Health Assessment

3122  |  Nursing Open. 2023;10:3122–3131.wileyonlinelibrary.com/journal/nop2

1  |  INTRODUC TION

The World Health Organization (WHO) on 11 March 2020 de- clared COVID- 19 as a pandemic and a serious threat to public health (Psevdos et al., 2021). From the beginning of the COVID- 19 pandemic, most countries adopted a serious quarantine policy and containment to stop the spreading of the virus. This disease has con- taminated more than half of the world's population (Bouillon- Minois et al., 2020). The older adults are more susceptible to COVID- 19 and at risk of its clinical side effects such as respiratory failure and death (Psevdos et al., 2021).

2  |  BACKGROUND

The most elevated rate of death from COVID- 19 occurs in debili- tated older adults. The current estimate of COVID- 19 mortality in individuals over 80 is up to 9.3%. (Bolt et al., 2021). This signifies the importance of attending to the older adults as a high- risk group that requires more precise preventive precautions than other age groups (Bolt et al., 2021; Lee et al., 2020); especially the older adults who have physical or cognitive impairments and live in long- term care centres or nursing homes (Jannat Alipoor & Fotokian, 2020; Lee et al., 2020; Psevdos et al., 2021; Thompson et al., 2020).

Received: 8 March 2022  | Revised: 14 November 2022  | Accepted: 10 December 2022

DOI: 10.1002/nop2.1562

R E S E A R C H A R T I C L E

The older adults' experiences of living in the nursing home during the COVID- 19 pandemic: A qualitative study in Iran

Zahra Asgari1  | Azar Darvishpour1,2

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. © 2022 The Authors. Nursing Open published by John Wiley & Sons Ltd.

1Department of Nursing, Zeynab (P.B.U.H) School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran 2Social Determinants of Health (SDH) Research Center, Guilan University of Medical Sciences, Rasht, Iran

Correspondence Azar Darvishpour, Address: Langeroud - Zeynab (P.B.U.H) School of Nursing and Midwifery, Martyr Yaghoub Sheikhi St. leyla kooh, Langeroud, Guilan, Iran. Email: [email protected] and [email protected]

Abstract Aim: This study aimed to describe the experiences of older adults living in a nursing home during the COVID- 19 pandemic. Design: A qualitative descriptive study. Methods: In present study, 20 older adults living in a nursing home in Rasht, north- ern Iran, participated. Purposeful sampling was applied until data saturation. The qualitative content analysis was done according to the steps proposed by Zhang and Wildemuth. Results: The central theme was “Intensification of life problems in the nursing home”, which emerged from the 115 primary codes, 4 main categories and 7 subcategories. The main categories included “feelings about COVID- 19,” “intensification of isolation and loneliness,” “imprisonment and feeling forgotten” and “difficulty in adapting”. Conclusion: Quarantine and special protocols have aggravated the hardships of life for older adults, and they experienced negative emotions in the nursing home. However, the older adults hoped that the situation would improve, and the pandemic would end.

K E Y W O R D S COVID- 19, epidemic, older adults, qualitative study

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In Iranian culture, providing care for the elderly is the family's re- sponsibility, and the family is considered to be the primary source of support (Foroughan et al., 2019). However, recently, nursing homes have been expanding in number, capacity and size in Iran (Ghazi et al., 2013). In Iranian nursing homes, most residents are poor and homeless with a range of physical and psychosocial problems. Such nursing homes provide assistance with grooming and bathing, dress- ing and eating and skilled care by Registered Nurses (Foroughan et al., 2019).In Iran, most nursing homes have hospital- like designs, so that older adults usually share a room with two or more roommates. While by paying more, older adults can have private rooms, where some stay alone or with their spouses (Khodaveisi et al., 2018).

During the quarantine due to the COVID- 19 pandemic, rapid identification and isolation of suspected and confirmed patients with COVID- 19 were the outmost policies of the nursing homes (Shoaee et al., 2022). So, residents living in nursing homes were not allowed to meet their families and visitors for long periods and walk outside or inside the building and had to keep a safe distance from each other, so they were confined to their rooms (Bouillon- Minois et al., 2020). According to the high rate of transmission of the virus, if a person is infected with COVID- 19 in these centres, the clinical situation in these centres will be complicated (Psevdos et al., 2021; Ventura et al., 2021). In this regard, to protect the health of older adults, nursing homes tried to incorporate particular pre- cautions and protocols precisely (Bouillon- Minois et al., 2020; Lee et al., 2020; Psevdos et al., 2021).

Beyond the positive effects of quarantine in preventing the spread of the disease, its negative consequences also have wide di- mensions (Bouillon- Minois et al., 2020). Reduced mobility and so- cial interactions are serious risk factors for accelerating dementia, memory impairment, dependence and increased risk of falls in older adults (Booth et al., 2012; Bouillon- Minois et al., 2020). Along with the physical consequences, living in a nursing home during quaran- tine is an unconventional experience with its psychological effects, of which depression and social isolation may be the most common. An acute fatal problem may be prevented through quarantine and restrictions. However, older adults may suffer serious consequences (Bouillon- Minois et al., 2020).

According to the experiences of older adults living in nursing homes, the results of one research showed that providing care based on the personal needs of each person along with playing the right role of staff is effective in inducing the residents to feel at home (Moore & Ryan, 2017). Also, by relying on five dimensions of health, including positive relationships, a sense of belonging, meaning- ful sources of existence, productive moments of feeling good and acceptance, the joy of life of older adults in nursing homes can be enhanced (Rinnan et al., 2018). There are two main categories of fac- tors that cause older adults' dissatisfaction in nursing homes: human and environmental factors. These factors indicate the need for in- tervention to improve the quality of care provided to the residents (Zamanzadeh et al., 2018).

Despite previous studies, the COVID- 19 epidemic has created new conditions for the older adults living in nursing homes, which

in addition to pre- existing experiences, can have significant physical and psychological effects on the older adults as a vulnerable group. Perceiving older adults' experiences could help improve their quality of life in nursing homes. Therefore, the present study aimed to ex- plain the experience of older adults living in a nursing home during the COVID- 19 pandemic.

3  |  METHODS

3.1  |  Design

The present study was a qualitative descriptive study that was con- ducted from April to September 2021.

3.2  |  Participants

The target population was the older adults living in a nursing home in Rasht, the capital of Guilan province, located in the north of Iran. This city only has one non- profit, public nursing home that oper- ates round the clock for older people and disabled. Thus, a single research setting was used for this study.

The purposeful sampling method was used to recruit the partic- ipants. Purposeful sampling is a technique widely used in qualita- tive research for the identification and selection of information- rich cases for the most effective use of limited resources (Patton, 2002). This type of sampling involves identifying and selecting individuals or groups of individuals that are especially knowledgeable about or ex- perienced with a phenomenon of interest (Cresswell & Clark, 2011). There are numerous purposeful sampling designs. Homogeneous sampling is a purposeful sampling method in which a group of peo- ple of the same age, gender, background or occupation is selected. It is often used when researching a specific trait, feature or area of interest (Palinkas et al., 2015). A homogeneous sampling design was used in the present study. The selection of participants was based on the inclusion criteria, and the sampling was continued until data saturation. Inclusion criteria included age of 60 years and older, liv- ing in a nursing home for at least 6 months before the COVID- 19 pandemic, and ability to express daily experiences, lack of cognitive and hearing impairment. The exclusion criteria were unwillingness to continue participating in the study. The data were saturated with 18 people and 2 other older adults were interviewed for more cer- tainty. A total of 20 older adults participated in the present study. The demographic characteristics of the participants are presented in Table 1.

3.3  |  Data collection

The interview was conducted in a semi- structured and in- depth manner. The time and place of the interviews were determined in coordination with the interviewees. The duration of each interview

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was 20– 30 minutes. Interviews started with questions such as “What was life like in a nursing home before the COVID- 19 pandemic?,” “What was the difference between living in a nursing home during the COVID- 19 pandemic?,” and then based on the participants' an- swers using exploratory and leading questions such as “What do you mean?,” “How?” and “Can you explain more about that?,” continued.

The researchers used field notes to record observations, inter- actions, communication and nonverbal gestures. Each interview was recorded with the patients' permission and transcribed verbatim and then coded on the same day. After analysing each interview, the next interview was conducted.

Interviews were conducted by both researchers. Detailed anal- yses were conducted independently by each researcher, and they reached a consensus in a face- to- face meeting after explaining the codes and classes to each other. External evaluation of research pro- cess was performed to resolve disagreements, by peer debriefing and member checking.

3.4  |  Analysis

In this study, the qualitative content analysis was performed. It offers opportunities to analysis manifest and descriptive content, resulting in categories, as well as latent and interpretative content, resulting in themes (Lindgren et al., 2020). Researchers avoid using pre- existing categories so that the categories and names for categories result

from the data (Hsieh & Shannon, 2005). The content analysis of in- terviews was done according to the stepsproposed by Zhang and Wildemuth, which included: (1) preparation of data, (2) definition of the unit of analysis, (3) development of categories and the coding scheme, (4) testing the coding scheme in a text sample, (5) coding the whole text, (6) assessment of the coding's consistency, (7) drawing conclusions from the coded data and (8) reporting the methods and findings (Zhang & Wildemuth, 2009). From the data analysis, 115 initial codes were obtained, which were divided into 7 subgroups by their continuous comparison. Finally, four main categories emerged, which are addressed in the results section. The MAXQDA 2020 software was used to analyse the data.

3.5  |  Ethics

The study was approved by the Ethical Committee at the Guilan University of Medical Sciences (Approval Number: IR.GUMS. REC.1400.442). Participation in the interview was completely volun- tary. The participants were informed that the interview would be re- corded and that the data collected would not be disclosed. Written informed consent was obtained from participants. They were as- sured that they could withdraw from the research whenever they wished, and all their information would remain confidential.

3.6  |  Rigour

Lincoln and Guba (1985) were the first to address rigour in their model of the trustworthiness of qualitative research (Lincoln & Guba, 1985). Trustworthiness is used as the central concept in their framework to appraise the rigour of a qualitative study (Cypress, 2017). In this study, the Lincoln and Guba criteria (1985) were used to ensure the trustworthiness of the study, including credibility, dependability, conformability, transferability and authen- ticity of data (Polit & Beck, 2008). To ensure credibility, researchers' engagement with data and continuous comparison was used. To en- hance conformability, the researcher referred the findings and ex- tracted codes to the participants for confirmation or correction, and by confirming them, the findings were validated. The dependability was improved by members of the research team and people who were qualified in this field. To establish transferability, researchers have recorded and reported all stages of the research, and by pro- viding a complete research method, along with examples of partici- pants' statements, it is possible for other researchers to follow and continue the research path.

4  |  RESULTS

From the data analysis emerged a central theme called “Intensification of life problems in the nursing home” and 4

TA B L E 1  Demographic characteristics of the participants

Demographic characteristics N (%) or mean (SD)

Age (year)

60– 74 14 (70)

75– 90 6 (30)

Sex

Male 11 (55)

Female 9 (45)

Marital status

Single 2 (10)

Married 5 (25)

Widow 11 (55)

Divorced 2 (10)

Living in nursing home (year)

<1 2 (10)

1– 5 14 (70)

>5 4 (20)

Education

No formal education 13 (65)

Elementary 5 (25)

Diploma 1 (5)

University 1 (5)

    |  3125ASGARI and DARVISHPOUR

main categories. Four main categories included “feelings about COVID- 19” with 4 sub- categories: Fear (with 3 sub- subcategories: severe fear of COVID- 19, fear of family getting COVID- 19 and fear of quarantine), the feeling of hatred of COVID- 19 (with 2 sub- subcategories: hatred of COVID- 19 and its consequences, ten- dency to leave the nursing home), Homesickness and Hope (with 2 sub- subcategories: hope for the effectiveness of the vaccines, hope and prayers for the eradication of the COVID- 19 despite a vague future), “intensification of isolation and loneliness,” “im- prisonment and feeling forgotten” and “difficulty in adapting with Conditions.” Figure 1 shows a diagram of the central theme, main categories and sub- categories.

4.1  |  Central theme: Intensification of life problems in the nursing home

Most of the participants mentioned the point that there were always some challenges and difficulties in daily living in nurs- ing homes. These vary from the adaptation to the food, room- mates, and staff to missing the family. The quarantine due to the COVID- 19 pandemic made the older adults get stuck in the many new challenges which exacerbated the previous ones. This central theme comprised main categories, included “feelings about the COVID- 19,” “intensification of isolation and loneliness,” “imprison- ment and feeling forgotten” and “difficulty in adapting,” which are discussed below.

4.2  |  Category 1: Feelings about COVID- 19

This category was about the different feelings of older adults to- wards COVID- 19, which included four sub- categories: feelings of fear, the feeling of hatred towards COVID- 19, homesickness and hope that is described below.

4.2.1  |  Feelings of fear

Fear in older adults is classified into three areas (fear of COVID- 19, fear of quarantine and fear of family getting COVID- 19). The first area was the intense fear of COVID- 19 and the consequent death. One of the older adults stated:

“Unlike before, when I was very active, now I do not even leave the room for fear of COVID- 19, because I know that if I get COVID- 19, I will die soon.”

(a 60- year- old).

The second area was the fear of being quarantined. Apart from the general quarantine in the nursing home, residents who left the home to visit family or were infected with COVID- 19 and tested positive through the PCR test had to be quarantined, which meant staying in a separate room and special protocols had to be followed for at least one week. Residents were worried about the changes quarantine would bring (a different ward and room, COVID- 19 patients as roommates,

F I G U R E 1  Diagram of the central theme, main categories and sub- categories

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gnisrun eht

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noitacifisnetnI

Feelings about COVID- 19

feelings of fear

Severe fear of COVID- 19

Fear of quaran�ne

fear of family ge�ng COVID-19

The feeling of hatred towards COVID-19

Hatred toward COVID- 19, and its consequences

Coercion of following the strict health protocols

Elimina�on of charitable, fun, and entertaining programs

Elimina�on of ou�ngs

Elimina�on of family and public visits

Lack of a proper schedule for spending spare �me

Tendency to leave the nursing homeHomesickness

Hope

Hope for the effec�veness of the vaccines

Hope and prayers for the eradica�on of the COVID-19 despite a vague future

Intensifica�on of isola�on and loneliness

Imprisonment and feeling forgo�en

Difficulty in adap�ng

3126  |    ASGARI and DARVISHPOUR

change in food, drugs and staff). So, as older adults hardly accept changes in their routines, being quarantined was a very scary situation and some, who could go on outings, refused. One of the participants said:

“I do not like to be quarantined even for a day. The thought of staying with a COVID- 19 patient is hor- rible. I have had a thousand thoughts and fantasies in my room and my bed for many years. In quar- antine I do not have any control over my food and drugs, I do not leave here so they cannot send me to quarantine!”

(a 67- year- old woman).

The third area was fear of the family getting COVID- 19. Having lim- ited communication, not being aware of their families' condition and having fewer visits from family and friends led residents to become even more concerned about their family member's health. One of the participants stated:

“There is not a single day that I do not worry about my children. My sons- in- law go to work every day. When they said that COVID- 19 can kill children too, I cannot sleep well at night. I am worried about my grandchil- dren. I live for them. I fear that my daughters or sons- in- law will bring Coronavirus from their work and get the children infected. I am constantly on the phone asking them to take care of themselves.”

(a 70- year- old woman).

4.2.2  |  Feeling of hatred towards COVID- 19

Participants felt disgusted at the time of the COVID- 19 pandemic, since the conditions in the nursing home were changed. This was due to strict health protocols, the elimination of entertainment pro- grammes, lack of a proper schedule for spending their spare time, elimination of outings, elimination of family and public visits.

Establishing strict health protocols and requiring older adults to follow these guidelines that did not exist in the past has made them hate the cause of this condition, COVID- 19. These rules included obligatory rules for wearing a mask outside the room, forbidding any gathering or group walking and going to other rooms or sections of the nursing home. One of the participants stated:

“I wish I had died before I came here so that I would not have experienced the COVID- 19 and its troubles. We had enough difficulty before… now we suffer so much. I have to wear a mask to go to the bathroom, sometimes I would go to my friend's room and talk and have tea together, but now we are not allowed to do so, are we captives?”

(An 89- year- old man).

One of the most important consequences of the COVID- 19 pan- demic was the elimination of charitable, fun and entertainment pro- grammes that were planned and implemented by nursing home or charities for older adults. On the other hand, the lack of alternative programmes to fill the increased spare time of older adults has added to their frustration and feeling of hatred. One of the participants said:

“Before the damn COVID- 19, benefactors, and fami- lies would come, once singers came to sing for us or have a show and this stuff… they made us not under- stand the passage of time. I would have forgotten that here is a nursing home … When there was no COVID- 19, there was not so much worry, and we sat together and talked. We laughed, but now I have to look out the window or stare at the TV until the day is over.”

(A 72- year- old man).

Elimination of outings, family and public visits were other reasons for older adults to hate COVID- 19. The multi- day outings until a few months before the pandemic were enjoyable days for the residents who were now stripped of their quarantine laws.

“I used to go from here to my children's house at least one day a month, but since COVID- 19, no one was allowed to go out for an hour, COVID- 19 is a great injustice.”

(A 90- year- old man).

Apart from a limited number of participants who were dissatisfied with their lives before living in the nursing home and did not want to leave the centre, others said their desire to leave the nursing home since the beginning of their arrival here. According to their statements, they had never come to the nursing home for permanent residence and thought that they would return home one day. A noteworthy point in these interviews was the effect of COVID- 19 on the intensification of the for older adults' desire to leave the nursing home. Those who previ- ously found it difficult to cope with the conditions of the nursing home and had concerns such as food quality, care and treatment services or leisure time, now COVID- 19 had created a new situation for them that had aggravated the previous conditions. One of the participants stated:

“From the first day I was thinking about the day I could leave here. I don't enjoy the meals or even sleep, but the quarantine makes it intolerable for me. I have called my son to get me out of here.”

(A 72- year- old woman).

4.2.3  |  Homesickness

One of the notable feelings of older adults from the experience of living in a nursing home during the COVID- 19 era was the feeling of

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missing their families. Generally, permanent residency in a nursing home causes separation of older adults from home and family or so- cial support, which has its psychological effects. When older adults meet their children and grandchildren, spend a cool time with them, and acquire what they need, they could better adjust to homesick- ness and discomfort caused by family separation. But the ban on face- to- face visits during the COVID- 19 era doubled the hardships for older adults; because, according to their statements, a face- to- face meeting in special circumstances, just for a few minutes, that too from a in the yard or the security room at the entrance of the nursing home, is not a relief to their suffering from distance and homesickness. One of the participants said:

“Before, my children used to come to see me late. However, it was valuable for me. Now, they call me sometimes and we talk for a few minutes. I have not seen them for a year…It is not their fault; no one is allowed to visit here…they may miss me…but I miss them more because I am a mother. I have not seen them thoroughly for a year. I want to see them, hear their voice, and hug them tightly. I pray every day to see them again before I die.”

(A 60- year- old woman).

4.2.4  |  Hope

Among the negative feelings of older adults, a noteworthy point was their sense of hope. Participants continued to hope for vaccine ef- ficacy and eradication of COVID- 19. Most of them were not indiffer- ent to the news of COVID- 19 and vaccines and followed it through television. The past experiences of older adults and their annual vaccination against the flu caused them to have a positive view of COVID- 19 vaccine as a solution to end the COVID- 19 pandemic. One of the participants stated:

“COVID- 19 has no mercy on older people and we have different kinds of diseases, but when they say that the COVID- 19 vaccine has been made, it means that there is still hope. We have consented for the in- jection of the COVID- 19 vaccine … even if I die from the vaccine, I still want to be vaccinated. Our current life does not differ from death … I hope we all get vac- cinated and live comfortably.”

(A 70- year- old man).

The prayer, wish and hope of older adults for the eradication of COVID- 19, despite the uncertain future, was evident in almost all the interviews. Life before and after the quarantine and its limitations were different for older adults in the nursing home, and their most important wish was the end of the quarantine and return to the past normal life.

4.3  |  Category 2: intensification of isolation and loneliness

Since the beginning of the COVID- 19 pandemic and the rule of quar- antine conditions in nursing homes, the communication of the older adults decreased even more. So that it was forbidden to eat together and the effort to make older adults closer to each other was replaced by the fear of transmitting the virus to each other and increased their loneliness. One of the participants stated:

“I was alone before COVID- 19. I have good relation- ships with my roommates and a few people from the rooms opposite. But we will not become a family. Will we become a family? Now I am lonelier. It is not al- lowed to talk for a few minutes. I was a person who farmed in the morning and returned home tired in the evening. I didn't understand how the day was going. I was busy all around. COVID- 19 doesn't let anyone get close to anyone. It has separated everyone. We are old people who are separated from the whole world.”

(A 70- year- old man).

4.4  |  Category 3: imprisonment and feeling forgotten

In most of the interviews, the older adults considered the most difficult conditions of quarantine to be the ban on entering and leaving the nursing home and the exclusion of visits and com- pared the current situation to a prison, with the difference that they have not committed a crime. Some of them believed that prisoners have better conditions than them. Because it is pos- sible to meet prisoners under special conditions and they have more possibilities to fill their free time. In the statements of the participants, the feeling of being forgotten was noticeable, and according to them, the quarantine has become a valid reason for forgetting and leaving them. A participant who has experienced prison in the past said:

“Prison is better. You have a meeting at least once a week. You talk to a psychologist. There are magazines and books to read. I was in prison and I say it was bet- ter there. There is nothing fun here. It used to be a party and program. Now the nursing home is like a prison and we are prisoners who have been forgot- ten. Family, children, friends, the government …they have all forgotten us. We wake up in the morning, we eat, look at the walls and the TV until night. When we complain, they say it's COVID- 19. It has become a good reason to get rid of us.”

(A 65- year- old man).

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4.5  |  Category 4: difficulty in adapting

Most of the participants believed that it is more difficult for them to cope with the current conditions and comply with the protocols due to their old age, special physical and mental conditions, and the physical and environmental characteristics of a nursing home. They considered the nursing home to be a mixed place similar to a home and a hospital, which is devoid of the seal of a home and at the same time lacks advanced hospital facilities.

“We are weaker than the others. We get COVID- 19 faster and we may die easily. There are no hospital facilities here. When someone is in a very bad condi- tion, they take him to the hospital by ambulance. For that, we need to consider the protocols more than other people, but it is hard. When I wear a mask, my heart hurts, my legs hurt. Every time I want to wash my hands, I have to go to the toilet. We have all kinds of pains. Now COVID- 19 has been added.”

(An 89- year- old woman).

5  |  DISCUSSION

The present study aimed to explore the older adult's experience of living in a nursing home during the COVID- 19 Pandemic. According to the results of this study, the COVID- 19 pandemic affected older adults in nursing homes in several ways. Their lives have become more difficult at these centres, and they have experienced different emotions and situations as a result.

The first category extracted from the experiences and state- ments of the older adults was their feelings about COVID- 19 and its associated issues. One of these feelings was fear and anxiety, which were categorized into fear of being infected by COVID- 19 and dying from it, fear of experiencing quarantine and fear of family members getting infected with the disease. Since older adults know they are at high risk for COVID- 19, their primary concern is contracting the dis- ease and any sufferings that may result from it, including quarantine. Additionally, when they realize that their children and grandchildren are at risk of contracting COVID- 19, they get worried about them. In this regard, the study of psychological reactions in response to real or perceived threats of COVID- 19 disease showed that the fear of COVID- 19 is higher in older adults (Schweda et al., 2021). Also, during the analysis of the older adult's experiences of the quarantine in the nursing home, one of the sub- themes of the negative conse- quences of quarantine was anxiety due to reasons such as illness, concern about the health of others and increased stress and tension caused by underlying diseases (Gholamzad et al., 2021).

Older adults expressed hatred towards COVID- 19 for various reasons, including the need to comply with strict hygiene protocols. These included wearing masks outside the room, banning crowds, eliminating family and public visits, as well as charitable and fun programmes, and going into quarantine for at least one week after

going on an outing. New challenges along with previous problems have intensified the desire of older adults to leave the nursing home. These findings are consistent with the results of previous studies. Since the onset of the COVID- 19 pandemic, seniors' physical con- tact with friends, family and others as an important component of intimacy has been replaced with telephone interactions and video calls that raise different emotions in them (D'cruz & Banerjee, 2020). Comparing data from nursing homes during the COVID- 19 pandemic appears that the nature of the pandemic requires immediate action, such as restricting resident visits and mobility. This results in both physical and psychological issues affecting older adults in nursing homes, such as cognitive dysfunction and fear, despair and social isolation (Levere et al., 2021). A study on the perceptions of social support of older adults in nursing homes found that meeting people was encouraging and supportive for all participants, as the quality of these interactions influenced their life satisfaction and adapt- ability to nursing home living (Salarvand & Abedi, 2007). A study in Iran found that the lack of amenities contributed to older adults' dissatisfaction with nursing homes. Their complaints were about the lack of entertainment programmes and the building's isolation (Zamanzadeh et al., 2018). However, residents with poor health, functional dependency and absence of care giving resources would prefer to remain in the nursing home (Abrahamson et al., 2018).

Nursing homes may cause older adults to feel homesick due to the physical and emotional separation from their family and friends. Outing, face- to- face visits and making phone calls are some of the most effective ways to combat homesickness, and centres use them on a regular basis. The COVID- 19 pandemic resulted in the elimina- tion of these cases and a complete quarantine. Visits were delayed, brief and without any physical contact and also going on an outing was only under certain conditions. Since the quarantine began, most residents have not been able to see their families, which made them homesick. These findings are consistent with a descriptive report about seniors' experiences of living in a nursing home during the COVID- 19 pandemic. The results indicate that older adults have had a difficult time not visiting their families during quarantine, as one participant in a study by Montgomery et al. (2020) said: “I miss hug- ging and touching, especially hugging and touching my family mem- bers,” that is consistent with the statement of a participant in the present study: “I miss them very much … to hug them, talk to them.”

While many older adults were experiencing negative emotions as a result of the COVID- 19 pandemic, there were glimmers of optimism among them. In addition to being attentive to the news about COVID- 19, its treatment and vaccination, they were waiting for a cure, maybe more than anyone else. Since news about differ- ent types of vaccines has become more widely broadcast on tele- vision and in the information centre of the home where they obtain written consent for vaccinations, the participants in the present study expressed their hope for the effectiveness of the vaccines. Despite a vague future, most older adults' responses were prayers, wishes and hopes for an end to the COVID- 19 pandemic. Hope for a better future is essential to achieving positive thoughts and feelings and forming a sense of belonging (Girdhar et al., 2020).

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Historically, living in a nursing home was associated with iso- lation for older adults (Sabzichy et al., 2017). There was a global pandemic of loneliness and isolation among older adults, and these issues are intensifying as a result of the COVID- 19 pandemic and quarantine for everyone around the world, which has impacted nursing home residents more (D'Cruz & Banerjee, 2020). The feel- ing of loneliness is caused by reducing social relationships in both quantity and quality and as an unpleasant feeling, impacts social interactions, health and a person's whole life (Moradi et al., 2019). Likewise, isolation means the objective destruction of social interac- tions (D'Cruz & Banerjee, 2020). Older adults who live alone or stay in nursing homes are more likely to suffer from mental disorders, such as loneliness and isolation than those who spend time with their families, because older adults in nursing homes may not have the same material and psychological support as those living with family (Hemmati Alamdarlou et al., 2008). Based on the findings of the present study, this issue has intensified during the quarantine of nursing homes. During the quarantine, residents had fewer interac- tion opportunities like walking, exercising or eating together, so they felt isolated, alone and imprisoned. A similar finding was found in reports about seniors living in nursing homes under the constraints of the COVID- 19 pandemic, which found that 76% felt more alone due to the constraints, and 64% did not even leave their rooms to socialize (Montgomery et al., 2020).

There were two quarantine conditions considered by partici- pants to be the most difficult: firstly, a ban on going on outings, and secondly, the removal of meetings. So it has turned the nurs- ing home into a prison in the minds of older adults. However, older adults perceived these restrictions as rational and protective. Furthermore, the absence of a plan to fill the older adult's time has greatly contributed to their sense of confinedness. These findings are consistent with findings from the study that examined the fac- tors causing psychological changes during the COVID- 19 quaran- tine. All mental health outcomes, including anxiety and depression, deteriorated in the first month, and the sense of imprisonment, security risk and level of information were predictors of quaran- tine anxiety along with the feeling of imprisonment (Filgueiras & Stults- Kolehmainen, 2020).

Ageing is a multidimensional process in which humans need to adapt to physical and cognitive changes and events such as the death of a spouse, the departure of children and economic losses; how successful a person is in adapting to old age is an important issue (Duru Aşiret & Dutkun, 2018). With the COVID- 19 pandemic, older adults in nursing homes faced new challenges in addition to those of old age. All age groups struggle with quarantine and strict health protocols, but older adults in this study found these chal- lenges more problematic because of their age, fatigue and poor physical health. COVID- 19 risks and protective behaviours of older adults were studied as part of the research. As ageing reduces older adults' ability to care for themselves and their social involvement opportunities, it could decrease their chances in getting information about COVID- 19 during the pandemic. The reduced perception of COVID- 19 could make protective behaviours more difficult for older

people (Sun et al., 2020). Adaptation to stress and social isolation following the COVID- 19 pandemic has been found to be mediated by emotional adjustment, fear of infection, loneliness and mental health in older adults (Lábadi et al., 2021).

This study provided a description of the lived experiences, feel- ings and situations of older adults living in nursing homes during the COVID- 19 pandemic. These findings can be useful in developing short- , medium- and long- term care plans for the older adults living in these facilities during the COVID- 19 pandemic, taking into ac- count their experiences and desires. An evaluation of the COVID- 19 pandemic's dimensions and effects on the conditions of older adults living in nursing homes could help health officials and managers of nursing homes minimize negative experiences and increase positive ones. The hope is that this could improve the mental health and qual- ity of life of older adults in nursing homes.

5.1  |  Limitations

The present study is limited in its generalizations due to the nature of qualitative studies and differences in older adults' conditions. Further research should be conducted in other nursing homes. Considering the residents' experiences in different nursing homes helps in comprehensive planning and providing a more pleasant en- vironment for them. It is possible that some participants were not honest in their answers for a number of reasons. Providing sufficient explanations was part of the researcher's effort to gain their trust. Researchers used bracketing to prevent the effects of their mental preconceptions on data analysis.

6  |  CONCLUSION

Most of the participants did not have pleasant experiences and views about living in the nursing home. The COVID- 19 pandemic, quarantine and strict health protocols have exacerbated the diffi- culties of living in the nursing home and led to the rise of negative emotions such as fear, hatred and homesickness in older adults. The older adults believed that they were more isolated and lonelier than before and found themselves imprisoned and forgotten. So, ad- aptation to living in the nursing home has become more difficult. However, they still hoped for the effectiveness of the vaccines and the end of the pandemic.

AUTHOR CONTRIBUTIONS All authors have participated in all stages of research such as con- ceptualization, data collection, data analysis, data interpretation, final discussion and review of the article.

ACKNOWLEDG EMENT The researchers thank all the older adults living in the nursing home in Rasht, Guilan province in northern Iran, for participating in this study.

3130  |    ASGARI and DARVISHPOUR

CONFLIC T OF INTERE S T The authors declare no conflicts of interest.

DATA AVAIL ABILIT Y S TATEMENT No data are available online. All supporting data can be provided upon request to the authors.

E THIC AL APPROVAL Sampling was done after approval from the research council of the Faculty of Nursing and Midwifery of Guilan University of Medical Sciences and obtaining permission from the Ethics Committee of this university (Approval Number: IR.GUMS.REC.1400.442).

ORCID Zahra Asgari https://orcid.org/0000-0002-0716-3094 Azar Darvishpour https://orcid.org/0000-0002-2825-9685

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How to cite this article: Asgari, Z., & Darvishpour, A. (2023). The older adults' experiences of living in the nursing home during the COVID- 19 pandemic: A qualitative study in Iran. Nursing Open, 10, 3122–3131. https://doi.org/10.1002/ nop2.1562

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