Relocation presents a major change in the life of any individual. When people have to change environments by moving, they experience an uprooting, stress-producing situation. The move generates anxiety and discomfort and demands coping responses far beyond those evoked by familiar routines.
The aged population is seen as a particularly vulnerable group to relocation . Muhlenkamp et al compared differences between an elderly and a normative (younger) sample in magnitudes assigned to life change events as measured by Holmes and Rahe's Social Readjustment Rating Scale.1·2 The elderly ranked changes in living conditions and residence as requiring significantly higher magnitudes of adjustment than the normative group.
Institutionalization also represents a profound environmental change, and relocation between institutions may be particularly difficult for the elderly . The transfer of thousands of elderly persons from room to room in nursing homes to capture Medicare benefits created serious concern among seniors and their advocates.3 With the increasing number of elderly people in the United States as well as nursing homes, the frequency of moves into, out of, between, and wimin institutions for the aged will probably increase rather than decrease. There is a need to document the effects of such moves.
The majority of studies of relocation effects among the elderly have concentrated on moves into or between institutions and on mortality rates. Between institution moves have been studied by a number of researchers with findings of higher mortality in the group moved than in an age-matched control group.4"7 Lieberman summarized overall findings from studies of 640 individuals by stating, "no matter what the condition of the individual, the nature of the environment, or the degree of sophisticated preparation, relocation entailed higher than acceptable risk to the majority of those who moved. "8
Despite the research indicating that institutionalization and relocation have adverse effects on the elderly, other studies that focused on healthy older people did not document deleterious effects of relocation.915 Major methodological shortcomings were cited as reasons for the discrepancy in the findings: most of the studies were small scale, populations were not comparable, selection of subjects was not random, and longitudinal design was lacking. In addition, many studies did not account for the possible non-equality of the new environments into which relocated subjects were moved.
Schultz and Brenner identified the voluntary-involuntary component as a critical dimension of a theoretical framework to encompass all relocation studies.6 They predicted that individuals moved involuntarily from their homes to an institution would show the greatest negative effects, with the outcomes being somewhat better for involuntary relocatees moved from institution to institution. The outcomes of individuals moved voluntarily should be the least negative compared with the other groups.
A study by iferrari found that within the first 10 weeks of residence in an institution, 16 of 17 persons (94%) in an involuntary group died, whereas 1 of 38 (2.6%) in a voluntary group died within the same period. 16 Bourestom and Tars studied the effects of involuntary relocations leading to a radical change in routine and environment as compared with the effects of relocation leading to a relatively moderate change. Radical change was defined as entailing adjustment to a new building, staff, program, and resident population. Based on their findings, the researchers contend, "preparatory programs should become mandatory policy in all situations which contemplate the radical and involuntary relocation of elderly individuals."17
Jasnau assessed the differences in post-relocation adjustment between a group of patients who were mass moved and a group given individualized preparatory treatment. Patients in the first group had an increased mortality rate after relocation, whereas persons in the second group had lower than expected mortality rates.18
The effects of intra-institutional relocation were studied by Haddad and Prunchno and Resch.19,20 Haddad did not find a relationship between the move and increased mortality19; Prunchno and Resch concluded mortality rates were highest for moderately competent individuals who were moved, and interpreted these results as supporting a modified environmental docility hypothesis.20 This hypothesis predicts that individuals at either extreme of competence would be less influenced by environmental change than the group in the mid-range of competence.
Despite a trend toward identification of successful preparatory programs, there is continued preoccupation of researchers in studying mortality rates. Based on an analysis of prior research on the phenomenon of relocation, considerable information exists regarding which groups have higher mortality rates. Additional efforts are needed to identify the effects of relocation on morbidity and the psychological well-being of the relocatees.
The purpose of this study was to determine the effects of involuntary relocation in a particular population of institutionalized aged. The hypotheses tested in this study were:
1. Anxiety is higher among subjects moving to dependent living situations than subjects moving to independent living situations.
2 . Anxiety is higher just before and just after the move than it is long before or long after the move.
3. Anxiety is significantly related to age.
4 . Anxiety is significantly related to the length of institutional residency.
This study used a quasi-experimental time-series design. It was conducted in a midwestern, metropolitan philanthropic home for the well and infirm aged. Due to an administrative decision, the home (Home I) was closed and all residents were moved to a newly built home (Home ?).
Home I was a 125-bed facility in which each resident living in the independent area had his own room furnished with many personal belongings. The residents took their meals in a central dining room and shared common toilet facilities. There was no direct nursing coverage, but residents did have access to a health clinic and there was an adjoining skilled nursing unit.
Home II was located approximately 15 miles from Home I. This 600-bed multi-purpose institution offered living arrangements that ranged from independent living in apartments to three types of dependent living: minimal, intermediate, and skilled care. Independent living was characterized by each resident having an apartment with a private bathroom and cooking facilities. Residents could either cook their own meals or eat in a central cafeteria. The independent living residents also furnished the apartments as tfiey saw fit. No direct nursing coverage was provided, although there was a call system in each apartment for emergency purposes and a health clinic was available. Dependent living was characterized by semi-private rooms, 24-hour nursing supervision, diet trays served in a dining room on each unit, and furniture provided by the facility. Both dependent and independent groups were studied for 2 months to gather data for this research.
DEMOGRAPHIC CHARACTERISTICS OF SUBJECTS
SUMMARY OF MEAN ANXIETY SCORES AND STANDARD DEVIATIONS FOR INDEPENDENT AND DEPENDENT GROUPS ON FOUR OCCASIONS*
Seventy-nine residents living in the independent area of Home I were asked to participate in this study. The majority of the residents were ambulatory, alert, and free from incapacitating illness. All residents in the study moved to either the independent or dependent units of Home II. The residents moving to independent living were scheduled so that two residents moved each weekday, whereas those going to dependent living all moved on the same day.
Written permission to conduct this study was obtained from the president of the home where the study was conducted. Of the 79 residents invited to participate in the study, 7 refused initially. All residents who consented to participate were asked to complete questionnaires on four occasions: 1 month prior to moving (Time I); within 1 week before moving (Time II); within 1 week after moving (Time III); and 1 month after moving (Time IV). The questionnaire at Time I was completed during the "floor meetings" or in individual interviews. At Times II, III, and IV, the questionnaires were administered to the subjects in a private interview lasting approximately 20 minutes. Five subjects refused to participate in the second, third, or fourth testing and five died before the testing was completed. Sixty-two completed all four administrations of the questionnaire.
The primary tool for data collection on each testing occasion was the State Anxiety Inventory taken from the StateTrait Anxiety Inventory developed by Spielberger et al.21 Subjects responded to each item by rating themselves on a four-point scale. The range of possible scores is from 20 to 80, with higher scores representing higher anxiety.
Additional data were obtained at Time I by asking residents to complete questions about whether they were looking forward to the move, their perceived health status, the frequency of previous moves, and religious affiliation. At Time IV, residents were asked about the number of visits they had made to Home II before moving and about assistance by family members during the move. Demographic data were obtained from admission records provided by the institution. Data regarding mortality were collected at Times H, IH, and IV.
Hypotheses 1 and 2 were tested through a 2 × 4 factorial analysis of variance with the time factor as the repeated measure (Lindquist Type I Design). Post-hoc tests between times within groups were made using the f-test on correlated measures. Post-hoc tests between groups at various times were made using the r-test on independent groups. Hypotheses 3 and 4 were tested through the Pearson-Product Moment Correlation. The probability level of 0.05 was selected as the level of significance.
Demographic data collected at Time I indicated the age, sex, length of residency in the home, and level of care to which subjects were moved (Table 1). The subjects ranged in age from 70 to 98 years (mean age, 86.8 years). There were 69 women (95.8%) and 3 men (4.2%) included in the study. The number of years the subjects had lived in the home ranged from 2 to 28 years with a mean of 8.8 years. The mean age of the 19 residents moving to dependent living was 87.6 years (R = 75-98); mean length of residency was 10.5 years (R = 4-28); mean age of the 59 residents moved to independent living was 86.4 years (R = 70-93); and the mean length of residency was 8.0 years (R = 2-20).
MEAN ANXIETY SCORES OF DEPENDENT AND INDEPENDENT GROUPS ON FOUR OCCASIONS
All of the subjects were white Protestants; 54 (75%) described religion as being very important to them while the remaining 18 (25%) described religion as somewhat or moderately important. Thirty-six (50%) of the subjects had experienced between one and five previous moves, 26 (36.1%) moved between six and 10 times, and the remaining 10 (13.9%) moved between 1 1 and 30 times. Eighteen residents (25%) reported their health as very good, 31 (43.1%) as good, 21 (29.1%) as fair, and 2 (2.8%) as poor. The majority (59.7%) of the subjects saw their health as better than others their same age.
Hypothesis 1 , proposing a higher anxiety level among residents moving to more dependent living situations than among residents moving to more independent living situations, was supported by the data. There was a significant main effect for groups, with the group that moved to dependent living more anxious overall than the group that moved to independent living (F = 6.63; df = 1,60; P <.05) (Table 2). This effect was due primarily to the significant difference between groups at Time III (/ = 3.31; df = 60; P < .01).
The Figure indicates that those assigned to dependent and independent living did not differ significantly at Time I, 1 month prior to the move. At Time II, 1 week before the move, anxiety for both groups had increased slightly; the increase was non-significant and the difference between the two groups remained non-significant. There was an important change after the move for those in independent living with a significant drop in anxiety (P < .001). The drop in anxiety for those in dependent living was very slight and the difference between these two groups at Time III was significant at the .01 level. In the ensuing 3 weeks, anxiety increased slightly for the independent group, but it remained almost constant for dependent group. At Time IV, 1 month after the move, the dependent group continued to have significantly higher (P < .05) anxiety than the independent group.
Hypothesis 2, proposing a higher anxiety level just before and just after the move than long before or long after the move, was partially supported. Analysis of variance of the two (groups) by four (times) indicates a significant main effect for times (F = 5.90; df = 3, 180; P < .0 1 ) . This effect was due primarily to the significant difference between Times II and III within the group that went to independent living (t = 4.72; df = 44; P < .001) (Table 3). Anxiety was highest just before the move, whereas just after the move there was not a period of higher anxiety.
SUMMARY OF ANALYSIS OF VARIANCE
Hypotheses 3, indicating a significant relationship between anxiety and age, and hypothesis 4, indicating a relationship between anxiety and length of residency, were not supported by the data.
In general, the findings support the commonly held belief that involuntary relocation of the aged is a stressproducing situation that generates anxiety. The results supported the hypothesis that the dependent group would have significantly higher levels of anxiety than the independent group (Table 3). There appear to be four major differences between the independent and dependent group that can be viewed within the context of the dependent group's inability to control or predict the outcome of the move.
First, although both groups had to give up familiar surroundings, the dependent group members also were asked to give away or sell their furniture to move into a room that was equipped with a "hospital" type bed and dresser. Those who moved to independent living kept as much furniture as they liked and also could choose furniture from the lobbies of Home I to furnish their apartments.
The loss of possessions also appeared to have provided the dependent group with fewer opportunities for reminiscence after the move. Lewis suggested that reminiscing may be a general way of coping with losses.22 Retrospective memories seem to provide the raw material for working through losses, crowding out unpleasant thoughts, and re-establishing a secure self-identity based on past experiences. Although the dependent group expressed much concern regarding the loss of possessions, once the move was completed, they talked very little about their possessions and did very little reminiscing. The independent group spent markedly more time talking about their furniture subsequent to the move. It appeared that the independent group had a great deal of reminiscence about personal possessions, whereas the dependent group either did not have the possessions to stimulate reminiscence or repressed the memories of lost objects.
A second difference between groups was a striking difference in freedom of activity in the new environment. The dependent group was continuously supervised by nursing personnel, who controlled medications and enforced a schedule of daily activities. The independent group had increased opportunities afforded by a private apartment, including a kitchen and bathroom, both absent at Home I.
The third difference between groups was the issue of privacy: the dependent group lost privacy in the new environment whereas the subjects who moved to independent living experienced increased privacy. The majority of those moving to dependent living repeatedly expressed their fears about having a roommate. Typical questions included, "Will there be a curtain to separate the room?" and "what do I do when I want to sleep and my roommate wants to watch television?"
Although preparation for the move was carried out in many similar ways for both the independent and dependent groups, there were differences in the amount of preparation each group received. The dependent group reported visiting the new home less often prior to the actual move: 11 (61%) did not visit Home II, 4 (22.2%) visited once, and 3 (16.7%) visited twice. Subjects in the independent group made anywhere from one to five visits prior to the move.
Another difference in preparation between groups involved the notification and scheduling of the date of relocation. The independent group was scheduled so that two subjects moved each weekday. A written schedule was distributed to the independent group so that each subject knew the moving date a month in advance. All subjects in the dependent group moved on the same day, and there was uncertainty regarding the actual date of the move due to a complication in the timing of licensure approval for occupation of the dependent living unit at Home II. The date was finalized only 1 week before the move, and it is unclear whether all dependent residents were told of the scheduled date at that time. It is evident that the dependent group suffered considerably more ambiguity about the date than did the independent group. Finally, preparation for the move differed to the extent that 37 (77%) of the independent subjects reported being helped by family or friends throughout the move whereas only 7 (41%) of the dependent group reported the same assistance.
Application of Schultz and Brenner's theoretical framework indicates that the difference between the two groups can be described in terms of control and predictability.6 The dependent group moved to an environment that was less predictable than did the independent group. The dependent group received less help by family and friends, less visits to the new home, and a less definite relocation date. The dependent group moved to an environment over which they had decreased control while the independent group moved to an environment characterized by increased control. Schultz and Brenner hypothesized that the less "predictability" and "controllability" in the new environment, the greater the negative effect of relocation.6 The dependent group, with its lower control and predictability, would be expected to experience greater negative effects of relocation. The dependent group had higher anxiety throughout the entire relocation process than did the independent group.
Anxiety per se is not a negative affect. A certain amount of anxiety in a stressful situation is expected and considered as a normal adaptive mechanism. Thus, one cannot equate anxiety directly with negative effects of relocation. Yet, Selye pointed out that if the stressor is severe enough and applied for a sufficient time, the individual can no longer adapt and a breakdown of resistance or death occurs.23 The increased anxiety of those in the dependent group could tax their adaptive capacity and increase their vulnerability to illness and death. The lower control and predictability for the dependent group was accompanied by increased anxiety, which over time could increase the vulnerability of this group to illness and death.
The non-random selection of subjects to dependent and independent groups is a limitation of the study and may have resulted in subjects most prone to anxiety being chosen for dependent living. Administrative personnel at Home I, who knew the residents for years, made the decision for relocation to dependent living. The administration, in conjunction with the subject's family, made most of the decisions regarding the need for dependent living placement, although a few subjects chose this unit on their own. The primary consideration was the presence of physical problems necessitating medical and nursing supervision. In data gathered for this study, 3 (15.8%) members of the dependent group reported their health as very good, 8 (42.1%) as good, and 8 (42. 1%) as fair, whereas 15 (28.3%) of the independent subjects reported their health as very good, 23 (43.3%) as good, 13 (24.5%) as fair, and 2 (3.5%) as poor. In light of the fact that the dependent group experienced higher levels of anxiety throughout the study, consideration should be given to the findings of Pruchno and Resch regarding the increased vulnerability of moderately competent individuals who are relocated.
Although both groups showed anxiety about the move, only the dependent group was highly concerned about specific issues. Their greatest concerns were loss of privacy, loss of personal possessions, and anxiety that these concerns could not be resolved to their satisfaction . The independent group was philosophical about the move; although the independent group did not particularly like the idea of moving, they were willing to go along with it. In fact, the independent group often accented the positive aspects of moving with the rationalization that the move was necessary and unavoidable.
The finding that anxiety was highest just before the move (Time II) is similar to the findings of Zweig and Csank and Kasl, and may be a function of the increasing stress associated with anticipation of the move.24,25 Based on their findings, Zweig and Csank commented that the level of anticipatory anxiety for the geriatric patient may be high enough to increase the probability of death. It is interesting to note that three subjects died unexpectedly in the interval between Time I and Time II. The independent group experienced a significant drop in anxiety from 1 week before the move (Time II) to 1 week after the move (Time III). The significant drop in anxiety between Time II and Time III in the independent group and the lack of a significant drop in anxiety between the same times for the dependent group may be a function of control and predictability associated with adjusting to the new environment. An increased control and predictability for the independent group contributed to the significant decrease in anxiety, whereas the loss of control and predictability for the dependent group contributed to the lack of a significant decrease.
Successful adjustment involves the resolution of many complex issues. Examples of issues identified from discussion with the residents were recognizing the differences between the old and new homes; grieving over the losses of the old home; learning the rules and routines at the new home and being able to accept these rules; and accepting the new environment while maintaining a sense of self-worth.
The effects of relocation on the elderly need to be identified and understood by individuals involved with the elderly. It is important that nurses, physicians, administrators, family members, and mental health workers be sensitive to the effects that relocation has on this age group. Instruction of nursing personnel should include emphasis of the effects of relocation.
The relocation of elderly living within an institution should be prevented if possible. If this is not possible, timely notification should be given to residents and their families, and an organized stress reduction program should be instituted, especially for the moderately competent residents. Health professionals should recognize that even the most positive relocation (such as moving to a nicer facility) produces a certain level of anxiety. Efforts should be made to identify individuals who are most vulnerable to the stressors associated with relocation. Nursing personnel are often the only members of the health team who consistently interact with individual residents. The nurse should anticipate the stressful nature of moving and could be the first to recognize a resident's specific concerns and anxieties.
Once the individual concerns are recognized, measures should be instituted to remove the source of concern or to reduce the anxiety toward this concern. The transferring facility has an important role in alleviating the stress of relocation in light of the increased anxiety just before the move. Nurses need to be aware of the anxiety an individual is experiencing in the week before the move. To assist the individual, the nurse must have information regarding die setting to which the individual is relocating. This may mean visiting the new home or obtaining as much information as possible about the new home. In addition, comprehensive transfer information should be provided to the personnel of the new facility with particular mention of the individual's reactions to the move, including fears, concerns, and losses to which the older person must adjust.
Because ethics, risks, and rights of human subjects preclude designing experimental studies on the relocation of the elderly, the opportunities for research should be seized whenever there are required moves, either inter-or intrainstitutional, of numbers of older persons. Only in this way can the influence of such important variables as control, predictability, independence, competence, privacy, loss of possessions, type of environment, preparation for the move, support from family, health status, and distance of the move be evaluated. Although morbidity and mortality are important and drastic measures of the effects of these moves, measures of anxiety, depression, and behavioral changes may provide a better overall understanding not only of the effects of relocation but also of measures to reduce untoward effects.20
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DEMOGRAPHIC CHARACTERISTICS OF SUBJECTS
SUMMARY OF MEAN ANXIETY SCORES AND STANDARD DEVIATIONS FOR INDEPENDENT AND DEPENDENT GROUPS ON FOUR OCCASIONS*
SUMMARY OF ANALYSIS OF VARIANCE