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Older adults' experiences of having managed well in making the transition to assisted living Gofton, Lucy Veryan 2014

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  OLDER ADULTS’ EXPERIENCES OF HAVING MANAGED WELL IN MAKING THE TRANSITION TO ASSISTED LIVING  by Lucy Veryan Gofton  M.Ed. University of Alberta, 2009  A DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY  in  The Faculty of Graduate and Postdoctoral Studies  (Counselling Psychology)  THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)  May 2014  © Lucy Veryan Gofton, 2014  ii  Abstract The number of Canadians over the age of 65 is rapidly increasing and it is estimated that, by 2026, over one-fifth of the population will be 65 years or older. A significant transition faced by individuals later in life is the move to residential care. In order to better understand the phenomenon of managing well in making the transition to assisted living, eleven individuals between the ages of 66 and 95 were interviewed. The study used an interpretive phenomenological approach guided by the research question:  What is the meaning and experience for older adults of managing-well in making the transition to assisted living?  Common aspects of the experience of managing well in making the transition to assisted living were identified from the interviews with the participants.  The results found that seven themes were common to their experiences of having managed well in making the transition: (1) sense of improved quality of life, (2) sense of belonging, (3) willingness to get involved, (4) sense of continuity, (5) sense of acceptance, (6) perceived sense of openness, and (7) not wanting to be a burden. This study provided an in-depth understanding of what may contribute to managing well in making what has previously been identified as a challenging transition.  Potential implications for counselling theory and research, as well as policies for assisted living facilities were also identified. In addition, implications of the VWXG\’VILQGLQJVIRU counsellors working with older adults and their families around entry into assisted living were addressed.        iii  Preface  This dissertation is original, unpublished, independent work by the author, L. Gofton. The research in this dissertation involved human subjects and as such, was reviewed and approved by the UBC Behavioral Research Ethics Board prior to the start of the research. The number of the original certificate pertaining to the research in this dissertation is: H12-00609.              iv  Table of Contents Abstract ........................................................................................................................................... ii Preface............................................................................................................................................ iii Table of Contents ........................................................................................................................... iv List of Tables ............................................................................................................................... viii List of Figures ................................................................................................................................ ix Acknowledgments............................................................................................................................x Dedication ...................................................................................................................................... xi  Chapter one: Introduction ................................................................................................................1 Statement of the Problem .............................................................................................................2 The aging population ................................................................................................................2 Assisted living ..........................................................................................................................4 Consequences of entering care  ................................................................................................6 Correlates of entering care  .......................................................................................................7 Transition to residential care  ...................................................................................................8 Purpose of the Study ......................................................................................................................10 Chapter Summary ..........................................................................................................................13  Chapter two: Literature Review .....................................................................................................15 Introduction ................................................................................................................................15 Older Adult Developmental Transitions ....................................................................................16 Stage-based perspective..........................................................................................................16 Contextual perspective  ..........................................................................................................20 Lifespan perspective ...............................................................................................................21 Transitional perspective..........................................................................................................25 Adult development and the transition to assisted living .........................................................26 Transition to Residential Care ....................................................................................................27 Relocation and adjustment .....................................................................................................28 Daily life in a residential facility ............................................................................................42 v  Chapter Summary .......................................................................................................................45  Chapter three: Methodology ..........................................................................................................48 Approach to the Research Question ...........................................................................................48 Historical and philosophical tenets of phenomenology..........................................................48 Hermeneutic phenomenological method ................................................................................49 My Pre-Understandings ..............................................................................................................51 Research Procedures ..................................................................................................................53 Participants .............................................................................................................................53 Recruitment ............................................................................................................................54 Data collection ........................................................................................................................55 Data analysis ...........................................................................................................................57  Hermeneutic circle .............................................................................................................59 Data representation .................................................................................................................60 Criteria for Evaluating Trustworthiness .....................................................................................61 Dependability .........................................................................................................................61 Researcher reflexivity .............................................................................................................61 Triangulation ..........................................................................................................................62 Participant review of themes ..................................................................................................63 Review of themes by an individual working in assisted living  .............................................63 Ethical Considerations ................................................................................................................64  Chapter four: Results .....................................................................................................................65 Overview ....................................................................................................................................65 Participant Biographies ..............................................................................................................66 Rev. Dr. David T. Hawkins ....................................................................................................66 Dianne.....................................................................................................................................67 Betty .......................................................................................................................................68 Ollie ........................................................................................................................................69 Larry .......................................................................................................................................70 Frank .......................................................................................................................................70 vi  Lou ..........................................................................................................................................71 Josie ........................................................................................................................................72 Amy ........................................................................................................................................72 Valerie ....................................................................................................................................73 Joan .........................................................................................................................................74 Common Themes of Managing Well in Making the Transition ................................................75 Sense of improved quality of life ...........................................................................................76 Sense of belonging .................................................................................................................80 Willingness to get involved ....................................................................................................85 Sense of continuity .................................................................................................................91 Sense of acceptance ................................................................................................................98 Perceived sense of openness .................................................................................................102 Not wanting to be a burden to others....................................................................................106 3DUWLFLSDQWV’'HILQLWLRQVRI0DQDJLQJ:HOO ............................................................................111  Chapter five: Discussion ..............................................................................................................112 Contextualization of the Findings ............................................................................................112 Significant Findings .................................................................................................................115 Importance of social connection ...........................................................................................115 Benefits of assisted living .....................................................................................................116 Timing ..................................................................................................................................117 Autonomy .............................................................................................................................118 Role of choice .......................................................................................................................118 Acceptance and individual differences .................................................................................119 Continuity with identity and relationships ...........................................................................120 Personal history ....................................................................................................................121 Relationship with staff ..........................................................................................................122 Implications ..............................................................................................................................122 Implications for future research ............................................................................................123 Theoretical implications .......................................................................................................125 Policy and counselling implications .....................................................................................128 vii  Researcher Reflections .............................................................................................................131  References ....................................................................................................................................133 Appendices ...................................................................................................................................141 Appendix A: Recruitment Poster .................................................................................................141 Appendix B: Screening Interview Script .....................................................................................142 Appendix C: Informed Consent ...................................................................................................144 Appendix D: Orientating Statements and Interview Guides........................................................146                                viii  List of Tables  Table 1. Participant demographics and the funding of their assisted living (AL) facility2056 .....65                        ix  List of Figures Figure 1. Percentage of Canadian population comprised of persons aged 65 or older, 1921 to     2005 and projections to 2056 .......................................................................1 Figure 2. Percentage of total population comprised of seniors, by group, Canada 1981 to 2005,     projections from 2011 to 2056 .....................................................................2 Figure 3. Coping resources ± 7KH6’V .......................................................................................119                                x  Acknowledgments   I would like to thank my research participants for reaching out and choosing to share their stories of the experience of making the transition to assisted living. I appreciated your openness and your willingness to give your time in order to ensure a deeper understanding of an event that I believe will impact many of us.   Thank you Dr. Judith Daniluk for the energy you have put into helping me ensure that this piece of research was the best work I was capable of. I have valued your guidance and appreciated your dedication in reviewing my work and providing insightful comments; all of which have helped me to produce this document. I have enjoyed working with you and getting to know you over the past five years.  I would also like to thank my committee, Dr. William Borgen and Dr. Anita Hubley, and express my appreciation for the time they have taken in supporting me throughout this process. Their thoughtful comments and questions have led me to consider new perspectives and ways of approaching this research. Your input has contributed to my deeper understanding of this transition.  My parents and sister have always been a tremendous source of support to me, and this was particularly true throughout the process of completing this research. They have listened to me talk about my proposed study, been interested in the process of completing the interviews and taken the time to review the final written product and to provide me with their feedback. For all they have given me throughout my life I truly thank them. Thank you to my husband, Julien, who has only known me as a PhD student and still chose to marry me. Julien, you have provided me with unwavering support that has carried me through this journey. Merci pour ton soutien, ta patience, ton humour et surtout ton amour. xi    Dedicated to those I love     1  CHAPTER ONE  Introduction  Growing up, I went with my mother to visit her patients who were living in residential care facilities. Even as a young child, I remember the connection I felt  with these individuals  during the visits as they shared their life stories with me. I recognize that personally I value these stories that come from a life - time of accumulate d experiences. However, within  broader North American society, ageism frequently results in older adults being devalued and stigmatized,  often leaving these members of our society silenced (Walsh, Olson, Ploeg, Lohfeld, & Macmillan, 7KHHIIHFWVRIDJHLVPKDYHEHHQFLWHGLQWKH:RUOG+HDOWK2UJDQL]DWLRQ’V:+2Missing Voices Report which was based on data collected through eight focus groups, six of which were comprised exclusively of older adults. The resulting data described the disrespect  that older adults felt they experienced. Canadian participants voiced instances when “ p eople talk down to us -  FDOOXVµVZHHWLH’RUµGHDULH’-  W OOXVZKDWWRGR  ´or to ³«MXVWVKXWXSWDNHZKDWZHgive you, and just enjoy ” (WHO, 2002, p. 14). Within the report, older adults also voiced opinions on the move to institutionalized facilities. While  participants felt that a move was often necessary, it was important that the older adult was involved in the decision, as they viewed the H[FOXVLRQRIROGHUDGXOWV’YRLFHVIURPVXFKDQLPSRUWDQWDQGOLIH- altering decision, to be a form of elder abuse (WHO, 2002). These perspectives speak to the importance  that many older adults place on having a voice in decisions that affect their lives and well - being.  It was  my intention in this research to work towards gaining an understanding of one of the most signif icant and challenging transitions experienced later in life, the entry into assisted living, from the perspective of this important and increasing portion of our society ’VPHPEHUV.          2  Statement of the Problem   The aging p opulation . In 2010, Canadians aged 65 and over made up 14.1% of the Canadian population (Milan, 2011). This reflects a steady increase in the size of this age group over the past 40 years, with a more than 4% increase from 1971 to 2010. While the size of the older adult population has been consistently increasing, the rate of growth is expected to accelerate in the next 10  to 15  years as the baby- boom cohort enters their later years. By 2026 , over one- fifth of the Canadian population will be 65 or older, which is exp ected to increase to over one- quarter of the population by 2056 (Milan) (see Figure 1).  Figure 1: Percentage of Canadian population comprised of persons aged 65 or older, 1921 to 2005 and projections to 2056     The increase in the older adult population reflects the movement of the baby - boom cohort into their later years, as well as the increasing life expectancy of Canadians (Gilmour & Park, 2003). In 2010, adults over the age of 80 comprised  3.9% of the Canadian population. However, it is projected that  the number of individuals over the age of 80 will have doubled by 2013 (Milan, 2011) (see Figure 2). The number of individuals living to become centenarians is also on the rise, reflecting the increase in life expectancy for Canadians.       3   Figure 2: Percentage of the total population comprised of seniors, by group, Canada 1981 to 2005, projections from 2011 to 2056   These statistics on the shifting demographics of the Canadian population indicate a need for increased attention to the experiences of t hese older individuals. This has been reflected in increased attention by researchers on LQGLYLGXDOV’living later into the life span who have begun to turn their attention to the ongoing physical and psychosocial changes and challenges associated with thi s life stage (Stevens- Long & Commons, 1992; Charles & Carstensen, 2009). For example, findings from the 2003 Canadian Community Health Survey (CCHS) indicate that 77% of men and 85% of women 65 years of age and older have at least one chronic health condition (Gilmour & Park, 2003). Common chronic conditions in the older Canadian population include arthritis, cataracts, heart disease, diabetes, thyroid conditions, the effects of strokes, and pulmonary diseases. In addition, older adults face changes in sens ory perception, through loss of sight related to cataracts, and reduced hearing, smell and taste (Solomon, 1999). Loss of, and     4  changes in, cortical cells as we age are also associated with cognitive decline and dementia in later years (Sherwood et al., 201 1).  In addition to the many physical changes related to increased age, o lder adults are more likely to face a variety of psychosocial changes including the loss of close relationships, changes in social roles, and new living arrangements (Charles & Carste nsen, 2009). Of the many challenges faced by the elderly, the relocation to a residential care facility is one of the most significant transitions because of its association with increased age and frailty, potential financial problems, decreased physical h ealth and the loss of a spouse or other significant relationships (Lee, Woo & Mackenzie, 2002). Although there is increased attention within the literature on aspects of development faced later in life, the experience of relocation to assisted living is a significant event that is still not well understood. It is this transition that was  the focus of this study.  Assisted living . Assisted living is defined along a continuum of care options for older adults (Kelsey, Laditka & Laditka, 2010). Older adults may  initially consider utilizing home and community supports in order to stay living independently in their own home for as long as possible. Assisted living is considered the next stage in the continuum of housing and care options.  It was introduced in the 1 980s  as an option for older adults who required some help with activities of daily living as a result of cognitive or physical decline, but who did not need the higher level of care provided by a nursing home facility (Ke lsey et al.). In British Columbia, assisted living facilities offer semi - independent housing and  must offer  housing, hospitality  services (meals, laundry, housekeeping, leisure and recreation progr ams as well as 24 - hour emergency  respons e) and personal assistance services (such as regular assistance with activities of daily living, including eating, mobility, dressing, grooming, bathing and personal hygiene)      5   (British Columbia Ministry of Health [BCMH], 2013 ). As of 2011, there were 1,256 individual assisted living units in the Vancouver Coastal Health region; 1,033  units funded by Vancouver Coastal Health Authority and 405 privately funded  units (Canadian Mortgage and Housing Corporation, 2011 ). The Vancouver Coastal Health Authority region includes Vancouver, Gibsons, North Vancouver, Squamish and West Vancouver. Within the community of Vancouver specifically, 15  assisted living facilities are registered with the British Columbia 0LQLVWU\RI+HDOWK’V$VVLVWHG/LYLQJ5HJLVWUDU7KHVHIDFLOLWLHVRIIHUHGDFRPELQHGindividual units; 315 private - pay units and 481 public ly subsidized units ( BCMH, 2013).   Further along the continuum of care  is ³FRPSOH[FDUH´³ORQJ- WHUPFDUH´RU³QXUVLQJKRPHV´that provide  24 hour nursing care for those whose  needs exceed what is provided by assisted living facilities (Frazee , 2011).   As the Canadian population ages, assisted living is becoming a necessary living arrangement for many older adults (Turcotte & Schellenberg, 2006). While only 2% of adults betwee n the ages of 65 and 84 live in an institutional facility, this increases to 32% in those 85 years or older (Turcotte & Schellenberg). This reflects a trend of older adults living longer either independently or with family, and only entering care when they  are in their later years. The 2007 Canadian General Social Survey on Family, Social Support and Retirement provided information on the demographics of care - providers over the age of 45 years and care - receivers aged 65 years and older (Cranswick & Dosman, 2008 ). While the results of the survey may not be representative of all Canadian care - receivers, they support an increased use of assisted living facilities with advanced age. The study found  that, for care- receivers aged 75 to 84 years, 15% of men and 20%  of women resided in an assisted living facility. These percentages doubled to 30% and 40% respectively, for care - receivers 85 years an d older (Cranswick & Dosman ). The     6   increased age of residents also makes it likely that those Canadians entering assisted living are facing more complex physical and psychosocial losses.    Consequences of entering care. What we know about the transition into care has mostly been studied within the fields of gerontology and nursing, and has been  predominantly  from the perspective of caregivers or facility staff. Much of the research on relocation has been correlational, and has looked at the impact of this event on the health and well - being of older adults who have entered care . Findings suggest that there is an increase in mortality associated with relocation to a care facility, as well as a negative impact on psychological well - being and on cognitive, functional and social abilities (Aneshensel, Pearlin, Levy- Storms & Schuler, 2000; Walsh & Waldmann, 2008; Wilson, 1997 ).  While older adults already face ageism, entry into an assisted living facility carries an additional stigma ( Lee et al.6WLJPDLVGHILQHGE\'REEVDQGFROOHDJXHVDV³WKHassignment of negative worth on the basis of devalued JURXSRULQGLYLGXDOFKDUDFWHULVWLFV´S 517). Their ethnographic study of 309 participants, (resident, family and facility staff) found that the stigma associated with entry into assisted living negatively impacted well - being, contributing to depression, lowered self - esteem, decreased functioning , and reduced or more limited social interactions for residents in care facilities.  As previously  mentioned, research that has looked at the implications of entry into care has primarily  focused on caUHJLYHUV’H[Seriences. Two studies, one using a structured questionnaire and the second using a phenomenological approach, have looked at the impact on family members of placing a relative into a care facility (Nolan & Dellasega, 2000; Kellet, 1999). The intention of these studies has been to build knowledge on how to support family members when they are adjusting to their relative being in care (Nolan & Dellasega, 2000;     7   Kellet, 1999). While this is inevitably a difficult experience for family members who may feel they have failed their relatives, the experience for the individuals relocating into care also involves significant challenges that need to be understood in order to provide these older adults with adequate support in making this transition .  Correlates of entering care. When considering adjustment to entry into a care facility, there also appear to be factors that contribute to the outcome of this event. These include the control an individual has over the move, their involvement in the decision, their physi cal and mental health at the time of the move, and their degree of preparation (Chenitz, 19 83 ). However, WKHUHDUHLQFRQVLVWHQFLHVDURXQGWKHLPSRUWDQFHRIUHVLGHQWV’LQYROYHPHQWLQWKHGHFLVLRQWRHQWHUcare on their future adjustment. While some research  indicates that having a chance to exercise choice and control around the decision contributes to adjustment (Lee et al., 2002), other research suggests that, in some regards , the decision to enter care is always forced by circumstances (Nay, 1995). As a r esult, it is suggested that, regardless of whether a resident enters care voluntarily or involuntarily, they are likely to have a similar experience of relocation. While research has begun to identify important considerations for family members and individuals in making decisions related to entry into care, it also reveals inconsistencies and a ODFNRILQIRUPDWLRQRQZKLFKIDFWRUVFRQWULEXWHWRROGHUDGXOWV’H[SHULHQFHVRIDGMXVWPHQWWRcare.  Decisions around changes in levels of residential care have also been studied from the perspective of family members and staff (Mead, Eckert, Zimmerman & Schumacher, 2005). In an ethnographic study of three assisted living facilities, researchers looked at the sociocultural factors which contributed to a resident being  moved from assisted living to a higher level of care due to increasing cognitive decline (Mead et al., 2005). The study indicated that the culture of     8   the facility towards cognitive decline and family involvement, were both factors that mediated decisions around changes in levels of care.  The presence of cognitive decline within residential facility populations may be one reason for why the voice of older adults has been predominantly left out of the research referred to above (Buhr, Kuchibhatla & Clipp , 2006; Kelsey et al.,  2010; Mead et al., 2005 ). Cognitive decline is a significant contributing factor to entry into care facilities, and has a relationship to the physical and psychosocial well - being of individuals following relocation ( Aneshensel et al., 2000; Mead et al., 2005).  As a significant portion of the population entering residential care is likely to be experiencing cognitive decline, there can be questions around their ability to consent to participate in research, which may lead  to the exclusio n. It is also likely that ageism associated with entry into care has contributed to the perspectives of older adults being underrepresented in research on the experience of entering assisted living. In combination, these factors have contributed to the pau city of older adult perspectives on the experience of entering residential care, which has left a significant gap in our understanding of this event and of the factors that contribute to being able to manage the  transition and adaptation to assisted living  well .  Transition to residential care. As the body of research on the transition to assisted living is particularly small, I have also looked at the research on the transition to nursing home facilities. I will use the term residential care, in order to i ndicate that the research cited encompass es both nursing home and assisted living facilities. The research on entry and adjustment to residential care facilities has looked at the different phases that may be involved in DGMXVWLQJWRDIDFLOLW\DVZHOODVWKHPHVSUHVHQWLQUHVLGHQWV’H[SHULHQFHVRf living in residential care (Brooke, 1989; Fiveash, 1998;  Iwasiw, Goldenberg, MacMaster, McCutcheon & Bol, 1996; 1D\3RUWHU	&OLQWRQ5HVLGHQWV’UHDFWLRQVWRHQWHULQJUHVLGHQWLDOFDUHKDYHEHHQ    9  broadly understood as either an acceptance of,  or resistance to, their circumstances (Chenitz, 1983 ). When Brooke (1989) carried out a longitudinal, participant - observer study of 42 participants who had entered residential care , it appeared that residents progressed through the phases of disorganizati on, reorganization, relationship building and stabilization in adju sting to their new environment . In a later qualitative study by Iwasiw and colleagues (1996) , in which 12 residents were interviewed, it appeared that the phases can act as a guide to commo n aspects of this experience, rather than as a linear representation, given that the participants in this study often experienced aspects of more than one phase at a time (Iwasiw et al., 1996). There also appear to be a broad range of adjustment approaches  used by residents following entry into residential care, including reframing the experience, attempting to get used to their new living situation, and a desire to fit in with their new environment (Porter & Clinton, 1992).   Research has also highlighted key themes that are present within the experiences of UHVLGHQWVDIWHUWKH\HQWHULQWRDIDFLOLW\7KHVHKDYHLQFOXGHGUHVLGHQWV’IHHOLQJVRIEHLQJSODFHGin a facility against their will, the impact of having to live in a public domain with limited privacy , the cultural implications of having to live with others, and the challenges of adjusting to living within the rules of a residential care facility (Fiveash, 1998). Other themes that have emerged from the research on the experiences of residents include t KHVHQVHRIORVVRIRQHV’home, a devaluing of self, and a belief that entry into care iVWKH³HQGRIWKHOLQH´IRUWKHPbecause they have no opportunities to make worthwhile contributions while living in this setting (Nay, 1995). Research looking at resid HQWV’SHUVSHFWLYHVRQZKDWFRQWULEXWHVWRTXDOLW\RIOLIHfollowing entry into assisted living has also indicated the importance of independence and autonomy, social relationships and meaningful activities following the move to assisted living (Ball et al., 2000).     10  &XOWXUDOGLIIHUHQFHVPD\DOVRSOD\DUROHLQWKHH[SHULHQFHVRIROGHULQGLYLGXDOV’transitioning to residential care. In a qualitative study of ten residents in a Hong Kong nursing home , Lee (1999) found that residents appeared to accept the reduc ed privacy and public living, and did not identify these as challenging in the ways that were reported in studies of seniors from Western cultures (Fiveash, 1998; Iwasiw et al., 1996). The author suggested that these challenges may have been less present i n this study because of the differences between traditional Eastern and Western values and living arrangements. The cultural emphasis of collectivism and maintaining harmony and balance may have allowed residents in /HH’V study to accept aspects of communal living which participants with more traditionally Western values would find challenging. In situating my own research, I was cognizant that Vancouver is a diverse city, with the 2006 census indicating that Chinese individuals made up the largest v isible minority in the city (Statistics Canada, 2006). As a result, I felt an awareness of the impact of difference s in cultural values on the experienc e of making the transition and adapting to assisted living would be important when carrying out this stu dy. Purpose of the Study  As is evident in the current statistics and predicted trends for the Canadian population, the number of older adults in our society is increasing at a rapid rate. More attention needs to be focused on those transitions experienced later in life in order to support this significant portion of the population. Of the many transitions that must be negotiated by older adults, the transition to residential care has been cited as one of the m ost difficult because of its relationship to the biopsychosocial losses described above ( Lee et al., 2002). We also k now that if individuals do not manage this transition  well , then there are significant consequences for their physical and emotional well - being (Aneshensel et al., 2000; Brooke, 1989; Lee et al., 2002;  Mead et al.,     11  2005). We currently lack an understanding of what is involved for older adults in managing well in making the transition to assisted living. In reviewing the literature, only two s tudies were found that looked specifically at older adults ’ experiences of  transitioning to or living in assisted living facilities (Ball et al., 2000; Cutchin, Owen & Chang, 2003).  Understanding experiences of managing this  transition well is central to the field of counselling psychology, which seeks to understand developmental transitions that typically occur across the life- span. Counselling psychology focuses on normative transitions within a developmental context. As previously mentione d, the limited research identified on the transition to residential care has been predominantly in the field of nursing. Although nursing shares some similarities to counselling psychology , the fields developed in different contexts and, therefore, are lik ely to offer different information and perspectives on the transition to assisted living. Nursing developed alongside the medical model and , while nurses fill a range of supportive roles, the primary role remains the provision of support for physical well - being. This is evident LQ&KHQLW]’VJURXQGHGWKHRU\VWXG\RIUHVLGHQWVHQWHULQJDQXUVLQJKRPH7KHDXWKRUhighlights that, while it is important to provide emotional support to residents, when residents are GLVSOD\LQJµUHVLVWDQW’EHKDYLRXUVWKH delivery of essential care takes priority in maintaining the physical safety of the resident (Chenitz, 1983). Even though it is a qualitative study which looks at the experience of older adults, the lens used for analysis of the data fits more of a medica l perspective, as the author views the event of entry into care as a crisis. The language surrounding WKHUHVLGHQWV’UHVSRQVHVWRHQWHULQJFDUHFRXOGDOVREHYLHZHGDVSDWKRORJL]LQJDVLWVSHDNVDERXWUHVLGHQWV³UHVLVWDQFH ´of this event (Chenitz, 1983).  In some instances , the data gathered in these studies also included the review of medical records and the perspectives of nurses and facility     12  VWDII7KHVHSHUVSHFWLYHVGRPLQDWHWKHUHVHDUFKILQGLQJVDQGWKHUHVLGHQWV’H[SHULHQFHVRIWKHevent are less evident (Brooke, 1989; Chenitz, 1983; Nay, 1995 ; Mead et al., 2005).  What counselling psychology offers in looking at this event i s a normative view of the transition to residential care as potentially  one of many  aspect s of aging. From a developmental perspective, this transition is understood as an event that many older adults will experience during their later years. While it is expected that a large number of older adults will enter care a t some point in their lives, t here is a lack of XQGHUVWDQGLQJRIKRZLQGLYLGXDOV’DGMXVWWRWKLVHYHQWAlthough many challenges associated with this transition have been identified, we have a very limite d understanding of what facilitates  this transition. The purpose of this study, th en, wa s to JLYHYRLFHWRROGHUDGXOWV’H[SHULHQFHVRIWKHSKHQRPHQRQ of managing well the  transition to an assisted living facility from a counselling psychology perspective. The question that guided this study wa s:  What is the meaning and experience for older adults, of managing well in making the  transition to assisted living?    Following from this research question, this was  a qualitative study using an interpretive  phenomenological approach . It sought WRUHSUHVHQWSDUWLFLSDQWV’DFFRXQWVRIWKHmeaning o f managing their  transition to assisted living well , as well as l ook  at the common aspects of the experience. This approach wa s guided by the belief that there are some essential aspects of this phenomen on that are present across  WKHSDUWLFLSDQWV’GHVFULSWLRQVRIWKHLUH[SHULHQFHVLopez & Willis, 2004). As little is known about the phenomenon of managing well in making the transition to assisted living from the perspective of older adults, a phenomenolog ical method w as XVHGWRXQFRYHUFRPPRQWKHPHVDQGPHDQLQJVDWWULEXWHGWRWKHSDUWLFLSDQWV’H[SHULHQFHVvan Manen, 1990).      13    Goodman, Schlossberg DQG$QGHUVRQ’V) model for analyzing adaptation to transition frame d P\XQGHUVWDQGLQJDQGLQWHUSUHWDWLRQRIWKHSDUWLFLSDQWV’H[SHULHQFHV:KLOHBridges’ (1980) process - focused approach to transition was also considered,  *RRGPDQHWDO’Vmodel was chosen because it situates itself within developmental theory and, therefore , fits with FRXQVHOOLQJSV\FKRORJ\’VOLIH- span development al focus. In addition, it incorporates a biopsychosocial perspective in identifying the resources and deficits which influence adaptation to life transitions. The model provide d a framework for view ing the contributions of the transition event, the environment, and individual factors and resources in understanding how an individual adapts to anticipated and unanticipated life transitions. In this model, adaptation involves a movement from preoccupati on with an event to its integration (Goodman, Schlossberg & Anderson, 2006). Using this model  provide d a way of considering the different factors that may contribute to, and influence , how individuals manage well  in making the transition to an assisted living facility.  Chapter summary  This study aimed to add  to our understanding of what it means  to manage the  transition to assisted living well  from the perspective of older adults who have lived the experience. As there is limited and inconsist ent research on the transition to residential care there remain s a need for further information on this event in order to clarify what factors may contribute to adaptation.  A focus specifically on having managed this transition well  allowed  DVSHFWVRILQGLYLGXDOV’experiences to inform our understanding of what internal and external resources and supports can contribute to the experience. This adds to the literature which is currently dominated by the negative impacts and challenges of this event (Aneshensel et al., 2000; Dobbs et al., 2008; Mead et al., 2005) . While the transition to assisted living was not previously  represented in the     14  counselling psychology literature, it is an event which fits well with the mandate of field. As developmen tal theory is a thread throughout counselling psychology which frames our understanding of the transitions that LQGLYLGXDOV’H[SHULHQFHRYHUWKHOLIHFRXUVHLWLVDSSURSULDWHthat the field begin to look  at this previously neglected developmental event wh ich will be experienced by an increasing number of older adults in the coming years. This deeper  understanding of this transitional event from a counselling psychology perspective, informs the  theory, and subsequently the practice, of counselling p sychologists with regards to what factors to consider in supporting olde r adults and their families in  negotiating the transition to assisted living.  The next chapter will review the research on adult development and on the specific transition in older adulthood to a residential care facility. Through this review, the specific developmental events  faced by older adults, as well as theoretical views of how older adults navigate these transitions, will be identified and lead to a discussion of how they may impact or  contribute to the experience of successful transition to an assisted living facility. From a review RIWKHOLWHUDWXUHRQUHVLGHQWV’H[SHULHQFHVRIWUDQVLWLRQLQJWRUHVLGHQWLDOIDFLOLWLHV, factors influencing the transition experience will be described and  discussed in relation to the current study.            15   CHAPTER TWO  Literature Review  Introduction  Transitions are one of the central concerns of the field of counselling psychology, because it takes a developmental approach in understanding and supporting individuals through ³WKHFKDOOHQJHVDQGDFWLRQVRIHYHU\GD\OLIH´(Young & Nicol, 2007, p.21). While developmental psychology has traditionally focused on understanding the developmental miles tones and challenges faced in childhood and early adulthood, as gerontological research gained popularity the focus shifted to understanding the unique developmental events faced later in life (Fisher, 1993 ; Levinson, 1986). The rising percentage of Canadi ans relocating to residential facilities makes this an important transitional event for many older adults.  While definitions of transition vary, it is broadly understood as a process of psychological adaption, or reorientation, which can lead to deterioration but more often leads to growth through new relationships, behaviours and self - perceptions ( Bridges, 1980; Schlossberg, 1981 ). The current research looked  at the experience of managing well in making the transition to assisted living, and aim ed to understand some of the common aspects of this experience.  This review of the literature  relevant to this event will first look at  different approaches to understanding developmental transitions  later in life. The research on development later in the life span  will be referenced in a discussion of the developmental tasks faced by older adults , and in an examination of  how older adults may respond and adapt to these events.  Research on successful aging and how this  construct fits within lifespan development will also be discussed.  Studies looking specifically at the experience of  relocation to a residential facility will then be reviewed and a discussion of  factors which appear to contribut e to the experience of relocation     16   wi ll be identified and placed in relation to the proposed research. In preparing the review of the literature, it became evident that much of the l iterature in this area is dated. Older Adult Development al Transitions Within developmental and counselling psychology, the construct of transition has been a significant focus of theorists and researchers. The field of adult development has recognized that adults face ongoing challenges, particularly in their later years when they face a number of normative and  non- normative psychosocial and physical changes (Stevens - Long & Commons, 1992; Charles & Carstensen, 2009). There are a variety of perspectives within the field which have focused on understanding how adults move through these developmental events. These included stage- based, age- based, contextual, lifespan , and transitional theories (Goodman, Schlossberg & Anderson, 2006). These different perspectives share some common aspects, but they vary in the extent to which they believe that adult development is si milar among , or varies across, individuals (Schlossberg, 1981).   Stage - based perspective. Using a stage- based approach, many psychologists believe that individuals move through distinct developmental stages. Using anecdotal evidence, Erikson built on FreuG’VVWDJHVRISV\FKRVH[XDOGHYHORSPHQWH[SDQGLQJWKHSLFWXUHRIGHYHORSPHQWRFFXUULQJin eight discrete stages across the lifespan (Erikson, 1997 a). Subsequent empirical research has DGGHGVXSSRUWWRWKHSUHVHQFHRI(ULNVRQ’VVWDJHVRISV\FKRVRFLDOGHYHORpment (Bjorklund, )URP(ULNVRQ’VSHUVSHFWLYHHJRGHYHORSPHQWRFFXUUHGWKURXJKWKHQHJRWLDWLRQDQGresolution of psychosocial crises which span from infancy to later in life, with approximate time periods provided for each stage. Within this model, around age 65 or above, individuals enter the eighth and final stage, where they faced a struggle between ego integrity and despair or disgust. Erikson believed that successful resolution of this strugg le was achieved if individuals a re able to     17   find meaning in reviewing their lives, and that this process result s in wisdom. While  (ULNVRQ’Vtheory focused on the movement through the stages in what theoretically appears to be a linear order, he acknowledged the variability in the pace at which individual s move, or fail to move, through the stages (Erikson, 1997 a). This theory provides some understanding of the psychosocial issues which older adults may be facing in conjunction with their relocation to a residential facility. In an extended version of The Life Cycle Completed, Joan Erikson proposed a ninth stage of psychosocial development, which reflected her observations of older age, as well as her own experiences of aging (Erikson, 1997 b). Reflecting increases in the life span , this stage addressed the development al issues relevant to individuals in their 80s and 90 s who had successfully resolved previous psychosocial crises and were open to the po ssibility of gerotransendence. The concept of gerotransendence was described as continued growth as an indivLGXDOHYHQLQWKHODWHU\HDUVRIRQH’VOLIH-RDQ(ULNVRQGHILQHGLWDVWR³UHDFKDERYHH[FHHGRXWGRJREH\RQGLQGHSHQGHQWRIWKHXQLYHUVHDQGWLPH´(ULNVRQES:KLOHthis is an abstract concept, it reflected the potential for continued growth and creativity later in life. It may be that those individuals, who identify as having successfully transitioned to an assisted living facility, may be more likely to experience gerotranscendence , as openness to growth and creativity could be import ant in successfully navigating this new experience.    Fisher (1993) also focused on stages of development, but specifically on those experienced later in the lifespan. He generated a framework to describe developmental change among older adults using a gr ounded theory approach with data from interviews with 74 older adults. The framework proposed  that older adults pass through five phases. The first phase is a continuation with daily life similar to that experienced in middle age. This is followed by the second phase, described as a first transition event, such as a loss of a partner or the onset of     18   illness. After this initial transition, Fisher proposed  that individuals entered a third phase in which they revise their lifestyle in order to adjust to the transitional event experienced. The fourth phase involve s a second or later transition, in whic h individuals typically experienced a significant loss of health or mobility. This is the stage at which participants frequently entered a residential care facility. As in the third period , during the final period,  individuals revised their goals and activities in adjusting to the later transition. This framework does not propose specific lengths of time for each period, but rather is helpful in describing common developmental changes experienced by older adults. Although Fisher found that most participants  moved through the phases in sequence without recycling, this framework was based only on the experiences of his participants. While it is helpful in describing commonalties in older adult development, it is important to acknowledge that the ordering of th ese phases may vary between participants who may not transition following a linear path between stages. What this research does provide is a  framework to situate the transition to residential care within other developmental changes faced by older adults. I n addition, the framework describe s a process of adjustment through revision of life activities that follow s transitional events. For participants of the current study, it is likely that th ose who identif ied as having managed well in  navigating the transition to assisted living had undergone a similar process. Both Fisher (1993) and Joan and Erik  (ULNVRQ’Va, 1997b ) work discuss  growth and adjustment  later in life, which will be important in understanding the experience of successful transition to assi sted living.  :KLOH)LVKHU’VIUDPHZRUNIRFXVHGRQGHYHORSPHQWODWHULQOLIH/HYLQVRQ, Darrow, Klein, Levinson and McKee (1978) also addressed development of older adults in their work. In addition to describing stages of development, Levinson and colleagues believed that development stages were tied closely to specific age - related periods. Through a longitudinal     19  study of 40 men, they conceived of the life cycle as a sequence of eras, each being associated with a specific age range. Within each era, different life structures and transitions were  described. Life structures were  created when a transition event comes to an end and an individual PDNHVOLIHFKRLFHVWKDWIRUP³WKHXQGHUO\LQJSDWWHUQRUGHVLJQRIDSHUVRQ’VOLIHDWDQ\JLYHQWLPH´Levinson et al., 1978, p.6).  Specific to older adulthood, Levinson and colleagues GHVFULEHGWKHHUDRIµODWHDGXOWKRRG’ZKLFKKHEHOLHYHGODVWHGIURPDURXQGDJHWRDQGZDVOLQNHGWRWKHHUDRIµPLGGOHDGXOWKRRG’E\WKHODWHDGXOWWUDQVLWLRQ7KHODWHDGult transition was not necessarily understood as a single event, but rather could be marked by several events, such as illness or retirement, which highlighted the physical, biological and social changes that the individual experienced with increased age. While Levinson and colleagues did not believe that all individuals faced the same changes, they VWDWHGWKDW³HYHU\PDQLVOLNHO\WRH[SHULHQFHVHYHUDODQGWREHJUHDWO\DIIHFWHGE\WKHP´S)ROORZLQJWKLVODWHDGXOWWUDQVLWLRQLevinson and colleagues described the era of late adulthood which was  characterized by a changed relationship with society in which a man had less power, less authority and received less recognition. The ideas present in this work are helpful in acknowledging the physical, biol ogical and social changes associated with adult development, and the experience of being powerless, which may EHDNH\SDUWRIWKHOLIHVWUXFWXUHRIWKHSURSRVHGVWXG\’VSDUWLFLSDQWV+RZHYHUDVWKHIRFXVRILevinson and colleagues work was only on men, i t is important to recognize that this informatio n may not be representative of women ’s experiences. As the study is also over 40 years old , it is possible that the experience of older adulthood may have evolved, although research on ageism suggests that reGXFHGUHVSHFWDQGUHFRJQLWLRQLQODWHU\HDUVFRQWLQXHWREHDSDUWRIROGHUDGXOWV’daily lives (Dobbs et al., 2008 ).       20  Contextual perspective.  A contextual perspective on development has also influenced conceptualizations of transition. From this perspective, transitions are situated within the FRQWH[WXDOLVVXHVRILQGLYLGXDOV’GDLO\OLYHV*RRGPDQHWDO7KLVPD\PHDQWKDWindividuals experience different transitions tied to the social factors that frame their lives. Conversely, those who share similar contexts may experience similar transitions over time. This YLHZLVVLPLODULQVRPHZD\VWR/HYLQVRQ’VFRQFHSWRIHUDVLQWKDWLWDOVRKROGVWKDWWKHUHare shared experiences of transition events. However, it differs by acknowledging that it is the context that acc ounts for the shared experience of transition  rather than all individuals experiencing the same sequence of events due to their age.  For example, from a contextual perspective, Rosenbaum  (1979)  challenged the idea that midli fe crisis is a transition related to increasing age. Using personnel records from a large American corporation, Rosenbaum examined the career mobility of a cohort of employees over a 13 year period. The study found that chances of promotion for those with DEDFKHORU’VGHJUHHappeared to decline sharply at around age 35. This was in contrast to individuals without a degree who experienced a gradual increase in their chance of promotion until between 35 and 40 years of age and then a gradual decline (Rosenbaum, 1979). Rosenbaum suggested that for these workers  ZLWKDEDFKHORU’VGHJUHH, it was this rapid decrease in chance of promotion that was associated with the transition considered to be  DµPLGOLIHFULVLV’UDWKHUWKDQWKHLU age. In this way , context was emp hasized  when explaining the occurrence of this transitional event.  For the current research, this shared context was decreased independence and increased  need for support, which contributed to  WKHHYHQWRIUHORFDWLRQ5RVHQEDXP’VVWXG\highlighted the importance of paying attention to potential cohort effects. The shared contextual experiences of a cohort will influence their understanding and experience of transition, but any     21  conclusions drawn regarding transitions  may only be relevant to that spe cific cohort. This was  important when looking the experience of managing well in making the  transition to assisted living, as the majority of residents of facilities were  a part of the same cohort, which was born after the first World War during the 1920s and 1930 s. As a result, it was likely they shared similarities in belief, experiences and responses to this event which were considered when reviewing  the findings of the current study.   Lifespan perspective.  Another theory of development to consider when looking at different conceptualizations of transition is the lifespan perspective. Lifespan theorists introduced the idea of adaptation that occurs in multiple different contexts for individuals, and suggested that this variation leads to heterogeneity in development, although the processes underlying it may be more universal (Baltes & Carstensen, 1996; Neugarten, 1976). Working from a lifespan perspective, Neugarten (1976) reviewed the research on adaptation to life events across the lifespan, and from the body of literature proposed that two factors are important in understanding adaptation to life events. The first is that whether or not an event is anticipated or unanticipated impacts adaption to an event. The second factor that Neugarten discussed is that events which do not fall in the anticipated sequence cause individuals more stress. For example, when a major illness causes retirement before it is desired, an event which Neugarten described DVµRII- time ’WKHQWKHHYHQWFDXVHVDQLQGLYLGXDOJUHDWHUVWUHVVWKDQSODQQHGUHWLUHPHQW)URPthis perspective, adaptation to any transition is influenced by the cultural and individual preparation an individual has had for the event. It is this understanding of imp ortance of timing of events to the individual which places an emphasis on individual factors rather than on chronological age or life stage when explaining responses to transitions. Taking these ideas into consideration, the preparation  an individual has to make the transition to a residential facility ,     22  and an individual’V perception that the occurrence of the transition is either on - time or off - time , are factors which may impact  the experience of having managed well in making this transition.  Other lifesp an theorists have also emphasised individual and contextual contributions to development, and hold that development occurs when an individual is functioning effectively in their system, within a specific domain or on a particular task (Baltes & Carstensen,  1996). The processes by which individuals are able to function in ways that meets their goals, are described in Baltes and Baltes’ metamodel of selective optimization with compensation (SOC) (Baltes & Baltes, 1990; Baltes & Carstensen, 1996). This theory DVVXPHVWKDWDQLQGLYLGXDO’VEHKDYLRXULVgoal directed and that they experience opportunities for growth, as well as limitations on their resources to achieve goals, across the lifespan. From this perspective, the development of resources and capacities t o achieve goals earlier in life allows an individual to master developmental tasks throughout the course of their life. However, with increasing age it is believed that the social, psychological and biological resources needed  to achieve goals are reduced. The processes involved in the metamodel of SOC allow a way of conceptualizing how individuals continue to reach their goals despite these limitations on their resources (Baltes & Carstensen, 1996). These processes are selection, optimization and compensat ion. In the process RIVHOHFWLRQLQGLYLGXDOV’FKRRVHGRPDLQVDUHDVRIIXQFWLRQLQJRUJRDOVRQZKLFKWRIRFXVWKHLUresources in order to maximize gains. This process of selection can involve change in one ’V environment, such as the decision to relocate, or changes in behaviour. The process of optimization involves choosing means for achieving these goals through the enhancement of the resources that an individual is directing towards it. The third process of compensation is a way of counteracting the loss of means to reach goals through either the identification of new resources or new goals if one is unable to achieve the previously established ones. Although these     23   processes are a way of understanding development across the lifespan, it is believed that t hey are amplified later in life as individuals experience greater health - related, psychosocial and biological losses, and the need for adaption in order to meet their goals becomes greater (Freund & Baltes, 1998). Lifespan theory and specifically the metam odel of SOC provide a way of XQGHUVWDQGLQJKRZLQGLYLGXDOV’DGDSWWRWUDQVLWLRQVODWHULQOLIHIURPDSHUVSHFWLYHWKDWincorporates losses but also emphasises resiliency and growth later in the lifespan. In looking at the experience of having managed well in making the transition to assisted  living, it was expected that  participants  would  have engaged in these processes of selection, optimization and compensation in navigating this transitional event.   Research being conducted through The Centre for Lifesp an Psychology at the Max Planck Institute for Human Development has moved towards highlighting the reciprocal effects of  brain mechanisms, behavioural patterns and environmental factors  and how these impact an LQGLYLGXDO’VGHYHORSPHQWLindenberger, Li, Lovden, & Schmiedek, 2007).  This research has emphasized how environmental factors outside of the individual, such as societal policies or interactions with others, have a reciprocal relationship with brain mechanisms that influence an LQGLYLGXDO’VGHYHOR pment. This research continues to emphasise the heterogeneity of development while also looking at the common processes underlying it.  $VGLVFXVVHGLQ%DOWHVDQG&DUVWHQVHQ’VZRUNWKHFRQVWUXFWRIVXFFHVVIXODJLQJhas been important within research  looking at development later in the lifespan. Initially , the construct was defined by objective criteria including low risk of disease and disease - related disability, good physical and mental health and active engagement with life ( Rowe & Kahn, 1997). How ever, more recent research has begun to include subjective components to reflect discrepancies that emerged between objective criteria of successful aging and the experience of     24  ROGHUDGXOWV’ZKRVHOI- identified as having aged successfully (Strawbridge, Wal lhagen, & Cohen, ,QWKHVWXG\E\6WUDZEULGJHDQGFROOHDJXHVSDUWLFLSDQWV’VXEMHFWLYHUDWLQJVRIVXFFHVVIXODJLQJZHUHFRPSDUHGWR5RZHDQG.DKQ’VGHILQLWLRQ6HOI- ratings of successful aging ZHUHFDSWXUHGXVLQJSDUWLFLSDQWV’UHVSRQVHVWRWKe statement ³,DPDJLQJVXFFHVVIXOO\RUDJLQJZHOO´3DUWLFLSDQWVZHUHSURYLGHGZLWKIRXUUHVSRQVHVFDWHJRULHVIRUWKLVVWDWHPHQWDJUHHstrongly, agree somewhat, disagree somewhat or disagree strongly. It was found that , while only RISDUWLFLSDQWVPHW5RZHDQG.DKQ’VGHILQLWLRQRIVXFFHVVIXODJLQJRIWKHparticipants  subjectively identified as aging successfully (Strawbridge et al., 2002).  These findings suggest that subjective definitions of successf ul aging provide greater depth to our understanding of this construct.  Using a sample from the Berlin Aging Study, Freund and Baltes (1998) also studied the construct of successful aging by testing the metamodel of SOC as a general model of successful aging. They looked at the association between self - reported use of SOC strategies and subjective measures of successful aging. They found that individuals who reported using SOC related life management strategies had higher scores on the measures of successfu l aging. The measures of successful aging used were subjective well - being, positive emotions , and absence of feelings of loneliness.  More recently, Prucho, Wilson- Genderson and Cartwright (2010) also tested a conceptual two - factor model of successful agin g that included both objective and subjective components. The study included 5,688 individuals aged 50 to 74 years. The definition of successful aging used in the study reflected the literature in the area which suggests that people can experience successful aging even with significant health problems. Using confirmatory factor analysis, this study found support for a multidimensional model of successful aging that included both     25   subjective and objective elements. This study by Prucho and colleagues , as well  as previous research by Freund and Baltes (1998) and Strawbridge and colleagues (2002) , highlight the LPSRUWDQFHRIWDNLQJLQWRFRQVLGHUDWLRQLQGLYLGXDOV’VXEMHFWLYHHYDOXDWLRQVLQXQGHUVWDQGLQJWKHconstruct of aging successfully. The recognition of the contribution of subjective definitions of successful aging in defining this construct has implications for the current study which looked at WKHWUDQVLWLRQWRDVVLVWHGOLYLQJ7KHFXUUHQWVWXG\DOVRHPSKDVLVHGSDUWLFLSDQWV’VXEMHFWLYHevaluations of their experiences, as recruitment was dependent on participants self - identifying as having managed well in making the transition to assisted living. It is likely that engaging in the processes of selection, optimization and compensation described in the meta - mod el of SOC had also contributed to participants feeling that they had managed this transition to assisted living well  (Baltes & Carstensen, 1996).  Transitional perspective. The transitional perspective of adult development also looks at how responses to e vents depend  upon the  context in  which the transitional event occurs (Goodman et al., 2006).  Goodman, Schlossberg DQG$QGHUVRQ’VWUDQVLWLRQPRGHO looks at  how the nature of a transition event and the resources available to an individual influence how the transition is navigated. The model has three components which inform how helpers can support individuals navigating transitions. The first component, Approaching Transitions, identifies the type and nature of a transition, as well as where an individual is in the transition process (i.e., moving into, through or out of the transition). The second component is Taking Stock of Coping Resources, during which the potential resources an individual possesses to manage a transition are identified. These resources, NQRZQDVWKH66\VWHPLGHQWLI\UHVRXUFHVLQRQH’Vsituation, within the self, as well as sources of support and strategies available to manage the transition. The final component of the model, Taking Charge, looks at how to strength en resources in order     26   to manage the transition. The 4 S System in particular provided a possible framewor k for XQGHUVWDQGLQJFRQWULEXWLQJIDFWRUVWRSDUWLFLSDQWV’ experiences of having managed well in navigating this transition.   Also emphasising how the stage at which a tran VLWLRQRFFXUVLQIOXHQFHVDQLQGLYLGXDO’Vresponse, Lowenthal, Thurnher, and Chiriboga  (1975)  looked at stress responses at different points in the life course. They asked 173 men and women at four diff erent points in the life course to complete the Life Events Questionnaire (LEQ), which is an 82 - item inventory questionnaire of life events or changes . Participants were young adults recently graduated from high school, individuals early in their marriage, midd le- aged parents , and individuals who had recently retired. Participants were asked to check off events on the LEQ that they had experienced during the last year, and also to rate how positively or negatively they felt about each event. Participants who wer e middle - aged parents and recently retired were found to have a larger measure of negative stress than the younger groups. While middle - aged parents also experienced an increase i n positive stress, the retired group was the only group found to have increased negative stress and decreased positiv e stress. This research suggested that retired older adults are facing increased negative stress, such as the transition to assisted living, without the balance of stressful events that are positively received.  Adult development and the transition to assisted living.  These different perspectives on adult development informed many aspects of the current study . Erik a QG-RDQ(ULNVRQ’V (1997a; 1997b)  work described  the stages of psychosocial development that participants  were  likely experiencing . The work of these researchers provided the context of the psychosocial developmental tasks that participants were likely engaged  in. The emphasis on growth in Joan (ULNVRQ’V (1997b)  QLQWKVWDJHDQGZLWKLQ)LVKHU’V (1993)  framework of development, also     27   inform ed my understanding of the ways by which my participants may have adapted to and navigated entry into assisted living. Research by contextual theorists, such as Rosenbaum (1979), also indicated the importance of e vents surrounding entry into assisted living, such as decreased LQGHSHQGHQFHRQLQGLYLGXDOV’UHVSRQVHVWRWKHHYHQW7KHORVVHVH[SHULHQFHGODWHULQOLIHwere  also recognized in Levinson and colleagues ’ (1978) work which characterized  the older adult era as one defined by loss of power, authori ty and recognition. From a lifes pan perspective, the preparation that an individual had and the timing of the move to assisted living  were expected to influence their experience of the transition  event (Neugareten, 1976) . In addition, the metamodel  of SOC, and the research on successful aging, provide d a way of understanding the processes underlying aging later in life (Baltes & Carstensen, 1996 ; Freund & Baltes, 1998, Prucho et al., 2010). The im pact of factors identified by these theorists on responses to transition, ( e.g. loss of power and autonomy; multiple stressors; preparation) may also have been impo rtant factors to the experience  of having managed well in making this  transition.  Transition to Residential Care  As discussed in chapter one, most research on the transition to residential care has emphasised the perspectives of medical professionals, family and facility staff rather than those making the transition to care ( Buhr et al., 2006; Mead et al., 2005; Kellet, 1999; Kelsey, Laditka & Laditka, 2010; Lee et al., 2002). Quantitative research looking at the consequences of entry into a facility has also added to our understanding of the impact of this event on measures of physical and psyc hological health (Aneshensel et al., 2000; Lee et al., 2002). Below is a review of the limited number of studies I have been able to find that included the perspectives of older DGXOWV’RQWKHWUDQVLWLRQWRDUHVLGHQWLDOIDFLOLW\,WLVLPSRUWDQWWRQRWHWhat all except for two of these articles have looked at the move to nursing home facilities rather than to assisted living     28   facilities ± with nursing homes being further along the continuum of care than assi sted living facilities (Kelsey et al., 2010). As described in chapter one, assisted living facilities provide support to adults who require some help with activities of daily living as a result of cognitive or physical decline (Kelsey et al. ). 1XUVLQJKRPHVDOVRUHIHUUHGWRDVµFRPSOH[FDUH’RUµORQJ- term FDUH’IDFLOLWLHVSURYLGHKRXUQXUVLQJFDUHIRUWKRVHZKRVHSK\VLFDOQHHGVH[FHHGZKDWLVprovided by assisted living facilities ( Kelsey et al.). Researchers have looked at both the experience of admission and the experience of adjusting to, and livin g in, a nursing home facility. Although the findings from these studies do not reflect the experiences of individuals making the transition to assisted living, they may shed some light on factors which will also be important when looking at experiences of managing well in making the  transition to assisted living facilities.    Relocation and adjustment.   Nay (1995) used a phenomenological approach to understand the meaning of relocating to a nursing home facility for 19 residents (14 female and 5 male) at f ive different nursing home facilities in Australia. The study included individuals who voluntarily made this transition, and others for whom the move was not voluntary. This study had broad inclusion criteria, simply requiring a willingness and ability to participate. The UHVHDUFKHUGLGQRWHODERUDWHRQWKHLUFULWHULDIRUDVVHVVLQJRUGHWHUPLQLQJSRWHQWLDOSDUWLFLSDQWV’ability to participate in this study. The researcher conducted conversational interviews with willing participants until thematic saturatio n was reached. The author stated that this study aimed RQO\WRXQGHUVWDQGWKHH[SHULHQFHRIUHORFDWLRQGHILQHGDV³WKHSHULRGIURPGHFLVLRQ- making up WRDQGLQFOXGLQJDFWXDODGPLVVLRQ´SDQGWKDWVKHGLGQRWORRNDWWKHDGMXVWPHQWWRDQGday- to- day experience of , living in a nursing home. However , after reviewing the demographic description of the participants in this study, the period of time since admission varied between     29  participants from two weeks to more than three years. PDUWLFLSDQWV’ ability to only refer to the experience of relocation, without also reflecting on their experiences of adjustment to daily life in the facility may have been more difficult for residents who had been in a nursing home facility for more than 6 months.  In interviews with participants, they were asked to speak about when the decision to enter a nursing home was made, who had made the decision, and what the experience of relocation was like for them (Nay, 1995). Four themes emerged from the analysis of the intervi ew data. The first theme, ‘there was no choice’ UHIOHFWHGSDUWLFLSDQWV’EHOLHIWKDWWKH\KDGQRRWKHUDOWHUQDWLYHbut to enter into a nursing home facility. Although  nine out of the 19 participants claimed to have made the decision to enter care, this theme indicated that even these individuals felt that there KDGUHDOO\EHHQQRRWKHUYLDEOHDOWHUQDWLYH2QHSDUWLFLSDQWVDLG³KH>WKHGRFWRU@WROGPHWKDW,would never go h RPHDJDLQWKDW’VZK\,GHFLGHGWRPRYHLQSHUPDQHQWO\´ (p. 322), while others described the move being necessary in order to reduce strain on their family members. The second theme, ‘everything went’ LGHQWLILHGWKHSDUWLFLSDQWV’VHQVHRIORVVDVDFRQVequence of relocation. These losses included the loss of home, possessions, friends, family, pets, freedom as well as life - roles and previous life - style that residents had enjoyed. ‘Devalued self’ was the third theme identified by the researcher, and refle FWHGSDUWLFLSDQWV’EHOLHIWKDWWKH\WKHPVHOYHVand their care, w ere a burden to family members. This was a common perception on the part of the participants which factored into their decision to enter into the nursing home, as they felt entering a facility would reduce the burden on their family members. The final theme that was SUHVHQWZLWKLQPDQ\SDUWLFLSDQWV’H[SHULHQFHVRIUHORFDWLRQZDVWKHEHOLHIWKDWHQWU\LQWRDnursing home represented ‘the end of the line’7KLVUHIOHFWHGSDUWLFLSDQWV’EHOLHIWKDt life as they knew it was over. Participants felt that relocation to a nursing home prevented the possibility of     30   being able to make future, worthwhile contributions to society. For these participants, relocation to a nursing facility reflected their deteriorating health and increased dependency on others.  As mentioned above, this study included participants who had voluntarily and involuntarily relocated to a nursing home. While previous research found that involvement in the decision to enter a nursing home resulted in differences in the relocation  experience ( Brooke, 1989; Chenitz, 19 83),  1D\IRXQGVLPLODULWLHVEHWZHHQUHVLGHQWV’H[SHULHQFHVRIWKLVtransition to a nursing home, regardless of whether or not they identified as having voluntarily chosen to relocate. It was interesting to note that , irrespective of whether relocation was voluntary or involuntary, for these participants , relocation was perceived of as a forced choice based on the circumstances of their lives and health, and on their des ire to reduce the burden on their loved ones for their care. Specific to the current study, the participant s’ reasons for entering an assisted living facility, and their perception of the transition as voluntarily or involuntary, may be important f actors in their ability to manage well in making the  transition to assisted living.  While the study by Nay (1995) looked at the meaning of relocation, a study by Porter and Clinton (1992) looked a t a GLIIHUHQWDVSHFWRIUHORFDWLRQE\H[SORULQJLQGLYLGXDOV’adjustment to entering a nursing home facility. Using data from a larger study, responses from 242 participants were included in the analysis. The specific number of female and male participants for the sample was not presented. Exclusion criteria included : (1) hearing impairment, (2) aphasia which prevented responding to questions, (3) having a private duty nurse, and (4) having an unsatisfactory score on a mental status examination. The exact score that was deemed unsatisfactory for the mental status exam  was not included, nor was the name of the examination used to screen participant s. The exclusion of individuals  with hearing impairments and aphasia would have allowed for participant engagement and participation in the interviews. However, the     31   reasoning for excluding individuals with a private duty nurse was not provided, so it is uncertain whether it was to exclude participants with lower physical ability or if this also pertained to screening participants with reduced cognitive abilities. More informati on regarding the rationale for these exclusion criteria would have been helpful in putting the findings of the study into context.   Porter and Clinton (1992) used a phenomenological approach, and analysed the responses to the open - HQGHGTXHVWLRQ³0RYLQJWRD QXUVLQJKRPHLVVRPHWLPHVDELJFKDQJHLQRQH’VOLIH+RZGLG\RXKDQGOHWKHFKDQJHZKHQ\RXILUVWFDPHWRWKLVQXUVLQJKRPH"´7KHOHQJWKRIresponses varied from a few words to five sentences, and as a result the findings were based on a limited amou nt of data. It is also likely that t he limited data collected impacted the depth of understanding of this phenomenon. Responses were categorised by meaning units in order to better understand the adjustment of the participants. Two meaning units were repor ted: ‘adjustment approach’ and ‘adjustment influence’. Adjustment approach captured responses ZKLFKUHIOHFWHGZD\VRISDUWLFLSDQWVDFKLHYLQJ³PHQWDODQGEHKDYLRXUDOEDODQFHEHWZHHQRQH’VRZQQHHGVDQGWKHGHPDQGVRIRWKHUV´0LVKDVFLWHGLQ3RUWHU& Clinton, 1992, p. 468). $GMXVWPHQWLQIOXHQFHVFDSWXUHGIDFWRUVWKDWLQIOXHQFHGWKHSDUWLFLSDQWV’H[SHULHQFHVRIQXUVLQJhome life.  The 234 examples of adjustment approaches given by participants were classified into 11 categories. The authors found ‘reframing’, ‘getting used to it’ and ‘going along’ to be the approaches present in the largest number of participant responses.  Approaches less frequently identified in the analysis were ‘renaming’, in which participants identified renaming the facility as their home, and coming to regard staff as family, ‘keeping quiet’ and ‘obeying’ staff members. The researchers found a large number of approaches to adjustment that were utilized by     32   residents, but these approaches were not common across the experiences of m any participants. As phenomenological inquiry looks at the essence of a phenomenon that is common across SDUWLFLSDQWV’H[SHULHQFHVWKHVHILQGLQJVGLGQRWFRQWULEXWHWRGHWHUPLQLQJHVVHQWLDODVSHFWVRIapproaches to adjustment. For example, the presence of  the most common approach ‘reframing’ was identified in 45 of the 234 examples of approaches, while the least common approach, ‘obeying’ was present in only 5 of the 234 examples of approaches provided by participants.  The process by which the researchers  conducted the analysis was outlined at length. Yet it would have been helpful to have a more thorough explanation of the differences between FDWHJRULHVDVVRPHDSSHDUHGWREHYHU\VLPLODULQQDWXUH)RUH[DPSOHµgetting used to it’ZDVGHILQHG³VLPSO\DVOLYLQJLQWKHIDFLOLW\ZKLOHWLPHSDVVHG´SDQGµgoing along’ZDVGHVFULEHGDV³SDVVLYHO\DFFHSWLQJQXUVLQJKRPHOLIH´S0RUHGHWDLOHGGHVFULSWLRQVRIWKHnuances between the categories would have provided a better understanding of the pr ocess by which the data was analysed. What these categories did provide, however, were many examples of adjustment to nursing home life as described by the indivi duals who had entered a facility. Frequently , WKHVHGLUHFWDFFRXQWVRILQGLYLGXDOV’H[SHULHQFHs of entering a residential facility are overwhelmed by the voices of health professionals, staff and family members and this study gave voice to the participan WV’H[SHULHQFHV%URRNH&KHQLW]).  For the second meaning unit, ‘adjustment influences’, Porter and Clinton (1992) identified 221 influences that they categorized into four groups: ‘transfer circumstances’, ‘life history’, ‘person-environment mesh’ and ‘belief in the only option’. Responses related to transfer circumstances reflec WHGSDUWLFLSDQWV’FLUFXPVWDQFHVEHIRUHHQWU\DVZHOODVWKHLULQYROYHPHQWLQor awareness of, decisions regarding entry into care. The second category captured ideas about the relationship between life in the facility and their previous circumstances. For  example,     33   individuals who had a history of moving residences throughout their lives viewed their history of relocation as a factor which eased their adjustment. Individuals who had been lonely in their previous living arrangement also described their previ ous loneliness as a factor that affected their adjustment positively. Responses that were identified as ‘person-environment mesh’ reflected the impact of interpersonal relationships, living environment and concurrent loses or worries on adjustment. The las WLQIOXHQFHRQDGMXVWPHQWWKHUHVHDUFKHUVLGHQWLILHGZDVSDUWLFLSDQWV’belief that they had had no other choice EXWWRHQWHUWKHIDFLOLW\7KHFDWHJRU\µtransfer circumstances’emerged as a potentially influential factor for the experience of transition to  assisted living. Involvement in decisions to enter care could also contribute to feeling prepared for the transition to a facility, and subsequent adjustment.  In addition, both of the studies by Nay (1995) and Porter and Clinton (1992) found that feeling one had no choice but to enter care was an important factor in the meaning they made of the experience of relocation and on subsequent adjustment. The overall experiences of SDUWLFLSDQWVLQ1D\’VVWXG\ZDVQHJDWLYHZLWKWKHHPHUJLQJWKHPHVUHIOHFWing the SDUWLFLSDQWV’beliefs that they had no choice, had lost everything and were no longer able to make YLDEOHFRQWULEXWLRQVWRVRFLHW\,QFRQWUDVW3RUWHUDQG&OLQWRQ’VUHYHDOHGDUDQJHRIadjustment approaches and influences, many of which ref lected positive experiences of adjustment. The belief that they had no choice but to enter care was used by some participants as a reason for why they needed to adjust to their new environment, and, therefore, facilitated adjustment (Porter & Clinton). For  the current study, participants ’ZLOOLQJQHVV to enter care may have contributed to their experience of making this  transition. Conversely, it may also be that participants recognized the importance of adjusting to their new environment when they felt they had no other alternatives.      34   3RUWHUDQG&OLQWRQ’VVWXG\IRXQGPDQ\DGMXVWPHQWDSSURDFKHVVHYHUDORIZKLFKFRXOGEHFRQVLGHUHGSDVVLYH:KLOHµgoing along’ZLWKRWKHUVµobeying’µkeeping quiet’DQGµgetting used to it’PD\KDYHOHGWRDGMXVWPHQWit was of interest  to see if these were  factors identified by parti cipants who identify as having managed well in making the transition to assisted living. It may be that the self - identification of having managed well  may be associated with more active approaches to navigating this event.  Another study which looked at the experience of adjustment to living in a nursing home DVNHGWKHTXHVWLRQ³:KDWSKDVHVGRUHVLGHQWVSDVVWKURXJKLQWKHSURFHVVRIDGMXVWLQJWRDnursLQJKRPHDIWHUWKHILUVWPRQWKRUWZR"´%URRNH7KLVVWXG\ZDVDORQJLWXGLQDOparticipant - observer study with 42 participants (31 women and 11 men) in which the researcher, who was a nurse, collected data while in an active care role. In collectin g data from participants, WKHUHVHDUFKHUDVNHGTXHVWLRQVVXFKDV³ZKDWLVLWOLNHWROLYHKHUH"´RU³KRZKDV\RXUGD\ZHHNEHHQ"´WZRWRILYHWLPHVDZHHNRYHUWKHFRXUVHRIDRQH- year period. The analysis included coded interview responses, observation RIUHVLGHQWV’EHKDYLRXUDQGQXUVLQJLQWHUYHQWLRQVDQGevaluations. Four phases were identified in the adjustment process: (1) disorganization, (2) reorganization, (3) relationship building, and (4) stabilization. In the first phase , individuals were dealing with their past and present los ses. Typically by the second to third month in the facility, individuals had reached the second phase in which they were finding meaning in their new experience. The third phases involved creating new social relationships with residents and staff and maintaining relationships with family. The final phase, stabilization, was found to typically occur within three to six months of entering a facility. It occurred when residents had come to terms with some of their losses, deve loped relationships with staff and residents, and settled in. These findings had implications for determining the timing of interviews for the current study.     35   %URRNH’VVWXG\VXJJHVWVWKDWLQGLYLGXDOVGRQRWVWDUWWRILQGPHDQLQJLQWKHLUH[SHULHQFHVof relocation until at least three months after they have entered a facility. An inclusion criterion for p articip ation in the current research was living in their  facility for at least a year prior to the data collection interviews in order to allow  partic ipants  to pass through the stages of adjustment described in %URRNH’VVWXG\. It was anticipated that  participants would be more  able to reflect on the meaning of having managed well in making the transition to assisted living at this point .  A strength of this study was the time that the researcher spent engaging with the residents. This longitudinal approach helped the researcher to understand the processes that individuals may undergo in adjusting to living in a nursing home community. The phases identified were also validated by residents and staff, adding to the trustworthiness of the findings. The study had a diverse sample of participants, with a range of physical and cognitive concerns, which reflected the demographics of nursing home populations. Sim ilar to the findings of the studies by Nay (1995) and Porter and Clinton (1992), voluntary or involuntary entry into the facility was again an important factor for subsequent adjustment.  There were some differences in SDUWLFLSDQWV’UHDFWLRQVWRHQWHULQJDIDFLOLW\GHSHQGLQJRQwhether or not they had voluntarily  entered the facility (Brooke, 1989). While the study found that individuals who had voluntarily and involuntarily entered the nursing home progressed through the stages in a similar fashion, individuals who were involuntarily admitted expressed anger and behaved in ways that the researcher identified as difficult for nurses to work with. These behaviours included refusal to eat, dress or participate in activities of daily living.  Brooke (1989) cautioned that these phases were intended to give nurses an understanding of the process of adjustment rather than to identify phases that all individuals will progress through sequentially. The need to prioritize the individual experiences of residents was     36   highlighted by the researcher as the most important aspect of supporting individuals through this transition. In keeping with these findings, the voice of participants was prioritized in th e current study.  The interviewer f ollow ed the lead of the participants throughout the interviews allowing WKHLUH[SHULHQFHVWRJXLGHWKHSURFHVV$V%URRNHPHQWLRQHGSULRULWL]LQJWKHLQGLYLGXDOV’experience is  also a key aspects of supporting individuals . Therefore, it may also be that having others recognize and be aware of their experience is an importance aspect of feeling that one has managed well in making the  transition to assisted living.  While this study showed respect and regard for the particip DQWV’H[SHULHQFHLWVLQWHQWLRQwas to understand the process of adjustment in order to help nurses to meet their goal of supporting their patients. As a result, this study included the perspectives of nurses as well as the review of nursing interventions and how they related to the adjustment experiences of residents. This is a different focus than was  used when looking at the transition to an assisted living facility from a counselling psychology perspective. Although healt h status may be one factor in ma naging well in making the  move t o assisted living, the focus on physical health was expected to play a less prominent role in understanding the experience for assisted living residents because it is lower on the continuum of care and residents are likely t o have fewer physical and cognitive concerns (Kelsey et al., 2010). %URRNH’VVWXG\ZDV helpful in developing the current study, as it provide d information on how long it may take  IRULQGLYLGXDOV’WRµVWDELOL]H’LQWKHLUQHZOLYLQJenvironment, so th at they can begin to make meaning of the event of managing well in making the transition. As mentioned above, this inform ed the timing of interviews with part icipants. In addition, it also highlighted factors which may play an important role in facilitating transition. As was the case in 3RUWHUDQG&OLQWRQ’VVWXGy, perceptions of entry into care being voluntary     37   or involuntary once again emerged as an important factor in adjustment. In this case,  involuntary entry negatively impacted relationships with facility staff, which is likely to correlate with not feeling one has managed this transition well . The development of positive relationships with other residents and other staff was also important in helping individuals adjust to life in a nursing home facility, and it may be that the development of relationships with friends and staff members is an important factor in successfully transitioning to an assisted living facility. Finally, the findings RI%URRNH’VVWXG\LQGLFDWHGWKDWEHLQJDEOHWRPDLQWDLQSHUVRQDOLGHQWLW\ZKLOHalso navigating the norms of the facility aided adjustment. This balance between autonomy and facility routines may also be an important factor in managing well in makin g the transition to assisted living.  %URRNH’VVWXG\ILQGLQJVDLPHG to guide nursing interventions. A study by Chenitz (1983) had the same focus on developing nursing interventions to help older adults manage the transition to a nursing home facilit y. Using a grounded theory approach, the study included 30 participants (22 female and 8 male), who were interviewed several times a week from the time of admission until six to nine months after entry. The interviews were aimed to determine older DGXOWV’responses to admission to a nursing home, the conditions that led to a negative response, and the consequences to older adults, their families and staff when a resident had a negative response to entering into a nursing home. The description of the data an alysis method was lacking, and limited information was provided on the process by which themes were identified.  7KHUHVHDUFKGHVFULEHGUHVSRQVHVWRHQWU\LQWRDQXUVLQJKRPHDVµacceptance’RU‘resistance’. Resistance was further differentiated by the res earcher as either ‘resigned resistance’ or ‘forceful resistance’)DFWRUVZKLFKLPSDFWHGUHVLGHQWV’UHVSRQVHVWRHQWHULQJDQXUVLQJKRPHZHUHIRXQGWREHWKHLPSDFWRIWKHGHFLVLRQWRHQWHUFDUHRQWKHLQGLYLGXDOV’LQGHSHQGHQFHDQG    38   autonomy, (2) the d esirability of the move, (3) the legitimacy of the move, (4) the voluntary nature of entry, and (5) the potential reversibility of the move. The ability for family members to enhance the presence of these factors, by identifying plausible reasons for an in dividual to enter care was also discussed. The finding that reduced autonomy contributed to a negative adjustment experience, was consistent with the importance of maintaining autonomy and personal identity RQVXFFHVVIXODGMXVWPHQWZLWKLQ%URRNH’VVtudy. The recurrence of this finding suggested that maintaining autonomy may  be an important factor in managing well in making the  transition to assisted living. Voluntary entry into a facility was again found to be a factor related to adjustment to a nurs ing home facility. The consistency of this finding thr oughout the literature strongly suggested that this would  be an important factor in  managing well  in making  the transition to an assisted living facility.  In contrast to the studies conducted by Brooke (1989) and Chenitz (1983), which looked at the process of adjustment over several months, the study of the transition experience in the first two weeks following admission to a long - term care facility was cond ucted by Iwasiw, Goldenberg, MacMaster and Bol (1996). The researchers were interested in understanding the immediate reaction of individuals entering into this type of residential facility, and factors which influenced LQGLYLGXDOV’UHDFWLRQVWRWKLVWUDQVition experience. Twelve participants (10 women and 2 men) were interviewed by the researchers in the first two weeks following entering the facility. They were asked questions about what it had been like since their arrival in the facility and how it comp ared to their expectations. Participants were also asked about what had been helpful to them in the past two weeks since entering the facility. This question which moved towards an identification of what was helpful to participants is similar to the focus of the current research which looked  exclusively at the experiences of having managed well in making this      39   transition. This is a departur e from previous studies, which  focused exclusively on the negative aspect s of adjustment (Chenitz, 1983)  or looked at ne gative and positive experiences (Porter & Clinton, 1992).  Using constant comparative qualitative analysis of the interviews, Iwasiw and colleagues FODVVLILHGSDUWLFLSDQWV’H[SHULHQFHVLPPHGLDWHO\SULRUWRHQWHULQJDQGGXULQJWKHILUVWtwo weeks of living in a long term care facility  as: (1) emotional reactions, (2) transition activities, (3) reflecting on their situation , and (4) connecting with a personal philosophy. Participants experienced a range of emotional reactions, including relief, increased autonomy  and worth , as well as shock, loneliness , and a sense of profound loss. Important transition activities included WKHSDUWLFLSDQWV’LQYROYHPHQWLQWKHGHFLVLRQWRHQWHUFDUH$JDLQWKLVLQYROYHPHQWLQWKHdecision to enter care emer ged as an important factor, even in these early reactions to entry into a nursing home facility. In addition, maintaining and forming new relationships and trying to make the facility feel like home by moving important possessions with them were also impor tant transitional activities that influenced their experiences of entering into the facility.  The LPSRUWDQFHRIFRPLQJWRYLHZWKHIDFLOLW\DVµKRPH’LV consistent with the findings of Porter and &OLQWRQ’VVWXG\ The importance of  connecting with ot hers through the formation of new relationships was DOVRIRXQGLQ%URRNH’VUHVHDUFK+RZHYHULQWKLVVWXG\, the importance of relationships was present even in the initial two weeks of entry into a facility, whereas Brooke (1989) found that this wa s associated with the final phase of stabilization which occurred three to six months after entry into care. This suggested that the formation of relationships was  also likely to be an important factor in managing well in making the transition to assisted living, and that some individuals may begin to form these relationships sooner than others. While Chenitz (1983) and     40  %URRNH’VVWXGLHVLQGLFDWHGWKDWDXWRQRP\PD\EHDPHGLDWLQJIDFWRULQDGMXVWPHQWWRassisted living, Iwasiw and colleagues (1996) st udy suggested that, for some , increased autonomy may even be a reaction to entry into a nursing home facility. For some partici pants, a nursing home facility  increased their autonomy as they were no longer reliant on family members. While autonomy may be an important factor in transition to assisted living, the impact of entry into care on autonomy is likel y to vary between individuals. Finally, Iwasiw and colleagues found that reflection on their situation was a common reaction to ent ry into assisted living. As the current study asked  participants to discuss the meaning of the experience of successful transition, their ability to reflect on their situation and to share their thoughts with  the researcher was  central to the understanding of this experience.  In a quantitative study looking at processes contributing to adjustment to assisted living, Cutchin and colleagues looked at the process by which residents become integrated into assisted living environments and begin to consider it to be ³home  ´(Cutchin, Owen & Chang, 2003). Data collection for the study was guided by pr eliminary qualitative study conducted with 35 residents of assisted living, 14 staff members and 12 family members of residents. This qualitative study highlighted issues for further exploration  which  Cutchin and colleagues then used to develop a standardized questionnaire  WRH[SORUHUHVLGHQWV’H[SHULHQFHV. This questionnaire  was mailed to 35  assisted living facilities chosen using purposive sampling. Ten of the assis ted living facilities did not participate in the research process, and 303  questionnaires were returned from the remaining 25  facilities. The questionnaire included 76  items and five open - ended questions. The items  measured place attachment, social involve ment within and outside of the residence and UHVLGHQWV’SHUFHSWLRQVRITXDOLW\RIOLIHDQGVDWLVIDFWLRQ      41  The structural equation model  found a relationship between social and physical attributes RIDVVLVWHGOLYLQJDQGUHVLGHQWV’VDWLVIDFWLRQRUTXDOLW\RIOLIH While residents’ attachment to the town and community was a necessary factor in the process of becoming at home, it alone  was n ot sufficient. It was found that engagement in social interactions with people in the residence, or in the community surrounding the residence, was key  to individuals’ process of attachment to place and sense of being at home in their assisted living facil ity. In addition, place valuation, which UHIOHFWHGSDUWLFLSDQWV’SHUFHSWLRQVRIWKHTXDOLWLHVRIWKHDVVLVWHGOLYLQJIDFLOLW\DQGWKHLUsatisfaction with the facility, was found to have a positive effect on the process of becoming at home.  The importance o f social interaction with those within SDUWLFLSDQWV’ community and the assisted living facility was consistent with findings of previous research which highlight role of social interaction in adjusting to resident ial care (Brooke, 1989; Iwasiw et al., 1996 ; Porter & Clinton, 1992). While previous research  has also highlighted the importance of relationship s with family members, this study found that non- family social interaction was a key factor i n the adjustment process ( Cutchin et al., 2003 ). This speaks to the potential importance of forming new relationship s within an assisted living facility in the process of transition. While previous research has identified the losses associated with entry into assisted living (Aneshensel et al, 2000; Brooke, 1989 ; Nay, 1995 ) limited research has looked at the value that residents place on  assisted living. Cutchin and colleagues (2003)  identified that seeing benefits in the assisted living facility environment wa s a factor contributing to adjust ment . It was anticipat ed that participants in the current study would appreciate some aspects of assisted living, and that this may have  contributed to their experiences of feeling they have managed well in making th is transition.      42   Daily life in a residential facility.  While the research above has looked at relocation, or adjustment, to a residential care facility, Fiveash (1998) conducted an ethnographic study looking at the experience of daily life in a  nursing home facility. Data were  collected through in-depth interviews with eight key informants and participant observations at two nursing home facilities. This reader was able to find demographic information for seven of the eight key informants, five of which were women and two of wh om were men. The researcher stated that FULWHULDIRUVHOHFWLQJNH\LQIRUPDQWVLQFOXGHGSDUWLFLSDQWV’³EURDGNQRZOHGJHRIWKHFXOWXUDOH[SHULHQFH´SDQGLWZRXOGKDYHEHHQKHOSIXOWRKDYHKDGIXUWKHULQIRUPDWLRQRQZKDWWKHresearcher considered to be broad knowledge.  From the analysis of the data emerged four themes of the experience of being a nursing home resident; (1) against my will, (2) living in the public domain, (3) cultural implications of living with others and (4) the impact of nursing ho PHUHVLGHQF\7KHWKHPHRIµagainst my will’spoke to the ongoing impact of non - involvement in decisions surrounding entering care on LQGLYLGXDOV’H[SHULHQFHHYHQDIWHUOLYLQJLQWKHIDFLOLW\IRUDORQJHUSHULRGRIWLPH$OORIWKHNH\informants in this s tudy felt that the decision to enter the nursing home had been made for them, which may have influenced the other themes identified within the experience of living in a QXUVLQJKRPH7KHVHFRQGWKHPHµliving in the public domain’UHIOHFWHGSDUWLFLSDQWV’Qegative experiences of living in a nursing home, including the beliefs that others were in charge of them and that they lacked privacy and a sense of belonging. The third theme also reflected a negative H[SHULHQFHRIOLYLQJLQDQXUVLQJKRPH7KHWKHPHµcultural implications of living with others’LQFOXGHGSDUWLFLSDQWV’GHVFULSWLRQVRIVKRFNDWVHHLQJ³VRPDQ\GLVDEOHGDJHGDQGVLFNSHRSOHOLYLQJWRJHWKHU´DQGGLVSOD\VRIVRFLDOO\LQDSSURSULDWHEHKDYLRXUVIURPFR- residents (Fiveash, 1998, p. 169). Living i n a facility surrounded by illness and declining health also served as a     43   reminder for the participants of their own declining health. A secondary cultural implication of OLYLQJLQDQXUVLQJKRPHZDVWKHSDUWLFLSDQWV’LQWHUDFWLRQVZLWKQXUVLQJKRPHVWDII$ll of the key informants described having to be subservient and compliant in order to get along with staff.  7KHILQDOWKHPHµimpact of nursing home residency’UHIOHFWHGSDUWLFLSDQWV’H[SHULHQFHVRIWKHmonotony and tediousness of daily life in the facili ty.  This study identified the impact of environmental factors, such as sharing space with others, inappropriate behaviours from co - residents and the monotony of the nursing home environment, which had not been discussed in previous research. The negative impact of these aspects of a nursing home environment in the study by Fiveash  (1998)  suggested that increased privacy and a more stimulating environment could be factors which contribute to a more positive  transition experience.  A study by Ball and colleagues (2000) looked at residents ’ perspectives on quality of life in assisted living. In this study researchers interviewed 55 participants in 17 different assisted living facilities using structured interviews. Care providers were also interviewed and the records of participants reviewed for 51 of the participants. Qualitative analysis of the interviews found 14 significant domains of quality of life. Not all of these domains were equally valued by participant s and the researchers reported differences between residents  in terms of which domains they valued.  While there were 14  domains valued by participants in relation to the quality of their lives, only five were discussed in depth : (1) psychological well - being, (2) independence  and autonomy,  (3)  social relationships and interactions, (4) meaningful activities, and (5) care from facility. The additional domains of :  comfort, cognitive functioning/memory, sleep, food,     44  connectedness to community outside facility, physical functioning, religion/spiritualit y, physical environment and safety and security  were discussed in relation to the first five domains.  While the authors indicated that, overall, participants described having experienced numerous significant losses that had impacted the quality of their lives, the y identified that there were still areas which could contribu te to improved quality of life. Although  participants identified that, overall, their independence and autonomy  had been impacted following  their move  into assisted living, they indicated that they were still able to be autonomous  in making smaller decisions . Maintaining their autonomy in these smaller  decisions was identified by  participants as  being important  to their quality of life .  Social relationships with friends, family and care providers were also identified as valuable aspects of quality of life, as was engagement in meaningful activity. Finally, participants in the study described the importance of care received at the facility on their quality of life . &DUHSURYLGHUV’ qualities of  kindness, caring,  being affectionate, patience, respectf ul, and responsive  were identified as important  WRWKHSDUWLFLSDQWV’quality of life.  Although Ball and colleagues (2000) identified that the majority of participants had not been involved in the decision to enter assisted living, ma intaining some sense of autonomy  emerged as important in contributing  to the quality of life experienced following entry into assisted living. Their study also identified the importance of staff, residents and family members working together to develop individualized care plans following entry into assisted living in order to promote improved  quality of life following this transition.  As social relationship s, maintained independence and aut onomy, and meaningful activity were  identified as being important domains of quality of life, it was expected that they may be  present in the experiences     45   of those who identify as having managed well in navigating the transition to assisted living  in the present study .   Chapter summary  A review of the literature on the experience of transition to a residential  care facility revealed that there is a limited amount of research that has been conducted in this area, and an even smaller proportion of the research which has focused specifically on understanding residents’ experiences of this event. However, within the literature , certain factors emerge d consistently as important to the experience of transition later in life, particularly to the experience of transition to a nursing home facility. The contributions of previous studies to the proposed research are outlined below.  In the deYHORSPHQWDOOLWHUDWXUH(ULNDQG-RDQ(ULNVRQ’Va, 1997b ) theoretical work drew  attention to the psychosocial development that continues into the la ter years. Their work recognized  WKHSRWHQWLDOIRUJURZWKDQGFUHDWLYLW\SUHVHQWLQROGHUDGXOWKRRG)LVKHU’Vdevelopmental framework also describe d the growth that older adults undergo as they navigate transitions and adapt to altered circumstances in their later years. Different perspectives on adult development describe the  potential for adaptation later in life  that exist s despite the multiple losses and negative transitions that older adults face as they enter their later years (Baltes & Carstensen, 2003; Levinson et al., 1978 ; Rosenbaum, 1979). The timing of an event also HPHUJHGDVDQLPSRUWDQWIDFWRULQXQGHUVWDQGLQJKRZLQGLYLGXDOV’QDYLJDWHWUDQVLWLRQV(Neugareten, 1976). Timing appears to be important because of its relationship to the anticipation or preparedness that an  individual has for an event at different points  in their lives. Models of successful aging also provide insight into how older adults navigate the psychosocial     46   losses experienced later in life and their subjective experiences of successful aging at this s tage of their lives (Freund & Baltes, 1996) .   For individuals transitioning to nursing home facilities, adjustment to entry appear ed to be significantly influenced by whether or not entry wa s voluntary. The importance of involvement in the decision to ent er care was a predominant  finding throughout the literature reviewed (Brooke, 1989; Chenitz, 1983; Fiveash, 1998; Iwasiw et al., 1996; Nay, 1995; Porter &  Clinton, 1992). By being involved in a decision, it is likely that individuals feel more prepared for the experience of relocation to a facility. Autonomy was another factor that emerged in several studies as important in the process of adjustment to entr y into a nursing home facility (Brooke, 1989; Chenitz, 1983; Iwasiw et al., 1996). A final factor which was present a cross multiple studies was the role  of developing new relationships in the adjustment to moving to a nursing home facility  (Brooke, 1989; C utchin et al., 2003; Iwasiw et al, 1996) . All of these factors were considered in the collection and analysis of data for the current study. It was expected that  involvement in the  decision to enter care and preserved autonomy in daily life once in an assisted living facility, may be LPSRUWDQWIDFWRUVLQFXUUHQWSDUWLFLSDQWV’H[SHULHQFHVRIhaving managed well in making the t ransition. Similarly, it was believed  that the development of relationships within an assisted living facility may also contribute to SDUWLFLSDQWV’transition experiences . The research on adult development served as context for the multiple losses that participants were likely to have faced, while also acting as a reminder of the continued pot ential for adjustment to transitions, such as  entry into an assisted living facility.   The synthesis of the literature on adult development and the transition to an assis ted living facility situated the research question “What is the meaning and experie nce for older adults, of managing well in makin g the transition to assisted living?” The met hod by which     47   the phenomenon of managing well in making the  transition was explored will be outlined in the following chapter .                           48   CHAPTER THREE Methodology  Approach to the Research Question   Phenomenology can be broadly understood as the study of lived experiences (van Manen, ,WVHHNVWRJDLQ³LQVLJKWIXOGHVFULSWLRQVRIWKHZD\ZHH[SHULHQFHWKHZRUOGSUH-UHIOHFWLYHO\ZLWKRXWWD[RQRPL]LQJFODVVLI\LQJRUDEVWUDFWLQJLW´YDQ0DQHQS9). As a result, rather than offering theory to explain or control the world, it provides us with insights that bring XVDGHHSHUDQGPRUHGLUHFWXQGHUVWDQGLQJRIWKHZRUOG7KHTXHVWLRQ³W hat is the meaning and experience for older adults, of managing well in making the  transition to assisted living? ´was  best answered using a ph enomenological approach which sought  to gain a deeper understanding of the experience of managing well in making the  transition to an assisted living facility.   There are two predominant approaches to phenomenological inquiry, descriptive and interpretive (Lopez & Willis, 2004). Each has different philosophical underpinnings which correspond to differences in the type of knowledge they seek to gain and the implications of their  research findings (Lopez & Willis ). A brief review of some of the assumptions underlying each approach will help to situate this particular research question within the field of interpretive phenomenological inquiry.    Historical and p hilosophical tenets of p henomenology.  Descriptive phenomenology GHYHORSHGIURP+XVVHUO’VSKLORVRSKLFDOZRUNDQGLVIRXQGHGRQWKHEHOLHIWKDWWKHHVVHQWLDOcommon aspects of a shared lived experience can be determined following a scientific approach (Lopez & Willis, 2004). In order to understand the experiences being studied, Husserl believed WKDWUHVHDUFKHUVPXVWFRQVWDQWO\ZRUNWRZDUGVLGHQWLI\LQJDQG³EUDFNHWLQJ´WKHLUSUHYLRXV    49  knowledge and theoretical assumptions in order to gain access to the actual phenomenon itself (Wertz, 2005). From a descriptive phenomenological perspective, objective reality exists and can be discovered outside of the context in which it is situated.   In contrast, interpretive phenomenology moves away from solely describing common, essential aspec WVRIH[SHULHQFHDQGORRNVWRUHYHDOWKHPHDQLQJRILQGLYLGXDOV’OLYHGH[SHULHQFHV&ULVW	7DQQHU5RRWHGLQ+HLGHJJHU’VSKLORVRSK\LQWHUSUHWLYHSKHQRPHQRORJ\LVEDVHGon the assumption that we cannot separate our experience from the context in w hich we live. Therefore, rather than seeking  solely WRLGHQWLI\GHVFULSWLYHFDWHJRULHVLQWRZKLFKLQGLYLGXDOV’experiences fit, interpretive phenomenology emphasizes the meanings individuals make of their H[SHULHQFHVDQG³KRZWKHVHPHDQLQJVLQIOXHQFHWKHFKRLFHVWKH\PDNH´/RSH]	:LOOLVS729). As a result, there is no one true meaning that an interpretive phenomenological study seeks to describe. Rather, the meanings identified  reflect the realities of the participants and are in keeping with the orien ting framework chosen by the researcher.   Hermeneutic p henomenological method.  The research question of the current study was  ³What is the meaning and experience for older adults, of managing well in making the  transition to assisted living? ´,was  interested in understanding the meaning attributed to the lived experience of managing well in making this  transition among older adults , as well as common elements of the experience . As such, this question was  best answered using an interpretive phenomen RORJLFDODSSURDFK,QWHUSUHWLYHSKHQRPHQRORJ\’VYLHZRINQRZOHGJHLVrelativist to the extent that it believes  that there is no one true meaning of an experience. This is consistent with the interpretive paradigmatic fr amework in which this question wa s situated, ZKLFK³SRVLWVPXOWLSOHHTXDOO\YDOLGVRFLDOUHDOLWLHV´DQGDOVRUHFRJQL]HVWKDWWKHUHVHDUFKHULVnot objective, but rather will influence the research process through his or her interactions with     50   participants (Haverkamp & Young, 2007). While this  is in contrast to descriptive SKHQRPHQRORJ\’VEHOLHILQDFRPPRQHVVHQFHRIH[SHULHQFHLWILWVZLWKLQWHUSUHWLYHSKHQRPHQRORJ\’VUHFRJQLWLRQWKDWH[LVWHQFHLVRQO\NQRZQLQUHODWLRQWRRWKHUSHRSOHDQGcontexts, thereby allowing for  the uniqueness of the meaning of  experience , while also acknowledging  essential common aspects .  This study was guided by  YDQ0DQHQ’VDSSURDFKWRSKHQRPHQRORJy, inform ing the way in which the data were gathered and the process of analysis. van Manen views in - depth LQWHUYLHZVDVDPHWKRGRIH[SORULQJDQGJDWKHULQJPDWHULDOWKDWDOORZVIRUD³ULFKHUDQGGHHSHUunderstanding of a human phenomen RQ´S7KLVDSSURDFKDOORZHG the contextual aspects of the experience to be acknowledged in determining the mea ning partic ipants mad e, and their experiences of, managing well with the  WUDQVLWLRQWRDVVLVWHGOLYLQJYDQ0DQHQ’VDSSURDFKWRthematic analysis also guided the process of identifying themes across the participants ’ experiences . This approach was  consistent with thi s researcher’VDLPWRXQGHUVWDQGWKHPHDQLQJDQGH[SHULHQFHRISDUWLFLSDQWV’experiences of this transition  in the context of their larger lived experience.  What is also important in using an interpretive paradigm is that the researcher examines his or her values and personal beliefs in order to understand how they will contribute to the meanings identified by participants ( van Manen, 1990). This is important to all aspects of the research process. My beliefs, presuppositions and biases are outlined in the following section, DQGUHIOHFWWKLVQHHGIRUUHVHDUFKHUUHIOH[LYLW\ZKHQXVLQJYDQ0DQHQ’VSKHQRPHQRORJLFDOapproach to data collection and analysis.        51   My Pre - Understandings   In preparing to carry out this research, I had numerous conversations about the focus of my dissertation. What struck me from these conversations is that for each individual  I spoke  with , a description of my research  brought to mind instances in their own lives when they have faced a transition to a care facility; whether it was that of a parent, a spouse, a grandparent , or a transition which they themselves had undergone. Evident in these conversations w as the individual’V desire to understand more about this experience because of the personal challenges they had faced in navigating it. I, too, brought my personal experiences to this research, particularly in relation to why I believed this research to be important. As I observe my grandmother aging, I am anticipating that , at some point , she will have to move from her home in order to receive adequate care. How she, and my family, will navigate this process is still uncertain, and I was  interested and invested in understanding how others manage this transition.  As there was , in part, a personal motivation to seeking some under standing of this phenomenon, I was constantly reflecting upon what personal biases or presuppositions might impact  this research. In considering the continuum of care options, I expect ed that assisted living facilities would offer a better quality of life than options further  along the continuum, such as nursing home s or complex care facilities. As assisted living facilities were developed to provide care for individuals who require only some assistance with daily living, I believe d that compared to a nursing home facility, assisted living facilities were  likely to offer more privacy and freedom, which may  have contributed to individuals managing this transition well.  Also, I held a belief that assisted living facilities w ould have residents with higher leve ls of physical and cognitive abilities, which w ould also impact the interactions between residents, possibly     52   allowing for more opportunities for the development of satisfying relationships, which may also  have facilitated the transition experience.  Perhaps  because the majority of research I reviewed on the transition to residential care looked specifically at the transition to a nursing home, I expect ed that often a move to residential care would be  planned by family members rather than by the individual themselves ( Brooke, 1989; Chenitz, 1983; Fiveash, 1998; Nay, 1995; Porter & Clinton, 1992 ). As the residents of a nursing home facility typically  face more physical and cognitive decline than residen ts of an assisted living facility, I assumed  that family members may  feel that they have to take the lead in decision making regarding entering care. However, I also felt that it may be  possible that for individuals who entered  assisted living, and only require d support with some as pects of daily functioning, they might have been more  involved in decisions and planning for entry into a facility and that, as a result, had an easier transition to their new living arrangement. I also expected  that having increased physical health and in creased cognitive abilities would  ease the transition experience. I t hought that individuals who have been socially isolated prior to entering an assisted living facility may transition with greater ease than individuals who had strong pre -existing  social connections. Finally, I expect ed that individuals who transitioned from an in terim  living arrangement (e .g., DQRWKHUIDFLOLW\RUOLYLQJZLWKLQDUHODWLYH’VKRPHZould transition mor e easily than individuals who had transitioned  directly from living independently in their own home.  The literature on the transition to residential care highlights a number of challenges of adjusting to and living in a new environment (Brooke, 1989; Porter & Clinton, 1992; Nay, 1995). As a result, wh en beginning this research, I was uncertain of how easy it would be to find individuals who identified as having managed well in making this transition. This reflected a     53   belief that for the majority of individuals the move to assisted living may be a diffi cult transition to make.  I was also cognizant that my age w ould influence my interactions with participants . I look to older adults as individuals with accumulated life wisdom. I had to be aware of how this view m ight influence the dynamic of my interactio ns with my participants. I also anticipat ed that they m ight be wary of my younger years and that they might  feel I had inadequate life experience to understand what they have been through. I was  aware that my concerns m ight also influence our interactions and the data collected. Research Procedure   Participants.  The inclusion criteria for volunteer participants wa s that they be: (1) 65 +  years; (2) able to speak English; (3) current resident of an assisted living facility in  the greater Vancouver area that they moved into within the past one to five years; (4) self - identify as having successfully navigated the transition to assisted living; and (5) have not entered the facility primarily because of cognitive decline. In terms  of the first criteria, there is no consensus on the DJHDWZKLFKDSHUVRQLVGHILQHGDVµROG’, with some studies including those 50 years and older under this umbrella (Hill & Brettle, 2006).  However, 65+ years of age was chosen for this study because most developed world countries have concurred that the chronological age of 65 years as a definition of an older person (WHO, 2011). In western societies , it is the age associated with retirement and other societal benefits and changes in status associated  with age (Roebuck, 1979). The second criteria of speaking English allowed  for participation in the interviews. The third criteria ensured that the researcher had easy access to the participants for the duration of the  study and that the residents had adeq uate time to undergo the process of transition. Criteria four was  self- explanatory and consistent with the notion of individual dete rmin ation in defining     54   whether they we re managing well with the transition . The fifth criteria was chosen to try and reduce the challenges around determining if participants ha d the capacity to consent to participate, while not excluding those individuals who may be experiencing some early symp toms of cognitive decline. Despite the fact that financial means of participants was n ot an inclusion criteria, eight of the 11 participants in the current study had made the transition to privately - funded assisted living residences. Eleven participants took part  in this project. The idea of a theoretical sample was  used in this study, reflecting the belief that there is no predetermined number of participants required to ensure an understanding of a phenomenon (Coyne, 1997). Rather, the process of data analysis informed  whether additional participants were needed to reach thematic saturatio n.   Recruitmen t.   Both p ublicly subsidized and private - pay  assisted living facilities in the greater Vancouver area were contacted to see if they would be willing to have recruitment posters placed in their facilities (Appendix A). One facility invited me to present information on the study to their residents. In addition, a family doctor who works with many elderly patients shared information about the study by providing the recruitment poster to individuals  that she felt may be interested in participating. The posters and presentation  provided  residents with information on the study to help them to determine their interest and eligib ility for participation. Posters provide d a phone number and email address to contact the researcher. An initial telephone interview was used to screen  potential participants  who contacted the researcher (Appendix B).  Thirteen initial telephone interviews were conducted and two potential participants were excluded at this stage . One potential  participant was excluded because , after completing the screening interview , they believed they had completed participation in the study . Despite cl arification from the researcher, the individual appeared not to understand what     55   participation  would involve. The second potential participant was excluded because they did not meet the fourth inc lusion criteria. Data collection interviews were  arranged with the first 11 participants who met the inclusion criteri a and were  interested in participating in the study. Additional potential participants w ere placed on a wait - list in the event that more participants we re required to reach thematic saturation  or to review  the themes .   Data collection.  Participants were  offered the choice of completing the data collection interviews in a quiet and private room at the assisted living facility in which they are residing, or if preferred, at a private office space in Vancouver. All of the participant choose to meet  at their residences, indicating that this was more convenient for them. If participants had preferred  to complete the interviews at a private office,  arrangements for transportation would have been made.  Prior to beginning the data collection interview, a copy of the informed consent form w as provided to the participants (Appendix C). The researcher read aloud the consent form, allowing participants to follow along on their own copy as able and/or desired. Th e form describe d the purpose of th e research, what participation would involve, and outlined the benefits and any possible consequences of participating in the research study. During and after the consent form  was read, participants had  the opportunity to ask any questions that they had about the study and the parameters of their participat ion. When the researcher and participant were  both satisfied that the consent form ha d been understood and que stions adequately addressed,  the consent form w as signed by both parties and participants were provided with  a copy for their records.    Two  open - ended, semi - structured, confidential, recorded interviews were  conducted in person with participants using a list of possible questions to deepen discussion and the exploration of topics raised by participants (Appendix D). In all of the interviews, the r esearcher     56   focused on developing an empathic environment in which participants fe lt comfortable discussing the phenomenon of managing well in making the transition to assisted living.  The first interview lasted between 60 to 90 minutes and w as an opportuni ty for participan ts to begin telling the story of their transition. The interview ended at 90 minutes, or earlier if the participant indicate d that they wer e fatigued or had shared all the information they wish ed to at that point. At the end of the first i nterview, arrangements wer e made for a second meeting , typically  in the next two to three weeks. In preparat ion for this second meeting, participants were asked to consider what advice they might give to someone preparing to enter assisted living. The second interview began by ask ing the participant if they had had any other thoughts on the experience of having managed well in making the  transition to assisted living since the first meeting . Before the termination of the second interview, I ask ed the pa rticipant to share any advice they would give to someone  else considering transitioning to assisted living. The length of this second interview ranged from 30 to 60 minutes with three of the interviews lasting approximately  60 minutes, five lasting  approxi mately  30 minutes and the remaining three interviews lasting  anywhere between 30 and  60 minutes.  Each of the interviews began with an orienting statement to focus the participa nt on the research question and invited them to share their experience of having managed well in making the transition  to assisted living and the meaning of this event in their lives. For each of the data collection interviews the length of the interview was determined by the participant , who indicated when they felt they were fatigue d or had nothing further to add about their experience of managing well in making this transition. Two data interviews were scheduled to allow the opportunity for participants to share any additional information on their experiences that they may have reca lled following the first data collection interview. Having two data collection interviews also provide participants with a     57   period of time for reflection on what advice they may offer to others  considering making a move to assisted living. The data collection interviews were c onducted over 13 months .  A final interview lasting between fifteen to thirty  minutes w as scheduled with participants , either over the phone or in person , to review the  common themes that had emerged from the analysis . In advance of this meeting , they were provided with their biographical information and a description of the themes identified across the participants . They were asked  to check the accuracy of their biographical information and read the themes with a view to assessing wh ether the themes resonated with and reflected their experiences . The interviews with participants to review the common themes were conducted  between six  to 18  months after the final data collection interviews. Interviews  to review the common themes  were completed with eight of the eleven participants.  Seven interviews were completed in person and one over the phone.  One of the participants was deceased at the time of the final interviews, another SDUWLFLSDQW’VKHDOWKSUHYHQWHGWKHPIURPWDNLQJSDUW, and a third participant had experienced cognitive decline which prevented their participation.    Data analysis.  From an interpretive phenomenological approach, thematic analysis is not a mechanical process. Rather, thematic analysis can be understood as D³SURFHVVRILQVLJKWIXOinvention, discovery or disclosure ± grasping and formulating a thematic understanding is not a rule- ERXQGSURFHVVEXWDIUHHDFWRIµVHHLQJ’PHDQLQJ´ (van Manen, 1990, p.  79).  In addition, phenomenological themes are not simply a  recurring element in the text, but rather they are ³PHWDSKRULFDOO\VSHDNLQJ«PRUHOLNHNQRWVLQWKHZHEVRIRXUH[SHULHQFHVDURXQGZKLFKFHUWDLQlived experiences are spun and lived through as meaningful wholes  ´(p.  90). In approaching the data for this study, this understanding of thematic analysis was used  as a guide to identifying the themes present in the interview texts.      58    Using van ManHQ’VDSSURDFKDQDO\VLV follow ed three dimensions: a wholistic approach, a selective or highlighting approach and a detailed approach. The wholistic reading involved attending to the text as a whole  to determine  the main significance of the interview s in understanding the experience of transition. Analysis then progressed  to a selective reading approach in which t he text was read  and re- read several times with the intention of determining which aspects seem ed to be the most essential to the phenomenon of managing well in making the transition to assisted living. As these phrases or sentences were  identified, they were  highlighted within the transcript. Finally, the analysis follow ed the detailed reading approach and look ed at each sentence or cluster of sentences separately in order to determine if they revealed anything further about the experience of managing wel l in making  the transition to an assisted living facility.  As these different themes and statements emerge d as common aspects of the transition experience , they were placed together. As each transcript was analysed, the common themes DFURVVSDUWLFLSDQWV’experiences emerged and the development of thematic descriptio ns was possibl e. This process of thematic analysis was engaged in following the transcription of both the first and second interviews. Descriptions of themes that emerged across participant inte rviews were then provided to participants during the interview scheduled to review themes and their responses informed the final findings.   After approximately the seventh interview, it appeared that no new themes were HPHUJLQJIURPWKHSDUWLFLSDQWV’H[SHriences and that thematic saturation had been reached. However, as additional interviews had been scheduled, and these individuals had indicated interest in participating in the study, 11 interviews were completed.      59    Hermeneutic circle. When approaching da ta from an interpretive phenomenological perspective, the ideas associated with dialectical hermeneutics must be considered (Sandage, Cook, Hill, Strawn & Reimer, 2008). Our Western understanding of hermeneutics has been influenced by several individuals, including Schleiermacher, Dilthey, Heidegger , and Gadamer (Sandage et al., 2008). Schleiermacher believed that literary texts needed to be understood in FRQWH[WDQGKLVWKHRUHWLFDOZRUNGHVFULEHGDKHUPHQHXWLFDOFLUFOHZKLFKLQYROYHGWKH³FLUFXODULW\of all understanding as a dialectical relationship between the parts and the whole, texts and FRQWH[WV´6DQGDJHHWDOS'LOWKH\EXLOGLQJRQ6FKOHLHUPDFKHU’VLGHDVH[WHQGHGWKHidea of the hermeneutical circle beyond literary texts to approaching o ur understanding of all human behaviour. In approaching data analysis, these ideas of the hermeneutic circle of inquiry were  reflected in the process by which I, the researcher, looked  at the meaning of phrases and individual sentences within the data and then place them in the context of the interview as a whole in identifying themes. The process also considered how the interview as a whole relate d to the individual thematic components being identified (Valle, King & Halling, 1989).  +HLGHJJHU’VSKLORVRSKLFDOZRUNIXUWKHUH[WHQGHGRXUXQGHUVWDQGLQJRIKHUPHQHXWLFVPRYLQJLW³EH\RQGDPHWKRGIRULQWHUSUHWDWLRQWRWKHSKHQRPHQRORJLFDOLQWHUSUHWDWLRQRIWKHKXPDQEHLQJZKRLQWHUSUHWVWH[WV´6DQGDJHHWDOS5). This extended the hermeneutical circle to include the interpreter, or researcher, thereby highlighting the role of UHVHDUFKHUUHIOH[LYLW\ZKHQDSSURDFKLQJGDWD,WZDV+HLGHJJHU’VVWXGHQW*DGDPHUZKRGHVFULEHGWKHSURFHVVE\ZKLFKWKHDXWKRUV’DQGWKHLQWHUSUHWHUV’SHUVSHFWLYHVFRXOGLQWHUDFWLQWKHIRUPRIDGLDORJXH6DQGDJHHWDO*DGDPHU’VZRUNKDVSDUWLFXODUUHOHYDQFHLQdescribing how the hermeneutical circle influences the process of data analysis for the current study. Gadamer believed  that we each approach our interpretation of experiences using existing     60   structures RIXQGHUVWDQGLQJZKLFK³LQYROYHSUHMXGLFHRUSUHMXGJPHQWVWKDWDULVHIURPWKHHIIHFWLYHKLVWRU\RIRQH’VVRFLDOORFDWLRQ´6DQGDJHHWDOS,WLVWKHVHSUH- understandings of the world, such as thos e I previously outlined , which were  important when approaching the data. An awareness of my beliefs and my context allowed  me to integrate my perspective with ³DQRWKHU’VKRUL]RQLQVXFKDZD\WKDWRQH’VRXWORRNLVFKDQJHGLQWKHSURFHVV´6DQGDJHHWDOS346). In approaching data analysis, I engaged in this process, by identifying the influences on my current way of knowing, and recognizing that the process of understanding  P\SDUWLFLSDQWV’experiences both inform ed, and was  informed by , my contextual beliefs.   Data representation. Following interviews, a paragraph was  prepared describing the SDUWLFLSDQW’VELRJUDSKLFDOLQIRUPDWLRQ7KHdata collection interviews were  transcribed verbatim, and following the process of analysis described above, the themes identified across the transcripts wer e written up, using supporting quotes from the interviews. This biographical information and description of common themes were provided to participants for their review  (see Criteria for Evaluating Trustworthiness below ). Participants received a written copy of the biographical information and theme descriptions in advance, but they were also  read aloud during the final interview , if necessary.  As a reflection of the process of herme neutic inquiry, it was  anticipated that there would  be multiple voices reflected in the written thematic analysis. While the intention was  to prioritize the voices of the participants, I  recognized that my voice, as well as the accompanying contextual influences of my presuppositions, w ould interact with the voice of the participants; each informing the other. While it was  the voice of the participants which was  privileged in the analysis, Goodman,  Schlossberg DQG$QGHUVRQ’s (1981) theoretical model of transition also     61   inform ed my approach to the analysis and in this way contribute d to the representation of  the SDUWLFLSDQWV’H[SHULHQFHV  Criteria for Evaluating Trustworthiness  The choice of criteria used to evaluate the trustworthiness of qualitative research should reflect the paradigm underlying the research (Morrow, 2005). The current study is rooted in an interpretivist epistemology, which recognizes and accepts the role of subjectivity  in the research process and that multiple differing meanings may be attr ibuted to an experience (Morrow ). +RZHYHULQDGGLWLRQWRWKHXQLTXHPHDQLQJVRILQGLYLGXDOV’H[SHULHQFHVWKHUHUHPDLQFRPPRQaspects of lived experiences (Lopez & Willis, 2004).  Re flecting these underlying beliefs, the criteria selected to evaluate the trustworthiness of this research are researcher reflexivity in PDLQWDLQLQJDZDUHQHVVRIRQH’VRZQELDVHVGHSHQGDELOLW\WULDQJXODWLRQ, and participant review of the themes .   Dependability.  Dependability provides the reader with a systematic process for analysis, which, if followed, should allow another researcher to arrive at similar conclusions (Morrow, 2005). In order to establish dependability, this research provide s the reader with the description of how decisions were made in the proces s of data analysis. The description of data analysis aims to provide  sufficient detail for the reader to understand both the process and rationale by which the decisions within the thematic analysis were made.   Researcher reflexivity . An interpretive phenomenological approach recognizes the role of context, particularly the interaction between the researcher and the participants, on the interview data collected. This interplay between resear cher and participants highlights the importance of researcher reflexivity. Researcher reflexivity  ³SURYLGHVDQRSSRUWXQLW\IRUWKHresearcher to understand how her or his own experiences and understandings of the world affect     62   WKHUHVHDUFKSURFHVV´0RUURZS)RUWKLVVWXG\UHVHDUFKHUUHIOH[LYLW\involved an ongoing process of reflection on the presuppositions that I b rought to the research process, which I began to describe above. During the collection and analysis of the data, I also reflected specifically on the how aspects of my experience, such as my younger age, my position as a doctoral student, and my role as a granddaughter contribute d to my interactions with participants and to how I approach ed the data. J ournaling was completed  shortly after each interview with participants. This journaling allowed  me to reflect on and identify what surprised me in interviews with participants and what supported my suppositions. These journal writings were  reviewed before each interaction with participants in order to put the interactions into context DQGXQGHUVWDQGKRZP\RZQDQGWKHSDUWLFLSDQWV’UHDFWLRQVwere  influenced by my expectations and previous experiences.    Triangulation.  Triangulation is described by Morrow (2005) as the process of capturing and respecting multiple perspectives. In the current study, triangulation of the themes  emerging from data analysis was provided by an individual who  had indicated interest in particip ating in the study, been placed on a wait - list, but not interviewed. This individual was an 83 year - old woman who had been in assisted living for four years. She had moved into assisted living because of the impact of osteoporosis on her ability to complet e tasks of daily living. She was living in the same facility as some participants in the study, and the facility offered both private pay and publicly subsidized units. This individual was asked to review the themes to verify whether or not they resonated with her lived experience of having managed well in making the transition to assisted living. Not only did this individual indicate that the themes resonated with her lived experience, she also provided examples from her experiences which were similar to q uotes shared by the research participants.      63    Participant review of themes . A final criteria for establishing the trustworthiness of the research were  the interviews with participants following data analysis and the identification of the common th emes. This  process  was based on the belief that , if the researcher has done a good job of interpreting the data, then the  themes would resonate with  SDUWLFLSDQWV’as an accurate reflection of their lived experiences of having managed well in making the  transition to assisted living (Benner, 1985). During this process, participants were provided with  a paragraph of their biographical information and the description of the themes that emerged through the analysis of DOOWKHSDUWLFLSDQWV’LQWHUYLHZV$PHHting lasting between 15 and  30 minutes was  scheduled with each participant  either in person or by phone . During this meeting , they provided any necessary changes to the biographical information and share d their reactions to the themes presented.  They also chose whether or not they would like a pseudonym or their real name to be used in the final representation of their biographical information.   Review of themes by  an individual working in assisted living . After the data collection, it became apparent  that many of the participants came from privately funded facilities. As a result, an Executive Director from a publicly subsidized facility was contacted to also review the common themes  in order to see if they were consistent with her experience of working with  individuals making  the transition to a publicly subsidized  assisted living facility. Following  the review of the themes , this individual shared that she was  surprised by the sense of commu nity described by participants.  Although she described being pleasantly surprised  by the ILQGLQJVVKHZDVFXULRXVDERXWKRZUHSUHVHQWDWLYHWKHVHWKHPHVZHUHRILQGLYLGXDO’Vexperiences of making this transition, as participants in the current study were t hose who had identified as having managed - well in making this move. This may suggest the potential for differences in the experiences of individuals in publicly and privately subsidized facilities.      64   Ethical Considerations  As mentioned in  discussing the inclusion criteria, the capacity to consent is a concern when working with older adult populations, particularly for those in assisted living facilities who may have entered a facility in part due to cognitive decline. None of the assisted living faciOLWLHV’staff or management was involved at any level in the consent process. In keeping with ethical standards, a process of informed consent was  undertaken with each participant before any data were  collected. Throughout the process of informed consent a nd participation in the study, I was  cognizant of the implications of cognitive decline on partic LSDQWV’DELOLW\WRFRQVHQWDQGZDVvigilant to possible indications that their participation was  no longer appropriate. When scheduling the interviews with par ticipants  to review the themes , one participant was unable to recall the study despite prompting from the researcher. It was determined at this point that participation was no longer appropriate. It was anticipated that s ignificant difficulties with coherence in speech and loss o f train of thought which impacted  WKHSDUWLFLSDQW’VDELOLW\WRVKDUHtheir reflections on their experience w ould also be indications that participation w as no longer be appropriate. However, this did not emerge as a concern during t he data collection interviews. Participants were also advised if they no longer wish ed to participate he/she  could withdraw from the study at any point. No participants chose to withdraw from the study. However, if any  participants  had chosen to withdraw , the interview data  which  had been collected at the point of withdrawal  would have been  removed from the analysis.           65   CHAPTER FOUR  Results  Overview   This chapter comprises of  the biographies of the 11 participants who took part in this study and the themes that were present in their experiences of having managed well in making the transition to assisted living.  The words of the participants have been used to explicate the themes and to bring their voi ces forward in describing what had allowed them to manage well in navigating this transition.    Table 1: Participant demographics  and the funding of their assisted living (AL) facility  Age Sex  Duration of time in AL  Transitioned with partner  Funding of AL (privately, publicly -subsidized, mixed)  David 82  Male 1 year 6 months  No  Private Dianne 87  Female  1 year 6 months  No  Private Betty 89  Female  3 years 4 months  No  Private Ollie >80  Female  1 year 6 months  No  Private Larry 91  Male 1 year No Private Frank  96  Male 5 years  Yes Private Lou 88  Male 1 year 6 months  No Private Josie  85  Female  3 years  Yes Private Amy  66  Female  1 year 3 months  No Publicly- subsidized  Valerie >80  Female  5 years  No Mixed  Joan  91 Female  4 years Yes Mixed        66   Participant B iographies   The 11 participants ranged in age from 66 to 95 years of age. All but one of the participants was over the age of 80, wh ich appears to be consistent with statistics indicating t he age at which  Canadians are entering residential care (Turcotte & Schellenberg, 2006). The amount of time they had lived in assisted living varied from a year to five years. The participants came from five different assisted living facilities in the greater Vancouver a rea; four in central Vancouver and one in South Surrey. The facilities ranged in cost with three of the 11 participants living in higher cost facilities, two participants living in a higher cost facility that offered both privately funded units and units s ubsidised by Vancouver Coastal Health, five participants living in midrange cost facilities, and one participant from a facility that was fully subsidised by Vancouver Coastal Health. These distinctions regarding the cost of facilities was guided by the pa rticipants ’ descriptions, with those living in what have been identified as higher cost facilities expressing that it was a more expensive facility than others they had considered. Similarly, those participants in midrange cost facilities identified that their facility cost less than other options they had looked at. Many participants also shared the dollar amount they spent per month and the costs were fairly consistent across facilities in each category. Below is biographical informati on on each of the pa rticipants.  Three of the participants chose to use their own name and the remaining participants chose to use a pseudonym. For those participants who did not participate in the review of the biographical information and themes,  a pseudonym was used.   Rev.  Dr. David T. Hawkins . David was 82 years of age and had been living in his current residence for approximately a year and a half at the time of the interviews. He was a former minister and had been married with no children. He described having difficulties with day- to- day activities following the loss of his wife, which had led him to consider moving from     67   his apartme nt to a new living arrangement.  David described strong support connections through his church, which had been important to him during the transition process. He desc ribed the LPSRUWDQFHRISXWWLQJ³RQH’VDIIDLUVLQRUGHU´EHIRUHPDNLQJWKHPRYHWRDQHZUHVLGHQFHDQGindicated that he felt it was important to have legal and financial decisions made with the support of a Power of Attorney. David described a process of  ³VHWWOLQJGRZQ´LQKLVQHZUHVLGHQFHDVKHcame to view it as his home and realised the advantages it offered him in terms of connection and security. He advised that those contemplating making a similar move consider whether the new residence offers a ma tch with what is important to them in terms of their lifestyle, so that there can be some continuity between the life they led prior to, and following, entry into their new residence.   Dianne. Dianne was 87 years of age and had been living in her current residence for nearly a year and a half at the time of the interviews. She moved directly from the hospital to her current residence. The move was arranged by her son and step - daughter. For the first week , she stayed in the guest suite of the assisted living residence and said she wanted to return to her apartment. Once she was moved to her new suite and was able to begin eating in the dining room and forming new friendships, she said the transition became easier. Dianne described having varied life experien ces: living at boarding school; initially training as a nurse; subsequently studying law and eventually becoming a judge; having lived with a diagnosis of Multiple Sclerosis for fifty- two years; having been married three times, with the second marriage bei ng an abusive relationship; and marrying for a third time in her sixties. She described that these experiences had given her context and perspective for the most recent move to her current residence. Dianne felt that assisted living was a better option for  her than having people come into her home to provide care. She felt that assisted living offered her more flexibility, increased     68   connection with others, and improved physical health. In offering advice to others preparing to make a move to assisted living , she recommended that people fully explore their options. If they want to stay in their home, she recommended that they consider what additional supports they would need to do so. She also encouraged those just arriving in a new residence to not stay in their room, but rather to connect with other residents through activities and conversation.   Betty . Betty was 89 years of age and had been living at her current residence for three years and four months at the time of the interviews. She had been living al one in her own home prior to making the move to assisted living. Immediately prior to the move , Betty went into the hospital with heart related complications and then moved from the hospital directly to her current residence. The hospital had wanted to mov e her to the Purdy Pavillion following her time in the hospital but she felt strongly opposed to this idea and instead chose to move to assisted living. Her mother had lived at the same assisted living residence, so Betty shared that it had been an easy deFLVLRQWRFKRRVHWKLVSDUWLFXODUIDFLOLW\%HWW\’VKXVEDQGKDGSDVVHGDZD\LQEXWprior to his death he had had to enter a care facility. Betty shared that having gone through the difficult experience of moving him to a care facility had prepared her  for making her own move to assisted living. She shared that it had given her an idea of what to expect in making this move. Betty spoke about the importance of becoming involved in activities and with staff and residents and the role of friendship in help ing her to manage this transition.  She shared that, as the daughter and wife of ministers , she had always found it easy to build relationship s. Betty also shared that she had continued to be involved with her writing group and church friends outside of her residence and indicated that these friendships and activities had been very important to her in the transition process. Betty had three sons and a daughter and spoke of the vital role that her children, their spouses , and her grandchildren played in her d DLO\OLIH6KHGHVFULEHGWKHµERRVW’    69   that these relationships gave her in navigating this transition and shared that those who struggled with the transition appeared to not have this family support. When providing advice to others considering making a sim ilar move, she spoke about the importance of getting information on different residences prior to making a move in order to determine if a residence met your needs and was convenient for family to visit and for you to stay in contact with existing doctors and supports.   Ollie .  Ollie was over the age of eighty years and had been living in her current residence for approximately a year and a half at the time of the interview. She had begun to consider making a move to assisted living after her doctor asked i IVKHKDG³HYHU\WKLQJLQRUGHU´2OOLHhad chronic health concerns and shared that this discussion with her doctor led her to begin exploring different assisted living options. This was a process that she went through with a good friend who was also prepar ing to make a similar move. Prior to making the move to assisted living, Ollie had been living with her son in her family home. This was the same home she had lived in with her husband prior to his death in 2002. Just after having mo ved into her current residence, Ollie had to go into hospital for 3 months after injuring her back. Ollie indicated she felt the timing of her move was just right as after the time in hospital she felt she would no longer have been physically able to make this move. She ha d two daughters and a son and described close relationships with her children, grandchildren , and sisters- in- law.  Ollie shared that her family had been a huge support in making the move, and that their visits to stay with her since she had moved in had been ver y important to her in managing this transition. Ollie wanted to prepare a handbook for new residents as she felt basic information on the routines and rules of the residence would be helpful to those making this transition. She also encouraged people considering making the move to get to know themselves so that they know what is important for     70   them to have in their new residence. She also spoke about the importance of timing and recognizing when you need to make the move to assisted living and taking action.  Finally, she spoke about the importance of involving family in the process of making the move.   Larry . Larry was 91 years of age at the time of the interviews and had been moved into his current residence by his children approximately a year earlier. Larr y had three sons and a daughter, all of whom live d outside of the province. While he was in hospital having a knee operation , his sons and daughter chose his new residence and moved him from his rented accommodation into his current home. Larry described that it had taken time to learn the routines around meals and get familiar with his surroundings. However, having made several  moves in his life, including: service with the Royal Canadian Air Force ; being on the road for work; and moving homes four times during his married life, he had experienced this move to assisted living DVMXVW³DQRWKHUPRYH´/DUU\VKDUHGWKDWLWZRXOGEH helpful for others making the move to be aware that it takes time to get familiar with new surroundings and indicated that he felt not isolating oneself was important to the transition process.   Frank. Frank was 95 years of age at the time of the intervi ews and had moved into his current residence with his wife in September of 2008. His wife died approximately two years after they had made the move. The participant was part of the Canadian Armed Forces from 1939  to1967 and then worked at an academic insti tution until he retired in 1980. Following retirement , he and his wife had lived on a Gulf island before moving back to Vancouver in 2000 due to increased health concerns. The participant had four children, three sons and a daughter, and described very close relationships with his family. He indicated that between 2005 and 2008 , he and his wife had considered moving to assisted living due to increased concerns with their health. While considering making this move, he and his wife had visited at least six fa cilities. In     71   2008 , the owner of the condominium  they were living in decided to sell and after deliberation they decided that the time had come to move to assisted living. Frank indicated that the decision was made after the issue was discussed at a family dinner and a unanimous family decision was UHDFKHG+HLQGLFDWHGWKDWKHIHOWLWZDVLPSRUWDQWWRFRQWLQXDOO\DVVHVVRQH’VKHDOWKDQGOLYLQJneeds to determine when a move to assisted living may be helpful. He described the importance of having the courage to make this move and the vital role of family support in making this decision. Frank shared that visiting facilities  and talking to current residents  can be helpful in providing information on what to expect prior to making this move. He also raised the importance of timing, indicating it was important to make a move prior to experiencing a health crisis.    Lou. Lou was 88 years of age and had been living in his current residence for a year and six months at the time of the interviews.  Lou had a son and a daughter, and he shared that his daughter had visited the assisted living facility and then brought him to see it. He indicated that his daughter had made all the arrangements for the move. /RX’V wife of 54  years had died two and a half years ago. After the death of his wife, Lou  had been living on his own in a condominium  prior to making the move to his current residence. He described that he felt less lonely since having made the move, and spoke particularly about the role of staff in creating a sense of connection in his current living situation. Lou described experiencing some difficulties forming new connections with fellow residents and felt that his difficulties with his hearing may impede building relationships. He indicated that he felt his previous experien ce of living at boarding school from a young age had been helpful to him in adjusting to his new living arrangement and coming to view it as home. Lou shared that it would be helpful if staff provided more information on what t o expect in making the move. He also felt it would be helpful to have     72   photos and the names of residents posted in the facility as this could help in the process of getting to know fellow residents.   Josie . Josie moved into her current residence with her h usband at age 85 and had been living there for almost three years at the time of the interviews. Her husband passed away after their move and she relocated to a different suite in the residence. Prior to moving to assisted living, she and her husband had been living in their own home. She reported that difficulty keeping up with activities like shopping and cooking, due to physical health concerns, had led them to consider assisted living. Josie and her husband had visited their current residence through thHLUVHQLRU’VFHQWUHDQGVRZHUHIDPLOLDUZLWKLWHYHQEHIRUHWKH\EHJDQFRQVLGHULQJmaking a move. When they began the process of choosing an assisted living facility , they visited it again, liked it , and rented a suite. Josie and her husband both had chil dren from previous marriages. Josie had a son and daughter and she said that she felt it was important to make sure your family is supportive of your move and that you make sure to keep in touch with family after moving in. Josie indicated that she felt he r attitude and commitment to making the move to assisted living had contributed to her managing this transition well. She described herself as RXWJRLQJDQGVWDWHGWKDWVKHIHOWVKHKDGEHHQ³UHDG\´WRHQWHUDVVLVWHGOLYLQJDQGWKDWWKLVKDGfacilitated the transition. She also offered advice around downsizing and carefully choosing what items you think you will need before making the move to a new residence as well as visiting different residences before choosing where to move.   Amy . Amy was 66 years of ag e and had been living in assisted living for the past year and three months at the time of the interviews. Approximately a year before making the move VKHKDGKDGDIDOOZKLOHOLYLQJLQDQLQGHSHQGHQWVHQLRU’VFRPPXQLW\DQGWKHIDOOOHGKHUWRbegin to consider her support options. She ha d significant, ongoing physical health concerns and     73   her family doctor ordered home care following the fall.  As she approached her 65 th birthday, Amy  decided to put her name of the waiting list for assisted living and moved in eight months later. Amy indicated that being close to St . 3DXO’V Hospital  and her existing medical supports had been important to her in choosing her assisted living facility. Am y wa s a Catholic Sister and described her previous experience living in her religious community as being a factor in helping her adjust to living in the assisted living community. She ha d a brother living in Richmond and another sibling living outside of the city. Amy shared her appreciation of  their support. Amy described the importance of  continued friendships with friends not living in the assisted living facility. She had also continued to be involved in her ministry work with refugees and shared that these activities continued to give her life meaning. Her advice to other people considering a similar move wa s to make sure to get involved in at least some of the activities offered at the assisted living facility in order to get to know fellow residents. She also suggested making a list of what is important to you in choosing a residence in order to try and make sure important lifestyle factors, such as distance to public transportation, continue to be available.   Valerie . Valerie was in her 80s and had b een living in her current residence for DSSUR[LPDWHO\ILYH\HDUV6KHKDGOLYHGRQKHURZQIRU³DORQJWLPH´IROORZLQJKHUKXVEDQG’Vdeath before she eventually moved to live with her family. She indicated that as her health deteriorated, she noticed that her family did not want to go out in case she needed their help and she felt worried that their freedom was being impacted. Valerie was on a disability pension and as result she had a caseworker. When her caseworker observed that it appeared Valerie needed  more care , the caseworker introduced the idea of assisted living. Valerie described feeling relief upon learning about this option. She moved to an assisted living facility in Su rrey in 2005. In 2006 , she had open heart surgery and , by that time , her family, who had previously been living     74   near Surrey, had settled in Vancouver. Valerie shared that it had been a long commute for her family to visit her in Surrey, particularly when she had to go into hospital following the surgery. Her daughter- in- law started looking at assisted living facilities in Vancouver and in 2007 she moved into her current residence. She described the challenge of losing friendships she had formed at her current residence as friends died or moved to other facilities that could  provide them with more care. Valerie said she was now aware of not wanting to form deeper connections in order to protect herself from further los ses. She indicated that, if she were to make the move again, she would choose a facility that offered differe nt levels of care so that she did not have to worry about having to move again if her own health declines and she requires more care. Valerie described the importance of timing in making the transition to assisted living. She indicated that moving to an as sisted living facility prematurely result s in an individual not being happy there, but waiting until their health has deteriorated may mean they will only be able to stay in assisted living for a short period of time and not be able to experience the benef its of it. She provided advice around down - sizing for others making a similar move. She suggested photographing and writing down memories associated with items that cannot be kept , as she felt that this can help with the transition from one ’s previous home  to their new living arrangement. She also identified that a counsellor would be helpful in supporting residents with adjusting to the initial transition to the assisted living facility, as well as with ongoing challenges that arise, particularly around loss.   Joan .  At the time of the interviews, Joan was 91 years of age and had moved into assisted living with  her husband four years earlier. She had three children, six granddaughters , and two great grandchildren. She and her husband had lived in the Okanag an until her eyesight deteriorated suddenly due to macular degeneration. At that time, Joan and her husband returned     75   to living in Vancouver in order to receive medical care and lived in the basement suite of their daughter and son- in- law ’s home. When it be came apparent that additional surgeries would not LPSURYHKHUVLJKWIXUWKHU-RDQ’VGDXJKWHUIRXQGDFDVHZRUNHUZKRSXWWKHLUQDPHVRQWKHZDLWLQJOLVWIRUDVVLVWHGOLYLQJ-RDQ’VGDXJKWHUFKRVHWKHDVVLVWHGOLYLQJIDFLOLW\DQG, a year and a half later, Jo an and her husband moved in. She described being extremely happy  that her husband no longer had to bear the responsibility for cooking and cleaning and indicated she felt VKHKDG³GLHGDQGJRQHWRKHDYHQ´-RDQGHVFULEHGVRPHLQLWLDOFKDOOHQJHVDURXQGNQRZing where to sit in the dining room as, although it was described as open seating, she discovered that residents had their usual spots. Joan felt that support for new residents in knowing which seats were available would be very helpful in that process of transitioning to living in assisted living. Common Themes of Managing Well in Making the Transition   )URPSDUWLFLSDQWV’GHVFULSWLRQVRIWKHLUH[SHULHQFHVRIKDYLQJPDQDJHGZHOOin making  the transition to assisted living, seven common themes emerged.  Each of the reported overarching themes was common to all participants, with the exception of the theme Not Wanting to be a Burden. This theme was still included as a common theme due to the salience for all of the other ten participants. Aspects of each of the overarching theme were more or less salient to specific participants, with not all participants identifying with every aspect of the theme. These different aspects within each theme were described in order to provide a more in -depth understanding of  SDUWLFLSDQWV’Wransition experiences.  The common themes are presented in no specific order:  1. Sense of Improved Quality of Life   Increased freedom   Enhanced social connections  Improved physical health       76   2. Sense of Belonging  With fellow residents   With staff  With friends and family   3.  Willingness to Get Involved  With activities  With fellow residents   4. Sense of Continuity  In interests and activities  In relationships   Just another change   5.  Sense of Acceptance   Of assisted living as the best option   Of assisted living as home   6.  Perceived Sense of Openness   Towards change   Towards fellow residents and routines   Towards diversity   7.  Not Wanting to be a Burden   Sen se of improved q uality of life. In speaking with participants about their move to assisted living, all participants described having experienced a sense of improved quality of life following the move. This sense of improved quality of life emerged as a common theme of having managed well  in making this transition to assisted living. Participants described experiencing improved quality of life in three primary areas:  increased freedom from no longer having to attend to tasks of daily living such as shopping, cooking and cleaning ; enhanced social connections ; and improved physical health or perceived ability to better manage living with their health concerns. Some participants identified experiencing improvement in only one of these areas while others indicated they had experienced improvem ent in multiple areas.      77    7KHZRUGVRIRQHSDUWLFLSDQWFDSWXUHLPSURYHPHQWVLQWKHSDUWLFLSDQWV’TXDOLW\RIOLIHLQrelation to increased freedom from daily living tasks, enhanced social connection and improved physical health:  I just enjoy the people here,  WKHPHDOVDUHJRRG,GRQ’WKDYHWRVKRS,GRQ’WKDYHWRFRRN,’PJUDWHIXOIRUDOORIWKDW«DQGRIFRXUVH,WKLQN,JRWPRUHHQHUJHWLFDQGVWURQJHUfrom having eaten properly.  The appreciation for no longer having to cook was expressed by all participant s. One participant VWDWHG³,OLNHWRJRGRZQWRP\PHDOVDQG,’PJODGHYHU\GD\WKDW,GRQ’WKDYHWRPDNHWKHP´This increased freedom  from  cooking also extended to other daily living tasks. As one participant shared:   ,I\RXVXUYLYHWKLVIDU«WKLVVKRXOG EHOX[XU\OLYLQJ7KLVVW\OHRIOLIH\RXGRQ’WKDYHWRFRRN\RXGRQ’WKDYHWREX\WKHUXGG\VWXII Increased freedom from the burden of shopping was particularly important to participants who described having had difficultly completing this task prior t o moving to assisted living:   7KHODVWWLPH,ZHQWVKRSSLQJZLWKP\VWHSVRQ,VDLG\RXNQRZ,ZRQ’WEHDEOHWRGRthis again. I was so tired, my ba FNKXUWHYHU\WKLQJKXUW«VR,MXVWGRQ’WKDYHWRERWKHUwith food!  Increased freedom from other daily tasks like laundry, cleaning and maintenance were also described by participants as an improvement from their previous living arrangements. As one participant shared:  «VRPHWKLQJVKHUHDUHGRQHIRU\RXDQGLI\RX’UHOLYLQJZKHUH,ZDVEHIRUHWKDW’VXSWRyou. Like here every two weeks they take the bed linen and run it through the laundry GRZQVWDLUVDQGWKHQEULQJLWEDFNGRQHXS«VRLW’VDGLIIHUHQWOLIHVW\OHDOULJKW     78   $QRWKHUSDUWLFLSDQWGHVFULEHGKRZVKH³IHOOLQORYH´ZLWKKHUFXUUHQWUHVLGHQFHEHFDXVHLt gave KHU³LQGHSHQGHQFHDQGSULYDF\EXWWKHFULWLFDOQHHGVWKDW[she] KDGDWWKHWLPH´ZHUHDOVRPHW7KHVHµFULWLFDOQHHGV’ZHUHWRUHFHLYHVXSSRUWGRLQJGDLO\WDVNVZKLFKKHUSK\VLFDOKHDOWKPDGHit challenging to complete.   7KHSDUWLFLSDQWV’GHVFULStions of their transition to assisted living revealed that no longer having to be concerned with  these tasks of daily living had led to a sense of improved quality of life. For those with health concerns,  no longer having to attend to these tasks was also described as contributing to improved physical health or allowing them to better manage their health concerns. In addition, the structure of assisted living, including activity programming and staff support, also contributed to improved physical health . One participant described how the exercise programs at her assisted living residence had contributed to improving her ability to walk without assistance. Another participant reflected on how living in an assisted living facility helped her feel supported wit h her existing health concerns. She described how, when she was previously living in her own house, she had feared that if she had a health crisis at night she would have been unable to get the support she needed:  «KRZZDV,JRLQJWRJHWRXWRIEHG"%HFDXVH,’YHKDGVRPHKHDUWSUREOHPVDQGKRZwas I going to get out of bed and unlock the doors?  6LPLODUWRRWKHUVHQLRUVLQWKLVVWXG\WKLVSDUWLFLSDQW’VIHDUs that emergency workers would not have been able to get into her home if she had needed them, were allayed by moving to an DVVLVWHGOLYLQJIDFLOLW\6KHLQGLFDWHGWKDWKHUQHZOLYLQJDUUDQJHPHQW³KDVEHHQSHUIHFW´LQWHUPVof providing this aspect of suppo rt.  $QRWKHUSDUWLFLSDQWGHVFULEHGKRZDVVLVWHGOLYLQJDOVRSURYLGHGWKH³FRQILGHQFHRINQRZ>LQJ@WKDWZKHQ\RXDUHVLFN\RX’UHQRWJRLQJWREHVHQW«IURP>WKHDVVLVWHGOLYLQJ    79   IDFLOLW\@WRWKHKRVSLWDO´7KHDGGLWLRQDOSHUVRQDODQGPHGLFDOVXSSRUWSURYLGHd in assisted living allowed the participants to feel confident that health issues could potentially be handled by caretakers within the facility, without the need for hospitalization.   In addition to increased freedom from daily tasks and improved physic al health, enhanced social connection was described by participants as contributing to their improved quality of life. One participant , who had moved into assisted living with her husband, shared that moving into assisted living had allowed her to have mor e company, as her husband was ³not social  ´and in assisted living there were many more opportunities for social interaction. The ease of connecting and socializing with others ± to whatever extent they wished ± was mentioned by all participants as an antid ote to isolation that significantly contributed to their quality of life in assisted living. This sentiment was reflected in the words of one participant:   «WKHDOWHUQDWLYHLVIRUPHWROLYHLQDQDSDUWPHQW«DQGP\FRPPXQLFDWLRQZRXOGEHwith the people in the apartment building purely, pretty well, because none of my friends QRZFDQGULYH«VRWKDWLVRODWHV\RX«DQGWKHUHDUHDORWRILQWHUHVWLQJSHRSOHKHUH Another participant echoed these sentiments describing the opportunity assisted living provided for enhanced social connection:  «EHIRUHWKLV,ZDVMXVWUHQWLQJDQDSDUWPHQWLQDQDSDUWPHQWEXLOGLQJDQG\RXZHUHRQyour own there. And you never got to know anybody and you very seldom saw DQ\ERG\«ZKHUHDVKHUH\RXVHHHYHU\ERG\DWPHDOWLPHVDWOHDVW Another participant indicated that , although he would like even more  social connection with others in his residence, he still felt that being in assisted living provided an improvement on his previous living arrangement:      80   «,ZDVYHU\JODGEHFDXVH,KDGEHHQOLving alone for about 18 months and I realised WKHUHZDVQRIXWXUHLQWKDWDWDOO«LWZRUULHGPHWKDW,ZDVOLYLQJDORQH«LWGLGQ’WKDYHWRbe very good to be a big improvement on where I was living.   Although the increased social connection with other resid ents was identified as important to all participants in terms of improving their overall quality of life, for some participants, the move to assisted living also made it easier to socially connect with members o f their family. This sentiment wa s captured i n the words of one participant who relocated to an assisted living facility in Vancouver so that she could be closer to members of her family:    I just knew that life was going to be easier for me and better for me to move into Vancouver because I could be in the loop of the family more.   For all of the participants the move to assisted living was described as offering a sense of improved quality of life, through enhanced social connection, increased freedom from daily tasks and/or improved physical health.  While discussed here in relation to quality of life, social connection emerged as  DQLPSRUWDQWDVSHFWRISDUWLFLSDQWV’H[SHULHQFHVRIKDYLQJPDQDJHGZHOOin making the transition to assisted living  and will also be discussed within the themes: Sense of Belonging, Willingness to Get Involved, and Sense of Continuity.   Sense of belonging.  $FURVVDOORIWKHSDUWLFLSDQWV’VWRULHVH[SHULHQFLQJDVHQVHRIbelonging emerged as important aspect of feeling they had managed well in making the transition to assisted living. This sense of belonging was described as being present in their relationships with fellow residents, in their interactions with facility staff and in their ongoing connections with family and friends outside of the assisted living facility.   Interactions with fellow residents were described by the participants as being an integr al part of feeling they belonged to, and were a part of, their new community. One participant     81   described the impact of having a fellow resident support her in the days immediately following her entry into the assisted living facility:  When I moved in there was a self - appointed lady and she was on my floor that helped >PH@6KHZRXOGFRPHDQGVKH’GNQRFNRQP\GRRUIRUHYHU\PHDODQGZDONZLWKPHWRthe dining room. It was a huge help.  For this participant, her fellow  resident helped her to feel that she was welcome  by reaching out to her upon her arrival in the facility. This was identified as being extremely helpful in allowing  the participant  to navigate the early part of this transition.   Other participants spoke of the close relationships they had formed  with other residents and how these relationships had contributed to their sense of feeling like they were part of the community. Two participants, both of whom had lost their partners after moving into assisted living, spoke of the importance of the fello ZUHVLGHQWV’HPRWLRQDOVXSSRUWDVWKH\FRSHGZLWKWKHloss of their spouses. One participant reflected on the importance of her assisted living community in helping her cope with, and adjust to, a number of personal losses:    This is like an extended famil y here, seriously. In one year, my older brother died, my husband died and my younger brother died, all in a twelve month period. How would I have managed living by myself? Here there was always someone to give you a hug or FRPHDQGVD\³KH\KRZDUH\RXGRLQJ"´DQ\WLPHRIGD\+RZZRXOG,KDYHPDQDJHGRQmy own? We still have that situation for a lot of people here. If something happens, a tragedy in your family, there is a lot of support. One of our ladies died, we knew she was very ill, and her husband, tKHGD\DIWHUKHFRXOGQ’WJHWYHU\IDUZLWKRXWVRPHRQHKXJJLQJhim.      82   Another participant echoed similar sentiments describing the importance of his fellow residents and being part of a community of other seniors who are also experiencing similar issues and losses:   When my wife and I went looking around at places, one of the managers we talked to said that one of the great things about living in this communal living as a pair is that when you lose one you have a new family. They are the people who live aroun d you. They are mostly of my generation whereas my children are of a different generation. They are a family and they do move around you and they do embrace you, not just with their spirit but with their arms.  The participants also spoke of the importance  of close friendships they had formed with other residents, in enhancing the quality of their day to day lives. One participant highlighted the LPSRUWDQFHRIWKHVHUHODWLRQVKLSVZKHQVKHVKDUHGWKDW³,KDYHYHU\LQWHUHVWLQJIULHQGVKHUH$QGthey really [a UH@WKHUHDVRQIRUP\SOHDVXUHLQEHLQJKHUH´$QRWKHUSDUWLFLSDQWVLPLODUO\VSRNHRIthe close bonds he had formed with his table mates, and the important role that these relationships played in his daily life in assisted living:  ,VLWDWDWDEOHLW’VFDlled the naughty boys table or the noisy boys table. We have a great WLPH:HKDYHWKHFRQILGHQFHWRODXJK«ZHKDYHJUHDWWLPHVWRJHWKHU>LW’V@EHLQJZKRyou are and looking forward to meals, not because you have nothing else to look forward to each day, b ut because this is a time for conviviality, for laughter and for OLVWHQLQJWRWKHRWKHUJX\V’SUREOHPV For all of the participants in this study, the friendships and bonds they formed with other residents, and the sense of community and belonging these r elationships provided, were perceived as being an important part of managing well in making the transition to assisted living.      83    Participants also spoke about the importance of the sense of belonging that staff members nurtured within the facility. Several  participants described how, in addressing them by their first names, staff members helped to make them feel like they were welcomed in their new FRPPXQLW\$VRQHSDUWLFLSDQWVWDWHG³WKH\FDOO\RXE\\RXUQDPHDVLIWKH\KDYHNQRZQ\RXDOOyour life, and they feel very comfortable with that, DQGZHIHHOYHU\FRPIRUWDEOH´Another participant shared a similar sentiment about the important role played by the staff members in creating a comfortable and welcoming environment:  The staff here are just like part  of the family, even the cleaning staff and the ones that FRPHLQWRKHOSLW’VOLNHRQHELJKDSS\IDPLO\«,W’VYHU\LPSRUWDQWEHFDXVHLIWKH\ZHUHDORRI\RXZRXOGQ’WIHHOUHOD[HG The way in which the staff interacted with participants on a daily basis w as identified by participants as being important in the creation of a sense of belonging in their new home. The impact that staff had on the participants transition experiences emerged throughout the interviews, with many participants highlighting the skil l of the employees in creating a ZHOFRPLQJHQYLURQPHQW2QHSDUWLFLSDQWGHVFULEHGWKHVWDIIDV³ZRQGHUIXOSHRSOH´DQGMRNHG «ZK\WKH\SXWXSZLWKDQROGIRJey OLNHPH,GRQ’WNQRZ7KH\DUHORYLQJSHRSOHWKH\are caring people, they are intelligent peopl e, they are skilled people.  The role of staff appeared to be a key contributing factor in helping participants to settle into, and feel like they belonged, in their new home.   In addition to the importance of their relationships with fellow residents and s taff members, participants also described the importance of maintaining ongoing relationships with family members and friends in providing a sense a belonging that was important in navigating     84   the transition to assisted living. One participant, who describe d a very close relationship with the members of his family, indicated that his family:  «LVRQHRIWKHUHDVRQVWKDWP\VWD\KHUHLVVXFFHVVIXO,I\RXDVNDURXQGWKH\’OOVD\³KH’VJRWVRPDQ\FKLOGUHQDQGJUDQGFKLOGUHQ+H’VVROXFN\´0\JUDQGVRQYLVLWHGPe ODVWQLJKW,’OOEHJRLQJWRP\GDXJKWHU’VIRUGLQQHUWRQLJKWWREHZLWKWZRRWKHUJUDQGFKLOGUHQRQHRIZKRPZDQWVWRWDONWRPHDERXWDUHQRYDWLRQSURMHFWKH’VSURSRVLQJIRUKLVSDUHQWV«WKRVHDUHWKHNLQGRIUHODWLRQVKLSVZHKDYH Involvement in famil y activities, family visits and having his grandchildren seek out his opinion were important to this participant in helping him feel  comfortable in assisted living . Another participant echoed similar sentiments about the importance of family visits in the transition process. She reflected:  «DQRWKHULPSRUWDQWWKLQJLVLI\RXUIDPLO\NHHSVLQWRXFK«\RXVHHWKLVRIILFHGRZQKHUHLVEXV\«DORWRISHRSOHFRPLQJLQWRVHHWKHLUIDPLO\WDNHWKHPRXWMRLQLQJWKHPIRUlunch or dinner.  Maintaining ongoing contact with their family members appeared to be an important part of making a successful transition to assisted living for the participants in  this study. The importance of maintain ed FRQQHFWLRQZLWKIDPLO\ZDVKLJKOLJKWHGE\RQHSDUWLFLSDQWZKRREVHUYHGWKDW³Whe RQH’V,ILQGZKRKDYHUHDOWURXEOH>DUH@WKHRQHVZLWKQRUHODWLYHVZKRFRPHWRVHHWKHP´  The importance of having a community outside of the facility was also highlighted by a participant who had no family. This participant described how his churc h community had helped to provide needed support and a sense of belonging before and following his transition to assisted living:      85   [My wife] and I had no children, so I can speak of [my church], and increasingly of this place, as my family. I can use the w ord family to apply to [my church] because there is a core of people waiting in the wings to help me if I need help.  Having his church community ready to support him, if needed, was important to this participant in being able to manage the transition to h is new residence.   For all of the participants, having a sense of belonging or connection to family, to friends, with facility staff and with their fellow residents was identified as an important aspect of the transition experience. Knowing that they belon ged to a community provided comfort in navigating challenges, such as becoming familiar with their new surroundings and managing the loss of loved ones. The sense of belonging also contributed to a greater sense of ease and comfort which helped participant s to feel more at home in their assisted living facility. Many participants also spoke of the integral role that family and loved ones played in this transition, highlighting that these relationships allowed them to maintain their sense of belonging within  their family and provided them with the knowledge that their loved ones were around them and willing to support them. All of these different relationships played a central role for participants, in helping to create a sense of belonging in their new resid ence, which was important in leading them to feel that they had managed well in making the transition to assisted living.   Willingness to get involved. In reflecting on their transition experiences, all of the participan ts described the importance of  being willing to become involved in their new HQYLURQPHQWLQWHUPVRIPDNLQJDSRVLWLYHWUDQVLWLRQWRDVVLVWHGOLYLQJ3DUWLFLSDQWV’GHVFULSWLRQVof how they actively and consciously chose to get involved in the life of their new setting fell into two main areas: involvement with activities offered at their new residence and involvement     86   with fellow residents. The extent to which participants chose to become involved varied, but all indicated that they had been willing to engage to some degree with their new surroundings.  All but one participant shared similar descriptions of how participation in the activities offered at their assisted living facility was important to their transition experience. Participants described a number of different activities they h ad become involved in since making the move to assisted living. These included attending the exercise classes, concerts, discussion groups and other activities organized by the assisted living facility. The participants described how, from the activities available at their respective facilities, they deliberately chose those in which they were most interested. One participant, who had moved into assisted living with her hus band, described the process they had initially gone through in selecting which activi ties they wanted to pursue from the available options:   Well you look at the events and you decide what you want to do. They list the events for WKHPRQWKDQG\RXORRNDWLW«<RXVD\³RKWKDWVRXQGVLQWHUHVWLQJ´VR\RXJRDQGWKHQyou find out if you like i t or not. So this is what we did. And they had one, it was on 0RQGD\FDOOHG1HZVDQG9LHZVDQG,VDLG³OHW’VJRLW’VMXVWGRZQWKHKDOOIURPZKHUHZHOLYH´DQGZHZHQWWRWKDWIRUWKHORQJHVWWLPH«6RLW’VXSWRWKHSHUVRQWRORRNDWWKHcalendar and say ³ZHOO,’OOWU\WKDW´ This participant spoke of how she and her husband had explored the various activities together and pondered whether it may have been more difficult to initially become involved if she had been on her own. Although this initial willin gness to engage in activities may have been facilitated by having her husband with her, the participant described how she continued to remain involved in various activities offered a t her assisted living facility, even following his death.      87    Another single participant who had lived in another assisted living facility before moving to her current residence, described her conscious effort to engage in activities as soon as she moved into her new residence as a way of managing the transition:   I just tried to get involved in what I could right off the start. One of the first things I did was, there was a clothing business that came to the facility and she wanted to put on a little fashion show using the tenants to fashion their [garments], put a scarf around th eir neck or throw a sweater on. So I volunteered for that, just to become a part of the gang.  Perhaps, to some extent, this willingness to get involved reflected the previous lifestyles and personalities of the seniors in this study. For example, one parti FLSDQW’Vwillingness to get involved in activities was described as being consistent with his identity. He described himself as a political activist and an outgoing member of his community ± someone who is curious and willing to try new things, including p articipating in this study:  They all know who I am, and I am very active in the community. And I do things, I GRQ’WUHDOO\WKLQNDERXWLW7KDW’VZK\,SKRQHGWKDW’VZK\\RX’UHKHUH7KDW’VZK\,’Pgoing to News and Views this afternoon!  This participant shared how his willingness to take action in all areas of his life had led him to contact the researcher in order to learn more about participating in the current study. It wa s this same willingness to act that led him to become involved in activities in h is assisted living facility, such as the topical discussion group, News and Views.    Some participants also spoke about the importance of becoming involved in the recreation programs, which were good for their physical health and also provided the opportu nity to meet others and form social connections.  These sentiments were reflected in the words of one participant who had moved to assisted living on her own:      88   The recreation program is vital for getting people to know one another. Otherwise you tend to stay in your room, wander out for a bit e to eat, and go back, you know.  Another participant explained how involvement in activities within the facility was an important DYHQXHWREHJLQQLQJWRIRUPIULHQGVKLSVLQKHUQHZ³KRPH´ ,WKLQNLW’VYHU\LPSRUWDQWWREHFRPHLQYROYHG«WRPDNHIULHQGV$QG\RXPDNHIULHQGVDWWKHWDEOHZKHUH\RX’UHHDWLQJRIFRXUVHEXW\RXDOVRPDNHIULHQGVZKHQ\RXMRLQgroups that you are interested in.    When offering advice to others who might be considering making a move to assi sted living, all of participants indicated they would encourage active and intentional involvement with events and activities going on at the residence. One participant offered the following words of ZLVGRP³«GRQ’WKLGH\RXUVHOILQ\RXUURRP*HWRXWDQGPHHWSHRSOHJHWWRNQRZWKHP´Another participant shared her concern that a fellow resident, who had recently moved into the assisted living facility, may experience difficulties because she was not involving herself in the recreational activities. This participant revealed  that:   >,’P@ZDWFKLQJWKLVQHZSHUVRQKHUHMXVWFRPHLQVLQFHZHODVWPHWWZRZHHNVDJRDQG,’PWKLQNLQJ³KPPP´ZHKDYHWKHDFWLYLWLHVDQGDOOWKDWDQGVKH’VQRWSDUWLFLSDWLQJLQDQ\WKLQJDQGLW’VJRLQJWREHPXFKKDUGHUIRUKHUto integrate. And the only time she VHHVSHRSOHLV>DW@PHDOV«\RXGRQ’WJHWWRNQRZWKHP\RXNQRZ",PHDQWKHUHDUHRQHV\RXZDQW>WRJHWWRNQRZ@DQGRQHV\RXGRQ’WEXWXQOHVV\RXUXEDELWZLWKWKHP\RX’UHQRWJRLQJWRILQGRXW<RXNQRZWKHUHDUHGLIIerent [activities], arts and crafts, or PXVLF\RXGRQ’WKDYHWRSDUWLFLSDWHLQDOORIWKHPEXWLI\RXGRQ’WSDUWLFLSDWHLQDQ\«     89   Echoing the perceptions of other individuals in this study, this participant believed that , without this type of engagement in  the activities offered in the assisted living facility, newcomers would likely find the transition more difficult, and they would experience more social isolation.  The one participant who did not identify the organized activities as being as relevant to his adjustment to assisted living shared that:   When I came here I imagined I would join in and get in the discussion groups and all WKRVHWKLQJVDQG,VWLOOWKLQN,VKRXOGEXWWKH\GRQ’WKDYHGLVFXVVLRQJURXSVLW’VDOOinformal. I prefer serious things , like this latest business in North Korea. I would be KDSS\WRVLWLQDJURXSDQGGLVFXVVWKDWEXWWKH\KDYHQ’WJRWWKDW,VKRXOGVWDUWWKDW Although this participant had not yet taken part in the organized activities, he still anticipated that he wou ld become involved in the future ± even if this meant initiating a group more aligned with his interest in current events. It is interesting to note that , throughout the data collection interviews, this participant repeatedly spoke of the difficulties he e xperienced in coming to terms with the loss of his wife of 54 years. It is possible that his ongoing efforts to deal with this loss may also have impacted his involvement  in the activities at his facility.  The willingness to become involved with fellow residents was identified as another important aspect of managing  well with the transition to assisted living. For some participants , this meant that they made the effort to acknowledge and say hello to fellow residents when SDVVLQJWKHPLQWKHKDOO³\RXFDQ walk down the hall and you say good morning and you could GRWKDWWRDQ\ERG\´$QRWKHUSDUWLFLSDQWGHVFULEHGPDNLQJDFRQFHUWHGHIIRUWWRFRQQHFWZLWKKHUIHOORZUHVLGHQWVE\GHOLEHUDWHO\³GULIWLQJDURXQG´WKHUHVLGHQFHDQG³VWULNLQJXSFRQYHUVDWLRQV´in order to get to know other residents. One male participant had attempted to expand his social circle by inviting specific residents to have coffee with him. Even though he felt his efforts had     90  not always been successful, he continued to be willing to try a nd build relationships with other UHVLGHQWV³$VDPDWWHURIIDFWWKHUHLVVRPHERG\KHUH,GRQ’WNQRZKHU,KDGWKRXJKWRIDVNLQJKHULIVKH’GOLNHWRZDONGRZQ«WRKDYHDFRIIHH´ While most participants described their willingness to engage with fell ow residents in common or public areas, one participant was also willing to invite other residents into her private space. She described how her interest in entertaining guests had been a factor in choosing her current residence stating:  I wanted a place w here I could join in with the planned activities if I wanted, but if I GLGQ’WZDQWWRWKDW,FRXOGKDYHSHRSOHLQ$QGWKHUH’VORWVRIURRPIRUWKDWWRR«1RZ,’PPRUHLQWRLQYLWLQJSHRSOHZLWKLQP\VSDFH/LNHODVWZHHN«,KDGDEOXHFKHHVHparty, and any body who liked blue cheese was invited here and I served blue cheese with fruits and punch and you know different things, I just thought would be kind of neat.  $QGIRUVRPHRIWKHPWKH\KDGVDLGWKH\KDGQHYHUEHHQLQDQ\ERG\HOVH’VVXLWHEXWWKHLUown, a QG,WKLQN\RXNQRZWKDW’VQRWPXFKRIDFRPPXQLW\LI\RXDUHOLPLWLQJLWWKDWway.  This participant shared how the selection of her assisted living facility had taken into consideration the availability of not only planned activities and services, but h aving adequate space in her own suite to invite fellow residents to social gatherings. She shared that her willingness to invite other residents into her suite was important in building a sense of community in her new home, and in allowing her to navigate this transition to assisted living.  Whether in public or private space s, all of the participants described their willingness to be involved with their fellow residents through creating opportunities for social interactions. While the way they elected to g et involved varied across participants, the importance of being     91  willing to get involved in the social fabric of their new homes was a theme that was present in all WKHSDUWLFLSDQWV’VWRULHVRIPDNLQJWKHWUDQVLWLRQWRDVVLVWHGOLYLQJ%\FKRRVLQJWREHFRPH involved in activities offered at their residences, and by making an effort to get to know their fellow residents , the participants felt they were better able to manage well with the transition to assisted living.   Sense of continuity. In reflecting on their move to assisted living, all of the participants described having experienced a sense of continuity that helped them to manage well in making this transition. They spoke of experiencing continuity in their interests and activities, their relationships and in viewing this specific move as just another change similar to others they had previously experienced in their lives.   Maintaining some continuity in terms of the interests and activities that had been important to the participants throughout their lives was identified as contributing to having managed well in making the transition to assisted living. Participants described how they had continued to take part in act ivities that they enjoyed and which  gave them pleasure ± such as gardening, music, going for walks, reading, swimming and writing ± even though the way they participated in these activities may have changed to reflect their new living and physical circumstances. As one participant who had a lways been an avid gardener shared:  :HOORQHRIWKHELJRQHVZDVP\LQWHUHVWLQJDUGHQLQJ,FDQ’WGRWKHSK\VLFDOZRUNRIJDUGHQLQJDQ\PRUHEXW,’PH[WUHPHO\LQWHUHVWHGLQVHHLQJHYHU\WKLQJJURZ$QG,FDQGRlittle things like pinch off the dead blooms a nd maybe make a planter, put some seeds in.  Another participant who always loved music, described how he was going to be playing his guitar for an upcoming holiday gathering at the residence. He shared that he had been playing the JXLWDUVLQFHDQGWKDWLQWKHSDVWKHKDGEHORQJHGWRDVHQLRU’Vgroup that did entertaining by     92  playing music at different events. Since making the move to assisted living, he continued to entertain others with his music by playing guitar for his fellow residents.  Participants shared numerous similar stories of the impo rtance of maintaining interests and activities that were meaningful to them, even after making the transition to assisted living. One participant described how this was important even in the selection of her facility. Prior to making the move, she had expl ored different assisted living facilities with a  friend, and described that, in the process of choosing their respective facilities , WKH\KDGOHDUQWWKDW³LWZDVourselves we were becoming acquainted with, what were our major interests, what did we look fRU´,QWKHHQGVKHKDGFKRVHQKHUFXUUHQWUHVLGHQFHLQSDUWEHFDXVHLWZDVFORVHWRWKHKRVSLFHsociety which allowed her to continue her volunteer work:  ,ZDQWHGWROLYHQHDUWKHKRVSLFHVRFLHW\DQG,’PYHU\DFWLYHLQWKDW«,’PYHU\comfortable workin JZLWKWKHG\LQJ«LW’VEHHQSDUWRIP\ZRUNDQGD part of my life. So, I go to the hospital regularly to visit the dying and I can still do that.   Another participant spoke of the importance of her writing group that she had attended for over thirteen years. She described how she had continued with this activity following the PRYHWRDVVLVWHGOLYLQJ³,’YHGHILQLWHO\NHSWXSWKHZULWLQJ,VWLOOJRRYHUWR%URFN+RXVHDQGWKHQWKH\VWDUWHGDVPDOO>ZULWLQJ@JURXSKHUHVR,’YHEHHQDWWHQGLQJLWWRR´:ULWLQJ had been a significDQWDVSHFWRIWKLVZRPDQ’VOLIH since she had begun taking a life writing class when GHDOLQJZLWKKHUKXVEDQG’VGHFOLQLQJKHDOWK6KHGHVFULEHGKRZKHUVRQKDGVXJJHVWHGWKDWVKHwrite a story for each Sunday night family dinner and tha t over the years she had written more than150 stories.   In providing advice to others considering making a move to assisted living, the importance of maintaining interests and activities was underscored by the participants in this     93   study. To facilitate this transition and ensure continuity, one man talked about the importance of EULQJLQJWKRVHLWHPVWKDWDUHLPSRUWDQWWRWKHLQGLYLGXDO’VLQWHUHVWVZLWKWKHPZKHQPDNLQJWKHmove to assisted living. He stated:   If a person is musical and they want to be able t o bring [this enjoyment of music] in to WKLVSODFH«\RXWKLQNµZKDWPXVLFGR,UHDOO\OLNHDQGZKDWPXVLFVKRXOG,EULQJLQZLWKme that has a special moment for me.  In addition to speaking of continued involvement in their recreational activities, particip ants also described the importance of experiencing continuity in terms of their past work activities and identity. For example, one participant who was a Catholic Sister, talked about the importance of maintaining that part of her identity within her new l iving situation:  ,WKLQNDOVRZKDWKDVKHOSHGPHKHUH«LVWKHIDFWWKDW,DPD6LVWHU,GRQ’WXVHWKHWHUPLQRORJ\KHUHEXWVRPHRIWKHPLW’V³6LVWHU´,WKLQNLW’VSUHWW\IRUPDOEXWWKHUHLVthis sort of type of relationship among the practicing Catholic V«\RXNQRZ,’YHGRQHWKLQJVZLWKWKHRQHVWKDWZDQW,’YHRUJDQL]HGRQFHDPRQWKDVHUYLFHDQGDOOWKDWW\SHRIthing. Another participant shared how in speaking with a member of staff, she had learnt that the ZRPDQ’VVRQZDVVWUXJJOLQJZLWKPDWK  We wer HMXVWFKLWFKDWWLQJDIWHUOXQFKRQHGD\«,DVNHGZKHUHLV>\RXUVRQ@KDYLQJKLVtrouble? I was the math department head at Kin g Edward campus for VCC for ten years, DQGVKHVDLGµPDWKHPDWLFV’DQG,VDLGµZHOO,GRQ’WNQRZZKHWKHUKH’GZDQWWRFRPHEXW,’Ye got lots of idle time . IIKHZDQWVWRFRPHRYHUKHUH,’OOWXWRUKLP’     94  This tutoring arrangement had been in place every Saturday since then, and was described by the participant as an important part of her experience of managing well in transitioning to assisted living.   Another participant felt that maintaining her interests in current events was similarly important to her sense of maintaining her identity as an educated, career woman. This woman KDGKDGDYDULHGSURIHVVLRQDOFDUHHUDQGVWDWHGWKDW³,Neep up with news, I keep up with politics. ,WKLQNWKDWDFFRXQWVIRUVRPHRIWKHGLIIHUHQFH«EHWZHHQVRPHERG\ZKRKDVJUDGXDWHGLQWRDSURIHVVLRQSUDFWLFHGLWDQGWKHQJRQHRQWRHQWHUWKDWILHOG,OLNHWRPDLQWDLQP\LQWHUHVWV´,WZDVWKLVSDUWLFLSDQW’s observation that having had this professional identity and maintaining associated interests was facilitative to her transition to assisted living.   A final description of continuity with previous vocational interests was described by a former Anglican m inister when talking about his involvement with the church. He stated that:   ,JRWR«FKXUFKDQG,GRQ’WRIILFLDWHDQ\VHUYLFHVQRZ1RWEHFDXVH,’YHORVWDQ\IDLWKRUDQ\WKLQJOLNHWKDWEXWEHFDXVH,’YHEHHQWKHUHGRQHWKDW$QGDW,’PKDSS\WREHthere in the congregation and I go every Wednesday and I host a bible study and I have friends there.  This participant shared how his role in the church community had shifted, but that he continued to be involved in his faith and had taken on different ro les, such as leading bible study. This quote also highlights another aspect of continuity described by participants; continuity in relationships.   Participants described the role of having continuity in their relationships with friends, family members and  health care professionals in their transition experience. To the extent possible, all of the participants described the importance of being able to continue to participate     95   in important family events, including family dinners and reunions. Maintaining the ritual of Sunday night family dinner was particularly important to one participant:  My son makes a big thing of the fact that fo r the past 51 years our family has all gone to WKHJUDQGSDUHQWVIRU6XQGD\GLQQHU«VRHYHU\6XQGD\QLJKWZHKDYHIDPLO\GLQQHU Similarly, another participant spoke about being involved in an upcoming family reunion:  «ZHDUHJRLQJXSWR6XPPHUODQGIRUDIDPLO\UHXQLRQ«,’PORRNLQJIRUZDUGWRWKDWYHU\PXFK,W’VDKLJKOLJKWRIP\VXPPHU«ZHKDYHDORWRIIULHQGVXSWKHUH$QGHYHQafter being here a while I still have quite a few personal friends.  As evident in the quote above, in addition to maintain ing their relationships with family members, many participants spoke of the importance of continuing to be involved in their relationships with friends living outside of their current residence. In reference to her closest personal friends, one participant ta lked about their willingness to come to the assisted living facility to pick her up or to stay for a visit:  I would say my closest friends are not here. I still have quite a support community from outside who come in, who visit or take me out.  Another par ticipant talked about how maintaining connections with friends outside of the facility, helped to break up the routines of everyday living that are common in assisted living IDFLOLWLHV,QKHUZRUGV³LW’VDOVRQLFHWRKDYHQHWZRUNVRIVRPHNLQGRXWVLGHVR that you break XS\RXUURXWLQHDELW´  Continuing relationships that they had had prior to moving into their current residence appeared to be important to participants in terms of bridging their past lives with their new lives in assisted living. Having WKHVHUHODWLRQVKLSVSURYLGHGFRQWLQXLW\EHWZHHQWKHSDUWLFLSDQWV’OLYHV    96   prior to, and following, entry into assisted living. These sentiments were captured in the following words of one participant:  I have a few people that phone me at partic ular times, a nd I look forward to their calls, so the phone represents the landline or lifeline out there to here.   Three of the participants spoke about the importance of maintaining relationships with health care providers. One participant who had significant health  concerns indicated that this had been an important factor in selecting her current assisted living facility. She stated that , in making the selection , ³WKHPRVWLPSRUWDQWWKLQJZDVWREHLQWKHFDWFKEDVLQWKDW,FDQJRE\DPEXODQFHWR6W3DXO’V .´ This w as important to ensure  that she was able to maintain continuity with existing doctors and specialists.  Another participant, who had moved into assisted living with his wife, indicated that they had had similar considerations when selecting their residence : ³2XUQXPEHURQHSODFHZDVQRWKHUHLWZDV5LFKPRQGEXWWKDWPHDQWWKDWZHKDGWRJHWDZKROHQHZPHGLFDOVXSSRUWV\VWHPVWKDWZHGLGQRW>IHHO@HTXDOWR´,QVWHDG, this p articipant and his wife chose  a facility in Vancouver in order to maintain existing relationships with health providers.   Previous life experiences were described by the participants as playing an important role in how they viewed and managed the transition to assisted living. Reflec ting the importance of attitude and perspective, the participants elected to view the move to assisted living as just another change ± comparable to previous transitions they had made in their lives. Reflecting this perspective, one participant spoke about  how the move to assisted living was similar to other PRYHVKHKDGPDGHLQKLVOLIH³«LWLVVLPLODUWRDQ\RWKHUPRYH,PDGH/LNH,KDYH,’YHGRQHDORWRIPRYHVLQP\GD\«VRLW’VQRWDELJGHDO\RXNQRZ´     97   The fact that participants had adjusted to man y significant transitions in their lives, seemed to allow for greater ease in making the adjustment to this new living situation. As one participant poignantly stated:  «,’YHOLYHGDORQHIURPJRLQJWRERDUGLQJVFKRROWRJHWWLQJPDUULHGVR\HDUVRIOLYLng DORQH\RXFDQDGDSWWRDQ\WKLQJ,’YHEHHQDGDSWLQJDOOWKHWLPH As evident in the quote above, participants expressed a sense that by the time they made the most recent move to assisted living they had already had a life - time of experiences which a llowed them to view this specific move as just another change. This sentiment was captured by one participant who stated:  «,ZHQWWRERDUGLQJVFKRROLQ7RURnto, and that prepares you for DQ\WKLQJ«E\WKHWLPH\RX’YHPDGHWKLVPRYHG\RX’YHSUHWW\ZHOOKDGDOO WKHOLIHH[SHULHQFH\RX’UHJRLQJWRhave.  Continuity with important activities and relationships was described by participants as being important to their experience of having managed well in making the transition to assisted living. Often participants  described that continuity with activities, whether related to their career or recreation, also provided the opportunity to continue existing relationships. Having continuity in relationships with health providers was described as particularly important to  some participants, and knowing these relationships were in place allowed for greater ease in making the transition to assisted living. In reflecting back on past changes the participants had experienced over the course of their lives, this specific transi tion to assisted living was also experienced as being just another change , SURYLGLQJFRQWLQXLW\ZLWKWKHSDUWLFLSDQWV’SUHYLRXVlife experiences and transitions. Having these continuous threads with previous aspects of their experiences, whether through in terests, activities, relationships or their perspective on change,     98   was identified by participants as being an important aspect of  having managed well in making the transition to assisted living.   Sense of acceptance. All of the participants described the  importance of accepting their move to assisted living, in their experiences of  managing well in making this transition. The level of acceptance appeared to exist on a continuum, and to include two components: a belief that assisted living was the best option for them at this point in their lives and an acceptance of their new residence as their home. Many of the participants also described a sense of readiness which they felt had been important to them coming to a place of acceptance of the move to assisted to living. For other participants, the move to assisted living had been in reaction to a sudden deterioration in health or organized by their family members. In these instances , the participants did not necessarily speak about their own sense of readiness , but still described a sense of acceptance of the move. Although not identified as necessary for all participants, the sense of readiness was described as facilitative of acceptance by some.   A sense of readiness to make this move was described by five of  the participants as having contributed significantly to their willingness and ability to accept this transition. As captured in the words of one participant:  ,ZDVUHDG\IRULW,MXVWNQHZ,FRXOGQ’WJRRQE\P\VHOIDQy OR JHU«DQGZKHQWKLVarrangement was explained to me, and I came to visit, it just fit like a comfortable shoe.  Another participant who had moved with her husband told a story they had come to recognize that it was time to move to assisted living:   Well I have a favorite story I say, I was sitting here, my husband was sitting on my right DQGLWZDVHYHQLQJ,VDLGµGHDUZKDWZRXOG\RXOLNHIRUGLQQHU"’DQGKHVDLGµZKDWKDYH\RXJRW"’DQG,VDLGµZKDWGLG\RXEX\"’'HDGVLOHQFH«,WZDVWLPHWRPDNHWKHPove.      99  No longer feeling able to keep up with daily living tasks such as grocery shopping was identified by this participant as contributing to her readiness to move to assisted living.  This sense of readiness was described as including many dimensions ± p hysical, emotional and psychological. Readiness included having come to the decision that this was the best option, as they could physically no longer continue living alone, as well as feeling emotionally ready to make the move. These beliefs contributed t RWKHSDUWLFLSDQW’VVHQVHRIacceptance of this transition. As one participant stated:  I mean I was prepared emotionally for it, I felt I needed it. So I think, and it was my decision, nobody else forced it on me, but the fact that I came to the decision knowing, I think helps to contribute to acceptance.  This participant highlighted the importance of having made the choice to move to assisted living. Those participants who described feeling ready to make the move also identified that they had made the dec ision to move to assisted living themselves. While independently making the choice to move to assisted living seemed to be related to a sense of readiness , it did not appear to be QHFHVVDU\IRUSDUWLFLSDQWV’VHQVHRIDFFHSWDQFHRIWKHPRYH  In speaking w ith participants, they described the process of having come to accept  that assisted living was the best option for them. The participants  in this study had contemplated their alternative living options, and determined that this option was the one that best  suited their current and future needs. As their ability to manage their lives on their own diminished, the participants recognized that they needed some assistance. When they considered the possible options, moving to an assisted living facility seemed to  be the most viable alternative. As one participant shared:      100  I would have had to have a girl come in [to the house] for five hours every day and you NQRZWKDW’VDZIXOO\LQFRQYHQLHQWZKHQ\RXDUHWU\LQJWROLYH\RXUOLIHVR,JXHVV,ZDVmore acquiescing ab out the move here.  Whether the move was initiated by the participant or his or her family members, all of the participants accepted that assisted living provided the best option in meeting their support needs while also allowing them to continue to live th e type of lives they wanted to live. This acceptance that assisted living was the best option was also expressed by another participant who had considered what other options were available. The participant stated:  «,ZDVIDFHGZLWKWKHXOWLPDWHTXHVWLRQRI if not here, where? And I imagine a lot of SHRSOHKDYHWKLVTXHVWLRQDQGWKH\GRQ’WRSHQO\YRLFHLWVRWKLVLVWKHSODFHWREH  While all participants accepted that assisted living was the best option for them, their degree of acceptance varied. Still in the throes of accepting his new living situation, one participant seemed to resign himself to the reality of his situation:  «,’PWU\LQJWREHVHQVLEOHDQGQRWILJKWLQJOLYLQJKHUHEHFDXVH,NQRZ,ZRQ’WGRDQ\better than this. Another participant des cribed coming to a deeper level of acceptance, by focusing on the gains of their new home, rather than focusing on the losses:  ,VXGGHQO\VDLGWKLVSODFHEHORQJVWRPH,GRQ’WKDYHWRVKDUHWKLVEHGZLWKDQ\RQHLI,GRQ’WZDQWWR«,FDQVSUHDGP\VHOIDURXQd here. This is home! And I began to rack up all the benefits of this place and there was hardly anything in the deficit list. All benefits.  In addition to feeling that this move was the best option for them, participants also described coming to accept th eir residence as their new  home. For some, coming to view their new residence as home was described as a relatively easy process:       101  ,WZDVQ’WGLIILFXOWDWDOO,WZDVMXVWRQHWULSLQDQGWDNLQJDORRNDQG\RXNQRZ\RXMXVWget a feeling about a place that  this could be home.  Other participants spoke of how this had been a more gradual process. One participant shared WKDWWKLVKDGLQYROYHGDGMXVWPHQW³ZKHQ\RXDGDSW\RXUVHOI«LW’V\RXUKRPH´6LPLODUO\another participant shared that coming to view his new  living arrangement as home had involved FKDQJLQJKLVSHUFHSWLRQRIKLVUHVLGHQFH+HVWDWHG³,JXHVVSDUWRIWKHWUDQVLWLRQZDVOHDUQLQJWRFDOOWKLVSODFHKRPH,WZDVQRWSULVRQ«LWZDVKRPH´  This sense of feeling like they were  at home extended beyond  SDUWLFLSDQWV’SULYDWHVSDFHto include the other areas within the facility. One participant captured this sentiment expressing WKDW³WKHZKROHEXLOGLQJIHHOVOLNHKRPHLWQHYHURFFXUVWRPHWKDW,FDQ’WJRDQ\ZKHUHH[FHSWLQWKHDSDUWPHQWV´  A sense of acceptance was described by all of the participants as being an important aspect of managing the transition to assisted living. For some participants , their internal sense of readiness to make the move appeared to facilitate the sense of acceptance that assisted living best met their needs at this time. For other participants , the move was  not their own decision, but rather initiated by family members, often a s the result of sudden changes in health. Although these participants did not identify as having been ready to make the move, they shared a similar sense of acceptance that this move was the best option for them. The acceptance of this new space as their home was described by participants as occurring along a continuum, with some participants identify ing that this occurred quickly and others describing it as a more gradual process. In both cases, coming to view the assisted living facility as home was identified as important to them adjusting to  their new living arrangement.      102   Perceived sense of openness. In speaking with participants about their move to assisted living, they described having a perceived sense of openness in their attitude towards change, towards individual differences in their fellow residents and routines, and towards diversity. This openness was described by participants as being important to their process of having managed well in adjusting to life in their new residences.  The importance of attitude and a positive mind - set towards change and life challenges was apparent to vary ing degrees in the transition stories of all of the participants. Participants  identified that their positive attitude toward change was important in managing their transition to assisted living. Reflecting on the importance of being open to and accepting of change, a participant who had moved into assisted living on her own said:   ,JXHVVWKDW’VSDUWRIZKDWOLIHWHDFKHV\RX<RX’YHJLYHQWKDWOHFWXUHWR\RXUFKLOGUHQDOO\RXUOLIHLWGHSHQGVRQ\RX,W’VOLNHZKHQ,ZDVKDYLQJDGD\WKDWIHOWDOLWWOHKDrd to get DGMXVWHG,PHQWLRQHGLWWRRQHRIP\NLGVDQGWKH\VDLG³QRZPXP\RXNQRZZKDWLWZDVOLNHZKHQZHKDGWRFKDQJHVFKRROVVRMXVWVXFNLWXS´ Another participant described similar sentiments about how his openness towards change and his self- confidence, had played an important role in his ability t o navigate this challenging move :   ,QWKHFRXUVHRIP\OLIH,’YHJDLQHGDORWRIFRQILGHQFH(YHQQRZDV,’PROG\RXWHQG>WR@ORVHVRPHFRQILGHQFH,GRQ’WWKLQN,KDYH,MXVWFDPHLQKHUHDQG,OLYHG/LYLQJLVMXPSLQJLQDQGVD\LQJZHOO,’YHJRWWRGRWKLV In this quote , he captu red how his openness to living this new life style had contributed to his adjustment. Both of these participants described experiencing some challenges in navigating this transition, although on balance they felt they had managed it well. Other participant s described experiencing this transition more easily due, in part, to their openness to life changes and their     103   past life experiences. For example, one participant who had done a lot of international traveling, felt that these experiences had influenced how  VKHDSSURDFKHGFKDQJH³,’PHDV\\RXNQRZ,PRYHHDVLO\´  Their sense of openness was also described by participants as being important in the ease of their interactions with their fellow residents. In the words of one participant:  Well you have to be really flexible and just willing to go the extra mile with people. /LVWHQWRZKDWWKH\’YHJRWWRVD\DQGUHVSHFWWKHLUVSDFH«VRPHSHRSOHFRPHLQKHUHZLWKDFKLSRQWKHLUVKRXOGHUDQG,GLGQ’WGRWKDW<RX’UHMXVWORRNLQJWREHDVDVQHXWUDODQGyou really do have to work on your attitude.  The role of a positive attitude and tolerance towards others was identified by all participants as being important in the transition process. Participants felt that those  who did not have this mind -set would likely fi nd the transition to assisted living more difficult. Several participants also spoke about the importance of being able to remain open in their interactions with their fellow residents, despite the potential challenges in some of these interactions. One pa rticipant captured WKLVVHQWLPHQWZKHQKHVSRNHRIWKHLPSRUWDQFHRI³WDNLQJSHRSOHDVWKH\DUHDOORZLQJIRUEORRG\PLQGHGQHVVLI\RXOLNH«PDNLQJDOORZDQFHVIRUSHRSOHDVWKH\DUH´ 7KLVDWWLWXGHRIRSHQQHVVZDVDOVRHYLGHQWLQSDUWLFLSDQWV’DFFHSWDQFHRI how tasks at the assisted living facility were done. As one participant stated:   I think being able to accept give and tak H«VRWKH\GRQ’WTXLWHPDNHWKHbed exactly like I ZDQW«ZKDWGLIIHUHQFHGRHVLWPDNH" Participants described similar flexibility in th eir attitude towards the way in which the food was prepared, which was often different than what they had been used to previously. Their openness     104  and flexibility in accepting different ways of completing household tasks appeared to contribute to the partic ipants having managed well in making their transition to assisted living.   Participants also described having a sense of openness to diversity, both in their fellow residents and in their life experiences more broadly. One participant described that , in her efforts to get to know fellow residents , she was open to learning about differences:  <RXNQRZHYHU\ERG\KDVDGLIIHUHQWEDFNJURXQGDQGKLVWRU\DQGLW’VLQWHUHVWLQJWRJHWWRNQRZHYHU\ERG\LW’VLQWHUHVWLQJZKHQ\RXILQGRXWZKDWSHRSOHKDYHGRQHLQWheir lives.  Another participant, who had immigrated to Canada from South Africa earlier in his life, shared similar sentiments:  :HDUHDOOGLIIHUHQWLWZRXOGEHDYHU\SRRUZRUOGLIZHGLGQ’WKDYHGLIIHUHQFHVDQGWKDW’VZKDWPDNHVXVVXFKDQLQWHUHVWLQJworld.  Participants also spoke about how previous life experiences had contributed to their perceived sense of openness to, and tolerance of, individual differences. One participant, who had worked with refu gees in her role as a Catholic Sister, captured these sentiments:  It becomes hard, some people have not learned in their life to accept differences. Some SHRSOHGRDQGJHWDORQJDOULJKWZLWKWKLQJVWKDWDUHGLIIHUHQW,WKLQNWKLVLV,’YHconsidered [it] one of my gifts, the work I did, I worked with people who were different. I worked with refugees and people who come from many different cultures, many different foods, many different customs, and I have no trouble with it.  Other participants also spoke of how previous life experiences had contributed  to their openness to diversity. In the words of one participant:      105   %HLQJLQQXUVLQJDQGOHDUQLQJDVPXFKDV,GLGDERXWPHGLFLQH«DQGKRZSHRSOHFRSHGwith their problems in hospital, all those experiences add to tolerance and understanding really.  A third participant shared similar sentiments of how past experiences had contributed to her sense of openness to diversity, which assisted in her transition to assisted living. She spoke of the influence of her University and Church experiences, stating:  «LWbecame apparent in my C KXUFKOLIHDQGP\UHVLGHQFHOLIHWKDWDOO*RG’VSHRSOHKDGZLQJV*D\V%ODFNV%URZQVDQGHYHU\WKLQJ«DQG,VWDUWHGWRGDWHDQ(DVW,QGLDQtheological student from Trinidad.  This acceptance of diversity also extended to participant s relationships with many of the staff and caregivers in their assisted living facilities. One participant shared how she felt her openness to diversity had impacted the relationships she had formed with staff. She shared how her previous life experiences had shown her that:  «\RXFDQ’WEHSUHMXGLFHd DERXWFRORXURUUDFH«EHFDXVH,ILQG,JXHVV,’YHDOZD\VEHHQYHU\DZDUHEXW,’YHWUDYHOOHGDORW\RXNQRZ«,’YHOHDUQHGWRWUXVWSHRSOHMXVWDVPXFK\RXNQRZ«,VHHSHRSOHVWUXJJOLQJKHUHZLWK³GR,PDNHIULHQGVZLWKWKHPDLG"´%HFDXVHthey have had no experience with anybody of another colour or of another race.  These varied life experiences were identified by participants as contributing to their perceived sense of openness to differences ± an openness that helped them in their transition to assisted living.   Perceived openness either to change in circumstances and/or to differences, was described by all of the participants as playing an important role in how they had navigated the transition to assisted living. Many of the participants described havin g had diverse life     106   experiences and talked about how these previous life experiences had contributed to their current attitude towards change and towards acceptance of individual differences. Several participants spoke about the effort they made to maintain  this attitude of tolerance and openness towards their fellow residents, staff , and daily routines within the facility, as they felt this was a key part of being able to navigate the transition to assisted living. Participants also described how their open ness and attitude towards change throughout their life had influenced how they approached and navigated this most recent move.    Not wanting to be a burden to others. All except one of the participants made reference to the fact that moving to assisted li ving meant that they would not be a burden on friends or family members ± something that was important in their motivations for making this move and in their perceived adjustment to assisted living. This perception of being a burden fell along a continuum , with some participants indicating , that prior to the move, they felt they were a significant burden to family and loved ones. Other participants shared that , even though family members had invited them to move in with them, they had felt assisted living w as the best option in not burdening their family, and also for their own independence and well - being.  Other participants shared that , even after moving to assisted living , they still felt that they were a burden or source of concern for their family membe rs, but that being in assisted living helped ease these feelings. The one participant  who did not explicitly talk about feeling like he was a burden to friends or family members spoke very little during the interviews about having ongoing contact with his family, only about their role in choosing the facility he moved into, and helping with the logistics around his move.   It was important to the participants that their move to assisted living helped to alleviate WKHLUIDPLO\PHPEHUV’ZRUULHVDERXWWKHLUZHll- EHLQJDQGWRUHGXFHWKHLUORYHGRQHV’VHQVHRI    107   responsibility for their ongoing care. One participant described that knowing her son no longer had to worry about her had been an important factor in her  feelings about making the move to assisted living:  I had to consider the fact that my son was married and had two sons, and I forget at what point he got divorced, but you know, he had to do a lot of juggling seeing his FKLOGUHQ«VR,GLGQ’WZDQWWRSXWPRUHEXUGHQRQKLPDQG,NQHZWKDWP\EHLQJKHUHKHknew that I would have three meals a day and that someone would be on hand if anything happened to me.  Participants talked about how some seniors insist on staying in their own homes because of their desire to be independent, when in fact their family mem bers are actually being burdened with their care. Reflecting these sentiments, one participant who moved to assisted living with her husband described how their realization that they were burdening their children had significantly contributed to their decision to move from their home:  Some people are committed to staying in their home forever and they make a terrible mistake of thinking they are being independent, but their children are having to run DURXQGWRORRNDIWHUWKHPDQGZRUU\DERXWWKHP«WKDW’VZKat was happening with us, we KDGP\NLGVRU>P\KXVEDQG’V@NLGVGRWKHVKRSSLQJDQG,VDLGµWKDW’VLW’ Another participant had significant health concerns which impaired her from doing any daily tasks such as cooking or cleaning. She had moved into the as sisted living facility with her husband and shared her relief that her husband no longer had to bear the burden of all the household tasks:      108   I was very happy because of two or three things; one my husband was relieved of all the cooking and washing dishes a QGWDNLQJFDUHRIWKHODXQGU\DQGVWXII«IRUPHLWZDVwonderful, because I knew he was getting tired of the responsibility of everything.  Others described that, even when family wanted to have them live with them, they felt that this was not in their own o UWKHLUIDPLO\PHPEHUV’EHVWLQWHUHVWV)RUH[DPSOHRQHparticipant who had been living with members of her family prior to the move, described feeling like a burden to her family and reflected on the negative impact that these feelings had on her own sen se of well - being:  I lived a long time alone after my husband died. And then I tried living with my family for a while, and then I saw that was not going to work long - term because their life is FKDQJLQJDOOWKHWLPH$QGWKH\KDYHWKHLUSUREOHPVDQG,FDQ’W solve their problems and PRUH«DQGWKHQDVP\KHDOWKGHWHULRUDWHGWKH\JRWWRWKHSRLQWZKHUHWKH\GLGQ’WHYHQwant to go out to leave me in case I needed help, and it was at that point that I thought this is not going to work. It was stressing me out know ing they were doing that. And I would rather that they have their freedom. And it was not good for me, it was making me sicker, worrying about them all the time.  Another participant shared that , prior to moving to assisted living, he and his wife had fran k conversations with their family members about their decision to move to an assisted living facility, indicating that they felt this was the best option for their children and also for themselves.  :HGLVFXVVHGWKLVZLWKRXUIDPLO\DQGWKH\VDLG³RKZK\GRQ’W\RXFRPHOLYHZLWKXV´DQGZHVDLG³WKDQN\RXYHU\PXFKEXWZHGRQ’WZDQWWR´«ZHZHUHPHUHO\H[SODLQLQJwhy we thought it was better for them and for ourselves to continue our separate lives.      109   Even after making the move to assisted living , some part icipants described their discomfort with their continued sense of feeling like a burden to their family members. One SDUWLFLSDQWVKDUHGWKDWKHRIWHQIHOW³XVHOHVV´FLWLQJWKDWKLVGDXJKWHUKDGRUJDQL]HGKLVPRYHWRassisted living whereas , in the past , organization and logistics had been one of his roles in the family. He also shared that visits with his son could be particularly challenging for both of them:  ,’YHQRWLFHGZKHQ,WDONWRP\IDPLO\SDUWLFXODUO\P\VRQKHVHHPVWKHODVWWLPH,VDZhim he also felt very uncomfortable with me. I feel like telling him, µGRQ’WERWKHUWRFRPHEDFNEHFDXVHLW’VDELWRIDVORJIRU\RX’ and even for me.  This participant appeared to appreciate that , by making the move to assisted living , he had more social support, and was therefo re able to feel less reliant on relationships with family .  Another participant described how, even after the move to assisted living, she felt guilty about the distance her relatives had to travel to see her. However, on a more positive note, the services offered at the assisted living facility, including the restaurant, allowed this participant a way of entertaining or giving back to her family members when they visited her, which helped reduce her feelings of being a burden. Since moving to assisted living , this participant delighted LQWKHIDFWWKDWZKHQKHUGDXJKWHUFRPHVWRVHHKHURQ)ULGD\V³VKHDOZD\VFRPHVRYHUKHUHIRUlunch, sR,GRQ’WIHHOJXLOW\DERXWWKDW´6LPLODUO\DQRWKHUSDUWLFLSDQWZKRGLGQRt have any children described how he had relied on his support community, particularly during the early period of transitioning to assisted living. He revealed that , with time , he had become less dependent on his support network, but when he did call on th HPKHZRXOG³XVXDOO\UHSD\WKHPE\DVNLQJWKHPWRVWD\IRUDPHDO´$JDLQWKHVHUYLFHVRIIHUHGDWWKHIDFLOLW\DSSHDUHGLPSRUWDQWin helping participants to feel they could repay family and loved ones for their support, thereby helping to reduce their feel ings of being a burden.      110   Several participants also spoke about how the physical and medical support available to them in their assisted living facility helped to reduce the burden on their friends and family members. One participant described how assisted  living provided the support for her physical health that she needed so she was able to protect her family from the burden of worrying about her deteriorating health. She poignantly stated that:  0\IDPLO\VWLOOWKLQNWKDW,’PGRLQJILQH,’PQRWJRLQJWRWHOOWKHP,’PQRWGRLQJILQH,could live another 10 years, but I very much doubt it. You know they are in their 50s, HDUO\VDQGRQHGDXJKWHULVOLYLQJLQ/RQGRQ,’PQRWJRLQJWRWHOOKHU,’PQRWGRLQJwell because she and her husband would postpone th eir sabbatical. Having the support with her health concerns allowed this participant  to keep from her family the challenges she was experiencing, so that she did not feel she was worrying them and impacting how they lived their lives.   Although not presen t for all of the participants, this sense of not wanting to be a source of concern or a burden to friends and family was a common aspect of the transition to assisted living for many participants. The move offered support with daily living tasks which allo wed participants to feel their relatives were freed from having to provide this care. Having the support RIDVVLVWHGOLYLQJUHGXFHGWKHSDUWLFLSDQWV’VHQVHRIEHLQJDEXUGHQZKLFKPDQ\SHUFHLYHGDVbeing beneficial not only to family members but also  for their own well - being. Knowing that the burden of their care had been reduced for their loved ones was identified by participants as being important in motivating their move to assisted living, and in feeling they were managing this transition well.        111  Participants’ Definition s of Managing Well   Participants were not asked to explicitly define what managing well meant to them . However, i n the screening interview s, when asked if they felt they had managed w ell in managing this transition , all self- identified that they had. Some  participants also provided additional information  when responding to this question  that gave a sense of what this term PHDQWWRWKHP:KLOHRQHSDUWLFLSDQWLQGLFDWHGWKDWWKHWUDQVLWLRQZDV³QRWUHDOO\DELJGHDO´WRhim  and had therefore been easy to manage , other participants described that managing well was more of a process of adaptation for them. For example , RQHSDUWLFLSDQWLQGLFDWHGWKDW³ultimately \HV>,KDYHPDQDJHGZHOO@EXWWKHUHDUHXSVDQGGRZQV,GRQ’WIHHODQ\RQHKDVILnished the WUDQVLWLRQEXW\RXJHWXVHGWREHLQJKHUHDQGVHWWOHLQ´&RQVLVWHQWZLWK the common theme of acceptance of assisted living as the best option, one participant indicated that managing well meant th at if she could not be on her own  VKH³ZRXOGQ’t rather be anywhere else than [in her current residence] ´$QRWKHUSDUWLFLSDQW’VUHVSRQVHUHflected the common theme  of perceived sense of openness. This participant shared that she definitely felt she had managed well and that VKHIHOW³LWDOOGHSHQGVRQ\RXUDWWLWXGH´WRZDUGVWKHWUDQVLWLRQFrom the screening and data collection interviews with participant s the definition of managing well appeared to be complex , but the common themes that emerged from the data analysis appear to encapsulate  the key aspect s of this concept  across participants in the current study.           112  CHAPTER  FIVE  Discussion   This research sought to understand the meaning and experience for older adults, of making a successful transition to assisted living. In this chapter, the findings of the study will first be contextualized in order to identify possible limitations of this research. The key findings of the study will then be discussed in relation to the available literature. This is followed by a discussion of their implications for theory, policy and counselling practice, as well as future research.   Contextualization of the Findings   While there were participants from both privately funded and subsidized  assisted living facilities, over half of the participants were from privately funded facilities. The region of Vancouver has 481 publicly subsidized and 315 private - pay assisted living units. In the current study, eight participants came from exclusively privately funded facilities, two came from a facility that had both private - pay and publicly subsidized units and one participant came from a IXOO\VXEVLGL]HGIDFLOLW\$VDUHVXOWLWLVLPSRUWDQWWRFRQVLGHUWKDWWKHVWXG\’VILQGLQJVPD\EHmore representative of the experiences of individuals who h ave the financial means to go into a higher cost facility. It is possible that these residences may provide a level of comfort and/or amenities not available in subsidized facilities. This may have, to varying degrees, contributed to WKHVHSDUWLFLSDQWV’H[periences of having managed well in making the transition to assisted living.  In addition to financial means, socioeconomic status is also likely to shape the experience of individuals making this transition. For the current study the participants were re latively homogenous in terms of their education, past occupations and financial resources. These factors     113   w ere also likely to have influenced and shaped their experiences of managing well in making this transition, and may limit the applicability of these f indings to individuals from other socioeconomic  groups.   Eight of the participants in this study had been involved in making, or had personally made, the decision to move to assisted living. Having had the choice about whether and when to move to assisted OLYLQJPD\KDYHFRQWULEXWHGWRWKHSDUWLFLSDQWV’SHUFHSWLRQVDQGH[SHULHQFHVRIhaving done well in making this transition. Although research findings have been somewhat mixed regarding the importance of active involvement in the decision to move to resid ential care, research suggests that involvement facilitates adjustment (Ball et al; 2000; Brooke, 1989; Chenitz, 19 83 ; Nay 1995). While there were no apparent differences in the experiences of the participants in this study who made the choice to move to a ssisted living, versus those whose family or life circumstances motivated their move, it remains to be determined the extent to which actual or perceived choice may shape the transition experiences.   In the current study, the three participants who had ha d a partner at the time they made the move to assisted living, were able to move into the assisted living facility with their partner. In speaking with participants , it was clear that this was not always possible for couples. Many participants described ho w, amongst their fellow residents, it was not uncommon for partners to live in different facilities, due to financial cost or differences in care needs between the partners. A study by Kemp (2008) indicated that making the move to assisted living with a pa rtner may bring considerable benefits, including ongoing companionship, support , and continuity. However, these benefits may also be accompanied by increased financial burden. As so much depends on individual circumstances, it is difficult to generalize as  to whether moving to assisted living with a partner makes the transition easier or more challenging. However, having the     114  VXSSRUWRIWKHLUSDUWQHUPD\KDYHFRQWULEXWHGWRWKHVHSDUWLFLSDQWV’H[SHULHQFHVRIPDQDJLQJZHOOin making this transition.   Through the interviews , it became apparent that the participants in this study had personal characteristics that they believed contributed to having managed well in making  WKHWUDQVLWLRQWRDVVLVWHGOLYLQJ7KHVHLQFOXGHGWKHLU³FXSKDOIIXOO´SRVLWLYHattitude (i.e., ³FKRRVLQJWREHKDSS\´DQGWKHLURSHQQHVVWRDQGDFFHSWDQFHRIFKDQJHDVDQRUPDOSDUWRIlife. This may have reflected specific personality traits that were well - represented among the participants in this study. A study by Gregory, Nettleback a nd Wilson (2010) suggested that the personality trait of openness to new ideas and values contributes to successful aging. This trait may also influence the experience of managing well in making the specific transition to assisted living. The participants in the current study also described a wide range of life experiences that included dynamic careers and extensive travel. It remains to be determined the extent to which personal characteristics (positive thinking, openness) and diverse life experiences, co ntribute to the perception of managing well with the transition to assisted living.   All but one of the participants in the current study were over  the age of 80  ± suggesting that these findings migh t be considered cohort specific (individuals born betwee n 1899 and 1933). There was also homogeneity in the ethnic backgrounds of participants, as all those who contacted the researcher regarding participating in the study were Caucasian. There is research suggesting that the transition experience of individual s living in Hong Kong may vary from that of individuals in Western cultures (Lee, 1999). In addition, potential cultural differences in what information is  considered private, and what is shared publicly, may be have influenced which individuals felt comfortable electing to participate in the study.  As a result, it is  possible that the demographic characteristics of the participants in this study may limit the extent to which the     115   themes from this research will resonate with individuals from different cohorts and cultural backgrounds.   This study also revealed some potential challenges in carrying out research with residents of assisted living. Changes in the physical health and cognitive abilities of two participants in the current study precluded connecting with them to complete the final interviews to review their biographical information and common themes. Changes in physical and cognitive health may be a factor that can impact the research process when carrying out research with this population.  Significant Findings   The current study had several key findings that confirm, or expand our understanding of, the phenomenon of managing well in navigating the tr ansition to assisted living. These include: the importance of social connection; the benefits of assisted living; timing of the transition; autonomy; the role of choice; continuity with identity and relationships; personal history; and relationship with st aff. Each of these will be discussed in detail.   Importance of social connection. The literature on the move to residential care suggests that social relationships facilitate the transition experience, particularly for those individuals who were socially isolated prior to making the move (Ball  et al., 2000; Brooke, 1989; Iwasiw et al., 1996; Porter & Clinton, 1992). The current study supported these findings, with participants speaking to t he importance of their existing and new social relationships  in their experience of having managed well in making the transition to assisted living. Participants described how maintaining relationships and connection with friends and family members who were part of their lives prior to the move, helped to provide a needed  sense of continuity to their previous lives and identities. They also emphasized how seeking out new relationships within the facility served to decrease their sense of isolation, increase their sense of belonging, and improve the     116   overall quality of their  daily lives within the facility.   Benefits of assisted living. Much of the emphasis in the popular and academic literature is on the losses experienced by older adults ± the loss of their health, the loss of their home, the loss of friends, the loss of identity, the loss of independence, etc. ± particularly when they make the transition to residential care (Aneshensel et al., 2000; Fiveash, 1998; Nay, 1995). What was noteworthy in this study, however, was the extent to which participants perceived their q uality of life as having been enhanced, sometimes significantly, when they moved to assisted living. In addition to the benefit of increased social connection, they spoke of being alleviated from the burden of shopping, cooking, cleaning and other domestic  tasks ± leaving them more time and energy to get involved in more interesting and desirable activities. They attributed their improved sense of health and well - being to better meals, and to the available and easily accessible health care and fitness activities within their facility. They also spoke of an increased sense of security in knowing that help was nearby and readily accessible if they needed something ± including tertiary level medical support ± which reduced the need for unnecessary visits to the  emergency room and increased their sense of wellbeing. The participants in this study seemed genuinely surprised and delighted by these largely unanticipated benefits of the transition.   In identifying the numerous benefits of assisted living, the current  study expanded our understanding of what it means to move to residential care by introducing the positives SRWHQWLDOO\DVVRFLDWHGZLWKWKHPRYHWRDVVLVWHGOLYLQJ,QGLYLGXDOV’UHFRJQLWLRQRIWKHVHEHQHILWVmay also be important to the experience of adjus tment, as research has identified the important role that valuing assisted living has in the process of becoming at home within this new environment (Cutchin et al .)RUWKHFXUUHQWVWXG\SDUWLFLSDQWV’UHFRJQLWLRQRIWKHEHQHILWVof assisted living seemed to have contributed to their experiences of having managed well in     117   making this transition.   The focus of the current study was on the experience of managing well in making the transition to assisted living. This focus may explain why the results of this study are different than those of previous studies, which identify predominately the challenges associated with this move. While participants in the current study reported having experienced losses and challenges, in reflecting on what had contributed to them having managed this transition well, they focused on the benefits, especially support with health care, daily living activities , and the companionship offered by assisted living.  Timing.  In the current study, five of the eleven participants spoke about the importance of timing on their experience of this transition. These participants indicated that it was important to make the move while they were still able t o appreciate the benefits offered by assisted living ± including activities and new relationships. Participants also identified the difficulties they had observed fellow residents experience  due, in part, to making the move at the wrong time. By waiting to o long to make the move, they observed that individuals may not have adequate time or intellectual and/or physical resources to fully engage with fellow residents or to enjoy the benefits of assisted living before needing to move to a higher level of care.  For example, one participant shared that she felt the timing of her move had been critical because , over the past year, she had noticed changes in her physical health and energy levels that she felt would have made it more challenging to engage in the pro cess of getting to know fellow residents and to participate in activities. The findings of this study suggest that the timing of the move to assisted living may also be critical in the forming social connections. If the timing of the move is delayed until DQLQGLYLGXDO’VSK\VLFDODQGPHQWDOKHDOWKKDVGHFOLQHGVLJQLILFDQWO\WKH\PD\ILQGLWPRUHdifficult to become involved in activities and to develop new relationships which facilitate the     118   transition experience, resulting in a more difficult adjustment.    Autonomy. 5HVHDUFKLQWKHDUHDKDVLQGLFDWHGWKDWSUHVHUYDWLRQRIDQLQGLYLGXDO’Vautonomy contributes to adjusting to living in a nursing home (Chenitz, 19 83 ; Iwasiw et al., 1996).  Iwasiw and colleagues also found that the structure and supports offere d by residential care can contribute to increased autonomy, as one participant shared that he felt liberated from a sense of obligation to his family following the move since he could now focus on living his own life (1996). Participants in the current stu dy also spoke about how the services offered at their residence, particularly around meals and daily household tasks, provided increased freedom and allowed them to focus on living lives that better reflected their interests and priorities. Prior to making  the move to assisted living, participants spoke of how they had had to rely on family members and friends to help them with a variety of daily tasks, such as shopping and meal preparation, which impacted the structure of their daily life as they felt obli gated to accommodate their schedules to fit with those of their family members or friends. They felt that having to rely on others in this way impacted their independence. One participant in the current study also spoke of how he felt assisted living affor ded him the freedom to come and go as he liked, while providing the security of having support available as needed. The current study found that the structure of the assisted living environment allowed participants to live independently while providing the  security and services necessary to live with decreasing physical  and, in some cases, mental health.    Role of choice. The role of choice on adjustment to residential care appears to be complex, with one study indicating that even when individuals chose t o enter assisted living they felt it was a forced choice due to limited options (Nay, 1995). However, several studies have highlighted the importance of involvement in the choice to enter assisted living on both initial     119  and ongoing adjustment (Brooke, 1989 ; Chenitz, 1983; Iwasiw et al., 1996). As a result,  it was expected that involvement in the choice to enter assisted living would be associated with a more positive transition experi ence. In the current study, eight of the 11 participants had been involved  in, or had made , the decision to enter assisted living on their own . Yet even those who had not been involved at all in the decision to make this move identified as having managed well in navigating this transition. Despite not having made the choice to enter assisted living, the experiences of these participants had the same common themes as those participants who had been more actively involved in the decision  making process. This finding diverges  from  the previous literature  and suggests that choice around entry may be less influential on the process of adjustment for some individuals. It may have been that the participants in this study, regardless of whether or not they had chosen to make the move, had shared personal qualities, such as attitude or ap proach to life, which contributed to the experience of having managed well in making the transition to assisted living. The possible impact of acceptance and individual differences on the experience of feeling one has managed well in making the transition to assisted living is discussed below.   Acceptance and individual differences . Both participants who had or had not been involved in the decision, spoke of their sense that this was the best option for them, sharing the VHQWLPHQWV³LIQRWKHUHWKHQZKHUH"´7KLVZDVVLPLODUWRWKHILQGLQJVRI3RUWHUDQG&OLQWRQ’VVWXG\ORRNLQJDWLQIOXHQFHVRQUHVLGHQWV’DGMXVWPHQWWRUHVLGHQWLDOFDUH7KH\LGHQWLILHGthat some participants who felt they had no other choice but to enter the residential care facility  indicated that this gave them extra motivation to adjust to their new environment, as they viewed living in this facility as their only option. In the current study, participants also described a sense of acceptance that assisted living was the best optio n for them, regardless of whether or not they     120  had made the choice to enter themselves. A study by Ball and colleagues (2000) looking at UHVLGHQWV’SHUFHSWLRQVRITXDOLW\RIOLIHLQDVVLVWHGOLYLQJDOVRKLJKOLJKWHGWKHLPSRUWDQFHRIDFFHSWLQJRQHV’FLUFXPVtances. They found that regardless of whether or not an individual had made the decision to enter assisted living themselves, their psychological well - being following entry into assisted living reflected, in part, their attitude towards life in the facilit y. Acceptance that assisted living was their best option contributed to their improved quality of life. The findings of the current study also suggest that acceptance of circumstances, regardless of involvement in decisions around entry into care, contribu tes to managing well in making this transition.  As mentioned earlier in the chapter, the participants in the current study were highly UHSUHVHQWDWLYHRID³FXSKDOIIXOO´SHUVSHFWLYHRQOLIH7KURXJKWKHLQWHUYLHZV, it became apparent that the participant s believed they had personal characteristics that had contributed to having successfully managed the transition to assisted living.  These individual differences ma y have also contributed to the participants ’ acceptance of their circumstances. The personal FKDUDFWHULVWLFVRIWKHSDUWLFLSDQWVLQWKHFXUUHQWVWXG\LQFOXGHG³FKRRVLQJWREHKDSS\´RSHQQHVVto change, and acceptance of differences  as being a normal and necessary part of life. This may have reflected specific personality traits that were well - represented among the participants in this study. There is research to suggest that the personality trait of openness to new ideas and values contributes to successful aging (Gregory et al., 2010). The findings of the current study suggest this aspect of successful aging may also contribute to our understanding of the experience of managing well in making the transition to assisted living.   Continuity with identity and relationships. While a previous study on t he move to assisted living found it was associated with a loss or devaluation of identity (Nay, 1995), the     121  current study found that, for the participants in this study whose identities were maintained through involvement in important life roles, interests , and relationships, this was an important contributor to feeling they had managed well in making the transition to assisted living.  Similar to the findings of the current study, there is also some research to suggest that maintenance of identity contributes to adjustment to residential care (Brooke, 1989) and that continuing with activities that are meaningful impacts quality of life in assisted living (Ball et al., 2000). In the current study, it was found that continuation with valued activities and rela tionships was central to individuals feeling they had managed the transition to assisted living well. For example, one participant had continued with her volunteer hospice work, and another participant who had been a teacher had begun tutoring a member of VWDII’VVRQLQPDWKHPDWLFV7KHSDUWLFLSDQWV’RQJRLQJrelationships with friends and family members outside of assisted living also provided them with a sense of continuity, which was identified as important in navigating this transition. By maintaining in volvement in meaningful activities and relationships, the participants felt they maintained continuity with their identity over the course of their move to assisted living. It appeared that having this continuity contributed positively to their adjustment to life in their new residence.   Personal history. The current study found that being able to view the move to assisted living as another move in a series of previous life transitions, contributed to participants feeling they had managed well. This was co nsistent with the findings of a previous study (Porter & Clinton, 1992) which also identified that life history could influence the adjustment to moving to a nursing home. Porter and Clinton found that participants  who had changed residences at various tim es throughout their lives viewed this as a factor which contributed to them adjusting positively to the move to a nursing home. Similarly, participants in the current study spoke about     122  how they felt previous moves, and varied life experiences, had helped t hem to manage well in making the move to assisted living.   Similarly, a study by Iwasiw and colleagues (1996) found that participants were better able to navigate the transition to residential care when their philosophy of life was manifested by a history of adaptability to changing circumstances. The participants in the current study also shared their accounts of how they had successfully adapted to numerous changes in their life circumstances prior to moving into assisted living. It seems that having an adaptable a ttitude towards life transitions  may influence adjustment to assisted living.   Relationship with staff. Another key finding of the current study was the importance of relationships with the facility staff in creating a sense of belonging within  the assisted living community for the participants in this study. Previous research has predominantly described negative relationships between residents and staff, with residents identifying the need to be subservient to facility staff members in order to  manage in residential care (Fiveash, 1998; Porter & Clinton, 1992). In contrast, the participants in the current study spoke of the positive relationships they had developed with staff members, and emphasized how these relationships had helped them to fee l welcome and comfortable in their new environment. While the degree of importance placed on relationships with staff varied across the participants, they all spoke of the sense of belRQJLQJFUHDWHGE\VWDIIPHPEHUV’DFWLRQV. These actions included support ive daily interactions, use of humour , and staff calling them  by their first name. Having these positive relationships with staff members contributed to them feeling that the assisted living setting was their home.  Implications   The key findings of this study have implications for future research, theory, policies of     123   assisted living facilities, and for counsellors working with older adults and their famil ies related to decisions to move into, and the ease of making the transition to, assisted living. Choosing to focus the current research study on the exploration of managing well in making the transition to assisted living also has implications for researchers and counsellors who want to better understand how to support individuals  who experience difficulties in making the transition.     Implications for future research. 7KHFXUUHQWVWXG\LQFOXGHGSDUWLFLSDQWV’experiences of having managed well in making the transition to assisted living. As mentioned previously, the majority o f these participants were living in facilities that were privately funded, while over half of the assisted living units in the Vancouver region are  publicly  subsidized. In addition, the review of the themes by an Executive Director of a publicly subsidized  facility raised questions about  the possibility of differences in  the experiences of individuals in privately and publicly funded facilities . Future research could focus exclusively on recruitment in subsidized facilities to explore whether the common themes emerging from this study are also present across the experiences of those transitioning to publically funded facilities.   Financial means was one demographic characteristic that may have influenced the findings of the current study, as the majority of participants had the financial means to pay privately for their current residence.  As mentioned previously, participants in the current study were also relatively h omogenous in terms of their age, ethnicity and socioeconomic status . Future studies could include a focus on diversity in terms of these as well as oth er demographic and cultural characteristics, to better understand how these factors may influence the experience of managing well in transitioning to assisted living.   The factors identified by participants as having contributed to managing the transition to assisted living well also indicated where possible challenges may emerge for individuals who     124  experience difficulty with this transition. For example, as maintaining continuity with relationships and interests was identified as helpful in navigating this transition, it may be that those who identify as having difficulty in making this transition find it challenging to preserve  this sense of continuity. Future research could explore these  different aspects of this transition in greater depth.  This could be done by asking  participants to identify not only what was helpful to them in making this transition , but also p ossible barriers to feeling one has managed well in making the transition to assisted living. Using the findings of the current study to inform the research question, a  critical incident technique could be used to deepen our understanding different aspects  of the process of transitioning to assisted living by helping us to understand what helps and hinders this transition.   The current study looked at the experience of managing well in making the transition to assisted living for individuals who had been in  assisted living for at least one year. As a result, participants were asked to reflect back on the early stages of their transition process, as well as their current experience. In order to gain an understanding of the experience of the transition to assisted living over time, a longitudinal study would provide the opportunity to follow individuals from the time they made the decision to entry assisted living throughout the actual transition process.   While the focus of the current study was on the common  WKHPHVLQSDUWLFLSDQWV’experiences of managing well with the transition, each participant had unique experiences of the transition which may not have been best captured using a phenomenological approach. A narrative method may have allowed these individu al meanings and differences in the experience of transition to assisted living to be explored in greater depth.   Finally, the current study suggests that individual differences around acceptance of the     125   transition and personality characteristics, such as op enness, may impact the transition to assisted living. A mi xed methods study would allow an XQGHUVWDQGLQJRIERWKSDUWLFLSDQWV’TXDOLWDWLYHexperiences of how these factors influenced their transitions, as well as demonstrating the relationship between indi vidual differences and the experience of managing the transition to assisted living well.   Theoretical implications . Goodman , Schlossberg and $QGHUVRQ’VWUDQVLWLRQmodel was used to frame the findi ngs of the current study. This model  takes into account how individuals, their situation, their supports and the strategies they use to adjust, contribute to the transition experience. The framework provide d a way of organizing the themes emerging from SDUWLFLSDQWV’H[SHULHQFHVRIPDQDJLQJZell in making the transition to assisted living (see Figure 3). Many participants spoke of their situation  prior to making the transition  and how stressors in meeting their care needs or social isolation had been alleviated following the move. These situational factors appeared within the themes of improved quality of life following the move and no longer wanting to be a burden. Supports available to the participants in navigating this transition were evident in relationships with family, friends and assist ed living facility staff. These supports were reflected in the themes sense of belonging and sense of continuity. The qualities of the participants themselves , which also influenced how they navigated the transition , were perhaps best revealed in sense of acceptance and perceived sense of openness. This UHIOHFWHGLQGLYLGXDOYDULDEOHVVXFKDVSDUWLFLSDQWV’RSWLPLVPDQGRSHQQHVVWRQHZFLUFXPVWDQFHVwhich appeared to play an important role in navigating the transition to assisted living. Finally, in reflecting on their experience of making this transition, participants spoke about strategies they had used, including actively engaging in activities, making a point of getting to know fellow residents, and continuing with important activities, interests, and rel ationships from their pre - care     126   facility lives, as captured in the themes  of sense of continuity and willingness to get involved.     Figure 3: Coping resources ± The 4 Ss        Source: Modified from Goodman , Schlossberg & Anderson (2006)    Goodman, Schlossber g DQG$QGHUVRQ’VWUDQVLWLRQPRGHOHPSKDVLVHVthe identification of possible resources available to an individual both within themselves  and their environment. The findings of the current study support  this conceptualization of  transition as the part icipants described how environmental resources, such as staff and the organization of their new environment, promoted a sense of belonging and improved quality of life that were facilitative of their transition. Participants also described the role of internal resources, such as their attitude towards change and diversity on their transition experience. Goodman, Schlossberg DQG$QGHUVRQ’VWUDQVLWLRQ model also highlights how to work within individuals to strengthen their resources to manage a transition. As  a result, the model may also be helpful in supporting individuals who are struggling in making the transition to assisted living. This model can be used to help individuals to identify where they may be experiencing deficits in resources in order to help them to strengthen  resources needed to navigate this transition.  SITUATION     SUP PORT  - Improv ed quality of life   - Sense of belo nging  - N o lo nger wanting to be a burden  - Sense of co ntinui t y   SEL F      STRATEGIES  - Sense of acceptance    - Sense of co ntinuity  - Perceived sense of openness   - Willingness to get inv o lv ed      127    The importance of timing in making the transition to assisted living was also highlighted by participants in the current study. From their experiences, it appeared that there was a window of time during which they felt the transition to assisted living offered the greatest potential EHQHILWV1HXJDUWHQ’VZRUNKLJKOLJKWVWKHLPSRUWDQFHRIWKHWLPLQJRIDQHYHQWZKHWKHUor not it is anticipated, on adaptation to life transitions. In pa rticular, Neugarten emphasised how the preparation an individual has had for an event will influence their response to the transition. The current study suggests that individual factors, such as health and preparedness to make the move to assisted living, influence responses to this transition event.   (ULNVRQ’Va; 1997b DQG)LVKHU’VWKHRUHWLFDOPRGHOVIRUDGXOWGHYHORSPHQWemphasise the growth that continues later into life. Fisher discussed how individuals , later in life, experience transitional events which cause them to revise their lifestyle in order to adjust to these events. This idea of adaptation and growth in order to allow continued involvement in important and meaningful activities, was present in the transition stories of participants in the current study. %DOWHVDQG&DUVWHQVHQ’VPHWDPRGHORIVHOHFWLYHRSWLPL]DWLRQZLWKFRPSHQVDWLRQprovides another way of understanding how older adults manage such developmental change over their life span . This model posits a relationship between the use of selection, optimization, and compensation strategies and successful aging.  ,QWKHFXUUHQWVWXG\SDUWLFLSDQWV’ experiences of managing well in making the transition to assisted living  provided instances  of when they had engaged in these processes . For example, the process of s election involves a change in behaviour or environment in order to continue to meet ones goals. For a number of  the participants, they made the choice to relocate to assisted living  in order to meet their continued goal of living a desired lifestyle. In describing the importance of continuity in valued activities participants also described engaging the processes of optimization and compensation. For one participant , who     128   identified w alking daily as an important activity to him, he described how getting a walker had allowed him to continue to achieve this goal  of a daily walk by enhancing the resources directed towards it. Another participant described how she engaged in compensation i n order to maintain involvement in key activities. This participant was an  avid gardener and she shared how she had compensated for  the loss of her garden by choosing a residence in which they had a roof top garden where she was able to tend to a small pla nter of her own. Throughout the interviews, participants revealed numerous examples of how they used selection, optimization, and compensation strategies to maintain involvement in activities and relationships that were meaningful to them, and to adapt to life in residential care.    Policy and counselling implications. Given that forming social relationships and a sense of belonging within the assisted living community were identified by participants as being important in managing the transition to assisted living well, assisted living facilities could put in place policies that would facilitate relationship development and belonging for new residents. For example, one participant identified that having a fellow resident pick her up from her room to walk to the dining room was extremely helpful to her in the days following her arrival. A peer ambassador program could be put in place by assisted living facilities management, to provide new residents with this social support and opportunity to build con nections with fellow residents following their entry into the residence. These ambassadors could offer companionship when going to the dining room for meals, as well as serve as a resource to those residents interested in having the support of a peer to fa miliarize them with their new environment, in the months immediately foll owing the move.  Also to facilitate a sense of belonging within the residence, a board or book with the name and photographs of residents could be compiled so that new residents could familiarize themselves with members of their new community.      129   Another significant finding of this study was the role that staff members play in creating a sense of belonging for residents in assisted living. Participants in the cu rrent study spoke of how  something a s smal l as having staff members refer to them by their first names gave them a sense of being at home and  contributed to their sense of belonging within the assisted living community. It appears that this practice would be beneficial for all resi dential care facilities to adopt, while taking into account the individual preferences of residents. Given that positive relationships with staff members have been identified as facilitative of this transition, training and providing opportunities for faci lity staff to build supportive and respectful relationships with residents would likely benefit the transition experiences of those entering assisted living.   The findings of this study also provide direction for counsellors working with older adults and their families around the timing and process of making the transition to assisted living. The emphasis , by participants, on the many benefits of moving to assisted living, was a particularly important finding. Contrary to the literature and social discourse  emphasizing the losses associated with this transition, when working with clients who are considering making the move to assisted living, counsellors can focus on identifying and exploring the ways in which a FOLHQW’VOLIHDQGZHOO- being may be enhanced b y making this move. Speaking with clients about their current daily challenges could provide opportunities to discuss resources available through assisted living that could help to better meet their needs, reduce their isolation, and improve the quality of  their lives.   Another significant finding of the study was the impact of maintaining a sense of continuity and identity on the experience of managing well in making the transition to assisted living. Given the importance of continuity, counsellors could support individuals preparing for, or in the process of transitioning to assisted living, to identify ways of maintaining continuity in     130   terms of their significant relationships and activities. This may involve identifying key interests and activities and determining how these may be continued and adapted, if necessary, within the assisted living environment. Continuity was also discussed by participants of the current study in the context of relationships with family and friends outside of the assisted livi ng community. As these relationships are important, counsellors could work with older adults and their families, to identify ways in which continuity in these relationships can be maintained and enhanced following their entry into assisted living.    The finding that a personal history of previous moves may be a facilitative factor for transitioning to assisted living also has counselling implications. When working with individuals considering making this transition, counsellors could support clients in tra cing their personal history, to identify how previous moves or life experiences may inform how they approach, and could best cope with, the changes and challenges associated with the move to assisted living. This may help older adults to recognize the reso urces they used previously to manage transitions, and help them to place the move to assisted living within the larger context of their lives.   Many participants spoke about the importance of timing in navigating the transition to assisted living. When wor king with individuals considering making this move to assisted living, counsellors can provide information on the benefits of transitioning at a time when physical and mental health will allow engagement with the activities and opportunities available in a ssisted living.  Discussion around factors that would i ndicate to an individual that the timing is appropriate to make this move may help increase motivation and readiness to make this transition at a time that is fac ilitative of their adjustment.   For individuals who have made the move to assisted living and are finding the transition challenging, the findings of the current study could also be used to support them in making the     131   transition. The findings suggest areas where individuals may experience  difficulties that would contribute to a more challenging experience (i.e., difficulty maintaining continuity with interests, or limited sense of social connection). In working with individual who are experiencing challenges in making this transition, coun sellors could explore the types of difficulties  they are having, and how they may strengthen resources in order to meet them.  For example, strategies to develop social connections or the discovery of previous interests and identification of how these interests may be resumed in their new environment.   One of the participants in the current study specifically described the role she felt a counsellor could fill in the residence. She indicated it would be helpful to have a counsellor to talk about the challen ges and emotions associated with making this transition to a new environment. A counsellor within an assisted living facility would be able to provide emotional support with the initial and ongoing challenges that arise in adjusting to a new environment, a nd could help residents to identify and strengthen resources to navigate this transition.      Researcher R eflections  The best advice I was given when  preparing to undertake this research was to choose a subject that interested me  and that would sustain me throughout the process . I was particularly happy that I followed this guidance when I got to the data collection portion of the study. The  interviews  with participants  were done  during a busy period of my life and I found that th e opportunity to speak with my participants about their transition experiences provided a much appreciated change of pace and opportunity f or reflection. While I had expected to enjoy learning more about this transition, I had not anticipated the extent to  which, i n talking about this specific life event, participan ts would introduce me to their life histories. In talking about the move to assisted living, participants shared with me how this event fit within their larger lived     132   experience. As a result of th eir openness , I took from our interaction s the lessons they had learnt about family, marriage, career, death, and how  to approach change. In a card I received from one of my participants , she thanked me for allowing her to feel that she was my mentor. She, and all of the participants, were mentors in teaching me  not only about this transition but also about life, and I will carry the ir stories with me . 7KURXJKWKLVUHVHDUFKP\KRSHLVWKDWWKHSDUWLFLSDQWV’mentorship  also extends t o those working in the assisted living industry and in counselling psychology, as well as to those individuals who may be considering making a move to assisted living themselves. In sharing their experience s of moving to assisted living , these participants  provided me with unique insights into how to navigate new, and somet imes challen ging, circumstances that are a part of life.                   133   References  Aneshensel, C.S., Pearlin, L.I., Levy- Storms, L. &  Schuler, R.H. (2000). The transition from home to nursing home mortality among people with dementia. Journal of Gerontology, 55, S152 - S162.  Ball, M.M., Whittington, F.J., Perkins, M.M., Patterson, V.L., Hollingsworth, C., King, S.V., and Combs, B.L. (2000 ). 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Counselling p sychology in Canada: Advancing  p sychology for all. Applied Psychology: An International Review,56(1), 20- 32.                         141   Appendices  Appendix A: Recruitment Poster    Do you feel you are managing the transition  to your new residence  well?  If you:   Are over the age of 65 years   Are currently a resident of an assisted living facility in Vancouver that you moved into within the last 1 to 5 years   Feel you are managing the  transition to assisted living well  Then you may be eligible to participate in a stu dy looking at the experience of successful transition to assisted living facilities. For information call 778 - 938 - 0368 or email gofton@interchange.ubc.ca     This study is being conducted by Lucy Gofton as part of her doctoral studies under the  supervision of Dr. Judith Daniluk               142  Appendix B: Screening Interview Script   Thank you for your interest in taking part in this study looking at the experience of successfully transitioning to an assisted living facility. It is a study that I am conducting under the supervision of my supervisor, Dr. Judith Daniluk, as part of my PhD studies in Counselling Psychology at the University of British Columbia. The goal of the study is to speak with individuals wh o feel they have successfully transitioned to assisted- living, in order to determine some of the common aspects of this experience. This will allow for a better understanding of what is involved in successful transition. Participation in the study will inv olve meeting on three separate occasions. The first meeting will be between 60 - 90 minutes long and will be a chance for you to share your experiences of successfully transitioning to the assisted living facility in which you are currently living. The second meeting will be between 30 - 60 minutes long and will be a chance for you to share any other aspects of your transition experience that you may have recalled after our first meeting. I will also be able to share which aspects of our first conversation stuc k out to me, and get your feedback on them. Approximately one month after our second meeting I will send you the themes identified through my conversations with all participants. We will set up a final meeting, which will be approximately 30 minutes, durin g which you can share your reactions to the themes identified.  I have a few questions to see if you are eligible to participate in the study.  1. Are you currently 65 years of age or more?  2. What assisted living facility do you currently reside in?  3.  How long have you been in your new residence?  4. Would you describe yourself as having successfully adapted to or transitioned to your new residence?      143   5.  What would you say was the primary reason you entered into the assisted living facility?  6.  Where did you live before you entered your current residence?              144  Appendix C: Informed Consent  The Experience of Managing Well the  Transition to Assisted Living  Principal Investigator:   Judith Daniluk, PhD      University of British Columbia  Department of Educational & Counsell ing Psychology     Phone: ( 604) 822 5768         Email: j udith.daniluk@ubc.ca    Co- Investigator:   Lucy Gofton, M.Ed, M.Sc., Doctoral Student             University of British Columbia  Department of Educational & Counselling Psychology Phone: (778) 938 0368    Email: gofton@interchange.ubc.ca   Thank you for expressing your interest in participating in this research project that  will explore the experience of overall managing well the  transition to the assisted living facility in which you currently live. Lucy Gofton (Co- Investigator) will carry out this research as part of the requirements for completing the Doctor of Philosophy degree in the Department of Counselling  Psychology at the University of British Columbia. The following letter outlines the study and information about your participation. If you require any further information or explanation please contact me at (778) 938 0368. My supervisor is Dr. Judith Dani luk (Professor and Principal Investigator) who may be contacted at the Department of Counselling Psychology, University of British Columbia at ( 604) 822 5768 .   Your participation is voluntary. You have the right to refuse to participate in this study. If you decide to participate, you may still choose to withdraw from the study at any time without any negative consequences . Before you decide, it is important for you to understand what the research involves.  This consent form will tell you about the study,  why the research is being done, what will be required in participating in the study and the possible benefits, risks and discomforts.   If you wish to participate in this study, you will be asked to sign this form.    The Objective of the Proposed Research: To examine and understand the meaning that LQGLYLGXDOV’PDNHRIWKHLUH[SHULHQFHof managing well the transition  to an assisted living facility.   Rationale for the Study: Canadians aged 65 years or older are a rapidly increasing segment of our society. Of the many transitions that must be negotiated by adults later in life, one of the most significant is the move to residential care. This transition can be difficult because of its relationship to changes in health and interpersonal relationships and a n egative transition impact KDVLPSOLFDWLRQVIRUDQLQGLYLGXDO’VSK\VLFDODQGHPRWLRQDOZHOO- being. We currently lack an understanding of what is involved for older adults in managing this  transition well . This research will seek to determine if there are co mmon aspects of this experience.         145   Your involvement in the process will require you to do the following: • Participate in two  interviews  asking to share your experience of managing the transition to assisted living; each interview being approximately 1- 1.5 hours in length. • Reflect on and discuss the meaning you make of your experience of managing the transition to assisted living well.  • Participate in a  third final interview , lasting no more than 30 minutes, to review the themes emerging from the interviews t o see if they resonate with your experience.   Possible Benefits of Participating in this Study:  By participating in the study, you will have the opportunity to explore and understand the possible impact that the experience of managing well this transition has had on your daily life. This exploration may allow you to reflect on the meaning of this life event for you.   Possible Risks of Participating in the Study:  It is possible that you may experience some psychological discomfort in discussing an event th at may have been challenging for you and had some difficult emotions attached to it. This is the only perceived risk to participating in this study.   Contact for Information About the Rights of Research Participants: If you have any concerns about your treatment or rights as a research participant, you may contact the Research Subject Information Line in the UBC Office of Research Services at (604) 822 8581.   Consent: Your participation in this study is entirely voluntary and you may refuse to participate  or withdraw from the study at any time.   Your signature below indicates that you have received a copy of this consent form and that you consent to take part in this research study.    _______________________________________    __________________  Participan t signature       Date   _______________________________________  Participant printed name    _______________________________________     Witness signature              146   Appendix D: Orientating Statem ents and Interview Guides   Orienting statement for the first interview:  ³7KDQN\RXIRUDJUHHLQJWRSDUWLFLSDWHLQWKLVVWXG\. As we discussed when we last spoke , the purpose of this study is to understand the experience of individuals who feel they are managing the transition to their current assisted living facility well . Previous research on the experience of transition to residential living facilities has focused on some  of the physical and emotional challenges that individuals experience in makin g this transition. As entering into assisted living is a common transition for many individuals later in life, I am interested in underst anding what contributes to an individual feeling that they are managing this event  well . Specifically, my goal is to understand your experience and to determine if there are shared or common aspects of your exper ience with those of others who also feel they are managing this transition well. Do you have any qu estions for me before we begin? Could you being by telling me ab out when you first EHJDQWKLQNLQJDERXWWKHPRYHWRDVVLVWHGOLYLQJ"´ The following question s are some possible prompts which  will be used if the participants raise these issues in the interviews.  1. What was it like for you to make the transition from your previous home to your current residence?  2. How did you talk about this experience of transition with your family members and/or close friends?  3.  How do you feel about your transition to assisted living?  4. What factors contributed to your experience of transition ? (e .g. preparation for transition, aspects of the facility, personal characteristics, influence of other individuals)      147   Closing:  Thanks very much for your time today. I wonder if before we meet next you could think about what advice you would give to someon e considering moving into assisted living?   Orienting statement for the second interview:  ³7KDQN\RXIRUPHHWLQJZLWKPHDJDLQWRGD\$V\RXPD\UHFDOOWKHSXUSRVHRIWKLVVWXG\LVWRunderstand your experience of managing the transition to assisted living well. Today  we can see if there was anything else that came up for you about your transition since we last met.  ,’G also appreciate hearing any advice you may give to someone who was preparing to move into assisted OLYLQJ  ´Again prompts will be used to follow up on what the participants are sharing.  e.g. Have you thought of other aspects of your transition  experience  since we last met?              


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