Relocation stress in long term care: How staff can help

Relocation stress in long term care: How staff can help
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Citation

Melrose, S. (2013). Relocation stress in long term care: How staff can help. Canadian Nursing Home, 24(1), 16-19.

Abstract

Relocating can be stressful and even traumatic for older adults, particularly when the relocation is involuntary. Reports that relocating older people is detrimental to their well being, health and survival are well documented (Holder and Jolley, 2012). For over two decades, relocation stress, previously known as Relocation Stress Syndrome, has been recognized as a real and approved nursing diagnosis (Morse, 2000; NANDA, 1992). And yet, supporting residents through the stress and trauma of relocating remains a challenge. This article defines relocation stress and suggests that gathering resources, extending a minimum four month welcome, and celebrating contentment can help.

Relocation stress was first defined as a syndrome where “physiological and/or psychosocial disturbances [were] a result of transfer from one environment to another” (Manion and Rantz, 1995). Later, the North American Nursing Diagnosis Association (NANDA) specifically connected the condition with admissions to long-term care and transfers between health care facilities, adapting the definition to “the physiologic and psychosocial disturbances caused by change in health care environment” (Carpenito-Moyet, 2007). Relocation stress is also known as transfer anxiety or even transfer trauma when the move is involuntary and outcomes are negative (Hodgson, et al., 2004).

Defining characteristics

Major defining characteristics of relocation stress are loneliness, depression, anger, apprehension and anxiety, while minor characteristics are changes in former eating and sleeping habits, dependency, insecurity, lack of trust and a need for excessive reassurance (Carpenito-Moyet, 2007). These characteristics are most pronounced during the first four months after arrival (Laughlin, et al., 2007).

Although associations between relocating and stress are well established, researchers have questioned the validity of relocation stress as a nursing diagnosis (Mallick and Whipple, 2000). Critical concerns have been raised that what “appears to be relocation stress syndrome may be a pre-existing, undiagnosed, and untreated endogenous depression, exacerbated by relocation” (Walker, et al., 2007). Clearly a key issue in any discussion of relocation stress is accurate assessment.

Prevalence in LTC

Residents in care facilities experience a high prevalence of endogenous depression (See box below), with the symptoms all too often undetected (Melrose, 2006).

Similarly, residents relocating also experience a high prevalence of adjustment disorders that go undetected (Maercker, et al., 2008). However, it is overly simplistic to assume that expressions of loneliness, depression and anxiety are linked solely to the stress of relocating.

Research reporting the effects of relocating older adults provides varied results. In one study where institutionalized residents were relocated suddenly and involuntarily, 45.8% died within the first year (Laughlin, et al., 2007).

Residents who are particularly vulnerable to mortality are those with low physical functioning (Borup, et al., 1980), women (Hertz, et al., 2008), and those over age 85 (Laughlin, et al., 2007).

Residents relocating from home to LTC found the changes impacted their sense of control, their self identity and their self worth, particularly as they adapted to the lack of privacy and sought to make new friends (Donald, et al., 2009). Sharing space and feeling safe with strangers was stressful (Piekarski, 2008). The psychological transition associated with relocating was highly stressful (Ellis, 2010).

Endogenous depression

Also known as unipolar depression, endogenous depression is a sub-categorization of general depression. It is based on the belief that the source of the disorder was internal, or endogenous, meaning that it was caused by factors inside the organism. Endogenous depression, therefore, was considered biological depression, as opposed to depression brought on by stressful events, known as reactive depression. Reactive depression occurs due to a stressful event, whereas endogenous depression may have no external cause or trigger.

Some of the characteristic features of endogenous depression include insomnia, depleting energy level, inability to focus or poor concentration, problems remembering and memorizing, and lack of interest in any form of physical activity.

“Upsetting and chaotic”

Even when residents and their families perceived the new location as a better facility, many describe the process of relocating as “upsetting and chaotic” (Capezuti, Boltz and Renz, 2004).

On the other hand, researchers have also indicated that the effects of relocating can be minimal, for example, residents experiencing only small changes in cognitive performance, depression, and social engagement (Castle, 2005). However, while reports on the extent of physiological and psychosocial disturbances may not be consistent, relocating can be expected to impact residents’ quality-of-life.

Priority for care staff

Family members are also impacted when their loved ones experience relocation stress (Ellis, 2010; Mintz, 2005). Prior to a long-term care admission, families may have already assisted their spouse or parent with a series of relocations. For example, moving from house to apartment, moving from living independently to an assisted living facility, and moving from unit to unit following hospital admissions.

Family members can be expected to have accompanied their loved one to numerous appointments with health professionals and to have reiterated the presenting of health concerns to a variety of individuals from different agencies.

Remaining connected to family can support residents’ ability to cope with relocating (Iwasiw, et al., 2003; Kao, Travis and Acton, 2004). However, family members also need respite from the stress of relocating their loved one. Helping relocated residents and their families cope should be a priority for long-term care staff.

Gathering resources

An important first step that management can take in supporting staff as they help residents and families cope with relocation is to gather resources geared to both professional caregivers and the lay public.
These supportive resources include:

Professional guidelines:

For professional staff, evidence-informed guidelines such as Management of Relocation in Cognitively Intact Older Adults delineate practices that help cognitively intact older adults successfully relocate (Hertz, et al., 2005). A summary of these guidelines is provided in a subsequent publication (Hertz, et al., 2007).

These guidelines are presented in two components. The first identifies risks for ‘relocating and planning for a move.’

The second component targets postrelocation and includes planning and facilitation of adjustment to the move. Useful, practical and efficient flowsheets are included for both components.

While the pre-location or pre-placement flowsheets may not be immediately relevant to long-term care staff receiving a new resident, staff as well as families would value knowing assessment points to consider. Once resources such as these guidelines with their pre-made flow sheets have been acquired, incorporating them into existing assessment protocols becomes more manageable.

Public/professional fact sheets:

Using bulletin boards to post pre-made fact sheets summarizing the characteristics of relocation stress can be an effective method of raising awareness. For paraprofessional staff, the Wisconsin Board on Aging and Long Term Care Ombudsman Program (WI BOALTC) (2011, April) developed a simple fact sheet that could be posted on a bulletin board in a staff education area. See box below.

Possible symptoms of relocation stress

For some residents, the symptoms of relocation stress may be obvious changes in health, personality or disposition. For others, the changes may be more subtle. It is critical that the receiving facility understand what a resident is usually like, so any changes are potentially recognized as symptoms of relocation stress:

• Depression
• Sadness/Crying
• Despair
• Confusion
• Indecision
• Apprehension
• Anxiety
• Falls
• Restlessness
• Sleep disturbance
• Dependency
• Insecurity
• Distrust
• Withdrawal/Isolation
• Loneliness
• Over-idealizing (Isn’t this place wonderful? Everything’s perfect!).
• Negative comments about staff
• Resistance/Unwillingness to move
• Anger
• Aggressiveness
• Change in eating habits
• Weight change
• Stomach problems

Edited from the Wisconsin Board on Aging and Long Term Care . . . April 2005, Revised, April, 2011

Similarly, for family members, visually pleasing fact sheets developed by cartage companies and commercial transitioning service companies are readily available on the internet and could be posted in a family education area.

Workshops:

Incorporate the topic of relocation stress into scheduled staff and/or family and resident education sessions. Select a recent publication to frame interactive discussions and elicit comments from attendees about their experiences with moving or relocating. Provide attendees with pen and paper and direct them to write out a strategy they found helpful during their own relocation experience. Collect the responses, transcribe them on colorful paper and post on a bulletin board beside the professional or lay public resources. Follow up by integrating the suggested strategies into practice whenever possible.

With front-line staff, the follow up process is especially important because, as a Canadian study revealed, “nursing staff, including aides, were found to be the primary source for both supportive and nonsupportive behaviours relevant to emotional support and practical assistance for relocated elders” (Donald, at al., 2009).

Involving staff in the creation of strategies to deal with relocation stress from their own successful experiences will strengthen commitment.

Control:

Issues of control, self identity, privacy and making friends are likely to emerge

for older adults during the first four months after relocating to long-term care (Donald, et al., 2009). Therefore, from the moment staff welcome residents to their new home, the process of intentionally sharing control and decision-making will establish a foundation for what the relocation experience will be like. While residents (and family members) are likely to perceive that they have little control over the admission process and facility regulations, they are entitled to control over their personal space. To this end:

  • offer choices of where personal belongings will be placed;
  • ensure availability of sufficient clothes to encourage choices about what to wear;
  • provide menu choices and record favorite foods;
  • whenever possible, invite residents to identify the times they wish to receive prn or sleeping medication; and finally,
  • include residents and families in care planning, making sure to follow through with their requests or suggestions.

Self-identity:

Find out the preferred name residents wish to be addressed; ensure that this information is communicated to all staff. While some individuals enjoy the informality of being called by their first name or a nickname, others find that this heightens their feeling of powerlessness. Titles such as Mr., Mrs., Dr., or non-English forms of address may remind residents of their former roles (Melrose, 2004).

Initiate 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 when visitors arrive. Include pictures and descriptions of residents, their past and present achievements and their families. Add signatures from greeting cards or bouquets of flowers that are 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 positive and relaxing process (Melrose, 2004).

Avoid situations where groups of staff members converse in a language not familiar to residents. When caregivers are within hearing distance of residents, ensure that any conversation is understandable and inclusive. Invite residents into staff banter using gentle, appropriate humor and positive overtures. Simply being included in friendly, everyday staff discussions can help residents establish their identity in a new place and with a new group.

Privacy:

Shared rooms are a reality in long-term care; but for residents and their families, this proximity to another individual can be overwhelming. Establishing boundaries related to personal belongings, bathroom hygiene, noise from TVs or radios, alone time, and accommodating visitors is essential. Policies related to noise and to the areas where residents in shared rooms can host their visitors must be clear.

Making friends:

Significant losses can delay residents’ interest in making new friends. Most have lost their spouse, their previous good health and many of the possessions that once adorned their home. Acknowledging these losses is important. While staff may not always have time to sit and reminisce, opportunities should be created so that residents can connect with volunteers or fellow residents as often as possible.

‘Buddy systems,’ where well-settled residents are assigned to mentor those newly admitted, may be a useful approach in some areas of long-term care.

Similarly, assigning a ‘job’ to the newly arrived resident, such as inviting a former librarian or avid reader to organize an area of reading material, may be fitting.

Accompanying new residents to activities and then remaining with them long enough to initiate conversations with others can set the stage for developing quality relationships and new friendships.

Celebrate contentment:

Stress can continue for residents and their families well beyond the first four months after relocating. Some residents who appear to be accepting of their life in long-term care may actually not be content or satisfied at all. Rather, they may simply be resigned (Brandburg, 2007).

Ongoing assessment of stress and other mental health issues, such as depression and adjustment disorder, must continue. However, when times of contentment occur, celebrating these events can go a long way towards increasing their frequency.

According to the Merriam-Webster dictionary, contentment is defined as “freedom from worry or restlessness, peaceful satisfaction.” The importance of acknowledging residents’ smiles, of genuinely enjoying their conversation and commenting positively on their successes, should not be underestimated.

Likewise, staffs’ own contentment and feelings of peaceful satisfaction with their workplace must also be celebrated. Caring for vulnerable elders is one of society’s most important jobs.

All staff employed in long-term care contribute to the well being of residents and their families. When staff share their experiences of pride, joy and achievement, residents celebrate these experiences as well. Consistent public acknowledgement of staff or facility achievements can set a subtle but strikingly powerful tone of contentment within the staff/resident group.

Three phases of relocation

According to Kao, Travis and Acton (2004), a resident relocating from a comfortable and familiar home, to a nursing home, experiences a variety of issues at different times. These authors specify that relocating to a nursing home may involve three phases:

  1. In the pre-institutionalized phase, the relinquishing of personal affects, cause feelings of grief and loss. Advance directives and having to consent to power of attorney can lead to symptoms of depression. Kao and colleagues explain that the choices and decisions required can be an overwhelming experience (Ibid., 2004).
    They also point out that, “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.”
  2. During the time they are in the transition phase, residents may experience acute feelings of “abandonment and vulnerability.” Following placement, “residents may respond with anger and a sense of injustice,” with negative responses especially common in those who were involuntarily placed in a facility (Jackson, et al., 2000). These negative reactions, which can endure as long as three months following placement, “. . . are in part related to feeling that staff do not acknowledge their former roles, through which they contributed to their families and society, and this reinforced their loss of social status and role” (Iwasiw, et al., 2003).
  3. In the post-institutional phase, the adjustment required can last up to one year. “Although residents, family members and caregivers may expect the stress of relocation to diminish once the resident has become oriented to their new home, clinical symptoms may continue throughout the first year” (Melrose, 2004). Psychological issues include establishing a sense of control and identity in a new environment. It has been maintained that it is this loss of control that leads to anger and difficulties with care (Mikhail, 1992).
    The post-institutional adjustment stage for those with cognitive impairment can be even more challenging as they may find it more difficult to settle in and initiate new social relationships (Melrose, 2004).

Conclusion

Relocation stress is a nursing diagnosis characterized by loneliness, depression, anger, apprehension and anxiety, changes in former eating and sleeping habits, dependency, insecurity, lack of trust and a need for excessive reassurance.

Residents moving into long-term care are at greatest risk for experiencing relocation stress during the first four months. Staff can help residents and their families cope by gathering resources such as professional guidelines, lay public fact sheets and interactive workshops.

Extending a four month welcome emphasizing residents’ control, self-identity, privacy and opportunities to make friends can also help.

Finally, intentionally finding ways to celebrate the times when both residents and staff feel contented and satisfied with their facility can help reduce some of the feelings of stress that residents experience when they relocate to long-term care.

References

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