The event of moving to a new home is a stressful event for any individual, regardless of age. Elderly individuals who are moving from their own homes into assisted living facilities could be subject to stress not only because of the move, but also because of the loss of independence.
Assisted living facilities for elderly individuals provide a homelike setting, usually a studio apartment with a kitchenette, yet also offer various levels of assistance in daily care as needed. Freedom and privacy accompany congregate dining, cleaning services, and nursing supervision as needed, with the expectation that residents will remain in place as they age. Professionally delivered personal care services help frail older adults avoid institutionalization and remain independent as long as possible.
Because nurses can assist relocated elderly individuals by learning from the insightful experiences of those who have made such a transition, this study was undertaken to explore the meaning of relocation to assisted living in a select sample of elderly individuals.
Although research exists on the effects of relocation of elderly individuals, most research in the past 40 years has focused primarily on involuntary relocation to nursing homes, with an emphasis on mortality and morbidity as a result of relocation (Danermark & Ekstrom, 1990). Few studies have focused on the psychosocial and emotional effects of relocation on elderly individuals, and little has been written about the meaning of relocation to elderly individuals. In addition, the objectives, care, and services are very different for assisted living facilities than for nursing homes.
The phenomenon of transition is important. Armer (1993) wrote:
As the number of aged in planned housing in this country grows, protecting the well-being of the relocated elderly continues to be a major concern. Through increased understanding of the factors influencing post- relocation adjustment and health and fuller understanding of personal meaning of the relocation experience for the older adult, the potentially detrimental effects of the stressful relocation event on the well-being of the older person can be minimized, (p. 158)
Several researchers have reported negative psychological adjustment to relocation. Johnson (1996) interviewed elderly nuns who were being relocated from one group residence to another and found evidence of relocation stress syndrome, with feelings of anxiety, loneliness and isolation, and worries about personal possessions.
Dimond, McCance, and King (1987) studied elderly individuals who were forced to move from private homes that were being demolished to new private homes and found psychological adjustment varied by time. Although depression was a significant factor before the move, it decreased between 6 and 18 months after the move. Life satisfaction continued to increase in the months postrelocation, and specific worries about relocation decreased after the move. The factor that took the longest time to improve (up to 18 months) was loneliness and alienation.
Mirotznik and Ruskin (1985) also reported adjustment varied by time. They found morale increased significantly from premove to 1 month postmove, with alienation decreasing significandy during the same time period.
Chenitz (1983) and Armer (1993, 1996) reported psychological adjustment of elderly individuals to relocation was influenced by perceived choice and control, perceived desirability of the move, reversibility of the move, social interaction and support, prior life satisfaction, recency of personal losses, coping strategies, and self-reported health. Borup (1981) and Dimond et al. (1987) reported psychological adjustment varied by age and sex. Although their findings on the relationship with age conflict, both studies reported initially significantly higher stress for elderly women than elderly men.
Thomasma, Yeaworth, and McCabe (1990) found levels of stress varied depending on whether elderly individuals were moving to an independent living situation or a dependent one, with those moving to dependent living situations experiencing significantly higher levels of anxiety. Other findings suggest elderly individuals experiencing voluntary relocation (Armer, 1993, 1996) fare better psychologically than those subjected to involuntary relocation (Dimond et al., 1987; Johnson, 1996; Johnson & Hlava, 1994; Thomasma et al., 1990).
Several researchers have reported specific positive outcomes from relocation. Rutman and Freedman (1998) studied elderly individuals moving from their private homes to senior citizen housing and found those who had already moved reported higher morale, overall psychological adjustment, social interaction, mobility, and environmental satisfaction than those who were waiting to move. Mitchell and Kemp (2000) reported "satisfactory" levels of quality of life in frail elderly individuals in assisted living facilities as well as satisfaction with the facility and low levels of depression.
Two conceptual models were used to guide this study. The Conceptual Model for Understanding Life Crises and Transitions (Moos & Schaefer, 1986) helps to explain why one individual reacts to a crisis or transition differently from another individual. This model uses the terms life transitions, crisis, and events interchangeably and looks to nurture the potential for growth at these times. Based on crisis theory, this model provides a broad biopsychosocial orientation to health care that is consonant with nursing holistic philosophy.
The second model, Roy's Adaptation Model of Nursing (Roy & Andrews, 1999), also aids in understanding the transition experience of elderly individuals. According to this model, psychosocial adaptation partly depends on focal, contextual, and residual stimuli related to self-concept, role, and interdependence. Nurses can intervene to increase adaptation in these three areas.
For elderly individuals who are undergoing a relocation, the adaptations they face include relinquishing home ownership, getting acquainted with other residents, and following rules and regulations in the new residence (Armer, 1993). Elderly individuals also fear loss of personal control and the recognition of declining functional abilities (Rutman & Freedman, 1998), as well as the disruption of familiar routines and severing of emotional attachments (Dimond et al., 1987).
CHARACTERISTICS OF STUDY PARTICIPANTS (N = 28)
Nurses can play a role in minimizing the negative effects of relocation. Armer (1996) suggested professionals can help minimize negative effects through increasing the predictability of the new environment by determining elderly individuals' expectations; supporting contact with family and friends and social interaction with fellow residents; and becoming aware of previous life satisfaction and prior losses. Thomasma et al. (1990) suggested having elderly individuals visit the new location several times and informing them well ahead of the moving date may help to reduce stress.
Although it is difficult to draw many generalizations from the literature because the situations being studied vary so widely, the consensus is that relocation of any type causes stress either pre- or postr elocati on and that the first move to an institutional type setting may cause the most adverse effects (Rosswurm, 1983). Assisted living, by definition, could cause less psychological discomfort than relocation to a nursing home. The fact that such a move is voluntary, provides personal freedom, choice, and privacy make it less disruptive than nursing home relocations and more like a positive move experienced by those moving into senior citizen housing. In addition, elderly individuals making the choice of assisted living also may view the assisted living facility as a residence to age in place, thus postponing or eliminating the need for a nursing home.
This qualitative study used a hermeneutical-phenomenological design to obtain descriptions of the experience of relocation to an assisted living facility by a method of presence and dialogue between the researchers and the participants. The description of relocation was provided by the participants, and the meaning of the relocation was uncovered through a hermeneutic or interpretive process. Van Manen 's (1990) methodology patterned the systematic attempt to uncover and describe the structures of the lived experience.
A total of 28 volunteers who resided in three different assisted living facilities were selected to participate in group interviews. Participants were selected based on their ability to recall and express feelings concerning their move into the facility. In addition, participants were required to have lived in the facilities between 6 weeks and 14 months, speak English, and be able to provide written and verbal consent.
Group size varied from three to six individuals at any given time. Most of the groups included both men and women, and one group included two married couples. All of the participants were White and ranged in age from 74 to 93. Perspective on how previous relocation and the availability of support systems was assessed by asking about living siblings, living children, and the number of moves the individuals had made (Table).
After obtaining Institutional Review Board approval, the researchers met with the administrators of three assisted living facilities to discuss the purpose of the research and elicit suggestions for participants. Administrators were assured complaints about the facility would not be elicited, and all information would be confidential. In addition, they were assured the reporting of data would not identify participants individually or collectively by a particular facility.
Willing participants met with the researchers in groups to learn the purposes of the study, procedures, and time commitment, and to sign the informed consent form. Group interviews were held at a later designated time with open-ended questions and free discussion from the individuals about their experiences of making the transition from a private home to an assisted living facility. Participants were encouraged to freely express ideas as they emerged during the group interviews. Clarifying questions were asked at appropriate times, but suggestive or leading questions were avoided.
Meeting in groups allowed for interaction with others, triggering thoughts from others' experiences, and enlarging the vision of the move beyond the individual experience. Discussion of differing points of view and opinions were encouraged. Demographic data also were collected during the interviews.
Interviews were tape-recorded, transcribed verbatim, and identified by number to protect confidentiality. Field notes also were taken during the interviews to add to the data.
The process of data generation in this method borrows from experiences of others to better understand the human context of relocation. Rigor of the process followed the steps suggested in "Self-as-Instrument in Qualitative Research" (Rew, Bechtel, & Sapp, 1993). Appropriateness was assured by a minimum of two researchers in each group so that boundaries of the discussion were set.
None of the researchers were involved with any of the participants' clinical care. Authenticity was achieved by sharing with the group members the credentials of the researchers and explaining the desire to understand their experience more fully. Credibility was demonstrated through peer review and member checks between die five researchers involved in the group interviews as well as rapport building with participants on days prior to the interviews and at the beginning of each session. The engagement of the researchers as part of the discussion allowed for direct contact and empathy with the life experiences described, and clarification was sought, which helped in intuiting the meaning. Neutrality was maintained by all researchers in an effort to withhold personal bias and avoid leading questions.
Tape recordings were, listened to while reading the transcripts and then field notes were added. The voice tone and inflection of the words added greater depth of meaning. The verbatim transcripts were analyzed for subthemes, themes, and unity of meaning using Van Manen's method of description, interpretation, and critical analysis. All five researchers participated in the analysis for themes and unity of meaning. The research activities included bracketing, cocreating, reflecting with inferences, writing and rewriting text, maintaining a strong relationship with the phenomenon, and balancing parts of the whole (Van Manen, 1990).
The general structural description of the transitional experience emerged from situated descriptions and reflected five recurring themes:
* Self-motivated move versus familial encouragement.
* Ties to the past versus starting anew.
* Independence versus dependence.
* Affection versus disdain.
* Adjustment versus maladjustment.
Themes were common across participants and reflected the essence of the phenomenon of transitional experience from a private residence to an assisted living facility (Sidebar).
Self-Motivated Move Versus Familial Encouragement
Participants shared a variety of reasons for making the transition to their current living quarters. A few of the residents claimed their deteriorating health and inability to keep up with household demands prompted their move. "We talked about moving before I broke my hip. I couldn't do the work - snow and grass," said one participant. Another commented:
My daughter brought me here because I needed supervision. I had fallen at home, and I laid there for two days.
In addition to health concerns, some participants stated they wanted to be closer to family, either children, nieces, or nephews. Many had moved to appease their siblings or children. Those speaking of moving to ease family members' minds also mentioned they did not want to burden their families.
Ties to the Past Versus Starting Anew
While ties to family were important, ties to home and possessions also influenced adjustment. Memories associated with home and the past were held dear in the hearts of the participants. Assisted living facilities allow residents to bring familiar pictures and furniture into their apartments, which helps ease their transition into a new location. One individual shared:
The pieces I wanted were brought up here. I knew everything would fit. So my apartment I am happy with. It is, to me, very attractive and has my own favorite things. It meant sorting out and getting rid of a lot and saving some that I did not have the heart to get rid of. But anyway, my apartment is very pretty and that has a lot to do with me being happy here.
One participant noted the homelike environment was conducive to inviting guests, which helped with transition. One woman remarked, "We can invite two guests for the meals, any meals. This way our children and grandchildren can come."
For some, assisted living did not provide adequate room for the past. One man "confessed" his car was full of personal belongings that would not fit into his apartment. He stated:
I've built shelves and put things under the bed, but I still have more things I can't part with, and I really hated to leave our Christmas tree behind.
Unfortunately, some ties to the past could not be compensated for by the new environment. Several people who had moved from inner cities missed the convenience of stores and shopping within reach. One participant commented, "I miss my friends in town. They can't get here, and I can't get there."
Many participants agreed they had made new friends and felt "like a family" in their new location. "We watch out for each other, and I try to hold the elevator for those who need more time," said one man.
Several had purchased new furniture and had taken this moving opportunity to "downsize" their possessions and share with others. One woman who gave a lot of possessions to her granddaughter said, "Now when I go to her home, I enjoy seeing my things in use." She also shared that in anticipation of the move, she bought an armoire she had always dreamed of owning.
Independence Versus Dependence
Participants' struggles with desired independence and necessary dependence also proved difficult, and the theme of independence versus dependence emerged as many participants reflected on becoming increasingly dependent on others. They realized that while this transition involved giving up some of their independence such as driving and cooking, they were able to make their own decisions concerning participating in the activities that were offered, as well as selecting from a menu at mealtime. Although participants appreciated services offered, they admitted at times it was difficult to depend on employees of the institution.
Independence was found by the choices residents made to attend social activities, monthly resident meetings, individual exercise programs, church services, guest speakers from museums, and trips off grounds. These choices were selected with more regularity by some than by others.
Affection Versus Disdain
Residents varied in their responses concerning living with others. For some, the transition to the assisted living faculty was positive as they welcomed more social interaction and developed affectionate relationships with other residents. One participant stated:
The help here is all very concerned for you and the people, the residents. If anyone hurts, the rest of the people feel it too.
For others, the social transition was difficult either because they were used to being alone or because they found it hard to be around others who were experiencing dementia. One woman commented:
There are a lot of people around here whose minds are not very good; they don't belong in assisted living anymore. At the dinner table, they don't mind their manners. One lady uses the tablecloth to wipe her nose.
Adjustment Versus Maladjustment
All of the participants recognized that it takes time to adjust to a new environment, but the length of time varied from individual to individual. For some, the adjustment period was as short as a week; for others, the adjustment continued for months. When talking about the adjustment time, one participant stated:
It is a matter of attitude. If you decide that it is an adventure, the next stage in life, then you accept it and go on from there.
Some felt the adjustment was eased by waiting to sell their homes. There was comfort in knowing they could return if things didn't work out. In reality, however, none had tried to go back home once they had moved into the assisted living facility.
Several participants stated it was difficult to return to paying rent after many years of home ownership. Although they didn't miss the upkeep and repairs, it seemed so expensive to make monthly payments. They also found it difficult to adjust to paying for individual services such as medication distribution, assistance with personal hygiene, and bandage changing.
The experience of transition for elderly individuals moving from their private home to an assisted living facility was unfolded through the five recurring themes. The basic elements of these themes correlate with the fundamental principles of assisted living. The self-motivation versus familial encouragement theme correlates to safety and security because the move arose from the conclusion reached by either the individuals themselves or their family that the home environment was no longer safe.
The theme of ties to the past versus starting anew coincides with personalization. Assisted living facilities encourage personal and unique environments that allow residents to furnish their rooms as they choose and entertain guests for social events and meals.
The independence versus dependence theme speaks to the principles of control, choice, autonomy, and social interaction. The elderly individuals in this study had choices about participating in scheduled activities and monthly governance meetings. Social activities provided interaction on various levels and were optional.
The theme of affection versus disdain addresses the principles of social interaction and privacy. Social interaction was seen in bingo games, meals, and organized events. Privacy was maintained by the opportunity to stay in one's room and perform independent activities.
The theme of adjustment versus maladjustment correlates to the principle of adaptability. This was seen in the data as an attempt to be flexible in meeting the needs of a diverse population.
The findings, therefore, bring to light the principles that assisted living facilities purport to address. Rutman and Friedman (1998) suggested the meaning of home to older adults included "comfort, familiarity, security, and independence." Home for participants in this study was expressed as a place where there was some control and the opportunity to express one's individuality through arranging of personal objects and choices within the daily schedule. In this study, as reported by Rutman and Friedman (1998), participants defined home as a place to entertain and socialize with family and friends.
This study revealed a beginning understanding of the experience of moving from a private home to an assisted living facility. The participants suggested numerous ideas to improve their transition and ease their adjustment into their new environment. In the area of self-motivated relocation, nurses need to be mindful that most individuals in this study did not feel they had a "free choice." Most were highly encouraged by family (particularly daughters), and several waited until physical events made it no longer possible to live in their previous homes.
Ties to the past were assisted when help was given with selecting the appropriate furniture to bring, residents were brought to the facility first for a visit, and in the possible selection of room location. Individuals who were given the option to stay a few days before making a commitment to the move were positive about that option.
After transitioning was complete, even visiting the previous home reassured some residents the right decision had been made to move to the assisted living facility. The groups enjoyed reminiscence, which nurses might use in linking the past to present hopes and dreams. The sharing of previous memories seemed to recapture what Davidhizar and Shearer (1999) labeled "previous strengths and feelings of self-worth which help put all of life in perspective" (p. 148).
As Sikorska (1999) found in studying determinants of resident satisfaction in assisted living facilities, these participants valued personal space and physical amenities. Small refrigerators allowed for some foods in the room, parking facilities were important to those still driving, and locked doors on the apartments attributed to the feeling of residents' independence.
In addition, monthly meetings held between staff and residents allowed residents to voice their concerns, needs, and desires. Some felt this governance structure was only a "token," while others felt it was somewhat effective. Availability of buses to go to the mall and arranged transportation to appointments were also big pluses to group living. Nurses should allow autonomy and client choice about how things are conducted to foster control over the environment and feelings of independence.
Affection was fostered in groups that had similar interests. Some potential participants agreed to meet if a certain person was also in the group, while others preferred not to join groups with certain participants. Several people refused interviews during favorite activities such as bingo and cards. One group was cohesive and felt free to tease each other and use nicknames. According to Davidhizar and Shearer (1999), clients who develop satisfying and enjoyable relationships are better able to cope with changes. Nurses can encourage clientto-client bonding and small group interaction to facilitate affection when finding new friends.
This study compels nurses to reflect on the experience of elderly individuals moving to assisted living faculties. The participants in this study collectively concluded that nurses can make a difference in the adjustment to a new living environment. Adjustment relates to the overall period of transition. Nurses should recognize this varies for each individual and is possibly dependent on family support as well as personal attitude. The adjustment to all of life's events seemed to radiate in the adjustment to this move in living location. Talking with clients about the meaning of the changes will facilitate any grief work accompanying the move and assist in the adjustment to the loss that moving has caused in their lives.
Using Roy's Adaptation Model (1999), nurses can assess residents' adjustment or adaptation. Examination of focal stimuli (immediate cause), contextual stimuli (other related causes), and residual stimuli (possible causes) can provide nurses with clues about how to promote and reinforce adaptation. Based on multiple personal and environmental factors, elderly individuals will move to the resolution phase (Moos & Schaefer, 1986) of the process of coping with the transition.
This study was limited to three assisted living facilities in northern New Jersey. It described the meaning of moving from a private home to an assisted living facility as experienced by 28 participants older than age 68. This study is, by its nature, nonrepeatable; however, all field notes, tape recordings, and verbatim transcripts were kept for inspection of procedures, protocols, and decisions.
The use of group interviews allowed individual attitudes and beliefs to evolve rather than to form in a vacuum. Listening to others' opinions may help individuals to understand and articulate their own feelings. In addition, this method was socially oriented and allowed participants to remain in their own environment rather than being exposed to a one-on-one interview. The facilitators were able to explore unanticipated issues as they arose, leading to increased face validity. Another advantage to group interviews was the decreased time needed, quick results, and increased sample size.
The disadvantages of group interviews included less control over the group discussion and sometimes the introduction of irrelevant issues. Data also were more difficult to transcribe and analyze because of the complex context of the group. Logistical problems also arose with occasional nonmembers attempting to join and noise distraction caused by the location of the groups.
Future research of this nature might look at the long-term effects of adjustment to an assisted living facility and the multiple factors in adapting. The "fit" between older adults and different long-term environments and their effect on outcomes need to be examined. Such research might alter funding and placement of older individuals and change policies related to Medicaid payment for assisted living.
Assisted living currently occupies an important niche in the continuum of care between total independence in one's home and full dependence and around-the-clock nursing care. Enabling frail elderly individuals to stay in the community regardless of income could actually decrease health-related costs and improve quality of living.
Another avenue of investigation that could prove fruitful would be to research the impact that living with individuals with dementia has on higher functioning residents. Several residents in this study mentioned their disdain for residents whose minds were "not very good." As residents age in place in assisted living, more of them will develop dementia. If the facility has no dementia unit, these residents will continue to live among the higher functioning residents, perhaps reducing the life satisfaction or quality of life for those with normal cognition.
Although the findings of this study are not generalizable, it goes beyond the established framework to challenge old ways of thinking. The five themes can assist residents to develop adapting strategies for positive transitional experiences. By better understanding the experience, gerontological nurses and assisted living administrators can take active roles in facilitating the transition of elderly individuals into assisted living facilities and making the facility feel like home.
This study provides a framework for a new vision of residents in assisted living communities in much the same way the general population regards exercise: for some, they are obligated to move; for others, moving is an opportunity to realize "a little bit of heaven." As with other research in transitional living, this study confirms that attitude is a major contributor to adjustment.
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CHARACTERISTICS OF STUDY PARTICIPANTS (N = 28)