Responses of nursing home residents to intrainstitutional relocation

Responses of Nursing Home Residents t o Intrainstitutional Relocation Relocation may be especially stressful for the geriatric patient. BY SALLY K E N N E D Y H O L Z A P F E L / C t t E R Y L JALANNE B. DODMAN/MARY McGowAN

POWLEY GRANT

early 30% of Americans 65 years of age or older will change their residences every 5 years) Such frequent relocation is often unavoidable as a result of loss of family members and support systems, as well as changes in both health and financial status. This is a reality of life for the elderly that will continue to increase in frequency in the future?, 3 Use of various housing options for the elderly, such as age-congregate complexes, r e t i r e m e n t centers, and nursing homes, has increased in the past 20 years. The increased longevity of older adults has led to growing numbers being cared for in long-term-care settings. 4 There is a 63% probability of some period of institutionalization after age 65 years. I Relocation is a potentially stressful event in anyone's life. 5 The stress response is a combination of behaviors associated with a perceived threat to personal well-being. The threat, a stressor, may be environmental, physiologic, or psychologic in origin. 6 According to Maddox, l relocation, as a stressor, can be a positive, negative, or neutral event, depending on an individual's particular needs and circumstances. A new environment is particularly stressful for the aged. 7 We were particularly interested in the responses of nursing home residents to intrainstitutional relocation.

N

SALLY KENNEDY HOLZAPFEL, MSN, RN, CS, is a gerontological clinical nurse specialist at the Department of Veterans Affairs Medical Center, Lyons, New Jersey; CHERYL POWLEY SCHOCH, MSN, RN, C, is an adult nurse practitioner at the Department of Veterans Affairs Medical Center, Lyons, New Jersey; JALANNE B. DODMAN, BSN, RN, is administrative assistant to the chief of staff, Department of Veterans Affairs Medical Center, Lyons, New Jersey; and MARY McGOWAN GRANT, MA, RN, was associate chief Nursing Service/Nursing Home Care Unit, Department of Veterans Affairs Medical Center, Lyons, New Jersey, during the research study. She is currently psychiatric clinical nurse specialist, Department of Veterans Affairs Medical Center, Huntington, West Virginia. 34/1/38192

192 Geriatric Nursing July/August1992

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Assuming that such an event could be viewed as a potential stressor, we conducted an exploratory, descriptive study designed to discern the cognitive, behavioral, and physiologic responses of residents who had been relocated within an institution. Because intrainstitutional relocation may occur several times in the life of a nursing home resident, relocation responses are important to identify and understand to design appropriate nursing interventions. Method Sample. This study was conducted in a 900-bed medical center in the northeastern United States. A total of 50 residents, relocated from an old wing of the facility to a new building in a l-day move, were included in the study. Although 90 residents were relocated, many of this total group could not participate because of the onset of acute illness, changes in medication regimen, or death. All the residents were men between the ages of 40 and 96 years, with a mean age of 68 years. Only residents with stable medical conditions and unchanged medication regimens were included in this study. Procedure. Several investigators 2,8q6 have examined relations among relocation and individuals' physiologic status, cognitive abilities, and emotional states. Although their findings are inconsistent in terms of morbidity and

AGE GROUPING OF RESIDENTS Age Group(yr)

n

40-64 65.85 86-96

14 17 18

mortality associated with relocation, the results signify the large degree of individual variation that exists in response to relocation. Because the present study was descriptive and nonexperimental in design, selected physiologic variables (i.e., blood pressure, pulse, and respiration), anxiety, and cognitive performance were examined in participating residents 2 months before relocation, 2 weeks after relocation, and 6 weeks after relocation for follow-up. We were interested in describing changes, if any, that developed in these three diverse sets of variables in relation to relocation. Instruments The variables were operationally defined as follows. Respiration, blood pressure, and pulse were the physiologic variables studied in this research. The use of these physiologic variables parallels the m e t h o d used by Mirotznik and Ruskin 2 in their study of long-term care residents. An idiosyncratic respiratory baseline was calculated for each resident by obtaining the subject's mean respiratory rate before the move. The respiratory intensity score was the total amount by which each resident's respirations exceeded the initial baseline mean. The respiratory frequency score was the number of times the subject's respirations exceeded the initial baseline mean. Blood pressure, the second physiologic v a r i a b l e studied, was measured with an automatic blood pressure device. An idiosyncratic baseline was calculated for each resident's systolic and diastolic blood pressure by obtaining the resident's premove means. Diastolic and systolic frequency and intensity scores were used for the findings and were calculated in a manner similar to the respiratory frequency and intensity scores. Pulse frequency and intensity scores were calculated in a manner similar to the respiratory scores. The pulse was obtained by using the automatic blood pressure device to ensure consistency of recordings.

EFFECTS OF RELOCATION A N D A G E O N SYSTOLIC A N D DIASTOLIC VARIABLES Source of Variance Systolic Intensity Relocation Relocation and age Systolic frequency Relocation Relocation and age Diastolic intensity RelOcation :Relocation and age Diastolic frequency Relocation Relocation and age R~emu,~ *p < o ~

F Ratio

Significance

! .53 O.51

0.222 0,729

0.21 1~03

O.810 0.398

12.89 5.22

0.001 * 0.001"

! O.73 1.:56

O.001 * 0.191

Each physiologic variable was measured on seven consecutive days 2 months before the move, then on seven consecutive days 2 weeks after the move, and finally on seven consecutive days 6 weeks after relocation for the follow-up. Anxiety was studied with the State Trait Anxiety Inventory (STAI Y-I). ]7 The alpha reliability coefficients for the inventory's scales are high, with a median coefficient of 0.90. The alpha reliability coefficients for the state-anxiety and trait-anxiety scales for form Y in the normative samples were 0.92 and 0.90, respectively. Cognitive performance was measured with the MiniMental State ( M M S ) examination. ]8 Concurrent validation of this instrument was obtained by correlation of MMS scores with the verbal and performance scores of the Wechsler Adult Intelligence Scale. For the M M S versus the verbal IQ, a Pearson reliability coefficient of 0.776 (p < 0.001) was obtained; for M M S versus performance IQ, a reliability coefficient of 0.660 (p < 0.001) was obtained. Reliability was also established by means of test-retest methods (r = 0.887). Both the STAI Y-I and the MMS cognitive and anxiety variables were measured 2 months before the move, 2 weeks after the move, and finally at 6 weeks for the follow-up. The data were collected by the four researchers, all of whom had been trained in the data collection methods. Findings

Analysis of variance with a significance level of 0.05 was used to investigate the relation between the three sets of variables both before and after relocation. Several significant findings were noted in the data as follows: (1) diastolic intensity over time (F = 12.89, p = 0.001); (2) diastolic frequency over time ( F = 10.73, p = 0.001); (3) pulse intensity over time ( F = 3.06, p = 0.052); (4) pulse frequency over time ( F = 6.90, p = 0.002); and (5) MMS over time ( F = 4.06, p = 0.020). Scores on the M M S measurement changed significantly from before reloca-

EFFECTS OF R E L O C A T I O N AGE O N PULSE A N D RESPIRATION Source of Variance Pulse intensity Relocation Relocation and age Pulse hequency Relocation Relocation and age Respiration intensity Relocation Relocation and age Respiration frequency Relocation Relocation and age

F Ratio

Significance

3.O6 0.89

0.052* 0.474

6.90 1.76

0.002* 0.145

3.58 0.04

0.032* 0.998

7.59 0.66

0.001" 0.622

ano/ys/sof ~=nce. *P < 0.0£

Geriatric Nursing July/August1992

193

EFFECTS OF RELOCATION A N D AGE O N M M S A N D STAI RESULTS Source of Variance

F Ratio

Significance

4,06 2.23

0.020* 0.072

0.28 0.25

(Z755 0.908

MMS

Relocation R~|ocafion and age STAI Relocation Relocation and age

Repeated-measuresmm/ys/s at ~ r / ~ . *P ~ 0.05.

tion to 2 weeks after relocation (T = -2.12, p = 0.010) and also from before relocation to 6 weeks follow-up (T = -2.12, p = 0.048). There was no significant relation between STAI scores before and after relocation. Discussion The relocated residents demonstrated alterations in some of the variables studied: significant physiologic responses were associated with relocation, as noted in several variables. Both diastolic frequency and intensity had significant changes from before to after relocation. Diastolic frequency decreased between before and 2 weeks after relocation, but subsequently increased at the 6 weeks' follow-up. Diastolic intensity increased from before relocation to 2 weeks after relocation, but then decreased at 6 weeks' follow-up. Diastolic blood pressure has been found to be a sensitive indicator associated with relocation response for individuals with a family history of hypertension. 19, 20 The physiologic measures, however, may not be the most reliable indexes in determining response to relocation. Multiple influences on blood pressure, pulse, and respiration were not accounted for in this study and are difficult to control, such as time elapsed since eating, drinking, smoking, exercise, and interactions with staff, other patients, and family, either positive or negative, to identify just a few. Cognitive responses improved between the two measurements after relocation, suggesting that the relocation had a positive effect on the cognitive abilities of the residents. This finding is consistent with theories of learning that state a degree of anxiety is necessary for learning to take place. We postulate that the residents' level of anxiety, before the move and at 2 weeks after relocation, remained relatively stable. This level may have been too low to improve their cognition or too high to allow them to focus on things or persons other than themselves, including responding to "test" questions. Once the residents were actually moved, they were inspired to explore their new environment, to validate what had been discussed with them before the move, and to interact with new residents and staff. This stimulation carried over to their test responses, which improved. The results of this

194 Geriatric Nursing July/August 1992

variable would indicate that stress had a positive effect and enhanced the residents' transition and acceptance. Relocation and subsequent adaptation is a necessity of life. The cycle of transition and growth toward higher complexity continues throughout the lifespan. M a n y transitions are marked by "rites of passage," that is, birth, baptism, communion, bar mitzvah, graduation, wedding, anniversaries, job change and relocation, and retirement. Although society tends to believe that the older adult's interest in participating in these rites diminishes with age, it must be remembered that even the aging individual would like to remain involved. Advancing age is not a barrier to the individual's willingness and capacity to learn and adapt, to enjoy and participate. During relocation, the care providers in the study encouraged the residents to view the relocation as a positive step. They appealed to the residents' inner strengths and coping skills and nurtured their capacity for growth. Personhood, not patienthood, was emphasized.

The greater the number of choices the residents had, the more predictable the new environment became. Counseling, orientation, and participation were techniques used to prepare the residents for the move. Site visits, group meetings, and discussions with families and staff before relocation were also used. Other strategies included videos of the new structure and bulletin boards with photos, site, and room layouts. Although all the residents were scheduled to be moved, they had the option of not moving to the new facility but instead to another unit in the main building. They were encouraged to indicate their choice of rooms and roommates, all of whom had to agree jointly on the location of their room; the residents' families frequently participated with them in this process. The opportunities for selection provided the residents with increased autonomy and stimulation. Summary Relocation effects may be positive when residents are prepared for the move. 9, 21 The degree to which they exercise control over their environment and participate in the decision-making process influences the outcome of relocation)2, 22 Planned interventions may offset adverse effects of stress. Prerelocation involvement of the residents we observed in visiting the new facility, and in selecting their bedrooms and roommates, reduced their anxiety to an acceptable, even positive level. These choices had a direct impact on their quality of life. The greater the number of choices the residents bad, the more predictable the new environment became. Any stress generated became a positive, rather than a negative, force. •

We acknowledge Arcola J. Perry, MSN, RN, chief, Nursing Service, Frances Quinless, RN, PhD, and Richard Mercer, MA, for their support and assistance. We also thank the staff and residents of the nursing home care unit.

REFERENCES !. Maddox G, ed. The encyclopedia of aging. New York: Springer, 1987. 2. Mirotznik J, Ruskin A. Inter-institutional relocation and its effects on health. Gerontology 1984;24:286-91. 3. Liebowitz B. Impact of intra-institutional relocation. Gerontology 1974;14:293-4. 4. Burnette K. Relocation and the elderly. Gerontol Nurs 1986;12:6-11. 5. Rosswurm M. Relocation and the elderly. Gerontol Nuts 1983;9:632-7. 6. Seyle H. The stress of life. New York: McGraw-Hill, 1978:55-95. 7. Mikhail M. Psychological responses to relocation to a nursing home. Gerontol Nurs 1992;18:35-9. 8. Borup J. The effects of varying degrees of inter-institutional environmental changes on long-term care patients. Gerontology 1982;22:407-17. 9. Kowalski N. Institutional relocation: current programs and applied approaches. Gerontology 1981;21:512-7. 10. Bourestom N, Pastalan L. The effects of relocation on the elderly: a reply to Borup JH, Gallego DT, and tt¢ffernan PG. Gerontology 1981;21:4-7.

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I I. Borup JH, Gallego DT, Heffernaa PG. Relocation and its effect on health, functioning and mortality. Gerontology 1980;20:468-79. 12. Pablo R. Intra-institutional relocation: its impact on long-term care patients. Gerontology 1977;17:426-35. 13. Thomasma M, Yeaworth R, McCabe B. Moving day: relocation and anxiety in institutionalized elderly. Gerontol Nuts 1990;16:18-24. 14. Engle V. Mental status and functional health four days following relocation to a nursing home. Res Nurs Health 1985;8:355-61. ! 5. Engle V. Temporary relocation: is it stressful to )'our patients? Gerontol Nurs 1985;I 1:28-31. 16. Mirotznik J, Ruskin A. Inter-institutional relocation and its effects on psychosocial status. Gerontology ! 985;25:265-70. 17. Spielburger C. Manual for the State Trait Anxiety Inventory. Palo Alto, California: Consulting Psychologist Press, 1983:1-29. 18. Folstein M, Fostein S, Mettugh P. Mini-mental state: a practical method for grading the cognitive state of patients for the clinician. Psychiatry 1975;12:189-98. 19. Jorgensen R, Houston B. Reporting of life events, family history of hypertension, and cardiovascular activity at rest and during psychological stress. Biol Psychol 1989;28:135-48. 20. Claytor R, Cox R, Howley E, Lawler K, Lawler J. Aerobic power and cardiovascular response to stress. Applied Physiol 1988;65:1416-23. 21. Petrou M, Obenchain J. Reducing incidents of illness posttransfer. GEalmR Nuns 1987;8:264-6. 22. Coffman T. Toward an understanding of geriatric relocation. Gerontology 1983;21:453-9.

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