Experiences and Perceptions of Older People Making the Transition to Living in a Care Home: An Integrative Literature Review

: Globally, along with population ageing, there is an increasing trend for older people with complex care needs to reside in care homes. It is recognised that moving into a care home can be a complex and emotional experience for the individual and their families. Despite this there is a paucity of research that takes into consideration an individuals experiences of the move. An integrative literature review and a thematic synthesis supported the identification of themes describing the experiences and perspectives of older people making the transition. A systematic search was conducted in six English electronic databases (CINAHL complete, ProQuest health and medical collection, PyscINFO, and Scopus). The quality of the research papers selected were assessed using the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) and the Critical Appraisal Skills Programme (CASP). Four predominant themes emerged from the review: (1) Decision making and control, (2) Process of transition, adjustment, and adaptation, (3) Psychological reactions, and (4) Connectedness, support, and companionship. Within the current body of literature there is a lack of understanding of the processes older people undergo that describe their experiences during the day to day adjustment and adaptation to living in a care home. Furthermore, there is limited research into the psychological and/or social experiences of older people moving into a care home that takes into consideration the total relocation process, incorporating residents, early and ongoing experiences during the transition.


Introduction
Population ageing is a global phenomenon with almost every country in the world experiencing a significant rise in the proportion of their older citizens. In 2019, there were 703 million people aged 65 years or over worldwide. This figure is projected to double to 1.5 billion in 2050 (UN, 2019). As the ageing population increases, so too do the levels of complex health care needs of people living with co-morbidity, dependency, and dementia (Kingston et al., 2018); requiring both informal and formal social care services (Kelly and Kenny, 2018).
Globally, in tandem with population ageing, there is an increasing trend for older people with complex care needs to reside in care homes, which poses challenges for health and social care systems, (WHO, 2018).
Additionally, the total prevalence of people living with dementia residing in care homes is estimated at 70% (Wittenberg et al., 2019). Within the UK in 2017, there were approximately 17,678 care homes caring for 426,000 older people (Age UK, 2017). These statistics highlight the implications of an ageing population and the necessity for a comprehensive understanding of older people's care needs including the requirement for long term care provision. Significantly, the COVID-19 pandemic has had a major impact on the care home sector with high numbers of COVID-related deaths (WHO, 2020). Globally, for 22 participating countries, an estimated 41% of all COVID-19 deaths were among care home residents, (Comas-Herrera et al., 2020).
It is known that moving to a care home is a significant life event for older people and making decisions about care home admission is recognised as a difficult challenge for everyone, including making decisions concerning a person's health and social care needs with those of carers. This relocation normally occurs at a point in life when an individual is at an advanced age with increasing likelihood of multimorbidities and dependency and who may no longer be cognitively able to make life decisions (Ryan and McKenna, 2015;O'Neill et al., 2020a). Moreover, older people moving to a care home are living with frailty (Steel et al., 2022) and there is a significant increase of mortality within six months of being admitted into care homes (Schön et al., 2016). Conversely, if individuals perceived that they had no choice about moving they experienced higher levels of sadness, anger, loneliness, and depression compared to those individuals who were involved in the decisionmaking process (Brownie et al., 2014;Bowers et al., 2016). Adapting to life in a care home can be a complex and emotional experience for older people (Brandburg et al., 2013;Ryan and McKenna, 2015;O'Neill et al., 2020a). Transitions, including the move to a care home, are characterised by different dynamic stages, or turning points and can be established through processes and outcomes (Eika et al., 2014). Thus, while transition is considered a natural process brought about by the changes in our lives, the transition to a care home represents a uniquely significant relocation for older people. Bridges (2004) defined transition as a psychological reorientation with three distinct phases: (a) Endings that involve letting go and experiencing loss in some form, (b) A neutral zone that is an inbetween phase, usually associated with uncertainty, and (c) The new beginning that may involve a new focus or new identity. Furthermore, the duration and extent of the 'transition' process has been defined as continuing until the adaptation to changes in one's life is complete. Thus, the transition process can subsequently produce fundamental changes to an individual's role or identity (Porter and Ganong, 2005;Wiersma and Dupuis, 2010). It is contended that care home transitions are oversimplified by assertions that individuals follow set phases in adjustment, or by describing positive adjustment by determining single aspects of functioning (Marshall and McKenzie, 2008). Furthermore, older people's perspectives of moving to a care home have been inadequately investigated (Backhouse et al., 2016). To the authors' knowledge, there are no identified integrative literature reviews focusing exclusively upon the experiences and perceptions of older people making the move from living at home to living in a care home which will add to the understanding of this phenomena.

Aim and Objectives of Literature Review
The aim of this literature review is to identify and critique pertinent literature and identify themes describing the experiences and perceptions of older people during the transition to a care home.

Inclusion Criteria
This literature review included studies that: (1) Were inclusive of qualitative, quantitative, mixed methodologies, case studies, and systematic literature reviews; (2) Considered older people's experiences before and during the transition to a care home environment; (3) Considered the older person's view of what supported and hindered the transition process: And (4) Included studies that identified long term care facilities comprising of nursing homes, residential homes, and care homes.

Exclusion Criteria
Studies were excluded if: (1) The research focused specifically on the sole view/opinions of relatives or care staff; (2) Studies which focused on only one factor of experience e.g., decision to move, physical health care needs, or mental illness as these studies provide limited detail about the overall experience of transition.

Integrative Literature Review Process
An integrative review includes both experimental and non-experimental research, thus facilitating the mapping of studies from different branches of science to integrate and synthesise knowledge about a particular phenomenon to reach new insights and conclusions (Whittemore and Knafl, 2005;Gough et al., 2012). This wider mapping of studies was supplemented by searching sources without time limits, since limiting literature searching can introduce bias (Cooper et al., 2018). The quality of the research papers selected for review were assessed using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) reporting system (Page et al., 2021) and the Critical Appraisal Skills Programme (CASP) (http://casp-uk.net/criticalappraisal).

Study Selection
This literature review provides a rigorous representation of the literature focussing primarily on peer-reviewed journals that were conceptual and empirical. The literature review was guided by Whittemore and Knafl (2005), integrative review framework. This framework provides a systematic method of examining research from varied empirical and theoretical sources which enhances the rigour of the integrative review process. The integrative review approach starts with problem identification and its related concepts, with the intention of obtaining data from the primary sources. It then defines distinct literature search strategies, incorporating search terms, and exclusion criteria in order to evaluate the importance of the primary sources. Thereafter, data evaluation takes place by examining the quality of primary papers against gold standard measures e.g., Critical Appraisal Skills Programme tools (CASP, 2018). After the most eligible primary sources are identified, studies are organised into groups and subgroups for the purpose of data extraction and reduction. The data are organized to create patterns, relationships, and variations among the concepts. This data reduction stage reinforces qualitative research iterative methods of analysis. Lastly, conclusions are derived and verified so that the complexities of the relevant literature are summarised in a logical sequence of evidence.  (Page et al., 2021) The search strategy was formulated with the support of a library manager who assisted with the identification of key databases. The search was limited to peer reviewed journal articles written in English. Key search terms and synonyms using Boolean search options (Cronin et al., 2008) were: (Elderly or aged or "old* people" or "old person*" or geriatric* or older or senior) and (transition or move or transfer or admission or relocate*) and (experience* or view* or attitude* or adjustment or adapt* or opinion* or feeling*) and ("nursing home*" or "residential home*" or "long term care" or "care home*" or "residential care facility*"). Searches were conducted using four electronic databases: Cinahl complete, ProQuest health and medical collection, PyscINFO, and Scopus. A supplementary search strategy was employed by searching the reference lists of all included studies. Grey literature searches were conducted using British nursing index and google scholar.

Data Extraction and Evaluation
The full text of all the articles (n = 34) were evaluated independently by two researchers who assessed the eligibility of the articles. Data extraction was performed by one reviewer and verified independently by another. The following data was extracted: First author and year of publication, study title, aim, study design, and collection methods, number of participants, and findings. The database searches identified a total number of 2,169 articles. After removal of duplicates, 1,514 papers remained. Paper selection and screening included reviewing the titles and abstracts (when available) and applying the inclusion and exclusion criteria. After this process, 1,440 papers were excluded. A total of 74 full text sources were screened and assessed for eligibility. Papers excluded focused on relatives' experience of care home admission, hospital admission and discharge to and from care homes, housing needs, health and mobility, palliative care, risk assessment, advanced care planning, and student nurses' care home experiences. Secondary sources of literature were also excluded. These exclusions resulted in 34 papers. The reference lists of all included papers were scrutinised, and one additional paper was identified. This resulted in 35 papers. One paper was subsequently excluded in the evaluation process, resulting in a final total of 34 papers included in the literature review.
The quality of the qualitative studies (n = 25) and the systematic reviews (n = 9) were assessed using the Critical Appraisal Skills Programme (CASP) (https://casp-uk.net/casp-tools-checklists/) checklist for qualitative studies (n = 25) (Table 1) and the CASP checklist for systematic reviews (n = 9) ( Table 2). The CASP checklists both have 10 questions that relate to rigour, reliability, and credibility of the studies. Questions are answered with either yes, cannot tell, or no. Each question is given a score based on a response of yes, no, or can't tell. Every yes response merits a score of 1. Articles that attained a summation score <6 were not included in the analysis. One study scored a CASP of 5 and was therefore excluded, resulting in a total of n = 33 studies that met inclusion criteria.

Findings Data Analysis and Synthesis
Data analysis was facilitated by becoming familiar with the data through several appraisals and critical reviews of each published paper. Consistent with Whittemore and Knafl (2005) framework, data synthesis was undertaken by comparing and contrasting study participants, methodological designs, and study findings, as well as the different types of Long-Term Care (LTC) facilities and country of origin. Details of methods, key outcomes, and findings were extracted from primary sources and tabulated to allow for identification of common themes and concepts. Data were grouped according to the research design, sample characteristics, and study setting and then coded. A concept map was created after assembling relevant data. After data comparison, similar concepts were regrouped and refined.
A descriptive thematic synthesis utilising Braun and Clarke (2006) six phases framework was employed. This involved: Becoming familiar with the data, generating initial codes, searching for themes, reviewing themes, defining themes, and finally writing up the themes. Synopsis of both the qualitative and quantitative findings from each study formed the data for analysis. Each paper was read and revisited to enable familiarisation through line-by-line coding of the extracted data. The final refinement of the themes was undertaken to identify the 'essence' of what each theme is about (Braun and Clarke, 2006). Four predominant themes were identified and presented in the synthesis of findings.

Description of the Studies
Five qualitative studies were conducted in the USA, eight in the UK, three in Canada, and two in Ireland, Sweden, and China, with the remainder undertaken in the Philippines (1), Switzerland (1), Slovenia (1), and Iran (1). The qualitative traditions represented in the current synthesis of studies were grounded theory (Wilson, 1997;Lee et al., 2002;Cooney, 2012;de Guzman et al., 2012;Brandburg et al., 2013;Sussman and Dupuis, 2014;Stevens et al., 2015;O'Neill et al., 2020a-c), phenomenology (Heliker and Scholler-Jaquish, 2006;Fraher and Coffey, 2011;Hutchinson et al., 2011;Johnson and Bibbo, 2014;Križaj et al., 2018) and what the authors describe as qualitative design studies (Iwasiw et al., 1996;Reed and Payton, 1997;Lee, 1999;Iwasiw et al., 2003;Andersson et al., 2007;Lee et al., 2013;Zamanzadeh et al., 2017;Koppitz et al., 2017;Paddock et al., 2019;Pocock et al., 2021). Systematic and integrative literature reviews were undertaken in UK (2), USA (1), Australia (1), China (3), and Netherlands (1) (Lee et al., 2002;Brandburg, 2007;Bradshaw et al., 2012Brownie et al., 2014Rijnaard et al., 2016;Fitzpatrick and Tzouvara, 2019). Two meta-analysis reviews (Sullivan and Williams 2017) was undertaken in the USA and (Sun et al., 2021) in China. Five papers were informed by theoretical or conceptual frameworks, namely Meleis's transition theory (Koppitz et al., 2017;Sullivan and Williams 2017;Fitzpatrick and Tzouvara, 2019); Bridge's transition framework (Brownie et al., 2014) and social identity perspective (Paddock et al., 2019) (Table 3 for Studies included).    experiences of daily life at the care home admitted to a care home, 69-90 years old, out with the older people (n = 13), their with living in the care home. All of the satisfied residents, except n = 1, Sweden after admittance with respect to their both single living and married, both moving relatives (n = 10) and contact persons (n = 11) had participated in the decision to move into the care home, n = 3 perceptions of participation in the from their own homes and from different residents reported dissatisfaction and n = 2 did not participate in the decision to move institutions who had lived up to two months decision to move. n = 2 of the dissatisfied residents did not find the at the care home move desirable, voluntary or legitimate Brandburg et al. To identify strategies that older adults use n = 21 participants, n = 17 women and n = 4 A qualitative research design, using a grounded The results of this study yielded 21 facilitative strategies. The core category (2013) USA to adapt to live in long-term care men aged 65-93 years, mainly Caucasian with theory approach. A total of 30 interviews identified was personal resiliency, which served as the underpinning for the n = 1 African American and n = 1 Hispanic.
were completed with a purposive sample of 21 strategies used by the participants. Strategies were identified in making the Length of stay 3 days to over 9 years living in participants (21 initial and 9 follow-up interviews) decision to move into long-term care and in day-to-day living LTC recruited from n = 3 care homes Cooney (2012) To understand older peoples' perceptions Residents (n = 61) living in four types Grounded theory methodology using unstructured Four categories were identified as critical to finding a home in long-term Ireland of 'being at home' in long-term care of LTC facilities. interviews with newly admitted residents, those care settings: 'continuity,' 'preserving personal identity,' 'belonging' and settings and the factors that influence n = 17 male and n = 44 female. who had lived in the facility for longer 'being active and working.' 'Finding Home' was conceptualised as the these perceptions Age range 65-90 plus than 3 months core category. The potential to 'find home' was influenced by mediating and facilitating/constraining factors De Guzman et al. To explore older people' process of 20 older Filipino adults aged 60-84, mentally Grounded theory methodology. Individual An Hourglass of acclimatization model emerged which yielded two (2012) adapting to new environment and the competent, and conversant were recruited interviews were conducted with participants who distinct phases contributing to successful acclimatization. First the Philippines emotional transition from admission had moved to the residential care facility for Conversion phase of transforming one's perspectives of their environment; until their acclimatization in a at least six months secondly the Immersion phase, which describes how an individual gets residential care facility completely involved into the life they are supposed to live. This model can contribute to the development of nursing interventions focusing on the entire course of relocation to a new environment Falk et al. (2013) To gain a deeper understanding of n = 25 respondents (n = 21 women and n = 4 Constructivist grounded theory. Simultaneous Findings show that a sense of home in residential care involves strategies Sweden the processes and strategies by which older men) mean age 82 years. The mean length theoretical sampling and analysis and related to three dimensions of the environment attachment to place, to people create a sense of home, place of stay at the residential facility at time of construction of theories space and attachment beyond the institution and that the circumstances attachment, and privacy in residential interview was for both sexes 9 months under which older people manage or fail in creating attachment, consist of care facilities.
psychosocial processes involving both individual and shared attitudes and beliefs Fraher and To explore older people's experience A purposive sample of (n = 8) over the A hermeneutic phenomenological approach There was considerable evidence that decisions about moving to Coffey (2011) of the decision to relocate to long-term age of 65 years. n = 2 male aged 78 and was adopted through an interpretation of long-term care were poorly handled, with inconsistencies, lack Ireland care and their early experiences 86 and n = 6 female 80-92 years. narrative text. individual audio-taped of choice and involvement in decisions. Although some post-relocation Participants had to achieve a cognitive interviews were conducted and analysed individuals had anticipated their move, decisions were often score of more than 23 using the using phenomenological method made hastily with little or no planning Individual experiences Mini-Mental test score (MMts) differed according to people's respective contexts, history and the (Folstein et al., 1975) and in LTC events that led to the move. People accepted, and adjusted no longer than three months to, their new situation more quickly when the admission was planned Heliker and To describe residents' perspectives of A convenience sample of n = 10 volunteers Hermeneutical phenomenology. Three constitutive patterns of transition to nursing home living emerged: Scholler-Jaquish admission and living in a nursing home were selected from newly admitted residents Participants were interviewed within Becoming homeless, Getting settled and learning the ropes and Creating a (2006) USA during their first 3 months in the who had to attain a MMSE (Folstein et al.,1 week of admission and then periodically place. Understanding residents' experience of transition leads to facility and develop evidence-based 1975) score greater than 24 during the next 3 months recommendation innovative practice changes in anticipation of individuals' needs strategies to ease the transition process s for the delivery of consumerdirected care are offered Hutchinson et al. The aim of this study was to investigate n = 23 elders from n=6 LTCFs. Sample was Phenomenology-qualitative interviews to Themes that emerged included (a) spirituality, death and dying, and (2011) USA person and environment factors of elders limited to African Americans and Caucasians capture the lived experience, personal and philosophy of life; (b) life experiences with change; (c) cultural heritage; that facilitate adaptation to relocation to aged 60 + who resided in an LTCF 6 months cultural of the phenomena of relocation to (d) health; (e) ethnicity; (f) social support, family, and friends; (g) longlong-term care skilled nursing facilities or less and scored 5 or less on the short a long-term care facility term care facility (LTCF) relationships; (h) LTCF system maintenance; and portable mental status questionnaire (i) LTCF support of personal growth Iwasiw et al.
Research questions were: 1. What n = 12 residents aged between 67 and 96 A Qualitative study was conducted with Experiences were classified into four categories: (1996) Canada are the experiences of newly admitted years in five LTCF's (1n = 10 women and purposive sampling. Constant comparative Emotional reactions residents in the first 2 weeks in a n = 2 men). All had been admitted directly method of qualitative analysis originally Transition activities LTCF following relocation from home? from home. Participants were required to described by was used Reflecting on their situation, 2. What are the needs, priorities, and attain a score of at least 24 on the Mini Connecting with a personal philosophy expectations of residents during their first -Mental State Examination Generally, conditions which seemed to influence the experience of the first 2 weeks in a LTCF? (Folstein et al., 1975) 2 weeks were whether residents had their desired amount of involvement 3. What are the residents' views about in planning for the move, the meanings they attached to the experience, and how this relocation can be facilitated? their emotional state Iwasiw et al.
Research questions were: 1. To Participants (n = 6) n = 5 men and n = 1 A longitudinal study using narrative method Themes emerging from resident and family perspectives (2003) Canada explore residents' perspectives woman aged between 75 to 88 years residing and semi-structured interviews with decision making associated with moving in of their first year in a LTCF after in two long term care facilities. (n = 5) had residents and family members Resident's Fitting in relocation from home. participated in the decision to move either and family members were scheduled Maintaining previous relationships and establishing new ones. 2.To explore perceptions of close alone or with a family member and came to be interviewed six times-at 2-and 6-weeks Emotional reactions. family members of the residents' directly from home and 3,6,9, and 12 months following the Reflecting on the situation situation in the LTCF. n = 3 family members participated resident's relocation. Some participants were Maintaining identity: Personhood. 3.To determine the needs, priorities in interviews unable to remain in the study for the full year The majority of residents appraised the LTCF negatively, particularly after and expectations of residents and a total of n = 31 interviews were obtained 3 months. Recognising their vulnerability, they and family members stated family members. they were reluctant to voice complaints to staff 4.To ascertain residents' and family members' view of desirable challenges for the first year Johnson and Questions posed were: Participants (n = 8) were admitted to Interpretive phenomenological approach which Statements of participants differed between the first interview and the Bibbo (2014) 1. How does the concept of home the facility within the previous two weeks was part of a longitudinal study investigating second in the ways in which they applied the concepts of place, USA emerge in older adults who have recently and have a minimum score of 18 on the the transition into nursing home facilities for possessions, safety, and autonomy to their new setting. While still feeling relocated into a nursing home? mini mental state examination older adults across three ethnic groups, African strong loyalties to their previous homes, they had by the second interview 2.To what extent does the concept of -Americans, European-Americans, and Latinos begun to meet people, and in particular to attach the concept of safety and home change following a period of to uncover how n=8 older adults in nursing availability of care to their new residence The majority of individuals did potential adjustment? homes in the Midwestern U.S. constructed the not consider the facility to be "home," but actively changed their attitudes 3.In what way does the degree of meaning of home shortly following the relocation toward the facility and themselves to better adjust to the setting. The perceived control over the decision and again approximately two months later findings demonstrate the importance of autonomy in older adults' making process seem to be related definitions of home to the sense of home developed in a nursing home Koppitz et al. To gain an in-depth understanding into Participants (n = 31) n = 8 males and n = 23 Qualitative interview design based on Meleis' This study presents a model of analysis to evaluate patterns of adaptation (2017) unplanned admissions to nursing homes females were recruited in n = 4 nursing homes. transition model. Mayring's qualitative following an unplanned admission to a nursing home after hospital Switzerland and to explore its impact on adaptation Mean age 83.1 years, had been living in the content analysis (2010) discharge. The following four patterns of adaptation emerged from the nursing home for over two weeks and up analysis: "being cut-off," "being restricted," "being cared for," and "moving to 93 months on." The patterns evaluate the relocation into nursing homes and provide an opportunity to appraise the stages of adaption Križaj et al.
Overarching themes developed from interviews were: "Holding on to what (2018) Slovenia experiences of transition into a care were recruited via a gatekeeper who was a Semi structured interviews before the relocation, I do," "The significance of others through transition," and "The time of loss home and how it influenced their social worker in one Slovenian care home 1 month after, and 6 months after the relocation and acceptance." The overarching theme "Holding on to what I do" with everyday engagement in meaningful into a care home superordinate themes of "This is who I am," "Adjusting my daily occupations occupations," and "The value of health" were discussed D.T.F Lee Research questions The participants (n = 10) included n = 4 male A qualitative study Design. Both latent and Significance of cultural influences in the transition experiences identified. To describe the process through which n = 18 elderly residents (n = 9 men and Grounded theory methodology 98 interviews Newly admitted elders adjusted through the four stages of orienting,

China
Chinese elders adjust following nursing n = 9 women) Age range 70-86 years with n = 18 residents newly admitted to a nursing normalizing, rationalizing, and stabilizing as they struggled to regain home placement home in Hong Kong one week after admission normality with a life that was as close to that lived before admission as and then monthly until no new information about possible. Barriers to adjustment e.g., living with rules and regulations, and their adjustment experiences could be discovered the communal nature of nursing home life were not regarded as important by Chinese elders. However, establishing relations with other residents was a particular challenge for them 1 year with residents, relatives, and staff autonomy, provoking residents to redefine this within the allowances of the (n = 4) relatives across three care homes. Data framework care home. Strict routines and resource constraints resulted in the bounded (n = 5) staff analysis, drawing on the social identity expression of personalities (n = 3) care homes perspective as an interpretive lens. Reed and Payton This study aimed to examine the n = 40 older adults n = 10 focus groups Qualitative study with thematic analysis. Theoretical categories crossed over topics, such as the 'settling in' (1997) UK processes of adaptation that older people with 3-6 staff. n = 6 care homes in one Semi structured interview before the move, processes and involved a range of different dimensions, ranging from the engage in when moving into care homes local health authority at 3 months post move, last interview physical environment to interpersonal relationships. The disparity between before 6 months the views of residents and staff suggests that the importance of other residents' support and companionship, is poorly understood by staff.
Residents are active in their social world, which they describe in detail and appear to value highly Stevens et al.
To explore the experiences of older 12 residents (ten women and two men), A qualitative study using a grounded theory Two main categories emerged: "choosing the path", which concerned the (2015) UK people with minimal care needs admission aged 86-99 years, participated in the study. method. Length of time living in care decision to enter the home, and "settling in," which related to adaptation to care homes with Registered Five were admitted to a care home from home prior to interview is not stated to the environment. Findings suggested participants who perceived they Nurse (RN) care hospital and seven from their own home had greater control over the decision-making process found it easier to settle in the care home. The two categories linked to form an emerging framework of "crossing the bridge" from independent living to care home resident Sussman and Research questions: (a) What conditions n = 10 participants from three LTCF's. Grounded theory methodology with selective Residents' accounts revealed a complex and layered intersection of Dupuis (2014) help or hinder older adults' positive Aged 75-97 years. Females n = 8 and males purposive sampling. Explored residents' conditions that shaped their experiences at each stage of the relocation Canada experiences with the decision-making n = 2. Residents who had newly experiences with three stages of the process. When conditions at individual, interpersonal, and/or systemic phase, the move itself, and the initial relocated for no longer than 6 weeks relocation process: Pre-move decision layers nurtured a sense of control, and respect for personhood, residents post-move adjustment? and (b) How do making, moving, and post move adjustment reported positive relocation experiences and their ability to develop a sense the presence or absence of conditions of comfort and belonging within LTC was facilitated. Conversely, when from one phase of the process influence conditions at one or a series of layers threatened or challenged control and residents' experiences with respect for personhood, residents reported negative experiences that subsequent phases? compromised their subsequent adjustment to LTC Wilson To identify variance in the initial n = 15 older adults, n = 11 females and A grounded theory approach was used in this Transition to nursing home life occurred in three phases: overwhelmed, (1997) USA responses of older adults whose n = 4 males, ranging in age from 76 to exploratory and descriptive study. Semi adjustment and initial acceptance phase. The major theme of adjusting to move to a nursing home is expected 97 years All were of Euro American origin structured interviews every other day for 2 nursing home life was protection and maintaining a facade of normalcy. to be a permanent move weeks, 1-month post-admission. and field notes Issues relating to autonomy and control were significant in the older adults' of the interviews and observations adjustment to the nursing home. and inhibit transition for older people long-term care facility to include older methods). Potential personal and community focused facilitators and who have re-located to a long-term people, families, and care facility staff inhibitors mapped to four themes: Resilience of the older person, care facility? interpersonal connections, and relationships, this is my new home, and the care facility as an organisation Lee et al. (2002) The purpose of this study is to review Articles from the years 1970±2000 were The review includes an analysis of the This review demonstrates that adjustment to residential care is more than China and synthesize the literature selected to investigate older people's perceptions and processes before and just a discrete event. It begins well before placement actually, occurs and related to older people's experiences experiences with residential care placement surrounding placement. Also, an continues beyond. A body of knowledge relating to the preplacement with residential care placement or the ways in which elders cope with, analysis of postplacement experiences and processes that influence subsequent adjustment has been master or succumb to the multitude of adjustment is undertaken identified demands presented  (3) transition process included four stages: The decision-making process, the Included older adults who could fluctuation process, the adjustment process, and the acceptance process speak and understand clearly in the sample Rijnaard et al. To provide an overview of factors Inclusion criteria were (1) original and A systematic review The sense of home of nursing home residents is influenced by 15 factors, influencing the sense of home of older peer-reviewed research, (2) qualitative, divided into three themes: (1) Psychological factors (sense of Netherlands adults residing in the nursing home quantitative, or mixed methods research, acknowledgement, preservation of one's habits and values, autonomy and (3) research about nursing home residents control, and coping); (2) social factors (interaction and relationship with (or similar type of housing), and (4) staff, residents, family and friends, and pets) and activities; and (3) The research on the sense of home, meaning built environment (private space and (quasi-)public space, personal of home, at-homeness, or home likeness belongings, technology, look and feel, and the outdoors and location) Sullivan and the purpose of the meta-synthesis was Inclusion criteria were recent qualitative A meta-analysis and meta-synthesis reporting Three themes were uncovered by this meta-synthesis: (a) Painful loss that Williams (2017) to provide an appraisal of older studies (published between 2005 and system was used to illustrate the deselection requires a mourning process, (b) Seeking stability through gaining. USA adults' transition experiences to LTC 2015), conducted in the United States or process of the compiled records (n = 181) autonomy to sustain a new sense of self, and (c) Acceptance when a unique Canada, published in English, with a focus on adults 65 or older transitioning to LTC inner balance is reached. The synthesis of the literature on older adults' transitions into LTC guided through MMRTT (Meleis et al., 2000) provided insight into healthy transitions

Characteristics of Included Studies
The number of participants varied in each study from six older people in both an interpretative phenomenological study (Križaj et al., 2018) and a longitudinal study (Iwasiw et al., 2003) to 61 participants in a grounded theory study (Cooney, 2012). In all of the 22 studies, the experiences and perceptions of older people were explored. In four studies, family members' perspectives were also investigated (Iwasiw et al., 2003;Andersson et al., 2007;Zamanzadeh et al., 2017;Paddock et al., 2019) and one study included staff perspectives (Reed and Payton, 1997). Studies were carried out in a range of care homes. Fifteen studies were based in a single care home, seven studies were drawn from two to six care homes and one study was undertaken across eight care homes. The timing of data collection varied and ranged from pre-move interviews (Reed and Payton, 1997;Križaj et al., 2018;O'Neill et al., 2020a) to three days to nine years post the move (Brandburg et al., 2013). Nine studies interviewed participants on more than one occasion during the first year after the move (Reed and Payton, 1997;Wilson, 1997;Lee et al., 2002;Iwasiw et al., 2003;Johnson and Bibbo, 2014;Križaj et al., 2018;Paddock et al., 2019;Pocock et al., 2021;O'Neill et al., 2020b-c).

Decision Making and Control
The lack of participation in decision making and choice about the move to a care home can create a negative experience causing emotional disturbance, isolation, anxiety, uncertainty, and personal loss when entering a new environment (Johnson et al., 2010;Fraher and Coffey, 2011;Lee et al., 2013;Zamanzadeh et al., 2017;Koppitz et al., 2017;O'Neill et al., 2020a). A qualitative study undertaken by Iwasiw et al. (1996) explored the experiences of newly admitted residents (n = 12) in the first two weeks in a long-term care facility following relocation directly from home. Older people's experiences were classified into four categories: Emotional reactions, transition activities, reflecting on their situation, and connecting with a personal philosophy. Conditions which appeared to influence their first two-week experiences were being involved in planning for the move, the meanings they attached to the experience, and their emotional state. A later study by Iwasiw et al. (2003) sought to explore residents (n = 6) and family members (n = 3) perspectives of the resident's first year in a long-term care facility after relocation from home. Five older people had participated in the decision to move either alone or with a family member. The researchers planned to interview participants at six time points, namely weeks 2-6, and then at 3,6,9, and 12 months following the relocation. However, not all participants remained for an entire year and because of the staged approach to recruitment, the total period of data collection was two years. As some participants were unable to remain in the study for the full year, 31 interviews were conducted instead of the originally planned 54 interviews. Six themes emerging from resident and family perspectives were: (1) Decision making associated with moving in; (2) Fitting in; (3) Maintaining previous relationships and establishing new ones; (4) Emotional reactions; (5) Reflecting on the situation; and (6) Maintaining identity, personhood. The majority of residents appraised the long-term care facility negatively, particularly after 3 months. Recognising their vulnerability, older people and their family members stated they were reluctant to voice complaints to staff. Andersson et al. (2007) in their qualitative interviews sought to explore the experiences of older people (n = 13), their relatives (n = 10), and contact persons' (n = 11) experiences of daily life in the care home after admission, with respect to their perceived involvement in the decision to move. Nine residents reported that they were satisfied with living in the care home, most of them almost immediately after their move. Reasons put forward for residents' positive statements included, the nice and competent staff and that 'one becomes safer in a way.' Two of them, however, had found care home living terrible at the beginning. All of the satisfied residents, except one, had participated in the decision to move into the care home. In contrast, three residents reported dissatisfaction with living in a care home. Two of the dissatisfied residents did not find the move desirable, voluntary or legitimate and had difficulty adjusting to living in the care home. Two of these three related that they had not participated in the decision to move.
Fraher and Coffey (2011) undertook a hermeneutic phenomenological study to explore older people's (n = 8) experience of the decision to relocate to long term care and their early experiences post relocation. Their findings conveyed that decisions about moving to long-term care were poorly handled, and inconsistent, with a lack of choice and involvement in decisions. Although some individuals had anticipated their move, decisions were often made hastily with little or no planning. Individual experiences varied according to the context, history, and events that led to the move to the home. Fraher and Coffey concluded that older people accepted and adjusted to their new situation more quickly when the admission was planned.
O'Neill et al. (2020a) undertook a grounded theory study with n = 23 participants in eight care homes to explore their experiences of moving into a care home. The first interview was taken with participants either preplacement (7 days) or immediately postplacement (within 3 days). Data analysis revealed five categories related to participants experience of the move: (a) Inevitability of the move: "I had to come here," (b) Making the move: "Abrupt departures," (c) Decision-making and exercising choice: "What can I do, I have no choice," (d) Maintaining identity: "Holding on to self" and (e) Maintaining connections: "I like my family to be near." The concept "you're at their mercy" encapsulated how participants perceived a sense of disempowerment being 'at the mercy' of their family and health care professionals throughout the admission process. A lack of opportunity and encouragement to participate in decision making, resulted in participants demonstrating a resigned acceptance to their fate. They were dependant on others to maintain independence and connections to their own identity, sense of self, family, and home. Sussman and Dupuis (2014), in their grounded theory study of residents (n = 10) in three long term care facilities highlighted the ideal stages of a planned admission to a care home environment as: The decision to move, premove preparation, and moving day circumstances. Residents reported a complex and layered intersection of conditions that shaped their experiences at each stage of the relocation process. When conditions at individual, interpersonal, and/or systemic layers nurtured a sense of control and respect for personhood, residents reported positive relocation experiences and their ability to develop a sense of comfort and belonging within the long-term care facility was facilitated. Conversely, when conditions at one or a series of layers threatened or challenged control and respect for personhood, residents reported negative experiences compromising their subsequent adjustment to long term care.
A longitudinal study undertaken by Pocock et al. (2021) employed a narrative approach, to explore the perspectives of n = 5 older care home residents, aged 85 years and over, on transitions to and life and death within two care homes over a ten-month period. A structural narrative analysis was undertaken and presented under three headings: 'Becoming a care home resident,' 'living in a care home' and 'death and dying.' Findings showed that care home residents experienced a loss of autonomy, and a lack of agency, and were often excluded from decision-making. Moreover, older residents have limited choices regarding end-of-life care.
Some research studies have identified that older people may experience a loss of autonomy and independence making adaptation to life in a care more challenging. Moreover, older people often struggle to adhere to the routine and rules of the care home environment (Wilson, 1997;Cooney, 2012;Bradshaw et al., 2012;Brandburg et al. 2013). There is also evidence to suggest that some care home environments are restrictive with a lack of privacy and offer limited opportunity for social interaction, hampered by institutional standardised routines and strict risk management policies that can threaten individuals' independence and autonomy (Cooney, 2012;Bradshaw et al. 2012;Križaj et al. 2018;Paddock et al. 2019). A systematic qualitative review undertaken by Bradshaw et al. (2012) examined residents' views of Quality of Life (QoL), specifically the factors that positively influence care home life. Thematic analysis and meta-ethnographic methods were incorporated into the synthesis of the studies (n = 31) identified. Findings revealed that people in care homes voiced concerns about lack of autonomy and difficulty in forming appropriate relationships with others. For a good quality of life in care homes, four key themes were deemed to be necessary: The person's 'acceptance and adaptation to their living situation,' their 'connectedness' with others, living in 'a homelike environment' and carers displaying 'caring practices.' This review also supports and extends the finding that a positive approach to living in care homes is associated with effective coping and adaptation.

Process of Transition, Adjustment and Adaptation
Numerous factors including health and social issues can influence the adaptation and adjustment process for older people when relocating to a care home (Bradshaw et al., 2012;Brownie et al., 2014;Križaj et al., 2018;O'Neill et al., 2020b). Furthermore, the 'transition' process has been defined as occurring as a result of change in a person's life continuing until adaptation is reached and producing fundamental changes to an individual's role or identity (Porter and Ganong, 2005;Wiersma and Dupuis 2010;Paddock et al., 2019;O'Neill et al., 2020b). A grounded theory study undertaken by Wilson (1997) explored variance in the initial responses of older adults (n = 15) who moved to a nursing home. Semi structured interviews were undertaken every other day for two weeks and at one month post admission. Data analysis conveyed the transition to care home life as occurring in three phases: (1) Overwhelmed, (2) Adjustment, and (3) Initial acceptance phase. The major theme of adjusting to nursing home life was protection and maintaining a facade of normalcy. A variance is reported in the process of transition between older adults planned and unplanned admission to the care home. A planned admission supported an individuals' adjustment better than an unplanned admission. Older people who had not planned the care home admission experienced more emotional responses and a 'desire to go home.' The transition to a care home represents a uniquely significant experience for older people which was explored within a hermeneutical phenomenology study undertaken by Heliker and Scholler-Jaquish (2006). The researchers describe the phenomenon of being admitted and living in a nursing home from the perspective of ten older residents. Participants were interviewed within one week of admission and then periodically during the next three months. The authors identified three patterns and themes of transition to nursing home living: (1) Becoming homeless, (2) Getting settled and learning the ropes, becoming known and knowing others and learning the rules and (3) Creating a place and making the best of it. The researchers concluded that understanding how residents are grieving their loss of home and may be experiencing an unfamiliar and unknown experience of transition, can lead to innovative practice changes in anticipation of individuals' needs.
In contrast, Brandburg (2007) described three identifiable processes associated with the transition to life in a care home as: (1) The 'initial reaction' or emotional response to the move which is not dependent on whether the admission is planned or unplanned; (2) 'Transitional influences' such as life experience and the meaning attached to the relocation and (3) 'Adjustment', where the individual comes to terms with the move. The second and third stages, transitional influences and adjustment, interact and interplay during the process of transition. As a result, older adults are in a dynamic process of adjusting and readjusting as they interact with various transitional influences such as the formation of new relationships with residents and staff. The end of adjustment occurs when the resident comes to terms with living in a care home, has developed new relationships, maintained old friendships, and reflected on their new home environment. According to Brandburg, the final 'acceptance' phase usually occurs between six and twelve-months post-admission. This marks the end of the transition period when new residents finally accept living in the nursing home.
Significantly, O'Neill et al. (2020b) found that adaption to life in a care home was not a linear process. Data analysis with n = 17 participants on their second interview between four and six weeks post-move to a care home identified five key categories: (a) Wanting to connect-'I am so lost here', (b) Wanting to adapt 'Well mentally you have to make the best of it', (c) Waiting for assistance-'it's a frustration for me', (d) 'Waiting on the end' I am making no plans' and (e) Wanting to re-establish links with family and home 'I love getting home and I like getting out to the town'. The core category, 'Waiting and Wanting,' captures the initial adaptation experiences of the individuals who experienced an unsettling period and were disillusioned by a loss of independence, autonomy, and continuity of former roles. They were waiting to reconnect with home and community and to establish connections within their new home. Adaptation was an ongoing process that individuals were trying to navigate themselves, with little or no support.
Similarly, a narrative exploration of eight older people's transitions into residential care was undertaken by Lee et al. (2013) with a focus on participants who had been living in a residential facility between 3-12 months. Narrative analysis revealed that the transition process appeared not to be time bound or linear, participants' experiences reflected key plots of 'control,' 'power,' 'identity' and 'uncertainty' interwoven within individual's daily and more long-term existence. Participants discussed not feeling confident in their decision to move, living in constant fear of losing their memory, and having limited expectations for their future. The authors asserted that the emphasis on older people 'accepting' transitions in a 'healthy' way may not encapsulate the reality of how they incorporated relocating to residential care into their narratives. In reality, 'resigned acceptance,' previously thought to indicate maladaptive adjustment (Brandburg, 2007) appeared more realistic for participants. This study highlighted that transitions can be ongoing and there is a need to consider broader issues such as identity and maintaining control if they are to fit with residents' life stories. Conversely, de Guzman et al. (2012) grounded theory study explored (n = 20) older people's process of adaptation to the change in their environment and the emotional transition starting from admission until their acclimatization, in a residential care facility. An 'Hourglass of Acclimatization Model' emerged which yielded two distinct phases contributing to successful acclimatization. One is the 'conversion' phase, the main notion being of transforming one's perspectives of themselves and his or her environment. This is followed by the' immersion' phase, which describes how an older person involves him/herself completely into the life they are supposed to live.
A meta-synthesis of ten studies undertaken by Sun et al. (2021) analysed the adaption of older adults' transition to residential care facilities and cultural factors. The two main findings identified were the impact of culture on adaptation which contained two items: Religion and 'God' which promoted adaptation and 'collectivity and harmony' which were seen as principles of relationship building. The transition process included four stages which were: The decision-making process, the fluctuation process, the adjustment process and the acceptance process. Sun et al. (2021) concluded that decision making, and culturally congruent care must be considered to meet the unique needs of older people and to facilitate their transition to residential care facilities.

Psychological Reactions
A major challenge associated with the transition into a care home is the loss of the individual's home life, therefore threatening identity, belonging and sense of self (Lee et al., 2013, Brownie et al., 2014Zamanzadeh et al., 2017;Paddock et al., 2019). Personal resiliency was identified by Brandburg et al. (2013) as the key strategy used by participants when making the decision to move into long-term care and in day-to-day living. The experiences and psychosocial effects of transitioning to a care home were explored with older people (n = 17) and staff caregivers (n = 3) by Zamanzadeh et al. (2017). Data analysis of semi-structured interviews categorised the psychosocial effects of transitioning into four themes: Communication isolation, resource change, monotone institutional life and negative emotional response. Participants lost their previous support systems when transitioning and were not able to establish new ones. Furthermore, routine care was provided by formal caregivers with minimal support and little attention to the needs and desires of individuals to maintain their own independence. These losses gave rise to negative emotions in some of the participants. Personal and environmental factors that facilitated adaptation to relocation were investigated in a phenomenological study undertaken by Hutchinson et al. (2011) with older people (n = 23) from six long term care facilities in America. Two tested qualitative instruments were used to obtain information regarding personal and cultural heritage factors. The themes that emerged included (a) Spirituality, death and dying, and philosophy of life; (b) Life experiences with change; (c) Cultural heritage; (d) Health; (e) Ethnicity; (f) Social support, family and friends; (g) Long-term care facility relationships; (h) Longterm care facility system maintenance and (i) Long-term care facility support of personal growth.
Personal and social identity were also explored within a multiple qualitative case study undertaken by Paddock et al. (2019) who investigated how living in a care home affected the identities of residents and how they addressed this in their daily lives. Residents (n = 9), relatives (n = 4), and staff (n = 5) staff took part in semi structured interviews and 260 h of observations over one year. A data framework analysis, drawing on the social identity perspective as an interpretive lens, was employed. Four themes were identified: (a) Changing with age, (b) Independence and autonomy, (c) Bounded identity, and (d) Social comparison. The impact of aging that initially altered residents' identities was exacerbated by the care home environment itself. Institutional restrictions jeopardized autonomy and independence, provoking residents to redefine this within the allowances of the care home. Moreover, strict routines and resource constraints resulted in the bounded expression of personalities.
In adapting to new surroundings, the importance of bringing a sense of home and possessions to the care home environment has been highlighted, which can have a significant psychological and emotional impact (Marshall and McKenzie, 2008;Cooney, 2012;Falk et al., 2013). The factors that impact on residents' transition and psychological adaptation to long-term care facilities was explored in a systematic literature review by Brownie et al. (2014), informed by the concept of home and Bridges' (2004) three stages of transition. This framework provided conceptual models for understanding the needs and aspirations of older people who are in the process of this late life transition. The authors identified 19 observational, descriptive, and cross-sectional studies exploring older people's views about their experiences relocating and adjusting to life in a care home. Positive adaptation was reported to be influenced by older people being able to retain personal possessions, continue valued social relationships and establish new relationships within the care facility.
The importance of connectedness to others is also highlighted in an Interpretative Phenomenological Analysis (IPA) study undertaken by Križaj et al. (2018) that explored six older people's experiences of transition into a care home and how it influenced their everyday engagement in meaningful occupations. Semi structured interviews were conducted at three-time intervals: Before the relocation and at one month and six months after the relocation into a care home. Overarching themes developed from interviews were: 'Holding on to what I do,' 'The significance of others through transition,' and 'The time of loss and acceptance.' The transition was seen as a challenging continuous process with older people striving to maintain their identities through engaging in their previously enjoyed occupations.
Meleis's theory of transitions explains how a person relates to their environment and health. A change in health and environment can change how a person perceives his/her role. Furthermore, an individual's response to change can be influenced by internal (attitude, knowledge, cultural beliefs) and external factors (social support, socioeconomic status) (Meleis, 2010). A qualitative metasynthesis undertaken by Sullivan and Williams (2017) reviewed eight studies of older adults' transition experiences to long-term care facilities. The synthesis of the literature was guided by Meleis's Middle Range Theory of Transition (MMRTT) which consists of types and patterns of transitions, properties of transition experiences, facilitating and inhibiting conditions, process indicators, outcome indicators, and nursing therapeutics (Meleis et al., 2000). Three themes were uncovered by this meta-synthesis: (a) Painful loss that requires a mourning process, (b) Seeking stability through gaining autonomy to sustain a new sense of self and (c) Acceptance, when a unique inner balance is reached. The study findings suggest that residents transitioning to long term care experience an inevitable loss; therefore, mourning the loss is necessary to progress through the transition. Residents expressed a longing for home related to having autonomy, privacy, and activities that provide personal meaning; they wanted to be known and valued for who they are and what they have achieved in life.
A narrative synthesis conducted by Fitzpatrick and Tzouvara (2019) also informed by Meleis's Theory of Transition sought to understand what factors facilitate and inhibit the transition for older people who have relocated to a long-term care facility. Thirty-four studies (25 qualitative, 7 quantitative, and 2 mixed methods) met the inclusion criteria. Data synthesis conveyed the transition following relocation, as being examined using a variety of terms, timelines, and study designs. Potential personal and community focused facilitators and inhibitors were mapped to four themes: (1) Resilience of the older person, (2) Interpersonal connections and relationships, (3) This is my new home, and (4) The care facility as an organisation. Within the theme of 'resilience of the older person,' person focused transition facilitators included self-efficacy, self-determined motivation, continuation of one's faith, values and beliefs, ethnic identity, a positive personal philosophy, and personal coping strategies. The authors concluded that these findings could inform the development of interventions to support change in these identified areas. They also emphasise that further research is warranted to understand how the culture of long-term care facilities can influence older people's transition and how this might be moulded to create and sustain a more caring culture for older people.

Connectedness, Support and Companionship
A major challenge associated with the transition into a care home is the loss of the individual's home, therefore threatening identity, belonging, and sense of self (Lee et al., 2013;Brownie et al., 2014;Fitzpatrick and Tzouvara, 2019;Paddock et al., 2019). Home is not only fundamental to a person's self-identity and social relationships, but homely environments are essential to promote recovery, well-being, and quality of life (Molony, 2010;Rioux and Werner, 2011). Additionally, individuals may lose previous social and communication networks (Zamanzadeh et al., 2017) putting them at risk of feeling lonely and isolated (Brownie et al., 2014). A qualitative study undertaken by Reed and Payton (1997) examined the processes of adaptation older people engage in when moving into care homes. The authors found that theoretical categories crossed over several topics, such as the 'settling in' processes, and involved a range of different dimensions, ranging from the physical environment to interpersonal relationships. The disparity between the views of residents and staff suggested that the importance of other residents' support and companionship, is poorly understood by staff.
A grounded theory study undertaken by Cooney (2012) explored older peoples' perceptions of 'being at home' in long-term care settings and the factors that influence these perceptions. Residents (n = 61) living in four types of long-term care facilities, aged 65-90 were interviewed either after admission or had lived in the long-term care facility for longer than three months. Four categories were identified as critical to finding a home in long-term care settings: 'Continuity,' 'preserving personal identity,' 'belonging' and 'being active and working.' 'Finding home' was conceptualised as the core category. The potential to 'find home' was influenced by mediating and facilitating/constraining factors. What made it simpler or more problematic for older people to 'find home' was either unique to the individual (adaptive responses, expectations, and/or past experiences) or occurred at an institutional level (ethos of care, institutional culture, environment of setting). The theory of finding home describes the factors central to 'finding home' in long-term care settings and identifies how nurses can support residents to feel at home. Comparably, a grounded theory study undertaken by Falk et al. (2013) aimed to gain a deeper understanding of the processes and strategies used by older people (n = 25) to create a sense of home, place attachment, and privacy in residential care facilities. Findings showed that a sense of home in residential care involves strategies related to three dimensions of the environment: (1) Attachment to place, (2) To space, and (3) Attachment beyond the institution. The authors conclude that the circumstances under which older people manage or fail in creating attachment, consist of psychosocial processes involving both individual and shared attitudes and beliefs.
The importance of connectedness was also identified by O'Neill et al. (2020c) who undertook a grounded theory study exploring how n = 17 older adults from eight care homes experience the transition to life in a care home between five and 12 months after the move. Five key categories were identified which were: (a) The lasting effect of first Impressions 'They helped me make my mind up' (b) On a journey 'I just take it one day at a time,' (c) Staying connected and feeling 'at home' 'You get something good out of it you know...you get hope.' (d) Managing loss and grief 'It was important for me to say cheerio to the house' and (e) Caring relationships 'I didn't realise that I was lonely until I had company.' Together these five categories formed the basis of the core category 'The primacy of 'home' which participants identified as a place they would like to feel valued, nurtured, and have a sense of belonging. The theory that emerged from this study suggests that care home residents who are connected, as evidenced by their participation in decision making about the move and the extent to which they can maintain existing connections to home and family while at the same time, creating new connections within the care home environment, have a more successful transition to life in a care home than individuals who do not have this connectedness. Rijnaard et al. (2016) undertook a systematic review of 17 mainly qualitative research studies to provide an overview of factors influencing the 'sense of home' of older adults residing in the nursing home. The 'sense of home' of nursing home residents was influenced by 15 factors, divided into three themes: (1) Psychological factors (sense of acknowledgement, preservation of one's habits and values, autonomy and control and coping); (2) Social factors (interaction and relationship with staff, residents, family and friends, and pets and activities); and (3) The built environment (private space and (quasi-) public space, personal belongings, technology, look and feel and the outdoors and location). Rijnaard et al. (2016) suggested further research to determine if and how the identified factors are interrelated, if perspectives of stakeholders involved vary and how the factors can be improved in practice.

Decision Making and Control
The findings of this literature review suggest that lack of participation in decision making and choice about the move to a care home can create a negative experience for some individuals causing emotional disturbance including anxiety, uncertainty, isolation, and personal loss (Johnson et al., 2010;Fraher and Coffey, 2011;Lee et al., 2013;Brownie et al., 2014;Zamanzadeh et al., 2016;Koppitz et al., 2017;O'Neill et al., 2020a). The extent to which individuals can exercise control over the decision to move to a care home is recognised as an important determinant of their relocation experience (Andersson et al., 2007;Johnson et al., 2010;Fraher and Coffey, 2011;Lee et al., 2013;Sussman and Dupuis 2014;Ryan and McKenna 2015;Stevens et al., 2015;Paddock et al., 2019;O'Neill et al., 2020c). Some research studies identified a loss of autonomy and independence making adaptation to life in a care more challenging (Wilson, 1997;Cooney, 2012;Bradshaw et al., 2012;Brandburg et al., 2013). There is also evidence to suggest that restrictive care home environments and practices can threaten individuals' independence and autonomy (Cooney, 2012;Bradshaw et al., 2012;Križaj et al., 2018;Paddock et al., 2019). International literature identifies that risk aversive practices are perceived as a threat to an individual's independence and autonomy (Wiersma and Dupuis 2010; Thein et al., 2011;Custers et al., 2012;Brownie et al., 2014;Paddock et al., 2019;O'Neill et al., 2020c). These findings suggest that it is imperative from the outset of a transition to a care home, to acknowledge and respect individuality in such a way as to recognise and act on a person's values and preferences in terms of physical and psychological safety and promoting independence.

Process of Transition, Adjustment and Adaptation
It has been recognised that numerous complex and multidimensional factors including health and social care issues can influence the adaption and adjustment process for older people when relocating to a care home (Reed and Payton, 1997;Wilson, 1997;Lee et al., 2002;Bradshaw et al., 2012;de Guzman et al., 2012;Brownie et al., 2014;Koppitz et al. 2017;Moore and Ryan 2017;Sullivan and Williams, 2017;Križaj et al., 2018;Paddock et al., 2019;O'Neill et al., 2020b). However, there is evidence to suggest that having a positive approach to living in a care home is associated with effective coping and adaptation (Bradshaw et al., 2012;Sullivan and Williams, 2017). Adaptation to life in a care home is not a linear process, rather the 'transition' is a changing and ongoing process in a person's life that continues until adaptation or acceptance is reached, impacting an individual's role or identity (Porter and Ganong, 2005;Wiersma and Dupuis, 2010;Lee et al., 2013;Paddock et al., 2019;O'Neill et al., 2020b). A planned admission to a care home can support an individuals' adjustment better than an unplanned admission which leads to emotional responses and a 'desire to go home' (Wilson, 1997;Heliker and Scholler-Jaquish, 2006;O'Neill et al., 2020b).

Psychological Reactions
It is recognised that individuals who felt that they 'had no choice' about the move to a care home reported feelings of sadness, regret, and lowered mood (Bowers et al., 2016;Brownie et al., 2014). Several studies have indicated that being separated from family and communities and losing previous support systems can compound feelings of loss and isolation (Iwasiw et al., 1996;Heliker and Scholler-Jaquish, 2006;Fraher and Coffey, 2011;Hutchinson et al., 2011;O'Neill et al., 2020a). Moreover, many older people are trying to manage losses associated with ageing, the loss of home, loss of independence, and bereavement, when they move to a care home and also when other residents die within the home (Ebrahim et al., 2015;Van Humbeeck et al., 2016;O'Neill et al., 2020c). It has also been recognised that when independence is removed from a person's life, an individual can feel defeated, depressed, or begin to doubt their own ability to care for themselves (Wiersma and Dupuis, 2010;Custers et al., 2012). Furthermore, low expectations can lead to reduced capabilities and can be self-fulfilling, causing deterioration in health and cognitive ability (Lee et al., 2013;Zamanzadeh et al., 2016). The importance of bringing a sense of home and possessions to the care home environment has also been highlighted as an important part of the adaptation process, which can have a significant psychological and emotional impact (Marshall and McKenzie, 2008;Cooney, 2012;Falk et al., 2013;Brownie et al., 2014;O'Neill et al., 2020b).

Connectedness, Support and Companionship
A major challenge associated with the transition into a care home is the loss of the individual's home, therefore threatening identity, belonging, and sense of self (Lee et al., 2013;Brownie et al., 2014;Paddock et al., 2019). Maintaining continuity between the older person's past and present role has been identified as a key factor in the adaptation process after entry to a care home (Bradshaw et al., 2012;Falk et al., 2013;Brownie et al., 2014;Križaj et al., 2018;O'Neill et al., 2020c). There is evidence to suggest that individuals may experience a greater sense of freedom; be able to regain some of their independence and feel less of a burden to others (Bradshaw et al., 2012;Sullivan and Williams, 2017). Moreover, it is recognised that care staff have an important role to play in encouraging new residents to develop new relationships (Cooney, 2012;Križaj et al., 2018;O'Neill et al., 2020a).

Conclusion
Twenty-six studies (involving ten countries across three continents) were included in this review. The importance of culture and the countries in which the studies were conducted provide some insight into older adults' transition to care homes. This information could be included into personalised interventions for residents during transition to a care home (Sun et al., 2021). It is also crucial to recognise that making the transition to a care home can cause additional difficulties to some groups of older people, for example those with dementia who embody a high proportion of people living in care homes, older people from black and minority ethnic communities and those with complex and multiple needs (Ellins et al., 2012;Khan, 2015). The international literature describes moving to a care home as a traumatic and life changing experience (Brandburg et al., 2013;Sury et al., 2013;Ryan and McKenna, 2015;O'Neill et al., 2020a). Moreover, the significance of moving to a care home does not appear to be acknowledged or supported by formal services (Cooney, 2012;Thein et al., 2011;Brownie et al., 2014;O'Neill et al., 2020a). Subsequently, older people are denied an active role in decision-making and choice, which adversely affects their transition experiences (Dossa et al., 2012;Fuji et al., 2013;Hanratty et al., 2012;Toles et al., 2012;O'Neill et al., 2020b). There is a need to increase health care professionals' understanding of the importance of making a transition to a care home from the perspective of older people making the move. It is imperative that health care professionals are able to collaborate and work in partnership with older people in the decision-making and management of the move to a care home. Moreover, they need to support and enable older people to make decisions and plans about their future health and social care needs including the possibility of living in a care home when they are unable to manage their own needs.
Within the current body of literature there is a lack of detailed understanding of the processes older people undergo that describe their experiences during the day-to-day adjustment and adaptation to living in a care home. Furthermore, there is limited research into the psychological and/or social experiences of older people moving into a care home that takes into consideration the total relocation process, incorporating residents' early and ongoing experiences during the transition.
The literature identified an increasing recognition of older people's need for continuing psychological and emotional support and the need to be supported to engage in honest and caring discussions to help with acceptance and adaptation to living in a care home. A culture of maintaining independence and maximising rehabilitation needs to be fostered by all health care staff taking due cognisance that individual's human rights are protected and actively endorsed within the care home environment. An effective management resource for promoting quality of life and positive change in care homes is offered by my home life (https://myhomelife.org.uk/). This international programme provides leadership support to managers by increasing knowledge and skills in effective management to inspire and direct culture change within care homes (Penney and Ryan, 2022) Despite the plethora of studies taking place in care homes, there is a paucity of research on older people's experiences of the move from a longitudinal perspective. The development of a comprehensive body of knowledge of older people' adjustment and adaptation to a care home has the potential to identify relevant social and health care practices that can facilitate adaptation. This literature review has identified that there is a significant dearth of studies not only of the pre-move experiences of the older person' moving to a care home, but there are also limited studies undertaken within the initial weeks and months following the move. The identified studies are also associated with small sample sizes. Significantly, there has only been one study identified that has followed participants' transition from their own home to a care home over a one-year period.

Limitations
The studies included were limited to those published in the English language. The focus of the review concerned the experiences of older people making the transition to living in a care home. The views of other key stakeholders involved in the transition process (e.g., families, hospital staff, and care home staff) may have offered additional insights. However, this must be considered in the context of the large body of evidence that exists with respect to the families' perspectives and involvement in care home transition in comparison to the paucity of research on residents' experiences.