Older people’s perceptions of intergenerational relationships in nursing homes: A qualitative content analysis : Journal of Family Medicine and Primary Care

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Older people’s perceptions of intergenerational relationships in nursing homes: A qualitative content analysis

Harouni, Mahboubeh D.1; Tabrizi, Kian N.1,; Fallahi-Khoshknab, Masoud1; Fadayevatan, Reza2; Maddah, Sadat S.1

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Journal of Family Medicine and Primary Care 11(8):p 4395-4403, August 2022. | DOI: 10.4103/jfmpc.jfmpc_273_22
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Intergenerational relations are an integral part of the cultural makeup of a society. These relations are defined and valued by the culture of the society.[1] People of different generations can be biologically or socially related.[23] Therefore, these relationships are not limited to the family but are present in other social structures.[1]

Due to the global decline in fertility and mortality as well as increase in life expectancy, the number of the elderly around the world is increasing.[4] Older people are particularly prone to chronic diseases that increase the demand for long-term care services, such as geriatric care facilities and family support, thereby increasingly complicating family relationships and prolonging care relationships due to increased life expectancy.[5]

Besides, structural changes, such as the growing trend of nuclear families and a complicated information technology basis, decrease opportunities for intergenerational relations that lead to a positive understanding of the elderly by young people.[6] Decreased interaction between family members, individualism, failure in the process of socialization and consequently disruption of the process of values and norms lead to conflict and generation gaps.[578] Intergenerational conflict is one of the components which helps to inappropriate communication patterns and ineffective interactions.

Thus, regarding the fact that one of the prominent challenges in modern societies is the rise of chronic diseases that often increases disability and dependence in society, despite more family preference for caring for the elderly with a chronic illness in the family, factors such as insufficient resources for home care and increasing care needs for the elderly lead families to place their elderly members in nursing homes.[9]

Older people admitted to a nursing home have higher dependencies and more complicated health care needs.[10] Various studies reported that the quality of care and its effect on the residents depend on the staff, and their role to improve the quality of care is vital.[11]

Valentina and David, quoting Peplau, believe that the interactive (professional) behavior of the nurse with the patient has a substantial effect on the latter’s welfare and quality of life and the outcome of nursing care.[12] Thus, effective communication has been a prerequisite in providing appropriate care to nursing home residents.[13] This is especially true of communication with the elderly due to some of their specific communication characteristics.[10]

Intergenerational relationship is crucial in nursing homes; individuals of different ages and generations like care providers and residents interact with each other.[14] Caregivers, including nurses, can cover intergenerational relationships in the form of care provided to the elderly.[15] It has also been discovered that making a new connection with the staff is vital to residents, and the quality of their life is well-supported by good staff–resident relationship. Any effort to improve programs and facilities in nursing homes is weakened by a lack of attention to communication and continuance of care.[16]

Bengtson et al.[17] considered conflicting relationships as an important element in understanding aging as part of the age classification system, where relationships between different age groups is based on mutual norms or equal exchanges.

Generational differences between residents of nursing homes and the nurses lead to difficulty in effective communication between them.[121819] As staffing pertains to the quality of care and there is emphasis on staffing as one important factor of quality in nursing home,[20] this communication while taking care of the elderly can cause anxiety, depression, misunderstanding and hopelessness, or a lack of quality of care.[12] The elderly need one or another kind of care and help, but prevalence of mistreatment and abuse by family members, especially the younger generation, has increased in health care centers.[21]

According to what we have is caused and the researcher’s knowledge that there is insufficient information, especially qualitative studies in the field of intergenerational relationships in nursing in Iran, the researcher has decided to conduct a study using the qualitative research method in this regard. In other words, in the present study, the use of qualitative research method helps the researcher to enter the mental world of the elderly and the staff in the nursing home and receive their opinions to identify their views on intergenerational relationships. Thus, this study was conducted in order to examine the elderly’s perceptions on intergenerational relationships in nursing homes. The theory used in this study was self- interaction group theory (SIGT). It was used as the guiding theoretical framework to discover the residents’ common way of adjusting to life in the nursing home and others’ daily role in providing intergenerational relationships.[22]

Theory Framework

Self-interactional group theory (SIGT) is used as a tool to study an individual’s interactions in a particular context, focusing on their interpersonal, intrapersonal, and group analysis units.[23] Intrapersonal analysis includes the mental experiences (feelings and perceptions) of the members of a generation. These feelings are considered as the outcome of interactional communications between individuals. Interpersonal analysis unit consists of five levels: the context of the interaction, definition of the relationship, communicational qualities (for instance, the observable behavior), social purposes, mental needs and also strategies to fulfil purposes and needs and interactional process.[24]

The context indicates who is interacting with who, where, and why. Additionally, the features of verbal and non-verbal communication about a specific context in a particular interaction between the members of a generation become meaningful.[22]

Group analysis describes the dynamics at the intergroup and intragroup level. Intragroup behavior refers to the interaction among members of the same generation group, while intergroup behavior refers to what occurs in a specific generation group.[24]

Materials & Methods

The present study was a qualitative study using directed content analysis. Participants included 12 residents and 6 staff members in nursing homes who were selected via purposive sampling method to collect relevant and in-depth data. All participants spoke Persian and without any specific illness that impeded verbal communication. To obtain a wide range of experiences and perspectives, sampling was performed with the approach of maximum variation of both sexes and nursing homes in different regions of Tehran province.[25] The inclusion criteria for the elderly were age 65 years and older, and cognitive health. The first part of the participants included eight males and four females with a mean age of 74.6 years.

The second part of the participants included six employees (three nurses, one supervisor, one psychologist and one nursing home manager) who were willing to participate in the study and share their experiences. These people had a work experience of 4–20 years and were aged between 25 and 45 years.

Data collection done through unstructured interviews with the open-ended question “Can you tell me about your relationship with the nurses who care for you” and then “Tell us about your experience when communicating with caregivers” or “How do you feel when you talk to employees or when they do something for you”. Then, according to the issues raised, specific questions were asked to further explain the details and increase the depth of the interviews. Later, particular questions were asked based on the mentioned items to further explain the details and increase the depth of the interview.

Nineteen interviews were held individually in a calm room. The time and place of the interview were chosen based on the participant’s agreement. The interviews were recorded digitally and immediately handwritten. The length of the interviews was between 25–60 minutes and the average time of the interviews was 35 minutes.

Data collection and analysis were performed simultaneously by the main researcher (first author of the article). Interviews were stopped when information saturation was obtained and the data and classes were a repetition of the previous data.

Data analysis was performed using qualitative content analysis method according to Graneheim and Lundman.[26] Each interview was handwritten verbatim immediately after the interview. Then, in order to immerse in the data and gain a general sense of the data, the text of the interview was read several times and analyzed before the next interview. First, the text of the interview was read line by line and semantic units were extracted. Then, semantic units were coded. Codes that had similar meanings were placed under a subcategory, then subcategories were subdivided, based on similarity and relevance, into more general subcategories, and finally, the analysis process was completed by identifying the main themes. How to form a subtheme is shown in Table 1.

Table 1:
How to form a subtheme

In order to ensure the accuracy of the findings, during the study, four criteria, that is, credibility, dependability, confirmability and transferability were considered.[27] Participants were reviewed and codes that did not reflect the participants’ views were corrected. Also, the text of the interviews, codes and groups were reviewed by two respected professors of nursing and experts in the field of qualitative research. The selection of participants with maximum diversity increased the validity of the data.

The ethical principles observed by the researchers in the study include obtaining a license to conduct research from the University of Social Welfare and Rehabilitation Sciences, Tehran with NO: IR.USWR.REC.1397.003 at 20/12/1397 and receiving a letter of introduction for sampling, giving participants the right to withdraw from cooperation at any time, maintaining anonymity and confidentiality of data, and providing results at the request of participants.


“Struggle for existence” was extracted as the main theme based on the participants’ explanations. Subthemes included “Prejudicious tendencies”, “communication nodes” and “Umbrella of society” which formed the elderly’s perception of intergenerational relationships in nursing homes [Table 2].

Table 2:
The main theme and subthemes of the elderly’s perception of intergenerational relationships

A. Prejudicious tendencies: Some studies show that the patients’ age and the nurses’ beliefs directly influenced the communication between the patients, and transfer of information and caring them.[28] Almost all observed studies back this notion that ageist tendencies are common in modern society and this discrimination influences the elderly’s quality of life and health care adversely.[2829]

A.1. Moral values vs immoral values: The prevailing culture and thought of society affects value systems, ethical norms, customs and deeds, and in an Iranian society, there is the religious and ethical belief to protect some traditions such as communicating with the elderly and taking care of them. Researchers show that moral values help nurses when they are communicating with and taking care of residents. This moral value has individual value and also improves the quality of care.[30]

The main purpose of the elderly is having a life full of self-esteem and comfort. In other words, they must feel valuable and confident. Life with self-esteem requires respecting their unity, individuality and participation. One of the employees said the following in this regard:

You know, I came here, I was pleased with the staff because they welcomed me very well. They had a good relationship with me. They didn’t let me feel lonely and sad. Now if they want to make a decision about me, for example if they want to change my bed or room, they first tell me. (Participant #2)

Dignity is challenged by negative communication between staff and the residents, a lack of attention to the resident’s privacy, and lack of attention to the resident’s needs and demands.[31] Another participant said the following:

People can’t be like each other. We aren’t the same, either. When the nurse is nice and good with me, I don’t care how old she is. I want her to behave well since we spend a lot of time with her. If she wants to speak angrily and proudly, we try to have less communication with her. (Participant #6)

A.2: Ignoring human identity vs recognizing it: Change of social status, lack of independence in decision-making, change in social communications and reduction of routine activities cause a great degree of obedience in the elderly and therefore, increase the level of care needs, mental and physical disorders, and the resident’s social withdrawal in nursing home, thereby finally leading to a loss of human identity.[32] Maintaining self-identity is closely related to well-being and self-esteem.[33] Besides, a person’s personality is formed through social communications. It means that identity progresses through social experiences, and activities and communication with other people.[32]

One of the participants stated the following in this regard:

We give responsibility to some of our elderly, for example, there are some of our elderly who work in the units and they say, we do not like to sit on the bed and they want to work. Now they work in the kitchen, in the units, for example, and this creates a sense of self-sufficiency and worth. (Participant #7)

But one resident reported some negative experiences at the nursing home, emphasizing the importance of caring for nursing staff:

Although we communicate with the nurses only for our needs, I don’t talk much with my roommate, either. Communication here is done ignorantly. (Participant #13)

Elderly residents expect their care to be accompanied with kindness and sympathy, and therefore, in order to develop more personal relationships, they try to define their personal lives during nursing care so that they can be identified and valued based on it.

Experience in a nursing home is associated with a struggle for independence and independent decision-making.[34] Another participant said the following:

Individuals don’t choose their roommates. We are chosen based on their own factors. (Participant #4)

In the current study, it seems that the residents of the nursing home tend to be independent in deciding on their daily activities, which should be based on their dignity and human rights.

A.3. Generational intelligence: Generational intelligence is used as a tool in social care environments to examine the communication between the youth and the elderly.[35] The starting point of generational intelligence is when you can place yourself in a situation of a different age and of a different generation. In other words, it is better perception of other people according to the similarities and differences between generations, critical awareness of the basic values of social theories about generations and the elderly, and finally, following the way which is generationally aware.[36] One participant mentioned the following:

Because we grow old. Our parents will grow old and we will be in the same situation. (Participant #13)

Another participant said,

We ourselves, who are admitted here, don’t have the perception and attention to understand issues, like the nurses. And we aren’t justified. (Participant #8)

A.4. Dynamic attitudes versus static attitudes: The nurses’ attitude has an effect on the quality of care and recovery of the elderly during an illness.[37] The attitudes are learned or change through different contexts (social, educational, cultural), and they can influence social interactions to a great degree.[38] The elderly believe that young people don’t respect them enough and behave too proudly with them.

One of the residents mentioned,

You know, behaviors are different, some people have the sense of anger in their makeup. Some faces are kind, some are calm. We enjoy it. (Participant #2)

One of the elderlies claimed the following:

It’s an opportunity to lend people a helping hand without considering who they are. It is a special place here. People who for any reasons have faced failure come here. They need special attention. It should be kind. It should bound kindness but it isn’t so here. (Participant #8)

B. Communication nodes: Caring in nursing homes includes different factors: skill in caregiving, independence, individual care, relationships and interactions with nurses and staff, which immensely influences the quality of life of the residents.[39] This subtheme emphasizes on the role and importance of positive communication between nurses and the residents of nursing homes and its effect on the quality of life of the residents. It includes caretaking communication, the elderly’s coping behaviors and the environment of the nursing home.

B.1. Care communication: Care communication can lead to effective and meaningful relationships between members of different generations and help in topics such as informing guidance and connection between people.[40] Care can be divided into two categories: practical and emotional. Practical care refers to some behaviors and actions that are done to fulfill an individual’s needs. Emotional care is associated with the individual’s feelings and specific attitudes toward anxiety, respect and empathy.[41] The elderly’s perception of their caregivers is that they are the source of emotional and practical care.

One of the staff said in this regard,

You know, the elderly look like children. They like to be hugged, accompanied and patted just like children. For instance, they ring the bell frequently. I go and ask what they want but they say nothing as if they like to have me by their side. They sometimes need attention, not anything to be done. (Participant #13)

Furthermore, time constraints and focus on tasks are among some of the factors that cause a negative impact on communication. One of the participants said the following:

The relationships here are cold, and human relationship is missing. There is a conflict at. You pay little and I work less. They don’t do more than their duties. The worst part is that the new generation who come here are worse than the previous ones. They learn from those who are affected by this negative work communication. (Participant #5)

Another participant commented on the nature of communication:

There are specific rules here. It is always the same and there is no variety. The nurse who comes in here gives us our medicine at a particular time. They are only staff and they follow the rules. (Participant #6)

B.2. Elderly coping behavior: Emotional instability is often associated with negative emotions such as fear, sadness, confusion, anger, guilt, and hatred; such individuals are liable to impulsiveness, aggressiveness and vulnerability.[42]

One of the participants said,

There are specific behaviors. For example, there is a caretaker who is very impolite. He swears when he talks to. He has a long work experience, too. I say,” There are several old people here. Don’t use bad words, this loud voice is an offence to everyone. (Participant #5)

B.3. Environment of the nursing home: The nursing home is a social communication system where the elderly receive emotional and social support.[43] The elderly are admitted to nursing homes for various reasons; some visit a nursing home due to deteriorating health, limited financial resources, child migration, or the death of a spouse,[44] and some are admitted so that they can have access to facilities and services that only a supportive environment can provide them with, such as emotional, social and medical support.[16] All of the participants mentioned the need for respect and trust in the nursing home in such a way that they can communicate with each other.

One of the elderlies said the following:

It is like a garrison here. You wake up at a particular time and the time of everything- breakfast, lunch and dinner- is clear. (Participant #1)

If the nursing home doesn’t have organized programs and activities for the residents’ free time, it can turn into a tiring place in which the elderly feel stuck.[44]

One of the participants said,

Life here is a routine and constant one. Suppose it is something that remains the same and never changes. Routine that causes boredom. (Participant #4)

C. Umbrella of society: Community has an important role in dynamics between both intragroup and intergroup generational levels. Simkins reported from Cooper that examining the impact of community on nurses’ perceptions and how their duties influence their beliefs about elderly patients. Based on their findings, nurses prefer patients who challenge the negative stereotypes of the elderly, especially patients who are mentally healthy.[28] Old age is stereotyped as frailty and an inevitable decrease of capacities. It portrays the elderly as a homogeneous group who need care, a group who increase health and social care costs and prevent economic development.[45] Pictures of ageism are common in the media.[46]

One participant said,

As time passes, we face less emotion and kindness in our lives. This fact that social relations depends on money has reflected itself here, too. (Participant #3)

Another participant said,

Some caregivers treat us if we don’t understand anything, They consider themselves superior to us. (Participant #8)

Discussion and Conclusion

The nursing home resident’s perception of intergenerational relationships and the challenges they face were analyzed in the study. Use of SIGT provides a wide approach to generational relationships, which shows the importance of social interactions in a specific situation to improve and maintain mental health and therefore increase quality of life in the special context of the nursing home. Observations showed that intergenerational relationships consist of “Struggle for existence” in the nursing homes, which referred to concepts such as “prejudicious tendencies”, “Communication nodes”, which are the result of intragroup and intergroup analysis, respectively, and the “umbrella of society”, which pertains to both of these features.

Important events in life, such as being admitted to the nursing home, can disrupt the elderly’s relations with social groups.[1647] Thus, maintaining social relationships or making new connections can protect them against negative consequences.[47] Struggle for existence refers to the elderly person’s effort in the nursing home to prove his or her individuality as a human being, to the extent that despite his or her inability or vulnerability, he or she tries to gain respect, dignity and maintain his or her identity as well as daily activities, while being forced to obey several specific disciplines in the nursing home. Subclasses such as moral values versus immoral values, disregard for human identity versus the recognition of it, generational intelligence, and dynamic versus static attitudes toward statics were obtained in intrapersonal analysis.

Those who were admitted to the nursing home encountered different types of changes such as social status, effect on independency, feelings of having no place to access home, social contact and decrease of normal activities.[34] Previous studies have also represented the importance of personal relationships between residents and staff and have suggested that the development of relationships often occurs in the context of delivery of care.[39] Good caregiving means the staff understands the emotional needs of the residents and behaves in a way that meets the latter’s needs and creates a sense of respect and dignity in the elderly.[48] Despite this fact, Babaei reporting from the Quality of Care committee that 3% of patients believed the nurses treated them impolitely and in fact, that the patients’ perception of care was associated with disrespect and lack of dignity by the nurses.[49]

Studies show that age difference is one of the important factors influencing the attitudes of nursing home staff, which is generally accompanied by ignoring respect and dignity.[5051] The results of this study highlighted the nurses’ focus on their therapeutic role regardless of emotional and mental needs of the elderly, which was consistent with the results of Babaei’s study. Respect and honor for parents and the elderly is a commitment in Islamic Iranian culture. Accordingly, the elderly inevitably expect respectful behavior from the staff and the staff’s respectful attitude can clearly cause the elderly to feel important and valued.

The elderly’s struggle to maintain independence, confrontation with the decisions made for them, and forced activities are the elderly’s experiences of living in nursing homes. They find it essential to completely obey the staff.[32] These findings are in contrast with the results of the current study regarding responsibility to the elderly. It seems that many factors influence this issue and they need more scrutiny and examination. Numerous studies suggest strategies such as maintaining personal independence and providing personal care, showing respect, counseling, and active listening to maintain or enhance the personal dignity of the elderly.[52]

On the other hand, the generational differences between the residents of the nursing home and nurses may lead to increased conflict or solidarity between them and also deep duality either in public or private places.[36] In this case, generational intelligence can be an examined approach. Dimensions of generational intelligence are recognizing and valuing generational differences, finding mutual fields, in addition to discussions about social and practical results of the situation.[35]

Chuang et al.[53] believed that caring and respectful attitude are considered as components of good quality of care. Therefore, one of the barriers to providing high quality services to the elderly is negative and stereotyped attitudes that can adversely influence the results of health care and its effect.[54] The results indicate that negative attitudes are perceived by those who use medical and health service, but it is not clear why.[29] In other words, according to the elderly, the younger generation doesn’t respect the elderly’s knowledge, skill and experiences, but the elderly still believe that they are entitled to be respected.[55] This issue leads to hopelessness in their interactions. Factors such as lack of emotional stability and negative emotions are associated with people with neurosis who experience symptoms such as anxiety, insecurity, anger, and negative attitudes toward others, leading to reduced personal success and, consequently, negative effects on their behavior with clients.[42]

In the interpersonal analysis in this study, subgroups such as caring relationships, coping behaviors of the elderly and the environment of the nursing home were obtained. Care has different meanings based on the context used; in health and nursing care literature, the emphasis is on the relationship between the caregiving team and the patient, as well as providing care and paying attention to the client’s health needs.[3] Intergenerational studies on the care between people, from different generations in particular, emphasize the provision of practical and emotional care to the elderly by the caregiving staff in the nursing home.[343]

Elderly people need emotional care which can reflect the positive attitudes of employees. Showing a respectful attitude helps to improve the sense of worth and self-esteem in the residents. Studies conducted in the US and Sweden represent observed that caregivers had very little verbal communication with older people living in nursing homes.[56] Thus, the residents see their staff as people who are mainly responsible for maintaining order and who pass their time doing clerical work.[32] The results of a study in Norway also supported the findings of the current study on providing physical care to the elderly and avoiding talking to them during treatment.[57]

In the current study, participants in caregiving relationships focused more on the physical level than emotional level of caregiving, and the emphasis was on meeting the physical needs rather than the emotional needs of the elderly; communication was not reciprocal in nature.

In addition, as the caregiver focuses more on doing the work than communicating with the older person, the whole caregiving process may lose its meaning as the older person feels like an object and, therefore, suffers from negative emotions such as helplessness, leading to frustration.[12] Khodabandeh-Shahraki et al. write in reference to a study by Chan et al. that “nurses at NHs are more concerned about their routines than talking to the elderly.”[56]

A study conducted by Teeri et al.[58] in Finland shows that nursing interference is usually done in a hurry and this fact leads to the elderly’s feeling of loneliness.[58] In the current study, the residents of the nursing home felt that the nurses were so busy doing their duties that they didn’t have time to converse with them. The results of Khodabandeh-Shahraki et al.[56] agree with that of the current study by mentioning that one of the obvious glories of communication between caretakers and the elderly in a nursing home is that the communication is based on work.

Also, Hall et al.,[59] in their study on dignity in hospital situations, clarified that privacy and communication are essential. In other words, caretaking communication is important in developing the disabled elderly’s independence and dignity in their communicational point of view. According to the results of a study by Heggestad et al., nursing home residents can experience communication with caregivers as a threat to their dignity.[60]

The results of the current study show that social communication of the elderly, both with other people or staff and with the world outside, is too limited. Thus, the elderly need the staff’s support to make interpersonal communications, and evidence shows that this support is insufficient. Riedl et al.[32] writes in a study that the elderly tend to keep in touch with family members and friends and, in this way, maintain their previous social communications. Maintaining previous contacts shows appreciation and respect for people living in nursing homes. Gharibian Adra et al. writes in reference to a study by McGilton et al. that care communication can be improved if care is provided in a supportive environment by trusted and empathetic staff.[39]

In this study, the social context affecting communication is an umbrella influencing both the elderly’s thoughts, feelings, beliefs and their interpersonal behavior and communications. It mostly made the challenge in intergenerational communication more difficult rather than simplify it. Thus, some participants considered the staff’s positive or negative behavior as a result of their family upbringing, culture and their personality, which is formed in society.

Besides, economic, cultural and social developments, which have led to a kind of difference in values and norms, and insufficient number of nurses have caused caregivers to communicate with the elderly only to the extent of their duties. It results in several barriers that influence relationships and affect the quality of care in nursing homes. When communications are more about responsibilities, communication without kindness and sympathy between the residents of the nursing home and the staff is inevitable.

Effective communication is a mandatory prerequisite in providing care that suit individuals.[13] This issue is more important while we are communicating with the elderly, because of their particular communicational features, and most of the nurses’ problems while communicating with the elderly who lack emotional and cognition can be the result of the following: first, difficulty of taking care of the elderly and the nursing features such as fulfilling assigned tasks; second, generational differences make effective communication more difficult because of the elderly’s varied expectations and values. One of the reasons for the low quality of care and, therefore, the elderly’s low quality of life is the fact that the patient can’t communicate with the caregivers properly since they have two different generational viewpoints.

Thus, it is suggested that health program policymakers must make an effort to fill this perceptional gap between these two age groups by using practical strategies from the beginning growth ages through culturalization.

According to the findings of the study, we suggest that first, although we can’t refine the staff and resource limitation easily, nursing homes can meet their residents’ needs as much as possible. Second, the results of this study can provide the managers with information on how to improve intergenerational relationships and the importance of organizing intergenerational programs in nursing homes to support the elderly’s mental and social needs, so that it leads to better care and improved quality of life.

This is a qualitative study that, like all qualitative studies, can’t be generalized. Although we have done our best to promote the validity of the data, it needs to be repeated in other places with different cultures.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


This study is a part of PhD thesis which has been confirmed in the university of social welfare and rehabilitation sciences. Great thanks to the assistant of technology and research of the university and the elderly and the staff’s participation in all three nursing homes to complete this study.


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Intergenerational relationships; nursing homes; qualitative study

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