Research in Gerontological Nursing

Meta-ethnographic Synthesis 

The Meaning of Home: A Qualitative Metasynthesis

Sheila L. Molony, PhD, RN, GNP-BC

Abstract

Practice-based initiatives have emphasized the need to provide “homelike” environments in long-term care. This study adds to the discourse on the meaning of home by synthesizing several individual qualitative studies using Noblit and Hare’s method of meta-ethnography. The purpose of this larger synthesis is to bring the findings from several discrete studies into a larger interpretive perspective that will lead to ongoing theory and practice development to enable experiences of home during residential transition, thereby informing nursing praxis in creating and shaping therapeutic environments.

Abstract

Practice-based initiatives have emphasized the need to provide “homelike” environments in long-term care. This study adds to the discourse on the meaning of home by synthesizing several individual qualitative studies using Noblit and Hare’s method of meta-ethnography. The purpose of this larger synthesis is to bring the findings from several discrete studies into a larger interpretive perspective that will lead to ongoing theory and practice development to enable experiences of home during residential transition, thereby informing nursing praxis in creating and shaping therapeutic environments.

In 2007, 15.1% of adults older than age 85 lived in a nursing home (U.S. Administration on Aging, 2008). More than 1.5 million adults resided in nursing homes, and nearly 1 million more lived in assisted living facilities, retirement communities with nursing services, and related environments (Hawes, Phillips, Rose, Holan, & Sherman, 2003; Jones, 2002). The rapid growth in the aging population, particularly those older than age 85, will result in increasing numbers of older adults having the experience of dwelling in a residential care environment.

For many of these older adults, this environment will become the de facto “home” until the end of life. Nurse leaders have recognized the importance of a homelike environment to humanistic nursing practice in hospice settings (Craven & Wald, 1975; Kayser-Jones, Chan, & Kris, 2005), and nursing scholars have continued to shed light on micro-environmental qualities that enhance wellness and quality of life (Hall & Buckwalter, 1987; Kayser-Jones, 1989). Warm, comfortable, homelike environments are also considered optimal for healing during hospitalization (Gearon, 2002).

Seminal writings on the person-environment relationship (Kahana, Liang, & Felton, 1980; Lawton, 1990), place identity (Proshansky, Fabian, & Kaminoff, 1983; Rowles, 1980, Rubenstein, 1989), and the meaning of the concept of home (Despres, 1991; Dovey, 1985) provide foundational knowledge regarding the person-environment relationship. Environmental gerontologists have continued to expand the philosophical, theoretical, and empirical base linking person to place (Cutchin, Owen, & Chang, 2003; Oswald & Wahl, 2005; Rowles & Chaudhury, 2005; A.J. Sixsmith & J.A. Sixsmith, 1991).

A grassroots movement currently sweeping long-term care (LTC), known as culture change, is emphasizing the “creation of home” within the nursing home environment (Deutschman, 2005), and numerous residential models, including assisted living, Green Houses®, and small houses, are highlighting the relationship between the “homey-ness” of the built environment and quality of life for older adult dwellers (Rabig & Rabig, 2008; Rabig, Thomas, Kane, Cutler, & McAlilly, 2006). Numerous individual studies have explored older adults’ experiences of residential transition, as well as their perceptions of the meaning of home, but the findings from these studies have not been well synthesized nor used to inform emerging LTC models.

This study adds to the discourse on the meaning of home by synthesizing several individual qualitative studies using Noblit and Hare’s (1988) method of meta-ethnography. The purpose of this larger synthesis is to bring the findings from several discrete studies into a larger interpretive perspective that will lead to ongoing theory and practice development to enable experiences of home during and after transition to a residential care setting, thereby informing nursing praxis in creating and shaping therapeutic environments.

Literature Review

Seamon (1979) used the term at-homeness to describe “the usually unnoticed, taken-for-granted situation of being comfortable in, and familiar with, the everyday world in which one lives, and outside of which one is ‘visiting,’ ‘in transit,’ ‘not at home,’ ‘out of place’ or ’traveling’” (p. 70). Marcus (1995) inextricably linked the residential home with identity and highlighted that home is not only a place but a dynamic construct that changes meaning as the relationships between inhabitants change. Jackson (1995) studied a migratory Aboriginal tribe and defined home as an experience embedded in shared traditions, place-based activities, and meanings.

Social connectedness is a recurrent metaphor in the gerontological literature (J. Sixsmith, 1986; Rubinstein & de Medeiros, 2005; Werner, Altman, & Oxley, 1985). Home connects individuals who have shared language, history, and experiences. Home provides a link to self-identity and to personal, societal, and cultural values, beliefs, and norms. Home conveys attachment to both people and place. Dovey (1985) refers to place appropriation to describe processes that result in place attachment and place identity. Places become linked to people when individuals cultivate and care for, become familiar with, exhibit territorial control over, personalize, or invest meaning in them. These places then become a part of the identity of the individual who has “appropriated” them. Meaning may be invested not only in the physical space, but also in the cherished objects found within (Joy & Dholakia, 1991; Rowles, 1983; Sherman & Dacher, 2005). Somerville (1992) associated the concept of home with physical, physiological, territorial, ontological, emotional, spatial, and spiritual security.

This literature suggests that therapeutic environments must be concerned with the self-concept and experiential history of individual dwellers, as well as the social systems, relationships, and meaningful objects and spaces that are important in their lives. New opportunities for place appropriation, as well as interaction with others who have shared experiences and cultures, may foster at-homeness after relocation to a new environment. The literature also suggests that attention to security in a therapeutic environment warrants a broader perspective than physical safety. Studies of the meaning of home before, during, and after residential transition may offer additional knowledge for nurses as they fulfill a therapeutic role that Watson (1999) referred to as “ontological architect,” creating and shaping places for being and healing. This study synthesizes several qualitative studies that have previously been viewed in isolation, with the goal of identifying similarities and core concepts, illuminating contradictions and gaps, and/or identifying a coherent line of argument that may further inform residential innovation in LTC.

Method

Noblit and Hare’s (1988) method of meta-ethnographic synthesis has been used by many nursing scholars to combine the findings of discrete qualitative studies (Beck, 2002; Coffey, 2006; Meadows-Oliver, 2006). Finfgeld (2003) identified 16 additional syntheses published since 1994. This method was chosen because of its emphasis on maintaining the richness and essence of the original studies while creating an integrated whole. Metasynthesis is not about aggregating or reducing findings but rather about “enlarging the interpretive possibilities of findings and constructing larger narratives or general theories” (Sandelowski, Docherty, & Emden, 1997, p. 369). There is a tension between the need to link individual qualitative studies to larger programs of scholarship and the risk of losing “the vitality, viscerality, and vicariism of the human experiences represented in the original studies” (Sandelowski et al., 1997, p. 366). This method requires careful attention to both literal and interpretive translation of key ideas in the studies (Noblit & Hare, 1988). Word choices, concepts, images, and ideas are compared and contrasted across studies. Noblit and Hare emphasized that any particular ethnographer’s account represents just one possible translation of the body of work.

While Noblit and Hare (1988) suggest methods to assure adequate breadth in the search for sources (e.g., reviewing references in other works, consulting other scholars in the field), they point out that it is neither practical nor desirable to attempt to synthesize all studies on a given topic. Such an effort may result in a trite analysis. Instead, an effort should be made to select substantive sources that are credible, of interest to the research audience, and relevant to the purpose of the study.

Sample

Potentially relevant articles published from 1990 to 2008 were identified by searching Cumulative Index to Nursing and Allied Health Literature, MEDLINE, PsycInfo, Scopus, and Dissertation Abstracts International. Key search terms included at-homeness, meaning of home, built environment, social environment, place attachment, and person-environment fit, in combination with aged or elderly, qualitative research, ethnography, phenomenology, or grounded theory. Reference lists from initial studies and recommendations from scholars in the field were used to supplement the sample of studies to address the concept of home before, during, and after residential transition.

The final sample was selected to maximize heterogeneity in terms of residential context and study participants. To be eligible for inclusion in the synthesis, studies needed to include participants who were age 65 and older, include primary data collection about the meaning of home or adjusting to a new home after relocation, be written in English, and use qualitative methods (any type). Published articles and unpublished dissertations were eligible for inclusion. Studies were excluded if they used a priori analytic categories.

Of the 45 studies read and screened for eligibility, 23 were included in this synthesis. In a metasynthesis, the research “participants” are the research studies themselves (Table 1). Fourteen of the studies were published in nursing journals, and the remaining represented the disciplines of social science, housing, leadership and training, occupational therapy, public health, geography, and gerontology. Most of the studies used either grounded theory, ethnographic, or hermeneutic analytic methods. Purposive sampling was used in several studies to include participants who were African American (Groger, 1995), men (Matthews, 2002), or diagnosed with dementia (Wiersma, 2008; Zingmark, Norberg, & Sandman, 1993). Residential contexts included community homes, congregate living, assisted living, summer camps, and nursing homes. Individual studies included participants experiencing health transitions, as well as those experiencing residential transitions.

Methodological Characteristics of Qualitative Studies in MetasynthesisMethodological Characteristics of Qualitative Studies in Metasynthesis

Table 1: Methodological Characteristics of Qualitative Studies in Metasynthesis

Procedure for Data Analysis

The first two steps in the analytic method—identifying a topic amenable to interpretive qualitative synthesis and identifying relevant studies—have been described above. The next steps included reading and repeatedly re-reading the studies with attention to interpretive details, metaphors and contexts, and determining the nature of the relationship between studies (e.g., reciprocal, refutation, forming a line of argument). As guided by the method, the interpretive findings of the studies serve as the units of analysis. Each was read individually and abstracted into a table identifying salient metaphors, phrases, ideas, and concepts. Rows were formed when similar concepts or metaphors were identified across studies. Constant comparison and a grounded, hermeneutic process were used, with recurrent analysis of whole texts as well as parts (e.g., concepts, ideas, metaphors) to inform the interpretive process. Table 2 provides exemplary memos that provide an audit trail to enhance credibility of the analysis.

Examples of Memos Written to Identify Convergence and Divergence Across Studies

Table 2: Examples of Memos Written to Identify Convergence and Divergence Across Studies

This interpretive process highlighted the relationships between studies, as well as the type of synthesis that best fit the data. Two types of syntheses were found to be of use; reciprocal translation was used to synthesize key metaphors representing the meaning of home in the context of residential stability. Individual study metaphors were translated into one another, and these translations were then synthesized into a higher level of abstraction, yielding four overarching metaphors (Table 3). A line of argument was identified that revealed phases and challenges in recreating or sustaining “home” during residential and/or health transitions (Table 4).

Individual Study Metaphors as Related to Overarching MetaphorsIndividual Study Metaphors as Related to Overarching MetaphorsIndividual Study Metaphors as Related to Overarching MetaphorsIndividual Study Metaphors as Related to Overarching MetaphorsIndividual Study Metaphors as Related to Overarching MetaphorsIndividual Study Metaphors as Related to Overarching Metaphors

Table 3: Individual Study Metaphors as Related to Overarching Metaphors

Phases of Integration in Home as a Transitional Process

Table 4: Phases of Integration in Home as a Transitional Process

Findings

Recurrent analysis of texts and residential contexts resulted in the identification of home as both a place (physical or existential) and a process. Similar to light, which has wave-particle duality, home may be seen both as a discrete entity and as continuity. A summary interpretation using overarching metaphors will first be presented for each aspect of this duality, followed by elucidation of the key metaphors emerging from individual studies that contributed to the synthesis. Individual study metaphors and participant quotes from the studies contributing to the reciprocal translation will be presented. Sample memos will be included to demonstrate the constant comparison and grounded, hermeneutic process used in the analysis. Finally, key metaphors and study findings related to home as a transitional process will be described.

Reciprocal translation provided the best interpretation of studies that characterize home as a place-based entity: Home is an empowering refuge of relationship and self-reconciliation. Many studies included a focus on “losing home,” contrasting “home” with “a place to live,” or experiencing “homelessness” within the context of residential dwelling. These studies contributed to a line of argument viewing home as a process. Rifts in the social or physical environment (or both) result in a process of becoming “homeless,” followed by emplacement. The conditions of the transition itself and the milieu of the new environment may facilitate or impede the process.

Home as a Place-Based Entity

Empowering. Two metaphors taken together convey the idea of home as a place of personal power. They include “I can do what I want” and “mastery.” Almost every study in this synthesis contained a variant of the statement “at home, I can do what I want to do.” Exemplary metaphors include “a place of personal power; my dominion” (Gattuso, 1996, p. 174) and “in your real home you’re the boss” (Groger, 1995, p. 147). The freedom to come and go is particularly salient to the experience of personal power, preventing a residence from feeling like “a prison,” rather than a home (A.J. Sixsmith & J.A. Sixsmith, 1991). Personal power is also exercised in making choices about personal space, schedule, and activity pattern.

Environmental competence is facilitated by an embodied knowledge of the environment and its contents. The places, spaces, rhythms, and rituals of home are so well known to its inhabitants that they become “virtuosos of the environment” (Swenson, 1998, p. 383). Familiarity not only fosters mastery but also comfort. The sounds, smells, sensations, and routines of home are known and reassuring (Zingmark, Norberg, & Sandman, 1995).

A key to mastery in the early post-relocation period is the ability to “master logistics” and “meet needs” (Rossen & Knafl, 2003). Mastery may be strengthened by the presence of what Lawton (1990) first termed “control centers,” where necessary resources are within a proximity that enables easy access and control (Swenson, 1998).

Having a defined role in a group, household, or community also facilitates a feeling of mastery and contributes to at-homeness. Home is a place that highlights personal strengths and enables feelings of accomplishment (Matthews, 2002), independence (Leith, 2006), responsibility (Hammer, 1999), and usefulness (Ekman, Skott, & Norberg, 2001). Home is described as a foundation of strength (Moloney, 1997) and also provides a challenge to its occupants. Home offers environmental engagements and opportunities for contribution that foster a sense of mastery. Home plays an active role in making its occupants feel needed.

Several studies include participant accounts of times when a LTC facility or hospital “really” felt like home. These involved stories of work or contribution. Participant quotes exemplify this: “The priest could not get along without me. Father depends on me to serve Mass.” (Hammer, 1999, p. 15) and “Bob had a hot water tank to put up…. I told him, well, I could do that job for you.... I fixed it for him.” (Matthews, 2002, pp. 45–46). A.J. Sixsmith and J.A. Sixsmith (1991) described home as providing a “kind of place imperative that challenges and sustains independence, but also provides a haven of rest in situation of decrease in personal vigor” (p. 184). Portrayals of home as a balanced context for both activity and rest suggest an image of health and recuperation commonly expressed in the metaphors of home as haven or refuge.

Refuge. Home is described as a haven, a place of safety and security, a place to “withdraw and shut the door” (Leith, 2006). Findings across studies translate into this metaphor portraying home as a place of comfort, safety, ownership, and insideness. The visual image of taking off one’s shoes and lying down on the sofa was frequently used to suggest refuge within a “sacred space” (Zingmark et al., 1995). There is a sense in the group of studies that home is a place that has fewer restrictions than the outside, public world—a relaxed, accepting permissiveness. Home also has a “proxy” or a line that clearly demarcates being “an individual person” from being a “facility member” (Leith, 2006). This concept includes a boundary that is respected and protected, along with the people and things inside. A delicate balance of freedom and enclosure prevents a refuge from becoming a prison. Words such as my and mine appear in studies related to the spatial dimension of the refuge and to valued possessions. One of Matthews’ (2002) participants described a boxcar where he experienced “home” while working on the railroad: “your bunk…that’s your place…. Even if you’re not there, nobody can come in there because when you get there, your place is always there” (p. 58).

This idea of home as a place that one “can always come back to” (Dahlin-Ivanoff, Haak, Fänge, & Iwarsson, 2007) translates across studies in this sample and supports the metaphor of refuge. Returning in the context of journey, experiencing internal familiarity and order in the context of external uncertainty, and experiencing welcome in the context of external exclusion strengthen and reinforce home as a place of safety, belonging, and inclusion. Rowles (1983) found physical, social, and autobiographical “insideness” to be the central characteristics of home. These metaphors implicitly raise awareness of outside and outsideness and highlight that home gains meaning and intensity in dialectic or opposition of two opposing concepts. Zingmark et al. (1995) explicitly identified three essential dialectics comprising home: part of/apart from, caring for/being cared for, and belonging/possessing. Each of these metaphors reflects a degree of connectedness or relationship, the next key metaphor for the experience of home.

Relationship. Almost every study included connection, relationship, or togetherness as essential to a meaningful home. A participant in Matthews’ (2002) study expressed, “You have to be a part of it…when somebody else does everything else, it’s a residence…to call it a home you have to build it…not only the structural part of it; you have to see to the binding of everybody” (p. 52). This is consistent with Rowles’ (1983) notion of “contributing to the social fabric” of the place. The presence of friends and family, those with whom one shares “bonds of intimacy” (Gattuso, 1996), also fosters an experience of home. A participant in Gattuso’s (1996) study highlighted that home as a refuge extends beyond the individual dweller to the loved ones in their lives: “To me home is where…my family can come when they are in trouble or for pleasure, happiness, celebration” (p. 173). Dupuis and Thorns (1996) echoed the importance of home to family gathering and social continuity: “Home is the site where family reassembles for the rites and rituals of their collective life” (p. 496).

Rowles (1983) used the phrase social insideness to describe the experience of connectedness and relationship that forms within a family, group, or community over time. Social insideness conveys the status associated with being a “somebody” in the community and engenders a sense of belonging as well as “a reservoir of accumulated social credit” derived from contributions made to the community over time (Rowles, 1983, p. 302).

Whereas social insideness conveys a spatial quality to relatedness, a more affective tone regarding reciprocal social transactions is struck by studies using metaphors of caring. Swenson (1998) described home as the “center of caring.” Matthews (2002) described home as being with “people with whom one belongs; who care about you deeply; who want you to be well and do well” (p. 40), and a participant in Moloney’s (1997) study characterized this need for reciprocal caring in a conceptually provocative way: “You need people…that you can trust with anything that you say, that you can help…you just build another family” (p. 170). Welcoming, including, or recreating family fosters social insideness and results in sharing and shaping identity.

Being known and knowing others are commonly referenced as concepts that distinguish “home” from “not home” across several studies conducted in residential LTC settings. Almost every study in the sample identified home as a focus of identity. Home is a place where the self is recognized, significant, and known. A key to creating and maintaining home is expressing individuality and uniqueness. A participant in Heliker and Scholler-Jaquish’s (2006) study who experienced initial distress in a new environment despaired, “They don’t know the meaning of me!” (p. 38). Processes to create and maintain home included personalizing the environment, surrounding oneself with autobiographical icons, and/or sharing one’s story (Ekman et al., 2001; Heliker & Scholler-Jaquish, 2006; Swenson, 1998; Zingmark et al., 1995). A concept that relates to self-reconciliation is the individualistic nature of place-based experiences cited by individual participants in the qualitative studies. Even within a common living environment, the reaction of each individual to a particular environmental feature is unique and dependent on that person’s life story (Hammer, 1999). The relational aspect of home is dynamic—a function of both the environment and the self.

Self-Reconciliation. Feeling at home after experiencing a major transition such as relocation, disruption in health, or loss of function requires “confirming a sense of self” and finding “continuity in their values and beliefs and personal identity” (Hersch, Spencer, & Kapoor, 2003, p. 330). Dissonance between previous self-concept and the sense of self experienced in the context of new health crises, loss of physical/functional capacity, and a new social milieu of strangers mirroring a feared future of undiluted old age (Young, 1998) require significant efforts to redefine, reconcile, re-narrate, and reconfirm the meaning of “me” in the new environment. Dissonance between a previous residential situation and a contemporary residential care situation in terms of mastery, competence, social insideness, and embodied virtuosity may result in a rift between past and present that may prohibit the experience of continuity of self in the new environment.

Self-reconciliation may range from passive acceptance of diminished possibilities and “making the best of it” (Heliker & Scholler-Jaquish, 2006) to “redefining independence” (Groger, 1995), learning to live with illness and dependency (Ekman et al., 2001) or to “synthesiz[ing] a new identity for themselves by re-adjusting their previous understanding of themselves and their place within their environment” (Leith, 2006, p. 329). Therefore, at-homeness is not only an experience of a static place but a process of dynamic integration of self into a person-place “mosaic” (Rowles, 1983) composed of individual meaningful, place-based experiences (“incident places” as described by Rowles, 1983). This is particularly salient for nurses as the place-based experiences include sites of nursing care, and the particulars of care delivery become part of the self-reconciliation process. Groger (1995) pointed out that having a fixed image of a prior home as a symbol of bodily health, autonomy, and social connection may preclude consideration of the nursing home as home. If the self is stuck in the past and can feel at home only if the body is functionally able, then the person may be unable to move forward to truly become a part of the contemporary environment. This highlights the importance of home as a transitional process.

Home as a Transitional Process of Integration

Integration. Overcoming existential homelessness and finding at-homeness after residential transition is fraught with challenge. Achieving at-homeness throughout life is a process of integration of the self with the environment; person and environment become “a part of” the other, thus opening the “self” to possibility, growth, and a future temporal and spatial perspective. While almost every study included the physical and social environment as part of home, only some authors explicitly included the temporal and spiritual environment. Zingmark et al. (1995) described dialectic imminent and transcendent experiences. Wiersma (2008) described person-place integration as “feeling a part of life,” and Zingmark et al. (1993) described “being in meaningful relationship” to others, time, events, objects, and God or the cosmos. Rowles (1983) used the term autobiographical insideness to describe the way in which each resident’s autobiography “becomes more and more a part of the place to the point where [the place] becomes an extension of self” (p. 303).

Phases or stages in the integration process are captured in the following metaphors: “Closing one door and opening another,” “nesting,” and “the meaning of me moves forward.” The metaphor of nesting (Young, 1998) best reflects the active process of creating and shaping home; in other words, building an empowering refuge of relationship and self-reconciliation. In the absence of integration, homelessness ensues. Person and place remain disengaged, and social withdrawal is common. Successful integration, or experiencing at-homeness after transition, enables continuity of self in the past and present, and the ability to grow, develop, envision, or embark on a future in the current residential context. This process of integration takes time and a willingness to relate or engage with a place, rather than distancing (Carboni, 1990; Johnson, 1996) or disengaging (Wiersma, 2008). The door to possible integration must be open.

Closing One Door, Opening Another. A participant in Moloney’s (1997) study stated that when “one door closes, another one opens” (p. 173). This metaphor symbolizes the need to “tie up loose ends of the past” (Young, 1998, p. 157) to invest oneself in the future. Acknowledging the need to relocate by recognizing a need that is not met in the current setting, developing rationale for a move, making/participating in the decision, and developing positive expectations for the future each facilitate forward movement in the ability to “uproot” the self from one location and begin to invest in another (Johnson, 1996; Leith, 2006; Rossen & Knafl, 2003; Young, 1998). Having previous positive experiences with a new environment (Groger, 1995), purposely selecting a macrosphere and microsphere suited to one’s needs (Leith, 2006), imagining positive features of the new environment (Johnson, 1996), and picturing oneself in a new environment (Zingmark et al., 1995) each facilitate a process of opening a door for the self and the new environment to begin integration.

Leith (2006) referred to this as “pre-place attachment,” and Groger (1995) described it as experiencing a feeling like “coming home.” The process of sorting through one’s possessions and deciding what to do with one’s treasures (Young, 1998) is symbolic of resolving the past in order to move forward. Skipping this activity may preclude integration and a healthy transition. Participants in several studies specifically mention the importance of “not turning back” or “not looking back” (Hersch et al., 2003; Leith, 2006). Closing the door does not mean forgetting the past, however. In fact, Zingmark et al.’s (1993) study of individuals with dementia revealed that having no memories impedes place integration and at-homeness, even in previously familiar environments. Being unable to remember the “collage” of “incident-places” described in Rowles’ (1983) study leaves the individual bereft of the intimate person-environment relationship created in the process of living. Many studies pointed out the importance of reminiscence to the experience of self-continuity and at-homeness. One key to permitting a new door to open seems to be the ability to link the present with the past in a meaningful way, creating a continuity Wiersma (2008) likened to “reawakening.” Personal possessions or furnishings may provide the touchstones for this link, providing feelings of comfort, belonging, and continuity.

Homelessness. If the transitional conditions do not permit integration between person and environment, an existential homelessness ensues. This may represent a brief period of uprootedness or a sustained condition of minimal or non-existent integration (Rossen & Knafl, 2003). The study metaphors used to describe this non-integration validate the interpretation of home as a place-based entity by describing distinct polarities of empowerment, refuge, relationship, and self-reconciliation. Carboni (1990) characterized homelessness as powerlessness, lack of choices, loss of identity, disconnectedness, loss of memories, uncertainty, meaningless space, intrusion, and dependent journeying. A participant in Zingmark et al.’s (1995) study shared, “I cannot offer anyone a home; I cannot take care of others anymore” (p. 57). A woman in Ekman et al.’s (2001) study recounted, “Staff say, ‘You’ll have to wait until we clear the tables’…it hurts me so…they don’t put human beings first” (p. 62).

Several studies incorporated quotes related to experiences of confinement, restriction, and powerlessness. In Heliker and Scholler-Jaquish’s (2006) study, “They’re [staff] out there, and I’m in here. I’m isolated” (p. 39) and “I’m a prisoner here” (p. 39). When integration is not achieved, the person has what Hammer (1999) described as “a pervasive, relentless desire to be elsewhere” (p. 14). Being offered a home, emotionally (Zingmark et al., 1995), and building a physical or social home, are both transitional activities that contribute to at-homeness. These transitional activities are part of place-making, described using the metaphor of nesting.

Nesting. Nesting is a metaphor used in Young’s (1998) study to describe the process of personalization of the environment and an attention to aesthetics that results in a feeling of comfort and belonging. Nesting is used in this synthesis as a metaphor to encompass a much broader set of ideas found across studies. Nesting requires investment of energy and effort into creating a protected place to care for and nourish the self and loved others. Nesting implies ownership and protection of place and its contents, as well as a hopeful, future orientation to time, and a place of return after expedition. Young (1998) described the “creation of home as an active endeavor of all members of the household” (p. 154). Matthews (2002) identified active participation and work as a key to differentiating a home from a residence. Moloney (1997) and Zingmark et al. (1995) described the importance of being able to share one’s home with others. These findings highlight the importance of participation on the part of the resident into “building” or investing energy into a home. A participant in Moloney’s (1997) study talked about the importance of finding a “niche” after relocation. Niche conveys a two-fold meaning appropriate to the integration process. A niche is a role or activity that a person can make his or her own and that is well suited to that particular person. It is also a place in nature where an organism “fits” with its natural environment and with other organisms in a manner, which ensures its survival (Encarta®, n.d.). Thus, through creating an ecological nest or niche, the self survives and possibly thrives.

The “Meaning of Me” Moves Forward. Groger (1995) wrote that “continuity of selected aspects of a person’s earlier life can…help to transform a nursing home into a home” (p. 148). Hersch et al. (2003) described the importance of the “symbolic process of reconstructing continuity” (p. 329) in a way that does not emphasize material possessions but has more to do with the continuity of life narratives. Heliker and Scholler-Jaquish (2006) discussed the merit of sharing one’s stories and storying the post-relocation experience to establish the thread of continuity. Wiersma (2008) described this as being able to experience the present environment with the eyes of the past.

The narrative thread of the autobiographical self continues to weave itself into the physical and social world of the new residence, resulting in the ability to move forward and grow. At-homeness is “an existence that involves possibilities” (Hammer, 1999, p. 15). Swenson (1998) described home as the center of physical, visual, emotional, and intellectual reach, and Rossen and Knafl (2003) portrayed individuals achieving full integration as “launching” as opposed to “marking time.” Rowles (1983) described the ability of the dwellers in his study to project the self vicariously to distant locations and other times. At-homeness as an experience of person-environment integration facilitates developmental growth or opening of the self to time and experiential possibility. When full integration is achieved, holistic or aesthetic words are often used to describe home, including warmth, harmony, joy, and an integrated whole.

Summary

At-homeness is an experience of dynamic person-place integration created in cycles of closing one door, opening another, nesting, and moving the reconciled self forward into future possible relationships with time, space, people, activities, and meanings. Therapeutic environments may enable at-homeness by providing an empowering refuge of relationship, a nurturing environment for the continuity of identity, and transitional support for reconciling life changes. The qualitative empirical support for this interpretation is strong, emerging from the synthesis of 23 discrete studies. This interpretation informs ongoing clinical practice and theory development focused on shaping environments for healing and enabling experiences of home during residential transition.

Discussion

The metaphors identified in this study may be used to create and test theories of person-environment-centered care. The role of the environment in “calling to” individual strengths and capacities is as important as the role of the individual’s readiness to “open a new door.” There is a need for psychosocial interventions related to grieving processes and facilitating readiness for change, as well as for environments that provide something to look forward to and that express confidence in the individual’s ability to successfully navigate the transition.

Environments engaging in person-environment-centered care would seek to learn the “meaning of me” for each dweller and provide opportunities for meaningful, individualized place experiences. The therapeutic environment would maintain boundaries, facilitate meaningful engagement, sustain important relationships, and continue or create routines and rituals. The physical environment would incorporate spaces that foster belonging, familiarity, navigation, and mastery. Opportunities would be provided to truly be a part of the environment, through activity, relationship, participation, and/or investment into some small piece of physical, social, or existential space. In homey environments, ways for individuals to make a home and share it with others would be intentionally created. Further research is needed to determine whether such individually tailored environments could create a bubble of existential at-homeness by incorporating the key metaphors identified in this synthesis and whether interventions that foster at-homeness increase the likelihood of health and thriving in a new residential environment.

Conclusion

Noblit and Hare’s (1988) interpretive method of metasynthesis enabled the blending of findings from numerous discrete studies of home and residential transition into a new interpretation. The conclusions reached in this effort are limited by the particular studies included in the translation and the interpretive skills of this author. Alternative interpretations are possible and may yield new and fruitful insights. The internal validity of this particular interpretation is supported with an audit trail and the inclusion of direct quotes from the sample studies. External validity is supported by the congruence between this synthesis and extent theories related to person-environment congruence (Kahana et al., 1980), place identity (Rubenstein & de Medeiros, 2005), nursing transitions (Meleis, Sawyer, Im, Messias, & Schumacher, 2000), and thriving across the life span (Haight, Barba, Tesh, & Courts, 2002).

The goal of this synthesis is to add to professional discourse at a time when Green Houses, small houses, life care communities, assisted living residences, and similar environments are struggling to define, design, implement, and evaluate therapeutic milieus. The interpretation of home as both a place-based entity and a process extends beyond any specific physical environment and enables a broader vision of caring in the context of transition. Environments that incorporate the metaphors emerging in this study may offer the possibility of creating an experience of home consistent with the ethos of nursing: putting the person first but also recognizing individuals as whole, situational, contextual, emplaced beings.

References

  • Beck, C.T. (2002). Postpartum depression: A metasynthesis. Qualitative Health Research, 12, 453–472. doi:10.1177/104973202129120016 [CrossRef]
  • Carboni, J.T. (1990). Homelessness among the institutionalized elderly. Journal of Gerontological Nursing, 16(7), 32–37.
  • Coffey, J.S. (2006). Parenting a child with chronic illness: A metasynthesis. Pediatric Nursing, 32, 51–59.
  • Craven, J. & Wald, F.S. (1975). Hospice care for dying patients. American Journal of Nursing, 75(10), 1816–1822. doi:10.2307/3423575 [CrossRef]
  • Cutchin, M.P., Owen, S.V. & Chang, P.J. (2003). Becoming “at home” in assisted living residences: Exploring place integration processes. Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 58, S234–S243.
  • Dahlin-Ivanoff, S., Haak, M., Fänge, A. & Iwarsson, S. (2007). The multiple meaning of home as experienced by very old Swedish people. Scandinavian Journal of Occupational Therapy, 14, 25–32. doi:10.1080/11038120601151714 [CrossRef]
  • Despres, C. (1991). The meaning of home: Literature review and directions for future research and theoretical development. Journal of Architectural and Planning Research, 8, 96–115.
  • Deutschman, M.T. (2005). An ethnographic study of nursing home culture to define organizational realities of culture change. Journal of Health & Human Services Administration, 28, 246–281.
  • Dovey, K. (1985). Home and homelessness. In Altman, I. & Werner, C.M. (Eds.), Home environments (pp. 33–64). New York: Plenum Press.
  • Dupuis, A. & Thorns, D. (1996). Meanings of home for older homeowners. Housing Studies, 11, 485–501. doi:10.1080/02673039608720871 [CrossRef]
  • Edvardsson, D. (2008). Therapeutic environments for older adults: Constituents and meanings. Journal of Gerontological Nursing, 34(6), 32–40. doi:10.3928/00989134-20080601-05 [CrossRef]
  • Ekman, I., Skott, C. & Norberg, A. (2001). A place of one’s own. The meaning of lived experience as narrated by an elderly woman with severe chronic heart failure. A case-study. Scandinavian Journal of Caring Sciences, 15, 60–65. doi:10.1046/j.1471-6712.2001.1510060.x [CrossRef]
  • Encarta®. (n.d.). Niche. Retrieved from http://encarta.msn.com/dictionary_/niche.html
  • Finfgeld, D.L. (2003). Metasynthesis: The state of the art—So far. Qualitative Health Research, 13, 893–904. doi:10.1177/1049732303253462 [CrossRef]
  • Gattuso, S. (1996). The meaning of home for older women in rural Australia. Australasian Journal on Ageing, 15, 172–176. doi:10.1111/j.1741-6612.1996.tb00024.x [CrossRef]
  • Gearon, C.J. (2002). Planetree: 25 years older: Hospitals & Health Networks, 76(10), 40–43.
  • Groger, L. (1995). A nursing home can be a home. Journal of Aging Studies, 9, 137–153. doi:10.1016/0890-4065(95)90008-X [CrossRef]
  • Haight, B.K., Barba, B.E., Tesh, A.S. & Courts, N.F. (2002). Thriving: A life span theory. Journal of Gerontological Nursing, 28(3), 14–22.
  • Hall, G.R. & Buckwalter, K.C. (1987). Progressively lowered stress threshold: A conceptual model for care of adults with Alzheimer’s disease. Archives of Psychiatric Nursing, 1, 399–406.
  • Hammer, R.M. (1999). The lived experience of being at home: A phenomenological investigation. Journal of Gerontological Nursing, 25(11), 10–18.
  • Hawes, C., Phillips, C.D., Rose, M., Holan, S. & Sherman, M. (2003). A national survey of assisted living facilities. The Gerontologist, 43, 875–882.
  • Heliker, D. & Scholler-Jaquish, A. (2006). Transition of new residents to long-term care: Basing practice on residents’ perspective. Journal of Gerontological Nursing, 32(9), 34–42.
  • Hersch, G., Spencer, J. & Kapoor, T. (2003). Adaptation by elders to new living arrangements following hospitalization: A qualitative, retrospective analysis. Journal of Applied Gerontology, 22, 315–339. doi:10.1177/0733464803253586 [CrossRef]
  • Jackson, M. (1995). At home in the world. Durham, NC: Duke University Press.
  • Johnson, R.A. (1996). The meaning of relocation among elderly religious sisters. Western Journal of Nursing Research, 18, 172–185. doi:10.1177/019394599601800205 [CrossRef]
  • Jones, A. (2002). The national nursing home survey: 1999 summary. Vital and Health Statistics, 13(152). Retrieved from the Centers for Disease Control and Prevention website: http://www.cdc.gov/nchs/data/series/sr_13/sr13_152.pdf
  • Joy, A. & Dholakia, R.R. (1991). Remembrances of things past: The meaning of home and possessions of Indian professionals in Canada. Journal of Social Behavior & Personality, 6, 385–402.
  • Kahana, E., Liang, J. & Felton, B.J. (1980). Alternative models of person-environment fit: Prediction of morale in three homes for the aged. Journal of Gerontology, 35, 584–595.
  • Kayser-Jones, J. (1989). The environment and quality of life in long-term care institutions. Nursing & Health Care, 10, 124–130.
  • Kayser-Jones, J., Chan, J. & Kris, A. (2005). A model long-term care hospice unit: Care, community, and compassion. Geriatric Nursing, 26, 16–20. doi:10.1016/j.gerinurse.2004.11.001 [CrossRef]
  • Lawton, M.P. (1990). Residential environment and self-directedness among older people. American Psychologist, 45, 638–640. doi:10.1037/0003-066X.45.5.638 [CrossRef]
  • Leith, K.H. (2006). “Home is where the heart is...or is it?”. A phenomenological exploration of the meaning of home for older women in congregate housing. Journal of Aging Studies, 20, 317–333. doi:10.1016/j.jaging.2005.12.002 [CrossRef]
  • Marcus, C.C. (1995). House as a mirror of self. Berkeley, CA: Conari Press.
  • Matthews, G.J. (2002). The meaning of “home” in the stories of older men living in long-term care. Unpublished master’s thesis, Royal Roads University, Victoria, British Columbia, Canada.
  • Meadows-Oliver, M. (2006). Homeless adolescent mothers: A metasynthesis of their life experiences. Journal of Pediatric Nursing, 21, 340–349. doi:10.1016/j.pedn.2006.02.004 [CrossRef]
  • Meleis, A.I., Sawyer, L.M., Im, E.O., Messias, H.D.K. & Schumacher, K. (2000). Experiencing transitions: An emerging middle-range theory. Advances in Nursing Science, 23(1), 12–28.
  • Moloney, M.F. (1997). The meaning of home in the stories of older women. Western Journal of Nursing Research, 19, 166–176. doi:10.1177/019394599701900203 [CrossRef]
  • Noblit, G.W. & Hare, R.D. (1988). Meta-ethnography: Synthesizing qualitative studies. Newbury Park, CA: Sage.
  • Oswald, F. & Wahl, H.W. (2005). Dimensions of the meaning of home in later life. In Rowles, G.D. & Chaudhury, H. (Eds.), Home and identity in late life: International perspectives (pp. 21–45). New York: Springer.
  • Proshansky, H.M., Fabian, A.K. & Kaminoff, R. (1983). Place-identity: Physical world socialization of the self. Journal of Environmental Psychology, 3(1), 57–83. doi:10.1016/S0272-4944(83)80021-8 [CrossRef]
  • Rabig, J. & Rabig, D. (2008, March). From “nursing home” to “home”: The small house movement. Long-Term Living. Retrieved from http://www.ltlmagazine.com
  • Rabig, J., Thomas, W., Kane, R.A., Cutler, L.J. & McAlilly, S. (2006). Radical redesign of nursing homes: Applying the green house concept in Tupelo, Mississippi. The Gerontologist, 46, 533–539.
  • Rossen, E.K. & Knafl, K.A. (2003). Older women’s response to residential relocation: Description of transition styles. Qualitative Health Research, 13, 20–36. doi:10.1177/1049732302239409 [CrossRef]
  • Roush, C.V. & Cox, J.E. (2000). The meaning of home: How it shapes the practice of home and hospice care. Home Healthcare Nurse, 18, 388–394. doi:10.1097/00004045-200006000-00015 [CrossRef]
  • Rowles, G.D. (1980). Toward a geography of growing old. In Buttimer, A. & Seamon, D. (Eds.), The human experience of space and place (pp. 55–72). London: Croom Helm.
  • Rowles, G.D. (1983). Place and personal identity in old age: Observations from Appalachia. Journal of Environmental Psychology, 3, 299–313. doi:10.1016/S0272-4944(83)80033-4 [CrossRef]
  • Rowles, G.D. & Chaudhury, H. (2005). Home and identity in late life: International perspectives. New York: Springer.
  • Rubinstein, R.L. (1989). The home environments of older people: Psychosocial processes relating person to place. Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 44, S45–S53.
  • Rubinstein, R.L. & de Medeiros, K. (2005). Home, self, and identity. In Rowles, G.D. & Chaudhury, H. (Eds.), Home and identity in late life: International perspectives (pp. 47–62). New York: Springer.
  • Sandelowski, M., Docherty, S. & Emden, C. (1997). Focus on qualitative methods. Qualitative metasynthesis: Issues and techniques. Research in Nursing & Health, 20, 365–371. doi:10.1002/(SICI)1098-240X(199708)20:4<365::AID-NUR9>3.0.CO;2-E [CrossRef]
  • Seamon, D. (1979). A geography of the lifeworld. New York: St. Martin’s Press.
  • Sherman, E. & Dacher, J. (2005). Cherished objects and the meaning of home: Their meaning and roles in late life. In Rowles, G.D. & Chaudhury, H. (Eds.), Home and identity in late life: International perspectives (pp. 63–79). New York: Springer.
  • Sixsmith, A.J. & Sixsmith, J.A. (1991). Transitions in home experience in later life. Journal of Architectural and Planning Research, 8, 181–191.
  • Sixsmith, J. (1986). The meaning of home: An exploratory study of environmental experience. Journal of Environmental Psychology, 6, 281–298. doi:10.1016/S0272-4944(86)80002-0 [CrossRef]
  • Somerville, P. (1992). Homelessness and the meaning of home: Rooflessness or rootlessness?International Journal of Urban and Regional Research, 16, 529–539. doi:10.1111/j.1468-2427.1992.tb00194.x [CrossRef]
  • Swenson, M.M. (1998). The meaning of home to five elderly women. Health Care for Women International, 19, 381–393. doi:10.1080/073993398246160 [CrossRef]
  • U.S. Administration on Aging. (2008). A profile of older Americans: 2008. Retrieved from http://www.aoa.gov/AoAroot/Aging_Statistics/Profile/2008/6.aspx
  • Watson, J. (1999). Postmodern nursing and beyond. New York: Churchill Livingstone.
  • Werner, C.M., Altman, I. & Oxley, D. (1985). Temporal aspects of home. In Altman, I. & Werner, C.M. (Eds.), Home environments (pp. 1–32). New York: Plenum Press.
  • Wiersma, E.C. (2008). The experiences of place: Veterans with dementia making meaning of their environments. Health and Place, 14, 779–794. doi:10.1016/j.healthplace.2008.01.001 [CrossRef]
  • Young, H.M. (1998). Moving to congregate housing: The last chosen home. Journal of Aging Studies, 12, 149–165. doi:10.1016/S0890-4065(98)90012-3 [CrossRef]
  • Zingmark, K., Norberg, A. & Sandman, P. (1993). Experience of at-homeness in patients with Alzheimer’s disease. American Journal of Alzheimer’s Care and Related Disorders and Research, 8, 10–16.
  • Zingmark, K., Norberg, A. & Sandman, P. (1995). The experience of being at home throughout the life span. Investigation of persons aged from 2 to 102. International Journal of Aging & Human Development, 41, 47–62.

Methodological Characteristics of Qualitative Studies in Metasynthesis

Study Purpose Discipline Country Qualitative Research Design
Carboni (1990) To answer the question: “Do institutionalized elderly consider themselves homeless?” Nursing United States Hybrid fieldwork
Dahlin-Ivanoff, Haak, Fänge, & Iwarsson (2007) To explore how very old individuals experience the meaning of home. Occupational therapy Sweden Grounded theory
Dupuis & Thorns (1996) To use empirical data to demonstrate that the meaning of home reflects specific sets of historical and social circumstances. Sociology New Zealand Sociological analysis
Edvardsson (2008) To describe what it means to be in a therapeutic environment. Nursing Sweden Qualitative, content analysis
Ekman, Skott, & Norberg (2001) To achieve a deeper understanding of the meaning of the lived experience of being an elderly woman with chronic heart failure. Nursing Sweden Case study, interpretive analysis
Gattuso (1996) To examine the meaning of home for older women living in rural Australia. Social science Australia Qualitative
Groger (1995) To determine whether, to what extent, and how older adults can achieve a sense of home in a nursing home. Nursing United States Qualitative
Hammer (1999) To investigate the elements present when individuals are able to describe themselves as “at home” in a particular situation. Nursing United States Heideggarian phenomenology
Heliker & Scholler-Jaquish (2006) To describe the phenomenon of living in a nursing home and to explicate key transitions during first 3 months. Nursing United States Hermeneutic phenomenology
Hersch, Spencer, & Kapoor (2003) To describe the process of adaptation to relocation and to identify indicators of successful adaptation. Gerontology United States Phenomenology
Johnson (1996) To construct the meaning of involuntary, intra-institutional relocation for a group of elderly religious sisters living in a retirement facility. Nursing United States Phenomenology
Leith (2006) To explore how a group of older women reconceptualized “home” after moving from long-term residences into a congregate long-term care facility. Social work United States Hermeneutic phenomenology
Matthews (2002) To define the meaning of home for older men living in long-term care. Leadership and training Canada Participatory action, appreciative inquiry
Moloney (1997) To explore the common meanings and shared practices in the stories of strength told by older women. Nursing United States Hermeneutic phenomenology
Rossen & Knafl (2003) To conceptualize the early relocation transition of older women who relocated from established family homes to congregate, age-specific living and to identify factors related to unhealthy outcomes. Nursing United States Naturalistic paradigm, descriptive
Roush & Cox (2000) To explore what clients mean when they express a strong desire to “go home.” Nursing United States Case study
Rowles (1983) To explore the phenomenon of attachment to place in old age. Gerontology geography United States Ethnography
A.J. Sixsmith & J.A. Sixsmith (1991) To examine the impact of wider life experiences on the meaning of home. Social gerontology United Kingdom Qualitative, content analysis
Swenson (1998) To understand the phenomenon of the meaning of home. Nursing United States Hermeneutic phenomenology
Young (1998) To explore the experience of moving to congregate housing among a group of older adults. Nursing United States Grounded theory
Wiersma (2008) To explore experiences of older adults living with dementia in two distinct environments: the long-term care setting and in a summer camp setting. Public health Canada Qualitative methods
Zingmark, Norberg, & Sandman (1993) To gain deeper understanding of the daily life of patients with dementia and to explore their behavior related to home. Nursing Sweden Participant observation, constant comparative analysis
Zingmark, Norberg, & Sandman (1995) To illuminate people’s experience of being at home throughout life. Nursing Sweden Phenomenology

Examples of Memos Written to Identify Convergence and Divergence Across Studies

• Young (1998; “mastering logistics to meet needs”) and Rossen and Knafl (2003; “mastery or competence)” both include metaphors related to mastery, but neither study explicitly discusses the role of the physical environment in facilitating or inhibiting mastery, whereas A.J. Sixsmith and J.A. Sixsmith (1991) speak of a “place imperative” that challenges and sustains independence.
• Interpretive memo: There is a difference in view of shared “agency” between person and physical environment versus more focus on role of the individual as independent actors in their own physical space. This may relate to discipline/theoretical framework in these studies (environmental gerontology versus nursing transitions, for example). Continue to look in other studies at role of the residential environment in “calling to” the individual to challenge, promote independence, or foster mastery.
• A participant in Gattuso’s (1996) study talks about “someone who cares and gets you going.” This seems to be a “call to” one’s strengths coming from a different source—the social environment, rather than the physical environment. Rowles’ (1983) discussion of social insideness includes the term “social credit,” created through contributions to the community over time.
• Interpretive memo: At-homeness is facilitated when something or someone in the environment provides a challenge to or creates a space for physical or social competence or mastery and/or facilitates a relationship of reciprocal exchange of social credit.
• Swenson (1998; “center of self”) and Hersch, Spencer, and Kapoor (2003; “confirm self”) have convergent ideas related to home and self-identity, but the need to “confirm” suggests that self is mutable and sometimes lost or threatened. Rossen and Knafl (2003) used the metaphor of “fitting in,” which suggests changing one’s contours a bit in response to an external shaping force, and Young (1998) discussed the need to reconcile life changes and respond to a new social/peer group that confronts one with the impact of aging, which may threaten self-concept. Groger (1995) discussed redefining independence and/or redefining the boundaries of privacy.
• Interpretive memo: Residential moves may pose a threat to self-concept; self-maintenance and/or self-“shaping” is part of the transitional experience and may also involve reconsideration of physical/spatial agency and social/spatial boundaries. These concepts seem to be at the critical margin of the residential transitional experience. Look across studies at elements of “home” or “environment” or other concepts that relate to selfhood.

Individual Study Metaphors as Related to Overarching Metaphors

Study Sample Empowering (Do What I Want) Empowering (Mastery) Refuge Relationship Self-Reconciliation
Carboni (1990) Nursing home (2 key informants + participant observation) “Power/autonomy: personal freedom; decision making; choices” (p. 34) “Meaningful experience of space”; “safety/predictability” (p. 34); “a safe haven” (p. 35) “Strong, intimate and fluid relationship exists between individual and environment” (p. 33); connectedness—with people, place; past; future “Identity: bonding of person & place, rootedness, belonging” (p. 34)
Dahlin-Ivanoff, Haak, Fänge, & Iwarsson (2007) Community (n = 40) “Freedom to leave one’s own mark” (p. 29) “Living in a familiar neighborhood” (p. 27); “everything functions”; “having sufficient skills” (p. 28) “Home as a central place in the lives of very old people” (p. 27); “home means security” (p. 27); “home is always there…it is a place one can always come back to” (p. 28) “A meeting place”; “being surrounded by family and friends” (p. 28) “A place for reflection”; “freedom to withdraw and be ‘sufficient unto oneself’” (p. 28)
Dupuis & Thorns (1996) Community (n = 53) Freedom to act like a child (p. 496) Becomes a burden as life circumstances change (p. 494) “Quest for security” (p. 488); “protecting families from macro and micro insecurities” (p. 489); hard to feel safe when living alone (p. 495) “Family continuity” (p. 496); “where family reassembles for rites and rituals of their collective life” (p. 496); “intergenerational relations of help, support and succor” (p. 496); “bequeathing family history” (p. 498)
Edvardsson (2008) Hospice, geriatric, medical, and oncology settings (n = 41) Therapeutic physical environments facilitate a shift of focus from oneself; “patients gained energy and were helped to forget themselves and their situation” (p. 36); “calm pace” (p. 37); “safety” (p. 37) Physical environments convey symbolic meanings of caring or uncaring (p. 35); a therapeutic physical environment supports the possibility of creating and maintaining social interaction (p. 35); “receiving a little extra (something without having to ask for it)” (p. 37) Familiar scents and sounds can facilitate recognizing oneself in the environment (p. 36)
Ekman, Skott, & Norberg (2001) Community then nursing home (n = 1) “Being at home in the body, in the room and with health care” (p. 63); participant quotes: “Do just a little something useful” (p. 61); and “there’s a lot of me that’s in good shape” (p. 61) “Being inside, belonging to a place, means security” (p. 64) “Felt a closer relation and a stronger feeling of at-homeness with both herself and her caregivers” (p. 64) Feeling at home in the body; practicing the new body; participant quote: “You have to learn to live with your illness” (p. 61). “Picturing oneself in the environment” (p. 64); participant quote: “My head is clear and I’m very happy for that. I have friends…who are senile” (p. 61)
Gattuso (1996) Community (n = 29) Participant quote: “Home is my dominion where I do as I like” (p. 174) “A place of personal power”; “a home of one’s own, on one’s own” (p. 174) “Where relationships are made and maintained” (p. 173); “bonds of intimacy” (p. 174); for family and for friends; a place for friends to stay; someone…who cares and “gets you going” (p. 174) A place where every nook and cranny tells one’s story (p. 174)
Groger (1995) Home care and nursing home (n = 20) Participant quotes: “Being able to do what I want to do” (p. 146); “in your real home you’re the boss” (p. 147) Participant quote: “Make things to help the crippled that was more crippled than I was” (p. 149); cleaning, changing things around, washing and dusting (p. 151) Family and relationships (p. 150); helping others (p. 148) “Redraw the boundaries of privacy” (p. 149); redefining independence (p. 150); “continuity of selected aspects of a person’s earlier life” (p. 148); defining attributes of person one used to be” (p. 148)
Hammer (1999) Intermediate care facility, skilled nursing facility, and life care (n = 10) To do “just as I please”; “one feels comfortable and confident seeking fulfillment of physical and psychological needs” (p. 14); wide variety/intensity of meanings of home “One feels in control and able to exert responsibility for one’s actions” (p. 14) “Provision is made for privacy” (p. 14); “boundaries are respected and protected” (p. 14); “space…is shared with others only by invitation” (p. 14) “A sense of belonging, of being on an equal footing with others...in the home” (p. 14); “reciprocity of...affection” (p. 14); “common bonds” (p. 14) “Significance vs. anonymity” (p. 15); “a place where life themes can continue to unfold” (p. 15)
Heliker & Scholler-Jaquish (2006) Nursing home (n = 10) “Getting settled and learning the ropes” (p. 37); “learning the rules”; “navigating the system” (p. 39) The meaning of place takes on a territoriality dimension (p. 40) “Becoming known and knowing others” (p. 37) “Making the best of it”; “playing the cards we are dealt” (p. 40)
Hersch, Spencer, & Kapoor (2003) Nursing home, personal care home, and community (n = 5) “Getting physical care needs met, engaging in valued activities” (p. 327) “Establishing a sense of place” (p. 327) “Developing valued social relationships” (p. 327) “Confirming a sense of self” (p. 330); “continuity in their values and beliefs and personal identity” (p. 330)
Johnson (1996) Relocation to assisted living in a religious retirement community (n = 12) Helping neighbors; “interpersonal richness contributed to their quality of life” (p. 180); old social networks altered (p. 182) Recognizing uncertainties as opportunities to strengthen their faith (p. 179); “perhaps as their basic needs were met in their improved environment, they were more able to concentrate on resolving their lives and moving closer to God” (p. 180)
Leith (2006) Senior congregate housing (n = 20) “To do as they pleased was crucial to the women’s sense of control and of ‘at-homeness’ at the facility” (p. 329) “Having independence and control over their micro- and macrospheres seems to generate a strong feeling of ‘at-homeness’” (p. 330) “The front door”; “a tangible sign that clearly demarcated…the line at which they crossed to and from being facility members or being individual persons” (p. 329); “the ability to withdraw…to shut the door behind them” (p. 329) “An active ongoing effort to become fully recognized and accepted as members of their new community” (p. 328) “Synthesized a new identity for themselves by readjusting their previous understanding of themselves and their place within their environment” (p. 329)
Matthews (2002) Intermediate care facility (n = 4) “Ability to take part or abstain from activities of their choosing; come and go with relative freedom” (p. 41) “Meaningful work, contributing toward their place in life” (p. 40); “power to have input into the environment” (p. 41); “the need to take on new challenges” (p. 40); “accomplishment for a job well done” (p. 46) “Knowing that one is safe and cared for” (p. 40); having a secure and consistent place”; participant quote: “That’s your place…even if you’re not there, nobody can come in there…your place is always there” (pp. 57–58) “People who care about them deeply and want them to not only be well but to do well; people with whom they belong” (p. 40); “community is a powerful component of home” (p. 51); “marriage, family and children” (pp. 51–52) “Having a defined role in the community and knowing what it is that one provides” (p. 40)
Moloney (1997) Community (n = 12) Home provides “the strength to survive life’s difficult experiences” (p. 169); “a safe place, a refuge” (p. 169) Home is a “way to be with one’s family by providing security” (p. 169); loss of a loved family member evokes “losing one’s home” (p. 171) Participant quote: “One door closes and another one opens” (p. 173); “trying to find a niche” (p. 173)
Rossen & Knafl (2003) Relocating to congregate housing (n = 31) Full integration (FI): expectations fulfilled after the move (p. 26); partial integration (PI): many positives but varied extent of expectation fulfillment (p. 28); minimal integration (MI): partially fulfilled expectations (p. 27) FI: “competence and capability in handling the demands” (p. 26); MI: “uncertain of or lacking in the ability to handle the demands [of the new situation]” (p. 27) FI: social competence; strong, multiple relationships; belonging; community (pp. 26–27); PI: “adequate or disappointing relationships with family and friends; responsive to the neighborliness of others” (p. 28); MI: “passive social response, few or strained relationships with friends, family, no belonging” (p. 27) Continuing life pattern or “centering their life in the routine of the [facility]” (pp. 25–26); FI: “venturesome; proactive, launching” (p. 26); MI: “marking time” (p. 27)
Roush & Cox (2000) Community hospice (n = 1) “Home as a familiar place of comfort and ease” (p. 389) “A place where privacy, identity and safety can be preserved and protected” (p. 391)
Rowles (1983) Community (n = 15) “Sense of physical insideness… inherent ‘body awareness’ of...this environment”; “internalized pathways…traversed during…their daily lives”; enabled...traversing spaces...beyond their…physiologic competence” (p. 302) “Sense of insideness” (p. 302) “Social insideness from integration within the social fabric of the community,” “could draw on a reservoir of accumulated reservoir of social credit” (p. 302); “conveyed status and a sense of belonging” (p. 303); “they are known and know others” (p. 303) “A mosaic of ‘incident places’” (p. 303) that accumulate within each resident’s autobiography, such that “she or he has become more and more a part of the place, to the point where it has become an extension of self” (p. 303)
A.J. Sixsmith & J.A. Sixsmith (1991) Community (n = 63) “A kind of place imperative that challenges and sustains independence” (p. 186) “Provides a haven of rest in situation of decrease in personal vigor” (p. 186)
Swenson (1998) Community (n = 5) Participant quote: “Do whatever you feel like…you can be noisy or be quiet or be messy or do anything you want” (p. 388) “Virtuosos of the environment” (p. 383); “control center...centrally located space where the woman was in charge” (p. 387) “Knew and valued the boundaries of the territory” (p. 389) “Center of caring,” “being needed” (p. 388) “Center of self” (p. 384); “center of reach...beyond their homes via social activities, travel, observation and surveillance…reading, television, daydreams and fantasies” (p. 389)
Young (1998) Relocating to congregate housing (n = 21) The freedom to be yourself (p. 153); participant quote: “This is my home because I can do as I please” (p. 154) “Working out logistics” (p. 158); “staff played a crucial role in assisting…with the routines and resources of the community” (p. 158); “know how to get what one needs” (p. 159); “the investment of energy in the environment” (p. 153); “home is what you make it” (p. 154) “Physical comfort” (p. 154); “nesting activities” (p.158); “a fit between the needs and the furnishings and physical layout”; “furniture, music, and possessions that convey a sense of belonging” (p. 154); “both privacy and license...a recognition of a boundary between home and the outside world” (p. 154) “A sense of interpersonal warmth in the form of love, congeniality, or friendship” (p. 153); “fitting in” (p. 159); “discovering commonalities” (p. 160); “those who achieve social integration in the new setting were…more likely to consider the new facility their home” (p. 160) “Reconciling life changes” (p.160); personal losses (e.g., role as family host, driving, physical mobility, physical challenge, physical home, possessions, routines) (p. 160); “discrepancy between inner feelings and the outward evidence of aging”; “a social context where frailties of old age were more evident and undiluted” (p. 161)
Wiersma (2008) Cognitive support unit of a veterans hospital and a summer camp setting (n = 10) Camp: freedom; LTC: “confinement” (p. 784); “limited opportunities for choice” (p. 785); Camp: engaging on their own initiative in unplanned, unscheduled, unfacilitated leisure activities” (p. 790) Camp: reminiscing focused on family and childhood experiences; LTC: reminiscing focused on work, nonpersonal topics (p. 789) LTC: differentiating themselves from other residents perceived as “crazy,” “sick,” or “off the beam” (p. 787)
Zingmark, Norberg, & Sandman (1993) Group home (n = 6) “Go home to escape overwhelming situations” [or threats] (p. 13) To be with others instead of feeling abandoned (p. 13); emotionally related to caregivers who are referred to as “my sister” or “my friend” (p. 15) “Related to themselves” (p. 14)
Zingmark, Norberg, & Sandman (1995) Community (n = 150) “Initiative, freedom” (p. 51) “Recognition, order, control, power” (p. 51) “Safety, rootedness, privacy, possession” (p. 51); “place of refuge” (p. 52) “Togetherness, nourishment” (p. 51); “the sense of being related” (p. 51); “dialectics between caring and being cared for, belonging and possessing” (p. 51) Being in relation with significant others, significant things, significant places, significant activities, oneself and transcendence (pp. 51–55)

Phases of Integration in Home as a Transitional Process

Closing one door, opening another

Tying up of loose ends of the past

Resolving to feel in place somewhere

Nesting

Building/investing energy

Place of personal power

Refuge

Relationship

“Meaning of me” moves forward

Self-reconciliation

Continuity

Projecting self in place, time

Authors

Dr. Molony is Assistant Professor, Yale University School of Nursing, New Haven, Connecticut, and was a 2007–2009 Claire M. Fagin Fellow, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania.

The author discloses that she has no significant financial interests in any product or class of products discussed directly or indirectly in this activity. Dr. Molony’s work was supported, in part, by an award provided by the John A. Hartford Foundation’s Building Academic Geriatric Nursing Capacity Award Program (07–208). The author acknowledges Lois K. Evans, PhD, RN, FAAN, and the faculty and geroscholars at the University of Pennsylvania for providing expert editorial review and advice; and Cheryl Beck, DNSc, CNM, FAAN, University of Connecticut, for initial instruction in methods of qualitative metasynthesis.

Address correspondence to Sheila L. Molony, PhD, RN, GNP-BC, Assistant Professor, Yale University School of Nursing, 100 Church Street South, Room 231, PO Box 9740, New Haven, CT 06536-0740; e-mail: sheila.molony@yale.edu.

Received: February 17, 2008
Accepted: September 08, 2009
Posted Online: March 31, 2010

10.3928/19404921-20100302-02

Sign up to receive

Journal E-contents