Do institutionalized elderly consider themselves homeless, mat is, without a home, even tiiough tiiey are sheltered in a nursing home?
The research metfiodology used in this investigation combined me field metiiod process of discovery and die knowledge-based metiiod of tiieoretical analyses based on die Hybrid Model developed by Schwartz-Barcott and Kim.1 The hybrid model interfaces tiieoretical analysis with empirical observation and is composed of three phases: theoretical, field work, and analytical.
After the concept was selected, the researcher used Reynold's analytical approach to concept analysis to begin a literature search, analyze die data, and select a working definition of homelessness.2 To identify and define homelessness, it was necessary to first identify and define home. The most fruitful sources of discussion, analyses, and description of die concept of home was found in die social ecology and environmental literature.3"9 Witiiin Ulis literature, home is predominandy viewed as a phenomenon wim existential ramifications. The phenomenon of homelessness was not as clearly discussed, altiiough much could be inferred from die discussions of home. The extensive literature on the homeless living in the streets was useful to compare similarities, differences, and focus wim die phenomenon of homelessness. I0"17 The literature on environment and aging provided a rich source of information on environment-elderly interactions; however, die data found in this area did not contribute to an understanding of die concept of homelessness.1827 Ultimately, die definition of homelessness evolved from die literature on home and die empirical evidence observed in die field study.
The fieldwork phase emphasized empirical observation and used field research metiiods to collect qualitative data for further analyses of die concepts of home and homelessness. The setting chosen was a 120-bed skilled nursing facility in a large Connecticut city. The data was collected via die field metiiods of participant observation including unstructured interviews. The researcher met individually with two primary informants for 1 hour a week for 8 weeks. In addition to diese meetings witìi die primary informants, the researcher met informally wim staff members during her weekly visits to die facility, formally attended one recreational activity, observed other activities as tiiey occurred in her presence, and twice met witìi a group of residents.
Field notes were recorded describing all observations and unstructured interviews and were organized into tiiree categories - observational, tiieoretical, and rnediodological - and provided an effective means of analyzing die data as it occurred (on-going analysis) and as it ultimately came together (final analysis).28
Before die literature review was completed, me actual field study was begun. The primary informants during the course of die fieldworic phase of die research were two elderly residents of die nursing home. Botii had lost their respective "homes" and seemed to be permanentiy institutionalized. The questions asked by die researcher included: Did eitiier or bodi of die informants feel homeless? Did "home" have a significant meaning for each of them, and if so, what was it? To what extent did each one's description and experience of home and homelessness coincide with that found in the literature?
Field notes were analyzed in light of die concepts of home and homelessness. It was concluded mat me initial selection of die concept of homelessness as a relevant experience in die life of a nursing home resident seemed justified. Support for this was found in die literature review, tiieoretical analysis, and empirical findings.
TOWARD A THEORY OF HOME AND HOMELESSNESS
The data supported die original definition of home culled from die literature: die experience of a fluid and dynamic intimate relationship between die individual and die environment. The environment is me physical, social, and psychological spaces around the individual. This relationship consists of interactions and transactions between the individual and these spaces, and is profoundly significant to die individual because it provides die critical connection to meaning in life. Home, described from this phenomenological perspective, is consequently seen as a lived experience that possesses deep existential meaning for die individual. The relationship diat makes up the experience of home emerges from die many complex interactions between die individual and die environment and evokes such meanings to the individual as identity, connectedness, journey, privacy, power/ autonomy, safety/predictability, and lived space (Figure 1). Despite die complexity and variability of diese different interactions and transactions, die individual can describe die totality of diese experiences with the word ' 'home.
The researcher defined homelessness based on observations and data obtained in the field and inferences drawn from the literature: it is the experience of the negation of home, where the relationship between the individual and the environment loses its intimacy and becomes severely damaged. The result of this disruption to the relationship is discontinuity and incongruence. This shattering of the highly significant relationship is perceived as an insult to the individual's meaningful existence. Thus, homelessness, too, can be viewed phenomenologically and can be seen as a lived, albeit painful, experience that brings about deep existential despair for the individual. The static and unfamiliar relationship of homelessness emerges from the many complex and varying interactions between the individual and the environment and evokes such meanings as non-personhood, disconnectedness, no journey, no boundaries, powerlessness/dependence , insecurity/ uncertainty, and meaningless space (Figure 2). The individual can describe the depth and profundity of these interactions in the statement "I have no home."
The Home-Homelessness Continuum
The experiences of home and homelessness can be conceptualized as existing on a continuum with varying degrees of home and homelessness (Figure 3). At one extreme is home, where a strong, intimate, and fluid relationship exists between the individual and the environment; at the other end of the continuum is homelessness, where the relationship between the individual and the environment is tenuous and severely damaged.
The individual located near the home end of the continuum has a strong, intimate, and dynamic relationship with the environment. To bring meaning to this diverse and complex relationship, the individual organizes the relationship into a whole and experiences a sense of "knowing"; the meaning of home becomes integrated within the individual's experience and a pattern forms. This whole is greater than the sum of its parts: it is more than a house, a particular relationship with another, possessions, identity, or safety. It is the experience one describes when, as one informant stated, "Home is home." Home becomes a total experience, a whole that cannot be broken down into parts without losing the sense or meaning of the whole. The experience of home thus acts as a center to the individual's existence; it provides meaning in a chaotic world and lies at the core of human existence.
Between the extreme ends of the continuum lie degrees of home and homelessness that are determined by the changing strength of the individual's relationship with the environment. The individual's relationship with the environment becomes weakened, impaired, disrupted, or actually broken as various losses, insults, and stresses are suffered. These factors impinge on the various components of home and either distort, impair, disrupt, damage, or destroy them. Disruptions affecting the individual include not only the loss of one's place of dwelling (living space and privacy), but also such losses as mobility (journeying), death of loved ones (connectedness), retirement (power/ autonomy and identity), and chronic illness (safety/predictability).
As individuals move toward the homelessness end of the continuum, they are at increasing odds with the environment and the relationship between self and the environment becomes weakened, distorted, or broken. As stresses and insults affect the relationship, the individual's ability to maintain balance and harmony decreases. Interactions with the environment begin to make less sense and the wholeness of the experience of home begins to weaken and its boundaries become lost. The closer individuals move to the state of homelessness, the less able they are to find meaning in the experience and consequently become more disorganized and confused.
As stressors and insults increase in severity and number, the relationship between the individual and the environment becomes extremely tenuous and static. As this occurs, the individual is no longer able to make any sense of the experience and becomes overwhelmed with a sense of confusion and lack of meaning in life. Homelessness is the predominate state when the individual's relationship with the environment has been severely damaged, and many pieces of the home mosaic either have become so distorted as to be unrecognizable or they are completely missing. Disorganization or fragmentation, disharmony, and disequilibrium result. Because individuals are no longer able to integrate experiences and form them into meaningful wholes, they are left adrift in a strange and frightening world without meaning.
Institutionalization and Homelessness
Because of the multiplicity of losses the elderly suffer and the consequent impairment or severance of their relationship with the environment, and because of the nature of the nursing home itself, it is suggested that the elderly individual who is institutionalized is located on the homelessness end of the continuum. The data supported the strong probability that, on entering the nursing home, the elderly person moves to the furthest end of the continuum -homelessness. The nursing home in no way represents "home" to the institutionalized person, either phenomenologically, existentially, or physically, as in "house." As one informant stated,] "no place will ever be me real place of your own home. "
Elderly residents in nursing homes face non-personhood: identity becomes murky because they no longer have special bond with a place that held significant, personal meaning. Informants demonstrated a pervasive sense of uprootedness and non-belonging, as well as confused feelings about self and identity. What is significant in this feeling of uprootedness is its finality. In both instances, it appeared that the roots that fed each informant's identity and provided nurturance were more than merely pulled up; it seemed that the roots were actually severed. For example, how can one recover the roots of one's house if it is sold, how can one identify with a place dial is no longer there? When possessions are dispersed among relatives or sold, they are no longer available to the individual for interaction and meaning; the relationship with objects and their memories become severed.
When loved ones the and the connectedness one had with them is severed, the loss is irrecoverable. When physical illness or injury strike and a chronic disability is die result, relationships with the environment such as autonomy and journey can be severely and permanently damaged. When roots remain, even if out of dieir native soil, there is a chance of new growth in a different soil, but if me roots are severed, men mere is little hope in the future and all that is left is to die; the situation with which both informants and many institutionalized elderly persons seem to be faced.
The primary informants, as well as residents who attended group meetings with the researcher, all revealed feelings of disconnectedness. Connectedness with people was severely limited or lost completely; spouses and friends having died, and children having moved or become unavailable. Connectedness with place was lost and connectedness with the past was severely tiireatened or completely severed tiirough inaccessibility or loss of familiar places that provided the memories of past experiences. Each informant's connectedness to the past was further damaged with the loss of or failure to keep personal possessions (the keepers of past memories) as demonstrated by the starkness of rooms and the lack of personal possessions of many of the residents of the nursing home. In all cases, connectedness to the future appeared to be entirely severed as many individuals spoke with resignation of dying in the nursing home. As the informants experienced this loss of home, the loss of hopes and dreams and each individual's ability to affect the future followed. This was aptly described by one informant who stated, "resignation would describe it. I get discouraged."
Homelessness and institutionalization are further experienced as a sense of placelessness. The institution itself is often merely a structure, lacking meaningful experience for the resident. Indeed, the elder in the nursing home is a stranger in an unfamiliar place that offers little in terms of the comfort found in the familiarity and safety of home. Both informants appeared to view the institution as more of a hospital or hotel where residents' status is defined as "patient" or "guest," but never as "family" or "friend." One informant commented, "it doesn't feel like home, there's something lacking." In addition to living in an unfamiliar dwelling, both informants shared communal space with strangers, which resulted in an absence of meaningful "lived space." What small space that could be identified as the resident's was open to the intrusions of others at any time; as one resident explained it, "they just come in when they want to." Therefore, space becomes public and lacks meaning for the individual. When one is homeless there is no private place to which one can withdraw, and this lack of privacy was evident for all residents of the nursing home. There seemed to be no retreat to call one's own, save for a retreat into self.
Homelessness engenders feelings of powerlessness and dependency, and these feelings were predominantly experienced by the informants. Both were aware that the institution, not they, made the rules, and that routine dominated the day. As a result of this lack of autonomy and imposition of rules, informants demonstrated increasing inability to make decisions for themselves. Endless repetition directed their lives and meaningless tasks seemed to add to the numbness that resulted in boredom and low energy. Both informants and group members shared feelings of anxiety, fearfulness, and uncertainty, indicating that to be in an institution and homeless is to be insecure in an uncertain world; it is to be filled with doubts and to be a stranger. To not have a home is to not have a safe haven in which to find protection. When one is homeless, one is vulnerable and in danger at all times. This clearly describes both informants and the majority of nursing home residents who say little, disclose even less, and distrust most people around them.
METHODS USED TO ENDURE PAIN
Response to Homelessness
The experience of homelessness results in overwhelming feelings of loss of meaning in life. This failure to find meaning results in a feeling of being adrift with no way to determine direction, which leads to disorganization and reduced ability to adapt to any new or additional stressors. The individual spirals down into helplessness where resources are extremely limited. At this point, the individual becomes vulnerable and often does not have the personal energy to pull out of the spin. It is significant to understand that this disorganization and confusion is experienced as a deep and intensely felt pain that cannot be endured for long. The research suggests that the elder's attempts to cope with this unendurable pain results in behaviors that are often misinterpreted by others as indicating acceptance or adjustment to die nursing home setting.
As tiie field research came to a close, the researcher attempted to identify tiirough coding, any significant and consistent patterns of responses or interactions that might be indicative of die identified concepts of home and homelessness. The coding method was patterned after Glaser and Strauss' Grounded Theory Metiiodology.29 In addition to identifying die categories of home and homelessness, various categories emerged that seemed to be indicative of strategies for coping with the disorganization and pain of die homeless state. The central or core variable that emerged from tiie data was a particular coping strategy that might be used to avoid tiie confusion and pain of die homeless experience. This was identified as pretending and was found to have several implementing processes mat were identified as living in die past, keeping die secret, distancing, and surrendering (Figure 4).
The core variable of pretending explains how nursing home residents manage the overwhelming emotional pain of homelessness. Pretending is a maneuver or game that the elderly resident plays to avoid feeling (experiencing) die pain of homelessness. When played effectively, elders often convince tfiemselves and others mat tiiey have accepted nursing home placement or have adjusted to institutionalization. It is a game that is played cautiously and unconsciously. If players inadvertendy discover tiiey are playing a game (for example if tiiey are asked "How can this be your home when you say that you have no home?"), they wül become disorganized and anxious until tiiey discover how to recover die pretense.
Living in die past is a strategy that allows die individual to continue to experience die centering and comforting feeling of home. Individuals are able to transcend die current instimtionalized and homeless state and return to a time when tiiey were "home."
Keeping die secret allows homeless elderly to avoid the sure knowledge of homelessness that exists within the secret recesses of their hearts. This is accomplished when die elder can say "I have no home" and then state "this place is my home." Because individuals are keeping the secret of their homelessness locked inside of themselves, there is no contradiction in making diese two opposing statements.
Distancing involves a pulling back from involvement with other residents and seems to be mutual and a perceived necessary protective maneuver. This could be because the pain of homelessness is mirrored by each resident. It is as if each is saying "If I do not see you, then I do not see (feel the pain in) me."
Surrendering entaUs succumbing to the fact that in coming to a nursing home, and therefore in becoming homeless, there was no choice; a kind of "what else could I do?" attitude prevails. This surrendering to the acceptance status offers protection from die experience of abandonment by family, die "I do not belong" aspect of homelessness.
The coping strategy of pretending and its implementing processes are tentatively identified at this point and need to be further investigated to be more clearly described and to further verify their validity in managing the pain and disorganization of die homeless state.
IMPLICATIONS FOR NURSING
When considering homelessness in the institutionalized elderly, a pressing issue is whetiier nursing homes should exist at all. If die consequence of being institutionalized is to be homeless, and if to be homeless is to lack meaning in hfe and to suffer intolerable pain, then can we justify providing and promoting this negative experience for the vulnerable and chronically ill elderly individual? Solutions to this dilemma might be found in die exploration and development of alternative settings, simdar in structure and philosophy to half-way houses, in an attempt to move away from die total institution of die typical nursing home.
In the meantime, nurses have the primary responsibUity for creating the environment of the nursing home; consequendy, efforts could be directed toward modifying the environment to strengthen the relationship between it and the individual. This would involve changes in management style, policies, and attitudes to move away from such homelessness-provoking attributes of me total institution as routine, loss of autonomy, and no journey. Of significance would be recognition, on nursing's part, of the state of homelessness and die implementation of psychosocial interventions that might alleviate the pain and assist in strengthening tiie individual's relationship with the environment. For example, investigation of the value of group psychotherapy might provide valuable data about possible interventions to strengthen the individual's connectedness with others. Another area to investigate is the establishment of a holistic, nurturing, affirming, and healing community in the nursing home and how tins might affect die homeless resident. How can nursing establish such a community, and can it reduce the degree of homelessness tiie individual is experiencing?
Nursing needs to address whether it is possible to adjust or accept the homeless state, and in so doing, question the use of these terms as meaningful at all. If a homeless state is intolerable, why would we ask individuals if tiiey accepted it and why would we describe what can only be identified (from tiie homelessness perspective) as a state of helplessness as being adjusted? Research could be re-evaluated in this light and discoveries might be made that there is no acceptance or adjustment to homelessness; there are only coping strategies that protect the individual from die intensely consuming pain of die homeless state.30,31
Identifying home and homelessness on a continuum suggests that one might intervene somewhere along this continuum before the individual reaches die homeless state. Identification of elderly individuals who are at risk of becoming homeless and initiation of interventions designed to prevent further movement along die continuum might be effective in preventing homelessness. For example, elderly hospitalized individuals, who are often extremely fragile and vulnerable, need to have an advocate to protect them from the thoughtless dismantling of their houses and a precipitous discharge to a nursing home. In addition, issues such as the inability of many hospital and nursing home nurses to deal with the pain of homelessness and their consequent need to participate in its denial need to be addressed.
This investigation of homelessness as an experience of the institutionalized elderly individual has provided a rich source of material for further exploration. The elderly individual wandering the streets is easily identified as homeless, yet there is an entire population of elders who suffer silently, enduring the painful state of homelessness within the confines of the total institution of the nursing home. To view as homeless these individuals who are, in fact, sheltered and fed seems incongruent; however, when one acknowledges these unrecognized homeless, the increased understanding can direct us in the discovery of ways in which we can alleviate or reverse the process.
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