Art & science | research

Reflections of older people living in nursing homes Christina Melin-Johansson and colleagues present the findings from a qualitative study that provides an insight into how residents experience ageing Correspondence [email protected] Christina Melin-Johansson is senior lecturer, Department of Nursing Sciences, Mid-Sweden University, Östersund, Sweden Ulrika Eriksson is lecturer, Department of Nursing Sciences, Mid-Sweden University, Östersund, Sweden Inger Segerbäck is registered nurse, Geriatric and Rehabilitation Unit, Ystad Hospital, Ystad, Sweden Sara Boström is registered nurse, Homecare, Östhammar Municipality, Alunda, Sweden Date of submission September 9 2013 Date of acceptance October 2 2013 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines nop.rcnpublishing.com

Abstract Aim To explore experiences of ageing in older people living in nursing homes, based on the gerotranscendence theory. Method Interviews were held with 14 people aged between 80 and 96 years. The results were analysed using content analysis. Findings The findings were divided into three categories: the self, the cosmic dimension, and social and personal relationships. These three categories were underpinned by eight subcategories. Most participants described improved knowledge about themselves, decreased concern about body and appearance, acceptance and appreciation of life, and less regard for social norms. A fewer participants IN WESTERN society today, people are living longer and the number of older people is increasing, along with age-related diseases and conditions such as dementia, depression, loneliness and social isolation (Gustafson and Olofsson 2012). The societal debate surrounding older people and ageing should focus more on opportunities and resources, and less on disability and costs (Swedish National Board of Health and Welfare 2001). It is generally thought that activity, rehabilitation and socialising are important factors for the wellbeing of older people. However, there should also be opportunities for reflection and spirituality, and to encourage discussions about the past and the future, including death, so that older people can connect with their own life story, and thus achieve wisdom and maturity.

Literature review Various theories about ageing have been developed over the years, such as the activity theory presented NURSING OLDER PEOPLE

described a greater affinity with past generations, or thought that the borders between past and present had become blurred. Conclusion This study provides a better understanding of how people experience old age. It also indicates how healthcare professionals could apply the gerotranscendence theory of ageing as a conversation model to enable care to be adjusted according to older people’s wishes. Keywords Ageing, care homes, community settings, gerotranscendence, nursing homes, qualitative methods by Havighurst and Albrecht (1953) and the disengagement theory (Cumming and Henry 1961). These theories explore different aspects of ageing. The activity theory focuses on social activities during retirement and the connection between self-perception and life satisfaction (Havighurst and Albrecht 1953). Disengagement theory on the other hand suggests that, when ageing, people become less active and withdraw from their social role to prepare for death (Cumming and Henry 1961). Tornstam (2005) did not accept the disengagement theory because it suggests that when ageing the person turns inwards and retreats from a social life, and developed the gerotranscendence theory (Tornstam 1989) in opposition to the activity theory, which denies ageing for as long as possible (Havighurst and Albrecht 1953). The gerotranscendence theory has been used in studies with older people from early old age to late old age and with nursing staff (Tornstam 1996, February 2014 | Volume 26 | Number 1 33

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Art & science | research 1997, 1999, 2000, 2003, 2005, 2011, Tornstam and Törnqvist 2000). The theory is predicated on the assumption that ageing is not necessarily a negative downward spiral, but can be a positive change, a transformation from a materialistic point of view – for example, owning fewer possessions – to a more cosmic understanding of life – for example, a redefinition of time and space. The degree and extent of this transformation may vary between individuals. Tornstam (1997) proposed that men and women develop gerotranscendence in a comparable way during life; however, after the age of 75 women continue their transcendence whereas men do not. The theory of gerotranscendence suggests an increased progression towards internal wellness and maturity with age (Tornstam 2005), and that to achieve gerotranscendence is to attain wisdom (Tornstam 1996, 1997, 2003, Tornstam and Törnqvist 2000, Wadensten and Carlsson 2007). The theory includes three main dimensions underpinned by five characteristic signs of change that are evident in older people in each dimension (Tornstam 2000, 2005) (Box 1). The older people and nurses who participated in Tornstam’s studies (1996, 1997) had, before agreeing to take part, received detailed information about the gerotranscendence theory or had shown an interest in participating in a study, knowing that the aim was to explore the extent to which they could relate to the characteristics of the theory. The present study explored experiences of ageing in older people who did not have any knowledge about the gerotranscendence theory before being interviewed. An additional aim was to discover whether it would be possible to use the theory as a basis for conversations about ageing with older people.

Aim The aim of this study was to explore experiences of ageing in older people living in nursing homes, based on the gerotranscendence theory.

Method Older people living in a 48-bed nursing home in the county of Simirishamn and in a 47-bed nursing home in the county of Östhammar in the south of Sweden, who were willing to speak about the process of ageing, were included in the study. Inclusion criteria for participants were that they had to be aged 65 or older, speak and understand Swedish, and have no diagnosis of dementia or other cognitive problems. Eighteen people met the criteria and expressed a willingness to participate 34 February 2014 | Volume 26 | Number 1

Box 1 Dimensions of gerotranscendence theory and their characteristic signs The cosmic dimension ■■ Time and childhood: transcendence of borders between past and present. ■■ Connection with past generations: increased attachment. ■■ Life and death: fear of death disappears and new understanding of life and death results. ■■ Mystery in life: acceptance of mystery dimension of life. ■■ Rejoicing: from grand events to subtle experiences. The self ■■ Self-confrontation: discovery of good and bad aspects of the self. ■■ Decrease of self-centredness: removal of self from centre of one’s universe. ■■ Development of body transcendence: taking care of the body continues, but individual is not obsessed with it. ■■ Self-transcendence: a shift may occur from egoism to altruism. ■■ Ego integrity: realisation that the pieces of life’s jigsaw form a whole. Social and personal relationships ■■ Changed meaning and importance of relationships: less interested in superficial relationships and increased need for solitude. ■■ Role playing: understanding of the necessity of roles in life. ■■ Emancipated innocence: new capacity to transcend needless social conventions. ■■ Modern asceticism: having enough for life’s necessities but not more. ■■ Everyday wisdom: transcendence of right-wrong duality, increased broadmindedness and tolerance. (Tornstam 2005)

in the study, however, four declined to take part at a later stage for reasons unknown. A total of 14 people – seven women and seven men – took part in the study, aged between 80 and 96 years. Permission to carry out the study was obtained from the head of each nursing home. At the same time, verbal and written information about the aim of and procedures involved in the study was given to the head of each nursing home, as well as a letter about participation that was given to residents. One head at each of the nursing homes signed a form giving consent for implementation of the study, and verbal information about the study was provided NURSING OLDER PEOPLE

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to nurses and nursing staff. Participants were verbally informed about the aim of the study and the procedures involved, and they gave informed consent verbally and in writing. An interview guide was developed, discussed and revised several times before the semi-structured interviews took place. The guide was based on the gerotranscendence theory (Tornstam 2000) without any changes to the core of the theory. It included questions addressing all three dimensions of the theory. The interviews were conducted by two of the authors (IS and SB). The interviews explored the dimension of self, with questions such as ‘How are you experiencing getting older?’ and ‘What do you think about yourself as a person?’ This was followed by the cosmic dimension, with questions such as ‘What gives you joy in life?’ and ‘What do you think about death?’ The interviews ended with discussion of social and personal relationships, with questions such as ‘Do you feel more open or tolerant in social relationships with increased age?’ and ‘What are your thoughts on openness in social relationships?’ Follow-up questions were used such as ‘Tell me more’, ‘What do you think about that?’, and ‘How do you feel about that?’ to encourage participants to speak in greater detail. Each interview lasted about 45 minutes, and all interviews were audiotaped and transcribed. The text was deductively analysed by content analysis, according to the methods of Hsieh and Shannon (2005). First, the interview text was organised under each dimension and characteristic sign, according to Tornstam’s (2000) theory, and from this text units of meaning were extracted and coded. All codes were checked against the units of meaning, dimensions and characteristic signs, and some codes were changed. This analysis Table 1

was repeated several times. All dimensions and characteristic signs were discussed and revised many times by the authors until agreement was reached. An example of this process of analysis is shown in Table 1. Ethical considerations The study was approved by the local research ethics committee of Mid Sweden University (MIUN 2011/594).

Findings Table 2 (page 36) presents an overview of the findings. The self Self-confrontation and self-centredness In remembering their life experiences, participants often confronted themselves about their behaviour in different situations. As a consequence, they became more aware of the different sides of their personality, good and bad, and they were able to analyse past behaviour and manners. Some participants expressed how they became less self-centred as they got older, which they explained was a result of no longer being needed to do any work or having to be at their former workplace every day. One said that she was still self-centred and put herself and her needs first. Others did not experience this at all; however, unlike the male participants, some female participants discussed feelings of being self-centred. Their focus in the earlier stages of life had been on the wellbeing of parents, spouses and children. In the past, there had been no time to think about themselves, because there was always someone else who needed attention and took priority. Acceptance of the body Some participants described how they had become less interested in their bodies

Example of the process of analysis of meaning units, codes, characteristic signs and dimensions of gerotranscendence theory

Meaning units

Codes

Characteristic signs

Dimensions

No, it was my brother and I. He is dead now. He died five years ago. I think a lot about what happened, and I understand my parents better now.

■■ Me and my brother. ■■ Death. ■■ Parents.

■■ Connection with past generations.

■■ The cosmic dimension.

I think I am more tolerant, more accepting. When I worked, I knew how things should be in that or in this way. In a way it was easier to care about. But that is in the past.

■■ Tolerance. ■■ Acceptance. ■■ Passé.

■■ Everyday wisdom.

■■ Social and personal relationships.

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February 2014 | Volume 26 | Number 1 35

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Art & science | research Table 2

An overview of questions and answers given in conversation with older people: dimensions, characteristic signs and related quotations

Questions

Dimensions

Characteristic signs

Quotations

How are you experiencing getting older?

The self

Self-confrontation and decrease of self-centredness

No, I’ve never experienced myself as important, not now or in the past. Other people have always been more important – parents, employer, my husband, my daughter – I was never important. I never thought of myself (participant D).

Acceptance of the body

I am less particular about what clothes or hairstyle to wear, and whether the make-up is perfect (participant B).

Time for reminiscence

My wife and I enjoyed dancing, and we danced a lot, which gave us a lot of new friends and acquaintances. But then… when one [partner of a couple] passes away, these friends one after another disappear. I’m a bit lonely (participant G).

Connection with past generations

Yes, I can kind of feel that sometimes. That I have become more like my mother. I’ve been… I have mostly worked as a maid. I’ve learned a lot, and if I may brag, I’ve been good at cooking and baking (participant D).

Feelings of joy and security

I had a happy childhood…We had a lot of fun (participant E). When you take a walk out in the forest, everything is still and quiet. It is a powerful feeling to take a walk in the forest. The thoughts are running, you perceive things in the forest that you never really thought of when you were younger (participant G).

Life and death

I dearly hope that I don’t have to suffer before I leave life on earth. That’s the only thing (participant H).

Changed relationships

I enjoy being alone. In peace (participant F). I think I am more tolerant, more accepting (participant A).

Everyday wisdom

I’m not that interested in money, but I think it is nice to give it away to my grandchildren and children (participant F).

What do you think about yourself as a person? What gives you joy in life?

The cosmic dimension

What do you think about death? Do you feel more open or tolerant in social relationships with increased age?

Social and personal relationships

as they got older. In the men, this manifested as not shaving as often as they used to, or not caring much about what clothes to wear. Grooming was not that important any more, and they had a more relaxed attitude. The women, however, were more attentive than the men about their appearance; it was important to wash their body and hair frequently, to take care of their feet and to buy new clothes when needed. However, they also commented that nowadays they had become less particular about what clothes to wear, what hairstyle they had, whether their make-up was perfect, and they admitted that they needed support from staff and family with activities such as dressing and personal care. 36 February 2014 | Volume 26 | Number 1

The cosmic dimension Time for reminiscence Participants had a lot of time to think about their younger selves, and recalling memories made them lapse back into the past. One participant mentioned that she had re-experienced a happy feeling, remembering times when her children were young. Reminiscing also awakened memories of people who had died. Participants also talked about positive memories of different job assignments when they were younger; remembering how it was when they were able to work and the colleagues they worked with, was something they often thought about. Some participants perceived that they lived in the past and the present at the same time, but the lines between past and present were clear. NURSING OLDER PEOPLE

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Connection with past generations A sense of connection with past generations was also described by a few of the participants, where they perceived that they were becoming more like their parents. As a result, they developed a new understanding of their parents’ thoughts, values and lifestyles. Previously, they had problems understanding their parents’ reasoning, but now they could see themselves in their parents’ behaviour. Participants explained this as being more mature, having life experience and being aware of the shifting conditions that life brings. Feelings of joy and security As participants aged they were able to appreciate the small things in daily life that brought joy. They did not feel a need to have great ambitions any longer such as a career, earning money, raising children and doing housework. In fact, they had no formal duties. With age and maturation they relived and thought a lot about their childhood. Many thought of it with joy, others with sadness, and many discussed their childhood home, school or playing with siblings. Moving to a nursing home was described by some as a great relief because they were now in a safe and secure place where they did not have to worry about property, possessions or daily duties that had to be performed. This feeling of being safe and secure enabled them to dedicate their time to activities such as reading, embroidery, listening to the radio or taking a walk with someone. Life and death Most participants said that they were not afraid of dying, and that they were preparing themselves to leave life. Some said they took one day at a time and were grateful for every day that passed, whereas others did not want to talk about their eventual death. Some of the widows or widowers described having experienced a loss of meaning in life when their spouses had died. Illness and pain also made life difficult for them, and there was a general wish that suffering would not precede death. Social and personal relationships Changed relationships Moving to a nursing home aroused feelings of loneliness and isolation in some participants. Isolation was often caused by disabilities, such as impaired vision or hearing. Some also commented that it was difficult to find others to talk to at the nursing home because some of the residents had memory problems. Only a few perceived that being alone was their personal choice and that they wanted to spend time alone in their rooms to reflect. NURSING OLDER PEOPLE

Some described being less strict about following accepted social codes or even being able to breach social norms. One participant commented that when you are old it becomes less important to care about what people think of your behaviour. For example, you do not have to worry about the room being untidy or leaving the toilet door open, even if there are people around. Everyday wisdom As participants aged, they related feeling less eager to express their thoughts about what they perceived as right and wrong, thus some thought that they had always been open-minded and liberal. A few perceived that it was best to let others make decisions about daily matters such as the economy or what to eat for dinner, since they thought others had more knowledge of these matters. They also expressed opinions about the importance of being self-confident when engaging in a discussion with others, and that they wanted to ‘do good’. They had neither the time nor the strength to spend their assets, so they distributed their money and possessions to children and grandchildren. They valued the fact that they thought more about others than about themselves. They also found it more important to have enough assets to live a pleasant life, and there was a general opinion that money and possessions were unimportant and only a practical necessity.

Discussion Participants were not introduced to the theory of gerotranscendence before taking part in the study, unlike those in previous studies, for example, Tornstam (1997). Therefore, they were not familiar with the theory’s concepts and had a different pre-understanding of the subject. This may be important with regard to study outcomes. In the interviews, the order of the dimensions in the theory of gerotranscendence was changed. The conversations initially focused on participants’ inner life with the purpose of opening dialogue, then proceeded towards dimensions concerning external life. This approach made it easier for them to speak more spontaneously. The limitation of using deductive qualitative content analysis may be that researchers are more likely to find statements that confirm the

Moving to a nursing home was described by some participants as a great relief because they were now in a safe and secure place February 2014 | Volume 26 | Number 1 37

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Art & science | research Participants enjoyed the little things in life and thought a lot about their childhood, which gave many joy theory under investigation. Future studies could use inductive content analysis when exploring older people’s reflections about ageing using the questions posed in this study. The main findings of this study were that older people had better knowledge about themselves, were less self-centred and less concerned about body and appearance than they were when they were younger. They sensed a connection with and reflected about their younger selves, and accepted and appreciated life. Furthermore, most did not fear death, did not feel lonely and did not care for social norms or material possessions. Participants spoke less about the fact that, mentally, they had returned to childhood and events (time and childhood); being aware that life’s puzzle had shaped the person (ego integrity); having a greater understanding of the difference between the self and the roles one plays (role playing); having a decreased interest in possessions and money (modern asceticism); and having a reduced need to maintain social conventions (emancipated innocence). A few experienced a greater affinity with previous generations, or thought that the borders between past and present became blurred as they aged. When participants talked about getting older they reflected on what they had confronted during their lifetime and were ultimately less self-centred. This may mean that, with age, they accepted the negative and positive aspects of their behaviour and personality. Ageing may come as a relief for some people in that they are not forced to live up to others’ expectations and thus have a more relaxed attitude towards accepting themselves and their mistakes (Tornstam 1997). Physical changes were sometimes symptomatic of diseases such as cancer, which is often perceived as a major threat to life. The findings indicate that healthcare professionals should focus less on the body and its function when talking to older people, and more on discussions about wellbeing (for example, Wadensten and Carlsson 2003). Older people may be reluctant to admit that they experience living in the past and the present at the same time because this could be wrongly labelled as senility or dementia. The joy in life was a transition from enjoying ‘the macro cosmos’ to appreciating 38 February 2014 | Volume 26 | Number 1

‘the micro cosmos’ (Tornstam 2011). Participants enjoyed the little things in life and thought a lot about their childhood, which gave many joy, even if a few also became sad; these findings are similar to those previously reported by Tornstam (1997, 2003) and Wadensten (2005). This is not surprising considering the physical inability of older people to participate in major events outside their homes, such as going to the theatre. Some participants were not able to watch television, read books or listen to music because of impaired vision or hearing, and this was viewed as transcending into old age. However, such activities can prevent depression during the latter stages of life (Gautam et al 2007), and so should be encouraged. Death and the meaning of life were important issues for the older people in this study; they had become less afraid of death and dying during the ageing process, and were prepared for death, which could be considered part of gerotranscendence. MacKinlay and Trevitt (2007) found that, despite weakness and disease, older people establish ways of handling life situations, and death and dying. Participants were more tolerant of social relationships with increased age and, when reflecting on their openness in social relationships, a few felt affinity with past generations (for example, Tornstam 2003). Feeling connected to past or future generations adds an important dimension to life; it is a positive sign of being a whole person and not a sign of illness or loneliness (Tornstam and Törnqvist 2000). Spending a lot of time alone may lead to feelings of loneliness, but some felt an inner peace when they were alone, explaining that being on their own was their personal choice. Spending time alone was sometimes due to a physical condition; however, there is also a need to be alone and healthcare professionals should be able to distinguish between the two. The need to be alone may also be affected by social factors, illness, life crises or not being satisfied with one’s life situation (Tornstam 1997, 2003). Wadensten (2005) found that older people need to be alone to reflect and rest. Isolation may also be a sign that some older people have reformulated their social needs and no longer feel obliged to follow the social norms of engagement. Participants distributed their possessions to their families, because material possessions were not important to them as they transcended into old age. In Western society, it is believed that activity, rehabilitation and socialising with others are important factors for older people’s wellbeing. It is also necessary, however, to include opportunities for reflection and spirituality, for example, to encourage NURSING OLDER PEOPLE

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discussions about the past, including childhood and death, and to offer opportunities for silence and meditation with the goal of connecting to one’s life story, and thus achieving wisdom and maturity.

Conclusion This study provides a better understanding of how people experience old age and how staff can support older people using the gerotranscendence theory as a model for conversation. The results can inform healthcare professionals through increased understanding of older people’s experiences of personal development in life and of getting older, and how they want to be treated by others. The signs of gerotranscendence should be considered part of the normal ageing process and not as something wrong or pathological that must be corrected. The findings appear consistent with older people’s views of themselves, which may be something that staff must have knowledge of and understand.

Implications for practice ■■ Gerotranscendence theory can be used as a conversation model when caring for older people in nursing homes. ■■ Questions such as: ‘How are you experiencing getting older?’; ‘What do you think about yourself as a person?’; ‘What gives you joy in life?’; ‘What do you think about death?’; ‘Do you feel more open or tolerant in social relationships with increased age?’; and ‘What do you think of your openness in social relationships?’, can be used when talking with older people and assist staff when conducting care based on the needs of individuals according to their wishes. ■■ Existing guidelines for care of older people should include how to support them when reflecting on ageing to encourage them along a path towards maturity and wisdom.

Online archive For related information, visit our online archive and search using the keywords Conflict of interest None declared

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Tornstam L (1989) Gero-transcendence: a reformulation of the disengagement theory. Aging. 1, 1, 55-63. Tornstam L (1996) Caring for the elderly. Introducing the theory of gerotranscendence as a supplementary frame of reference for caring for the elderly. Scandinavian Journal of Caring Sciences. 10, 3, 144-150.

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Reflections of older people living in nursing homes.

To explore experiences of ageing in older people living in nursing homes, based on the gerotranscendence theory...
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