Awaiting nursing home placement may be viewed as a crisis for elders as institutionalization represents an emotionally significant, radical change in their lives. This article will relate crisis intervention theories and the literature on relocation of elders to the situation of tíiose awaiting nursing home placement. A care plan for crisis intervention will be presented for such elders in acute care facilities.
A crisis is a turning point in the life of an individual. The individual faces a problem that he feels unable to solve on his own as the coping mechanisms he has used before are no longer effective. Crisis intervention is a short-term therapy that focuses on solving the immediate problem in the person's life to re-establish emotional equilibrium in the individual. Although there is an abundance of literature on crisis intervention theory and techniques, no one comprehensive crisis theory exists.
Although several authors have contributed to the crisis intervention treatment approach, Caplan has laid the foundation for current crisis intervention approaches.1,2 According to Caplan, a crisis is a transitional point in a person's life marked by cognitive and emotional upset that is self-limiting in nature. It is precipitated by identifiable situational or interpersonal stresses. The goal of crisis intervention is to re-establish the individual's emotional equilibrium. Caplan believes that a crisis can be a turning point for the individual in which the individual moves toward or away from mental illness. The goal of treatment is the restoration of functioning to the precrisis level.
In contrast to this approach, Narayan and Joslin have proposed a holistic nursing model of crisis theory in which crisis is viewed as an experience for promoting growth of the client.3 When old patterns of behavior have proven ineffective in coping with a crisis, the individual is faced with the opportunity to review such responses and to adopt new patterns of behavior, leading to a higher level of functioning than before the crisis.
Morley et al have outlined a problem-solving approach to crisis intervention.4 An intervention paradigm that analyzes balancing factors that affect the development of a crisis from a stressful event was subsequently proposed by Aguilera and Messick.5 Balancing factors that promote emotional equilibrium are a realistic perception of the event, adequate situational support, and adequate coping mechanisms. If such balancing factors are absent, the unresolved problem is likely to lead to disequilibrium and consequent crisis. The paradigm has extensive clinical use. It may be used in the assessment, planning, intervention, and resolution stages of problem solving in a crisis situation. The average length of treatment for crisis intervention is one to six counseling sessions.
There is little indication in either the nursing or social science literature that crisis intervention techniques have been widely used with elders awaiting nursing home placement. There is, however, a body of knowledge concerning relocation of elders and discussion of the benefits of counseling elders awaiting relocation.
Although there is a conflicting body of literature on whether or not interinstitutional relocation is life-threatening to elders, the likelihood that a given relocation will result in increased mortality seems to depend on the conditions under which the relocation occurs and the characteristics of the patients being relocated.6 This review of the literature noted that several authors indicate that the degree of preparation for relocation influences subsequent mortality. Mirotznik and Ruskin conclude that any questions patients may have about their future home or any other aspect of the relocation should be answered. The patients' sense of control even in involuntary relocations can be enhanced.
Schulz and Brenner have emphasized the importance of an elder's sense of predictability and control in relocation.7 They reviewed the literature on relocation and developed a theoretical model to explain the information found. They postulate that the greater the choice the individual has in the relocation process, the less negative the effects of relocation. Another postulate is that the more predictable a new environment is, the less negative the effects of relocation. They believe that to the extent that an individual is prepared for a new environment through educational programs or counseling, he or she should be less adversely affected by relocation than an individual who is not prepared.
A recent study analyzing anxiety levels in relocated elders supports the postulate that increased predictability leads to less negative effects from relocation. Thomasma et al found lower anxiety levels in elders who were more actively involved in their relocation than in those elders who were relocated without such involvement.8 Although few other studies have analyzed the effects of relocation on physical health and psychosocial status, Mirotznik and Ruskin believe that many of the factors that mediate the impact of relocation on mortality also influence its effects on the elder's health.6
Neugarten has described developmental changes in aging that reflect the elderly 's perceptions of control over their environment.9 Neugarten referred to the elder's witfidrawal of ego energy from the external environment as "the increased interiority of personality."9 Elders view the outer world as more dangerous and complex than they did in their youth. Elders feel they lack energy to take advantage of and overcome obstacles in the outer world and thus are no longer able to reform the external environment in line with their wishes. Rotter operationalized the concept of external locus of control as the person's perception that rewards are the result of external factors beyond the control of one's own behavior.10 On the other hand, an internal locus of control is a person's perception that rewards from the environment are the result of his behavior.
The concept of locus of control in counseling elders is demonstrated in Sherman's integrative counseling approach." It is an eclectic counseling approach that focuses on enhancing the development of problem-solving capabilities that promote an internal locus of control in the elder. Sherman's approach is based on the "social reconstruction syndrome" of Kuypers and Bengtson.12 It represents a comprehensive social-psychological framework mat incorporates elements of social system, self-concept, and labeling theories as they might be applied to practical problems of aging in our society. Recently, Sherman operationalized key variables from his approach in a study exploring the relationship of these variables.13
Burnside also discussed guidelines for counseling elders. She used principles of brief psychotherapy and related her crisis intervention focus directly to the theme of loss in the aged. 14
CRISIS INTERVENTION WITH ELDERS
Crisis intervention theory may be used as a framework for assisting elders awaiting nursing home placement in an acute care setting. Nursing home placement may be viewed as a situational crisis in which the elder is faced with threat of permanent loss of home environment, threat of social role changes, loss of control over daily activities of living, and fear of impending financial losses. The threat of such changes may promote emotional disequilibrium in the elder. Although the period of adjustment to living in a nursing home may also be considered a crisis, coming to terms with the potential changes represented by such a move, prior to the move, is a separate process of adjustment. Crisis intervention techniques are general and therefore adaptable to use with the elderly. Furthermore, crisis intervention is readily adaptable to the acute care setting as it is short-term in nature.
A CARE PLAN FOR CRISIS INTERVENTION WITH ELDERS AWAITING NURSING HOME PLACEMENT IN AN ACUTE CARE FACILITY
Knowledge from personal experiences of counseling elders and from the literature discussed in this article was used to develop the care plan for crisis intervention with elders awaiting nursing home placement in an acute care facility. The plan is specifically designed to assist nurses in providing counseling within the time constraints of the daily routine on a busy acute or extended care unit in a hospital setting. Although family members of the elder may be asked for input, the plan's focus is to provide individual counseling to the elder who requires emotional support in a setting where he often feels alone (Figure).
The care plan reflects the stages for crisis intervention outlined by Morley et al: assessment, planning, interventions, and crisis resolution.4 The focus is limited to the situational crisis of awaiting nursing home placement, although counseling regarding multiple stressors may be incorporated into the plan. Input from nursing staff and patients' families will assist die counselor in individualizing the plan for each patient.
The balancing factors cited in Aguilera and Messick's paradigm - a realistic perception of the event, adequate situational support, and adequate coping mechanisms - provided the guidelines for the assessments indicated in the plan.5 The interventions include the direct approach used by Morley et al to clarify the crisis by explaining to the patient the relationship between the crisis and the event of awaiting nursing home placement.4 They reflect the body of literature supporting education of the elderly regarding relocation and their active involvement in the relocation process as a means of reducing the adverse effects of relocation. Furthermore, the interventions reflect Sherman's emphasis on promoting problem-solving capacities in the elder.11 The crisis resolution stage outlined by Morley et al, which includes reinforcement of progress made by the patient and anticipatory guidance, is also integrated into the intervention section of the care plan.4
It must be noted that cognitively impaired or severely anxious elders cannot be expected to have realistic perceptions of the crisis-precipitating event nor adequate coping mechanisms to deal with it. Thus, interventions focusing on increasing such elders' ability to cope with the relocation may not be realistic. Individualized plans for such patients would focus on providing immediate emotional support and promoting participation in activities of daily living.
A review of the crisis intervention literature and the literature on the relocation of elders reveals no formalized approach to counseling elders awaiting nursing home placement. The proposed care plan offers a simple, timesaving technique to counsel elders in acute care facilities, and it may be adapted to the individual needs of the patient. Although the cognitively impaired elder may not fully comprehend the crisis situation, ethically it must be assumed that he will benefit from some form of counseling prior to nursing home placement.
Crisis counseling should promote emotional equilibrium in the elder and thus mediate the negative effects of the relocation. The development of a more positive attitude in the elder will enable him to adapt more easily to the environment of the nursing home. From a holistic viewpoint, crisis intervention may enhance growth of new behavior patterns that reduce anxiety and thus decrease the likelihood of negative emotional and physical effects resulting from the stress of relocation.
A similar plan of care could be implemented for the patient on his arrival to the nursing home. Continuation of counseling should further facilitate the process of adjustment to living in the nursing home environment. The nursing home staff would benefit from review of the individualized plan of care developed at the acute care facility to more quickly acquaint them with the patient's individual needs.
Research is needed to refine crisis counseling techniques for elders facing relocation and to demonstrate their therapeutic benefits. Demonstration of the nurse's role in meeting the psychosocial needs of elders awaiting nursing home placement in acute care facilities is necessary to strengthen and further define this role for nurses.
- 1 . Caplan G. An Approach to Community Mental Health. New York: Grane & Stratton; 1961.
- 2. Caplan G. Principles of Preventive Psychiatry. New York: Basic Books Ine; 1964.
- 3. Narayan SM, Joslin DJ. Crisis theory and intervention: A critique of the medical model and proposal of a holistic nursing model. ANS. 1980;2(7):27-39.
- 4. Morley WE, Messick JM, Aguilera DC Crisis paradigms of intervention. J Psychiatr Nurs. 1967;5:531-544.
- 5. Aguilera DC, Messick JM. Crisis Intervention: Theory and Methodology, 4th ed. St Louis: CV Mosby; 1982.
- 6. Mirotznik J, Ruskin AP. Interinstitutional relocation and the elderly. Journal of Long Term Care Administration. 1985; 13(4):127131.
- 7. Schulz R, Brenner G. Relocation of the aged: Review and theoretical analysis. J Gerontol. 1977; 32:323-333.
- 8. Thomasma M, Yeaworth RC, McCabe BW. Moving day: Relocation and anxiety in the institutionalized elderly. Journal of Gerontological Nursing. 1990; 16(7):18-25.
- 9. Neugarten BL. Continuities and discontinuities of psychological issues into adult life. Human Development. 1969; 12:121-130.
- 10. Rotter JB. Generalized expectancies for internal versus external control of reinforcement. Psychology Monographs. 1966; 80(1): 1-28.
- 1 1 . Sherman E. Counseling the Aging: An Integrative Approach. New York: The Free Press; 1981.
- 12. Kuypers JA, Bengtson VL. Competence and social breakdown: A social-psychological view of aging. Human Development. 1973; 16:37-49.
- 13. Sherman E. Social reconstruction variables and the morale of the aged. Int J Aging Hum Dev. 1985;20:133-144.
- 14. Burnside IM. Crisis intervention with geriatric hospitalized patients. Journal of Psychiatric Nursing. 1 970; 8(2): 1 7-20.