Social Contact and Belonging Among Older People Receiving Home Care Nursing

Introduction

The promotion of opportunities for social contact and enhancement of the sense of social belonging are important for home-dwelling older persons. Social contact and belonging may also be critical to avoid the feeling and experience of loneliness.^1,2 Studies have shown that a proportion of older persons did not feel involved in the society, and they felt excluded from activities due to their age.^2,3

Belonging has been described as a multifaceted concept and phenomenon. Social belonging has been defined as an individual emotional sense of feeling comfortable at home and safe in the living environment, both physically and socially. Moreover, the feeling of belonging has been associated with relationships to the environments through practice.⁴ Chin underlined that the sense of belonging has been presented as how a person judges their belonging, and how other individuals assess that person’s belonging.⁵ In that way, the sense of belonging may promote a feeling of being understood and recognized as belonging.⁵

In a group interview study, older suburban dwelling persons recognized belonging as a “feeling”.⁶ Interaction with other persons and involvement in activities were described as aspects of belonging as well as assessment to information and knowledge about available resources.⁶ Moreover, in a study of older home-dwelling persons, Carlsson et al found that confinement due to the pandemic promoted the feeling of disconnection with other persons and family members, and social inactivity promoted the feeling of loneliness that might be boring.⁷ Further on, a proportion of older persons have stated that they felt worthless and excluded when they perceived themselves ignored. Such feelings may also be evoked by healthcare professionals and family members.⁸

Cramm and Nieboer showed that changes related to social connection and belonging in the lives of older persons may influence their well-being.⁹ Assistance and support with regard to social involvement when needed may be important for preventing the negative effects among frail older persons living at home.⁹ Colin explored the meaning of nostalgic belonging among older persons and the mechanism through which memories may influence the present sense of belonging to the neighborhood. Talking about their life in the past and earlier environments, may be a way for older persons to link their previous sense of belonging to the present. This may assist in the adoption of a renewed sense of belonging or be a barrier.⁴ However, Chan et al reported that religious belief may help persons to overcome their social disconnection.¹⁰

Most persons who receive help and assistance by local home care services in Norway are aged >70 years. Although they may have extensive care needs, a large proportion of older persons live in their original homes. In addition, numerous frail old persons have moved into flats in sheltered living facilities located near the healthcare services.¹¹

Studies have shown that the organizational structures in home care nursing may be a barrier for meeting the social needs of older persons,^12,13, and the social care may depend on the individual caregiver that older persons meet.¹³ Chin pointed out the importance that the political profile of a community promotes the sense of belonging in people by valuing their voices and rights.⁵

“A full life – all your life” is the title of the Norwegian “quality reform for older persons”.¹⁴ This reform addresses the health care professionals. An objective of this reform is to promote the inclusion of older persons in the community and living environments, as well as provide opportunities for social participation and activity despite the presence of health problems. To achieve these goals, it is necessary to interact with older persons and consider their viewpoints on this matter.¹⁴

This study gave an opportunity to older persons who are dependent on help and assistance in their everyday life at home to share their experiences regarding their social contact and belonging. The aim of this study was to explore the features that influence social contact and belonging among older persons who receive home care nursing.

Materials and Methods

This study has a qualitative design based on individual in-depth interviews.

Recruitment and Participants

Home-dwelling persons aged >65 years who received home care nursing were recruited for participation in this study. The recruitment was performed based on a cooperative agreement with the Center for Development and Home Care Services in Southern part of Norway. The study was introduced to the first line managers of three Home Care Services by contacts at the aforementioned center. The primary investigator (first author) presented further information to the Home Care Services. The home care nurses asked potential participants whether they wanted a full account from the research manager and an invitation to participate in the study. Nine older persons (three men and six women) were included in the study. All participants lived alone in their own homes. Six of the informants had moved into flats and three of those informants lived in flats in sheltered residences. The age of the participants ranged from 73 to 97 years, with most aged 80–89 years.

Data Collection

Data collection in this study was conducted during 2016. The interviews took place at the homes of the informants. The interview guide included the following questions:

Please tell me about your experience regarding social contact and belonging with other people.

Please tell me about your positive experience regarding social contact and belonging with other people.

Please tell me about your negative experience with social contact and belonging with other people.

Follow-up questions were raised to enrich the responses.

The informants were encouraged to speak openly regarding their experiences in accordance with the methodological approach of this study. The interviews were audio recorded and transcribed verbatim. The average duration of each interview was 50 min.

Analysis

The analysis of interview transcripts was performed in accordance with the model of content analysis described by Graneheim and Lundman.¹⁵ Two investigators were responsible to conduct this analysis. However, the steps in the analysis were discussed with the other researchers. Further on, the analysis was based on the manifest content in the interview transcripts, that is what the interview texts did say.¹⁵ The following steps were performed:

1) The interview transcripts were initially read to obtain an impression of the content.

2) The interview transcripts were reread and divided into meaning units.

3) Each meaning unit was summarized in condensed text.

4) The following process was to abstract these texts into codes.

5) Finally, the various codes from all the interviews were compared to create categories based on commonalities.

The following categories were created:

• Social activity – availability of the necessary resources
• Importance of contact with family and friends
• Importance of housing
• Interaction with helpers and accommodation of needs
• Reflection on the past and considering life in context

Examples from the analysis are presented in Table 1.

Table 1 Examples of the Manifest Analysis

Ethical Considerations

The study was presented to the regional ethics committee (reference number: 2014/1571B) and was approved by the Norwegian Centre for Research Data (Norwegian Social Science Data Services; project number: 40064). The investigation was performed in accordance with the tenets of the Declaration of Helsinki.¹⁶ The informants provided written informed consent for their participation in the study that also included publication of anonymized responses. They were informed regarding voluntary participation and the possibility to withdraw from the study at any time.^16,17 The COnsolidated criteria for REporting Qualitative (COREQ) checklist was used as a guide for reporting the findings of the study.¹⁸

Findings

Social Activity – Availability of the Necessary Resources

Social activity varied among the informants and appeared to depend on the availability of the necessary physical and mental resources, as well as sufficient support to join other persons in social activities.

Regular participation in social activities together with other older persons was strongly appreciated by some of the informants and this was also something to look forward to. This provided opportunities to participate in hobby communities and joint activities, as well as spend time together, have meals, etc. One informant stated that she got transport to the local daycare center 3 days per week. Although she expressed the desire to participate more often in these activities, she was economically unable to do so. She stated the following:

This is very important to me. There we use our first names, and we do needle work together all the time; that is the life. (Informant 1)

Going to a local swimming pool once weekly to meet with other friends and perform swimming activities was also expressed as a preferred social activity by another informant:

It means a lot to me. We are a very nice bunch there. And they are pleasant people, and good friends are meeting each other. We arrive at 11 o’clock and swim for 1 h. Afterward, we drink coffee, eat cakes, and chat for about 2 h. This is very nice, and then that day is over. We can look forward to the next time. (Informant 8)

Although this informant did not always participate in the swimming activity, he looked forward to meeting his friends for the social aspect of this arrangement, and he received assistance with transportation from another participant.

However, several of the informants were unable to participate in the same way as they did before because of worsened health problems; consequently, they had to select and regulate participation in social activities. Help from volunteers, who brought persons to the local social activities at the living places, was appreciated. An informant expressed that she was dependent on help from other persons, and she did not prefer to go to the local meeting places. She appreciated the weekly visits of a volunteer who joined her during trips to the town.

Feelings of loneliness and isolation varied among the informants. Watching television was considered important for receiving information and following the latest developments. Moreover, television was considered useful as company to avoid loneliness and as a possibility to join community.

However, several of the informants revealed that they had limited social contact with other people. Increased health problems were perceived as barriers to social contact. Two of the informants stated the following:

I am in such bad shape, and I do not have the energy to contact other people and talk with somebody. I have enough with myself. (Informant 2)

It is some telephone talking…Otherwise I am a lot alone” …“Many times, I feel lonely”. (Informant 5)

Loneliness was also described as a continuous feeling of boredom:

I have always felt lonely, and that has been very boring for me. Loneliness is the most boring feeling that exists. (Informant 4)

A painful loneliness may also be experienced, although the residents at the living place had meal-sharing offers and opportunities to visit each other.

Social contact is equal to zero. Everybody lives in their bubble. No one visits each other…I try to go downstairs to eat dinner, but other than that, there is no social contact. (Informant 3)

Importance of Contact with Family and Friends

Contact with family and friends was perceived as important and useful. However, some informants indicated lack of such contact. Several informants stated that they appreciated visits by family and friends. Having family members who cared for them was valued by the informants. An informant expressed this as follows:

Then, my children visit me, and they carry me on their hands. They have been absolutely incredible. (Informant 9)

For some informants, practical support is provided by family members residing nearby, as needed. An informant stated that she could not pay for the municipal home help, and one of her children provided practical help. Another informant needed help from his family to remove the support stockings. Telephone contact with close family members was also reported as important when feeling sad. One informant expressed this as follows:

Life goes up and down. Nowadays I am very down… Therefore, it so good that my son calls me. He called me yesterday, and he will call me again in this evening. (Informant 3)

Contact with family members may also stimulate the engagement and interest of the older persons. Some of the informants talked (proudly) about their children and grandchildren, sharing information regarding their education and jobs. Furthermore, they were engaged in the everyday lives of their family members. Sharing memories were also valued, and there may be future visits to look forward to. An informant stated that it is important to have family descendants.

Some of the informants also reported limited contact with family members and friends, that may induce a feeling of worthlessness. They expressed that their family members were busy in their everyday life, hence they stated that they avoided bothering the family and friends. An informant also expressed that, although previously her family found her useful, currently, contact was infrequent. Increased health problems were also experienced as barriers to visit family or family members were not living nearby.

An experience was also that friends had passed away. An informant expressed this as follows:

When you get very old, all your friends are dead… No friends are living any longer. It is not fun being old. (Informant 2)

Several of the informants reported missing a deceased spouse and loss of close family members. An informant stated that she had to overcome loneliness, but cherished memories. Another informant said he had to accept the feeling of longing. However, he described such changes in life as follows:

It hurts very much in life when suddenly a person is no longer there. (Informant 6)

Importance of Housing

The older persons were concerned about their life at home, and most of the informants had moved into flats or flats in sheltered residences. The transition to new housing facilities was considered a necessary step due to their health problems. However, the informants might describe their previous housing arrangement as their real home. Two informants expressed the following:

And then, if it had not been for my legs, I would have stayed at home. (Informant 7)

Of course, one could have wished for another life in house and home, but now it is once like that. (Informant 9)

However, living in a place for several years and maintaining the same routines as in the past may evoke a feeling of comfort at home. To put the housing situation in a life perspective seemed important in varied ways. An informant stated that, although she felt comfortable in her flat, she also appreciated visiting her childhood home. The informants who had lived in their houses for many years talked about memories in their homes and changes in their lives, such as losing their spouses.

Some of the informants expressed enjoyment with regard to the design of their flats and stated that decoration of the house based on the personal style of the older person is important. Observation through the windows was also described positively; for example, watching cars on the road and people passing by. An informant stated that she could look at people dressed in beautiful national costumes passing by on National Day. This informant also reported that she was safe at her living place and there was nothing to be afraid of. She also enjoyed doing purposeful needlework in her flat. She stated the following:

I cannot feel better than I have. Now I am sitting in my chair, and then I can finish this needlework. I thought it could be finished in a week. (Informant 1)

Feeling safe at the living place was also reported as important by another informant. Contact with the neighbors was emphasized by some of the informants. An informant stated that she could ask the neighbors for practical help. Another informant appreciated the possibility of joining a hiking community, trips by car, and visits at home that involved interaction with another person. Contact with neighbors could also result in new acquaintances and provide an experience of unity.

However, wintertime poses barriers to going out and meeting people in the neighborhood. Furthermore, it was also reported a feeling of not being accepted by the neighborhood.

An experience of being alone in the flat most of the time was reported as providing a feeling of dissatisfaction. An informant stated the following:

Now I cannot even read. I must listen to audiobooks. That is a different thing. And then I sit in a chair that is so painful to sit in. I am getting completely cramped. I have so much pain. …Here, we do not visit each other. It is very painful to me. (Informant 3)

Interaction with Helpers and Accommodation of Needs

All informants elaborated on their experience regarding help and support in their daily life. Interaction with helpers and accommodation of their needs were important to older persons. Their relationships with the healthcare system in the community, that might include both professional and volunteer help and support, influenced their daily life.

Several of the informants stated that they appreciated visits by home care nurses that were associated with safety and predictability. Moreover, the informants judged the help as caring and pleasant. Two informants stated the following:

They are very nice to me and help me. So, I feel well. I’m as good as possible. One cannot expect everything when you are almost 90 years old. (Informant 9)

I think I am well taken care for. And then I also do my best. (Informant 5)

Regular visits may secure social contact. However, the communication with the home care nurses was described in various ways (eg, good, nice, and cheerful, as well as limited and unidirectional).

Two informants shared the following experiences with regard to communication:

I am the one talking. They basically say nothing. (Informant 8)

Sometimes they have time to sit down and talk with me for a while. Other times they are busier. (Informant 5)

An informant stated that she received praise by the home care nurses when she managed to perform selfcare activities, and she appreciated that the nurses noticed her effort. She described this as follows:

I exist, but it is a good feeling when they think you do a good job, that you are not only a burden. (Informant 9)

However, the ability for selfcare may also result in receiving less help by the helpers. An informant expressed that she encountered barriers when she asked for some simple practical housework assistance by the home care nurses. She was told she had to apply formally for more assistance. The informant thought that this policy was strange and reported that she did not take further action. This informant stated that old persons should receive more help. According to her claim, she had to work hard to receive the necessary help, and she judged the help as minimal.

Another informant revealed that she waited for a decision regarding an application for a special chair adapted to her needs based on her health problems, and she reported that this was a time-consuming process. This made the participant feel ignored by the community. She stated the following:

You know, when we are not productive, we do not count. (Informant 3)

Reflection on the Past and Considering Life in Context

Several of the informants talked about their lives in the past. Reflection on the past may promote exciting memories and stories about successfully overcoming a stressful life. An informant stated the following:

When I look back, I do not understand how I managed to overcome all the work I have done. Nowadays, the evenings come very soon. (Informant 6)

Life in the past may also be described as a fairytale despite hard times. Pleasant and unpleasant memories were used to explain how the informants manage their present situations and what they are missing. Several informants stated that they had been social and active in their working life.

An informant recounted many good memories, and she enjoyed looking in her photo album. Another informant revealed that he had had a good life with many friends. He did not know whether these friends looked upon him as a friend, but he took care of those who continued to visit him.

Some of the informants expressed that their belief in God was important in their lives:

The first thing I do in the morning, is to read my devotional book, and the last thing I do in the evening is to read the Bible. (Informant 1)

Furthermore, this informant stated that she would appreciate having a devotional community at the day care center.

Another informant expressed that trust in God had been helpful in hard times through life:

This is the foundation of my life, and it is good for me to have a safe anchorage for what is coming. I know that sooner or later I have to leave this life. (Informant 6)

In addition, this informant stated that the community at the meeting house was very important to him. Religious reflections with other aspects were also presented. An informant who had decided to leave church reported the following:

I do not talk about death. I only speak about the other side. It is just to leave a room for another. Then you can’t return to the previous room. And your next life depends on how you lived your previous life. (Informant 3)

Discussion

The aim of this study was to explore the features that influence social contact and belonging among older persons who receive home care nursing.

Belonging requires a person’s self-awareness of the right to belong, and other people in the community must accept the person as belonging.⁵ This may be an overall perspective. Consequently, in older persons, this sense of belonging may depend on the respect they receive from society. This indicates that the society must acquire the important things for older persons and understand their desires and needs.¹⁹

The lack of social contact is perceived as a barrier to the sense of belonging in older persons.⁶ Our findings showed that social activity may pose risks among frail old persons depending on both external and internal resources. Transportation, financial status, support, and assistance were identified as factors influencing the ability to join valued meetings. Jakubec et al reported similar findings with transportation and support.⁶ In the present study, older persons who were able to use the offers for joining social meeting places valued these possibilities. Those older persons appreciated being able to perform activities together with other people, and that these activities were predictable.

Ongoing and predictable social activities among older persons may promote a feeling of belonging.⁶ Consequently, people may be familiar with each other in social meeting places, thereby strengthening the sense of belonging. Chin pointed out the social perspective of belonging to a group as a feeling of mutual recognition.⁵ However, the present study shows that health problems may be a barrier to social activity, and, for some older persons, the feeling of loneliness was a challenge. Loneliness have been described in the literature²⁰ as the lack of relationships desired by the person. Feeling lonely may reduce the sense of belonging.¹ Interestingly, during the pandemic, older persons felt disconnected when they did not have opportunities to interact with other people.⁷ This finding confirms the importance of access to valued relationships for older persons.

In a previous study,¹² home care nurses expressed difficulty in posing questions concerning loneliness to older persons. Such communication requires time that is usually not available. Healthcare professionals have also pointed out that loneliness may be perceived as a taboo subject.^12,21 Suffering from loneliness may be a silent pain among older persons.²¹

Our study showed that regular visits by home care nurses were valued. Furthermore, it can be claimed that, for some older persons, such visits may be directly linked to their sense of belonging. Belonging has been described in the literature as the core of the membership of a person in the community.⁵ The findings of the present study showed that communication with home care nurses and volunteer helpers is important in the lives of older persons. Based on the perspectives of belonging stated by Chin,⁵ the relationships with healthcare professionals and volunteer helpers may be important possibilities to be confirmed and respected and following enhance the sense of belonging in older persons. This may also include to link the individual to his/her rights, and interests and listen to the person’s voices.⁵ These aspects may require a person-centered approach in care of older persons that focus on the individuals’ preferences.¹⁴

Healthcare professionals, such as home care nurses, should offer their services in a way that confirm the worth and eligibility for assistance of an older person.^19,22 In our study, some older persons expressed that receiving the help they needed was challenging, and communicated a type of resignation regarding organizational structures in the healthcare system. In another study, older persons expressed that the availability of information regarding help and access to resources affected their sense of belonging.⁶

In our study, contact with family and friends was important for several older persons. Such contact was linked to access to support and help, sharing of memories and engagement in activities, and in contrast, loss of contact with family members and friends induced feelings of uselessness and being a burden. In a previous study,⁸ older persons stated that the absence of friends or family to share thoughts and experiences, as well as rely on, may promote a sense of disconnection.

However, the findings of our study showed that a group of older persons depend on other family members, volunteer helpers, and healthcare professionals for social contact and further on a sense of belonging. A previous study showed that the presence of relatives or healthcare professionals who respect the dependency and needs for care of older persons may promote feelings of being valued and further on a status of being cared for.²² Moreover, self-awareness of that intrinsic value may be at the core of the sense of belonging in older persons.⁵ This may also depend on the political stance of the society with regard to old age.¹⁴ Old age and the need for help should be valued by society.²²

Our findings also showed that several of the older persons had moved from their previous homes into flats, and several of them stated that they continued to consider their previous housing arrangement as their home. The move to a new residence may be necessary due to health problems. For some older persons who had not moved into a new house, their homes offered the comfort of memories. In another study, older persons considered home a place associated with their past, present and future, and this influenced their sense of belonging.²³ It can be claimed that a broken-up process demands a challenged adaption to frail old persons, and further on influence their sense of belonging. In our study, some older persons stated that they valued the feeling of safety, maintaining routines, vibrant surroundings, nice flats, and contact with neighbors. However, feelings of being trapped were also reported.

A life span perspective was a central aspect of our findings. This might involve linking life in the past to the present and future. This process might cause older persons to become more anchored in their aging process.²⁴ This may also improve their sense of belonging. However, nostalgic belonging may also negatively affect the present life of older persons and become a barrier to a renewed sense of belonging.⁴ Professionals have expressed the importance of contact with older persons and awareness of their reflections and thoughts with regard to belonging. Thus, healthcare professionals must be able to converse with older persons about life and death and may be overcome their own fear for doing that.²⁵

Strengths and Limitations

The strength of this study is that the analysis was based on direct interviews of older persons who received home care nursing. Nevertheless, selection bias may exist in this investigation due to the influence of healthcare professionals on the recruitment of participants. However, the findings showed variability in common features. This may support solid findings in the study. However, a larger sample size could potentially provide an enhanced understanding of social contact and belonging. Furthermore, this study included both men and women informants. If the number of men had been larger, this could also provide more varied findings. However, the data were rich, and saturation was obtained.

All researchers in this study have PhD degrees with specialization in geriatrics and have work experiences as nurses in geriatrics. The second author performed most of the interviews. The first author conducted one of the interviews. The analysis of the interview transcripts was performed by the first and second authors. All steps in the analysis were discussed with the other authors. This approach was taken to ensure unbiased data analysis, which is important when assessing the validity of the study. Furthermore, quotes are used to emphasize the findings. The findings are also compared with those of other studies. This improves the reliability of the present study. We assess that the findings in the present study are plausible. The data collection was performed in 2016, that can be considered as a limitation in the study. However, comparing the findings with other studies, the topics and findings are still relevant.

Conclusions

The findings of the study revealed important common features that influence social contact and belonging among older persons who receive home care nursing; however, the analysis indicated variability in those features. Social contact and belonging among older persons in need of help depended on the availability of resources, support, and the sense of being cared for. Engagement with family and contact with friends and neighbors are valued or a strong missing among some of the older persons. Volunteer helpers might play key roles in access to social contact. Communication with home care nurses seemed to be important for recognition as valued persons and as a link to the healthcare system in the community. Consequently, it can be claimed that contact with the home care nurses is essential for the sense of belonging in older persons. This is an aspect that also must be accentuated in the nursing education. A life span perspective on current life situations and living places appears to be important for several older persons seeking to be anchored in old age and their homes. This may also be a challenging task. To enhance the sense of belonging among older persons who receive home care nursing, the healthcare system and community must understand and accept the dependencies of older persons in a manner that recognizes them as valued individuals.