Introduction
Difficulties associated with aging may make community-dwelling no longer possible for some older adults, especially when home care options are not accessible in rural areas (O’Neill, Ryan, Tracey, & Laird, Reference O’Neill, Ryan, Tracey and Laird2020). These difficulties can result from chronic physical and/or mental health diagnoses that create the need for more care (Lee, Simpson, & Froggatt, Reference Lee, Simpson and Froggatt2013). In the United States and Canada, over two million older adults live in residential, continuum of care retirement communities (Harris-Kojetin et al., Reference Harris-Kojetin, Sengupta, Lendon, Rome, Valverde and Caffrey2019, Resnick et al., Reference Resnick, Boltz, Galik, Holmes, Fix and Zhu2019). Continuum of care retirement communities include various areas of care like assisted living homes (ALH) and long-term care homes (LTCH) and theoretically are designed to allow older adults to transition from independent living to more supportive care as the need arises (Fields, Koenig, & Dabelko-Schoeny, Reference Fields, Koenig and Dabelko-Schoeny2012). In Canada, ALHs are also referred to as congregate care, retirement care, independent supportive living, and supportive housing (Resnick et al., Reference Resnick, Boltz, Galik, Holmes, Fix and Zhu2019).
Although ALHs are part of the continuum of care retirement communities, they are distinct from LTCHs in services provided (Stone & Reinhard, Reference Stone and Reinhard2007). An LTCH can be defined as a home where adults live that provides skilled nursing care (e.g., injections, wound care) and supportive services (e.g., assistance with bathing, feeding, toileting) (Harris-Kojetin et al., Reference Harris-Kojetin, Sengupta, Lendon, Rome, Valverde and Caffrey2019). ALHs provide some supportive services but do not provide skilled nursing care (Zimmerman et al., Reference Zimmerman, Carder, Schwartz, Silbersack, Temkin-Greener and Thomas2022). ALHs also vary in services provided and often have extra fees for additional services such as assistance with bathing, dressing, toileting, and shopping (Stevenson & Grabowski, Reference Stevenson and Grabowski2010; Zimmerman et al., Reference Zimmerman, Carder, Schwartz, Silbersack, Temkin-Greener and Thomas2022). While older adults living in ALHs have been shown to be generally healthier than those in LTCHs (Stone & Reinhard, Reference Stone and Reinhard2007), older adults living in ALHs have still demonstrated unwanted changes in health over time due to age, health conditions, and limited or non-participation in physical activity (Abken, Perkins, & Bender, Reference Abken, Perkins and Bender2022; Stevenson & Grabowski, Reference Stevenson and Grabowski2010). There is also a dearth of research understanding older adults’ transitions into ALHs in rural settings with the one article addressing older adults’ future preferences for urban verses rural ALHs (Abramsson & Andersson, Reference Abramsson and Andersson2016) and another about older adults’ transitions that included both rural and urban ALHs (O’Neill et al., Reference O’Neill, Ryan, Tracey and Laird2020).
Transitioning from independent living into an ALH can negatively impact the physical, mental, and psychosocial well-being of older adults because of various factors and circumstances surrounding the transition (Scott & Mayo, Reference Scott and Mayo2019). The transition process is understood as the one-month time surrounding older adults’ relocations into residential homes that is often accompanied with periods or events of adjustment or maladjustment (Brandburg, Reference Brandburg2007). Transitions into ALHs can occur from a number of independent living situations, including moving from a home in the community, another family member’s home, or an independent living apartment within the retirement community (Grabowski, Stevenson, & Cornell, Reference Grabowski, Stevenson and Cornell2012). During a transition into an ALH, older adults’ well-being may be influenced (Mueller, Reference Mueller2022; Mueller, Van Puymbroeck, Crowe, & Davis, Reference Mueller, Van Puymbroeck, Crowe and Davis2021). Well-being is defined as the state when older adults have their needed social, physical, and psychological resources to overcome the challenges that occur during a transition into an ALH (Dodge, Daly, Huyton, & Sanders, Reference Dodge, Daly, Huyton and Sanders2012). Prior research on older adults’ well-being and ALHs is limited, yet it does include findings about the moving into an ALH and its influence on various domains of older adults’ well-being, including physically, mentally, and psychosocially (Fields et al., Reference Fields, Koenig and Dabelko-Schoeny2012; Scott & Mayo, Reference Scott and Mayo2019; Tracy & DeYoung, Reference Tracy and DeYoung2004).
Older adults’ well-being may be negatively influenced from reductions in older adults’ physical and mental abilities that can happen both before and during the transition into the ALH (Scott & Mayo, Reference Scott and Mayo2019). In addition, negative changes in mental (Fields et al., Reference Fields, Koenig and Dabelko-Schoeny2012) and psychosocial well-being (Tracy & DeYoung, Reference Tracy and DeYoung2004) can occur after a transition due to disorientation to the new setting and residents/staff in the ALH. Changing social circles and family roles can add to the challenge of transitioning to an ALH (Fields et al., Reference Fields, Koenig and Dabelko-Schoeny2012; O’Hora & Roberto, Reference O’Hora and Roberto2019). One study found that older adults were more likely to experience feelings of loneliness in the transition process into an ALH due to decreasing family and friend visitors (Saunders & Heliker, Reference Saunders and Heliker2008). Other studies found that downsizing possessions was a challenge for older adults transitioning into an ALH (Scott & Mayo, Reference Scott and Mayo2019). Additional studies have described a decreased sense of well-being for older adults during the transition (Fields et al., Reference Fields, Koenig and Dabelko-Schoeny2012; Scott & Mayo, Reference Scott and Mayo2019), which can also carry the risk of developing future challenges, such as depression and anxiety (Jun, Lee, & Bolin, Reference Jun, Lee and Bolin2015). Alternatively, some positive outcomes have been reported as a result of transition to an ALH, such as making new friends, finding new volunteer opportunities, and feeling cared for by staff (Fields et al., Reference Fields, Koenig and Dabelko-Schoeny2012; Scott & Mayo, Reference Scott and Mayo2019).
Overall, there is limited research on older adults’ transition process into an ALH regarding influences on their well-being (Saunders & Heliker, Reference Saunders and Heliker2008; Tracy & DeYoung, Reference Tracy and DeYoung2004). Understanding all aspects of the transition process is essential for health care practitioners to better care for the well-being of older adults moving into ALHs. To address these gaps in the literature, the aim of this study was to explore negative influences on older adults’ well-being during a transition into an ALH.
Methods
This study is part of a larger research project that explored older adults’ well-being when relocating into ALHs. Results reflective of positive influences on older adults’ well-being when relocating into ALHs have been published (Mueller et al., Reference Mueller, Van Puymbroeck, Crowe and Davis2021); negative influences on older adults’ well-being during transition into an ALH are presented in this paper. A thematic analysis guided by grounded theory was used to analyse data collected from residents in an ALH in a rural town in the southeastern U.S. Strauss and Corbin’s Grounded Theory approach guided this qualitative study to allow for theories, frameworks, and models to emerge from the data (Strauss & Corbin, Reference Strauss and Corbin1990; Tie, Birks, & Francis, Reference Tie, Birks and Francis2019). This allowed for theory to be derived from the data, systematically gathered, and analysed through constructing meaning out of an intersubjective experience (such as a transition) (Cooney, Reference Cooney2010; Tie et al., Reference Tie, Birks and Francis2019).
The study was conducted at a 54-bed ALH part of a continuum of care retirement community that provides a variety of levels of care, including independent living, skilled nursing care, and subacute rehabilitation. Consistent with the majority of ALHs, this ALH did not accept payment from government programs, which may have resulted in residents being from higher socioeconomic classes. A university institutional review board approved the study.
Using a convenience sampling procedure (Creswell & Poth, Reference Creswell and Poth2016), participants were recruited through referrals by health care administrators at the ALH and educated about the premise of the study by the principal investigator (PI). If a participant met the following criteria, they were invited to sign the consent form to be included in the study: (a) score of 4 or higher on the Six-Item Screener (Callahan, Unverzagt, Hui, & Anthony, Reference Callahan, Unverzagt, Hui and Anthony2001); (b) willing to complete a media release for consent to have their interview audiorecorded; and (c) current resident at the home where the study occurred. The Six-Item Screener is a valid and reliable assessment tool for measuring cognitive abilities in older adults where a score of 4 or higher indicates no cognitive impairment (Callahan et al., Reference Callahan, Unverzagt, Hui and Anthony2001). Participant demographics were also collected that included gender, age, relationship status; whom they lived with at their previous residence; length of time since move into the ALH; number of times they had moved in their lifetime (including the move into the ALH); and the primary reason for moving into the ALH.
To develop the questions for the interview guide, the literature about influences on well-being and the circumstances that impact older adults in the transition into an ALH were extensively reviewed (cf. Fields et al., Reference Fields, Koenig and Dabelko-Schoeny2012; Mulry, Reference Mulry2012; Plys & Smith, Reference Plys and Smith2021; Saunders & Heliker, Reference Saunders and Heliker2008; Scott & Mayo, Reference Scott and Mayo2019; Tracy & DeYoung, Reference Tracy and DeYoung2004). Findings from this review directly informed the interview guide, resulting in questions in the following domains: decision to transition, moving day, feeling settled, changes in physical strength, changes in mental strength, feelings of independence, past and current leisure pursuits, and feelings of home in the ALH compared to the previous residence. Example questions included:
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1. Since you said your social circles changed during your transition into (name of ALH), how did that make you feel?
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2. Tell me about your activity and hobby participation during your move and how you felt engaging in those. Did that participation influence your well-being as you moved in?
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3. Since you said your feeling of independence changed during your move into (name of ALH), how did that make you feel? Did it influence your well-being?
Individual semi-structured interviews were then conducted in the participant’s room to ensure privacy and confidentiality. Participants were asked to recall back to the one-month surrounding their move into the ALH when answering interview questions.
Interviews were audiorecorded and transcribed verbatim, and all participants were given pseudonyms to protect confidentiality. Data were collected until saturation, as evidenced by the repetition of themes about the transition experience into the ALH. The data analysis began with repeated readings of the transcripts by the PI. The transcripts were first open coded by the PI, using the constant comparative method where similarities and differences between each participant were explored (Creswell & Poth, Reference Creswell and Poth2016). Following open coding, axial coding was used as a procedure to restructure the data by making connections between categories (Strauss & Corbin, Reference Strauss and Corbin1990). Selective coding was then used for choosing a core category and systematically relating it to other categories for validation of relationships (Strauss & Corbin, Reference Strauss and Corbin1990). For example, the core category “Losses During the Transition” was created and other categories such as “Losing Relationships,” “Losing Possessions,” and “Losing a Sense of Freedom” were all compared to that core category.
Themes were then identified through an emergent, thematic analysis from the coded categories. The emergent thematic analysis consisted of meaning units being condensed into clusters of meaning and concentrated themes emerged from within participant data (Creswell & Poth, Reference Creswell and Poth2016). Data were synthesized once themes were classified about perceived factors that influenced well-being during the transition process into the ALH (Creswell & Poth, Reference Creswell and Poth2016). Strauss and Corbin’s approach to grounded theory helped guide this process (Cooney, Reference Cooney2010; Strauss & Corbin, Reference Strauss and Corbin1997). This grounded theory approach involves identifying concepts about an event or phenomenon to further understand the overall situation around such an event, like a transition into an ALH (Strauss & Corbin, Reference Strauss and Corbin1997).
A secondary researcher independently reviewed all the transcripts and checked for accuracy of the coded categories. This allowed the researchers to compare their findings and establish trustworthiness within the data (Creswell & Poth, Reference Creswell and Poth2016). To clarify any personal bias that may have impacted the interpretation of data, a reflexivity diary was used by the PI (interviewer) to document assumptions made. These assumptions were discussed among both researchers to ensure the findings were supported by participant data (Creswell & Poth, Reference Creswell and Poth2016). Trustworthiness of data collection and analysis was enhanced by a peer debriefing between the PI and secondary researcher, as well as a negative case analysis. The researchers purposely tried to elaborate on all the stages of the study for the confirmability of the data.
Seventeen older adults indicated interest in participating in the study and were screened for eligibility. However, three individuals were excluded from the study because they scored less than a 4 on the Six-Item Screener. Fourteen participants between the ages of 86 and 97 participated in this study with interviews averaging 20 minutes in length.
Results
Participant demographics are found in Table 1 and summarized here. Participants were primarily female (n = 10) and were all living alone in the ALH (n = 14). Participants’ length of stay in the ALH ranged between three weeks and four years for an average of two years. Participants had moved only once or twice in their lifetime before transitioning to live in the ALH. Three of the participants still owned their previous residences and hoped to return there one day.
Table 1. Participant demographics (n = 14)
The findings that emerged highlight older adults’ complex transition process into an ALH. Two central findings that negatively influenced participants’ well-being during the transition process were loss of independence (sub-themes include loss of physical and mental health, and loss of driving) and downsizing in space and possessions.
Loss of Independence
All participants identified that loss of independence negatively influenced their well-being when transitioning into the ALH. When asked about her first realization of this loss of independence after her transition, Theresa stated, I don’t feel as free to do things. It’s not anybody’s fault… but there are people coming in and out all the time. And they knock first but they’re still coming in. Because of this, Theresa perceived the intrusion of the ALH staff as a challenge that negatively influenced her well-being when transitioning into the ALH. Agatha also expressed frustrations with the staff helping her too much after she moved in:
What bothered me was that they kept wanting to do everything for me and I took my stand that I didn’t come here to be taken cared for: I came here to feed my husband. But they never took time to know…and understand that.
The new reality of needing assistance with medication management also attributed to Stewart feeling less independent. The ALH nurses distributed his medication to him multiple times a day to treat both physical and mental conditions: Well for instance…they [ALH staff] give me the medications and I’m very cognizant of them [his medications] … because I gotta now have somebody scheduled for medication help. Stewart perceived his new strict medication schedule as contributing to feelings less independent during the transition into the ALH compared to before his move into the ALH.
Participants also expressed that they felt less independent in the transition because they felt like they lost their freedom. Some participants lost their daily routines, which decreased their sense of freedom. Gertrude said, I don’t have any choice but to try to feel settled here. That’s what I miss now…having that choice in my routine. Many of the participants talked about the policies of the ALH that contributed to their decreased feelings of freedom. For example, Natalia said, Well you can’t go out of here without signing yourself out, and then signing yourself back in afterwards.
Not all the participants, however, saw this policy as a loss of freedom; some participants found the policies of the ALH to provide more opportunities for them. For example, Norman described signing out of the ALH as a way for the ALH’s shuttle to transport him around town: All I have to do is sign out if I want to go somewhere, no matter where I’m going, they will take me where I need. Josephine also stated that the daily program schedule, mandated by an ALH policy, made her feel more independent: Everything is so well planned that I don’t have to do much but show up and feel like I can participate. However, the majority of the participants expressed that the transition to the ALH constrained their well-being by feeling less independence in one or more ways.
Loss of Physical or Mental Health
Many of the participants also experienced losses in their health that made them feel less independent when transitioning to the ALH. Natalia moved into the ALH after a prolonged hospital stay from a new health diagnosis. Natalia spoke of feeling less independent during her transition after falling soon after her move in because, Once I got sick…I started using that [four-wheeled walker]. But now since I’ve fallen [here in the ALH] it’s more of like [sic] I have to have this walker now. When asked about her feelings of independence, Katherine said, I’ve just about lost all of it. Between the strokes and the arthritis, it’s inhibited me in what I can do. Additional changes in physical health, such as older adults’ reading abilities, can further influence well-being as the older adults transition into the ALH. Richard spoke of this:
Now since moving here I just don’t do much of anything. I used to read all the time, well I lost one of my eyes, my right eye, I completely lost it… so I don’t read much anymore. You know the print in a newspaper is so small anymore. I can’t make out all the words.
When asked about maintaining her feelings of independence while navigating mental health changes during her relocation, Katherine answered, I don’t feel mentally as sound [as when living in the community]. Well because I had strokes. Many strokes in fact. Bernice, who has memory loss and feelings of loneliness, explained how her mental health has influenced her well-being as she transitioned into the ALH: It’s hard and scary for me to keep things straight. Sometimes I get so mixed up. The participants overall stated that feeling a loss in physical and/or mental health resulted in negative feelings about their well-being in the transition into the ALH.
Declines in physical health also led to participants experiencing consequent changes in their social leisure pursuits. Stewart tried out many of the group leisure programs in the ALH upon initially moving in. However, Stewart explained that his hearing loss decreased his ability to attend those group programs: I don’t go to all the meetings that they have because I can’t hear. No speaker programs anymore for me, no, I now only go to the movies [sic] cause they got the captions along the bottom. Harold, whose macular degeneration was the primary reason for his transition into the ALH, cannot see well enough to fully participate in most leisure activities in the ALH: Now some of the activities I’m afraid I can’t do so I just I go to attend… I’m not sure how much I can do.
Due to these health issues when moving into the ALH, some participants decided to stop attending prior leisure programs or clubs. Natalia addressed her decline in attending the group outings because, Before I got sick…, I would go when they [ALH staff] would take you out to eat … but it’s an awful lot of trouble to put yourself all together to go eat and then come back. Overall, participants’ loss of independence through health resulted in changes to their social leisure pursuits during their transitions into ALHs.
Loss of Driving
Some participants expressed their loss of independence was exacerbated during their relocation into the ALH by not being able to drive a car. As Mary stated, As long as I could drive and all [sic] I felt that I was independent. However, upon moving into the ALH, Mary gave up driving since everything was here. Penny also shared of feeling negative influences on her independence when moving into the ALH as she had been driving my car but I have macular degeneration and I realized I did not need to drive anymore so I gave my car up…It was stressful and I did feel like it made me feel less independent, yes.
Along with a new health diagnosis, Richard described feeling less independent after losing his car when moving into the ALH because it was unexpected and disempowering: They [his children] took my driving away from me, took my cars away from me and left me sitting there with nothing to move with. Natalia, on the contrary, described her relief of not having to drive her husband to doctor appointments now once she moved into the ALH because she didn’t like driving in the mountains. I much rather stay here and wait for people [doctors and nursing staff in the ALH] to call on us.
Downsizing in Space and Possessions
Downsizing in both space and possessions was described as a negative influence on participants’ well-being when transitioning into the ALH. Participants mentioned the initial shock of the small space in the ALH apartment limited their ability to host visitors. This included Stewart who said, No not too much [sic] visitors here. I tell people that I’m here in my trailer because you see I don’t have room for a table. Dorothy added that losing her possessions during her transition was difficult because, I had to just you have to just keep cutting down and cutting down.
Downsizing in the transition into the ALH further changed participants’ social leisure pursuits. Some of these changes resulted from the small, physical environment of the ALH apartment. Katherine said that she gave up her passion for baking since moving to the ALH since she used to be able to make candy and desserts and things like that. Well I can’t do that anymore cause I don’t have a stove… I miss that. Many participants also expressed that no longer owning a vehicle led to changes in their social leisure groups. Even though the ALH provided residents with shuttle services, not all participants felt the shuttle was able to meet their transportation needs based on driver availability. Mary gave up her car due to health issues when moving into the ALH and feels the loss of the physical possession of her car as it affects her participation in church services and activities. She had been attending the same church for over 50 years:
I guess the thing I miss most about being here is I can’t go to my church…We don’t have a bus [on day needed for church service] and even though people say we’ll come and get you and pick you up, I just feel that’s an imposition on anybody.
Overall, losing space, possessions, including vehicles, during the transition into ALHs decreased most participants’ social leisure pursuits, potentially adversely influencing their well-being.
Discussion
The purpose of this study was to explore negative influences on older adults’ well-being during their transition into an ALH. Consistent with Strauss and Corbin’s grounded theory approach, the themes around the constraints to well-being appeared to align with the Hierarchical Leisure Constraints Theory (HLCT) (Crawford & Godbey, Reference Crawford and Godbey1987). This theory comprises three categories of constraints to describe hindrances to participating in leisure: intrapersonal, interpersonal, and structural constraints (Crawford & Godbey, Reference Crawford and Godbey1987). Intrapersonal constraints are individual factors that impede leisure participation (i.e., ability level, personality needs, stress, depression, prior knowledge, and supposed attitudes). Interpersonal constraints are factors that result from relational interactions or characteristics about social relationships (Crawford & Godbey, Reference Crawford and Godbey1987). Structural constraints are environmental factors that interfere between leisure preferences and participation (i.e., life stage, financial resources, scheduling availability, season, and climate) (Crawford & Godbey, Reference Crawford and Godbey1987). Prior research on leisure constraints in later life includes constraints on physical leisure activities for older adults (Adams, Crowe, Van Puymbroeck, Allison, & Schmid, Reference Adams, Crowe, Van Puymbroeck, Allison and Schmid2019; Zhou, Cai, & Cai, Reference Zhou, Cai and Cai2020) or those related to travel experiences (Kazeminia, Del Chiappa, & Jafari, Reference Kazeminia, Del Chiappa and Jafari2015). However, no prior research addresses constraints for older adults when transitioning into residential homes like an ALH. Therefore, it is interesting that the themes that emerged from this study converge with the components of this theory and provide insights into older adults’ thoughts about constraints to well-being during the transition process into an ALH.
Like other studies on transitions to ALHs (Fields et al., Reference Fields, Koenig and Dabelko-Schoeny2012; Resnick et al., Reference Resnick, Galik, Vigne and Carew2015; Scott & Mayo, Reference Scott and Mayo2019), loss of independence, an intrapersonal constraint in the transition process, was identified as a negative influence on well-being. Loss of independence included two sub-themes: loss of physical and mental health and loss of driving. These intrapersonal constraints also contributed to decreased well-being for the older adults who experienced less physical and/or mental health, and decreased independence from a loss of driving. Other studies have identified that older adults feel less independence and freedom in the transition to an ALH (Branson, Branson, Pozniak, Tookes, & Schmidt, Reference Branson, Branson, Pozniak, Tookes and Schmidt2019; Mulry, Reference Mulry2012; Phillips, Leary, Blankenship, & Zimmerman, Reference Phillips, Leary, Blankenship and Zimmerman2019; Saunders & Heliker, Reference Saunders and Heliker2008); however, the feelings of losing independence specific to not driving a car anymore had only been reported in one previous study (Scott & Mayo, Reference Scott and Mayo2019). This previous study did not specifically associate loss of driving as a constraint to well-being in the transition process into an ALH; therefore, this is a novel finding.
An additional finding was that downsizing in space and possessions, as a structural constraint, negatively influenced well-being. Downsizing, as a factor in the transition into an ALH, had been previously reported in one study as the process giving away possessions such as family heirlooms, furniture, and cars (Scott & Mayo, Reference Scott and Mayo2019). Interestingly, the present study expanded downsizing to include both personal possessions and the physical space of the ALH apartment.
This study also found that if an older adult experienced an intrapersonal and/or structural constraint, it often led to an interpersonal constraint that impacted their social leisure pursuits. Therefore, changes in social leisure pursuits (as interpersonal constraints) are identified as a secondary, ripple effect of the main themes in this study. Interpersonal constraints were evident for many of the older adults because of decreases in health (as an intrapersonal constraint) that then impacted leisure participation (as an interpersonal constraint) when transitioning into the ALH. This included older adults who were not able to physically or mentally perform a leisure skill required for successful participation in leisure groups due to a structural or intrapersonal constraint. For example, an older adult may not be able to easily frequent a restaurant or church service with family and friends, as once favorite group-oriented leisure pursuits. By discontinuing attendance in these social groups, unwanted changes in friendships may also result in the older adult moving into the ALH. This finding parallels prior studies that found older adults living in an ALH experienced discontent with the lack of continuity of former relationships (Plys & Qualls, Reference Plys and Qualls2019; Tompkins, Ihara, Cusick, & Park, Reference Tompkins, Ihara, Cusick and Park2012), but neither linked this to constraints to well-being.
The structural constraint of downsizing also changed the social leisure pursuits of many participants by limiting out-of-town family visitors as a form of social leisure. Further, the older adults could no longer cook for friends or bake for the holidays like they used to do because of downsizing to the smaller ALH apartment space. This lack of space to perform social leisure pursuits emerged as an unwelcome constraint to well-being for the older adults in transition. Further, the older adults commented that their social relationships changed after moving to the ALH because they could no longer access transportation to attend lifetime leisure spaces, such as their church. Transportation became a structural constraint to accessing these social leisure settings. When older adults encounter intrapersonal and/or structural constraints, the chance of experiencing interpersonal constraints increases. Consequently, these interpersonal constraints can also negatively influence older adults’ well-being in the transition process into an ALH.
Although connections were made from the findings of this study between the HLCT and constraints to well-being, there could be greater implications for older adults transitioning into an ALH. The themes of this study could be applied to the broader sense of constraints for all domains of well-being (physical, mental, emotional, social, and spiritual). Therefore, the researchers proposed that this theory could be applied to more than just leisure constraints by including constraints to all domains of well-being during the transition process for older adults into an ALH. The Modified Constraints to Wellbeing model is proposed from these findings (see Figure 1).
Figure 1. Modified Constraints to Wellbeing model.
Limitations
This research study has several limitations. First, the data were only collected from one ALH that was located in a rural town, limiting the ability to generalize to larger groups. Future research should consider studying a broader sample of participants and collecting data on participants’ racial, ethnic, and socioeconomic backgrounds to better understand how varying identities and backgrounds can impact the transition process. Results may also vary for older adults in ALHs being of different sizes, locations, and payment types, in particular an urban city ALH. Second, the participants in this study were interviewed at varying times after transitioning into the ALH, ranging from weeks to years. This adds the possibility for recall bias when asking participants to recollect on their transition during the one-month time frame surrounding their move into the ALH.
Implications for Practice and Research
More research is needed on better understanding older adults’ well-being when relocating into an ALH. Currently, there are no standardized assessment tools to specifically measure constraints to well-being that could negatively impact older adults when transitioning to an ALH. Developing and piloting such an assessment measure could give older adult health care practitioners a better method to quantify the constraints to well-being for a new resident moving into their ALH. This would allow for older adult health care practitioners working in ALHs to know of challenges influencing older adults’ well-being during their transition. Consequently, older adults could be intentionally referred to person-centred services or interventions to maintain or improve their well-being when in the transition process.
In addition, it would be important to know what older adults are currently doing to adapt and cope with constraints to well-being during the transition process to an ALH. Older adult health care practitioners could help by intentionally identifying and, if possible, easing older adults of intrapersonal, structural, and interpersonal constraints during the transition to an ALH. There would be also a need for a broader analysis of constraints to well-being during transition to a variety of older adult care homes (LTCH, independent living apartments, adult day centers, and even sub-acute rehabilitation) in both rural and urban locations, varying in size, diversity, and payment options. More specifically, a further study in an urban ALH replicating this study could provide insights for the transition influences on older adults’ well-being when living in varying geographical areas. Last, this study occurred at an ALH in the United States, but future research could investigate older adults’ well-being when transitioning into Canadian ALHs or congregate care homes.
Conclusion
In summary, the main contribution of this article is to provide a better understanding of constraints to well-being that are evident for older adults during the transition process into an ALH. Interestingly, a connection between the HLCT and all domains of well-being resulted in the Modified Constraints to Wellbeing model. Following the components of this model, older adult health care practitioners should be cognizant of the constraints to well-being that are often present for older adults during a relocation into ALHs. Future research is needed to measure older adults’ well-being and provide intentional strategies to ease their transitions in ALHs.
