Perceptions of Technical Director of Nursing Home About Associated Factors and Intervention Strategies to Reduce Loneliness Among Older Adults

Abstract

Loneliness is one of the most prevalent problems faced by older nursing homes (NHs) residents. Technical Directors (TDs) of NHs can play an important role in combating loneliness, so it is important to understand how they perceive this phenomenon. This study aimed to describe the perceptions of TDs about factors associated with loneliness and relevant areas of training and intervention. A total of 163 TDs (mean age = 42 years; 90% female) filled an online survey. The main NHs factors related to loneliness were residents’ mental and physical health problems; mistreatment in care provision; poor relationships between residents, with staff and family/friends; loss of loved ones; and family members’ work schedules and their geographical distance. Intervention domains that need to be improved were the policy of greater proximity to families and community, partnerships with the outside world, civic participation by residents, technical team diversity, and increase of staff/resident ratio. Dementia care, stress management, crisis intervention, person-centered care, and coping with death/bereavement were identified as relevant themes in professional training. This study appears as a relevant contribution to the deepening of knowledge not only about the phenomenon of loneliness among older residents in NHs, but also about the perceptions of TDs regarding this problem.

1. Introduction

Nursing homes (NHs) deal with various challenges of caring for older adults, and many other prevalent problems faced by these residents (Zhang et al. 2023). One of them is the loneliness in older residents (e.g., Zhao et al. 2018), which is characterized by a subjective and negative experience due to the perception of inadequate social relationships and support (e.g., Yang and Victor 2008).

Loneliness is very prevalent among older adults in NHs (e.g., Chawla et al. 2021). A recent systematic review (Gardiner et al. 2020), with 13 articles, representing 5115 participants (mean age of 83.5 years), estimated an average prevalence of “moderate loneliness” of 61% and “severe loneliness” of 35% among care home residents.

Upon admission to NHs, older people tend to find it difficult to maintain relationships and contact with family and friends, which leaves them emotionally disconnected (Smith et al. 2023). Furthermore, the unfamiliarity of institutionalization leads to a lower sense of belonging and superficial relationships with other residents and staff, which may contribute to older people in NHs being more likely to experience loneliness (Buckley and McCarthy 2009; Victor 2012). In addition, the lack of common interests with other residents and activities carried out at NHs that often do not correspond to residents’ previous lifestyles or current preferences make it difficult for residents to get involved socially (Buckley and McCarthy 2009).

Moreover, NHs residents may have few opportunities to make personal decisions or exercise control over their lives, which, together with the time they often spend in passive activities (e.g., watching TV), can contribute to feelings of boredom and loneliness (Buckley and McCarthy 2009; Brownie and Horstmanshof 2011; Gardiner et al. 2020).

Several studies have emphasized that loneliness is linked to negative consequences for older adults, such as higher risk of mortality (Holt-Lunstad et al. 2015; Rico-Uribe et al. 2018; Wang et al. 2023) and damage to physical health (e.g., cardiovascular diseases, stroke) (Leigh-Hunt et al. 2017; Golaszewski et al. 2022) and mental health (e.g., dementia, depression) (Evans et al. 2019; Sundström et al. 2020). For example, a recent qualitative study (Piven et al. 2025) compared the perspectives of thirty-one older persons regarding the factors that exaggerated loneliness and concluded that serious health problems and financial strain increase loneliness among these persons, whereas social networks and strong family and support connections can alleviate their loneliness.

Bearing this in mind, it is becoming increasingly necessary to develop and implement interventions to combat loneliness in older people, which has already been considered a public health problem worldwide by the World Health Organization (World Health Organization 2021).

Scientific evidence covers numerous intervention approaches focused on minimizing loneliness among older people living in NHs, such as reminiscence therapy, digital technologies, cognitive approaches, horticultural therapy, among others, and a recent review concluded that many of these approaches are effective in the reduction in loneliness (Quan et al. 2020).

In a recent study, Carcavilla-González et al. (2025) highlighted the relevance of incorporating a person-centered approach when developing interventions to combat loneliness. In this vein, these authors presented a study aimed at exploring the benefits of a multicomponent person-centered support initiative for older people living in NH, concluding that the intervention group showed significant improvements in loneliness and depression, as well as better health-related quality of life.

In the context of developing approaches to combating loneliness, Technical Directors (TDs) of NHs can play an important role. In fact, TDs’ perceptions could influence the strategies they implement to prevent, detect, and manage loneliness. Therefore, it is crucial to understand how they describe and perceive loneliness among older adults, allowing us to approach the problem from a different perspective.

Taking this into account, the main objective of the present study was to describe and understand the perceptions of TDs about the internal and external factors of NHs that may explain the loneliness of older residents. It also intends to identify TDs’ views of areas of intervention that need to be improved, as well as which topics should be included in professional training to reduce the loneliness among these residents. As a secondary objective, this study aims to explore differences in the identification of these factors and areas of intervention/training according to the age and length of experience of the TD.

2. Materials and Methods

This study is part of a larger ongoing research project called “Intervention strategies to combat loneliness among older people in nursing home: current challenges”, under the coordination of a Research Unit, in partnership with two higher education institutions. This research project was approved by the Ethics Committee of the University where the coordinating Research Unit is integrated, and its main objectives were to contribute to a deeper understanding of the implications of loneliness in the daily lives of older residents of NHs, as well as to identify intervention strategies to combat loneliness among these residents.

In this context, this cross-sectional descriptive study design included a convenience sample of adults working as TDs in one of the national NHs. The eligible participants were identified by consulting the database of the National Register of Social Care and Services. Afterward, the TDs of each national NHs were contacted by email, with a presentation of this study and providing a hyperlink to the online survey.

After written informed consent, participants were asked to fill this semi-structured online survey, created specifically for this research project, based on a brief literature review of scientific articles about loneliness in older adults’ residents in NHs (prioritizing review studies), as well as on some reports or recommendations from international organizations [e.g., WHO Report about social isolation and loneliness (World Health Organization 2021)]. Subsequently, a pre-test study was carried out with a sample of 10 TDs, with the aim of assessing the level of comprehensibility of the questionnaire, as well as analyzing other research techniques in preparation for the larger study.

This survey included a total of 107 questions across the following eight sections: (1) TD sociodemographic characterization; (2) NHs characterization; (3) Perception of TD about the organizational factors that may explain loneliness among older people living in NHs; (4) Perception of TD about the factors outside the organization that may explain loneliness among older people living in NHs; (5) Intervention domains that need to be improved to reduce loneliness; (6) Relevant themes to comprise in professionals’ training programs to reduce loneliness among these residents; (7) Characterization of the NHs and residents; and (8) Good practices for combating loneliness among older residents. In sections 3–6, the TD was asked to rate the statements presented on a 5-point Likert scale (“Not at All Important”, “Not Particularly Important”, “Important”, “Very Important”, and “Extremely Important”).

Statistical analyses were carried out using Statistical Package for the Social Sciences (SPSS) version 29.0 for Windows (SPSS, Inc., Chicago, IL, USA). For the descriptive analysis of the data collected in each of the eight sections of the online survey, raw frequencies and percentages were used for the categorical variables and mean and standard deviation for the continuous variables.

To analyze the differences in the various items of the questionnaire, according to TD’s age and professional experience in NH, non-parametric tests were used, since the data did not have a normal distribution. Thus, the Mann–Whitney U test was used for continuous variables, at a significance level of 0.05. For this analysis, the response options (5-point Likert scale) of the questionnaire were recoded into two categories, with the first one comprising the options “Not at all Important” and “Not Particularly Important” and the second category including the options “Important”, “Very Important”, and “Extremely Important”.

In addition, the internal consistency of questionnaire surveys was assessed by using Cronbach’s alpha coefficient (α). An alpha of 0.80 or higher reflects high internal reliability (e.g., Cortina 1993; Nunnally 1994; Bland and Altman 1997).

3. Results

3.1. Characterization of Technical Director and Institutions

The final sample included 163 TDs, with a mean age of 42 years (SD = 8.9), mostly female (90%) and in TD functions for an average of 9 years (

Table 1. Sociodemographic and professional characterization of TD.

Age (Years), Mean (SD)	41.15 (8.9)
Sex, n (%)
Male	16 (9.8)
Female	147 (90.2)
Education level, n (%) *
Degree	76 (46.9)
Master’s or Postgraduate	84 (51.9)
Other	2 (1.2)
Field of Degree, n (%) *
Social Work	89 (54.9)
Psychology	22 (13.6)
Social Education	17 (10.5)
Gerontology	10 (6.2)
Other	24 (14.8)
Number of years working as TD, mean (SD) *	9.15 (7.2)

* n = 162; SD = standard deviation; TD = Technical Director.

). About 44% have attended specialized training to work as TDs and 43.6% had training in Gerontology. The majority of NHs (61%) was a Private Social Solidarity Institution (n = 7021 older residents; n = 6689 NHs staff). Regarding the localization of the NHs, most of them were localized in the three of the country’s most populated regions. More specifically, in the North (31%), Centre (26.4%), and Lisbon and Vale do Tejo (29.4%). Only 20.2% of these NHs had quality certification, on average about 8 years ago. Half of the NHs with a certificate had implemented the International Organizational Standardization (ISO) standards.

3.2. Factors Associated with Loneliness, Relevant Areas of Intervention and Training

Bearing in mind the objectives of the present study, it was considered to highlight the top five responses with the highest cumulative percentage in the “Very Important” and “Extremely Important” response options for the following main sections of the survey questionnaire (

Table 2. Main factors associated with loneliness, areas of intervention, and themes for training professionals that need to be improved.

Organizational Factors
Mental health problems of residents	71%
Physical health problems of residents	68.1%
Abuse or neglect in the provision of care	58.3%
Lack of quality in relationships with NHs staff	56.4%
Lack of quality relationships between residents	55.8%
Factors outside the organization
Lack of quality in relationships with family	72.2%
Lack of quality in relationships with significant others and/or friends	71.6%
Loss of loved ones	71.6%
Family members’ work schedules and demands	70.4%
Geographical distance between families and older residents	66.1%
Intervention areas that need to be improved
Invest in a policy of greater proximity to families	63.8%
Diversify the staff team	62.6%
Promote productive activities that favor relations with the community and sustainability of the institutions (e.g., shared vegetable garden)	61.1%
Establish more partnerships with the outside world	60.7%
Promote residents’ civic participation (e.g., electoral acts)/Increase the ratio between staff and the older residents	58.9%
Relevant themes in professionals’ training programs
Dementia care	88.9%
Stress management	84%
Crisis intervention	83.3%
Person-centered care	82.1%
Coping with death and bereavement	82.1%

This table includes the top five responses with the highest cumulative percentage in the “Very Important” and “Extremely Important” response options of survey questionnaire.

): Perception of TDs about the organizational factors that may explain loneliness among older people living in NHs; Perception of TDs about the factors outside the organisation that may explain loneliness among older people living in NHs; Intervention domains that need to be improved to reduce loneliness; and Relevant themes to comprise in professionals’ training programs to reduce loneliness among these residents. The descriptive analysis of all responses in the referred main sections of the survey questionnaire is presented in detail in the Supplementary Materials (Tables S1–S4).

For these TDs, the main internal NHs factors associated with loneliness were residents’ mental (71%) and physical (68.1%) health problems, mistreatment in care provision (58.3%), and poor relations with staff (56.4%) and between residents (55.8%) (Table 2). From another perspective, some of the factors with the highest percentage of responses in the “Not at All Important” and “Not Particularly Important” response categories were also identified. In terms of organizational factors, the following stood out: no flexible mealtimes (45.7%), users’ difficulties accessing the internet/social networks (45.1%), no rooms for couples (44.8%), and architectural barriers and other constraints to accessibility, circulation, and movement of the residents in the facilities (43.5%) (Table S1).

Regarding factors external to the NHs, the following were the most relevant: inadequate relationships with family (72.2%) and/or friends (71.6%), loss of loved ones (71.6%), and family members’ work schedules (70.4%) and geographical distance of families (66.1%) (Table 2). The negative stereotypes surrounding older adults (18.5%) and lack of a culture of networking in the community (17.9%) were the two factors external with the highest percentage of responses in the categories “Not at All Important/Not Particularly Important”.

For TDs, the furthermost pertinent intervention domains that need to be improved were policy of greater proximity to families (63.8%), diversity of the staff team (62.6%), productive activities that favor relations with the community (61.1%), partnerships with the outside world (60.7%), civic participation by residents and increasing the staff/resident ratio (both with 58.9%) (Table 2). Make mealtimes more flexible (43.5%), make pick-up times more flexible (35.6%), facilitate accessibility, circulation, and movement in the facilities (34.4%), and opening the canteen to family and friends (33.1%) were considered by TDs to be the least relevant areas of intervention for combating loneliness in older people (Table S3).

Dementia care (88.9%), stress management (84%), crisis intervention (83.3%), person-centered care (82.1%), and coping with death and bereavement (82.1%) were identified as relevant themes for professional training (Table 2). In this section, the highest percentage of answers in the “Not at All Important” and “Not Particularly Important” response categories was found for the following two themes: innovative technologies (16.7%) and drawing up individual plans (12.4%) (Table S4).

3.3. Other Study Findings

An additional statistical analysis was carried out to assess potential differences in the responses of TDs according to their age and years of professional experience in the NH (Table S5).

From this analysis, statistically significant differences were only found for the number of years of professional experience in the NHS in the following three items: “geographical distance between families and older residents” (Domain: Factors external to the organization), “making diagnoses”, and “dementia care” (Domain: “Topics in training programmes”). More specifically, there was a higher proportion of TDs with more professional experience who described these factors as important to extremely important (median = 10.5 vs. 7, p = 0.047; median = 10 vs. 5.5, p = 0.040; median = 10 vs. 3, p = 0.037, respectively). No statistically significant results were found for the age of the TDs (Table S5).

Regarding the internal consistency analysis of the questionnaire used in this online survey, Cronbach’s alpha coefficients obtained for item total and for the domains ranging from α = 0.940 to α = 0.983 (

Table 3. Internal consistency analysis results.

Domains	Cronbach’s Alpha Coefficient (α)	Total Number of Items
Organizational factors	α = 0.980	26
Factors outside the organization	α = 0.940	11
Intervention areas that need to be improved	α = 0.956	16
Themes in professionals’ training programs	α = 0.941	11
Item total	α = 0.983	64

) reflected high internal consistency.

4. Discussion

The current work intended to describe and analyze the perceptions of national NHs’ TDs about internal and external factors associated with loneliness, as well as their point of view regarding the relevant areas of intervention and themes in professional training to reduce loneliness among NHs residents. With this objective, a semi-structured online survey was created specifically for this work, based on a brief literature review of scientific articles and guidelines about loneliness in older adults’ residents in NHs. This questionnaire revealed high internal consistency.

Concerning the main factors that may contribute to loneliness among NH residents, from the perspective of TDs, the presence of physical or mental health conditions, abuse or neglect in the provision of care, and poor quality of relationships with staff and other residents were identified as the most relevant.

NH residents are often very old persons with many health problems such as chronic illnesses, dementia, cognitive impairment, and disabilities, which often require increasing functional assistance. These conditions may limit the ability to engage them in daily activities, reducing their possibilities for social interactions with other residents (Pinquart and Sorensen 2001). Moreover, communication difficulties and even behavioral disturbances (e.g., agitation, aggression) are common in some chronic conditions such as dementia, which may be an obstacle to these residents’ involvement and participation in social activities, as well as establishing meaningful connections or relationships with other residents (Boamah et al. 2021). In addition, the intensive workload of NH staff makes it difficult for them to provide support for residents’ social needs or promote interaction between residents (Iden et al. 2015).

Evidence suggested older people with physical or cognitive disabilities (in many cases representing most NH residents) are especially vulnerable and therefore more likely to be abused or neglected (e.g., Schiamberg et al. 2011; Fang and Elsie 2018). In addition, they are less likely to report abuse or ask for help (Arms and Mccumber 2023), particularly for fear of retaliation, which can contribute to them becoming more isolated (even as a defense mechanism) and feeling more alone as a result (Sun and Yan 2023). Furthermore, the lack of resources, the high workload of the staff, and their inadequate training have been reported as some of the most common causes of abuse or neglect in the NH (e.g., Hall et al. 2009). All of this may partly explain why TDs recognized and were aware that mistreatment in the provision of care is a significant contributing factor to loneliness among residents. Along the same line, TDs highlighted, on the one hand, the need of staff team diversity and an increase in staff/resident ratio as two central areas for intervention, and on the other, dementia care, stress management, and crisis intervention as relevant themes to be included in professionals’ training programs to reduce loneliness among these residents.

With regard to factors external to the NHs, the loss of loved ones, maintaining contacts or the lack of quality in relationships with family or significant others and/or friends were the most relevant factors for the TDs. It is well known that transition and adaptation into a NH can be a distressing and particularly isolating experience, considering that most residents may feel some form of loss or social and emotional disconnection after this event, following, for example, leaving their home, family, friends or the loss of loved ones (Grenade and Boldy 2008; Paque et al. 2018; Zhang et al. 2023). In addition, the NH’s geographical location, lack of integration with the wider community, restricted visiting policies, and limited family support can also contribute to or even exacerbate the isolation of these residents, leading to their greater vulnerability to loneliness (Sya’diyah et al. 2020; Boamah et al. 2021).

The absence or scarcity of family contact, connection, and support is one of the factors that stands out as relevant to the appearance of feelings of loneliness in older people. By way of example, a qualitative study (Evangelista et al. 2014) that explored the perceptions and experiences of elderly people in NHs reinforced this perspective, since these people described feelings of isolation and loneliness in relation to less satisfaction with contact and support from family members.

In line with this, it is not surprising that the TDs emphasized the promotion of a policy of greater proximity to families and community, partnerships with the outside world, and the civic participation of residents as priority areas of intervention to improve against loneliness.

Nevertheless, it was intriguing that some factors (e.g., not making meal times more flexible, users’ difficulties in accessing the internet/social networks) or areas of intervention (e.g., making mealtimes or pick-up times more flexible and opening up the canteen to family/friends) were not recognized as relevant by some TDs, particularly because these could be potential strategies that would allow them to be closer to their families and/or significant others, thus preventing or acting on this problem of loneliness.

In the context of NHs, some strategies can be implemented easily and even effectively to promote greater family involvement and proximity, for example, by promoting a more welcoming institutional climate and encouraging visits with very long opening hours or inviting the family to take part in social and sociocultural activities, with a special focus on involving the residents’ reference figures in intergenerational sharing activities. On the other hand, the NH could create suitable conditions for family members to celebrate symbolic dates at the institution (e.g., resident family member’s birthday), ensuring privacy for them. The participation of the family in defining the resident’s individual plan (if the resident allows it) can also contribute to greater closeness. In addition, the NH should develop sharing groups for these relatives focused on relevant topics (e.g., dealing with dementia). Another strategy that will contribute to greater family involvement and proximity is the creation of conditions that ensure accompaniment to death, providing logistical and emotional conditions at the end of life.

One result that deserves to be analyzed is that the TDs considered that negative stereotypes surrounding older adults are not a factor that can contribute to the loneliness of older people. This finding is worrying, given that ageism, defined by Robert Butler (Butler 1980) as the social stereotyping and discrimination of people based on age, has been stated in several studies (e.g., Marques et al. 2020; Shpakou et al. 2021) as a factor that favors loneliness in older people.

Research on loneliness or social isolation in NH contexts is scarce, which can be explained by the common assumption that older people in these contexts are less likely to experience loneliness and social isolation due to their environment, which allows physical proximity to other people (e.g., Boamah et al. 2021). Bearing this in mind, this study appears to be an important contribution to the deepening of knowledge not only about the phenomenon of loneliness among older residents in NHs, but also about the TDs’ perceptions regarding this problem.

However, this study has some limitations, namely due to the non-probabilistic convenience sample and its small size, thus not guaranteeing adequate representativeness of the diversity of SNS in the country, and consequently requires some caution when interpreting the results. On the other hand, it is necessary to consider the potential social desirability bias in the TDs’ responses, which may have influenced some of the findings. Furthermore, this study only offered an exploratory statistical analysis. Then, more and advanced statistical techniques are needed to identify complex patterns and correlations between variables. Furthermore, the lack of a previous validation study of the online questionnaire survey is also a limitation.

Therefore, future studies are needed, particularly with larger samples and using more robust analyses, particularly multivariate analyses, for a better understanding of this phenomenon. Further research should also focus on analyzing the perspectives of the different stakeholders (NHs residents, families, and staff) and include other variables potentially related to loneliness.

In this respect, the current research project will continue the investigation of loneliness in the context of NHs. Firstly, by drawing up a manual of good practices using the analysis of the section “Good practices for combating loneliness among older residents” of the online survey, which allowed the collection of strategies implemented by the NHs to combat loneliness. On the other hand, this project will carry out a second study involving the analysis of loneliness from different perspectives (older residents and staff), using focus groups with older people and staff from different national NHs.