Geriatric Nursing
Volume 30, Issue 2 , Pages 126-129, March 2009

There's No Place Like Home

Article Outline

The notion of home in assisted living is intrinsically connected to aging—and dying—in place. Yet little is known about what makes a house a home, an interactive environment imprinted with individual choices, styles, relationships, and histories. This article presents meanings of home, from playground to prison, and theories of home and well-being. Intended to provoke thoughtful discussion about the meaning of home for assisted living residents and staff, the article includes the Experience of Home Scale that could be used for quality improvement purposes. Implications for assisted living nursing practice with regard to person–environment interactions that constitute home (for better or worse) are discussed.

 

“There's no place like home.”

—Dorothy, The Wizard of Oz

The philosophy, mission, values, and marketing of assisted living communities (or residences) speak to their “homelike environment.” This notion is intrinsically connected to aging—and dying—in place, that is, in one's home. But what do we mean by home? Whose concept, version, image, or environment makes a place home? Homey? This article describes different notions of home expressed by philosophers, sociologists, nurse researchers and ethnographers, families, and, oh yes, residents of assisted living and other retirement and independent housing residences. The article contains an “Experience of Home” scale, a measure offered for our use for quality improvement purposes by the nurse who developed it: S. L. Molony, PHD, RN. This article hopes to provoke discussion of what is meant by a homelike environment (“homeyness”) among assisted living staff and residents. Given the hours of planning and monies spent to create what we think (and hope) is this special kind of environment, are we getting what we want? Is the resident? Nursing acts to assist the resident in expressing his or her feelings about being “at home” are faithful to nursing's holistic approach to creating an environment that restores and sustains well-being.

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Meanings of Home 

Some authors suggest a definition of home that is both bounded and clarified by what constitutes home and not-home.1 Connotations of home are political, emotional, tangible, spiritual, social, economic, cultural, and geographic. Traversing a broad spectrum of perspectives, home is an architectural phenomenon but has actual physicality and structure; motherland/fatherland/birthplace country; a final resting place (e.g., “Home-Going” funeral ceremony: moving from the physical to the spiritual world); belonging, identity, and status; safety; domesticity; role/gender identification and obligation (e.g., “a woman's place is in the home”); haven; “my space.”2 Home can be a place of terror and abuse, of feeling imprisoned (i.e., being “homebound”), a place to generate income, a hated place for the person who is out of work, a family dwelling place with a history.2 Other dialectical ways of defining home speak of it as “privacy versus intrusion, warm versus cold, control versus powerlessness, caring and being cared for, significance versus anonymity” (p. 250).1

Interestingly, homeless people also have different feelings about home—some idealized, some based on what they once knew and very much want again,2 or never want to go back to (thinking about homeless people who refuse to spend a cold night in a shelter). The notion of home speaks to “inclusion” and “exclusion” and has significant cultural baggage.2 Home is also a place that one leaves from and comes back to (e.g., “home base” in baseball parlance); it takes on meaning because it is a place one journeys away from.2

What else is home? It's a frame, literally and figuratively, that shapes experience and personhood. Home is a place of “individuation,” a place where preferences are expressed through choices made. Simply put, home is where a person can make choices. It speaks to possessions and placement. For Carl Jung, home is a symbol of the self.2 In terms of Maslow's hierarchy of needs, home is a place of psychological comfort that meets social and physiologic needs.2 People invest themselves in their home. The person and the environment are bound together in an existential relationship that contains memory, meaning, identity, and connections.3

How is the notion of home constructed in assisted living? Whose preferences are considered? Is the vision of “homelike” based on some ideal, or on the real-life experiences and preferences of the residents? What is the range of choices encouraged in the expression of home, and how often are they rechecked with the residents (given the turnover)?

Consider holding a staff or a resident meeting to talk about the many notions of home. The earlier-noted defining phrases can be used to get the conversation going. Think and talk about phrases that conjure up home: “home is where the heart is,” “a house is not a home,” “I left my heart in San Francisco,” “This little piggy cried all the way home,” and so on.

You might want to also talk about the meaning of “not-home.” Residents of long-term care facilities (i.e., nursing homes and assisted living) feel that “not home” is being in an institution, in a public place with no privacy—a place of lost identity and without a future.1 Seven life themes regarding “home” and “not home” were identified in a study with older adults living in long-term and life care communities.4 In apposition to each other, not being at home is bracketed in comparison to being at home: privacy [intrusion]; respect [disrespect]; affection [disdain]; security [fear]; autonomy [dependency]; commonality [discordance]; significance [anonymity]. Not being literally at home and forced to be with people who are not of one's choosing can create feelings of discomfort if not anger and depression.4 The overwhelming sensation is feeling not in control, not liked, without purpose or importance, without meaning.4 Other studies looking at the phenomenon of home report similar findings; that is, that notions of home mean privacy, security, family, intimacy, comfort, and control.2 Is this useful for understanding what “homelike” might mean to an assisted living resident?

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House and Home in Assisted Living 

A characterization of housing-by-privacy arrangement can be useful in framing expectations, idealizations, and discussions about homeyness in assisted living. Four housing models are suggested based on degree of privacy and services: low versus high.5

•Low Privacy-Low Services: shared rooms; little assistance with activities of daily living (ADL)

•Low Privacy-High Services: most residents live in rooms, not apartments; some shared rooms; nursing services available

•High Privacy-Low Services: private room or apartment living; little to no help with ADLs

•High Privacy-High Services: private room or apartment living; nursing services available

Rather than assume that absence of privacy is a negative indicator of homeyness, it is necessary to ask the resident(s) who will be experiencing limited privacy if this, in fact, is an issue. Personal history and culture cannot be ignored. In fact, as several writers have shown, “togetherness” is a positive aspect of family, and privacy has many interpretations. Given the increasing cultural diversity of older adults in the United States, it would be culturally insensitive not to consider other ways of knowing “homeyness.”

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Theories of Home and Well-Being 

The defining quality of “home” appears to be that it is a place of emotional interrelationship, even if living alone (there is an interaction and investment with the environment). Two mainstream theories regarding home are “Place Attachment” and “Place Identity.” The first theory, Place Attachment, focuses on the affective components of what it means to “bond” with a particular place. This bonding depends, in part, on satisfaction derived from the experience and identity derived from the place, involvement, and social networks. Think about the statement, “I have my roots in (or I put my roots down) in XX place.” The theory of Place Identity is similar to Place Attachment but is more concerned with the intellectual evaluation of “place” and its impact on self-development and identity; it is a more objective appraisal.

There is a positive relationship between where older adults live and their physical and psychological health.6 This means that “place matters.” Home, then, is a physical form and the surrounding neighborhood and networks such that an older adult's diverse needs are met and they retain their self-respect and identity.6 The meaning of home for older women might be a composite of their life role and identity and, as such, have connotations different from those of older men.6

Most older adults want to stay “at home”; it is a repository of meanings. As stated by Leith,6 aging in place is “a transaction between an aging individual and his or her environment that is characterized by changes in both person and environment over time, with the physical location of the person being the only constant (p. 319).” For an older adult, “home” is the freedom to do whatever, wherever, however.6

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The Experience of Home Scale 

The notions of “home” and “homelike” are typically relegated to a criterion of quality of life (QoL) rather than an outcome criterion of independent stature. The Experience of Home (EOH) Scale focuses on the person–environment relationship; home is a specific aspect of QoL.1 However, home in this context is not the color scheme or furniture or food choices but, rather, a composite existential phenomenon, an experience consisting of multiple aspects. The phrase “at homeness” is the experience of home rather than a specific location.1 There are four dimensions of at-homeness: separation, connection, dynamic transaction, and atmosphere.1 Themes of separation include personal space, privacy, safety, control, ownership, identity, individuation, and choice. Connection denotes relationship, continuity, reciprocity, caring for others and being cared for, tradition, and meaningfulness.

Validity of the scale and the theoretical model that supports it has been established and is undergoing further evaluation. The EOH Scale has not been used with cognitively impaired older adults. However, it bears noting that cognitively impaired older adults have the capacity to consent to low-risk treatments and research participation7 and have the capacity to respond to questions about QoL.8 The EOH Scale is provided in Table 1 for use as an internal quality improvement measure, by permission of its creator. An alternative to the 5-choice scaled responses can be Yes, No, or Not Sure. Open-ended, nonthreatening questions can be added, such as, “What makes you feel at home?” and “What does not home feel like to you?”1

Table 1. Experience of Home Scale—Version VIII
Think about this place and your experience here. Answer the following questions about your experience here. For quality improvement (QI) purposes, items can be eliminated based on features of the environment and other factors.
Note: The respondent can fill out the questionnaire independently or work with someone who reads each item and records the respondent's answer.
Scale options:
1. SA = strongly agree; A = agree; N = neutral; D = disagree; SD = strongly disagree
2. Yes; no; not sure.
1. I feel at home here.
2. I can do what I want here.
3. This place feels cold and sterile.
4. I feel safe here.
5. I have things that I cherish around me.
6. I can be myself here.
7. I have my favorite places/spaces to spend time in here.
8. I have enough privacy to meet my needs here.
9. I feel cared for here.
10. I feel like an outsider here.
11. I am valued as a person here.
12. This place needs me.
13. I feel connected to people I care about.
14. I feel isolated here.
15. I feel welcome here.
16. There is a feeling of warmth and coziness about this place.
17. When I am away, I look forward to coming back to this place.
18. I feel cut off from my life here.
19. I am treated as an individual here.
20. I feel a part of this place.
21. I am among my own people here.
22. I am surrounded by strangers.
Optional:
23. Amount of choice in living here: none; a little; a lot; totally my choice.
24. How much did you know about this place before living here? None; a little; a lot; everything.

Note: Used with permission of S. Molony, PhD, RN, Yale University, New Haven, Connecticut.

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Nursing Implications 

Feeling “at home” appears to depend on the “fit” between a person's life themes and the themes or opportunities in the environment to express and enjoy them.4 The caring ethic of nursing speaks to the need to discover, identify, and describe each resident's life themes such that the environment can be responsive to these personal and, yes, idiosyncratic imperatives. The service plan has to identify or describe the specific needs and preferences of the resident with regard to “what makes this home for me” (somewhat like the “I” plan of care in nursing homes). Whereas residents who felt “at home” were engaged in making new friends and constructing a future, those who felt “not-at-home” were in despair, unable to “journey away from home,” lacking the energy to experience the world's possibilities.4

Assisted living nurses view aging as an ongoing opportunity for growth and positive experience. The vitality of the sense of home is that it provides and maintains identity and self-esteem. This is precisely where nurses matter: to facilitate person–environment transactions that heal, support, and restore, or create meaning. Home, in fact, has the capacity to disappoint, aggravate, confine, and neglect as much as it does to comfort and inspire.2 The EOH Scale can help assisted living nursing champion the notions of “homeyness” and “homelike” that respect the person–environment relationship. It moves the notion of “home” from a physical artifact to one that is embedded with meaningfulness, caring, and comfort.

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References 

  1. Molony SL, McDonald DD, Palmisano-Mills C. Psychometric testing of an instrument to measure the experience of home. Res Nurs Health. 2007;30:518–530
  2. Moore J. Placing home in context. J Environ Psychol. 2000;20:207–217
  3. Molony SL. The meaning of home. Unpublished paper. University of Connecticut; 1999;
  4. Hammer RM. The lived experience of being at home. A phenomenological investigation. J Gerontol Nurs. 1999;25:10–18
  5. Hawes C, Rose M, Phillips CD. A national study of assisted living for the elderly. U.S. Department of Health & Human Services, 1999. Available at http://aspe.os.dhhs.gov/daltcp/reports/facres.htmCited Nov. 12, 2008
  6. Leith KH. 2006 Home is where the heart is… or is it? A phenomenological exploration of the meaning of home for older women in congregate housing. J Aging Studies. 2006;20:317–333
  7. Mity E, Post LF. Healthcare decision making. In Capezutti E, Zwicker D, Mezey M, et al., eds. Evidence-Based Geriatric Nursing Protocols for Best Practices. 3rd ed. New York: Springer Publishing Company, p. 521–538.
  8. Kane RA, Kling KC, Bershadsky B, et al. Quality of life for nursing home residents. J Gerontol A Biol Sci Med Sci. 2003;58:240–248

ETHEL L. MITTY, EdD, RN, is an adjunct clinical professor of nursing at the John A. Hartford Institute for Geriatric Nursing, College of Nursing, New York University, New York.

SANDI FLORES, RN, C, is the education director at Community Education LLC, San Marcos, CA.

PII: S0197-4572(09)00038-X

doi:10.1016/j.gerinurse.2009.01.004

Geriatric Nursing
Volume 30, Issue 2 , Pages 126-129, March 2009

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