Copyright 1992 by The Cerontological Society of America The Cerontologist Vol. 32, No. 6, 834-842
Residents of two older nursing homes (n = 196) were relocated to a new 238-bed facility. A nonequivalent control group (n = 74) design with two pretests and two posttests was used to assess the impact of this move on their well-being and health. The relocated residents and control-group residents required a similar level of nursing care. Residents to be relocated participated in a preparation program designed to enhance their sense of control and predictability over the move. Analyses of medical records, nurses' ratings, and interviews strongly suggest that the move had no negative effect on the residents as a group or on vulnerable subgroups of residents. Key Words: Stress, Health, Well-being, Transfer
The Impact of an Interinstitutional Relocation on Nursing Home Residents Requiring a High Level of Care1
It seems clear from recent reviews of the relocation stress literature that moving elderly institutionalized residents into a new chronic care facility does not usually result in trauma serious enough to cause death (Coffman, 1981; Borup, 1982,1983; Borup & Gallego, 1981; Rowland, 1977). In particular, relatively recent studies in which nursing home residents were well prepared for a move into a better facility rarely found such an effect (Kasl & Rosenfeld, 1980). In our view, the lessons drawn from these reviews are that interinstitutional relocations are stressful but usually not life-threatening, and that the negative effects of this stressful experience can be minimized by preparing nursing home residents for the move (see also Kowalski, 1981). Nowadays, nursing staff usually develop preparation programs tailored to the particular needs of their residents and this was the case for the study reported here. It was designed, therefore, to test the less extreme relocation stress hypothesis that an interinstitutional relocation causes serious decrements in the psychological well-being and health of frail individuals who were prepared extensively for the move. In spite of the plausibility of this hypothesis, there is very little evidence that the well-being and health of nursing home residents are adversely affected by an interinstitutional relocation, regardless of the degree to which residents are prepared for the move. This is because the vast majority of the studies on interinstitutional relocation stress have used mortality rates as the sole dependent
1 Parts of this paper were presented at the 1988 annual meeting of the Gerontological Society of America, San Francisco, as part of a symposium entitled, "Planning and Evaluating the Relocation of Extended Care Residents." The authors thank the administration and board of the Parkridge Centre for their cooperation and support; Therese Chandra, Marilyn Bain, Christina Forster, and Natalie Polvie for their able assistance; and Gloria Gutman for continuing to provide her expertise and mentorship. department of Psychology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada S7N OWO. 3 Program evaluator, Career Placement Office, University of Western Ontario, London, Ontario, Canada. ••Department of Psychology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
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variable (Borup, 1982; Grant, 1985b; Kasl, 1972; Nirenberg, 1983). Table 1 shows the eleven studies that we were able to find that examined the effects of a relocation on the psychological well-being, health, and physical functioning of institutional residents. These studies are classified in terms of strength of the quasi-experimental design (nonequivalent pretest/posttest design with control group, pretest/posttest design, or posttest only design), degree of environmental change (moderate — moved to a new building with the same staff and resident, or radical — moved to new building with unfamiliar staff and residents), status of the residents (interviewable or not), and whether the residents were prepared for the move. First, consider the effects of a relocation on nursing home residents' psychological well-being. There appear to be very few negative effects following a moderate relocation (Bonardi, Pencer, & Tourigny-Rivard, 1989; Borup, 1982; Bourestom & Tars, 1974; Mirotznik & Ruskin, 1984, 1985; Nirenberg, 1983). In contrast, a more radical relocation, which results in a new social as well as physical milieu, usually results in psychological distress — indexed as lowered life satisfaction and increased levels of dependency, withdrawal, and depression (Anthony et al., 1987; Bourestom & Tars, 1974; Chanfreau et al., 1990; Wells & Macdonald, 1981). However, this negative effect is not always obtained. Some studies have shown no change (Borup, 1982), or even some positive change (Pihkanen & Lahdenpera, 1963; Pino, Rosica, & Carter, 1978) in response to such a relocation. Second, six studies have examined physical health using self-report and/or medical observations. Four of these studies were of a radical relocation and the residents were not prepared for the move. Of these, two found increased health problems following the move (Bourestom & Tars, 1974; Miller & Lieberman, 1965) and two did not (Borup, 1982; Borup, Gallego, & Heffeman, 1980; Pihkanen & Lahdenpera, 1963). The other two studies involved a less radical relocation and the residents were prepared for the move (Chanfreau et al., 1990; Mirotznik & Ruskin, 1984). No changes in health were observed. It seems that a radical relocation may affect health negatively, although this is by no means certain.
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Peter R. Grant, PhD,2 Rodney R. Skinkle, MA,3 and Garth Lipps, MA4
Table 1 . Studies that Have Examined the Impact of a Relocation on the Psychological Well-being, Health, and Functional Ability of Nursing Home Residents'
Citation
Design
Sample
Relocation
Preparation
Radical
No
Moderate
No
Anthony etal., 1987
Pretest/posttest with control
Bonardi, Pencer, & Tourigny-Rivard, 1989 Borup, Callego, & Heffernan, 1980; Borup,1982
Pretest/posttest with control
At-risk subsample Total population
Pretest/posttest with control
Interviewable
Moderate & Radical
No
Pretest/posttest with control
Interviewable
Moderate & Radical
No
Bourestom& Tars, 1974
Dependent variable Well-being, Functioning Well-being, Functioning Well-being, Health, Well-being, Hpalth
Moderate -» Radical
Yes
Functioning Well-being, Health,
Interviewable
Radical
No
Well-being,
Interviewable
Moderate
Yes
Nirenberg, 1983
Pretest/posttest with control & Pretest/posttest Pretest/posttest
Interviewable
Moderate
Yes
Well-being, Health Well-being,
Pihkanen & Lahdenpera, 1963
Posttest only
Total population
Radical
No
Well-being, Health,
Pino, Rosica, & Carter, 1978
Pretest/posttest with control
Interviewable
Radical
Both
Well-being,
Wells & Macdonald, 1981
Pretest/posttest
Interviewable
Radical
Yes
Well-being, Functioning
Chanfreau etal., 1990
Pretest/posttest with control
Total population
Miller & Lieberman, 1965
Pretest/posttest
Mirotznik & Ruskin, 1984,1985
Health
Third, a number of studies have measured the ability to perform a variety of everyday tasks using activity of daily living (ADL) scales. The results from most of these studies have shown no change over time for the relocated group (Anthony et al., 1987; Borup, Callego, & Heffernan, 1980; Bonardi, Pencer, & Tourigny-Rivard, 1989; Bourestom & Tars, 1974; Nirenberg, 1983; Pino, Rosica, & Carter, 1978; Pihkanen & Lahdenpera, 1963; Wells & Macdonald, 1981). Interpretation of this lack of change rests on the findings from the four studies that used control groups. Two found that the control group declined in functional abilities relative to the relocated group, suggesting that maintenance of physical functioning following the move was a positive effect (Borup, Callego, & Heffernan, 1980; Pino, Rosica, & Carter, 1978), and two found no difference between the activities of nursing home residents experiencing a moderate environmental change and the activities of a control group (Bonardi, Pencer, & Tourigny-Rivard, 1989; Bourestom & Tars, 1974). In contrast, Bourestom and Tars (1974) found a decline in the functional abilities of nursing home residents who had experienced a radical environmental change, and Chanfreau and her colleagues (1990) obtained an increase in physical dependency in a group of chronic psychiatric patients who were moved to a new hospital. On balance, however, it would seem that relocating to a new facility rarely impacts negatively on nursing home residents' functional abilities. In sum, it appears that moderate relocations involving a move to a new facility with familiar staff and residents do not have a negative effect. However, a more radical environmental change may cause psychological distress and health problems in the months following the move. In this regard it is interesting to contrast the results obtained by Borup (1982) and Bourestom and Tars (1974). In both of these studies, there was no preparation for the move and residents who had experienced a radical relocation were
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compared both with those who had experienced a moderate relocation and with a control group. Therefore, these studies provide the strongest evidence for or against the hypothesis that a radical relocation without preparation causes stress or health problems. The results of the two studies are contradictory. In general, the radical relocation group responded in the same way as the control group in Borup's (1982) study, but significantly worse in Bourestom and Tars' (1974) study. It may be that the negative effects obtained 1 month following the move by Bourestom and Tars would have dissipated after 3 to 6 months (the time period during which Borup administered his posttest measures). Indeed, there is evidence that the move is most stressful during the first 3 to 4 months following a relocation (see Rowland, 1977, for a review). However, the relocation may have been more radical and/or the residents more frail in Bourestom and Tars' study. Consistent with this reasoning, Bourestom and Tars found a significant increase in the mortality rate for the radical relocation group; Borup did not. In all but three of the research projects listed in Table 1, only interviewable residents were studied, and only one of these (Bonardi, Pencer, & Tourigny-Rivard, 1989) involved a large sample using a pretest/posttest with nonequivalent control group design. This is a serious limitation because residents who are interviewable are likely to be less frail, especially less mentally frail, than those who are not. The present study used a pretest/posttest quasi-experimental design with a control group to study the impact on all the residents of two older nursing homes of a relocation into a modern, state-of-the-art facility, the Parkridge Centre. The relocation was unique in that the residents were moved into a facility that was much bigger than their old residence and that contained a mixture of familiar and unfamiliar residents and staff. Thus, it was neither a moderate nor a radical environmental change but somewhere in between.
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•A study by Krai, Crad, and Berenson (1968) was omitted because it was unclear whether an interinstitutional relocation was being discussed. They found an increase in cortisol in the blood of men but not women from 1 week before to 1 to 2 weeks after the move.
Method Sample It was decided to examine the impact of the move on the entire resident population — the 196 residents who were living in the older 65-bed and 129-bed extended care facilities 3 months prior to the, move. Of these, 58 (29.6%) were judged by staff to be interviewable, and 47 (81.0%) of these were successfully interviewed at least twice. Of the remainder, three died and eight refused to be interviewed. Nurses' ratings were completed for 147 to 159 residents (75.0% to 81.1 %), depending on the measurement point, and medical records were coded for 157 residents (80.1%). Two samples were obtained from the control nursing home. The first consisted of 34 residents who were identified as interviewable by the nursing home staff. Of these, three died after the first interview. The second consisted of 40 noninterviewable residents who were matched to the relocated residents in terms of the incidence of an organic psychotic disorder and circulatory system problems. Thus, the residents of the control nursing home who took part in this study were not a representative sample of residents from this home; rather, they were chosen because they were similar to members of the relocation group.
The Similarity Between the Residents of the Two Nursing Homes
Characteristics of the Relocation Residents
Analyses were conducted to determine the extent to which the sample of residents of the control nursing home were similar to the relocation group 2 to 3 months prior to the move. In general, the results of these analyses showed that the two groups were quite similar. On average, they had a similar number of medical conditions and consumed a similar number of prescription drugs (x2 (1,227) = 1.79, ns; x2 (1,225) < 1, ns, respectively). Further, the incidence of two common types of medical disorders, diseases of the circulatory system and paralytic syndromes, did not differ (both x2(1,227) < 1 , n s ) . However, Table 2 shows that the relocation group was significantly more cognitively impaired. This is true whether the prevalence of senile dementia or communication problems due to cognitive impairment is considered (X2 (1, N = 227) = 5.16, p < .05; x2^,N = 227) = 4.59, p < .05, respectively). As well, the greater incidence of physical complaints (f(189) = 3.80, p < .01) and the greater use of antibiotics (x 2 (1, N = 225) = 6.26, p < .05) suggests that the relocation residents were physically more frail than control group residents. In view of these differences, special care was taken to consider the possible effects of cognitive
Detailed background information on the relocation residents 2 to 3 months prior to the move was obtained from their medical records. Their average age was 68 years, ranging from 18 to 102 years. Almost exactly half were male (49.4%). Approximately one-third of the relocated residents were married (35.2%) or widowed (32.7%), with the rest being single (23.9%) or separated/divorced (8.2%). Over one-third (37.9%) did not have children. Of the remainder, most had from one to four children with two being the modal number. Most commonly the designated family contact was a spouse (31.4%) or daughter (20.3%). Over 80% of the sample had been living in a nursing home for over a year prior to the relocation. Of the 28 residents who had been admitted recently, 10 (35.7%) came from hospital and 3 (10.7%) from a Geriatric Assessment Unit. Details on the income of one-third of the relocated residents were not available in their records. Of the remainder, 85.1% received the Canada Pension Plan — a federal pension plan to which all salaried Canadians are entitled. One-third (35.7%) had income from a private source. The relocation residents commonly had multiple health
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problems and required a high level of nursing care. Their medical charts showed that, on average, residents had almost four different medical conditions (ranging from 1 to 10). Some of the most frequent were senile dementia (29.7%); atherosclerosis (12.7%), cerebrovascular disease (27.8%), and other circulatory problems (16.5%); disorders of the eye such as glaucoma or cataracts (23.4%); hemiplegia or hemiparesis (17.7%), quadriplegia, paraplegia, or other paralytic syndromes (16.5%); arthritis (17.7%); epilepsy (13.9%); depression (12.0%); and diabetes (10.8%). Examination of the physical problems recorded in the daily nursing notes showed that, on average, residents had four (usually minor) physical complaints a month (range 0 to 15) such as colds and flu, fever and vomiting, headaches, constipation, cuts and bruises, and edema of the hand or foot. On average, residents took two to three different medications a day (range 0 to 11). The most common of these were central nervous system drugs: antidepressants (19.1%), tranquilizers (24.8%), sedatives (26.1%), analgesics and antipyretics (39.5%), and anticonvulsants (18.5%); cardiovascular drugs: cardiac drugs (10.2%) and hypotensive drugs (16.6%); autonomic drugs (19.7%); anti-infective agents: antibiotics (22.3%), ear, eye, or nose preparations (10.2%), and skin preparations (23.6%); and cough preparations (11.5%). The level of disability of the residents was very high with 32.9% of all residents being unable to attempt any activities of daily living such as bathing, eating, toileting, or dressing even when assisted. Indeed, three-quarters of the residents (74.0%) were bedridden or confined to a wheelchair and even more were incontinent (88.7%). A full 31.7% of the residents had to be toileted in bed because of severe physical disabilities. Very few residents (10.4%) could walk up a flight of stairs without help and almost none (2.6%) obtained their food tray from the dietary cart at meal times. One-third (35.7%) of the residents had one or both hands or arms paralysed or missing, and 41.8% had one or both feet or legs paralysed or missing. Communication problems were very prevalent. Almost two-thirds (64.3%) had communication problems because of cognitive impairment. However, vision problems (33.8%), hearing problems (31.2%) and speech problems (35.0%) also caused communication difficulties.
A program was designed to prepare the relocated residents and staff for the move. This program involved: consulting with the residents and their families on the location and color of their room and the packing of their belongings; tours of the new facility before and immediately after the move; and in-service training for the staff. We felt that it would be unethical not to provide a preparation program because of the degree of environmental change involved and because the residents were from nursing homes that specialized in looking after very frail chronic care residents requiring up to 90 minutes of nursing care per day. Indeed, 70% of the relocated residents were judged by staff to be noninterviewable. Therefore, residents would be at risk even if they were prepared adequately for the relocation. This ethical constraint made it impossible to evaluate the impact of the preparation program. Rather, the study examined the impact of the relocation on the psychological well-being, health, and mortality of residents who had received extensive preparation for the move.
Table 2. Differences Between the Relocation Group and the Control Group at the First Measurement Point
Croups Characteristics Indices of Mental Frailty Senile dementia Organic psychotic disorder Communication problems due to cognitive impairment Indices of Physical Frailty Antibiotics Number of physical problems Cough medication Other Differences Incontinence Speech problems Parkinson's disease Mental retardation
Relocation
Control
29.7% 32.3% 64.3%
14.5% 17.4% 41.4%
22.3% 3.93 11.5%
7.4% 2.58 1.5%
88.8% 35.0% 5.1% 8.9%
76.8% 17.1% 17.4% 0.0%
impairment and physical disability in the analyses that examined whether the relocation had an adverse effect. Research Design and Analysis Strategy Croup (relocation or control) and diagnostic category (present or absent) were the between-subjects factors in a split-plot factorial design. The within-subjects factor was time. We felt that it was important to examine the wellbeing and health of residents prior to making preparations for the move and just before it took place. Following the relocation, we wanted to document the immediate and long-term effects of the move itself. Thus, there were four measurement waves: 2 to 3 months prior to the move, just before the move, just after the move, and 3 months after the move. If the residents in the relocation group were adversely affected by the move, then a significant interaction between group and time should be obtained. If only a subset of relocation residents were adversely affected by the move, a three-way interaction should be obtained among group, diagnostic category, and time. For example, if residents with a heart condition were the only ones to be distressed by the move, then a significant three-way interaction would be obtained in a 2 (group) by 2 (diagnosis of a heart condition or not) by 4 (measurement wave) split-plot design. Due to sample size limitations, it was only possible to include one classification factor at a time in the split-plot design. This meant that negative effects on small groups of residents classified as members of two or more high-risk groups (e.g., very old residents with a heart condition) could not be examined. In addition, it meant that many analyses with the same dependent variables were repeated using different classification variables. This strategy increased the chance of detecting a negative effect should one occur, but also made it more likely that a "significant" finding would be detected that was due to chance factors rather than the stressful nature of the move. We deliberately chose this analysis strategy because we preferred to risk making a Type I rather than a Type II error. If the evidence supported the null hypothesis, we felt that it was important to feel confident that a negative effect of clinical significance had not gone undetected. To this end we also calculated the power of the main effects and interactions to detect a medium effect at a significance level of .05
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Research
Procedures
The general approach to measurement was to obtain multiple indicators of each resident's psychological wellbeing and health from medical records, nurses' ratings, and interviews with the residents. Residents' medical diagnoses at the first measurement point, their change of diagnoses over the study period, and their drug use at the four measurement points were all recorded by a trained coder with extensive medical experience. In addition, nursing notes were coded for indications of psychological distress and physical complaints during the month at each measurement point. The behavior of the relocation residents at the four measurement points was recorded by nurses on a number of rating scales. Nurses were trained to use the rating scales and then, at every measurement point, each nursing station was provided with booklets containing these scales. Nurses only rated residents with whom they had interacted during the previous week. Unfortunately, it was not possible to obtain similar ratings for residents of the control nursing home. Approximately one-third (29.6%) of the residents were judged by staff as being interviewable. The interviewers (primarily psychology students at the University of Saskatchewan) were introduced to each resident by a nurse on their ward and a convenient time for the interview was arranged. On average the interview took 1 hour (range 30 to 90 minutes). (Detailed analyses of the responses of the interviewable residents in this study are described in Skinkle, 1988.) Dependent Variables Medical Records. — Diagnoses were classified using the International Classification of Diseases (U.S. Department of Health and Human Resources, 1980) using a coding scheme developed by Grant (1985a, 1985b). This information was collected so that subgroups of residents with different medical problems could be examined to see if a particular kind of person was especially likely to be affected negatively by the move. As well, any change in diagnoses during the period under study was recorded. Drug use at the four measurement points was recorded from monthly medical charts using the classifications detailed in the Saskatchewan Formulary (1986) in a coding scheme developed by Grant (1985a, 1985b). The use of central nervous system drugs, such as tranquilizers, sedatives, and antidepressants, and of hypotensive drugs was of particular interest since they are medical indicators of stress. In addition, this scheme allowed nurses' notes on the medical charts to be coded for behavioral indications
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Note. The percentages and number of physical problems are based upon 129 to 158 residents in the relocation group and 62 to 70 residents in the control group. All differences are significant at the p < .05 level or better.
(Cohen, 1988). These calculations showed that the analyses of the medical records had very good power ( > .94). However, the power of the analyses involving the interview data was not very high ( > .70). Analyses of the nurses' ratings omitted the group factor. It had proved impossible to obtain these ratings in the control nursing home because of senior management's understandable reluctance to commit staff time to a project that did not directly benefit the institution. This meant that significant time main effects or diagnostic-categoryby-time interactions would be obtained if the relocation had negative effects. The power to detect a medium effect of this kind at the p < .05 level was very good ( > .89). Finally, institutional records allowed the mortality rate of the relocation group during the 6 months prior to and following the move to be compared with mortality rates over the previous 5 years using multiple regression.
of psychological distress (e.g., unable to sleep, confused, upset, weepy, anxious, worried, irritable, agitated, uncooperative, wanders, hostile toward other residents or staff), and the incidence of relatively minor health problems (e.g., cold, flu, infection, swollen ankles, indigestion, headache, and arthritis flare-up).
The Interview Schedule. — The Perceived Stress Scale (PSS), the Memorial University of Newfoundland Scale of Happiness (MUNSH), Radloff's CES-D Depression Scale, and Rosenberg's Self-Esteem Scale (SE) were the measures that formed the basis of the interview at the four measurement points. All but the PSS have been used in the past with both older and younger people and are wellestablished measures (Cohen, Kamarck, & Mermelstein, 1983; Kozma & Stones, 1980; Radloff, 1977; Rosenberg, 1965). The Perceived Stress Scale is a relatively new scale that measures the extent to which people feel upset, distressed, and overwhelmed by the events in their life (Cohen, Kamarck, & Mermelstein, 1983). The major reason for including this scale was that it seems to measure the distress people feel when they believe that their life is slipping out of their control. Pilot testing in trial interviews showed that the nursing home residents (from the control nursing home) understood the items and felt they were relevant to their experience. This was born out in the actual study as residents in both nursing homes had no difficulty with this scale and it proved to be reliable (a = .75, n = 69, Time 1). The MUNSH assesses happiness and satisfaction with life. It was developed for use with older people and is a direct measure of psychological well-being (Kozma & Stones, 1980). Radloff's CES-D scale measures nonclinical depression in the general population (Radloff, 1977). This instrument measures how much a person is feeling "blue" or " d o w n " because of difficult life circumstances. Rosenberg's (1965) Self-Esteem Scale measures how positively persons evaluate themselves, that is, to what extent they feel that they are worthwhile persons. Evidence that all these scales were responded to mean-
Results
Psychological Distress The major focus of this study was on documenting whether the move caused psychological distress during the first 3 months in the new facility. The evidence from the medical records and nursing notes shows that the move caused very little psychological distress. In particular, no significant group-by-time interactions were obtained for a measure of the use of tranquilizers and sedatives or the use of hypotensive drugs; F(3,585) = 1.93, ns; F(3,585) < 1 , respectively. Detailed analyses examined whether certain groups of residents might be particularly likely to suffer adversely from the move, but again no evidence of an increase in the use of tranquilizers and sedatives or of hypotensive drugs was obtained. The incidence of signs of psychological distress recorded in the nurses' notes on each resident's medical chart were also analyzed and a group main effect qualified by a group-by-time interaction was obtained; F(1,195) = 16.64, p < .001; 5(3,573) = 3.64, p < .05. Table 3 shows the means, which indicate that proportionately more residents in the relocation group experienced psychological distress immediately following the move and that this increase declined back to the premove baseline after 3 months in the new facility. Only one variable, age, qualified the group-by-time interaction; F(3,573) = 5.24, p < .001 (Table 3). In comparison to the premove baseline, proportionately more relocated residents who were 80 years old or older were described as psychologically distressed by nursing staff both immediately and at the 3-month follow-
Table 3. Proportion of Psychologically Distressed Residents as a Function of Group and Age Across Time
Measurement wave Croups Total sample Relocation group (n = 135) Control group (n = 62) Old residents (80 + ) Relocation group (n = 51) Control group (n = 20) Younger residents Relocation group (n = 82) Control group (n = 42)
1
2
3
4
.53 .44
.57 .31
.65 .32
.59 .39
.59 .60
.55 .45
.75 .30
.73 .30
.49 .36
.59 .24
.59 .33
.49 .43
Note. Whether a resident was psychologically distressed was determined from the nursing notes.
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The Behavioral Rating Scale. — The nurses used a multidimensional assessment instrument called the Physical and Mental Impairment-of-Function Evaluation (PAMIE; Gurel, Linn, & Linn, 1972). It has several scales that measure behavioral manifestations of mental disorganization/ confusion (a = .92, n = 83, Time 1), anxiety/depression (a = .72, n = 117, Time 1), withdrawal/apathy (a = .85, n = 118, Time 1), paranoia/suspicion (a = .74, n = 107, Time 1), and belligerence/irritability (a = .92, n = 108, Time 1). These scales have been used by Wells and Macdonald (1981) to study an interinstitutional relocation of extended care residents in a Canadian context. Two rating scales were used to track changes in the residents' functional abilities by measuring their ability to perform various activities of daily living. The first was a sixitem ADL scale developed by Katz (Katz et al., 1970). It was scored by summing the ratings on the individual items with a high score indicating a high level of disability (a = .86, n = 155, Time 1). The second was the self-care subscale of PAMIE (a = .74, n = 153, Time 1). Consistent with the majority of studies that were reviewed in the introduction, there was no change in the relocation group's ability to perform simple ADLs during the study period. This finding must, however, be regarded with caution because nurses' ratings of functional ability were not obtained for the control group.
ingfully by residents is shown by the fact that they were found to be reliable and that they related to each other in expected ways. For example, residents with low selfesteem tended to be depressed and less satisfied with life, and to feel more stressed (r = .54, p < .001; r = - .56, p < .001; r = .61, p < .001, respectively). A measure of support from family and friends was also included in the interview at measurement waves 1, 2, and 4. This was a short form of Sarason's Social Support Questionnaire that was adapted for older people by Grant (Grant & Skinkle, 1988; Sarason et al., 1983). It asks people whom they would rely on for help and how satisfied they are with the help they receive in ten different social situations. Reliability for the quantitative scale was .94 (n = 40, Chronbach's alpha) and for the qualitative satisfaction scale was .91 (n = 63, Chronbach's alpha). No significant effects were obtained when the data from this measure were analyzed.
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Table 4. The Happiness of the Interviewable Residents as a Function of Group and Disease of the Circulatory System Across Time Measurement wave Croups Residents with disease of the circulatory system Relocation group (n = 7) Control group (n = 13) Other residents Relocation group (n = 20) Control group (n = 11)
1
2
3
4
1.13 0.87
1.21 1.14
0.98 1.14
1.32 0.98
0.87 1.46
1.00 1.42
1.06 1.52
0.96 1.44
Note. Scores that could range from 0 to 2 were obtained by averaging across the items of the MUNSH. Higher scores indicate greater happiness.
Altogether, there are so few statistically significant effects of the kind that would indicate that the relocation group as a whole or vulnerable subgroups of residents were stressed by the move that the results just discussed could have been Type I errors. In the third wave of interviews, residents were asked several open-ended questions designed to find out their immediate reaction to the move. Approximately onequarter of the interviewable residents (13 out of 51) said that they had been worried in the month prior to the move. The most common worries were whether their belongings would be packed properly and would not be lost (5 residents), and whether the quality of care would decline (3 residents). A third of the interviewable residents (17 of 51) stated that they had adjustment problems during the first month in the new facility. The three most common complaints were that they were unable to find their way around the new facility (4 residents), that they felt lonelier because family and friends were unable to visit as frequently as before (4 residents), and that they felt that the staff took longer to respond to their needs than in their old facility (4 residents). Finally, 38% of interviewable residents (19 of 50) stated that they would have liked more information about the new facility prior to the move. Information needs varied a great deal. However, the three most common were a need to know more about the general physical layout of the new facility (4 residents), the need to have more information about their own room (3 residents), and the need to know more about the other residents on their new wing (2 residents). Clearly, this group of residents were not expressing a great deal of upset over the move but rather minor concerns and a desire for more information about particular issues of personal importance. Health Information was collected on whether each resident had been diagnosed as having a new medical condition during the 7-month period under study. For most diagnostic categories, the incidence of a particular medical disorder during this period was too low to allow a meaningful comparison between the two nursing homes. However, marginally more relocated residents suffered a new medical condition than residents of the control nursing home (40.4% vs. 26.1%; x2 (1,N = 220) = 3.62, p < .06). The greater mental and physical frailty of the relocated residents could account for this difference. The most frequent new diagnoses for the relocated residents during the study period were diseases of the genitourinary tract (19 occurrences), diseases of the respiratory system (10 occurrences), bedsores (8 occurrences), diseases of the circulatory system (7 occurrences), and eye disorders (6 occurrences).
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up. In contrast, proportionately more younger residents were distressed at the second and third measurement points (immediately prior to and following the move). Turning to the nurses' ratings of the residents in the relocation group, the five subscales of the PAMIE that measured behavioral signs of psychological distress were analyzed to see whether the move affected the residents negatively. A main effect for time was obtained for the measure of belligerence and irritability; f(3,189) = 3.37, p < .05. However, this analysis was based upon the ratings of only 64 residents because this PAMIE subscale included items (such as "Doesn't make sense when she or he talks to you") that required the resident to speak. Excluding these items increased the sample size to 113 and, again, the main effect for the belligerent/irritable subscale was significant; F(3,336) = 6.04, p < .001. In both analyses, residents were described as less belligerent and irritable immediately following the move than at the other three measurement points. No significant effects were found for the other subscales. As well, no significant time-bydiagnosis interactions were obtained for these measures. Clearly, these results provide no support for the hypothesis that the move caused the residents to be stressed. Finally, the four indices of psychological distress (PSS, MUNSH, CES-D, and SE) obtained from the interviewable residents were analyzed. Complete data at all four measurement points on these measures were available from 27 to 30 residents in the relocation group and 22 to 24 residents in the control group. Again, nonsignificant groupby-time interactions suggested that the move was not felt to be stressful by this high-functioning group of residents. Significant time main effects showed that interviewable residents from both nursing homes felt more stressed, depressed, and less satisfied with life at the time of the first interview (just before or after Christmas) than at the other three measurement points; F(3,150) = 3.47, p < .05; F(3,144) = 2.79, p < .05; F(3,156) = 2.74, p < .05, respectively. As expected, residents with any sort of cognitive impairment were rarely judged to be interviewable by nursing staff. Therefore, the analyses of the data from the interviews could not include indices of cognitive impairment as an additional between-subjects factor in the design. For example, only two interviewable residents in the relocation group were judged to have communication problems due to cognitive impairment. However, a sizeable number of interviewable residents had serious medical conditions that limited their physical functioning. In particular, interviewable residents often had a disease of the circulatory system and, when this was included as a between-subjects factor, a marginally significant group-by-heart-conditionby-time interaction was obtained on the MUNSH; F(3,141) = 2.62, p < .06. Table 4 shows the means, which indicate that interviewable residents in the relocation group with a disease of the circulatory system (n = 7) felt most unhappy immediately following the move. Finally, when whether a resident was diagnosed as having a new medical condition during the study period was included as a factor, a time main effect, a group-by-time interaction, and a group-bytime-by-new-diagnosis interaction were obtained for the measure of perceived stress (PSS); F(3,129) = 5.59, p < .001; F(3,129) = 2.68, p < .05; F(3,129) = 2.75, p < .05, respectively. The pattern of means did not support the relocation stress hypothesis, however, as it showed a decline in perceived stress for the small number of residents in the control group (n = 5) who had contracted a new disorder. Very little variation in perceived stress occurred among the remaining residents from the control group or the relocation group.
ing this 6-year period and averaged 20 deaths every 6 months (R2= . 0 1 ; F < 1). Further, the 95% confidence interval around this mean value indicated that this mortality rate fluctuated between 9 and 31 deaths. Because the mortality rate in the 6 months before (30 deaths) and after the move (10 deaths) lie w i t h i n this confidence interval, the evidence suggests that there was neither a significant increase nor a significant decrease in mortality in the year surrounding the move. If these mortality rates are plotted against t i m e , it can be seen that they decrease in 1981 and then increase steadily over the next 5 years. A trend analysis shows that f r o m April 1982 to September 1986 the n u m b e r of deaths in these institutions increased, o n average, by o n e or t w o every 6 months (R2 = 68.6%; 5(1,7) = 15.32, p < .01). This trend analysis was used to calculate upper and lower limits to the death rates in the 6 months before and after the move. The range was calculated such that, if the identified trend c o n t i n u e d t h r o u g h o u t 1987, there w o u l d only be one chance in twenty that the actual mortality rate w o u l d lie outside these limits. The results suggest that there was no increase or decrease in the mortality rate in the 6 months prior t o the move. The actual n u m b e r of deaths in this period was 30, w h i c h lies w i t h i n the range of 20 to 31 deaths that were predicted. In contrast, the trend analysis suggests that the 10 deaths that occurred in the 6 months f o l l o w i n g the move was a significant d r o p in mortality. This is because this n u m b e r of deaths falls outside the 19 to 34 deaths that were predicted. I n d e e d , it lies outside the w i d e r range of 15 to 38 deaths, even t h o u g h there is less than one chance in a h u n d r e d that this w o u l d have occurred should the trend have continued.
Mortality
Other
The results of many studies have shown that relocation to a new institution rarely causes increased mortality. To see if this was also the case in this study, the number of deaths d u r i n g the 6 months prior to and f o l l o w i n g the move were compared to the number of deaths that w o u l d be predicted f r o m the c o m b i n e d mortality rates at the t w o older nursing homes d u r i n g the same 6-month periods since 1981 (Table 6). Using multiple regression, a trend analysis showed that this mortality rate was constant dur-
A n u m b e r of significant results show that residents w i t h a particular medical disorder or background characteristic differ in certain ways. Specifically, residents w i t h more medical disorders t o o k more prescription drugs; 5(1,192) = 12.64, p < .001. Those w h o developed a new medical c o n d i t i o n d u r i n g the study period were more likely to take antibiotics and had more m i n o r physical complaints recorded on their clinical record (5(1,191) = 9.96, p < . 0 1 ; 5(1,185) = 17.54, p < .001, respectively). Residents judged at admission to have c o m m u n i c a t i o n problems due to a cognitive impairment (including those w i t h an organic psychotic disorder) were described by nurses as more psychologically distressed o n the clinical record and rated as more mentally disorganized/confused and w i t h d r a w n / apathetic on the PAMIE (5(1,190) = 5.22, p < .05; 5(1,62) = 57.31, p < .001; 5(1,109) = 18.57, p < .001; respectively). However, they t o o k fewer drugs (particularly analgesics) and had fewer physical complaints (number of drugs — 5(1,190) = 7 . 4 0 , p < . 0 1 ; analgesics — 5(1,190) = 2 2 . 9 1 , p < .001; complaints — 5(1,185) = 4.88, p < .05). Residents diagnosed as clinically depressed were rated as more anxious/depressed by nursing staff; 5(1,112) = 5.08, p < .05. Residents w i t h a disease of the circulatory system t o o k more hypotensive drugs and were rated as more w i t h drawn/apathetic; 5(1,193) = 6.30, p < .05; 5(1,110) = 6.00, p < .05, respectively. Residents 80 years o l d or older were rated by nurses as more withdrawn/apathetic and mentally d i s o r g a n i z e d / c o n f u s e d , b u t less paranoid/suspicious (5(1,110) = 9.85, p < . 0 1 ; 5(1,62) = 18.49, p < .001; 5(1,49) = 4.24, p < .05, respectively). Finally, residents w i t h a paralytic syndrome (usually y o u n g men w h o had had a car accident) were less likely to be described as psychologically distressed or to be rated as mentally disorganized/
Table 5. Proportion of Residents Taking Analgesics as a Function of Group and Age Across Time Measurement wave Groups Older residents (80 + ) Relocation group (n = 51) Control group (n = 20) Younger residents (
Residents of two older nursing homes (n = 196) were relocated to a new 238-bed facility. A nonequivalent control group (n = 74) design with two pretests and two posttests was used to assess the impact of this move on their well-being and health. The relocated residents and control-group residents required a similar level of nursing care. Residents to be relocated participated in a preparation program designed to enhance their sense of control and predictability over the move. Analyses of medical records, nurses' ratings, and interviews strongly suggest that the move had no negative effect on the residents as a group or on vulnerable subgroups of residents. Key Words: Stress, Health, Well-being, Transfer
The Impact of an Interinstitutional Relocation on Nursing Home Residents Requiring a High Level of Care1
It seems clear from recent reviews of the relocation stress literature that moving elderly institutionalized residents into a new chronic care facility does not usually result in trauma serious enough to cause death (Coffman, 1981; Borup, 1982,1983; Borup & Gallego, 1981; Rowland, 1977). In particular, relatively recent studies in which nursing home residents were well prepared for a move into a better facility rarely found such an effect (Kasl & Rosenfeld, 1980). In our view, the lessons drawn from these reviews are that interinstitutional relocations are stressful but usually not life-threatening, and that the negative effects of this stressful experience can be minimized by preparing nursing home residents for the move (see also Kowalski, 1981). Nowadays, nursing staff usually develop preparation programs tailored to the particular needs of their residents and this was the case for the study reported here. It was designed, therefore, to test the less extreme relocation stress hypothesis that an interinstitutional relocation causes serious decrements in the psychological well-being and health of frail individuals who were prepared extensively for the move. In spite of the plausibility of this hypothesis, there is very little evidence that the well-being and health of nursing home residents are adversely affected by an interinstitutional relocation, regardless of the degree to which residents are prepared for the move. This is because the vast majority of the studies on interinstitutional relocation stress have used mortality rates as the sole dependent
1 Parts of this paper were presented at the 1988 annual meeting of the Gerontological Society of America, San Francisco, as part of a symposium entitled, "Planning and Evaluating the Relocation of Extended Care Residents." The authors thank the administration and board of the Parkridge Centre for their cooperation and support; Therese Chandra, Marilyn Bain, Christina Forster, and Natalie Polvie for their able assistance; and Gloria Gutman for continuing to provide her expertise and mentorship. department of Psychology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada S7N OWO. 3 Program evaluator, Career Placement Office, University of Western Ontario, London, Ontario, Canada. ••Department of Psychology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
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variable (Borup, 1982; Grant, 1985b; Kasl, 1972; Nirenberg, 1983). Table 1 shows the eleven studies that we were able to find that examined the effects of a relocation on the psychological well-being, health, and physical functioning of institutional residents. These studies are classified in terms of strength of the quasi-experimental design (nonequivalent pretest/posttest design with control group, pretest/posttest design, or posttest only design), degree of environmental change (moderate — moved to a new building with the same staff and resident, or radical — moved to new building with unfamiliar staff and residents), status of the residents (interviewable or not), and whether the residents were prepared for the move. First, consider the effects of a relocation on nursing home residents' psychological well-being. There appear to be very few negative effects following a moderate relocation (Bonardi, Pencer, & Tourigny-Rivard, 1989; Borup, 1982; Bourestom & Tars, 1974; Mirotznik & Ruskin, 1984, 1985; Nirenberg, 1983). In contrast, a more radical relocation, which results in a new social as well as physical milieu, usually results in psychological distress — indexed as lowered life satisfaction and increased levels of dependency, withdrawal, and depression (Anthony et al., 1987; Bourestom & Tars, 1974; Chanfreau et al., 1990; Wells & Macdonald, 1981). However, this negative effect is not always obtained. Some studies have shown no change (Borup, 1982), or even some positive change (Pihkanen & Lahdenpera, 1963; Pino, Rosica, & Carter, 1978) in response to such a relocation. Second, six studies have examined physical health using self-report and/or medical observations. Four of these studies were of a radical relocation and the residents were not prepared for the move. Of these, two found increased health problems following the move (Bourestom & Tars, 1974; Miller & Lieberman, 1965) and two did not (Borup, 1982; Borup, Gallego, & Heffeman, 1980; Pihkanen & Lahdenpera, 1963). The other two studies involved a less radical relocation and the residents were prepared for the move (Chanfreau et al., 1990; Mirotznik & Ruskin, 1984). No changes in health were observed. It seems that a radical relocation may affect health negatively, although this is by no means certain.
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Peter R. Grant, PhD,2 Rodney R. Skinkle, MA,3 and Garth Lipps, MA4
Table 1 . Studies that Have Examined the Impact of a Relocation on the Psychological Well-being, Health, and Functional Ability of Nursing Home Residents'
Citation
Design
Sample
Relocation
Preparation
Radical
No
Moderate
No
Anthony etal., 1987
Pretest/posttest with control
Bonardi, Pencer, & Tourigny-Rivard, 1989 Borup, Callego, & Heffernan, 1980; Borup,1982
Pretest/posttest with control
At-risk subsample Total population
Pretest/posttest with control
Interviewable
Moderate & Radical
No
Pretest/posttest with control
Interviewable
Moderate & Radical
No
Bourestom& Tars, 1974
Dependent variable Well-being, Functioning Well-being, Functioning Well-being, Health, Well-being, Hpalth
Moderate -» Radical
Yes
Functioning Well-being, Health,
Interviewable
Radical
No
Well-being,
Interviewable
Moderate
Yes
Nirenberg, 1983
Pretest/posttest with control & Pretest/posttest Pretest/posttest
Interviewable
Moderate
Yes
Well-being, Health Well-being,
Pihkanen & Lahdenpera, 1963
Posttest only
Total population
Radical
No
Well-being, Health,
Pino, Rosica, & Carter, 1978
Pretest/posttest with control
Interviewable
Radical
Both
Well-being,
Wells & Macdonald, 1981
Pretest/posttest
Interviewable
Radical
Yes
Well-being, Functioning
Chanfreau etal., 1990
Pretest/posttest with control
Total population
Miller & Lieberman, 1965
Pretest/posttest
Mirotznik & Ruskin, 1984,1985
Health
Third, a number of studies have measured the ability to perform a variety of everyday tasks using activity of daily living (ADL) scales. The results from most of these studies have shown no change over time for the relocated group (Anthony et al., 1987; Borup, Callego, & Heffernan, 1980; Bonardi, Pencer, & Tourigny-Rivard, 1989; Bourestom & Tars, 1974; Nirenberg, 1983; Pino, Rosica, & Carter, 1978; Pihkanen & Lahdenpera, 1963; Wells & Macdonald, 1981). Interpretation of this lack of change rests on the findings from the four studies that used control groups. Two found that the control group declined in functional abilities relative to the relocated group, suggesting that maintenance of physical functioning following the move was a positive effect (Borup, Callego, & Heffernan, 1980; Pino, Rosica, & Carter, 1978), and two found no difference between the activities of nursing home residents experiencing a moderate environmental change and the activities of a control group (Bonardi, Pencer, & Tourigny-Rivard, 1989; Bourestom & Tars, 1974). In contrast, Bourestom and Tars (1974) found a decline in the functional abilities of nursing home residents who had experienced a radical environmental change, and Chanfreau and her colleagues (1990) obtained an increase in physical dependency in a group of chronic psychiatric patients who were moved to a new hospital. On balance, however, it would seem that relocating to a new facility rarely impacts negatively on nursing home residents' functional abilities. In sum, it appears that moderate relocations involving a move to a new facility with familiar staff and residents do not have a negative effect. However, a more radical environmental change may cause psychological distress and health problems in the months following the move. In this regard it is interesting to contrast the results obtained by Borup (1982) and Bourestom and Tars (1974). In both of these studies, there was no preparation for the move and residents who had experienced a radical relocation were
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compared both with those who had experienced a moderate relocation and with a control group. Therefore, these studies provide the strongest evidence for or against the hypothesis that a radical relocation without preparation causes stress or health problems. The results of the two studies are contradictory. In general, the radical relocation group responded in the same way as the control group in Borup's (1982) study, but significantly worse in Bourestom and Tars' (1974) study. It may be that the negative effects obtained 1 month following the move by Bourestom and Tars would have dissipated after 3 to 6 months (the time period during which Borup administered his posttest measures). Indeed, there is evidence that the move is most stressful during the first 3 to 4 months following a relocation (see Rowland, 1977, for a review). However, the relocation may have been more radical and/or the residents more frail in Bourestom and Tars' study. Consistent with this reasoning, Bourestom and Tars found a significant increase in the mortality rate for the radical relocation group; Borup did not. In all but three of the research projects listed in Table 1, only interviewable residents were studied, and only one of these (Bonardi, Pencer, & Tourigny-Rivard, 1989) involved a large sample using a pretest/posttest with nonequivalent control group design. This is a serious limitation because residents who are interviewable are likely to be less frail, especially less mentally frail, than those who are not. The present study used a pretest/posttest quasi-experimental design with a control group to study the impact on all the residents of two older nursing homes of a relocation into a modern, state-of-the-art facility, the Parkridge Centre. The relocation was unique in that the residents were moved into a facility that was much bigger than their old residence and that contained a mixture of familiar and unfamiliar residents and staff. Thus, it was neither a moderate nor a radical environmental change but somewhere in between.
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•A study by Krai, Crad, and Berenson (1968) was omitted because it was unclear whether an interinstitutional relocation was being discussed. They found an increase in cortisol in the blood of men but not women from 1 week before to 1 to 2 weeks after the move.
Method Sample It was decided to examine the impact of the move on the entire resident population — the 196 residents who were living in the older 65-bed and 129-bed extended care facilities 3 months prior to the, move. Of these, 58 (29.6%) were judged by staff to be interviewable, and 47 (81.0%) of these were successfully interviewed at least twice. Of the remainder, three died and eight refused to be interviewed. Nurses' ratings were completed for 147 to 159 residents (75.0% to 81.1 %), depending on the measurement point, and medical records were coded for 157 residents (80.1%). Two samples were obtained from the control nursing home. The first consisted of 34 residents who were identified as interviewable by the nursing home staff. Of these, three died after the first interview. The second consisted of 40 noninterviewable residents who were matched to the relocated residents in terms of the incidence of an organic psychotic disorder and circulatory system problems. Thus, the residents of the control nursing home who took part in this study were not a representative sample of residents from this home; rather, they were chosen because they were similar to members of the relocation group.
The Similarity Between the Residents of the Two Nursing Homes
Characteristics of the Relocation Residents
Analyses were conducted to determine the extent to which the sample of residents of the control nursing home were similar to the relocation group 2 to 3 months prior to the move. In general, the results of these analyses showed that the two groups were quite similar. On average, they had a similar number of medical conditions and consumed a similar number of prescription drugs (x2 (1,227) = 1.79, ns; x2 (1,225) < 1, ns, respectively). Further, the incidence of two common types of medical disorders, diseases of the circulatory system and paralytic syndromes, did not differ (both x2(1,227) < 1 , n s ) . However, Table 2 shows that the relocation group was significantly more cognitively impaired. This is true whether the prevalence of senile dementia or communication problems due to cognitive impairment is considered (X2 (1, N = 227) = 5.16, p < .05; x2^,N = 227) = 4.59, p < .05, respectively). As well, the greater incidence of physical complaints (f(189) = 3.80, p < .01) and the greater use of antibiotics (x 2 (1, N = 225) = 6.26, p < .05) suggests that the relocation residents were physically more frail than control group residents. In view of these differences, special care was taken to consider the possible effects of cognitive
Detailed background information on the relocation residents 2 to 3 months prior to the move was obtained from their medical records. Their average age was 68 years, ranging from 18 to 102 years. Almost exactly half were male (49.4%). Approximately one-third of the relocated residents were married (35.2%) or widowed (32.7%), with the rest being single (23.9%) or separated/divorced (8.2%). Over one-third (37.9%) did not have children. Of the remainder, most had from one to four children with two being the modal number. Most commonly the designated family contact was a spouse (31.4%) or daughter (20.3%). Over 80% of the sample had been living in a nursing home for over a year prior to the relocation. Of the 28 residents who had been admitted recently, 10 (35.7%) came from hospital and 3 (10.7%) from a Geriatric Assessment Unit. Details on the income of one-third of the relocated residents were not available in their records. Of the remainder, 85.1% received the Canada Pension Plan — a federal pension plan to which all salaried Canadians are entitled. One-third (35.7%) had income from a private source. The relocation residents commonly had multiple health
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problems and required a high level of nursing care. Their medical charts showed that, on average, residents had almost four different medical conditions (ranging from 1 to 10). Some of the most frequent were senile dementia (29.7%); atherosclerosis (12.7%), cerebrovascular disease (27.8%), and other circulatory problems (16.5%); disorders of the eye such as glaucoma or cataracts (23.4%); hemiplegia or hemiparesis (17.7%), quadriplegia, paraplegia, or other paralytic syndromes (16.5%); arthritis (17.7%); epilepsy (13.9%); depression (12.0%); and diabetes (10.8%). Examination of the physical problems recorded in the daily nursing notes showed that, on average, residents had four (usually minor) physical complaints a month (range 0 to 15) such as colds and flu, fever and vomiting, headaches, constipation, cuts and bruises, and edema of the hand or foot. On average, residents took two to three different medications a day (range 0 to 11). The most common of these were central nervous system drugs: antidepressants (19.1%), tranquilizers (24.8%), sedatives (26.1%), analgesics and antipyretics (39.5%), and anticonvulsants (18.5%); cardiovascular drugs: cardiac drugs (10.2%) and hypotensive drugs (16.6%); autonomic drugs (19.7%); anti-infective agents: antibiotics (22.3%), ear, eye, or nose preparations (10.2%), and skin preparations (23.6%); and cough preparations (11.5%). The level of disability of the residents was very high with 32.9% of all residents being unable to attempt any activities of daily living such as bathing, eating, toileting, or dressing even when assisted. Indeed, three-quarters of the residents (74.0%) were bedridden or confined to a wheelchair and even more were incontinent (88.7%). A full 31.7% of the residents had to be toileted in bed because of severe physical disabilities. Very few residents (10.4%) could walk up a flight of stairs without help and almost none (2.6%) obtained their food tray from the dietary cart at meal times. One-third (35.7%) of the residents had one or both hands or arms paralysed or missing, and 41.8% had one or both feet or legs paralysed or missing. Communication problems were very prevalent. Almost two-thirds (64.3%) had communication problems because of cognitive impairment. However, vision problems (33.8%), hearing problems (31.2%) and speech problems (35.0%) also caused communication difficulties.
A program was designed to prepare the relocated residents and staff for the move. This program involved: consulting with the residents and their families on the location and color of their room and the packing of their belongings; tours of the new facility before and immediately after the move; and in-service training for the staff. We felt that it would be unethical not to provide a preparation program because of the degree of environmental change involved and because the residents were from nursing homes that specialized in looking after very frail chronic care residents requiring up to 90 minutes of nursing care per day. Indeed, 70% of the relocated residents were judged by staff to be noninterviewable. Therefore, residents would be at risk even if they were prepared adequately for the relocation. This ethical constraint made it impossible to evaluate the impact of the preparation program. Rather, the study examined the impact of the relocation on the psychological well-being, health, and mortality of residents who had received extensive preparation for the move.
Table 2. Differences Between the Relocation Group and the Control Group at the First Measurement Point
Croups Characteristics Indices of Mental Frailty Senile dementia Organic psychotic disorder Communication problems due to cognitive impairment Indices of Physical Frailty Antibiotics Number of physical problems Cough medication Other Differences Incontinence Speech problems Parkinson's disease Mental retardation
Relocation
Control
29.7% 32.3% 64.3%
14.5% 17.4% 41.4%
22.3% 3.93 11.5%
7.4% 2.58 1.5%
88.8% 35.0% 5.1% 8.9%
76.8% 17.1% 17.4% 0.0%
impairment and physical disability in the analyses that examined whether the relocation had an adverse effect. Research Design and Analysis Strategy Croup (relocation or control) and diagnostic category (present or absent) were the between-subjects factors in a split-plot factorial design. The within-subjects factor was time. We felt that it was important to examine the wellbeing and health of residents prior to making preparations for the move and just before it took place. Following the relocation, we wanted to document the immediate and long-term effects of the move itself. Thus, there were four measurement waves: 2 to 3 months prior to the move, just before the move, just after the move, and 3 months after the move. If the residents in the relocation group were adversely affected by the move, then a significant interaction between group and time should be obtained. If only a subset of relocation residents were adversely affected by the move, a three-way interaction should be obtained among group, diagnostic category, and time. For example, if residents with a heart condition were the only ones to be distressed by the move, then a significant three-way interaction would be obtained in a 2 (group) by 2 (diagnosis of a heart condition or not) by 4 (measurement wave) split-plot design. Due to sample size limitations, it was only possible to include one classification factor at a time in the split-plot design. This meant that negative effects on small groups of residents classified as members of two or more high-risk groups (e.g., very old residents with a heart condition) could not be examined. In addition, it meant that many analyses with the same dependent variables were repeated using different classification variables. This strategy increased the chance of detecting a negative effect should one occur, but also made it more likely that a "significant" finding would be detected that was due to chance factors rather than the stressful nature of the move. We deliberately chose this analysis strategy because we preferred to risk making a Type I rather than a Type II error. If the evidence supported the null hypothesis, we felt that it was important to feel confident that a negative effect of clinical significance had not gone undetected. To this end we also calculated the power of the main effects and interactions to detect a medium effect at a significance level of .05
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Research
Procedures
The general approach to measurement was to obtain multiple indicators of each resident's psychological wellbeing and health from medical records, nurses' ratings, and interviews with the residents. Residents' medical diagnoses at the first measurement point, their change of diagnoses over the study period, and their drug use at the four measurement points were all recorded by a trained coder with extensive medical experience. In addition, nursing notes were coded for indications of psychological distress and physical complaints during the month at each measurement point. The behavior of the relocation residents at the four measurement points was recorded by nurses on a number of rating scales. Nurses were trained to use the rating scales and then, at every measurement point, each nursing station was provided with booklets containing these scales. Nurses only rated residents with whom they had interacted during the previous week. Unfortunately, it was not possible to obtain similar ratings for residents of the control nursing home. Approximately one-third (29.6%) of the residents were judged by staff as being interviewable. The interviewers (primarily psychology students at the University of Saskatchewan) were introduced to each resident by a nurse on their ward and a convenient time for the interview was arranged. On average the interview took 1 hour (range 30 to 90 minutes). (Detailed analyses of the responses of the interviewable residents in this study are described in Skinkle, 1988.) Dependent Variables Medical Records. — Diagnoses were classified using the International Classification of Diseases (U.S. Department of Health and Human Resources, 1980) using a coding scheme developed by Grant (1985a, 1985b). This information was collected so that subgroups of residents with different medical problems could be examined to see if a particular kind of person was especially likely to be affected negatively by the move. As well, any change in diagnoses during the period under study was recorded. Drug use at the four measurement points was recorded from monthly medical charts using the classifications detailed in the Saskatchewan Formulary (1986) in a coding scheme developed by Grant (1985a, 1985b). The use of central nervous system drugs, such as tranquilizers, sedatives, and antidepressants, and of hypotensive drugs was of particular interest since they are medical indicators of stress. In addition, this scheme allowed nurses' notes on the medical charts to be coded for behavioral indications
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Note. The percentages and number of physical problems are based upon 129 to 158 residents in the relocation group and 62 to 70 residents in the control group. All differences are significant at the p < .05 level or better.
(Cohen, 1988). These calculations showed that the analyses of the medical records had very good power ( > .94). However, the power of the analyses involving the interview data was not very high ( > .70). Analyses of the nurses' ratings omitted the group factor. It had proved impossible to obtain these ratings in the control nursing home because of senior management's understandable reluctance to commit staff time to a project that did not directly benefit the institution. This meant that significant time main effects or diagnostic-categoryby-time interactions would be obtained if the relocation had negative effects. The power to detect a medium effect of this kind at the p < .05 level was very good ( > .89). Finally, institutional records allowed the mortality rate of the relocation group during the 6 months prior to and following the move to be compared with mortality rates over the previous 5 years using multiple regression.
of psychological distress (e.g., unable to sleep, confused, upset, weepy, anxious, worried, irritable, agitated, uncooperative, wanders, hostile toward other residents or staff), and the incidence of relatively minor health problems (e.g., cold, flu, infection, swollen ankles, indigestion, headache, and arthritis flare-up).
The Interview Schedule. — The Perceived Stress Scale (PSS), the Memorial University of Newfoundland Scale of Happiness (MUNSH), Radloff's CES-D Depression Scale, and Rosenberg's Self-Esteem Scale (SE) were the measures that formed the basis of the interview at the four measurement points. All but the PSS have been used in the past with both older and younger people and are wellestablished measures (Cohen, Kamarck, & Mermelstein, 1983; Kozma & Stones, 1980; Radloff, 1977; Rosenberg, 1965). The Perceived Stress Scale is a relatively new scale that measures the extent to which people feel upset, distressed, and overwhelmed by the events in their life (Cohen, Kamarck, & Mermelstein, 1983). The major reason for including this scale was that it seems to measure the distress people feel when they believe that their life is slipping out of their control. Pilot testing in trial interviews showed that the nursing home residents (from the control nursing home) understood the items and felt they were relevant to their experience. This was born out in the actual study as residents in both nursing homes had no difficulty with this scale and it proved to be reliable (a = .75, n = 69, Time 1). The MUNSH assesses happiness and satisfaction with life. It was developed for use with older people and is a direct measure of psychological well-being (Kozma & Stones, 1980). Radloff's CES-D scale measures nonclinical depression in the general population (Radloff, 1977). This instrument measures how much a person is feeling "blue" or " d o w n " because of difficult life circumstances. Rosenberg's (1965) Self-Esteem Scale measures how positively persons evaluate themselves, that is, to what extent they feel that they are worthwhile persons. Evidence that all these scales were responded to mean-
Results
Psychological Distress The major focus of this study was on documenting whether the move caused psychological distress during the first 3 months in the new facility. The evidence from the medical records and nursing notes shows that the move caused very little psychological distress. In particular, no significant group-by-time interactions were obtained for a measure of the use of tranquilizers and sedatives or the use of hypotensive drugs; F(3,585) = 1.93, ns; F(3,585) < 1 , respectively. Detailed analyses examined whether certain groups of residents might be particularly likely to suffer adversely from the move, but again no evidence of an increase in the use of tranquilizers and sedatives or of hypotensive drugs was obtained. The incidence of signs of psychological distress recorded in the nurses' notes on each resident's medical chart were also analyzed and a group main effect qualified by a group-by-time interaction was obtained; F(1,195) = 16.64, p < .001; 5(3,573) = 3.64, p < .05. Table 3 shows the means, which indicate that proportionately more residents in the relocation group experienced psychological distress immediately following the move and that this increase declined back to the premove baseline after 3 months in the new facility. Only one variable, age, qualified the group-by-time interaction; F(3,573) = 5.24, p < .001 (Table 3). In comparison to the premove baseline, proportionately more relocated residents who were 80 years old or older were described as psychologically distressed by nursing staff both immediately and at the 3-month follow-
Table 3. Proportion of Psychologically Distressed Residents as a Function of Group and Age Across Time
Measurement wave Croups Total sample Relocation group (n = 135) Control group (n = 62) Old residents (80 + ) Relocation group (n = 51) Control group (n = 20) Younger residents Relocation group (n = 82) Control group (n = 42)
1
2
3
4
.53 .44
.57 .31
.65 .32
.59 .39
.59 .60
.55 .45
.75 .30
.73 .30
.49 .36
.59 .24
.59 .33
.49 .43
Note. Whether a resident was psychologically distressed was determined from the nursing notes.
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The Behavioral Rating Scale. — The nurses used a multidimensional assessment instrument called the Physical and Mental Impairment-of-Function Evaluation (PAMIE; Gurel, Linn, & Linn, 1972). It has several scales that measure behavioral manifestations of mental disorganization/ confusion (a = .92, n = 83, Time 1), anxiety/depression (a = .72, n = 117, Time 1), withdrawal/apathy (a = .85, n = 118, Time 1), paranoia/suspicion (a = .74, n = 107, Time 1), and belligerence/irritability (a = .92, n = 108, Time 1). These scales have been used by Wells and Macdonald (1981) to study an interinstitutional relocation of extended care residents in a Canadian context. Two rating scales were used to track changes in the residents' functional abilities by measuring their ability to perform various activities of daily living. The first was a sixitem ADL scale developed by Katz (Katz et al., 1970). It was scored by summing the ratings on the individual items with a high score indicating a high level of disability (a = .86, n = 155, Time 1). The second was the self-care subscale of PAMIE (a = .74, n = 153, Time 1). Consistent with the majority of studies that were reviewed in the introduction, there was no change in the relocation group's ability to perform simple ADLs during the study period. This finding must, however, be regarded with caution because nurses' ratings of functional ability were not obtained for the control group.
ingfully by residents is shown by the fact that they were found to be reliable and that they related to each other in expected ways. For example, residents with low selfesteem tended to be depressed and less satisfied with life, and to feel more stressed (r = .54, p < .001; r = - .56, p < .001; r = .61, p < .001, respectively). A measure of support from family and friends was also included in the interview at measurement waves 1, 2, and 4. This was a short form of Sarason's Social Support Questionnaire that was adapted for older people by Grant (Grant & Skinkle, 1988; Sarason et al., 1983). It asks people whom they would rely on for help and how satisfied they are with the help they receive in ten different social situations. Reliability for the quantitative scale was .94 (n = 40, Chronbach's alpha) and for the qualitative satisfaction scale was .91 (n = 63, Chronbach's alpha). No significant effects were obtained when the data from this measure were analyzed.
Vol. 32, No. 6,1992
Table 4. The Happiness of the Interviewable Residents as a Function of Group and Disease of the Circulatory System Across Time Measurement wave Croups Residents with disease of the circulatory system Relocation group (n = 7) Control group (n = 13) Other residents Relocation group (n = 20) Control group (n = 11)
1
2
3
4
1.13 0.87
1.21 1.14
0.98 1.14
1.32 0.98
0.87 1.46
1.00 1.42
1.06 1.52
0.96 1.44
Note. Scores that could range from 0 to 2 were obtained by averaging across the items of the MUNSH. Higher scores indicate greater happiness.
Altogether, there are so few statistically significant effects of the kind that would indicate that the relocation group as a whole or vulnerable subgroups of residents were stressed by the move that the results just discussed could have been Type I errors. In the third wave of interviews, residents were asked several open-ended questions designed to find out their immediate reaction to the move. Approximately onequarter of the interviewable residents (13 out of 51) said that they had been worried in the month prior to the move. The most common worries were whether their belongings would be packed properly and would not be lost (5 residents), and whether the quality of care would decline (3 residents). A third of the interviewable residents (17 of 51) stated that they had adjustment problems during the first month in the new facility. The three most common complaints were that they were unable to find their way around the new facility (4 residents), that they felt lonelier because family and friends were unable to visit as frequently as before (4 residents), and that they felt that the staff took longer to respond to their needs than in their old facility (4 residents). Finally, 38% of interviewable residents (19 of 50) stated that they would have liked more information about the new facility prior to the move. Information needs varied a great deal. However, the three most common were a need to know more about the general physical layout of the new facility (4 residents), the need to have more information about their own room (3 residents), and the need to know more about the other residents on their new wing (2 residents). Clearly, this group of residents were not expressing a great deal of upset over the move but rather minor concerns and a desire for more information about particular issues of personal importance. Health Information was collected on whether each resident had been diagnosed as having a new medical condition during the 7-month period under study. For most diagnostic categories, the incidence of a particular medical disorder during this period was too low to allow a meaningful comparison between the two nursing homes. However, marginally more relocated residents suffered a new medical condition than residents of the control nursing home (40.4% vs. 26.1%; x2 (1,N = 220) = 3.62, p < .06). The greater mental and physical frailty of the relocated residents could account for this difference. The most frequent new diagnoses for the relocated residents during the study period were diseases of the genitourinary tract (19 occurrences), diseases of the respiratory system (10 occurrences), bedsores (8 occurrences), diseases of the circulatory system (7 occurrences), and eye disorders (6 occurrences).
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up. In contrast, proportionately more younger residents were distressed at the second and third measurement points (immediately prior to and following the move). Turning to the nurses' ratings of the residents in the relocation group, the five subscales of the PAMIE that measured behavioral signs of psychological distress were analyzed to see whether the move affected the residents negatively. A main effect for time was obtained for the measure of belligerence and irritability; f(3,189) = 3.37, p < .05. However, this analysis was based upon the ratings of only 64 residents because this PAMIE subscale included items (such as "Doesn't make sense when she or he talks to you") that required the resident to speak. Excluding these items increased the sample size to 113 and, again, the main effect for the belligerent/irritable subscale was significant; F(3,336) = 6.04, p < .001. In both analyses, residents were described as less belligerent and irritable immediately following the move than at the other three measurement points. No significant effects were found for the other subscales. As well, no significant time-bydiagnosis interactions were obtained for these measures. Clearly, these results provide no support for the hypothesis that the move caused the residents to be stressed. Finally, the four indices of psychological distress (PSS, MUNSH, CES-D, and SE) obtained from the interviewable residents were analyzed. Complete data at all four measurement points on these measures were available from 27 to 30 residents in the relocation group and 22 to 24 residents in the control group. Again, nonsignificant groupby-time interactions suggested that the move was not felt to be stressful by this high-functioning group of residents. Significant time main effects showed that interviewable residents from both nursing homes felt more stressed, depressed, and less satisfied with life at the time of the first interview (just before or after Christmas) than at the other three measurement points; F(3,150) = 3.47, p < .05; F(3,144) = 2.79, p < .05; F(3,156) = 2.74, p < .05, respectively. As expected, residents with any sort of cognitive impairment were rarely judged to be interviewable by nursing staff. Therefore, the analyses of the data from the interviews could not include indices of cognitive impairment as an additional between-subjects factor in the design. For example, only two interviewable residents in the relocation group were judged to have communication problems due to cognitive impairment. However, a sizeable number of interviewable residents had serious medical conditions that limited their physical functioning. In particular, interviewable residents often had a disease of the circulatory system and, when this was included as a between-subjects factor, a marginally significant group-by-heart-conditionby-time interaction was obtained on the MUNSH; F(3,141) = 2.62, p < .06. Table 4 shows the means, which indicate that interviewable residents in the relocation group with a disease of the circulatory system (n = 7) felt most unhappy immediately following the move. Finally, when whether a resident was diagnosed as having a new medical condition during the study period was included as a factor, a time main effect, a group-by-time interaction, and a group-bytime-by-new-diagnosis interaction were obtained for the measure of perceived stress (PSS); F(3,129) = 5.59, p < .001; F(3,129) = 2.68, p < .05; F(3,129) = 2.75, p < .05, respectively. The pattern of means did not support the relocation stress hypothesis, however, as it showed a decline in perceived stress for the small number of residents in the control group (n = 5) who had contracted a new disorder. Very little variation in perceived stress occurred among the remaining residents from the control group or the relocation group.
ing this 6-year period and averaged 20 deaths every 6 months (R2= . 0 1 ; F < 1). Further, the 95% confidence interval around this mean value indicated that this mortality rate fluctuated between 9 and 31 deaths. Because the mortality rate in the 6 months before (30 deaths) and after the move (10 deaths) lie w i t h i n this confidence interval, the evidence suggests that there was neither a significant increase nor a significant decrease in mortality in the year surrounding the move. If these mortality rates are plotted against t i m e , it can be seen that they decrease in 1981 and then increase steadily over the next 5 years. A trend analysis shows that f r o m April 1982 to September 1986 the n u m b e r of deaths in these institutions increased, o n average, by o n e or t w o every 6 months (R2 = 68.6%; 5(1,7) = 15.32, p < .01). This trend analysis was used to calculate upper and lower limits to the death rates in the 6 months before and after the move. The range was calculated such that, if the identified trend c o n t i n u e d t h r o u g h o u t 1987, there w o u l d only be one chance in twenty that the actual mortality rate w o u l d lie outside these limits. The results suggest that there was no increase or decrease in the mortality rate in the 6 months prior t o the move. The actual n u m b e r of deaths in this period was 30, w h i c h lies w i t h i n the range of 20 to 31 deaths that were predicted. In contrast, the trend analysis suggests that the 10 deaths that occurred in the 6 months f o l l o w i n g the move was a significant d r o p in mortality. This is because this n u m b e r of deaths falls outside the 19 to 34 deaths that were predicted. I n d e e d , it lies outside the w i d e r range of 15 to 38 deaths, even t h o u g h there is less than one chance in a h u n d r e d that this w o u l d have occurred should the trend have continued.
Mortality
Other
The results of many studies have shown that relocation to a new institution rarely causes increased mortality. To see if this was also the case in this study, the number of deaths d u r i n g the 6 months prior to and f o l l o w i n g the move were compared to the number of deaths that w o u l d be predicted f r o m the c o m b i n e d mortality rates at the t w o older nursing homes d u r i n g the same 6-month periods since 1981 (Table 6). Using multiple regression, a trend analysis showed that this mortality rate was constant dur-
A n u m b e r of significant results show that residents w i t h a particular medical disorder or background characteristic differ in certain ways. Specifically, residents w i t h more medical disorders t o o k more prescription drugs; 5(1,192) = 12.64, p < .001. Those w h o developed a new medical c o n d i t i o n d u r i n g the study period were more likely to take antibiotics and had more m i n o r physical complaints recorded on their clinical record (5(1,191) = 9.96, p < . 0 1 ; 5(1,185) = 17.54, p < .001, respectively). Residents judged at admission to have c o m m u n i c a t i o n problems due to a cognitive impairment (including those w i t h an organic psychotic disorder) were described by nurses as more psychologically distressed o n the clinical record and rated as more mentally disorganized/confused and w i t h d r a w n / apathetic on the PAMIE (5(1,190) = 5.22, p < .05; 5(1,62) = 57.31, p < .001; 5(1,109) = 18.57, p < .001; respectively). However, they t o o k fewer drugs (particularly analgesics) and had fewer physical complaints (number of drugs — 5(1,190) = 7 . 4 0 , p < . 0 1 ; analgesics — 5(1,190) = 2 2 . 9 1 , p < .001; complaints — 5(1,185) = 4.88, p < .05). Residents diagnosed as clinically depressed were rated as more anxious/depressed by nursing staff; 5(1,112) = 5.08, p < .05. Residents w i t h a disease of the circulatory system t o o k more hypotensive drugs and were rated as more w i t h drawn/apathetic; 5(1,193) = 6.30, p < .05; 5(1,110) = 6.00, p < .05, respectively. Residents 80 years o l d or older were rated by nurses as more withdrawn/apathetic and mentally d i s o r g a n i z e d / c o n f u s e d , b u t less paranoid/suspicious (5(1,110) = 9.85, p < . 0 1 ; 5(1,62) = 18.49, p < .001; 5(1,49) = 4.24, p < .05, respectively). Finally, residents w i t h a paralytic syndrome (usually y o u n g men w h o had had a car accident) were less likely to be described as psychologically distressed or to be rated as mentally disorganized/
Table 5. Proportion of Residents Taking Analgesics as a Function of Group and Age Across Time Measurement wave Groups Older residents (80 + ) Relocation group (n = 51) Control group (n = 20) Younger residents (
