According to a report from the United Nations (2015), the number of individuals in the world age ≥60 is expected to increase from 901 million to 1.4 billion over the period of 2015 to 2030, reaching a 56% growth by 2050. Older adults age ≥65 in Turkey amounted to 8.5% of the population in 2017, which is estimated to rise to 25.6% in 2080 (Turkish Statistical Institute, 2018). There are approximately 7 million people age ≥65 in Turkey. Among these individuals, 0.4% were living in nursing homes in 2017 (Ministry of Family and Social Policies, 2017).
There are two different types of nursing homes in Turkey—those that are sponsored by the government and those that are privately run. Living in a government-sponsored home is free of charge for older adults with no income, and the price of service is considerably low for retirees. Having a low income is a factor that has an adverse effect on the quality of life of older adults (Unalan, Gocer, Basturk, Baydur, & Ozturk, 2015; Zhou et al., 2011).
A low quality of life is a risk factor for diminished self-esteem and reduced social support (Sun et al., 2017). The current study was conducted at a government-sponsored nursing home in view of the importance of increasing the perceived self-esteem, self-compassion, and social support offered to older adults, especially those residing in government institutions, and to improve their state of mental health.
Residing in a nursing home introduces many stress factors into the lives of older adults. One of the most important factors that cause psychological issues in nursing home residents is a low level of perceived social support (Gokler & Aydin, 2011). Living conditions are also factors associated with social support (Dai et al., 2016). Perceived social support is related to suicidal thoughts (Zhang et al., 2018). When social support is weak, individuals feel unappreciated and their self-esteem suffers. In a study conducted by Karagozoglu, Arikan, Inan, and Hoyuk (2013), low self-esteem was found to be a frequent problem among older adults living in nursing homes.
Gokler and Aydin (2011) found a positive correlation between perceived social support and self-esteem among older adults. Individuals with inadequate social support and low self-esteem go through a process of self-judgment and, as a result, their self-compassion can be affected. Self-compassion is the ability to be open to feelings of pain and discomfort, to approach one's own self with care and affection, to be understanding in the face of incapacity and failure, and to accept negative experiences as a natural process (Neff, 2003). The process of aging brings with it a need for practices to improve mental health (Kozar-Westman, Troutman-Jordan, & Nies, 2013).
Nurses play an important role in improving the mental health of older adults (Moore, Metcalf, & Schow, 2006). Social support, self-esteem, and self-compassion are important concepts in the care of older adults, but studies on improving social support and self-esteem are limited. In addition, no study has evaluated self-compassion in older adults. Therefore, the aim of the current study was to assess the effects of the Tell Me About Me program on the perception of social support and the self-esteem and self-compassion levels of older adults residing in a nursing home.
The current quasi-experimental study was conducted to assess the effect of the Tell Me About Me program on the perceived self-esteem, social support, and self-compassion levels of older adults. Assessments were made before (pretest), after (posttest), and 3 months (retest) following the program. The Kocaeli University Ethics Committee approved the implementation of the study.
The study was conducted at a government-sponsored nursing home. There were 76 older adults living at the home from May 2015 to May 2016. A total of 29 participants were excluded from the study; 22 were excluded because they met the exclusion criteria and seven were excluded because they did not meet the inclusion criteria. All participants who met the inclusion criteria and agreed to participate were taken into the current study (n = 47). Over the course of the research, two participants died and one had to be excluded because of admittance into intensive care (N = 44).
Inclusion criteria were: being a resident of the study nursing home; fluency in Turkish; consenting to participate; and signing the informed consent form. Exclusion criteria were: having a chronic mental illness (e.g., schizophrenia) that makes it difficult for an individual to distinguish between reality and delusion and affects social relations; having an illness (e.g., Alzheimer's disease, vascular dementia, Lewy body dementia) that causes clouding of consciousness to the degree that healthy communication is not possible; being bedridden; and loss of sensation (e.g., deafness, blindness) at the level of preventing communication.
The data collection instruments used in the research were a sociodemographic questionnaire, the Multidimensional Scale of Perceived Social Support (MSPSS), the Coopersmith Self-Esteem Inventory, and the Self-Compassion Scale. All instruments were completed based on self-reporting by older adults who could read and write and by the authors for older adults who were illiterate.
MSPSS. The MSPSS was developed by Zimet, Dahlem, Zimet, and Farley (1988). The first adaptation of the scale to the Turkish language and culture was produced by Eker and Arkar (1995). The Turkish form of the scale, as well as the original form, comprises three subscales that refer to the source of social support (i.e., significant other, family, and friends) and 12 items. The MSPSS is a self-report Likert-type scale with seven responses ranging from 1 (I completely disagree) to 7 (I completely agree).
Eker and Arkar (1995) found that the reliability coefficients of the scale displayed high consistency levels ranging from 0.80 to 0.95. The validity and reliability of the Turkish scale was verified by another study (Eker, Arkar, & Yaldiz, 2001). The higher the scores on the scale, the higher the level of perceived social support. In the current study, Cronbach's alpha internal consistency coefficient was 0.86.
Coopersmith Self-Esteem Inventory. The Coopersmith Self-Esteem Inventory, a commonly used tool in Turkey, was used in the current study. Cronbach's alpha reliability was 0.77 for older adults residing at one nursing home in Turkey (Karagozoglu et al., 2013).
The inventory comprises 25 statements that are marked like me or not like me. These statements relate to the participant's outlook on life, familial relationships, social relationships, and the power of endurance. Scores range from 0 to 100. Scores lower than the mean indicate low self-esteem, whereas those above the mean indicate a high level of self-esteem. This inventory has two versions (i.e., one for children, one for adults) and no subscales. The adult version was used in the current study. Cronbach's alpha internal consistency coefficient was 0.77.
Self-Compassion Scale. The original Self-Compassion Scale developed by Neff (2003) comprised 26 statements and six subscales, with a 5-point Likert scale that asks the responder to rate the frequency related to the specified circumstance on a scale of 1 (almost never) to 5 (almost always).
The scale was tested for validity and reliability in the Turkish language by Deniz, Kesici, and Sümer (2008). In the Turkish adaptation, the scale differed from its original and offered a one-dimensional construct and no subscales. Two items with item-total correlations <0.30 were removed from the scale, leaving 24 items in total. Furthermore, internal consistency was calculated as 0.89 and the test to retest correlation was 0.83 (Deniz et al., 2008). The higher the score on the scale, the stronger the participant's level of self-compassion. In the current study, Cronbach's alpha internal consistency coefficient was 0.86 for all 24 items.
The Tell Me About Me program has three basic components: self-esteem, social support, and self-compassion. The authors developed this program and implemented it once per week (every Tuesday) between 1:00 p.m. and 4:00 p.m. for a duration of 24 weeks to increase the social interaction, self-esteem, and self-compassion of nursing home residents. Sessions were conducted in the main lounge shared by all residents. The autobiographical narratives of two different residents were presented at each session. These narratives were put together and written by the author (K.M.) during interviews with residents in their respective rooms and included the following: birth place; occupation; information about parents and siblings; marital status; information about children and grandchildren; photographs from family albums; and personal characteristics (e.g., how they define themselves, what they like, their competencies, hobbies, best friends at the nursing home, things that make them happy, their happiest memories in life). Forty-four narratives were presented in the form of PowerPoint® presentations throughout the program.
The program also included activities, such as birthday celebrations, visiting friends in the hospital, and writing letters to friends/family members. The activities taking place as part of the program are shown in Figure 1. The content of the program and the activities held at the sessions are shown in Table 1.
The research process and Tell Me About Me program.
Tell Me About Me Program Content
Descriptive statistics, such as percentage, mean, and frequency, were used in the evaluation of sociodemographic data. In the comparison among the pretest, posttest, and retest of the mean scores of older adults, all data displayed nominal distribution. The analysis was performed with the dependent t test (paired sample test) and repeated measures analysis of variance. In the repeated measures, the Bonferroni adjustment was made as a post-hoc test.
Mean age of participants was 76.93 (SD = 6.26 years) and 52.3% were female. The income status of 29.5% of participants was less than needed, which is defined as poverty according to population statistics in Turkey. When the reasons why participants lived in a nursing home were examined, it was found that 47.7% lived there because they chose to, 18.2% lived there due to loneliness, and 15.9% were there because their children did not want to care for them (Table 2).
Sociodemographics of the Study Sample (N = 44)
There were statistically significant differences between the mean scores on the MSPSS Significant Others subscale (pretest, 9.90 [SD = 6.68]; post-test, 9.54 [SD = 5.57]; retest, 10.31 [SD = 6.59]; p = 0.002); Family sub-scale (pretest, 13.09 [SD = 8.39]; post-test, 14.29 [SD = 6.95]; retest, 14.79 [SD = 7.11]; p = 0.001); and Friends subscale (pretest, 13.25 [SD = 6.96]; posttest, 17.63 [SD = 5.37]; retest, 18.52 [SD = 4.91]; p < 0.001). Significant differences were also found in terms of mean scores of the overall scale and in the repeated measures (p < 0.001) (Table 3). The most prominent and significant increase in mean scores was in the Friends subscale (p < 0.001), indicating that the program had been influential in expanding the interaction between friends.
Multidimensional Scale of Perceived Social Support, Self-Esteem, and Self-Compassion (MSPSS) Scores of Older Adults Participating in the Tell Me About Me Program (N = 44)
There were significant differences in the repeated measure scores on the Coopersmith Self-Esteem Inventory (p = 0.001). The differences in mean scores between the pretest (80.84 [SD = 9.29]) and posttest (82.56 [SD = 8.02]) were significant (p = 0.001), but the differences in the mean scores between the posttest and retest were not significant (p = 0.496) (Table 3). These findings imply that there was significant change to the posttest/retest; therefore, the effect of the program on self-esteem had continued after the program concluded.
The differences in the total mean scores and repeated measures for the Self-Compassion Scale pretest (84.52 [SD = 14.25]), posttest (82.40 [SD = 17.43]), and retest (84.61 [SD = 14.15]) were not significant (p = 0.320) (Table 3).
The Tell Me About Me program was effective in improving social support among older adults. With group activities planned for 24 sessions, the program provided an opportunity for group members to share their ideas, visit friends in the hospital, write letters to friends/family members, and participate in birthday celebrations, which increased interactions between individuals and increased perceived social support. The Tell Me About Me program allowed older adults to remember positive experiences they had throughout their lives as well as their achievements and the cherished value systems that had made them the person they are now. By giving nursing home residents a chance to share their memories with their fellow residents, the program helped older adults expand their sense of self-esteem.
As older adults age, they are more likely to witness the death of loved ones (e.g., spouse, child, friend, sibling) and sometimes this loss leads to making changes in their living arrangements. Such circumstances can cause older adults to experience diminished social support (Zhang et al., 2018). Older adults living in nursing homes can feel lonesome and abandoned (Zhao et al., 2018). An integrative review that examined the mental health of older adults living in nursing homes reported that lack of social support was a risk in terms of mental health (Wang, Shang, & Kearney, 2016).
The social support perceived by older adults living in nursing homes is at a lower level compared to older adults who do not live in nursing homes (Nasiri, Dadkhah, & Koulai, 2012). Programs that enhance social interaction are important in promoting the mental health of older adults (Quatrin, Galli, Moriguchi, Gastral, & Pattussi, 2014). Organizing activities to increase social interaction will improve the emotional state and quality of life of older adults (Davidson, McCabe, Knight, & Mellor, 2012). In a study in China with older adults living in different nursing homes, the most basic factor found influencing older adults' satisfaction was social support (Yan, Gao, & Lyon, 2014).
In the Tell Me About Me program, a sharing period was designated in which participants shared their autobiographical narratives with each other. This served to have participants get acquainted and discover what they had in common. Positive effects from this program on older adults may be enhanced through support from friends (e.g., based on common personal interests) rather than family support (e.g., kinship bonds) (Li, Ji, & Chen, 2014).
The Tell Me About Me program was effective in increasing the self-esteem of older adults. The Coopersmith Self-Esteem Inventory mean score (80.84 [SD = 9.29]) in the current study was higher than the mean score (37.35 [SD = 2.25]) researchers found in another study conducted in Turkey using the same inventory at another nursing home (N = 80) (Karagozoglu et al., 2013). This difference may have occurred because older adults in the previous study had more challenging health issues. It has been shown that health issues, chronic illnesses, and advanced age are factors that have an adverse effect on self-esteem (Mirucka, Bielecka, & Kisielewska, 2016; Sun et al., 2017). In a study conducted with older adults living in nursing homes in Australia (N = 45), self-esteem was among the important determinants of wellness (Grace & Toukhsati, 2014).
Other studies have been conducted to increase levels of self-esteem among older adults. A study on the residents of a nursing home in Taiwan indicated that when nurses offered a group of individuals 1 hour of group therapy for 9 weeks, self-esteem scores rose significantly (Chao et al., 2006). In a nursing home in the Philippines (N = 40), a “Third Age” program resulted in self-esteem increases among older adults participating in the study (Escolar Chua & de Guzman, 2015). Nurses applied reminiscence therapy, a psychotherapeutic technique in which self-esteem and personal satisfaction are restored, to 20 older adults in a nursing home in India in eight sessions. Introductions and a pretest constituted the first session, whereas the other six sessions comprised reminiscences of pleasurable moments with family, family of origin, education, marriage, occupation, and social/personal life achievements. A posttest was administered at the eighth session. The study revealed the program was effective in increasing the self-esteem of older adults and decreasing their level of depression (Poorneselvan & Steefel, 2018).
After nurses in Belgium applied the reminiscence intervention based on the SolCos model to older adults living in nursing homes, it was observed that older adults became open to communication and cooperation and were much more satisfied (Van Bogaert et al., 2016). An individual reminiscence program based on autobiographical memory was performed in Portugal where researchers found that older adults had reduced anxiety and increased cognitive function after the program (Lopes, Afonso, & Riberio, 2016).
The Tell Me About Me program differs from reminiscence therapy. During a preparatory session in the Tell Me About Me program, older adults are asked to produce an autobiographical narrative, an activity that not only causes them to feel a sense of self-worth but also reminds them of their past achievements. Relating their life stories provides a means for older adults to discover the positive sides of their personalities. Applications such as this are effective in increasing self-esteem among older adults. It has been reported that autobiographical narratives put together with boldness, wisdom, and humor make the narrator and listeners happy to take part in such an experimental learning experience (Haber, 2015).
However, the Tell Me About Me program was not effective in improving levels of self-compassion. Self-compassion includes three components: (a) kindness, (b) common humanity, and (c) mindfulness (Neff, 2003). To improve levels of self-compassion among older adults, a long-term program may need to be developed for each of these components. There was no opportunity to make any comparisons of the levels of self-compassion of participants in the program because no other study could be detected in the literature that examined the status of self-compassion.
Strengths and Limitations
A strength of the current study was that it provided an opportunity to communicate with a group of older adults with similar characteristics in the same setting. A limitation to the study was lack of a control group, which was unavoidable because of the inability to engage a control group due to the public nature of the residence. It was not possible to divide older adults into groups because all nursing home residents could see the activities conducted by the authors and wished to participate. The authors believed that it would be unethical to exclude any interested older adults. The inclusion of a control group was also not possible because a similar long-term care facility does not exist in proximity to the study nursing home.
The Tell Me About Me program was effective in improving perceived social support and self-esteem among older adults and can be recommended for this purpose. Sharing autobiographical narratives within the group was instrumental in helping participants value themselves more and experience an increased sense of self-esteem. Henceforth, their social interactions expanded because of the activities.
Nurses should implement the Tell Me About Me program to improve social support and self-esteem among older adults, as nurses provide full-time care at these nursing homes and have the closest interaction with residents. Nurses should ensure that older adults living in a nursing home are provided with an atmosphere that promotes psychosocial well-being and allows them to express themselves freely and effectively, organizing activities at the same time to increase interaction among residents.
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Tell Me About Me Program Content
Give participants the opportunity to get well acquainted with other residents in the group.
Ensure that participants with common characteristics become aware of each other.
Ensure that participants in the group become aware of their common problems and develop recommendations to find solutions to these problems.
Increase social interaction among participants (e.g., visiting friends at the hospital or in their rooms).
Ensure that participants become aware of their friends' and family's social support.
Present autobiographies and enable participants to discover common values and features.
Receive positive feedback from peers and friends.
Identify importance of social support (e.g., oral presentations, group discussions).
Celebrate birthdays, visit friends in the hospital, look at photographs, write letters to friends/family members).
Ensure that participants become aware of their own personality traits.
Ensure that other individuals (e.g., rest home employees, friends) provide participants with positive feedback.
Provide means for participants to exercise their positive qualities in social settings (e.g., singing, reading poetry, doing impressions, playing games).
Present autobiographies to enable participants to realize their growth.
Discover positive qualities in others.
Recognize the importance of self-compassion and self-esteem (e.g., oral presentations, group discussions).
Share the achievements of participants.
Appreciate the life stories told by participants.
Take photographs and hang them on the wall.
Ensure that participants are able to assess their present situation realistically (i.e., aging, medical conditions, living in nursing home).
Ensure that participants accept their present situation and adapt to it (i.e., aging, medical conditions, living in nursing home).
Ensure that participants accept things they cannot change about the past.
Determine regrets participants may have.
Accept situations in their lives that cannot change.
Discuss the negative effects of excessive self-judgment (e.g., oral presentations, group discussions).
Adapt to changing conditions in life (i.e., oral presentations).
Sociodemographics of the Study Sample (N = 44)
| Female||23 (52.3)|
| Male||21 (47.7)|
| Illiterate||5 (11.4)|
| Primary school||25 (56.8)|
| Secondary school/higher||14 (31.8)|
| Yes||35 (79.5)|
| No||9 (20.5)|
| Covering needs (€145)||19 (43.2)|
| Less than needed (<€145)||13 (29.5)|
| Just enough (€290)||12 (27.3)|
|Duration of stay at nursing home|
| Less than 1 year||7 (15.9)|
| 1 to 5 years||20 (45.5)|
| 6 to 9 years||11 (25)|
| >9 years||6 (13.6)|
|Reason for residing at nursing home|
| By choice||21 (47.7)|
| Loneliness||8 (18.2)|
| Children do not want to care for them||7 (15.9)|
| Spouse deceased||4 (9.1)|
| No relatives||3 (6.8)|
| Siblings do not want to care for them||1 (2.3)|
|Sharing problems with others|
| Yes||25 (56.8)|
| No||19 (43.2)|
Multidimensional Scale of Perceived Social Support, Self-Esteem, and Self-Compassion (MSPSS) Scores of Older Adults Participating in the Tell Me About Me Program (N = 44)
|Item||Mean (SD)||F/p Valuea||t/p Valueb|
| Significant others||9.90 (6.68)||9.54 (5.57)||10.31 (6.59)||7.309/0.002||1.096/0.048||2.332/0.024||3.448/0.001|
| Family||13.09 (8.39)||14.29 (6.95)||14.79 (7.11)||8.267/0.001||2.340/0.024||2.581/0.013||3.438/0.001|
| Friends||13.25 (6.96)||17.63 (5.37)||18.52 (4.91)||24.017/0.001||6.069/ 0.001||2.839/0.007||6.977/ 0.001|
| Total||36.25 (15.92)||41.47 (12.54)||43.63 (13)||24.978/0.001||4.955/0.001||4.095/0.001||6.815/0.001|
| Total||80.84 (9.29)||82.56 (8.02)||81.29 (8.07)||14.002/0.001||3.772/0.001||3.121/<0.05||0.687/0.496|
| Total||84.52 (14.25)||82.40 (17.43)||84.61 (14.15)||1.402/0.320||0.926/0.359||0.968/0.339||0.613/0.543|