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Older adults worked through 3 phases as they made the initial transition to permanent residence in a nursing home
  1. John Pugh, RN, RCNT, ONC, MN
  1. Head of Nursing Practice and Research Doncaster Healthcare NHS Trust Yorkshire, UK

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Question What are the initial experiences of older adults who are admitted to nursing homes on a planned or unplanned basis as they make the transition to nursing home life?


Grounded theory.


3 long term care facilities with religious affiliations in a large city in Midwestern USA.


15 adults ≥65 years (age range 76–97 y, all of Euro-American origin, 73% women) who were admitted to a nursing home for expected permanent residence, were able to understand and speak English, were able to give informed consent, and who passed a short mental status questionnaire. 2 of the adults had mild confusion.


Indepth semistructured interviews lasting 45–60 minutes were conducted with each participant every other day for 2 weeks and 1 month after admission. Discussion focused on adjustments to institutional life. Field notes were made during the interviews and observations of participant behaviour (eg, stayed in room) were recorded. Data saturation was reached after the 15th participant was interviewed. Interviews were recorded and transcribed verbatim. Data were analysed using the constant comparative method.

Main results

The transition to nursing home life had 3 phases: overwhelmed, adjustment, and initial acceptance. Participants who had planned their admission to the nursing home progressed through the phases more quickly than those who had unplanned admissions.

The overwhelmed phase consisted of the emotional response to the admission, including crying, feelings of loneliness and sadness, and longing to go home. Participants made conscious efforts to protect their families and attempted to hide their feelings. Problems included experiencing too many changes at once, adjusting to reduced personal space, and the lack of privacy.

During the adjustment phase, participants began the process of adjustment by internalising their admission. They began to think about the future and everyday living. They tried to have a positive attitude, establish new social networks, and deal with issues about control and autonomy (eg, rules and regulations of the nursing home and lack of participation in decision making).

In the initial acceptance phase, participants began to take action (eg, made new friends, got involved in activities), felt more self confident, and began to take control of their situation, realising that they had a future.


Older adults went through 3 phases of adjusting to a permanent nursing home admission: feeling overwhelmed, adjustment, and initial acceptance. Adults who had planned their admission progressed through the phases more quickly than those who had unplanned admissions.


The number of older people entering nursing homes is rising and will continue to rise for the foreseeable future. This relocation can be a traumatic event and often occurs at a time when the person is experiencing a personal crisis or physiological change. It is therefore vital for nurses to understand more about nursing home entry if they are to help make this transition a success. This study by Wilson is timely and pertinent and contributes to a growing understanding of the characteristics of entry to a nursing home. Evidence suggests that this transition is a huge challenge to the person, but that effective proaction may assist with a successful passage.1 A simple theory has emerged that will assist nurses and other professionals to assess and plan for older people during the transition to nursing home life. Wilson seems to indicate that participants can easily be classified as having planned or unplanned admissions, but has not made clear what constitutes a planned and unplanned event. Indeed, there may be varying degrees of each. The choice of a grounded theory design is appropriate, because nursing home entry is a complex social process and there may be many variations in the way people respond. This method of research never suggests generalisability and the author rightly says nothing about the results being applicable to all environments. The study simply provides an emergent theory of nursing home entry, with the expectation that others will replicate it and modify it in light of further data. Lack of replication for grounded theory studies is one of the major obstacles to their acceptance as a valid method of research. The study's failure to address specifically the role of informal carers as a central concern at nursing home entry may be an important omission, but could be addressed in an adjunct study in the future.



  • Source of funding: not stated.

  • For article reprint: Dr S A Wilson, Marquette University College of Nursing, Clark Hall, PO Box 1881, Milwaukee, WI 53201–1881, USA. Fax +1 414 288 1597.