Sense of Belonging in the Transition to Residential Aged Care Matthew Condie and Rob Ranzijn University of South Australia National Conference of the Australian Association of Gerontology, Sydney NSW Nov 27 2013
Background The transition from independent living to residential care is a significant life event for many older adults It is often sudden, unplanned and frequently traumatic Residents in aged care facilities experience about double the rates of depression of those still living in their own homes Some of this may be due to the disruption that the transition causes.
Background Lack of knowledge about the experiences of people going through this transition Understanding the transition process may help to ease the transition and reduce the rate of depression Literature suggests sense of belonging (forming a positive connection with the new environment) may be a protective factor
Sense of belonging Close physical proximity does not guarantee a psychological sense of belonging Active involvement with others produces Active involvement with others produces sense of belonging, which is a factor in wellbeing
Sense of belonging Residential facilities increasingly provide gyms and structured activities, hence physical proximity, but rates of depression remain high Gap in research into sense of belonging in the transition to residential care
Research questions What is the impact of transitioning from living at home to a residential facility on participants ability to develop and maintain a sense of belonging in their new environment? To what extent is sense of belonging a protective factor against depressive symptomatology?
Method Qualitative design, semi-structured interviews Initial informal conversation to establish relationship with resident, followed up later by formal audiotaped interview 6-month follow-up interviews Thematic analysis of transcripts
Participants Residents of facilities using positive ageing collaborative principles of aged care Exclusion criteria: younger than 65, cognitive impairment (MMSE <21), not fluent in English, resident more than 8 weeks 5 men, 3 women, aged 77-95 years all but 1 participated in 6-month follow-up
Examples of interview questions What do you miss most about living independently? How did you feel about coming into residential care? Thinking back to when you first arrived at [the residential centre], has there been a time where you felt that you didn t feel connected to the staff and/or residents at [the residential centre]? Tell me a bit more about that?
Results of first set of interviews: Five main themes negative perceptions of aged care facility grief and loss social relationships the physical environment depressive symptomatology
1. Negative perceptions of aged care facility Confined like animals: You re like a dog locked in a kennel, you can t do what you want to do. (P3-95yo) Like being in gaol: I suppose I have to say Like being in gaol: I suppose I have to say do the time We could be referred to caged birds in here. Sure we have the codes to go out, but if birds stay in their cage for long enough, when you open the door, they would have forgotten what it s like to leave the cage and fly around. (P4-82yo).
2. Grief and loss loss of independence, loss of their previous lifestyle at home, and loss of ability to perform daily activities I can only wish that I could go home now, I can only wish that I could go home now, but I know that s not the case because I can t get on I can t dress myself. If I could do things for myself I d be off. What am I used to now? I can t do nothing (P3-95yo)
2. Grief and loss loss of independence, loss of their previous lifestyle at home, and loss of ability to perform daily activities I had my garden and my dog. Those are the two differences and those are the things I miss most. (P1-87yo) I m signing the papers away today. Signing my life away as they say. (P8-80yo)
3. Social relationships Disruption of previous close relationships: It was the whole shock of it all for me, thinking I was going to be parted from [my spouse] I miss my [spouse]. It s hard, very hard. Especially when we haven t been away from each other. (P3-95yo) I ll miss my daughter of course We had a few cries until she gets used to me not being there You would have to feel connected to someone if you lived with them for that long [18-years]. (P8-80yo)
3. Social relationships Minimal interaction with other residents: They just do their own thing you know. Stay in room, keep to themself I don t think I know anybody of staff here No staff. Everybody running around and I don t know who s who. (P5-88yo) You re mixing with old people They re a certain age. They re in their own little world... I talk to them but that s it. (P4-82yo).
4. The physical environment Important of respite care: I came in here on respite, and whilst I was here I had the discussion with my family So it was decided that if I was agreeable I should stay on here. (P1-87yo) Importance of living within close vicinity to their previous home and having family support nearby: I said to the [spouse], if I have a row with them [the staff] I can walk home it s nice and close to home. (P3-95yo)
5. Depressive symptomatology Emerged from responses to questions not directly related to depression: I ve never told my family that I m depressed so they wouldn t worry. Because there is nothing they can do about it I m hoping that this depression will lift in time. (P1-87yo) Well I ve been sleeping a lot since I ve been in here Your mental capacity seems to drop Not much stuff to occupy your mind. (P4-82yo)
Results of 6-month follow-up interviews Factors in smooth transition Factors in disruptive transition Depressive symptomatology
1. Factors in smooth transition Acceptance of changed circumstances: I ve just realised I can t do what I used to do, and now I ve embraced what I can do I ve accepted life here Being at peace with one s circumstances But this is my room now. This is my place of residence now. (P1-87yo) I belong here because I live here. I feel part of here now. (P2-95yo)
1. Factors in smooth transition Motivation to engage: You ve just gotta get around and meet people and join in... Once you get in here and get around you got no time to worry about yourself actually (P8-80yo). I m not going to sit down and die in this dear little room if I could have been somewhere else [in the facility]. (P6-77yo)
1. Factors in smooth transition Increased social participation compared to home: There s always someone around I m doing more here than when I was at home (P1-87yo) There s always something to do and you re always in communication with someone all day long which was different to the life I had at home because I had to go out for company, but here it s everywhere. (P2-95yo)
2. Factors in disruptive transition Ongoing negative perception of aged care facility: It is a bit like a prison. Once the door shuts behind you, you can t get out. I have that feeling about it You re locked in one little cell. (P3-95yo)
2. Factors in disruptive transition Perception that other residents don t want to engage:... Hardly see them [other residents] All they do is stay in their room, and I ve walked around a bit but everyone seems to be staying in their room. When I go for a walk outside I don t meet a soul so most of them must spend most of their time in their room. (P1-95yo)
3. Depressive symptomatology Fewer symptoms in people who had experienced a smooth transition Initial difficult transition puts residents at risk: [Points to the ground]... Low. Being here is not the best for me. Some might be able to accept it but I can t. It s lower that when I was livin at home. To be at home, it was higher I m sad nearly all the time You can t go around and say, oh I m happy. Oh it s wonderful. (P4-82yo).
Discussion Successful transition seems to depend on willingness to engage with the new environment, acceptance of changed circumstances, and initial level of depressive symptomatology These factors interact in a reciprocal way, so intervening at one point may influence the other factors
Discussion The five participants whose transition was smooth reported fewer depressive symptoms at the follow-up interview The two participants whose transition was The two participants whose transition was disruptive did not have reduced depressive symptoms and seemed to attribute them to their new physical environment.
Implications Need for comprehensive assessment of psychological state, not just physical health and function, on admission Pharmacological intervention remains the Pharmacological intervention remains the primary form of treatment for depression, yet this study points to the potential usefulness of psychological intervention
Implications Psychological interventions into depression may not only reduce depressive symptoms but also increase social engagement and sense of belonging
Psychologists in the transition to residential care Explore grief and loss impacts of transitioning into full-time care Reframe negative perceptions of residential facilities (eg a better life than before - see later paper) Develop adaptive coping strategies to optimise their well-being in their new environment