Research findings present an ambiguous picture. Nurses need to consider the steps in relocation assess the needs of the aged.
Nurses, working in long-term care facilities, often witness a rapid decline in function among elderly persons immediately after their relocation. Repeated observations support the belief that some relationship between these two factors exists.
Relocation is a potentially stressful event in anyone's life. For the older person, relocation is often preceded by declining health, financial problems, death of a spouse, and/or urban renewaJ. The changes in lifestyle thai relocation brings can create stress in the older person whose homeostasis may be precarious.
For over twenty years, gerontological researchers have studied relocation, primarily in regard to its effects on the survival of the aged. Recent studies have investigated relocation effects on health slants and physical and psychosocial functioning, as well as considering the variables affecting the responses. Research findings on relocation are inconsistent. The evidence seems to stem from the diversity of investigative procedures and methods of analysis. Despite this criticism, there is a need for healthcare personnel and family members to consider those findings before any relocation occurs.
The older person frequently experiences at least one of the following environmental changes upon relocation:
* Residential (moving from one residence to another)
* Intel-institutional (transferring from one institution to another)
* Intrainstitutional (transferring from one room or unit to another within an institution)
* Residential/institutional (transferring from a residence to an institution or the reverse).1
Although residential relocation is then most common environmental change, its effects have been poorly researched both quantitatively and qualitatively. Studies of voluntary residential moves tend to show positive outcomes.2,3 These outcomes of improved morale and personal adjustment can be attributed to the person's choice to move to an environment because of its improved living conditions.
Brand and Smith used a control group to study the effects of involuntary relocation.4 The outcomes show decreased life satisfaction and a decrease in the activity level among the relocated group. In their study of forced residential relocation, Dimond and associates attempt to identify facilitators and barriers to relocation adjustment.5 Their data indicate that persons who rank high on coping resources tend to have few physical symptoms and very little depression after relocation. The coping resources Dimond and her colleagues considered included selfrated health, support systems, general happiness, life satisfaction, selfesteem, and emotional stability. Their findings suggest that a profile of coping resources may be an accurate predictor of adjustment ability helping Healthcare personnel to identify those individuals most in need of assistance.
The majority of relocation studies have dealt with Intel-institutional relocation. This environmental change is more stressful than residential relocation. Conflicting data from the extensive surveys of Borup, Schulz and Coffman concludes that increased mortality as a consequence of relocation itself is not a typical finding.6,7,8 Coffman attempts to explain the differing mortality outcomes by examining the transfer operations of certain relocations.
All relocations involve both disintegrative and integrative processes and what really matters is which type predominates. Every relocation means that some elements of support are lost and other elements of support must replace them. When the loss of support is faster and greater than its replacement, the predominant process is disintegrative and potentially quite harmful.8
Most of the interinstirutional studies in Schulz's review show significantly higher mortality rates when the moves are involuntary moves with no preparation for relocation. Kowalski's survey (1981) also supports this finding and lists several studies that indicate the benefits that site visits and meetings with families and staff have prior to relocation.
Higher mortality rates in relocation are more often associated with severe brain syndrome, limited physical function, and depression. Those who are more demanding, aggressive, and irritable are more likely to be "survivors." The importance of environmental control is frequently cited as a major factor affecting relocation outcomes. Postrelocation improvement is evident in older persons who transfer to environments that encourage them to be independent, to make their own decisions, and to develop new relationships and activities. Persons placed in cold, dependency-fostering , dehumanizing environments show rapid deterioration. These findings indicate that the effects of relocation depend upon the conditions under which relocation occurs and the characteristics of the population.
Borup's most recent study looks at the relationship between the degree of interinstitutional environmental changes and the variables of mortality, health and functioning, life satisfaction and self-concept.1 His findings show that the moderate environmental change has the most positive effects on awareness and adjustment. Both radical and moderate environmental changes decrease hypochondria and improve daily functioning abilities in the early post-relocation period. The findings of this study support the idea that the institutional time lapse effect is what causes deterioration rather than relocation. In other words, more deterioration occurs in elderly persons who remain for a period of time in an unstimulating, rigid, institutionalized environment than would occur if they were to be relocatd to a new, more stimulating environment. In fact, a moderate change to a less restrictive environment seems to neutralize the institutional time effect, at least for a brief period.
The interinstitutional relocation from nursing home to acute care hospital is a change that may increase the deteriorating condition of an older person. The hospital environment typically subjects the older person to sensory alteration, immobility, social isolation, and lack of control - all of which tend to contribute to disorientation. Unfortunately, the treatment for this disorientation frequently includes the same elements that precipitate the problem - those of isolation, restraints, and medications. The consequence is an increase in the confused state of the patients. Roslaniec and Fitzpatrick study changes that occur in the mental status of a group of 25 elderly persons during four days of acute-care hospitalization on medicalsurgical units.9 The most significant change is the increase in disorientation, since 68% of the sample became disoriented to time, place and/or person. There is a need for further research on this type of interinstitutional relocation especially in the area of identifying high risk elderly and environmental features that contribute to negative effects.
Studies dealing with intrainstitutional relocation indicate that this type of relocation has the least detrimental effects on the older person. The degree of disturbance is affected by such qualifying factors as characteristics of the people moved and of the new environment, the conditions of the move, the patient's degree of participation in decision-making preparation, and follow up after the move.10
Pablo looks at the variables of physical and mental functioning and finds no significant changes after intrainstirutional relocation.11 Haddad reports on the findings of 389 elderly residents who are transferred to intermediate, skilled-nursing, or psychiatric units depending on the suitability of the unit for meeting the assessed needs of each person.12 This relocation process did not contribute to measurable behavioral deterioration or increased mortality. Haddad concludes that any potential hazards associated with relocating elderly persons are outweighed by the benefits of transfer to rehabilitationoriented facilities.
The older person relocating from a residence to an institution for the first time will probably experience the mosi drastic environmental change. Schulz cites several studies which show an increased incidence of adverse effects when a person transfers from a dissimilar environment.7 These adverse effects are more pronounced when the new environment is a constraining one which forces the person into a passive role with feelings of helplessness and loss. Residential/institutional relocation also presents greater risks of detrimental effects because it frequently involves involuntary relocation of older persons who are in compromised physical and mental states. These are older persons whose families' energy and financial resources are likely to be nearly depleted.
CRISIS INTERVENTION PARADIGM17
Morris' research findings caution against the inappropriate placement of older persons in restrictive environments when their functional abilities do not warrant it.13 Increased depression and more rapid deterioration tend to occur with such placements. Unfortunately, it is estimated that 15% to 40% of the people placed in nursing homes could live in noninstitutional settings.14 Such findings emphasize the need for more careful functional assessments, to determine the type of care required.
A survey of possible impediments to relocating nursing home residents back into the community cites numerous studies that support the high percentage of inappropriately institutionalized persons.15 She also describes an equally high percentage who are placed in more skilled levels of care than is needed, within the nursing home. In addition to inadequate functional assessment, the fear of potential relocation trauma, possible family resistance, and limited available alternative services are impediments to deinstitutionalizing nursing home residents. Allison-Cooke and others believe these impediments are all related to systemic fragmentation of long-term care services.
An analysis of the structure of coping, which could be applied to relocation research, is that which (Marlin and Schooier present in their discussion of coping with problematic social experiences in general.16 They identify three protective functions of coping: (1) responses that modify or eliminate conditions of a problematic situation, (2) responses that perceptually control the meaning of the situation so as to neutralize its threat, and (3) responses that control the stressful consequences of the problematic situation after it has occurred. Some integration of these functions of coping are evident later in this paper. Research on effective coping resources during relocation is vitally important for nursing interventions; it remains an area waiting to be explored.
A sysnthesis of the relocation research findings gains some practical application for nursing with the use of Aquilera and Messick's problem-solving paradigm for crisis intervention.17 This paradigm serves as a useful tool for organizing the findings into a framework that lends support for nursing interventions.17 When using this paradigm, relocation becomes the stressful event that creates a state of disequilibrium. Disequilibrium, in turn, initiates the stress reduction process within the older person. The presence of three factors - (1) realistic perception of the event, (2) adequate situational support, and (3) adequate coping mechanisms - promotes adaptation to the stress and restores equilibrium, thus avoiding a crisis. When one or more of these factors is absent, disequilibrium continues and a crisis results. (See Figure)
The significance of the older person's perception of relocation is repeatedly demonstrated in all types of relocation research and is closely related to predictability of the event. By allowing the older person the chance to express feelings about the meaning of the event and by providing information needed to neutralize any threatful meaning, the nurse can promote a more realistic perception of relocation. Individual and/or group counseling sessions with the older person and his family as well as multiple site visits to orient them to the new facility and staff are interventions the nurse can promote during the pre-relocation phase.
When the first two balancing factors of the crisis intervention paradigm receive adequate attention, there is a greater probability that the third factor, coping mechanisms, will be more effective. As mentioned earlier in this paper, there is a dearth of nursing research identifying coping mechanisms that promote adaptation to relocation. Despite this lack of knowledge about effective coping, the nurse can increase the adequacy of the older person's learned coping mechanisms by helping him/her to focus on those mechanisms, by supporting his/her use of those mechanisms, and by keeping the new environment as similar to the old as possible. Personal belongings and memorabilia help bridge the gap of the old to the new environment, and information from family to staff or staff to staff about the older person's style of living and his ways of dealing with stress should be transferred.
A nurse clinician can obtain a thorough health history and perform the functional assessment to ensure the most appropriate environment for meeting the older person's needs and goals.
These measures draw the older person into the decision- making process, give him a sense of controllability and thus promote a more realistic perception of the need for relocation.
Another balancing factor, according to the crisis intervention paradigm, is adequate situational support. The support of the family and the staff, as well as having an environment that enhances personal growth , can reinforce the older person's ego integrity during the relocation process and in the post-relocation adjustment period. Several of the relocation studies suggest that open communication among all those involved with the relocation process decreases anxiety and negative attitudes.
As a nurse clinician who has frequently participated in intra- and inter institutional relocation of older persons, the author has observed that one of the most helpful interventions in reducing the stress of relocation is having a trusted staff member present. This seems especially true when the older person is in a vulnerable condition, such as when he/she is transferred to the emergency room because of an acute problem. Having a trusted nurse accompany the older person to the emergency room transfers the feelings of control of the situation to the older person and things are seen as less threatful. This is an area worthy of investigation for the sake of both quality care and cost-effectiveness.
The nurse's role in facilitating situational support also involves initiating communication networks with our nursing colleagues. Nurses working in long-term care facilities, in acute care facilities, and in the community have a wealth of information that could facilitate relocation of elderly persons as changing health needs warrant. Nurses can facilitate continuity of care by using their broader perspective and exchanging information with nurses in other systems.
In summary, the investigative efforts on relocation have yielded many ambiguous findings. It seems fairly evident that relocation does create stress which may be harmful, but on occasion, may be beneficial. We cannot say that relocation is an event which causes deterioration, when actually it may have been the elderly person's deterioration which precipitated relocation. What is most important for nurses to examine is the process by which we relocate elderly persons. Have we helped the person to gain a realistic perception of the event? Have we provided adequate situational support and have we considered the adequacy of his coping mechanisms?
Indeed much research is needed before we can reach predictive and prescriptive stages. For now, we must consider the available findings and engage in clinical research to improve our nursing interventions.
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