- Email: [email protected]
Frail Older Persons' Experiences of Interinstitutional Relocation
FEATURE ARTICLE Frail Older Persons’ Experiences of Interinstitutional Relocation Hanna Falk, PhD, RN Helle Wijk, PhD, RN Lars-Olof Persson, PhD
This study examined the effects and experiences of an interinstitutional relocation on older persons’ quality of life, wellbeing, and perceived person-centeredness. A pre-test/ post-test mixed method design, with an equivalent reference group, was used to examine relationships between variables and to explore personal meaning. Results indicate a significantly larger deterioration in perceived person centeredness among those cognitively intact residents that moved compared to the nonmovers. Interviews with moving residents revealed that the relocation was experienced as uncontrollable, un-affectable, and uncertain. However, no significant relocation effects were found from the proxy ratings of the cognitively impaired residents. Nursing interventions that involve, inform, and prepare older persons prior to interinstitutional relocation to enhance their sense of control of the move might minimize adverse relocation effects. Further research is needed on the effects of interinstitutional relocations, which procedures that should be used, as well as effects of preparatory interventions. (Geriatr Nurs 2011;32:245-256)
Background pproximately 50% of all facilities housing older people in Sweden comply with the international definition of assisted living, emphasizing social model values that uphold choice, dignity, accessibility, security, and the ability to age in place.1,2 Compared with many other countries, the living standards in Sweden are high.3 During the past 60 years, there has also been a continuous upgrading of housing standards, based on the premise that residential care facilities are homes rather than institutions,4 and approximately 50% of all residential care facilities in Sweden now offer residents single rooms with a kitchenette and private bathroom.5 However, creating supportive psychosocial environments
A
Geriatric Nursing, Volume 32, Number 4
in accordance with a therapeutic design usually necessitates further upgrading or the construction of new facilities. Due to extensive reconstruction, residents of such facilities must temporarily relocate to new environments.6 One way to solve this problem is to use provisional transit facilities during the reconstruction period, and once completed, the residents return to their own facility. Interinstitutional relocation can be defined as the movement from one institution to another.7 Although such relocations might be expected to have negative effects on residents, more specific and consistent knowledge is needed.8,9 There are several studies on peoples’ responses to both voluntary and involuntary change.10 Researchers have noted that stability for those living in institutions correlates positively with their level of trust toward the institutional authorities.11 Others12 argue that relocations from inferior to superior living conditions ultimately have positive effects on older residents’ well-being. However, it has been concluded that when change is forced or imposed, the opportunity for innovation combined with restriction, rather than promotion of one’s personal autonomy and right of expression, is the result.13 A frequently studied outcome measure of forced relocation is mortality rates. Some research has found no change in mortality among older persons after relocation,14-17 whereas more recent studies show a 50% increase in mortality within the first 3 months following transfer.18,19 It has also been shown that relocation disrupts unit routines and social relations among residents, which may cause increased confusion and depression in those with dementia,7,20 One study21 found that relocated residents showed significant differences in salivary cortisol and mood 1 week after an immediate and permanent move to a new nursing home, followed by a significant decline in cortisol 4 weeks after the move. This suggests that the stress imposed by relocation is time limited when the move is to an upgraded or better facility. Other research showed few or no adverse effects
245
on older persons with dementia when residents and staff moved as a unit.22 Despite disparities in the findings, most agree that institutional relocation is a major life change and, consequently, a stressful event.21 Using a nursing perspective, research focusing on adjustment difficulties in relation to relocation suggests that adverse effects could be minimized by preparation and the early involvement of residents.18,23 Supporting the older persons to recognize legitimate reasons for relocating, as well as playing an active role in the decision making surrounding the move, have been shown to be important. Nursing interventions that focus on anxiety and stress reduction, such as anticipatory guidance and coping enhancement, have been associated with successful relocation of older persons.7,19,24,25 Research has also shown the more options residents are given to choose from, the less negative are the effects of relocation,8,26 which raises the question of whether adverse relocation effects might be determined more by the nature of the relocation in terms of execution rather that the act itself. Person-centered nursing is today widely considered to be an essential element of effective care of frail older persons.27 It can be defined as shared decision making and visions for practice that incorporate how residents make sense of what is happening regardless of cognitive ability and acknowledges that the older person should be the focus of care, not the illness or disease.28 No previous research on the effects and experiences of forced relocation to provisional transit facilities has been found in the existing literature. In addition, there are no national guidelines on how adverse relocation effects might be avoided in Sweden29 and no national statistics on how many frail older persons who, because of various types of reconstruction, are interinstitutionally relocated to provisional transit facilities each year.5 This study arose as the result of an opportunity for the authors to follow a naturally occurring event when the municipal government and facility administrators decided to reconstruct 2 residential facilities in Gothenburg, Sweden. The extent of the reconstruction required that the residents were interinstitutionally relocated to a provisional transit facility approximately 7 miles from their home facility for a period of 1 year. The aim of this study was to examine the effects of that relocation on the residents quality of life, well-being, and perceived person-centeredness, 246
as well as to describe their experiences in relation to the relocation.
Methods Design Both to examine relationships between variables and to explore the personal meaning ascribed to the relocation in a single study, a simultaneous, explanatory, mixed-method design was used.30-32 The quantitative measures assessed the residents’ quality of life, well-being, and perceived person-centeredness before and after the temporary relocation, and semistructured interviews with cognitively intact residents were conducted to capture their experiences after the move to the transit facility. Setting and Sample One-hundred and fifty-five residents participated in the study at baseline, of whom 74 were interinstitutionally relocated (designated hereafter as movers) and 81 served as an equivalent reference group (designated as nonmovers). All participants gave their informed consent, either independently or through next of kin. Before the move, the residents lived in 1 of 2 residential care facilities in the central part of the city. Both were originally built in the 1970s with a traditional institutional design including long hallways, dualand single-occupancy bedrooms, shared bathrooms, prominently located nursing stations, and a large open area for activities and meals. The equivalent reference group (nonmovers) lived in a third facility in the central part of the city, which was partially rebuilt in 2001, using a more intentionally therapeutic design that allowed residents to personalize their living spaces and enhance the domestic ambience. There were no significant differences in demographic data between the groups at baseline. However, at baseline, the nonmovers had significantly more symptomatic treatment for mild to moderate Alzheimer’s (cholinesterase inhibitors) than the movers (P 5 .02). At follow-up, 128 (83%) residents were still participating (57 [77%] movers; 71 [88%] nonmovers). Figure 1 illustrates the initial and internal dropout in the study. Relocation The move from the original to the temporary facility was accomplished in 1 day. At both Geriatric Nursing, Volume 32, Number 4
Figure 1. Flow chart illustrating the initial and internal dropout for the study. facilities, the nursing staff and the residents moved as a unit. Residents and family members were notified about the approaching reconstruction and relocation approximately 3 months before the scheduled moving date. No other preparation of the residents or their relatives was undertaken beyond giving this verbal information because it was believed that further action would disturb the daily routines at the facility, which could upset residents and make them more anxious. The nursing staff visited the transit facility before the scheduled moving date to prepare the spatial arrangements. About 2 weeks before the scheduled moving date, personal belongings such as large items of furniture were stored in a warehouse because of the limited space at the transit facility. Approximately 2 weeks before the scheduled moving date, shared spaces such as hallways, living areas, and dining areas where emptied, and about 3 days before the scheduled moving date, smaller personal items belonging to the residents were packed by the nursing staff and sent to the transit facility. Rooms Geriatric Nursing, Volume 32, Number 4
were assigned to the residents upon arrival at the transit facility. Instruments The Person-Centered Climate Questionnaire (PCQ) is a self-report instrument designed for use in evaluating the extent to which a climate (i.e., physical and psychosocial environment) is perceived as being person-centered (i.e., supporting the older person by placing his or her needs and expectations at the center of care). The instrument comprises 3 related domains; safety (10 items), everydayness (4 items), and generosity (3 items). The items are rated on a 7-step scale, ranging from “I disagree completely” to “I agree completely.” The questionnaire is sum scored, and scores can range between 17 and 119, with higher scores indicating a more person-centered climate.33 In our study, the Cronbach alpha coefficient for the total score was .9. The Quality of Life in Late-Stage Dementia Scale (QUALID) is a domain-specific, brief, proxy-based instrument with a 1-week recall period.34,35 The scale 247
comprises 11 items with both positive and negative dimensions of concrete and observable mood and performance, thought to be indicative of quality of life in late-stage dementia. The items are rated as to frequency of occurrence on a 5-step scale, and scores are summed to range from 11 (best quality of life) to 55 (worst quality of life). The instrument is administered in a structured interview format, and the average time of administration is 5 minutes. The proxy informants need to be well acquainted with the person with dementia and to have spent a significant amount of time with the person during the week before the QUALID assessment. In this study, the Cronbach alpha coefficient for the 11 items was .73. The Patient Mood Assessment Scale (PMAS) and the General Behavior Assessment Scale (GBAS) are 2 proxy-based instruments constructed to assess mood and psychosocial behavior among older people.36 The proxy informant needs to be well acquainted with the older person and to have spent a significant amount of time with him or her the week before the assessments. The PMAS comprises 3 related domains: strength (4 items), satisfaction (3 items), and security (3 items). Scores range from 5 to 50 points, with higher values indicating poorer well-being. The GBAS comprises 2 related domains: confidence (4 items) and accessibility (4 items). Scores range from 5 to 40 points, with higher values indicating poorer well-being. Total scores summarizing the domains may also be calculated for both scales. In this study, the Cronbach alpha coefficient for the total score in the PMAS was .87 and in the GBAS .84. Procedure The data collection period ranged from March 2008 to October 2009. Information about residents’ age, length of residence at the residential care facility, psychotropic drug treatment, and dementia diagnosis was gathered from medical records. To adapt the collection procedure to the cognitive ability of the residents (i.e., proxy assessment/ self-report), an initial assessment using a standardized cognitive test, the Mini-Mental State Examination (MMSE),37 divided all residents into 1 of 2 subgroups according to cognitive functioning,38 dichotomized as #20 points (low functioning) and $21 points (high functioning). Among the movers, 62 residents (84%) were assessed as low functioning. Among the nonmovers, 55 residents (68%) were assessed as low functioning. Baseline data 248
were collected 4 weeks before the scheduled moving date and follow-up data 6 months after relocation. Data were collected at corresponding times among the nonmovers (i.e., a gap of 7 months between collections 1 and 2). Low-functioning residents were proxy-assessed using QUALID, GBAS, and PMAS by their personal contact person (CP), that is, a designated nursing staff member with extensive knowledge about the resident. Highfunctioning residents provided self-report assessments using PCQ in a face-to-face interview format. To obtain a joint assessment of both lowfunctioning and high-functioning residents, highfunctioning residents were also proxy-assessed by the nursing staff using PMAS and the GBAS. Approximately 10-12 weeks after the relocation, all high-functioning residents (n 5 12) among those who moved were asked to describe spontaneously their experiences of the interinstitutional relocation. The opening question for each interview was, “Can you tell me about the move?” Interviews lasted between 15-60 minutes and were conducted in the private room of the resident at the transit facility. In cases in which rooms were shared with another resident, the interview was held in a secluded part of the unit. Interviews were digitally recorded and transcribed verbatim. Statistical Analyses The characteristics of the residents were analyzed descriptively. Internal consistency was calculated using Cronbach alpha.39 Differences between groups at baseline were tested with independent samples t tests for continuous variables and chi-square for frequency data. Two-way repeated-measures analysis of variance was used to identify differences in changed scores within groups and between groups over time. The SPSS statistical software package (version 17.0; SPSS, Chicago, IL) was used for all statistical analyses. Statistical significances were set at .05 (2-tailed) for all analyses. Qualitative Content Analysis The interviews were subjected to qualitative content analysis, aimed at identifying prominent categories and patterns in the text.40 The analysis was made in several steps, starting with reading all the transcribed interviews to gain an overall understanding.41 Meaning units that were relevant to the research question were Geriatric Nursing, Volume 32, Number 4
then identified and shortened, preserving their core. The condensed meaning units were coded into short and immediate descriptions of the experiences related to the relocation. Codes were compared for similarities and differences. To preserve the temporal sequence in the original interviews, codes were categorized into 3 content areas: experiences related to the actual move, experiences related to the daily life at the transit facility, and expectations related to the future and moving back. Within each content area, codes were compared, subcategorized, and categorized, leaving the qualitative content analysis on a descriptive level, thereby maintaining the role of a supplementary strategy in the mixed-method design.42
Results
Ethics
Group Differences over Time
The Regional Ethics Board at the University of Gothenburg (572-06) approved the study.
Differences between groups over time were analyzed using repeated-measures ANOVA. F values
Group Differences at Baseline For most variables, no significant differences were found at baseline between the movers and the nonmovers (Table 1). Table 2 compares mean values in the questionnaire data at baseline. A significant difference between groups was found for PMAS strength (P 5 .039) and security (P 5 .030), GBAS confidence (P 5 .017), and on all scales of the PCQ (P 5 .000). These differences indicate that the movers already tended to have lower levels of well-being and perceived person centeredness before the relocation compared with the nonmovers.
Table 1. Participant Characteristics and Differences Between Groups at Baseline Relocation Group (n 5 74) Female Age (M, SD) MMSE (M, SD) Low-functioning (#21 points) Dementia diagnoses Alzheimer and Parkinson Vascular dementia Nonspecific dementia Psychotropic drugs Antipsychotics Antidepressants Sedatives Cholinesterase inhibitors PCQ total score (M, SD) Safety Everydayness Generosity PMAS total score (M, SD) Strength Satisfaction Security GBAS total score (M, SD) Confidence Accessibility QUALID (M, SD)
Reference Group (n 5 81)
P Values
57 86 10 62
77% (8.5) (9.5) 84%
63 86 11 55
78% 6 10 68%
ns ns ns ns
10 28 12
14% 38% 16%
9 26 27
11% 32% 32%
ns ns ns
10 37 18 7 57.3 34.8 12.1 10.4 25.3 10.7 6.7 2.6 21.6 9.7 11.8 22.5
14% 50% 24% 10% 14.6 9.1 4.8 2.6 7.4 3.6 2.6 2.6 6.5 3.9 4.1 7.2
15 50 24 19 84.2 49.7 19.8 14.8 22.4 9.4 6 7 19.7 8.3 11.4 20.9
19% 62% 30% 24% 10.8 5.3 4.6 2.5 7.8 3.9 2.3 2.8 7 3.5 4.5 6.5
ns ns ns .020 \.000 \.000 .001 .000 .017 .039 ns .030 ns .017 ns ns
GBAS 5 General Behavior Assessment Scale; MMSE 5 Mini-Mental State Examination; PCQ 5 Person-Centered Climate Questionnaire; PMAS 5 Patient Mood Assessment Scale; QUALID 5 Quality of Life in Late-Stage Dementia Scale.
Geriatric Nursing, Volume 32, Number 4
249
Table 2. Means and Standard Deviations for Questionnaire Data Relocation Group
PCQ total score Safety Everydayness Generosity PMAS total score Strength Satisfaction Security GBAS total score Confidence Accessibility QUALID
Reference Group
Baseline M (SD)
Follow-up M (SD)
Baseline M (SD)
Follow-up M (SD)
57.3 (14.6) 34.8 (9.1) 12.1 (4.8) 10.4 (2.6) 25.3 (7.4) 10.7 (3.6) 6.7 (2.6) 8.0 (2.6) 21.6 (6.5) 9.7 (3.9) 11.8 (4.1) 22.5 (7.2)
51.9 (10.8) 32.6 (8.1) 8.1 (3.3) 11.1 (3.1) 26.7 (8.7) 11.2 (4.1) 7.4 (2.6) 8.1 (2.9) 22.3 (6.8) 10.0 (3.8) 12.3 (4.1) 24.4 (8.7)
84.2 (10.8) 49.7 (5.3) 19.8 (4.6) 14.8 (2.5) 22.4 (7.8) 9.4 (3.9) 6.0 (2.3) 7.0 (2.8) 19.7 (7.0) 8.3 (3.5) 11.4 (4.5) 20.9 (6.5)
83.2 (10.9) 49.4 (6.9) 19.6 (3.0) 14.2 (2.8) 23.1 (7.1) 9.8 (3.7) 6.1 (2.2) 7.1 (2.7) 19.7 (6.2) 8.2 (2.9) 11.5 (4.7) 21.6 (6.7)
GBAS 5 General Behavior Assessment Scale; MMSE 5 Mini-Mental State Examination; PCQ 5 Person-Centered Climate Questionnaire; PMAS 5 Patient Mood Assessment Scale; QUALID 5 Quality of Life in Late-Stage Dementia Scale.
and probability values from these analyses are presented in Table 3. No significant effects were found for the QUALID scale. Significant group effects were found for PCQ (total score, safety, everydayness, and hospitality), PMAS (total score, satisfaction, and security), and GBAS (total score and confidence). These results indicate that the movers had significantly lower scores than
the nonmovers in perceived person-centeredness and well-being over the entire assessment period. Significant time effects were found for PCQ (total score and everydayness), suggesting that perceived person-centeredness decreased over time for both groups. Significant interaction effects were only found for PCQ total score and PCQ everydayness. Thus, the movers showed
Table 3. Results of Significance Tests Between Groups over Time (2-Way RepeatedMeasure Analysis of Variance)
PCQ total score Safety Everydayness Hospitality PMAS total score Strength Satisfaction Security GBAS total score Confidence Accessibility QUALID MMSE
Group Effects
Time Effects
Interaction Effects (Group 3 Time)
F 5 33.435; P \ .000 F 5 30.511; P \ .000 F 5 28.852; P \ .000 F 5 8.242; P 5 .010 F 5 6.585; P 5 .012 F 5 3.864; ns F 5 8.000; P 5 .005 F 5 4.984; P 5 .027 F 5 4.275; P 5 .041 F 5 7.834; P 5 .006 F 5 .941; ns F 5 1.913; ns F 5 .682; ns
F 5 6.907; P 5 .017 F 5 2.620; ns F 5 10.375; P 5 .005 F 5 1.237; ns F 5 1.781; ns F 5 1.730; ns F 5 3.511; ns F 5 .048; ns F 5 .334; ns F 5 .022; ns F 5 .558; ns F 5 1.892; ns F 5 18.038; P 5 .0005
F 5 7.308; P 5 .015 F 5 4.112; ns F 5 9.969; P 5 .005 F 5 .137; ns F 5 .975; ns F 5 .476; ns F 5 2.826; ns F 5 .076; ns F 5 .596; ns F 5 .900; ns F 5 .146; ns F 5 2.837; ns F 5 .000; ns
GBAS 5 General Behavior Assessment Scale; MMSE 5 Mini-Mental State Examination; PCQ 5 Person-Centered Climate Questionnaire; PMAS 5 Patient Mood Assessment Scale; QUALID 5 Quality of Life in Late-Stage Dementia Scale.
250
Geriatric Nursing, Volume 32, Number 4
a significantly greater deterioration of perceived person-centeredness over time than the nonmovers. To test whether differences in cognitive functioning might influence the obtained results, MMSE scores were introduced as a covariate and all analyses based on PMAS and GBAS data were recalculated, because these 2 measures had been used on both high-functioning and lowfunctioning residents. However, this had only a minor effect on the results. Cognitive functioning (MMSE) and mortality were also assessed over time. A significant time effect was obtained suggesting that cognitive functioning tended to decrease over time in both groups (Table 3). Mortality also tended to differ between the movers and the nonmovers (c2 5 3.16; P 5 .08). Between baseline and follow-up, 24% died among
those who moved, and 11% died among the nonmovers (Fig. 1). The Relocation Experience All high-functioning residents who moved (n 5 12) were asked to describe spontaneously their experiences of the interinstitutional relocation. The analysis of the interviews revealed that the relocation experience was described as uncontrollable, unaffectable, and uncertain (Table 4). The content of the categories is presented in the following comprehensive description. The relocation was actuated by reasons beyond the residents’ control. The actual move to the transit facility was described by a minority
Table 4. Examples of the Qualitative Content Analysis Content Area Experiences related to the actual move
Code -
Experiences related to the daily life at the transit facility
-
-
Experiences related to the future and moving back
-
It happened so fast Others packed my private stuff The move was sudden To be unprepared To be left outside Not allowed to decide There is no point in complaining To have no saying You have to accept what is happening This is what you can expect from an institution This is where you await death Nothing is in order The environment is unfamiliar The staff seem unhappy Disappointment Sadness Our days being numbered I don’t care about the move back Looking forward to the move back Hope to live to see the new facilities
Geriatric Nursing, Volume 32, Number 4
Subcategory -
-
-
Category
Being unprepared Feeling insecure Feeling excluded No one cares about your opinion
-
The relocation was experienced as uncontrollable
Feeling indifferent Feeling anxious Feeling abandoned Feeling disappointed
-
The relocation was experienced as un-affectable
Limited time left Here and now Hopefulness
-
The relocation was experienced as uncertain
251
of the residents as well executed. The preparations before the move were described as being carried out by others at a fast pace without the participation of the residents. Information about the purpose and execution of the relocation, as well as about the transit facility, was described as limited and insufficient. Limited participation in the preparations was described to create feelings of exclusion. Having no other option than merely to “follow the course of events” and “having no say” was described to evoke feelings of powerlessness. The daily routines at the transit facility were described as unchanged compared with those in the old facility, leaving the residents indifferent toward their new living environment. Others reported that they found the physical and psychosocial environment in the transit facility institutional, confined, and cold. Although the old nursing staff accompanied the residents to the transit facility, new staff members and altered floor-level routines contributed to feelings of confusion and uncertainty. Residents speculated that a prevailing discontent among the nursing staff seemed to have a negative influence on their work performance. The spatial layout of the transit facility, with long doublesided hospital-like corridors and great distances between units, contributed to feelings of abandonment. Some expressed disappointment in those responsible for the relocation, as well as the Swedish elderly care system in general, longing for the return to the rebuilt facility with high expectations that it would be attractive, spacious, and homelike. However, the awareness of their advanced age, frailty, and of their “days being numbered,” darkened their hopes for the future, and some felt certain that they would not live to experience the rebuilt facility, and that the reconstruction was intended for future residents. Others refused to speculate about their future, taking 1 day at a time, and were reluctant to reflect on their current living environment and the remaining time in the transit facility.
Discussion This naturalistic inquiry (i.e., study of a group in its natural setting) reports on the effects and experiences of an interinstitutional relocation to transit facilities for a period of 12 months because 252
of extensive reconstruction at the home facility. A majority of the participants in this study were cognitively impaired, which represents the general population in residential care facilities in Sweden,1 where it has been estimated that about 50% show cognitive impairment equivalent to dementia disease, subsequently resulting in integrated populations including both cognitively intact and impaired older persons.43 The North American Nursing Diagnosis Association’s24 definition of relocation stress states that dependency, confusion, depression, and withdrawal are associated with relocations, and that these adverse effects need to be recognized and addressed.44,45 In this study, no formal efforts to prevent such effects where made by the facility administrators. The results indicate that residents in the relocation group showed a greater deterioration over time than the reference group concerning perceived personcenteredness (i.e., PCQ total score and PCQ everydayness). This questionnaire was self-rated and only used in the high-functioning groups in the study. It is well acknowledged that the care environment has a major impact on the ope rationalization of person-centered nursing as it either enhances or limits the facilitation of person-centered processes27,28; as such, the theoretical framework underpinning the PCQ questionnaire describes a person-centered environment as consisting of 3 dimensions: a climate of safety, a climate of everydayness, and a climate of hospitality.33,46,47 Our results suggest that the high-functioning residents, who where able to answer the questions in the PCQ, perceived the environment as less person-centered after the relocation, which is supported by the interviews (i.e., relocation was experienced as uncontrollable, uneatable, and uncertain). One might assume that the temporary nature of the environment at the transit facility contributed to its institutional character and that despite attempts to decorate the environment with noninstitutional and everyday objects, such as paintings, flowers, and furniture, the residents described the climate at the transit facility as deserted, confined, and cold compared with that in the old facility. A further finding, possibly indicating an adverse effect of the relocation, was the differences in mortality between the relocating group and the reference group during the assessment period. Twenty-four percent in the relocating group died between baseline Geriatric Nursing, Volume 32, Number 4
and follow-up compared with 11% in the reference group. This difference was close to significant (P 5 0.08). The assessments of the low-functioning residents (PMAS, GBAS, QUALID) did not show any significant group changes over the assessment interval. One might speculate that those most affected in terms of lack of control and dependency as a result of the relocation are those who, before the move, experienced more control and independence at the home facility (i.e., the highfunctioning group), which, in accord with our result, were those who seemed most negatively affected by the relocation. The ability to function independently in residential care is primarily associated with the person’s cognitive and intellectual abilities. A further explanation for the lack of significant changes among the low-functioning residents could be that the nursing staff and the residents moved together, which has been shown to minimize the disruption of daily routines associated with relocations,22 thereby shielding those with cognitive impairment more than those who are cognitively intact. It could also be that the low-functioning group experienced adverse effects in relation to the relocation but that the proxy ratings of their states and behavior were unable to detect them either because of the insensitivity of the instruments or the staff not being skillful enough to detect changes. Probably, proxy ratings of respondents with dementia should be complemented with other measures, such as nutritional status, body mass index, and sleeping behavior. Others have shown that relocated older persons with cognitive impairment had statistically significant weight loss 3 months after relocation.9 In retrospect, such measures would have strengthened our study. Limitations The relocation was not research-driven, and it would have been carried out regardless of our participation. For that reason, we had no influence on the selection of the participants in the study nor the procedure for relocation. In a naturalistic study such as this, is it is difficult to know whether it is the “intervention” or other factors that account for the changes observed. Changes may depend on “natural developments” and other uncontrollable factors, such as progression of illnesses, aging, changes in staff, or simply timing. To control for potential maturation, we tried to Geriatric Nursing, Volume 32, Number 4
select a reference group representing the “natural history” of older people in an equivalent residential care. Experimental intervention/control designs are more efficient for determining the potential effects of an intervention, as well as controlling for potential confounders. Unfortunately, in practice it is difficult to assign older people randomly to experimental and control groups to study the effects of relocation. A further limitation of the study is that we were not able to follow the relocation group when its participants returned to their refurbished home facility. However, it might be possible to assign subjects randomly to groups using various approaches to preparation before relocation, because it is known that preparatory programs are associated with successful relocation.7,9,48 A major problem in the interpretation of the results from this study is that the relocation group already tended to be significantly worse off regarding perceived person-centeredness (self-rated) and well-being (proxy-rated) compared with the reference group at baseline, a difference that was also consistent at follow-up. These group differences may have several explanations. First, they could reflect a true difference between the residents in the relocated facility and the reference group. The reference facility was chosen because all 3 facilities were situated in the center of the city, had the same catchment area, and did not differ regarding basic demographic and clinical variables. The reference facility was, however, relatively new and up-to-date in its design and functionality, whereas the relocated facilities were considerably older and in need of extensive rebuilding and refurbishment. A second explanation could be that baseline data were collected too close to the actual moving day; that is, that the imminent relocation influenced the care climate and resident’s wellbeing even 4 weeks before moving day. A third explanation could be that the nursing staff members’ own attitudes toward the relocation might have influenced their assessments of the residents’ moods and behavior.49 As far as we know, the nursing staff was engaged in, and positive toward, the rebuilding and the relocation. However, some residents interviewed said that they witnessed discontent among the nursing staff about how the relocation was finally accomplished. It is well known that proxy assessments 253
have less validity than self-assessments,50 but in cases of respondents with dementia, there is little alternative to their use. According to a review of the literature assessing the validity of proxy reports, the accuracy of proxy ratings is higher when the information sought is concrete and observable.49,51,52 We used 3 proxy assessment tools in this study: QUALID, PMAS, and GBAS. Of these, the QUALID is the most explicit in its ratings of only concrete and observable behavior, and this questionnaire did not show any significant group effects between the relocated group and the reference group, in contrast to PMAS and GBAS. Thus, it is possible that the significant group effects found for PMAS and GBAS might at least partially reflect the proxy’s own emotions about the relocation. However, this does not explain the significant group effects also found for the PCQ questionnaire, which was self-rated, particularly given that controlling for cognitive impairment (MMSE) did not change the results obtained for PMAS and GBAS. In addition, the Swedish versions of all 3 instruments (QUALID, GBAS, and PMAS) have shown good to excellent interrater reliability.35,36,53 Implications for Practice and Research As suggested elsewhere,54 one might assume that person-centered interventions that support the older person to recognize legitimate reasons for relocating, as well as playing an active role in the decision making surrounding the move, is important. Person-centered nursing is widely considered to be an essential element of effective care of frail older persons. To prepare, inform, and involve older persons before relocation, one must incorporate how the older person makes sense of what is happening, regardless of cognitive ability, which might increase their feelings of being in control, and subsequently reduce feelings of uncertainty and insecurity.55 It has been suggested25 that individuals who believe they are in control of their lives experience lower levels of anxiety and depressive symptoms, regardless of their appraisal of the relocation. However, when planning such preparatory interventions, researchers and nursing home staff members should not forget that they are dealing with very old people. The minority who were cognitively intact nonetheless considered themselves to be old and frail and also had 254
a natural feeling of uncertainty about being alive even for a couple of months irrespective of relocation.
Conclusion Our results suggest that a temporary interinstitutional relocation might have adverse effects on perceived person-centeredness in older people who are cognitively intact. It is experienced as being beyond their control, that the environment at the transit facility is obstructive, and that the future is fraught with uncertainty. However, we could not show any significant relocation effects from the proxy ratings of the cognitively impaired. It could be that these ratings are partially influenced by the proxy’s own emotions about the relocation. The significant differences between groups already found at baseline, might indicate that residents started to worry long before the relocation. Nursing interventions that involve, inform, and prepare older people before interinstitutional relocation to enhance their sense of control and the predictability of the move might minimize adverse relocation effects. There is a need for further research on the impact of relocations on old and cognitively impaired people, the methods that should be used, and the effects of preparatory interventions.
References 1. Swedish Government Official Reports 2008-5. Aging with Dignity in the Care of Elderly. Stockholm: The Government Offices of Sweden; 2008. 2. Why can’t our need for special housing for the elderly be met? Artikelnr: 2004-110-2. Stockholm: The National Board of Housing, Building and Planning; 2003. 3. SOU 2008-13. The Swedish Government Official Report 2009. High Quality Living in Old Age. The Government Offices of Sweden; 2009. 4. Westerlund P. Salutogen design a€r framtidens a€ldreboende. Stockholm: Fortbildning; 2010. 5. Open Comparisons 2009: Swedish Elderly Care. Swedish Association of Local Authorities and Regions, Stockholm, 2009. 6. McFadden SH, Lunsman M. Continuity in the midst of change: behaviors of residents relocated from a nursing home environment to small households. Am J Alzheimers Dis Other Demen 2010;25:51-7. 7. Castle NG. Relocation of the elderly. Med Care Res Rev 2001;58:291-333. 8. Thorson JA, Davis RE. Relocation of the institutionalized aged. J Clin Psychol 2000;56:131-8.
Geriatric Nursing, Volume 32, Number 4
9. Lander SM, Brazill AL, Ladrigan PM. Intrainstitutional relocation. Effects on residents’ behavior and psychosocial functioning. J Gerontol Nurs 1997;23:35-41. 10. Wang M. Profiling retirees in the retirement transition and adjustment process: examining the longitudinal change patterns of retirees’ psychological well-being. J Appl Psychol 2007;92:455-74. 11. Devos T, Spini D, Schwartz SH. Conflicts among human values and trust in institutions. Br J Soc Psychol 2002;41: 481-94. 12. Mirotznik J, Kamp LL. Cognitive status and relocation stress: a test of the vulnerability hypothesis. Gerontologist 2000;40:531-9. 13. Sverdlik N, Oreg S. Personal values and conflicting motivational forces in the context of imposed change. J Personal 2009;77:1437-65. 14. Borup J, Gallego D, Heffernan P. Relocation: its effect on health functioning and mortality. Gerontologist 1980;20: 468-79. 15. Borup J. Relocation process: stress, attitudes, informational network and problems encountered. Gerontologist 1981;21:501-11. 16. Borup J. The effects of varying degrees of interinstitutional environmental change on long-term care patients. Gerontologist 1982;22:409-17. 17. Borup J. Relocation mortality research: assessment, reply, and a need to refocus on the issues. Gerontologist 1983;23:235-42. 18. Laughlin AM. Effects of involuntary inter-institutional relocation on the physical, psychosocial, and cognitive functioning of older individuals. Unpublished doctoral dissertation. University of Nebraska, Lincoln; 2005. 19. Laughlin AM, Parsons M, Kosloski KD, et al. Predictors of mortality following involuntary inter-institutional relocation. Gerontol Nurs 2007;33:20-6. 20. Wimo A, Nelving A, Nelving J, et al. Can changes in ward routines affect the severity of dementia? A controlled prospective study. Int Psychogeriatr 1993;5:169-80. 21. Hodgson N, Freedman VA, Granger DA, et al. Biobehavioral correlates of relocation in the frail elderly: salivary cortisol, affect, and cognitive function. J Am Geriatr Soc 2004;52:1856-62. 22. McAuslane L, Sperlinger D. The effects of relocation on elderly people with dementia and their nursing staff. Int J Geriatr Psychiatry 1994;9:981-4. 23. Farhall J, Trauer T, Newton R, et al. Minimizing adverse effects on patients of involuntary relocation from longstay wards to community residences. Psychiatr Serv 2003;54:1022-7. 24. Johnson M, Bulechek G, Butcher H, et al. (eds.), and North American Nursing Diagnosis Association. NANDA, NOC, and NIC linkages. 2nd ed. St. Louis, MO: Mosby Elsevier; 2006. 25. Keitser KJ. Predictors of self-assessed health, anxiety, and depressive symptoms in nursing home residents at week 1 post relocation. J Ageing Health 2006;18: 722-42. 26. Bekhet AK, Zauszniewski JA, Wykle ML. Milieu change and relocation adjustment in elders. West J Nurs Res 2008;30:113-29. 27. McCormack B, McCance TV. Development of a framework for person-centred nursing. J Adv Nurs 2006;56:472-9.
Geriatric Nursing, Volume 32, Number 4
28. Edvardsson D, Innes A. Measuring person-centred care: a critical comparative review of published tools. Gerontologist 2010;50:834-6. 29. Social Services Act. Ministry of Health and Social Affairs, 2001:453. Available at http://www.regeringen.se. Cited September 1, 2010. 30. Andrew S, Halcom EJ, eds. Mixed methods research for nursing and health sciences. Ames, IA: Wiley-Blackwell; 2009. 31. Creswell JW. Research design: qualitative, quantitative, and mixed method approaches. 3rd ed. Thousand Oaks, CA: Sage; 2009. 32. Morse JM. Principles of mixed methods and multimethod research design. In: Tashakkori A, Teddlie C, eds. Handbook of mixed methods in social and behavioural research. Thousand Oaks, CA: Sage; 2003. p. 189-208. 33. Edvardsson D, Sandman PO, Rasmussen B. Swedish language person-centred climate questionnairedpatient version: construction and psychometric evaluation. J Adv Nurs 2008;63:302-9. 34. Weiner MF, Martin-Cook K, Svetlik DA, et al. The quality of life in late-stage dementia (QUALID) scale. J Am Med Dir Assoc 2000;1:114-6. 35. Falk H, Persson LO, Wijk H. A psychometric evaluation of a Swedish version of the quality of life in late-stage dementia (QUALID) scale. Int Psychogeriatr 2007;19: 1040-50. 36. Edberg AK. Assessment by nurses of mood, general behavior and functional ability in patients with dementia receiving nursing home care. Scand J Caring Sci 2000;14: 52-61. 37. Folstein MF, Folstein S, McHugh PR. Mini-mental-state: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-98. 38. Nirenberg TD. Relocation of institutionalized elderly. J Consult Clin Psychol 1983;15:693-701. 39. Nunnally JC, Bernstein IH. Psychometric theory. 3rd ed. New York: McGraw-Hill; 1994. 40. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achive trustworthiness. Nurse Educ Today 2004;24: 105-12. 41. Kvale S, Brinkmann S. Interviews: learning the craft of qualitative research interviewing. 2nd ed. Thousand Oaks, CA: Sage; 2009. 42. Morse JM, Niehaus L. Combining qualitative and quantitative methods for mixed-method designs. In: Munhall P, ed. Nursing research: a qualitative perspective. 4th ed. London: Jones and Bartlett; 2007. 43. The Swedish Council on Health Technology Assessment (SBU). The Dementias, Stockholm, 2006. 44. Mallick MJ, Whipple TW. Validity of the nursing diagnosis of relocation stress syndrome. Nurs Res 2000;49:97-100. 45. Brugler C, Titus M, Nypaver J. Relocation stress syndrome. J Nurs Admin 1993;23:45-50. 46. Edvardsson D. Therapeutic environments for older adults: constituents and meanings. J Gerontol Nurs 2008; 34:32-40. 47. Edvardsson D. Atmosphere in care settings: towards a broader understanding of the phenomenon. Doctoral dissertation, Ume a University, Ume a, Sweden; 2005.
255
48. Bourestom N, Pastalan L. The effects of relocation on the elderly: a reply to Borup, Gallego, and Heffernan. Gerontologist 1981;21:4-7. 49. Novella JL, Jochum C, Jolly D, et al. Agreement between patients and proxies’ reports of quality of life in Alzheimer’s disease. Qual Life Res 2001;10:443-52. 50. Novella JL, Boyer F, Jochum C, et al. Health status in patients with Alzheimer disease. An investigation of interrater agreement. Quality of Life Research 2006;15:811-9. 51. Bond MJ, Clarks MS. The accuracy of proxy ratings of life-style activities using the Adelaide activities profile. Aging 2000;12:388-92. 52. Rabins PV, Kasper JD. Measuring quality of life in dementia: conceptual and practical issues. Alzheimer Dise Assoc Disord 1997;11:100-4. 53. Falk H, Wijk H, Persson LO. The effects of refurbishment on residents’ quality of life and wellbeing in two Swedish residential care facilities. Health Place 2009;15:687-94. 54. Amenta M, Weiner M, Amenta D. Successful relocation. Geriatr Nurs 1984;Nov/Dec:356-60. 55. Walker CA, Curry LC, Hoqstel MO. Relocation stress syndrome in older adults transitioning
256
from home to a long-term care facility: myth or reality. J Psychosoc Nurs Ment Health Serv 2007;45: 38-45. HANNA FALK, PhD, RN, is a Postdocotral Research fellow at the Institute of Health and Care Sciences at Sahlgrenska Academy (GPCC), University of Gothenburg, Gothenburg, Sweden, and Duke University School of Nursing (DUSON), NC. HELLE WIJK, PhD, RN, is an Associate Professor at the Institute of Health and Care Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. LARSOLOF PERSSON, PhD, is an Associate Professor at the Institute of Health and Care Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. ACKNOWLEDGMENTS This work was funded by Tre Stiftelser, Gothenburg, Sweden, and Swedish Brain Power at the Karolinska Institute, Stockholm, Sweden. 0197-4572/$ - see front matter Ó 2011 Mosby, Inc. All rights reserved. doi:10.1016/j.gerinurse.2011.03.002
Geriatric Nursing, Volume 32, Number 4
This study examined the effects and experiences of an interinstitutional relocation on older persons’ quality of life, wellbeing, and perceived person-centeredness. A pre-test/ post-test mixed method design, with an equivalent reference group, was used to examine relationships between variables and to explore personal meaning. Results indicate a significantly larger deterioration in perceived person centeredness among those cognitively intact residents that moved compared to the nonmovers. Interviews with moving residents revealed that the relocation was experienced as uncontrollable, un-affectable, and uncertain. However, no significant relocation effects were found from the proxy ratings of the cognitively impaired residents. Nursing interventions that involve, inform, and prepare older persons prior to interinstitutional relocation to enhance their sense of control of the move might minimize adverse relocation effects. Further research is needed on the effects of interinstitutional relocations, which procedures that should be used, as well as effects of preparatory interventions. (Geriatr Nurs 2011;32:245-256)
Background pproximately 50% of all facilities housing older people in Sweden comply with the international definition of assisted living, emphasizing social model values that uphold choice, dignity, accessibility, security, and the ability to age in place.1,2 Compared with many other countries, the living standards in Sweden are high.3 During the past 60 years, there has also been a continuous upgrading of housing standards, based on the premise that residential care facilities are homes rather than institutions,4 and approximately 50% of all residential care facilities in Sweden now offer residents single rooms with a kitchenette and private bathroom.5 However, creating supportive psychosocial environments
A
Geriatric Nursing, Volume 32, Number 4
in accordance with a therapeutic design usually necessitates further upgrading or the construction of new facilities. Due to extensive reconstruction, residents of such facilities must temporarily relocate to new environments.6 One way to solve this problem is to use provisional transit facilities during the reconstruction period, and once completed, the residents return to their own facility. Interinstitutional relocation can be defined as the movement from one institution to another.7 Although such relocations might be expected to have negative effects on residents, more specific and consistent knowledge is needed.8,9 There are several studies on peoples’ responses to both voluntary and involuntary change.10 Researchers have noted that stability for those living in institutions correlates positively with their level of trust toward the institutional authorities.11 Others12 argue that relocations from inferior to superior living conditions ultimately have positive effects on older residents’ well-being. However, it has been concluded that when change is forced or imposed, the opportunity for innovation combined with restriction, rather than promotion of one’s personal autonomy and right of expression, is the result.13 A frequently studied outcome measure of forced relocation is mortality rates. Some research has found no change in mortality among older persons after relocation,14-17 whereas more recent studies show a 50% increase in mortality within the first 3 months following transfer.18,19 It has also been shown that relocation disrupts unit routines and social relations among residents, which may cause increased confusion and depression in those with dementia,7,20 One study21 found that relocated residents showed significant differences in salivary cortisol and mood 1 week after an immediate and permanent move to a new nursing home, followed by a significant decline in cortisol 4 weeks after the move. This suggests that the stress imposed by relocation is time limited when the move is to an upgraded or better facility. Other research showed few or no adverse effects
245
on older persons with dementia when residents and staff moved as a unit.22 Despite disparities in the findings, most agree that institutional relocation is a major life change and, consequently, a stressful event.21 Using a nursing perspective, research focusing on adjustment difficulties in relation to relocation suggests that adverse effects could be minimized by preparation and the early involvement of residents.18,23 Supporting the older persons to recognize legitimate reasons for relocating, as well as playing an active role in the decision making surrounding the move, have been shown to be important. Nursing interventions that focus on anxiety and stress reduction, such as anticipatory guidance and coping enhancement, have been associated with successful relocation of older persons.7,19,24,25 Research has also shown the more options residents are given to choose from, the less negative are the effects of relocation,8,26 which raises the question of whether adverse relocation effects might be determined more by the nature of the relocation in terms of execution rather that the act itself. Person-centered nursing is today widely considered to be an essential element of effective care of frail older persons.27 It can be defined as shared decision making and visions for practice that incorporate how residents make sense of what is happening regardless of cognitive ability and acknowledges that the older person should be the focus of care, not the illness or disease.28 No previous research on the effects and experiences of forced relocation to provisional transit facilities has been found in the existing literature. In addition, there are no national guidelines on how adverse relocation effects might be avoided in Sweden29 and no national statistics on how many frail older persons who, because of various types of reconstruction, are interinstitutionally relocated to provisional transit facilities each year.5 This study arose as the result of an opportunity for the authors to follow a naturally occurring event when the municipal government and facility administrators decided to reconstruct 2 residential facilities in Gothenburg, Sweden. The extent of the reconstruction required that the residents were interinstitutionally relocated to a provisional transit facility approximately 7 miles from their home facility for a period of 1 year. The aim of this study was to examine the effects of that relocation on the residents quality of life, well-being, and perceived person-centeredness, 246
as well as to describe their experiences in relation to the relocation.
Methods Design Both to examine relationships between variables and to explore the personal meaning ascribed to the relocation in a single study, a simultaneous, explanatory, mixed-method design was used.30-32 The quantitative measures assessed the residents’ quality of life, well-being, and perceived person-centeredness before and after the temporary relocation, and semistructured interviews with cognitively intact residents were conducted to capture their experiences after the move to the transit facility. Setting and Sample One-hundred and fifty-five residents participated in the study at baseline, of whom 74 were interinstitutionally relocated (designated hereafter as movers) and 81 served as an equivalent reference group (designated as nonmovers). All participants gave their informed consent, either independently or through next of kin. Before the move, the residents lived in 1 of 2 residential care facilities in the central part of the city. Both were originally built in the 1970s with a traditional institutional design including long hallways, dualand single-occupancy bedrooms, shared bathrooms, prominently located nursing stations, and a large open area for activities and meals. The equivalent reference group (nonmovers) lived in a third facility in the central part of the city, which was partially rebuilt in 2001, using a more intentionally therapeutic design that allowed residents to personalize their living spaces and enhance the domestic ambience. There were no significant differences in demographic data between the groups at baseline. However, at baseline, the nonmovers had significantly more symptomatic treatment for mild to moderate Alzheimer’s (cholinesterase inhibitors) than the movers (P 5 .02). At follow-up, 128 (83%) residents were still participating (57 [77%] movers; 71 [88%] nonmovers). Figure 1 illustrates the initial and internal dropout in the study. Relocation The move from the original to the temporary facility was accomplished in 1 day. At both Geriatric Nursing, Volume 32, Number 4
Figure 1. Flow chart illustrating the initial and internal dropout for the study. facilities, the nursing staff and the residents moved as a unit. Residents and family members were notified about the approaching reconstruction and relocation approximately 3 months before the scheduled moving date. No other preparation of the residents or their relatives was undertaken beyond giving this verbal information because it was believed that further action would disturb the daily routines at the facility, which could upset residents and make them more anxious. The nursing staff visited the transit facility before the scheduled moving date to prepare the spatial arrangements. About 2 weeks before the scheduled moving date, personal belongings such as large items of furniture were stored in a warehouse because of the limited space at the transit facility. Approximately 2 weeks before the scheduled moving date, shared spaces such as hallways, living areas, and dining areas where emptied, and about 3 days before the scheduled moving date, smaller personal items belonging to the residents were packed by the nursing staff and sent to the transit facility. Rooms Geriatric Nursing, Volume 32, Number 4
were assigned to the residents upon arrival at the transit facility. Instruments The Person-Centered Climate Questionnaire (PCQ) is a self-report instrument designed for use in evaluating the extent to which a climate (i.e., physical and psychosocial environment) is perceived as being person-centered (i.e., supporting the older person by placing his or her needs and expectations at the center of care). The instrument comprises 3 related domains; safety (10 items), everydayness (4 items), and generosity (3 items). The items are rated on a 7-step scale, ranging from “I disagree completely” to “I agree completely.” The questionnaire is sum scored, and scores can range between 17 and 119, with higher scores indicating a more person-centered climate.33 In our study, the Cronbach alpha coefficient for the total score was .9. The Quality of Life in Late-Stage Dementia Scale (QUALID) is a domain-specific, brief, proxy-based instrument with a 1-week recall period.34,35 The scale 247
comprises 11 items with both positive and negative dimensions of concrete and observable mood and performance, thought to be indicative of quality of life in late-stage dementia. The items are rated as to frequency of occurrence on a 5-step scale, and scores are summed to range from 11 (best quality of life) to 55 (worst quality of life). The instrument is administered in a structured interview format, and the average time of administration is 5 minutes. The proxy informants need to be well acquainted with the person with dementia and to have spent a significant amount of time with the person during the week before the QUALID assessment. In this study, the Cronbach alpha coefficient for the 11 items was .73. The Patient Mood Assessment Scale (PMAS) and the General Behavior Assessment Scale (GBAS) are 2 proxy-based instruments constructed to assess mood and psychosocial behavior among older people.36 The proxy informant needs to be well acquainted with the older person and to have spent a significant amount of time with him or her the week before the assessments. The PMAS comprises 3 related domains: strength (4 items), satisfaction (3 items), and security (3 items). Scores range from 5 to 50 points, with higher values indicating poorer well-being. The GBAS comprises 2 related domains: confidence (4 items) and accessibility (4 items). Scores range from 5 to 40 points, with higher values indicating poorer well-being. Total scores summarizing the domains may also be calculated for both scales. In this study, the Cronbach alpha coefficient for the total score in the PMAS was .87 and in the GBAS .84. Procedure The data collection period ranged from March 2008 to October 2009. Information about residents’ age, length of residence at the residential care facility, psychotropic drug treatment, and dementia diagnosis was gathered from medical records. To adapt the collection procedure to the cognitive ability of the residents (i.e., proxy assessment/ self-report), an initial assessment using a standardized cognitive test, the Mini-Mental State Examination (MMSE),37 divided all residents into 1 of 2 subgroups according to cognitive functioning,38 dichotomized as #20 points (low functioning) and $21 points (high functioning). Among the movers, 62 residents (84%) were assessed as low functioning. Among the nonmovers, 55 residents (68%) were assessed as low functioning. Baseline data 248
were collected 4 weeks before the scheduled moving date and follow-up data 6 months after relocation. Data were collected at corresponding times among the nonmovers (i.e., a gap of 7 months between collections 1 and 2). Low-functioning residents were proxy-assessed using QUALID, GBAS, and PMAS by their personal contact person (CP), that is, a designated nursing staff member with extensive knowledge about the resident. Highfunctioning residents provided self-report assessments using PCQ in a face-to-face interview format. To obtain a joint assessment of both lowfunctioning and high-functioning residents, highfunctioning residents were also proxy-assessed by the nursing staff using PMAS and the GBAS. Approximately 10-12 weeks after the relocation, all high-functioning residents (n 5 12) among those who moved were asked to describe spontaneously their experiences of the interinstitutional relocation. The opening question for each interview was, “Can you tell me about the move?” Interviews lasted between 15-60 minutes and were conducted in the private room of the resident at the transit facility. In cases in which rooms were shared with another resident, the interview was held in a secluded part of the unit. Interviews were digitally recorded and transcribed verbatim. Statistical Analyses The characteristics of the residents were analyzed descriptively. Internal consistency was calculated using Cronbach alpha.39 Differences between groups at baseline were tested with independent samples t tests for continuous variables and chi-square for frequency data. Two-way repeated-measures analysis of variance was used to identify differences in changed scores within groups and between groups over time. The SPSS statistical software package (version 17.0; SPSS, Chicago, IL) was used for all statistical analyses. Statistical significances were set at .05 (2-tailed) for all analyses. Qualitative Content Analysis The interviews were subjected to qualitative content analysis, aimed at identifying prominent categories and patterns in the text.40 The analysis was made in several steps, starting with reading all the transcribed interviews to gain an overall understanding.41 Meaning units that were relevant to the research question were Geriatric Nursing, Volume 32, Number 4
then identified and shortened, preserving their core. The condensed meaning units were coded into short and immediate descriptions of the experiences related to the relocation. Codes were compared for similarities and differences. To preserve the temporal sequence in the original interviews, codes were categorized into 3 content areas: experiences related to the actual move, experiences related to the daily life at the transit facility, and expectations related to the future and moving back. Within each content area, codes were compared, subcategorized, and categorized, leaving the qualitative content analysis on a descriptive level, thereby maintaining the role of a supplementary strategy in the mixed-method design.42
Results
Ethics
Group Differences over Time
The Regional Ethics Board at the University of Gothenburg (572-06) approved the study.
Differences between groups over time were analyzed using repeated-measures ANOVA. F values
Group Differences at Baseline For most variables, no significant differences were found at baseline between the movers and the nonmovers (Table 1). Table 2 compares mean values in the questionnaire data at baseline. A significant difference between groups was found for PMAS strength (P 5 .039) and security (P 5 .030), GBAS confidence (P 5 .017), and on all scales of the PCQ (P 5 .000). These differences indicate that the movers already tended to have lower levels of well-being and perceived person centeredness before the relocation compared with the nonmovers.
Table 1. Participant Characteristics and Differences Between Groups at Baseline Relocation Group (n 5 74) Female Age (M, SD) MMSE (M, SD) Low-functioning (#21 points) Dementia diagnoses Alzheimer and Parkinson Vascular dementia Nonspecific dementia Psychotropic drugs Antipsychotics Antidepressants Sedatives Cholinesterase inhibitors PCQ total score (M, SD) Safety Everydayness Generosity PMAS total score (M, SD) Strength Satisfaction Security GBAS total score (M, SD) Confidence Accessibility QUALID (M, SD)
Reference Group (n 5 81)
P Values
57 86 10 62
77% (8.5) (9.5) 84%
63 86 11 55
78% 6 10 68%
ns ns ns ns
10 28 12
14% 38% 16%
9 26 27
11% 32% 32%
ns ns ns
10 37 18 7 57.3 34.8 12.1 10.4 25.3 10.7 6.7 2.6 21.6 9.7 11.8 22.5
14% 50% 24% 10% 14.6 9.1 4.8 2.6 7.4 3.6 2.6 2.6 6.5 3.9 4.1 7.2
15 50 24 19 84.2 49.7 19.8 14.8 22.4 9.4 6 7 19.7 8.3 11.4 20.9
19% 62% 30% 24% 10.8 5.3 4.6 2.5 7.8 3.9 2.3 2.8 7 3.5 4.5 6.5
ns ns ns .020 \.000 \.000 .001 .000 .017 .039 ns .030 ns .017 ns ns
GBAS 5 General Behavior Assessment Scale; MMSE 5 Mini-Mental State Examination; PCQ 5 Person-Centered Climate Questionnaire; PMAS 5 Patient Mood Assessment Scale; QUALID 5 Quality of Life in Late-Stage Dementia Scale.
Geriatric Nursing, Volume 32, Number 4
249
Table 2. Means and Standard Deviations for Questionnaire Data Relocation Group
PCQ total score Safety Everydayness Generosity PMAS total score Strength Satisfaction Security GBAS total score Confidence Accessibility QUALID
Reference Group
Baseline M (SD)
Follow-up M (SD)
Baseline M (SD)
Follow-up M (SD)
57.3 (14.6) 34.8 (9.1) 12.1 (4.8) 10.4 (2.6) 25.3 (7.4) 10.7 (3.6) 6.7 (2.6) 8.0 (2.6) 21.6 (6.5) 9.7 (3.9) 11.8 (4.1) 22.5 (7.2)
51.9 (10.8) 32.6 (8.1) 8.1 (3.3) 11.1 (3.1) 26.7 (8.7) 11.2 (4.1) 7.4 (2.6) 8.1 (2.9) 22.3 (6.8) 10.0 (3.8) 12.3 (4.1) 24.4 (8.7)
84.2 (10.8) 49.7 (5.3) 19.8 (4.6) 14.8 (2.5) 22.4 (7.8) 9.4 (3.9) 6.0 (2.3) 7.0 (2.8) 19.7 (7.0) 8.3 (3.5) 11.4 (4.5) 20.9 (6.5)
83.2 (10.9) 49.4 (6.9) 19.6 (3.0) 14.2 (2.8) 23.1 (7.1) 9.8 (3.7) 6.1 (2.2) 7.1 (2.7) 19.7 (6.2) 8.2 (2.9) 11.5 (4.7) 21.6 (6.7)
GBAS 5 General Behavior Assessment Scale; MMSE 5 Mini-Mental State Examination; PCQ 5 Person-Centered Climate Questionnaire; PMAS 5 Patient Mood Assessment Scale; QUALID 5 Quality of Life in Late-Stage Dementia Scale.
and probability values from these analyses are presented in Table 3. No significant effects were found for the QUALID scale. Significant group effects were found for PCQ (total score, safety, everydayness, and hospitality), PMAS (total score, satisfaction, and security), and GBAS (total score and confidence). These results indicate that the movers had significantly lower scores than
the nonmovers in perceived person-centeredness and well-being over the entire assessment period. Significant time effects were found for PCQ (total score and everydayness), suggesting that perceived person-centeredness decreased over time for both groups. Significant interaction effects were only found for PCQ total score and PCQ everydayness. Thus, the movers showed
Table 3. Results of Significance Tests Between Groups over Time (2-Way RepeatedMeasure Analysis of Variance)
PCQ total score Safety Everydayness Hospitality PMAS total score Strength Satisfaction Security GBAS total score Confidence Accessibility QUALID MMSE
Group Effects
Time Effects
Interaction Effects (Group 3 Time)
F 5 33.435; P \ .000 F 5 30.511; P \ .000 F 5 28.852; P \ .000 F 5 8.242; P 5 .010 F 5 6.585; P 5 .012 F 5 3.864; ns F 5 8.000; P 5 .005 F 5 4.984; P 5 .027 F 5 4.275; P 5 .041 F 5 7.834; P 5 .006 F 5 .941; ns F 5 1.913; ns F 5 .682; ns
F 5 6.907; P 5 .017 F 5 2.620; ns F 5 10.375; P 5 .005 F 5 1.237; ns F 5 1.781; ns F 5 1.730; ns F 5 3.511; ns F 5 .048; ns F 5 .334; ns F 5 .022; ns F 5 .558; ns F 5 1.892; ns F 5 18.038; P 5 .0005
F 5 7.308; P 5 .015 F 5 4.112; ns F 5 9.969; P 5 .005 F 5 .137; ns F 5 .975; ns F 5 .476; ns F 5 2.826; ns F 5 .076; ns F 5 .596; ns F 5 .900; ns F 5 .146; ns F 5 2.837; ns F 5 .000; ns
GBAS 5 General Behavior Assessment Scale; MMSE 5 Mini-Mental State Examination; PCQ 5 Person-Centered Climate Questionnaire; PMAS 5 Patient Mood Assessment Scale; QUALID 5 Quality of Life in Late-Stage Dementia Scale.
250
Geriatric Nursing, Volume 32, Number 4
a significantly greater deterioration of perceived person-centeredness over time than the nonmovers. To test whether differences in cognitive functioning might influence the obtained results, MMSE scores were introduced as a covariate and all analyses based on PMAS and GBAS data were recalculated, because these 2 measures had been used on both high-functioning and lowfunctioning residents. However, this had only a minor effect on the results. Cognitive functioning (MMSE) and mortality were also assessed over time. A significant time effect was obtained suggesting that cognitive functioning tended to decrease over time in both groups (Table 3). Mortality also tended to differ between the movers and the nonmovers (c2 5 3.16; P 5 .08). Between baseline and follow-up, 24% died among
those who moved, and 11% died among the nonmovers (Fig. 1). The Relocation Experience All high-functioning residents who moved (n 5 12) were asked to describe spontaneously their experiences of the interinstitutional relocation. The analysis of the interviews revealed that the relocation experience was described as uncontrollable, unaffectable, and uncertain (Table 4). The content of the categories is presented in the following comprehensive description. The relocation was actuated by reasons beyond the residents’ control. The actual move to the transit facility was described by a minority
Table 4. Examples of the Qualitative Content Analysis Content Area Experiences related to the actual move
Code -
Experiences related to the daily life at the transit facility
-
-
Experiences related to the future and moving back
-
It happened so fast Others packed my private stuff The move was sudden To be unprepared To be left outside Not allowed to decide There is no point in complaining To have no saying You have to accept what is happening This is what you can expect from an institution This is where you await death Nothing is in order The environment is unfamiliar The staff seem unhappy Disappointment Sadness Our days being numbered I don’t care about the move back Looking forward to the move back Hope to live to see the new facilities
Geriatric Nursing, Volume 32, Number 4
Subcategory -
-
-
Category
Being unprepared Feeling insecure Feeling excluded No one cares about your opinion
-
The relocation was experienced as uncontrollable
Feeling indifferent Feeling anxious Feeling abandoned Feeling disappointed
-
The relocation was experienced as un-affectable
Limited time left Here and now Hopefulness
-
The relocation was experienced as uncertain
251
of the residents as well executed. The preparations before the move were described as being carried out by others at a fast pace without the participation of the residents. Information about the purpose and execution of the relocation, as well as about the transit facility, was described as limited and insufficient. Limited participation in the preparations was described to create feelings of exclusion. Having no other option than merely to “follow the course of events” and “having no say” was described to evoke feelings of powerlessness. The daily routines at the transit facility were described as unchanged compared with those in the old facility, leaving the residents indifferent toward their new living environment. Others reported that they found the physical and psychosocial environment in the transit facility institutional, confined, and cold. Although the old nursing staff accompanied the residents to the transit facility, new staff members and altered floor-level routines contributed to feelings of confusion and uncertainty. Residents speculated that a prevailing discontent among the nursing staff seemed to have a negative influence on their work performance. The spatial layout of the transit facility, with long doublesided hospital-like corridors and great distances between units, contributed to feelings of abandonment. Some expressed disappointment in those responsible for the relocation, as well as the Swedish elderly care system in general, longing for the return to the rebuilt facility with high expectations that it would be attractive, spacious, and homelike. However, the awareness of their advanced age, frailty, and of their “days being numbered,” darkened their hopes for the future, and some felt certain that they would not live to experience the rebuilt facility, and that the reconstruction was intended for future residents. Others refused to speculate about their future, taking 1 day at a time, and were reluctant to reflect on their current living environment and the remaining time in the transit facility.
Discussion This naturalistic inquiry (i.e., study of a group in its natural setting) reports on the effects and experiences of an interinstitutional relocation to transit facilities for a period of 12 months because 252
of extensive reconstruction at the home facility. A majority of the participants in this study were cognitively impaired, which represents the general population in residential care facilities in Sweden,1 where it has been estimated that about 50% show cognitive impairment equivalent to dementia disease, subsequently resulting in integrated populations including both cognitively intact and impaired older persons.43 The North American Nursing Diagnosis Association’s24 definition of relocation stress states that dependency, confusion, depression, and withdrawal are associated with relocations, and that these adverse effects need to be recognized and addressed.44,45 In this study, no formal efforts to prevent such effects where made by the facility administrators. The results indicate that residents in the relocation group showed a greater deterioration over time than the reference group concerning perceived personcenteredness (i.e., PCQ total score and PCQ everydayness). This questionnaire was self-rated and only used in the high-functioning groups in the study. It is well acknowledged that the care environment has a major impact on the ope rationalization of person-centered nursing as it either enhances or limits the facilitation of person-centered processes27,28; as such, the theoretical framework underpinning the PCQ questionnaire describes a person-centered environment as consisting of 3 dimensions: a climate of safety, a climate of everydayness, and a climate of hospitality.33,46,47 Our results suggest that the high-functioning residents, who where able to answer the questions in the PCQ, perceived the environment as less person-centered after the relocation, which is supported by the interviews (i.e., relocation was experienced as uncontrollable, uneatable, and uncertain). One might assume that the temporary nature of the environment at the transit facility contributed to its institutional character and that despite attempts to decorate the environment with noninstitutional and everyday objects, such as paintings, flowers, and furniture, the residents described the climate at the transit facility as deserted, confined, and cold compared with that in the old facility. A further finding, possibly indicating an adverse effect of the relocation, was the differences in mortality between the relocating group and the reference group during the assessment period. Twenty-four percent in the relocating group died between baseline Geriatric Nursing, Volume 32, Number 4
and follow-up compared with 11% in the reference group. This difference was close to significant (P 5 0.08). The assessments of the low-functioning residents (PMAS, GBAS, QUALID) did not show any significant group changes over the assessment interval. One might speculate that those most affected in terms of lack of control and dependency as a result of the relocation are those who, before the move, experienced more control and independence at the home facility (i.e., the highfunctioning group), which, in accord with our result, were those who seemed most negatively affected by the relocation. The ability to function independently in residential care is primarily associated with the person’s cognitive and intellectual abilities. A further explanation for the lack of significant changes among the low-functioning residents could be that the nursing staff and the residents moved together, which has been shown to minimize the disruption of daily routines associated with relocations,22 thereby shielding those with cognitive impairment more than those who are cognitively intact. It could also be that the low-functioning group experienced adverse effects in relation to the relocation but that the proxy ratings of their states and behavior were unable to detect them either because of the insensitivity of the instruments or the staff not being skillful enough to detect changes. Probably, proxy ratings of respondents with dementia should be complemented with other measures, such as nutritional status, body mass index, and sleeping behavior. Others have shown that relocated older persons with cognitive impairment had statistically significant weight loss 3 months after relocation.9 In retrospect, such measures would have strengthened our study. Limitations The relocation was not research-driven, and it would have been carried out regardless of our participation. For that reason, we had no influence on the selection of the participants in the study nor the procedure for relocation. In a naturalistic study such as this, is it is difficult to know whether it is the “intervention” or other factors that account for the changes observed. Changes may depend on “natural developments” and other uncontrollable factors, such as progression of illnesses, aging, changes in staff, or simply timing. To control for potential maturation, we tried to Geriatric Nursing, Volume 32, Number 4
select a reference group representing the “natural history” of older people in an equivalent residential care. Experimental intervention/control designs are more efficient for determining the potential effects of an intervention, as well as controlling for potential confounders. Unfortunately, in practice it is difficult to assign older people randomly to experimental and control groups to study the effects of relocation. A further limitation of the study is that we were not able to follow the relocation group when its participants returned to their refurbished home facility. However, it might be possible to assign subjects randomly to groups using various approaches to preparation before relocation, because it is known that preparatory programs are associated with successful relocation.7,9,48 A major problem in the interpretation of the results from this study is that the relocation group already tended to be significantly worse off regarding perceived person-centeredness (self-rated) and well-being (proxy-rated) compared with the reference group at baseline, a difference that was also consistent at follow-up. These group differences may have several explanations. First, they could reflect a true difference between the residents in the relocated facility and the reference group. The reference facility was chosen because all 3 facilities were situated in the center of the city, had the same catchment area, and did not differ regarding basic demographic and clinical variables. The reference facility was, however, relatively new and up-to-date in its design and functionality, whereas the relocated facilities were considerably older and in need of extensive rebuilding and refurbishment. A second explanation could be that baseline data were collected too close to the actual moving day; that is, that the imminent relocation influenced the care climate and resident’s wellbeing even 4 weeks before moving day. A third explanation could be that the nursing staff members’ own attitudes toward the relocation might have influenced their assessments of the residents’ moods and behavior.49 As far as we know, the nursing staff was engaged in, and positive toward, the rebuilding and the relocation. However, some residents interviewed said that they witnessed discontent among the nursing staff about how the relocation was finally accomplished. It is well known that proxy assessments 253
have less validity than self-assessments,50 but in cases of respondents with dementia, there is little alternative to their use. According to a review of the literature assessing the validity of proxy reports, the accuracy of proxy ratings is higher when the information sought is concrete and observable.49,51,52 We used 3 proxy assessment tools in this study: QUALID, PMAS, and GBAS. Of these, the QUALID is the most explicit in its ratings of only concrete and observable behavior, and this questionnaire did not show any significant group effects between the relocated group and the reference group, in contrast to PMAS and GBAS. Thus, it is possible that the significant group effects found for PMAS and GBAS might at least partially reflect the proxy’s own emotions about the relocation. However, this does not explain the significant group effects also found for the PCQ questionnaire, which was self-rated, particularly given that controlling for cognitive impairment (MMSE) did not change the results obtained for PMAS and GBAS. In addition, the Swedish versions of all 3 instruments (QUALID, GBAS, and PMAS) have shown good to excellent interrater reliability.35,36,53 Implications for Practice and Research As suggested elsewhere,54 one might assume that person-centered interventions that support the older person to recognize legitimate reasons for relocating, as well as playing an active role in the decision making surrounding the move, is important. Person-centered nursing is widely considered to be an essential element of effective care of frail older persons. To prepare, inform, and involve older persons before relocation, one must incorporate how the older person makes sense of what is happening, regardless of cognitive ability, which might increase their feelings of being in control, and subsequently reduce feelings of uncertainty and insecurity.55 It has been suggested25 that individuals who believe they are in control of their lives experience lower levels of anxiety and depressive symptoms, regardless of their appraisal of the relocation. However, when planning such preparatory interventions, researchers and nursing home staff members should not forget that they are dealing with very old people. The minority who were cognitively intact nonetheless considered themselves to be old and frail and also had 254
a natural feeling of uncertainty about being alive even for a couple of months irrespective of relocation.
Conclusion Our results suggest that a temporary interinstitutional relocation might have adverse effects on perceived person-centeredness in older people who are cognitively intact. It is experienced as being beyond their control, that the environment at the transit facility is obstructive, and that the future is fraught with uncertainty. However, we could not show any significant relocation effects from the proxy ratings of the cognitively impaired. It could be that these ratings are partially influenced by the proxy’s own emotions about the relocation. The significant differences between groups already found at baseline, might indicate that residents started to worry long before the relocation. Nursing interventions that involve, inform, and prepare older people before interinstitutional relocation to enhance their sense of control and the predictability of the move might minimize adverse relocation effects. There is a need for further research on the impact of relocations on old and cognitively impaired people, the methods that should be used, and the effects of preparatory interventions.
References 1. Swedish Government Official Reports 2008-5. Aging with Dignity in the Care of Elderly. Stockholm: The Government Offices of Sweden; 2008. 2. Why can’t our need for special housing for the elderly be met? Artikelnr: 2004-110-2. Stockholm: The National Board of Housing, Building and Planning; 2003. 3. SOU 2008-13. The Swedish Government Official Report 2009. High Quality Living in Old Age. The Government Offices of Sweden; 2009. 4. Westerlund P. Salutogen design a€r framtidens a€ldreboende. Stockholm: Fortbildning; 2010. 5. Open Comparisons 2009: Swedish Elderly Care. Swedish Association of Local Authorities and Regions, Stockholm, 2009. 6. McFadden SH, Lunsman M. Continuity in the midst of change: behaviors of residents relocated from a nursing home environment to small households. Am J Alzheimers Dis Other Demen 2010;25:51-7. 7. Castle NG. Relocation of the elderly. Med Care Res Rev 2001;58:291-333. 8. Thorson JA, Davis RE. Relocation of the institutionalized aged. J Clin Psychol 2000;56:131-8.
Geriatric Nursing, Volume 32, Number 4
9. Lander SM, Brazill AL, Ladrigan PM. Intrainstitutional relocation. Effects on residents’ behavior and psychosocial functioning. J Gerontol Nurs 1997;23:35-41. 10. Wang M. Profiling retirees in the retirement transition and adjustment process: examining the longitudinal change patterns of retirees’ psychological well-being. J Appl Psychol 2007;92:455-74. 11. Devos T, Spini D, Schwartz SH. Conflicts among human values and trust in institutions. Br J Soc Psychol 2002;41: 481-94. 12. Mirotznik J, Kamp LL. Cognitive status and relocation stress: a test of the vulnerability hypothesis. Gerontologist 2000;40:531-9. 13. Sverdlik N, Oreg S. Personal values and conflicting motivational forces in the context of imposed change. J Personal 2009;77:1437-65. 14. Borup J, Gallego D, Heffernan P. Relocation: its effect on health functioning and mortality. Gerontologist 1980;20: 468-79. 15. Borup J. Relocation process: stress, attitudes, informational network and problems encountered. Gerontologist 1981;21:501-11. 16. Borup J. The effects of varying degrees of interinstitutional environmental change on long-term care patients. Gerontologist 1982;22:409-17. 17. Borup J. Relocation mortality research: assessment, reply, and a need to refocus on the issues. Gerontologist 1983;23:235-42. 18. Laughlin AM. Effects of involuntary inter-institutional relocation on the physical, psychosocial, and cognitive functioning of older individuals. Unpublished doctoral dissertation. University of Nebraska, Lincoln; 2005. 19. Laughlin AM, Parsons M, Kosloski KD, et al. Predictors of mortality following involuntary inter-institutional relocation. Gerontol Nurs 2007;33:20-6. 20. Wimo A, Nelving A, Nelving J, et al. Can changes in ward routines affect the severity of dementia? A controlled prospective study. Int Psychogeriatr 1993;5:169-80. 21. Hodgson N, Freedman VA, Granger DA, et al. Biobehavioral correlates of relocation in the frail elderly: salivary cortisol, affect, and cognitive function. J Am Geriatr Soc 2004;52:1856-62. 22. McAuslane L, Sperlinger D. The effects of relocation on elderly people with dementia and their nursing staff. Int J Geriatr Psychiatry 1994;9:981-4. 23. Farhall J, Trauer T, Newton R, et al. Minimizing adverse effects on patients of involuntary relocation from longstay wards to community residences. Psychiatr Serv 2003;54:1022-7. 24. Johnson M, Bulechek G, Butcher H, et al. (eds.), and North American Nursing Diagnosis Association. NANDA, NOC, and NIC linkages. 2nd ed. St. Louis, MO: Mosby Elsevier; 2006. 25. Keitser KJ. Predictors of self-assessed health, anxiety, and depressive symptoms in nursing home residents at week 1 post relocation. J Ageing Health 2006;18: 722-42. 26. Bekhet AK, Zauszniewski JA, Wykle ML. Milieu change and relocation adjustment in elders. West J Nurs Res 2008;30:113-29. 27. McCormack B, McCance TV. Development of a framework for person-centred nursing. J Adv Nurs 2006;56:472-9.
Geriatric Nursing, Volume 32, Number 4
28. Edvardsson D, Innes A. Measuring person-centred care: a critical comparative review of published tools. Gerontologist 2010;50:834-6. 29. Social Services Act. Ministry of Health and Social Affairs, 2001:453. Available at http://www.regeringen.se. Cited September 1, 2010. 30. Andrew S, Halcom EJ, eds. Mixed methods research for nursing and health sciences. Ames, IA: Wiley-Blackwell; 2009. 31. Creswell JW. Research design: qualitative, quantitative, and mixed method approaches. 3rd ed. Thousand Oaks, CA: Sage; 2009. 32. Morse JM. Principles of mixed methods and multimethod research design. In: Tashakkori A, Teddlie C, eds. Handbook of mixed methods in social and behavioural research. Thousand Oaks, CA: Sage; 2003. p. 189-208. 33. Edvardsson D, Sandman PO, Rasmussen B. Swedish language person-centred climate questionnairedpatient version: construction and psychometric evaluation. J Adv Nurs 2008;63:302-9. 34. Weiner MF, Martin-Cook K, Svetlik DA, et al. The quality of life in late-stage dementia (QUALID) scale. J Am Med Dir Assoc 2000;1:114-6. 35. Falk H, Persson LO, Wijk H. A psychometric evaluation of a Swedish version of the quality of life in late-stage dementia (QUALID) scale. Int Psychogeriatr 2007;19: 1040-50. 36. Edberg AK. Assessment by nurses of mood, general behavior and functional ability in patients with dementia receiving nursing home care. Scand J Caring Sci 2000;14: 52-61. 37. Folstein MF, Folstein S, McHugh PR. Mini-mental-state: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-98. 38. Nirenberg TD. Relocation of institutionalized elderly. J Consult Clin Psychol 1983;15:693-701. 39. Nunnally JC, Bernstein IH. Psychometric theory. 3rd ed. New York: McGraw-Hill; 1994. 40. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achive trustworthiness. Nurse Educ Today 2004;24: 105-12. 41. Kvale S, Brinkmann S. Interviews: learning the craft of qualitative research interviewing. 2nd ed. Thousand Oaks, CA: Sage; 2009. 42. Morse JM, Niehaus L. Combining qualitative and quantitative methods for mixed-method designs. In: Munhall P, ed. Nursing research: a qualitative perspective. 4th ed. London: Jones and Bartlett; 2007. 43. The Swedish Council on Health Technology Assessment (SBU). The Dementias, Stockholm, 2006. 44. Mallick MJ, Whipple TW. Validity of the nursing diagnosis of relocation stress syndrome. Nurs Res 2000;49:97-100. 45. Brugler C, Titus M, Nypaver J. Relocation stress syndrome. J Nurs Admin 1993;23:45-50. 46. Edvardsson D. Therapeutic environments for older adults: constituents and meanings. J Gerontol Nurs 2008; 34:32-40. 47. Edvardsson D. Atmosphere in care settings: towards a broader understanding of the phenomenon. Doctoral dissertation, Ume a University, Ume a, Sweden; 2005.
255
48. Bourestom N, Pastalan L. The effects of relocation on the elderly: a reply to Borup, Gallego, and Heffernan. Gerontologist 1981;21:4-7. 49. Novella JL, Jochum C, Jolly D, et al. Agreement between patients and proxies’ reports of quality of life in Alzheimer’s disease. Qual Life Res 2001;10:443-52. 50. Novella JL, Boyer F, Jochum C, et al. Health status in patients with Alzheimer disease. An investigation of interrater agreement. Quality of Life Research 2006;15:811-9. 51. Bond MJ, Clarks MS. The accuracy of proxy ratings of life-style activities using the Adelaide activities profile. Aging 2000;12:388-92. 52. Rabins PV, Kasper JD. Measuring quality of life in dementia: conceptual and practical issues. Alzheimer Dise Assoc Disord 1997;11:100-4. 53. Falk H, Wijk H, Persson LO. The effects of refurbishment on residents’ quality of life and wellbeing in two Swedish residential care facilities. Health Place 2009;15:687-94. 54. Amenta M, Weiner M, Amenta D. Successful relocation. Geriatr Nurs 1984;Nov/Dec:356-60. 55. Walker CA, Curry LC, Hoqstel MO. Relocation stress syndrome in older adults transitioning
256
from home to a long-term care facility: myth or reality. J Psychosoc Nurs Ment Health Serv 2007;45: 38-45. HANNA FALK, PhD, RN, is a Postdocotral Research fellow at the Institute of Health and Care Sciences at Sahlgrenska Academy (GPCC), University of Gothenburg, Gothenburg, Sweden, and Duke University School of Nursing (DUSON), NC. HELLE WIJK, PhD, RN, is an Associate Professor at the Institute of Health and Care Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. LARSOLOF PERSSON, PhD, is an Associate Professor at the Institute of Health and Care Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. ACKNOWLEDGMENTS This work was funded by Tre Stiftelser, Gothenburg, Sweden, and Swedish Brain Power at the Karolinska Institute, Stockholm, Sweden. 0197-4572/$ - see front matter Ó 2011 Mosby, Inc. All rights reserved. doi:10.1016/j.gerinurse.2011.03.002
Geriatric Nursing, Volume 32, Number 4