1. Introduction

With the rapid global aging of populations, the sense of loneliness among the elderly is emerging as a significant global issue [1]. Research indicates that loneliness has a profound impact on the physical and mental health of the elderly, increasing their rates of illness and mortality [2-4]. This issue is particularly pronounced in China as the process of population aging continues to deepen [5]. According to data from the National Committee on Aging under the National Health Commission, by the end of 2021, the number of individuals aged 60 and above in China has reached a staggering 267 million, constituting 18.9% of the total population [6]. As the elderly population continues to expand, a host of health issues linked to the sense of loneliness among the elderly is expected to increase. Loneliness not only increases the likelihood of the elderly developing mental health conditions such as depression and anxiety [7], but it also diminishes their sense of well-being [8]. Additionally, loneliness is associated with an increased risk of elderly individuals developing physical ailments, such as hypertension [9], and is linked to higher mortality rates and an increased incidence of thoughts of suicide among the elderly [10, 11].

As people age and face various life transitions, such as retirement, the loss of friends and family members, as well as deterioration in health condition, they often become excessively vulnerable to feelings of loneliness. Long-term care facilities, also known as care homes, are designed to provide a supportive and safe environment for seniors, but they can also present unique challenges related to social isolation and emotional well-being. Therefore the problem of loneliness is projected to be exacerbated among elderly individuals who reside in long-term care facilities.

In 1973, Weiss published the paper “The experience of emotional and social isolation,” which laid the foundation for research in the field of loneliness [12]. Weiss’s interactionist theory proposed that loneliness can be categorized into two types: social loneliness, which arises from a lack of meaningful social connections, and emotional loneliness, which results from the absence or deficiency of intimate emotional attachments. Current research in the related field often focuses on specific factors related to overall loneliness among the elderly, with relatively fewer studies examining the combined effects of various factors from both the dimensions of social and emotional loneliness. Past research has shown that, although social loneliness and emotional loneliness are correlated, they represent distinct states that affect different groups of people. The distinction between social and emotional loneliness is relevant in the development of strategies to address loneliness. According to Weiss’s theoretical framework, social loneliness may be alleviated through reintegration into social networks, while emotional loneliness may find relief through the cultivation of close, affectionate relationships.

In recent years, researchers and healthcare professionals have shown increasing interest in understanding and addressing the issue of loneliness among elderly residents in care facilities. However, there is still a need for in-depth exploration of the experiences of these individuals and the factors that contribute to their feelings of loneliness. This study aims to contribute to the existing body of knowledge by conducting a qualitative investigation into the loneliness experiences of elderly residents in long-term care facilities.

2. Research Objects and Methods

2.1. Research objects

Using purposive sampling, 12 elderly participants were recruited from a nursing facility in Zhengzhou City between March and May 2023 for semi-structured interviews. Inclusion criteria were: ① aged ≥60 years old; ② first-time residents of a nursing facility for ≥3 months; ③ moderate to high loneliness levels, scoring of ≥3 on the De Jong Gierveld Loneliness Scale (DJGLS) [13]; ④ normal cognitive function, scoring of ≥8 on the Abbreviated Mental Test (AMT) [14]; ⑤ provided informed consent and voluntary participated; ⑥ no communication barriers, able to complete surveys independently or with assistance. Exclusion criteria were: ① history of mental illness or recent psychotropic medication use; ② serious or terminal illnesses; ③ recent major life events. The sample size was determined by information saturation, i.e. more new themes emerged. Loneliness levels ware categorized as moderate (3 to 8 points), severe (9 to 10 points), or extreme (11 points). The 12 participants, anonymized as A1 to A12, were described in Table 1. This study was approved by the Ethics Committee of Zhengzhou University (ZZUIRB2023-108).

Table 1. General information about the participants

2.2. Research Methodology

2.2.1. Interview outline. The primary research questions guiding this study are as follows:

(1) How long have you been residing here? How often do you engage in daily activities? What motivates you to participate in these activities?

(2) How do you define loneliness? Do you experience loneliness? If not, why not? If yes, is it a continuous feeling, or does it occur intermittently? When is it most likely to occur, and how do you experience it?

(3) Could you please discuss what, in your opinion, are the causes of loneliness?

(4) Can you describe the methods you employ to alleviate loneliness? How effective are these methods?

(5) Could you please elaborate on the specific assistance or support you believe would help alleviate this feeling of loneliness?

2.2.2. Data Collection. Data was collected through individual in-depth interviews. Prior to each interview, the purpose and process were explained to interviewees, and informed consent was obtained. Open-ended, non-leading questions allowed respondents to express their genuine perspectives and feelings. Interviewees’ nonverbal behaviors including movements, expressions, and tone were observed and recorded. The interview outline provided the framework, with follow-up questions and clarifications used as needed. Each interview was recorded and transcribed verbatim into a separate transcript shortly after completion. To protect interviewees’ privacy, transcripts were assigned code numbers rather than names. Interviews lasted 30-60 minutes in duration.

2.2.3. Data analysis. The researcher listened to the audio recordings repeatedly within 24 hours after completing the interviews. They transcribed the recordings verbatim into text, which was proofread by the second researcher and returned to the interviewees for confirmation. The data was analyzed using qualitative content analysis. The process involved: repeatedly reading to gain a holistic sense of the content; analyzing the data sentence by sentence, identifying important ideas and concepts, beginning to refine and code statements of significance; grouping similar codes to form categories and subcategories; defining and refining categories, subcategories, and codes; summarizing codes to arrive at key themes; reviewing themes until saturation (no new themes emerged). The two researchers independently conducted data analysis. Upon completion, they compared and discussed the analysis until an agreement was reached. Any inconsistencies were discussed with the third researcher to achieve consensus.

3. Thematic Analysis

3.1. Experiences of Loneliness

Loneliness is a complex emotional state characterized by a sense of isolation, solitude, and discontentment that often emerges when individuals are placed in unfamiliar, sequestered, or distinctive settings [15]. Upon relocating to retirement facilities, elderly individuals encounter a detachment from their accustomed living environment and loved ones, rendering them susceptible to the onset of loneliness [16]. The experiences of loneliness can be diversified according to this study. Here are several types in accordance with research data:

(1) Lack of Security

Lack of Belonging

Most of the older adults in this study expressed feelings of insubstantiality, lack of belonging, entrapment, and rejection while living in the nursing home.

“Do you know that feeling in a pet store? I am here waiting for my children to visit me, it is like those pets waiting for their owners to take them home... they can go home, but I no longer have a home; this isn’t my home.”(A3):

“Well, I’ve been here for eight hundred days. The Monkey King was trapped for five hundred years, and I’ve been here for eight hundred days... I gave my phone to my family, let them take it with them; I don’t trust leaving it here; I’m afraid it’ll get stolen.” (A1)

Lack of Self-Worth

Elderly individuals often feel inadequate and prone to self-blame due to the contrast between their past capabilities and their present state.

“Sometimes thinking about these things makes me very uncomfortable and in pain; it’s just feeling that I’m incapable, I’ve become useless, a burden to my family, a burden to myself.”(A9):

“Back when I was working, I could do anything. I would climb twenty-five utility poles in a day. Now, I can’t do anything, alas.”(A10)

(2) Helplessness and Compromise with Reality

In this study, the older people felt helpless and numb to the reality of life due to their inability to alleviate or eliminate the sense of loneliness until they compromised. There were over 20 repetitive phrases in the text, such as “what can be done about it” and “there is no way out”, which are characterized by a sense of emptiness, helplessness, and meaninglessness in life.

“I used to look at palmistry, which said I might live a long life, but I don’t care about it anymore; I’ll live as long as I live. I don’t want to think about it; I don’t want to think about anything; it’s not worth it.” (A1)

“We have no way to stop illness, no way to stop death, and we can’t control our emotions. We can’t control what we think in our minds; it’s like being useless; we can only tell ourselves to let go a little.” (A9)

(3) Uncertainty About the Future:

The elderly individuals lost hope for the future due to the perception that their life in the nursing homes was a monotonous routine, as evidenced by their uncertainty about the future, waiting for family members, and waiting for death.

“Who knows what the future holds; how good can it get?” (A1)

“My roommate, her family visits her once a week, and she marks each day on a calendar. She has a notebook, and she marks off a day every day.” (A2)

“There’s not much of a life here; it’s just eating and sleeping... we’re basically just waiting for death. This isn’t living.”(A9)

3.2. Causes of Loneliness

There could be multiple reasons for the elderly to feel lonely. Abraham Maslow introduced the famous “Hierarchy of Needs” in his 1943 paper “A Theory of Human Motivation”, which he later elaborated on in his 1954 book “Motivation and Personality” [17]. According to this theory, human needs are divided into five levels: physiological, safety, love and belonging, esteem, and self-actualization. These levels represent the hierarchy of needs, with people seeking to fulfill higher-level needs only after their lower-level needs have been satisfied. This theory has had a profound impact on understanding human needs and motivation and has become one of the fundamental theories in the field of psychology. Hence this study can draw some causes of loneliness from this theory.

(1) Internal Factors

These are due to the physiological, safety, and love and belonging needs cannot be met. Evidences are displayed below through the old people’s talking.

“Ever since I got sick and my speech became less clear, I feel embarrassed talking to people.”(A8)

“I’ve been introverted my whole life. Unlike my late spouse, who was outgoing and had many friends, I’m not good at conversing with people, so I easily feel lonely.”(A11)

“I moved from my hometown to live with my son. I don’t know anyone here, and my son is busy. I think about going back.”(A1)

Social Relationship Discord and Impaired Social Interaction

Esteem emanates from both internal and external sources. In the latter case, social activities can be extremely important. Below are the residents’ opinions on ailing social relationship, thus a testify of failing to meet esteem needs.

“In this facility, there are several residents who don’t talk to anyone. They sit by the door all day, waiting for visitors, but their family and friends don’t come to the nursing home to see them.”(A4)

“We’re old and useless; we can only be sent here. They (family members) are not filial.”(A6)

“No one here knows how to play chess. No one wants to play with you. We just watch TV, and even that can lead to arguments.”(A5)

“(Crying) Normally, I don’t tell anyone (that I’m lonely). The people here are (silent). They are all people with either incontinence problems or they’re really dirty.”(A10)

“Whenever there’s an issue, I go to them (nurses), but they don’t like me. They find me troublesome.”(A2)

“They sit over there, and we don’t pay attention to anyone. We don’t know what to talk about. Anything we say feels awkward, so we just sit, and they don’t call me over.”(A6)

“I have nothing in common with others. I can’t have a conversation, and even if others talk, I can’t get a word in. Everyone is quiet.”(A7)

“I can’t fit in. They’ve been here for several years, and I arrived late. I’m not too old, but I still can’t fit in. It’s even more challenging for the other residents; some of them can’t even speak.”(A2)

“I can’t have more than a few words with others. We’re all old, and I don’t know where I say something wrong and annoy someone, so it’s unnecessary.”(A5)

Unable to Satisfy Needs

Maslow believed that for the entire human race, these five levels of needs manifest as a pyramid, with the most basic needs affecting the daily lives of nearly everyone, while the top-level need for self-actualization is achieved by only very few people, and often not until after the age of 60. However, the truth for these citizens whose ages are apparently over 60 turns out to be less promising than anticipated.

“I can mostly take care of myself now, go up and down, and my commode is here (next to the bed). They won’t let me go to the restroom, so I have to relieve myself here. I’m embarrassed to close the door, and this disturbs me.”(A1)

“I wish someone could tell me what I should do, or show me how to use a phone. I can’t handle that device; I can’t even answer a phone call.”(A7)

“I used to take care of my grandson and granddaughter at home, which made me feel useful. Now, I can’t do that.”(A6)

“Because we can’t contribute to society anymore.”(A12)

3.3. Strategies to Cope with Loneliness

Identically, this research is able to find some resolutions according to Maslow’s hierarchy of needs.

(1) Cultivating a Positive and Optimistic Attitude:

According to a Chinese ancient philosopher Xunzi, he states in his work “Jie Bi” (Demasking), the ancient “Tao Jing”(The Classics of Tao) divided the human mind into “human’s heart” and “the heart of Tao” , emphasizing the former as often perilous and the latter as exceptionally subtle [17]. The term “Dao Xin”(i.e. the heart of Tao) likely refers to the manifestation of the Heavenly Way within the human spiritual system. From the perspective of Maslow, it represents a “kind of god-like perfection” and constitutes the deep-seated “self” in an individual’s psyche [18]. If, through subsequent cultivation, it becomes the ruler of one’s thoughts and actions, then that person aligns with Maslow’s concept of a self-actualized individual.

“Sometimes, I think this is it. Our children are all busy, so you have to console yourself.”(A10)

“In old age, as long as you have food and clothing, it’s enough... I keep telling myself it’s okay, and it works.”(A12)

“But when I think about it, all the aged here are like this, and some can’t even speak. I can still move around, and it seems fine.”(A2)

(2) Occupy Oneself and Keep Busy

Engaging in meaningful busyness can provide a sense of fulfillment rather than exhaustion. For elderly residents living in nursing homes, moments of busyness are far more luxurious than idle ones.

“In my room, I have a companion to talk to, and I subscribe to newspapers. I also read old stories from some books. It calms my mind.”(A12)

“I just played mahjong, or maybe read a book.”(A11)

“We’ve created a game where we put things here and use a ring to try to catch them. It’s fun, and it kills the time. It gives us something to do.”(A4)

“There are activities downstairs, and young people come. I participate in them, watch them sing and dance. I like watching, and so do the elderly.”(A9)

4. Discussion and Conclusion

Respecting and honoring the aged is a traditional virtue of the Chinese nation. The elderly population is one of the most deserving of respect and is also one of the most in need of care and assistance from the entire society. Therefore, improving the quality of life for the aged has become a current social priority. Subjective well-being refers to an individual’s overall evaluation of their life circumstances, their satisfaction with life, which includes the presence of positive emotions and the absence of negative emotions. It comprises two dimensions: positive affect and negative affect, both of which are independent and associated with subjective well-being [19, 20]. Various factors influence the subjective well-being of the aged, with social support and employment status being two important contributing factors. Older adults who have strong social support and continue to engage in social activities post-retirement tend to have higher levels of subjective well-being [21, 22].

In the course of this research, three fundamental themes were identified: the experiential dimension of loneliness, the etiological factors contributing to loneliness, and the strategies for mitigating this emotional state. The findings of this investigation are consistent with extant literature, substantiating the ubiquitous nature of loneliness within elder care facilities. In contrast to antecedent studies, our research provides a more nuanced examination of diverse categories of loneliness and their interrelated determinants. These encompass intrinsic factors, social discordance, and constraints impeding social interactions.

The study encounters limitations primarily due to the constrained sample size, which focused on a limited number of elderly participants. Furthermore, the research scope was restricted to elder care facilities within a specific geographic region, potentially constraining its applicability to other regions or facility types. Future research endeavors should consider enlarging the sample size to enhance the comprehensiveness of the investigation into loneliness. Additionally, an examination of various categories of elder care facilities could facilitate comparative analyses of their impact on the experience of loneliness among elderly residents. Moreover, the exploration of intervention measures’ implementation to mitigate loneliness in elderly individuals could offer a promising avenue for further scholarly investigation.

In this study, the main findings of the thematic analysis of loneliness are summarized, including the multidimensional experience of loneliness and its contributing factors. The study underscores the significance of loneliness in nursing homes and how it relates to the well-being of the aged. The research findings can assist care facilities in formulating more compassionate policies and practices. Based on the study, it is recommended that nursing homes implement measures to enhance social interaction, provide psychological support, and improve the living environment to alleviate the loneliness experienced by the residents. These improvements will contribute to an enhanced quality of life for the older residents.

Acknowledgments

The assistance and encouragement from colleagues.