Melrose, S. (2004). Reducing relocation stress syndrome in long term care facilities. Journal of Practical Nursing 54(4), 15-17.
Current literature reflects that relocation stress syndrome is a real (Morse, 2000) and valid (Mallick & Whipple, 2000) disorder where individuals experience difficulty coping with the process of relocating from a familiar secure environment to one that is unfamiliar. Traditionally known as “transfer anxiety” the condition has been an accepted nursing diagnosis in the North American Nursing Diagnosis Association (NANDA) classification scheme (2001) since 1992.
Relocation stress syndrome can be defined as “physiologic and/or psychosocial disturbances as a result of transfer from one environment to another” (Manion & Rantz, 1995, p. 108). According to Brugler, Titus, and Nypaver (1993) all individuals involved in the relocation are at risk of developing this human reaction, including family members.
Dependency, confusion, anxiety, depression and withdrawal are the five defining characteristics of relocation stress syndrome (Mallick & Whipple, 2000). Jackson, Swanson, Hicks, Prokop, & Laughlin (2000) suggested that symptoms of anxiety, depression, apprehension, loneliness and increased confusion occur 80% of the time. Sad affect, withdrawal, sleep disturbances, weight loss and gastrointestinal upsets occur 50% to 70% of the time (Jackson et al, 2000).
When older adults find themselves in the position of requiring institutional long-term care, they arrive at their new home under some of the most vulnerable circumstances of an individual’s life (Kao, Travis & Acton, 2004). Seeking to understand what relocation stress syndrome might look like and how staff can help to reduce that stress is an important responsibility for nurses.
What Does Relocation Stress Syndrome Look Like?
Before During and After Relocating
The human dynamics of relocating arc complex and different issues emerge for residents and their families at different times. Kao, Travis and Acton (2004) summarized that adults moving to long term facilities progress through three phases; pre-institutionalization, transitional, and post-institutionalization.
Whether residents experienced this phase as a result of transferring from a hospital or arriving directly from their own home, the choices and decisions required can be overwhelming.
In the first, pre-institutional phase, selling a home and relinquishing personal belongings stimulate feelings of loss and grief. Similarly, legal decisions such as advance directives and power of attorney designations can stimulate feelings of depression and powerlessness. Whether residents experienced this phase as a result of transferring from a hospital or arriving directly from their own home, the choices and decisions required can be overwhelming.
Long term care accommodation may not be available in residents’ home communities and their request for a particular facility may not have been granted. In addition, family members may also be coping with feelings of stress and guilt due to placement activities (Kao, Travis & Acton, 2004). While nursing staff are not usually involved with residents and their families during this chaotic time, it is important to imagine the physical and mental exhaustion that residents and their families go through.
The First Three Months
In the second phase, a time of transition, older adults’ feelings of helplessness, abandonment and vulnerability arc the most acute. Immediately after institutionalization and for as long as three months, residents may respond with anger and a sense of injustice (Jackson et ah, 2000). Negative responses are especially common among involuntarily admitted residents.
Iwasiw, Goldenberg, Bol & MacMaster (2003) also identified that the majority of residents in their research study appraised the long term care facility the most negatively at three months. Reasons for these residents’ negativity, in part, related to feeling that staff did not acknowledge their former roles, through which they contributed to their families and society, and this reinforced their loss of social status and role.
Further, during this time of transition, families may also be disturbed by the physical, social and emotional changes in their loved one and may question the placement decision. Thus, knowing that emotional concerns for residents and their families are expected to be heightened around three months after admission, it is useful to flag this particularly vulnerable time for residents and plan extra time for listening and collaborative problem solving.
The First Year
The third, post-institutional phase is an adjustment expected to last at least one year. Key psychological issues for residents in this phase include seeking a sense of control over their new environment, establishing an identity in that new environment and remaining connected to family and friends. Mikhail (1992) emphasized how it is loss of control that sustains residents’ anger and allows conflicts regarding care to arise. When older adults with cognitive impairment relocate, the process can become even more challenging as difficulties with remembering and making decisions make it hard for residents to settle in and initiate new social relationships.
Offering residents and their families’ choices whenever possible is essential. Also, facilitating communication among residents, families and staff is critical. Frequent team meetings and individualized care plans that keep medical and nursing records up to date and well-organized will greatly reduce relocation stress syndrome (Iwasiw el al, 2003; Kao, Travis & Acton, 2004; and Morse, 2000). Modifying the institutional environment in response to individual’s usual habits and acknowledging residents’ personal histories, values and preferences will help.
Implications for Practice
Although many residents, family members and caregivers may expect the stress of relocation to diminish once an older adult has become oriented to their new home, clinical symptoms related to the syndrome may continue throughout the first year. The process of settling in is seldom straightforward. Recognizing and accepting that physical and psychological disturbances are expected to emerge can help. Negative responses precipitated by fatigue and sensory overload are anticipated and nurse responses that reflect patience and compassion are invaluable.
Most residents will have had limited if any opportunities to tour their new home, meet their new “family” and attend facility activities before they are actually admitted. While choices related to many aspects of the move and the way the institution must be managed are non-negotiable for residents, they are entitled to control over their personal space. Offer choices of where personal belongings will be placed and define physical boundaries to provide privacy.
Offering residents and their families choices whenever possible is essential. Also, facilitating communication among residents, families and staff is critical.
Provide opportunities for residents to exert control by offering opportunities to choose from different selections of healthy food and fluid items. Identify individual likes and dislikes, invite suggestions for meal planning and whenever possible, involve residents in activities such as setting the table and food preparation.
Find out the name residents prefer to be addressed by and ensure that this information is communicated to all staff. While some individuals enjoy the informality of being called by their first name or even a nickname, others find that this practice heightens their feelings of powerlessness. Titles such as Mr., Mrs., Dr., or non-English forms of address may remind residents of their former roles.
Other opportunities to offer choices to residents include inviting them to decide which clothes they wish to wear and which activities they would or would not like to be involved in. Encouraging residents’ to assess optimum times for prn medication and then consistently responding to their instruction can reduce anxiety and promote trust.
Promote Personal Identity
Create an ongoing biography or “life-story” scrapbook style document and keep it on display in residents’ rooms. Involve family members in the project and ensure that supplies such as paper and glue are on hand whenever visitors arrive. Include pictures and descriptions of residents, their past and present achievements and their family members. Add signatures and brief excerpts from greeting cards or flower bouquets that arc sent in and children’s drawings for color. For many residents and their families, the experience of piecing the collection together during visits can be a relaxing process.
Document past experiences residents have had with loss and abandonment in the assessment area of their chart. It is not necessary for nursing staff to complete comprehensive psychological explorations; issues related to loss and abandonment often comes up during everyday conversation. For example, childhood experiences of “being left,” the deaths of parents, family and friends, divorce or living through catastrophic events such as a war or natural disaster.
What is particularly important about these experiences is to label the processes and strategies individuals used to cope during and after the event. Tor example, asking: “How did you get through that?” provides important insight into ways of handling stress. Reminiscing about previous success during stressful situations reminds residents of their strengths and in turn illustrates those strengths to caregivers.
When residents express feelings of sadness, loneliness and anger, it can be difficult for family members and caregivers to hear. However, venting emotions, whether they are positive or negative, is a healthy response to stress. Rather than distracting from or invalidating residents’ feelings by trying to cheer them up, it is important to encourage honest discussion. Iwasiw et al (2003) emphasized that listening to residents and providing opportunities to talk about their feelings helped meet their needs to maintain an identity and dignify them as individuals.
Maintaining relationships with family and friends for new residents of long-term care facilities can be stressful. Symptoms of depression, such as withdrawal and disinterest in activities usually enjoyed can precipitate behaviors such as avoiding others, not returning telephone calls and declining invitations to go out. However, friends and family offer emotional strength and motivation, so facilitating communication within these relationships is therapeutic.
Provide hosting areas where residents can offer visitors simple refreshments like tea, coffee or juice. As much as their physical conditions will allow, encourage residents to organize the serving and seating arrangements they prefer for their guests. If the cost of providing light refreshments is an issue, provide a discreet container where guests can drop coins to pay for the supplies. Feeling unable to host guests can be a deterrent to maintaining precious relationships.
Initiate communication with residents’ family members and friends by inviting them to join care planning meetings. Write down comments visitors make about residents’ likes and dislikes as they are shared and later transfer the information to the chart. The process of recording comments while an individual is speaking can be very affirming. When visitors sense that the information they offer is acted on, they are more likely to remain involved.
Similarly, invite visitors to participate in any social activities available at the facility and ask for their help in making the event a success. Sign up sheets for tasks or items to bring promote commitment and increase attendance.
Support groups for family and friends can ease the stress of relocation as well. Establishing a consistent time and place each week where residents’ loved ones can speak freely and discuss their concerns can alleviate anxiety. Often, visitors develop friendships during these meetings, making coming to the facility a pleasant experience.
Listening intentionally; offering choices, promoting personal identity and reinforcing residents’ own coping strategies can significantly lesson the trauma.
Relocation stress syndrome is a potential problem for residents, their families and their caregivers. Both physical and emotional responses attributed to this disturbance may occur throughout the first year after moving to a long term care facility. In particular, new residents and their loved ones may express negative feelings during the first three months. Listening intentionally, offering choices, promoting personal identity and reinforcing residents’ own coping strategies can significantly lesson the trauma. Recognizing relocation stress syndrome and providing empathetic, well documented and person centered nursing care is both a challenge and an opportunity for Licensed Practical Nurses.
Brugler, C., Titus, M., Nypaver, J. (1993). Relocation stress syndrome: A patient and stall approach. JONA, 23(1), 335-361.
Iwasiw, C, Goldenberg, D., Bol, N., MacMastcr, L. (2003). Resident and family perspectives: The first year in a long-term care facility. Journal of Gerontological Nursing, 29(1), 45-57.
Jackson, B., Swanson, C., Hicks, L.E, Prokop, L., & Laughlin, J. (2000). Bridge of continuity from hospital to nursing home-Part 1: A proactive approach to reduce relocation stress syndrome in the elderly. Continuum (Society for Social Work Leadership in Health Care), 20(1), 3-8.
Kao, II., Travis, S., Acton, G. (2004). Relocation to a long-term care facility: Working with patients before, during and after. Journal of Psychosocial Nursing and Mental Health Services, 42(3), 10-17.
Mallick, M.J., Whipple, T.W. (2000). Validity of the nursing diagnosis of relocation stress syndrome. Nursing Research, 49(2), 97-100.
Manion, P. S., & Rantz, M.J. (1993). Relocation stress syndrome: A comprehensive plan for long-term care admissions. Geriatric Nursing, 16(3), 108-112.
Mikhail, M.L. (1992). Psychological responses to relocation to a nursing home. Journal of Gerontological Nursing, 18(3), 35-39.
Morse, D. (2000). Relocation stress syndrome is real. American Journal of Nursing, 100(8), 24AAAA-24BBBB, 24DDDD.
North American Nursing Diagnosis Association. (2001). NANDA nursing diagnoses: Definitions and Classification, 2001-2002. Philadelphia: Author.