Newsletter No. 195

CUHK Newsletter No. 195 4th January 2002 3 There's No Place Like Home or Is There? Study Examines Families' Response to Placing Elderly in a Home ' Ha v i ng an e l de r ly person at home is like having a treasure,' goes the saying. I n a society like Hong Kong, the dictates o f filial piety f r own upon putting parents and grandparents i n homes for the elderly. Yet l i v i ng space is scarce, w i t h large families often having to cram into unbelievably small homes, and the young too busy w i t h wo r k and school to take care o f someone o l d and frail. A n increasing number o f elderly people are mov i ng into r e s i d e n t i a l c a r e h o m e s . According to figures released by the Social Welfare Department in 2000, there are at present over 40,000 elderly people residing in r e s i d e n t i al ca re f a c i l i t i e s , representing five per cent o f the entire elderly population i n the territory. What adjustments do family memb e r s go t h r o u gh a f t er placing their elderly relatives in a r es i den t i al home? H o w do these adjustment experiences change over time? What role do Chinese cultural beliefs play i n this experience? To exami ne these and other questions, Prof. D i ana Lee o f the Ne t he r so le School o f Nu r s i ng emba r ked on a s t udy en t i t l ed ' Ch i nese Families' Experiences w i t h Residential Care P l acement o f Their Elderly Relatives' w i th the study's co-investigator, Pr o f. A n n Mackenzie. Preparation and Methodology The groundwork for the study was l a i d i n N o v e m b e r 2 0 0 0 , w h i c h consisted o f approaching the homes, exp l a i n i ng the study, sorting out the wo rk schedule, and contacting potential informants. Data collection began i n January 2001. Funded by the Research Grants Council, the project is expected to last until July 2002. The families o f some 20 elderly people are the subjects o f this study. In- depth interviews are conducted upon admission w i t h the ma in f ami ly carer (pre-admission), who can be a daughter, a w i f e, a husband, a daughter-in-law, or a son. The interviews are repeated at one to two weeks f o l l owi ng admission, and then every t wo months thereafter until no new information is found. The e l de r ly peop le themselves are also i n t e r v i ewed to gauge their potential influence on the families' adjustment experiences. Prof. Lee predicts that a total o f 80 interviews w i th family carers w i l l have been conducted by the end o f the project. Five care homes are involved in the s t u d y , a l l o f t h em g o v e r n m e nt subvented. Prof. Lee has decided not to m i x private and non-private homes in this study because they are expected to generate very different data. There is a huge discrepancy between the two types o f homes in terms o f the system o f ca r e, e l d e r l y p o p u l a t i o n, and q u a l i f i c a t i o ns o f ca r e - t ake r s. The experiences o f the elderly people and their families towards the homes are also ve ry d i f f e r en t. Adm i s s i on to a g o v e r n m e n t s u b v e n t ed h ome is p r eceded by a s t r i ct e v a l ua t i on o f e l i g i b i l i ty and a wa it o f three to four years. Those admi t t ed usua l ly f eel ' l ucky' to have been admitted. Initial Emotional Response The study's p r e l imi na ry findings show that i n the one to t wo weeks f o l l ow i ng their relatives' admission, families express emotions ranging f r om sadness to a sense o f r e l i ef that their relatives are being taken care of. The latter leads, in some cases, to improved relationships w i t h their relatives. They see the r e s i d e n t i al p l a c eme nt as beneficial as it makes the future more certain. This greater sense o f certainty appears to r eassu re f am i l i es and moderate their emotional reaction to the placement. Other emotions f o l l ow i ng placement are found to be linked to the reaction o f the elderly relative to being a dm i t t e d, to k i n s h i p, to r e l a t i ons between the carer and the relative prior t o p l a c e m e n t, a nd w h e t h e r t he admission is voluntary or not. A t this early post-placement stage, s o c i o - c u l t u r al i n f l u e n c es on t he families' experiences are not evident. Informants try to j us t i fy the admission i n t he ir m i nds but are r e l uc t ant to discuss their emotions w i th other family members. They are unable to describe the emotions o f other family members. T h ey p r e f er to s o l i c it adv i ce and support f r om outside. Th is l ack o f c o m m u n i c a t i o n a m o n g f a m i l y members may be due to feelings o f guilt a nd t he e m o t i o n a l t u r m o i l t h ey expe r i enced be f o re c om i ng to the decision. This is an area to be followed up in later interviews. A t this early stage, f ee l i ngs o f ambivalence about relinquishing care and uncertainties o f residential care provision common ly described i n the literature, largely Western, do not seem to apply to the Chinese families in this study. Two Months Later About two months after admission, i n f o rman ts beg in to verbalize mo re conflicting emotions. They may say the p l a c eme nt has no t r e l i e v ed t h em emotionally or physically. They may say they are still wo r r i ed about their elderly relatives, they s t i ll cook f or them every day and bring them meals, they find transportation a headache, etc. A t the same time, the effects o f socio- c u l t u r a l i n f l u e n c es be c ome mo r e evident. Howe v e r, such effects are different on different carers. Wi ves, daughters, and daughters-in-law who are themselves elderly often wonder i f they have done the right thing in placing their relatives in a home. They are afraid to tell other family members about their uncertainties. Young sons and daughters do not see this as a p r ob l em. The ir attitude is one o f 'I care, therefore I put t hem i n the home .' They f eel t he ir d e c i s i on has i m p r o v e d f a m i l i a l relationships and their relationship w i th the elderly relative. Shift of Families' Focus A t this stage there is also evidence that families are starting to shift their focus f r om the relative to the home itself. They become more critical o f the q u a l i ty o f the homes and beg in to propose ways o f improvement based on observations made during visits. A l t hough the different rounds o f interviews have not been completed, Prof. Lee has made some predictions about the r eac t i ons o f the e l d e r ly residents based on the f i n d i n gs o f ano t her r esea r ch o f hers on h ow Chinese elders adjust to residential care placement. ' E l de r ly people i n Ho ng Ko ng do not have the same problems as their Western counterparts. They don't tend to complain about the lack o f p r i vacy i n the homes and they are mo re relaxed about hav i ng to share facilities. They instead wo r r y about how to deal w i t h their families after a dm i s s i o n. T h e y ma y m i ss t h e i r families yet feel gu i l ty about hav i ng them come to visit too often. They may also have to deal w i t h being bullied by more domineering inmates', said Prof. Lee. 'We may have underestimated how rational elderly people are nowadays. We may still expect them to be thinking i n the o l d way but i n fact many o l d people now do not want to be a burden to their families,' she continued. Implications for the Community The f i nd i ngs o f the p r o j ect w i l l p r ov i de a theoretical f r amewo rk f or health care professionals to identify and evaluate interventions that meet the specific needs o f families at particular points i n the post-placement period. Wh e n f am i l i es are g i v en he lp to overcome the d i f f i cu l t i es associated w i t h the placement, they w i l l be able to continue contributing to the physical and emotional well-being o f their loved ones in residential care homes. Piera Chen Researcher Profile Prof. Diana Lee, associate professor in the Nethersole School of Nursing, obtained her Master's in nursing and education from the University of Edinburgh in 1993, and her Ph.D. in medical sciences from The Chinese University in 2000. She joined The Chinese University as lecturer in 1994. Her research interest includes gerontology and long-term care, in particular community care of elders with chronic illness, residential care and nurse- led developments in the rehabilitative and community care of elders. She is now pursuing post-doctoral work at the University of London.