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research-article2014

QHRXXX10.1177/1049732314551990Qualitative Health ResearchChen

Article

Decisions for Institutionalization Among Nursing Home Residents and Their Children in Shanghai

Qualitative Health Research 2015, Vol. 25(4) 458­–469 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049732314551990 qhr.sagepub.com

Lin Chen1

Abstract An increasing number of elders in Shanghai have moved into nursing homes to meet their needs for long-term care. This shift from family caregiving to nursing home care calls for an exploration of caregiving decision making in urban China. In this article I present both generations’ experiences of deciding to institutionalize. Face-to-face, semistructured interviews took place with 12 dyads of matched elders and their children (N = 24) in a governmentsponsored, municipal-level nursing home in Shanghai. Spatially situated in a Cartesian coordinate system, the essence of participants’ experiences showed that they either proactively or reactively chose institutionalization. Proactive families were motivated to prevent potentially increasing caregiving burdens that might exceed family caregiving capacity, whereas reactive families sought institutionalization after they had depleted caregiving resources at home. The findings illuminate diverse needs for long-term care of Chinese elders–the world’s largest aging population–in the coming decades. Keywords aging; China, Chinese culture; decision making; families, caregiving; health care, long-term; phenomenology; relationships, parent–child Government-sponsored nursing home care has traditionally been the only formal support in urban China to care for the mentally ill, the impoverished, and the “three-nos” elders (i.e., no child, no income, and no spouse; Wong & Leung, 2012). Resources remain scarce for other groups who need ample long-term care services; for example, frail elders living with their children. Based on the analysis of the Chinese Longitudinal Healthy Longevity Survey (CLHLS) in 2005 (N = 15,593), nearly 60% of elderly respondents have experienced unmet and undermet needs for long-term care. This number is projected to reach 16 million in 2050 given the current aging rate in China (Gu & Vlosky, 2008). China’s Ministry of Civil Affairs began its Star Light Program (i.e., Xing Guang Ji Hua) in 2000 to promote long-term care services for the elderly, including increasing nursing home care (China Social Sciences Aging Science Research Center, 2007). However, the current classification “nursing home care” in urban China seems to cover a wide variety of available residential care; considerable variations in residents’ functional dependence and acuity levels exist across institutional facilities (Feng et al., 2011). This status might be similar to that of nursing homes in the 1960s or 1970s in the United States, when a postacute industry had not yet developed (Feng et al.).

Understandably, most Chinese elders prefer family caregiving to formal long-term care because of ingrained filial piety (Flaherty et al., 2007), which entails unconditionally respecting, obeying, and caring for elderly parents (Chou, 2011). This concept has profoundly contributed to Chinese parent-centered family caregiving tradition (Ikels, 2004); however, Chinese economic reform has led to greater control of economic resources for the younger generation than for the older generation. Members of the younger generation—the traditionally expected caregivers—have become less available for their elderly parents because of geographic mobility and conflicting work and family obligations (e.g., Chen & Ye, 2013; Zhan, Feng, & Luo, 2008). As a result, an increasing number of elders in urban China have chosen nursing home care (Chu & Chi, 2008; Feng et al., 2011). Shanghai exemplifies this trend. Being one of the largest cities (by population) in the world, it has recently 1

Fudan University, Shanghai, China

Corresponding Author: Lin Chen, 901 Humanities and Social Science Building, Department of Social Work, Fudan University, 220 Handan Road, Shanghai, China, 200433. Email: [email protected]

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Chen experienced a record-setting increase in the aging population, which has led to a rapid growth of nursing home care. People aged 65 or older accounted for 25.7% of the total 23.5 million population (i.e., more than 6 million) in 2012 (Shanghai Statistic Bureau, 2013). Likewise, the number of nursing homes in Shanghai has increased nearly 25% in the last 6 years, from 505 in 2006 to 631 in 2012. The number of nursing home beds has increased almost 50%, from approximately 60,000 in 2006 to more than 105,000 in 2012. In 2012 alone, the number of nursing home beds increased by 6,000 (Social Welfare Department of Shanghai Civil Affairs Bureau, 2013). This dramatic increase in nursing home care calls for an exploration of the dynamics of caregiving decision making between generations in urban China.

for social support, especially when elders suffer from chronic illness (Wykle, 2011). Chinese economic reform has brought transformative, unbalanced power change between generations and created different forces affecting traditional family caregiving (Lee & Kwok, 2005). The underlying psychosocial complexity of caregiving decision making deserves investigation. Thus, the purpose of this study was to describe Shanghai elders’ and their children’s experiences of deciding to institutionalize. I hypothesized that this decision-making process involves different caregiving perceptions from each generation and a range of diverse, evolving psychosocial contexts.

Method Study Design

Literature Review The decision for institutionalization is a complex and difficult process for elders and their families (e.g., Byrne, Goeree, Hiedemann, & Stern, 2009; Hoving, Visser, Mullen, & Borne, 2010). This decision typically involves many psychosocial contexts (Byrne et al., 2009), such as allocation of time to family caregiving and work (Byrne et al.), lack of and/or burnout of family caregivers, and culturally diverse caregiving values (Hoving et al., 2010). However, existing studies have left out nuanced dynamics of caregiving decision making. First, large-scale quantitative studies have found predictors of elders’ institutionalization, such as declining activities of daily living (ADLs) and/or instrumental activities of daily living (IADLs), diagnosis of dementia, bladder incontinence, falls, and behavioral issues (e.g., aggression, wandering; Gaugler, Yu, Krichbaum, & Wyman, 2009), but the qualitative aspects of this decision-making process remain understudied. Qualitative studies on this topic have often been focused only on how child caregivers decide to institutionalize their elderly parents with dementia (e.g., Chang & Schneider, 2010; Wackerbarth, 1999). Issues around institutionalizing elders with dementia are clearly important, but investigating the dynamics of decision making around institutionalization among cognitively intact elders can become a starting point to examine this process in the family context. In addition, qualitative studies specifically focusing on elders’ institutionalization in urban China are rare. Existing studies have investigated only a single generation, such as the elders (e.g., Chen, 2011). Furthermore, salient psychosocial contexts of the dynamics of caregiving decision making in urban China need exploration. Investigating filial piety alone often cannot illustrate a holistic understanding of caregiving decision making (Torsch, & Ma, 2000). In fact, it can prevent elders and their children from seeking early interventions

A phenomenological study describes the meaning of individuals’ lived experiences of a phenomenon, with the aims of providing the basis for a reflective analysis and capturing the essences of these experiences (Moustakas, 1994). These essences are the core meanings shared by those who have had similar experiences (Moustakas). They are a set of relevant qualities related to a phenomenon and its emerging structure (Husserl, 1970)–“essences and essential relations” (Husserl, 1965, p. 116). Investigating intentionality helps to understand the essences of participants’ experiences in a phenomenological study. Intentionality refers to the power of individuals’ minds to describe and represent things, properties, and states of events (Jacob, 2010). Husserl (1970) argued that intentionality actively consists of intentional objects (Holstein & Gubrium, 1994) that researchers extract from people’s experiences to see how they give meanings to and organize their world (Mortari & Tarozzi, 2010). Intentional objects can be things, such as tables, houses, and people, and/or psychological phenomena, such as remembering, imagining, and planning (Husserl, 1970). When intentional objects, regardless of whether a table or a memory, appear in people’s reflections–when people have thought of them, perceived them, and interpreted them–they become phenomena (Wagner, 1970). Every experience is not only a consciousness, but also simultaneously consists of the intentional objects that construct this consciousness, “bringing together the objectivity and subjectivity that intentionality encapsulates” (Crotty, 1996, p. 42). Furthermore, people use intentionality to typify objects, emotions, and behaviors to produce a familiar world–a process of typification (Holstein & Gubrium, 1994). During this process, people’s consciousness makes finer distinctions with different typifications and continues to develop these typifications based on new observations or experiences to construct their world. Meanwhile, people

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continue to classify these typifications into types with particular qualities, from which typical courses of action can be expected (Benton & Craib, 2001); that is, people assume that those who share similar experiences are likely to share similar understandings, which gives people common sense about the society that they share. As a result, the society is built up from a complex of typifications–a taken-for-granted stock of knowledge–that people share with others (Benton & Craib). When encountering changing circumstances, people begin to question their everyday life (i.e., suspending former intentional objects, a group of typifications, and/or the stock of knowledge). They tend to reflect on or interpret their prior experiences and distinguish these experiences from their current living–that is, only the already experienced is meaningful, not that which is being experienced (Wagner, 1970). So intentionality and typifications show how people meaningfully construct experiences, how these experiences make sense to them, and how people react when their taken-for-granted typifications are no longer meaningful under evolving psychosocial circumstances. Following Husserl’s (1965) phenomenology, I performed psychological phenomenological reduction to discover the fundamental, invariant features of elders’ and their children’s experiences of deciding to institutionalize with their intersubjective perceptions (Mortari & Tarozzi, 2010). Psychological phenomenological reduction is to bracket the world to make the experiences and natural attitudes more accessible (Giorgi, 1997). I bracketed my values and judgments concerning this phenomenon but did not undermine participants’ descriptions (Levinas, 1998; see below for a detailed discussion of bracketing). Epoché and bracketing are two important strategies in performing phenomenological reduction. Epoché is the first step in conducting a phenomenological study (Zaner, 1975). It refers to a critical stand of on the part of researchers that requires them to take nothing for granted (Crotty, 1996; Moustakas, 1994). The fundamental process of epoché focuses on a phenomenon as it appears–a return to the phenomenon itself (Zaner). I concentrated on participants’ own beliefs, perceptions, and reflections about their experiences of caregiving decision making throughout the study. Bracketing is the next step for phenomenological reduction. Bracketing is the suspension of taken-for-granted knowledge of the phenomenon (Crotty, 1996). This process requires researchers to disconnect from all the assumptions related to the phenomenon but believe in the existence of the phenomenon of interest (Koch, 1995). I bracketed my knowledge, understanding, and previous experience of a similar study (Chen, 2011) as much as possible throughout the study. Similar to epoché, bracketing is a dynamic

process. I constantly appraised my own stance in relation to participants’ descriptions throughout the study, treating every aspect of the phenomenon equally. Thus, a phenomenological approach was ideal for this study because participants had already questioned, reflected, and interpreted their experiences of deciding to institutionalize. They suspended their familiar typifications of family caregiving, filial piety, and nursing home care and made sense of new ones. Recording their trajectories of typifications and intentionality during the decision-making process provided an opportunity to understand the essences and the essential relations of their experience.

Study Setting I purposively selected a government-sponsored, municipal-level nursing home in Shanghai that was administered and subsidized directly by the Shanghai Civil Affairs Bureau. This nursing home was similar to a skilled nursing facility in the United States that had residential physicians. The reason for selecting this facility was that it represented the type of nursing homes that most elders and their children in urban China would like to choose, with low fees and government-monitored services (Feng et al., 2011); however, residents in private nursing homes can be better off than those who live in government-sponsored ones. The decision to enter a private nursing home might have more to do with elders’ or their family members’ ability to afford it than with other psychosocial contexts. Recruiting from a private nursing home would have generated a different group of elders and their children, and potentially a different decision-making process, shifting away from the focus of this study. There were 320 beds in the nursing home. The average age of all residents was 82.3 years. The nursing home consisted of three caregiving areas: independent living, assisted living, and constant care. The independent living area was for residents who needed a minimum level of care. The assisted living area was for those who had some physical disabilities and needed a moderate level of care. The constant-care area was mainly for residents who had severe cognitive and/or physical impairment.

Sampling I used a purposive sampling strategy to recruit participants. The criteria for participating elders included (a) aged 65 years and above, (b) minimal cognitive impairment symptoms assessed by the physician in the nursing home, and (c) lived with children before institutionalization. Participating elders helped to identify and invite their children who were their primary caregivers before institutionalization to participate in the study.

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Study Procedures After receiving approval from the Human Subjects Review Board of the University of California, Los Angeles, I obtained agency approval and conducted three site visits before the actual study began. The chief social worker helped me to identify 20 potentially eligible elders. Then I held an information briefing session for these 20 elders at their convenience. During the session, I introduced the background, main research questions, and study design. I answered their questions and addressed their concerns. In particular, I stressed the confidentiality of the interview, and the fact that I would not share their identity with anyone else or share their responses with their children. Eighteen elders volunteered to participate and 16 consented after I discussed the interview procedure with them individually. All 16 identified residents identified one of their children as the primary caregiver prior to institutionalization and agreed to invite him or her to participate in the study. The nursing home contacted their children. After their initial agreement to be consented, I introduced the study to them over the phone and invited each of them to meet during their visits to the nursing home. Among the 16 adult children, 4 refused to participate because of privacy concerns; 12 agreed to participate. I arranged time to meet them at their convenience and obtained their consent. In the end, I interviewed 12 dyads of elders/children, with a final sample of 24.

Participants Three men and 9 women participated in the interviews, reflecting the unbalanced gender ratio in the nursing home. All elders were more than 80 years old. On average, they had spent a little over 3 years in the current nursing home. They were all widowed when they moved to the nursing home, with the exception of one female participant. On average, each had four children. All elders had lived with their children for an average of 10 years prior to institutionalization. Almost half of elders perceived their health condition as stable. Nine of them lived in the independent living area and the other 3 lived in the assisted living area. Eight child caregivers were sons and 4 were daughters. Eight children were the youngest child, 3 were the eldest son, and 1 was the second daughter. The average age of participating children was 55.3 years (SD = 4.35; range 49 to 61).

Data Collection and Analysis I conducted 24 individual, face-to-face, semistructured, in-depth interviews in a private conference room in the nursing home. The rationale for interviewing elders separate from their children was to avoid potential data

contamination; that is, elders and their children might have masked their true answers if they had been interviewed together. We talked in Mandarin and Shanghai dialects. Topics included, but were not limited to, family caregiving contexts prior to institutionalization, health conditions, conversations and negotiations regarding the caregiving decision, factors influencing decision making, and the final decision to institutionalize. With the participants’ permission, I audio-recorded all of the interviews in their entirety. In general, each interview took between .5 and 2 hours—an average of 1.7 hours for children and 1.2 hours for elders. In consideration of their low level of stamina, when interviewing the 3 elders living in the assisted living area I divided their interviews in 2 days. I contacted 3 children a second time when I needed clarification regarding some of their answers. I collected and analyzed data concurrently to identify when saturation had been reached; that is, the basic patterns reappeared in each subsequent interview analysis (Creswell, 2007). I transcribed and translated interviews into English immediately after each interview. In the translation I aimed to convey the entirety and emotions involved, so it was not necessarily verbatim. All interview data were analyzed together. Initially, I open-coded the complete interview transcripts after reading them thoroughly. I used the same words that participants used as codes to retain authenticity. After open coding, I divided the original transcripts into statements that pertained directly to participants’ experiences of deciding to institutionalize. I transformed these statements into clusters of meanings (Creswell, 2007). Then I clustered codes and linked statements in a codebook to create a general description common to all the participants’ experiences of deciding to institutionalize. Finally, I reread the original Mandarin and English transcripts to ensure that no significant statements remained unidentified. I kept all the memos and field notes as audit trails.

Results Etiology of Family Caregiving The unexpected reality of family caregiving. All elders moved to their child’s home after their spouse passed away, at the request of their child. The reasons included monitoring their health status and providing necessary instrumental support; however, coresidence did not necessarily benefit elders. Different living habits between generations negatively affected coresidence. For example, Mrs. Zhang1, an elder (E), reported that the different living schedule between generations disturbed her life greatly when living with her youngest son. The condition of children’s apartments did not suit elders’ needs. For example, Mr. Zhou, a child (C), found that his apartment

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was not optimal for his father’s health condition: “My father was very alert at night because of his asthma. But my apartment was quite old and not that soundproof. It was not possible for him to sleep well.” Furthermore, exchanging property for their children’s caregiving did not guarantee that these elders would receive family caregiving. For example, Mr. Zhou (E) described his experience: When my wife fell ill, my daughter suggested that we move to her place, which was close to the hospital. Her place is quite spacious, so we thought that we would live with my daughter’s family for the rest of our lives. Then my wife and I decided to give our youngest son our apartment, because we were always fond of him. After my wife passed away, my daughter felt it was unfair that we gave the apartment to her younger brother instead of her after she undertook all the heavy lifting of caregiving, instead of him. In the end, she asked me to leave her home.

Both generations implicitly agreed that the child who received the parents’ property was supposed to live with the parents and undertake family caregiving, but this contract could be revoked because of unbalanced caregiving responsibilities among siblings and unfair compensation from their parents. This revoked agreement created additional emotional disturbance to elders, which might have related to the elders’ losing their sense of belonging. For example, Mrs. Fan (E) said, “I never felt at home after giving my son the apartment, even though I still lived in the same apartment. It was just different.” These elders felt frustrated, powerless, and disappointed. Because of these expected and unexpected difficulties, coresidence became increasingly unreliable for elders, both instrumentally and emotionally. Familial discordance regarding the caregiving tradition. All elders had high caregiving expectations of their children because of their ingrained understanding of filial piety. For example, Mrs. Lin (E) said, We Chinese elders, especially like me, an almost disabled old lady, want to rely on our children, not paid caregivers, not nursing homes. It is our tradition, isn’t it? If everything was fine, like if my hip was not injured, I would like my children to take care of me.

However, elders realized the disappointing reality. They had strained relationships with their children or childrenin-law, which culminated during coresidence. For example, Mrs. Huang (E) complained about her daughter-in-law’s reluctance to care for her. For elders, their child’s willingness to provide caregiving was more important than the actual caregiving. Contrary to their parents’ views, participating children considered that filial piety could be

manifested only in providing instrumental support. For example, Mr. Huang (C) stated that no emotional attachment existed between him and his mother, and that providing sufficient instrumental support was the only way to show that he honored filial piety. This discrepancy between children’s declining beliefs in filial piety and elders’ high expectations led to familial discordance in caregiving. For example, as Ms. Ye (C) described, “We had trouble communicating for a long time. She wanted to do everything her way. If I did not follow her instructions, she thought I was a bad daughter who did not honor filial piety.” The once-congruent understandings of filial piety between generations shifted away from elders’ expectations of integrated caregiving– including instrumental and emotional support–and made way for children’s oversimplified notions of instrumental support only. Thus, discordant family caregiving might have catalyzed the proposal to institutionalize.

Two Players in One Game Figure 1 categorizes the 12 families in terms of who proposed institutionalization and their primary reasons. Four elders voluntarily proposed to institutionalize because of strained intergenerational relationships (Mrs. Fan and Mrs. Nie), loneliness, and potentially increasing caregiving burdens (Mrs. Huang and Mrs. Shen). Children proposed to institutionalize in the remaining eight families because of other family members’ health conditions (Chen and Wang families), children’s caregiving precautions (Cao and Yang families), and elders’ deteriorating health conditions (Lin, Ye, Zhang, and Zhou families). Seizing the remaining decision-making autonomy. Healthy elders voluntarily proposed to institutionalize. Mrs. Fan initiated the decision because she was too lonely at home and wanted more social interactions with peers. Mrs. Shen wanted to have a more active lifestyle rather than staying at home alone. Mrs. Huang and Mrs. Nie, however, desired more reliable caregiving because unstable caregiving arrangements and strained relationships with their childrenin-law made them feel unwanted at home. For example, Mrs. Nie was disappointed: “I was like a ball bounced among my children. No one wanted me. So I decided to move to a nursing home rather than rely on them.” Using their remaining decision-making autonomy, these 4 elders decided to institutionalize before their children suggested it. Children of these 4 elders reacted differently. Mr. Shen (C) valued being able to provide family caregiving for his mother, so he was strongly against his mother’s proposal at first. After many discussions, he knew that he had to respect his mother’s decision. The other three families reached consensus more smoothly; children united behind their mothers. Ms. Nie (C) and her siblings discussed the

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Figure 1.  Families categorized by which generation initiated the decision to institutionalize, and their primary reasons. a

Mrs. Fan moved to the current government-sponsored nursing home twice within 3 years. Mrs. Ye and Mrs. Zhang had both lived in private nursing homes for several months before moving to this current government-sponsored nursing home. b

issue and agreed with their mother’s decision. Mr. Fan (C) had family meetings with his siblings to discuss their mother’s proposal in Mrs. Fan’s presence: My siblings and I discussed with our mother about her decision several times. We agreed with her to take advantage of the professional health care in the nursing home. We had a couple more meetings following about which nursing home to choose. We considered various conditions, including food, services, staff, and administration.

These three families only weakly resisted when their mothers suggested ending coresidence. They implied that they were aware that their mother’s decision to institutionalize was an attempt to avoid family discordance and a potential increase in caregiving burden. Despite various

family caregiving situations, these 4 elders were exceptionally motivated to change their caregiving arrangements and maintain their autonomy. Taking the initiative, they decided to institutionalize. Preempting caregiving depletion. Children from the Cao, Chen, Wang, and Yang families preventively chose to institutionalize their parents. Children in the Chen and Wang families proposed to do so because of exceeding caregiving burden from other family members’ health problems. For example, Ms. Wang (C) had had a car accident when her father was recovering from a minor stroke, which dramatically reduced the family’s caregiving capacity. When Mrs. Chen (E) fell ill, family caregiving was collapsing: “My paralyzed husband used to rely most on me. When I was hospitalized, I knew my children

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were not able to take care of both of us. So I agreed with my eldest son’s suggestion and moved here with my late husband.” Both families realized that they had to find an alternative to family caregiving before all of their resources were depleted. Elders accepted their children’s proposals to institutionalize without questioning whether they honored filial piety when they experienced collapsing family caregiving. Children in the Cao and Yang families proposed to institutionalize to avoid a potential increase in caregiving burden, even though their parents’ health conditions were stable. Mr. Yang (C) and Ms. Cao (C) decided to institutionalize their parents rather than leaving them alone at home, because staff could monitor their parents in the nursing home; however, their parents were strongly against the decision. Their health conditions were comparatively stable for their age and they were able to take care of themselves. Mrs. Yang (E) blamed her daughter-in-law for avoiding caregiving responsibilities by institutionalizing her. Mr. Yang (C), however, insisted, “If anything happens to my mother when she was alone at home I could not handle the situation. As long as I still visit her in the nursing home regularly, there should not be a difference.” Mrs. Yang (E) finally agreed to move to the nursing home because of her strong feeling of obligation to her son: “My son told me that he had pulled some connections to find me a place in this nursing home. I knew I could not insist on staying with him any more. I had to accept his decision.” Mr. Cao (E) eventually accepted the decision, because he realized that his children were not as capable as the staff in the nursing home. Mr. Yang (C) and Mr. Cao (C) were aware of their parents’ old age and risks of increasing frailty, with the possibility of exceeding their family caregiving capacities, but excluding their healthy parents from the decision-making process raised elders’ feelings of abandonment and angst, as well as misunderstanding between generations.

The last straw The Lin, Ye, Zhang, and Zhou families encountered tremen-dous family caregiving pressure before deciding to institutionalize.For example, Mrs. Lin (E) fell in the shower and had a hip replacement. Mrs. Ye (E) sprained her ankle and required surgery. Their children admitted that the caregiving burden had suddenly become excessive and left them unprepared. For example, Mr. Lin (C) said, “Professional caregivers in the nursing home know how to improve my mother’s condition. I am sixty-one years old myself. I do not have the stamina to provide constant care for her anymore.” Mrs. Zhang (E) and Mr. Zhou (E) had chronic conditions that kept deteriorating as they aged, gradually exceeding their family’s caregiving capacities. In particular, children’s

lack of medical knowledge or skills impeded the provision of adequate or proper health care for their parents. For example, Mr. Zhou (C) said, Before my father moved to [the current nursing home], he was very ill. His asthma broke out frequently at night. I had to take him to the doctors every week and he had to be hospitalized almost every month. He needed some special care but I could not provide it.

Both generations realized that family caregiving had become inadequate when elders’ health conditions steadily deteriorated or suddenly worsened. Children reached their mental and physical limits because of the demanding family caregiving. Their awareness of failing to provide proper caregiving became the last straw, calling for resolution. Their weak parents gradually realized that family caregiving was no longer adequate for their conditions, despite their initial confusion, nervousness, and fury. For example, Mrs. Ye (E) agreed to move to the nursing home for her daughter’s sake: “I knew that I could not say ‘No’ to her. I knew it was too much for her to take care of me. My daughter had no choice. I had no choice.” With their children’s insistence, these 4 frail elders eventually accepted institutionalization as the next caregiving phase.

Spatially Situated Decision Making I conceptually categorized the 12 families’ experiences of deciding to institutionalize and situated them in a Cartesian coordinate system (see Figure 2). The different distances between each family and the origin in the Catesian coordinate system indicated to what extent both generations were motivated to institutionalize. The horizontal axis represents participants’ voluntariness when deciding to institutionalize, from reactive to proactive. Reactive decision making meant that because family caregiving exceeded children’s capacities, they had to seek institutionalization for extra instrumental and/or health care support. Proactive decision making meant that elders proposed to institutionalize themselves, or children decided for their parents to prevent a potential increase in family caregiving burden. The vertical axis represents participants’ needs for institutionalization, ranging from instrumental to psychosocial. Instrumental needs related to either generation’s deteriorating health conditions. Psychosocial needs related to elders’ needs for social interactions and avoiding strained intergenerational relationships. Thus, above the horizontal axis participants were concerned with psychosocial needs, whereas below the horizontal axis participants emphasized increasing instrumental needs. On the left of the vertical axis, participants focused on coping with collapsed family

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Figure 2.  A Cartesian coordinate system of participants’ experiences of deciding to institutionalize.

caregiving. On the right of the vertical axis, participants were vigilant about depleting family caregiving resources. In this study, the 12 families fell into three quadrants in the Cartesian coordinate system. The first quadrant contained four families in which elders decided to institutionalize themselves. Two elders were healthy and longed for social interaction in the nursing home; however, the other 2 elders were motivated to escape strained intergenerational relationships. These four families were high in both proactive decision making and psychosocial needs with different motivations. In the third quadrant, elders’ needs for health care exceeded their children’s caregiving resources. Children decided for their parents to institutionalize, to seek extra instrumental assistance and medical support from the nursing home. These four families appeared high in both reactive decision making and instrumental needs. Another four families fell into the fourth quadrant. Two elders were relatively healthy, yet their children institutionalized them to prevent a potential increase in caregiving burden. These two families were comparatively low in both proactive decision making and instrumental needs. In contrast, the other 2 weak elders and their children reached mutual understanding of institutionalization because their family members’ health problems subsequently impaired family caregiving. These two families were high in instrumental needs and also comparatively high in proactive decision making.

This Cartesian coordinate system divided participants’ experiences into three groups: a proactive decision to meet psychosocial needs, a proactive decision to meet instrumental needs, and a reactive decision to meet instrumental needs. Children who proactively made the decision were aware of potential caregiving pressure that might have exceeded family caregiving capacity. Children who reactively made the decision controlled caregiving decision making to face tremendous caregiving pressure. Elders in proactive families retained some decision-making autonomy and emphasized their increased psychosocial needs. Elders in reactive families complied with their children’s decision, despite their initial objections.

Discussion Psychosocial Contexts of Deciding to Institutionalize Evolving family caregiving.  Coresidence remained the primary type of family caregiving for all participating elders, in accordance with filial piety (Cong & Silverstein, 2011). Elders’ widowhood (Frankenberg, Lillard, & Willis, 2002) and their functional limitations (Zimmer & Korinek, 2008) commonly activate coresidence; however, children’s declining beliefs in filial piety made coresidence less dependable for participating elders.

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Family caregiving in urban China has evolved along with its socioeconomic development. Participating elders exchanged property to secure their children’s caregiving–an emerging trend for elders in an attempt to ensure family caregiving in urban China (Wang, 2010)–although the practice contrasts with traditional filial piety (Cong & Silverstein, 2011). Children’s acceptance of the property became an implicit agreement to provide family caregiving for their elderly parents (Wang); however, this agreement might have made children tolerate their caregiving role as well as contributed to their feelings of unfairness about caregiving arrangements among siblings (Hsu & Shyu, 2003). Contradicting elders’ intent to secure their entitled family caregiving, this study showed that exchanging property did not necessarily work. Some children withdrew caregiving when they did not receive the “payment.” Depleting family caregiving resources. Elders’ declining health conditions gradually depleted family caregiving resources, including financial, emotional, and instrumental. When elders had accidents and/or their health suddenly worsened, caregiving pressure often exceeded their children’s capacities (e.g., Chen, 2011). For those with chronic conditions, their devolving health led to increased needs for both custodial and skilled health care. In addition, children’s own ongoing and emergent constraints complicated caregiving situations (Talley & Montgomery, 2013). Because participating children were also aging, they could barely keep up with the increasingly demanding family caregiving responsibilities. Shifting away from the family caregiving tradition. Participating elders maintained high standards of filial piety. When they received family caregiving as they expected it, elders praised their children for honoring filial piety; however, when their expectations were not met, they felt disappointed and viewed their children as violating the virtue of filial piety. This finding exemplified elders’ strong sense of entitlement to children’s reciprocation, which strongly related to filial piety (Holroyd, 2003). In addition, facing gradual emotional detachment in accordance with their children’s declining beliefs in filial piety, elders became increasingly dissatisfied. In contrast to their parents, children admitted that they were not able to fully comply with filial piety. Instrumental support occurred disproportionately at the expense of emotional support because children decisively prioritized the former. This finding suggests that although children moved between interpersonal and pragmatic phases when reaching their limits to continue family caregiving, a shift to a more practical decision might occur (Caron & Bowers, 2003). Moreover, children with limited resources (e.g., medical knowledge, work, and other family responsibility)

might have been motivated to increase instrumental support to minimize their own feelings of guilt about not providing adequate or proper caregiving (Lin, 2008). Participating children viewed the professional health care in the nursing homes as offsetting declining instrumental support at home. Children’s wide acceptance of caregiving alternatives was similar to the acculturated filial piety among Chinese immigrants in the United States (Hsueh, Hu, & ClarkeEkong, 2008), which indicates that the evolution of filial piety might have adopted some Westernized long-term care characteristics (Cheung & Kwan, 2009). In addition, because 77.3% of women in urban China are currently in the labor market (Maurer-Fazio, Connelly, Lan, & Tang, 2009), they can be substantially disadvantaged when trying to balance demanding work and caregiving responsibilities. Children’s social and financial costs might influence their parents’ caregiving arrangements.

Methodological Implications Phenomenological reduction. I systematically performed phenomenological reduction (Moustakas, 1994) to discover the essence of participants’ experiences of deciding to institutionalize. Elders’ intentionality changed slowly but dramatically during the decision-making process. They noticed that family caregiving had become inadequate prior to institutionalization and realized that family caregiving might have reached, or was near reaching, its limits. Aligning with their children’s proposal for institutionalization, they gradually suspended their beliefs in traditional filial piety and attempted to establish a new understanding of weakening family caregiving. Their acceptance of nursing home care subsequently followed. Compared with their parents, participating children’s intentionality changed rapidly, possibly because of the implications of socioeconomic developments in urban China. They quickly suspended their beliefs in filial piety and did not hesitate to seek alternatives to confront depleting family caregiving resources, although they remained keenly aware of their parents’ traditional caregiving expectations. Thus, both generations’ intentionality evolved over the decision-making process, albeit at a different pace for each generation. Furthermore, participants’ typifications of filial piety, family caregiving, and nursing home care transformed during the decision-making process. Elders typified filial piety as a holistic concept, emphasizing both instrumental support and emotional support. Children’s typification of filial piety became limited to instrumental support because they prioritized to alleviate family caregiving burdens. Elders’ typification of family caregiving remained exclusively within families; however, children’s typification of family caregiving broadened. They considered institutionalization

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Chen a form of family caregiving as long as they still visited their parents in the nursing home. Elders’ typification of nursing home care transformed dramatically during the decision-making process, especially for those who were from reactive families. These elders might have “bought into” the deeply rooted, stigmatized image that Chinese people had of those who lived in nursing homes. Encountering family caregiving difficulties, elders gradually realized that nursing home care could provide what their children could not: professional and medical assistance. In contrast, children’s typification of nursing home care remained relatively consistent throughout the decision-making process. It became one of the viable caregiving alternatives to provide professional health care for their parents. Thus, participants voluntarily or passively suspended their old typifications of filial piety, family caregiving, and nursing home care. They accepted salient information and reconstructed new typifications accordingly. This evolution matched their transforming intentionality during the process. When both generations gradually accepted a common system of typifications, the intergenerational discrepancies reduced and led to a homogeneous understanding of nursing home care (Wagner, 1970). A dyadic perspective.  I applied a dyadic perspective to highlight the relational aspects of how both generations communicated about making the caregiving decision. For example, after their children described professional services in the nursing home during uncertainty management, elders began to recognize their original stigmatized impression and adjusted to the current notion of nursing home care. These interactions helped both generations to acknowledge, negotiate, and accept, willingly as well as unwillingly, each other’s views on caregiving arrangements. Eventually, they reached consensus on institutionalization. These underlying linkages might not have been identified if these conversations had been analyzed separately.

Research and Policy Implications Implications for caregiving decision-making research. This study captured a silhouette of the evolution of filial piety and its role in the decision to institutionalize. Children considered filial piety impractical, whereas elders’ reminiscence of it continued to influence their caregiving expectations. This intergenerational discrepancy indicates that although filial piety evolved for all generations in urban China, its historical roots remained deeply ingrained, even among different generations. Future investigation on filial piety should characterize its longitudinal changes since the Chinese economic reform. Furthermore, filial piety alone cannot represent the dynamics of caregiving decision making in Chinese families. Various traditional

values and identity around caregiving are essential in Chinese society (Holroyd, 2003). Future researchers should explore other sociocultural nuances, such as intergenerational identities, social desirability, and feelings of obligation and guilt between generations. In this study I categorized three groups in terms of participants’ voluntariness and primary reasons for institutionalization (i.e., proactive vs. reactive, psychosocial vs. instrumental); however, no families fell into the second quadrant in the Cartesian system, which represents a reactive decision to meet psychosocial needs. Future research can explore under what circumstances families would make such a decision. One possible situation might be in families in which elders have cognitive impairment, causing their children to seek institutionalization to help with their parents’ mental health and psychosocial needs. Long-term care policy development in China.  Proactive and reactive caregiving decision making can inform the development of home- or community-based service support programs. For example, children took precautions to choose institutionalization, whereas their parents still considered themselves independent. Home- or community-based long-term care can meet children’s needs for instrumental assistance and avoid curtailing elders’ remaining independence. Children’s premature decisions to place their parents in a nursing home might unnecessarily increase elders’ sense of a loss of self (Forbes & Hoffart, 1998). These services can also be helpful in maintaining emotional attachment between generations. Specialized long-term-care housing services can save more nursing home care resources for the group of elders most in need. Various types of alternative residential care, such as in-law apartments, housing for elders, and board and care homes can assist elders who have difficulty taking care of themselves but do not yet need nursing home care. These long-term care services can cater to elders’ needs at different levels. Another important reason for establishing more long-term care services is the socially rendered “invisible” dementia population in China (Feng et al., 2011). Nursing homes need to better allocate resources and be better prepared for dementia care that will surely deplete family caregiving resources in rapid and unique ways relative to “regular” long-term care needs.

Study Limitations A purposive sample might have resulted in selection bias. Participating elders were recruited from social workers’ recommendations. These elders might have been comparatively more outgoing and more confident in discussing personal and social experiences with an outsider than

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Qualitative Health Research 25(4)

those who were not recruited but also lived in the same nursing home.

Conclusion In sum, the essence of participants’ experiences of deciding to institutionalize was that elders and their children proactively or reactively chose institutionalization because of depleting or depleted family caregiving resources. Children had strong preferences for nursing home care, if only because it provided professional health care. Yet it was not easy for their parents to recognize the advantages of nursing home care and admit that family caregiving might be inadequate. Various cultural and psychosocial contexts intertwined in the decision-making process, such as undesirable coresidence, revoked agreement of exchanging property for caregiving, and evolving filial piety. The findings of this study can inform long-term care policy to develop diverse and specialized home- and community-based long-term care to consider various needs of the growing aging population in urban China. Acknowledgments I thank all of the elders and their children for graciously agreeing to participate in this study. I thank the nursing home for supporting this study. I am very grateful to my dissertation committee chair, Lené Levy-Storms, and appreciate the committee members: Laura Abrams, A. E. Benjamin, and Marjorie Kagawa-Singer.

Author’s Note This study received Honorable Mention of the American Society on Aging’s 2014 ASA Graduate Student Research Award.

Declaration of Conflicting Interests The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: She received the Dissertation Year Fellowship from the Graduate Division, University of California, Los Angeles, to conduct this study.

Note 1.

All participant names used in the article are pseudonyms.

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Author Biography Lin Chen, PhD, is an assistant professor in Department of Social Work, Fudan University, China.

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