradually loses their ability to perform daily affairs due to greater rates of physical and cognitive disability (2) mental and physical diseases and consequences and no one may have the opportunity to look after and help the elderly at home, and due to family and financial problems, the impossibility of hiring a private nurse, etc. the elderly's maintenance at home is becoming more and more difficult every day (3, 4), it may be necessary that such older people and the elderly people in certain conditions, such as physical and mental illness, stay in nursing homes temporarily or permanently (4). The emergence of nuclear families has also changed the roles and functions of family members (5).
Unfortunately, nowadays, the elderly have faced restrictions in terms of entering into their children’s lives. Accordingly, children do not consider themselves obliged to meet the needs of their elderly parents in terms of financial support, health services, or housing; thus, the old belief that children are the best support for older adults is diminishing (6). In a study conducted in Shahr-e-Kord city, Iran, only 21.8% of elderly people in nursing homes had favorable physical health and less of half had favorable mental health (7). The trend of transferring elderlies to nursing homes has been increasing in Iran (6). A study in the city of Isfahan showed, illness is the most common reason of transfer to nursing homes (8). According to the results of similar studies, being woman, illiteracy or low literacy, loss of spouse and children, inadequate funding, homelessness, dissatisfaction with place of residence, conflicts with family members, and children’s weak faith (9, 10), cognitively impaired, incontinent, need to high levels of health care, could play a significant role in the transfer and entry older adults to nursing homes (11).
The living environment of the elderly is an affecting and major factor on their health, life expectancy (12, 13), comfort, and mental health (13). A study to compare the quality of life and mental health among the elderly people resident in the nursing homes and other elders in Shiraz showed a significant difference in quality of life, mental health and all of its subscales between the two groups of the elders (13). Admission to nursing homes is a great (14) and stressful event (15, 16) in the elderly life that can evoke negative mental consequences such as sense of rejection, mental tension, depression and insecurity (8).
Among the various transfers, the transfer to the nursing home has been considered in the literature to be the most important effective transfer on the elderly (17), and it is essential for the elderly to be informed about this displacement before and so that its adverse effects could be minimized.
Exclusion, isolation, monotony, and disturbance in communications were among the main themes hidden in life experiences of elderly residents of nursing homes. According to their statements, it seemed that amount of elderly interference and satisfaction from transferring to nursing home has a significant role in reducing negative feelings (2).
Despite several quantitative studies which has been investigated the issue, few researches has been studied the issue in a qualitative approach, so this study aimed to investigate the elderlies’ lived and tangible experiences of transferring to the nursing homes.
Methods
Study Design
This qualitative study was conducted using a phenomenological approach. Phenomenology refers to the description and study of lived experiences as they have occurred in life (8, 18) and in other words, description of an experience, as it has been lived by the participants in the study and will be interpreted by the researcher (19). In this study, the studied phenomenon is the elderly’s experience of transfer to nursing homes.
Participants
Participants were the elderly residents in Bam city, Kerman province, Iran, nursing homes and their care givers that selected by purposeful method. Sampling began from late December 2016 and continued till late April 2017 when data saturation (lack of the extraction of new codes) achieved with 22 Participants (16 elderly people and 6 their care givers). Care givers who had at least one year of working experience in nursing home and elders who were conscious were eligible to participate the study.
Data collection
Data collection methods were unstructured in-depth interview and field-notes. In the elderly group, seven individuals were interviewed in their own room and six people in the yard of nursing home. All interviews with the care givers were conducted at the station of the nursing home building as they wished so.
The time chosen by the participants in both groups was before noon and each interview lasted 35-45 minutes. Although the researcher had explained certain details about the interviews to the participants, whenever the participants became tired, they could continue the interview in the following days. No case of interview repetition occurred in our study. To begin the interview and to achieve a comprehensive understanding of the elderly's experiences of transfer to nursing home, first the open-ended question was asked: How did you feel about the first time you came to this place? And what do you feel at the moment? And continued with questions about the elderly's experiences of moving to the nursing home, and also with exploratory questions such as can you explain a little more? And do you have any specific suggestions or comments?
Ethical Considerations
Before the interview the interviewer introduced herself, described research objectives for participants and got oral informed consent from them. In this way, the interviewer took precise conversation notes and wrote all non-verbal movements. The participants were assured about the confidentiality of their information and their voice. The time and place of the interview was determined by them. The participants were free to leave the study at each stage of it or to continue the interview in the following days if they became tired. The study was approved by review board at Bam University of Medical Sciences. (Ethical approval code: MUBAM.REC.1395.27).
Data analysis
In the end of every day, interviews were carefully listened, typed and wrote word by word. Data were analyzed by Colaizzi's method. First, involvement of researcher in the data, second, to extract important sentences, third; named of adjusted terms, fourth, to organize concepts or main themes. Fifth, to combine of the findings for comprehensive expression of the phenomenon under study (incorporate results) and sixth, a comprehensive expression of the under study phenomenon in the form of an explicit statement was formulated and presented (structure of subject or phenomena). The final stage was data validation .That was assessed through Lincoln and Guba method to ensure trustworthiness criteria, including credibility, transferability, confirmability and dependability (20). the results of interviews and extracted codes were presented to the people who had participated in the research to be able to amend and rectify the results (member check), and in the cases who the participants were not willing to analyze the results, the interviews and extracted codes were delivered to the second researcher for approval them (peer check). Finally, a team ofexperts reviewed the extracted codes (external check) to ensure the credibility and confirmability of the data and codes. Maximum variation sampling in age, sex, experiences of resident, social and economic class was used to be sure of transferability. Data analysis was started after the first interview, and continued with the saturation of data.
Results
Totally, 22 individuals participated in the study (p1-6 care givers and p7-22 the elderly people). Regarding the elderlies, their average age was 57.8±0.34 year-old. Majority of them were female (60%) and illiterate (65%) with 7 months to 6 years duration of residence in nursing home. All care givers were female, with high school diploma education level and average age was 35.3±0.64 with 1-13 years work Experience in the nursing home.
The analysis identified 47 initial and conceptual codes, 4 sub- categories and 2 categories (table 1).
Table 1. categories and subcategories derived from the primary and secondary data (causes of transferring to nursing home)

1-The causes of transfer from the viewpoint of the care givers: The first category extracted from the data and includes two sub-categories (the elderly problems and the family problems).
1-1- The elderly problems: All care givers stated that certain Psychological problems and physical problems were some of the most important causes for moving the elderly to the nursing homes.
One of the care givers that has a lot of work experience in nursing home stated:
"As far as I seen, majority of the elderly people are here are so exhausted or had a history of strokes or Alzheimer disease" (p 4).
Another care giver said about cases of elders transferred in nursing home:
"An elder, who is healthy and takes care of himself, is usually easier to keep, either at his own home or alternatively at his children's homes, but if you exhausted, they feel [it is] hard to keep you one by one and take you here" (p 2).
1-2-Family problems: Most of care givers also stated that family disputes due to living with the elderly, the financial problems of maintaining the elderly at home, and the limitation of the relatives at home were some other reasons for transferring the elderly to the nursing home.
In this regard, one of the care givers said:
"Some elderly people have taken here because of do not have the facilities to keep and the cost of their medication and treatment "(p1).
One of the care givers said pointing to two old women that looked healthy:
"These two [God’s] servants (women) lived in their children's homes, but the one (referring to the woman who was older), when she was taken, god [knows], her daughter was not satisfied with the heart, but she said that since our mother has came to our house, we could neither go anywhere nor hospitalize [someone] well. She doesn't have patience and tells something to our guests. She herself tells [that] she wasn't going to come somewhere, my children and my husband constantly complained" (p 5)
2- The causes of transfer from the viewpoint of the elder people:
The second category extracted from data, consisted of two subcategories, compulsory transfer and voluntary transfer to the nursing home.
2-1- compulsory transfer to the nursing home: In this regard, the elderly mentioned certain cases such as disease and uselessness of the children’s viewpoint, deceiving and convincing by their children and their care givers at home and lack of being appreciated by their children.
One of the old women said about this:
"My daughter’s husband has also died, both of us are lonely, but she brought me here because he is so wrecked" (p11).
One of the old men, while tears surrounding his eyes, stated:
"Lady! the world isn't loyal !as long as your life, you make effort for your children to achieve a position, then, they take you here, they neither have affection nor understand appreciation, They have the right, I’m sick, I have shared my property as well, I have no benefit for them anymore" (p19).
2-2 - voluntary transfer to the nursing home: A number of the elderly had given consent and volunteered to move to the nursing home for certain reasons such as loneliness, disappointment from children and security feeling in the nursing home.
One of the old women said with a bitter laugh:
"I myself insisted on coming here. It’s much better than loneliness at home. Even here, if you have stroke or your blood sugar goes down and you faint, someone will come to help you. At home, it's possible that two days pass since your death [and] then they'll find out "(p17).
One of the old men said about cause of his transfer: "Lady! I myself came to this place because I had no place. I was vendor a few times, but nothing was obtained. I finally got here. I also have family. But when they knew [that] I’m here, they became happy from bottom of heart because I had no place" (p 13).
Discussion
Among the reasons of elderly transferred to nursing homes were elderly problems including physical and mental ones. Similar research results also confirmed this issue. According to Salarvand, as older adults are affected with chronic illnesses or disabilities and there is no possibility to run an independent life, nursing homes are the only alternative for independent living so the evidence has often indicated that transfer decision to such centers, in many cases, has been made after increased burden of care such as hospitalization or exacerbated disabilities (8) or death of wife (6). The results of another study by Smalbrugge and Jongenelis in Netherlands also showed that 40.5% of the residents in nursing centers had mild symptoms of pain and 27.5% of them severe levels of depression (21). Therefore, it was recommended to train caregivers working in these centers about diagnosis, early treatment, and prevention of the consequences of physical and mental problems in older adults in order to prevent unwanted complications of these problems as well as exacerbated burden of illnesses in the elderly.
Financial problems and family constraints were the other causes for transferring to nursing homes. Salarvand and abedi also reported that some elderly people were living in nursing centers because of family issues and lack of financial affords to live independently (8). Mokhtari and Ghasemi also concluded in their study that socioeconomic status of all older adults residing in nursing centers was at poor level (13). To confirm this issue; Darvishpoor Kakhki and Abed saeedi concluded that children, financial problems, and loss of spouse were endangering the control of life in the elderly (22). The significant difference between routines and lifestyles in older adults and their children, changes in the family structure and houses from traditional to apartments in the current social conditions of Iran caused the elderly unable to live independently at their children’s homes like that in the past. On the other hand, some financial problems could not permit them to live alone and independently. Therefore, it is essential to inform the elderly at least before their transfer in order to minimize the adverse effects of this involuntary displacement.
In our study; disappointment from children, loneliness, homelessness, and no security were among the causes of voluntary transfer of the elderly to nursing facilities which had been underscored in similar investigations. Adib Hajbaghery and Rejaee in their study, pointed out to lack of gratitude and affection by children extracted from the statements raised by older adults (23). In other investigations; absence of caregivers, loneliness, homelessness (24); absence of spouse or other family members providing informal support for the elderly were considered among the most important factors affecting residence in nursing facilities (13). Accordingly, older adults could find new friends and develop their social relationships in the given centers (25). The older adults could feel more comfortable and security after admission to nursing centers (26).
In a similar investigation, a group of researchers examined authority and lack of authority by the elderly about going to nursing homes and its effects on their behaviors. They were faced with the fact that there was no voluntary transfer despite the diversity of reasons for admission and the elders were in a position wherein they had no other alternatives and it was the best choice (27).
However, in some cases, the elderly has emphasized on compulsory transfer them. Studies in this domain have also shed light on this point. In the similar investigation, the common main concepts by all participants were lack of a role in their future life and were residence in such centers against their will (8).
Conclusion
Most of elderlies residing are not happy with their transfer to nursing homes, although some are satisfy with their transfer. Elderlies’ physical disease and loneliness, homelessness, and no security were among the causes transfer of the elderly to nursing facilities. Using the elder´s experiences for creating a sense of being useful in them and if it needed to transfer the elderly in the nursing homes, it is necessary, arrangements with them beforehand and to obtain their consent and to coordinate with authorities and families, for regular and weekly meeting plan.
Study limitations
One of the limitations of the study is that it was conducted only in the elderly homes of Bam and the results may not be generalized to other cities in Iran. Also elderly families did not included the study, which may have had different viewpoints. Therefore, it is recommended that the study be replicated with samples living in other regions of Iran and their families.
Conflict of interest
There is no conflict of interest to be declared.
Acknowledgment
This research was funded by Bam University of Medical Sciences. We thank Mrs. Farashi Supervisor of sepehr charity and nursing home , elders and care givers who helped us collect the data for this study.
Authors' contributions
All authors read and approved the final manuscript.
Study design: MR, NM
Data collection and analysis: MR, NM
Manuscript preparation: NM
Manuscript editing: MR