PhD

dissertationThe purpose of this study was to describe phases in adjustment of older adults living in a nursing home during the first 6-8 months; describe residents' perceptions of the nursing home environment; and develop a nursing model to help older adults adjust to living in a nursing home. This was a longitudinal participant-observation clinical study. The nurse-researcher assumed the role of care provider while collecting data over 10-months. The sample consisted of 41 newly admitted adults (mean age 84.5), 11 males, 31 females, and 4 married couples, followed in one 155 bed intermediate care nursing home. Data were also gathered on mental and functional status, level of depression, characteristics of the environment, family visits, perceived state of health, voluntary nature of the move, falls, daily medications ordered, and tranquilizers taken weekly. Phases describing adaptation to living in a nursing home were divided into four major concepts. Newly admitted residents were highly upset for about 4 to 6 weeks and developed behavioral patterns of turning-in toward themselves. This was called 'disorganization.' Residents in this phase were challenged to deal with losses of self, relationships and accustomed space. Residents then appeared to begin problem-solving, and directing some of their own care, 'reorganization,' and were challenged to find meaning in the experience. During the 'relationship-building' phase, about month 3, residents established supportive ties with family, staff and other residents. Married couples offered each other support, but faced changes such as loss of physical and mental capacity that challenged their relationship. About the third or fourth month, residents seemed to 'fit-in' to the nursing home environment, 'stabilization,' being motivated to become established while maintaining self-definition. Residents returned to disorganization during any emotional or physical setback. The perceived voluntary (70% of the sample) or involuntary (30% of the sample) nature of the move was a key to understanding various responses to institutionalization. Nursing care should focus on the residents' cognitive, physical and emotional perceptions of reality and vary according to which phase residents are experiencing. The goal of nursing care during disorganization is helping the resident grieve the losses and learn about a new environment; during reorganization is supporting problem-solving efforts, helping find meaning in the experience of living in a nursing home, and supporting attempts at managing care; during relationship building supporting intimacy, mediating conflict, and supporting through loss; and during stabilization supporting integrity and acknowledging decline