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This is to certify that the

thesis entitled

THE EFFECTS OF ORIENTATION TO AN EXTENDED CARE FACILITY
ON THE ELDERLY PERSON'S ADAPTATION TO THE PATIENT ROLE

presented by

Janet Lee Elgood

has been accepted towards fulfillment
of the requirements for

Master of Science degree in Nursing

 

 

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THE EFFECTS OF ORIENTATION TO AN EXTENDED CARE FACILITY

ON THE ELDERLY PERSON'S ADAPTATION TO THE PATIENT ROLE

By

Janet Lee Elgood

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements

for the degree of

MASTER OF SCIENCE IN NURSING

College of Nursing

1988

 

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ABSTRACT

THE EFFECTS OF ORIENTATION TO AN EXTENDED CARE FACILITY

ON THE ELDERLY PERSON'S ADAPTATION TO THE PATIENT ROLE

By

Janet Lee Elgood

A descriptive study of 30 elderly individuals who relocated over
a four month period from the acute care setting to a skilled nursing
facility in the Midwest was completed. A retrospective medical
record audit was performed on 22 of the participant's medical records
and the individuals were described according to sociodemographic
characteristics, physical health status, social status, communication
status, and status relative to prior nursing home familiarity. A
description was completed of the remaining eight study participants
based upon pretest data from the original intended experimental study
design. Mean scores and percentages were reported relative to the
number and type of characteristics of the newly admitted skilled
nursing facility population. The conclusions of this study were
drawn relative to the findings of the audit and the pretest data

which was obtained from eight of the participants.

 

 

ACKNOWLEDGMENTS

I would like to thank Barbara Given for her ongoing and
never-ending support and encouragement throughout this endeavor. I
am very grateful for the opportunity to have worked with her as my
thesis chairperson and as the Director of the Graduate Nursing
Program. She is an outstanding role model for all nurses and it has
been a privilege to know her.

Also, thanks to my thesis committee members: Clare Collins,
Sharon King and Carol Garlinghouse. Thank you for your continued
support and assistance this past two years. I appreciate the
continual availability whenever I needed to talk to someone.

To Jayne Yoder, I am very grateful for such superb typing skills
and organizational ability. She was an integral figure in helping me
meet the many deadlines which were imposed throughout this project.

A great deal of very special thanks to my loving husband, Ross,
who was always available to listen, encourage and assist me in every
way possible in order that I could accomplish my goal. Thanks for
believing in me. To Laura, my darling daughter, thanks for being
such a good girl and for understanding when I could not be there. I
hope you will learn from this experience that whatever you really
want to achieve in life is possible if you believe in yourself and

have lots of love and support from those who are close to you.

Lastly, I would like to say thank you to my parents and my
brother. I am grateful to my parents, Jean and Jim Root, for all of
the assistance they provided in caring for Laura and in lending
support with errands and household tasks when I could not be there.
To my brother Larry, I am grateful for his belief in me and for his

continual support over the years as my "big brother.”

 

Chapter I: The Problem
Introduction . . . .
Purpose . . . . . .

Problem Statement

TABLE OF

Definition of Variables

Assumptions and Limitations

Assumptions .

Limitations . .

0

CONTENTS

Criteria for Inclusion in the Study . . . . . . . .

Overview . . . . . .

Chapter II: Conceptual Framework

Overview . . . . . .
Relocation . . . . .
Orientation . . . .
Orientation Programs
Adaptation . . . . .

Conceptual Framework

Page

d

O‘O‘J.‘

14
14

I9
21

23

Page

Chapter III: Review of the Literature

Introduction . . . . . . . . . . . . . . . . . . . . . . . . 39
lnterinstitutlonal Relocation of the Elderly . . . . . . . . 39
Effects of Relocation on Mortality Rates . . . . . . . . . . #0
Effects on Morbidity . . . . . . . . . . . . . . . . . . . . #6
Lack of Effect on Morbidity/Mortality. . . . . . . . . . . . #9
Summary Morbidity/Mortality. . . . . . . . . . . . . . . . . 52
Adaptation . . . . . . . . . . . . . . . . . . . . . . . . . 53
Summary - Adaptation . . . . . . . . . . . . . . . . . . . . 58

Knowledge . . . . . . . . . . . . . . . . . . . . . . . 59

Socialization . . . . . . . . . . . . . . . . . . . . . S9
Orientation Program . . . . . . . . . . . . . . . . . . . . 60
Summary - Orientation Program. . . . . . . . . . . . . . . . 68
Relationship of Literature to Nursing. . . . . . . . . . . . 68

Summary of Literature. . . . . . . . . . . . . . . . . . . . 69

Chapter IV: Methodology and Procedure
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Design . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Experimental/Quasi-Experimental . . . . . . . . . . . . 72
Threats to Internal Validity . . . . . . . . . . . . . . . . 75
Population, Subjects, Sampling Technique . . . . . . . . . . 76
Sampling . . . . . . . . . . . . . . . . . . . . . . . 78

Assignment to Experimental/Control Group . . . . . . . 79

Operational Definition of Major Concepts . . . . . . . .
Instruments . . . . . . . . . . . . . . . . . . ......
Pilot Testing of Instruments . . . . . . . . . . .

SPMSQ . . . . . . . . . . . . . . . . . . . . . . . . .
Knowledge Questionnaire . . . . . . . . . . . . . . . .
Social Activity Record . . . . . . . . . . . . . . . .
Socioeconomic and Demographic Questionnaire . . . . . .

Data Collection Procedures . . . . . . . . . . . . . . .
Chart Audit . . . . . . . . . .......

Reliability and Validity of Study Measures . . . . . . . .
SPMSQ . . . . . . . . . . . . . . . . . . . . . . . . .

Reliability . . . . . . . . . . . . . . . . . .
Validity. . . . . . . . . . . . . . . . . . . . . . .

Knowledge Questionnaire . . . . . . . . . . . . . . .

Reliability . . . . . . . . . . . . . . . . . . . . .
Validity. . . . . . . . . . . . . . . . . . . . . . .

Social Activity Record . . . . . .....

Reliability . . . . . . . . . . . . . . . . . . . . .
Validity . . . . . . . . . . . . . . . . . . . . . .

Scaling . . . . . . . . . . . . . . . . . . . . . . . . .
Data Analysis . . . . . . . . . . . . . . . . . . . . .
Protection of Human Subjects . . . . . . . . . . . . . . . .

Sumary O O O O O O O O O O O 0 O O O O O O ..... O O O

Page

79
82
82
83
8A
8A
85
86
88
89
89

89
90

9l

91
91

92

92
92

92
92
9b
95

 

Chapter V: Data Presentation and

Overview . . . . . . . . .
Study Findings . . . . . .

Sample Characteristics

Eligibility Criteria .

Number of Participants

Pretest Findings . . .

SPMSQ . . . . . . . . .

Knowledge Questionnaire

Posttest Findings . .
Additional Findings . . . .
Methods. . . . . . . .
Independent Sample . .

Hospitalizations . . .

Familiarity with Nursing

Medical Insurance . .
Responsible Party . .
Admission Diagnoses .
Physical Status . . .

Disabilities . . . . .

Course of Institutionalization

Analysis of Results

0 O O O O O O O 0

Home Procedures . .

Social Activity/Social Events.

Discussion . . . . ......... . . . . . .

Summary . . . . . . . . . .

vi

Page

...... 96

...... 96
. . . . 99
. . . . 96

O O O O 0 O 100

. . . . . . . 101

. . . . . . 103

. . . . . . . 103

. . . . . . 103
...... 106
. ..... 106
. . . . . . 107
. . . . . . l07
. . . . . . 107

..... 109

o o o o o o 119

Page

Chapter VI: Summary and Conclusions
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Summary of Findings . . . . . . . . . . . . . . . . . . . . . 121
Description of Study . . . . . . . . . . . . . . . . . . 121
Purposes . . . . . . . . . . . . . . . . . . . . . . . . 121
Conceptual Framework . . . . . . . . . . . . . . . . . . . . 122
Problem Statement . . . . . . . . . . . . . . . . . . . . . . 124
Variables . . . . . . . . . . . . . . . . . . . . . . . 124
Hypotheses . . . . . . . . . . . . . . . . . . . . . . . 124
Recommendations . . . . . . . . . . . . . . . . . . . . . . . 127
Recommendations for Future Research . . . . . . . . . . 127
Criteria for Future Study . . . . . . . . . . . . . . . 128
Orientation Program . . . . . . . . . . . . . . . . . . . . . 129
Recommendations for Nursing Practice . . . . . . . . . . . . 136
Relationship to Theoretical Model . . . . . . . . . . . 139
Nursing Education . . . . . . . . . . . . . . . . . . . 139
Nursing Service . . . . . . . . . . . . . . . . . . . . 140
Implications for Advanced Practice in Nursing . . . . . 141
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . 146
Discussion of Conclusions . . . . . . . . . . . . . . . 147
Theoretical Implications . . . . . . . . . . . . . . . . 151

Study Contributions . . . . . . . . . . . . . . . . . . 152

References . . . . . . . . . . . . . . . . . . . . . . . . . . . 154

vii

LIST OF APPENDICES

Appendix A: Sociodemographic Questionnaire

Appendix 8: Short Portable Mental Status Questionnaire
Appendix C: Knowledge Instrument

Appendix D: Social Activity Record

Appendix E: Chart Audit

Appendix F: Routine Services Guide

Appendix G: Human Subjects

Appendix H: Consent Forms

viii

 

LIST OF FIGURES

Page

Figure 1: The Person as an Adaptive System . . . . . . . . . . . 25
Figure 2: Flow Chart Illustrating the Nursing Process on the

Roy Adaptation Model of Nursing . . . . . . . . . . 34
Figure 3: The Effect of Orientation on the Elderly Individual

in Relocation . . . . . . . . . . . . . . . . . . . 38

Table
Table
Table
Table
Table
Table

Table

Table

1:

3:

5

0.

LIST OF TABLES

Short Portable Mental Status Questionnaire Summation

Short Portable Mental Status Questionnaire Scoring .

Knowledge Questionnaire Scoring . . . . . .
Summary of Sociodemographic of Chart Audits
Admitting Diagnoses . . . . . . . . .
Summarization of Chronic Illness Scoring . .
Summarization of Physical, Communication and
Discharge Status (Form 1) . . . . . . .

Summary of Medical Record Audit (Form 2) . .

Page

93
100
101
105
108

110

112

114

CHAPTER I
The Problem

Introduction

 

lnterinstitutlonal relocation of the elderly is a traumatic event
(Mirotznik 8 Ruskin, 1984; Pino, Rosica 8 Carter, 1978; Yurick, Robb,
Spier, 5 Ebert, 1984). Relocation of the institutionalized elderly
has been viewed as both resulting in an increased morbidity and
mortality (Pastalan 8 Bourestom, 1977; Thomas, 1979), and as
resulting in no significant increase in morbidity and mortality
(Borup, Gallego 8 Heffernan, 1979). Therefore, although the event of
relocation is viewed as a stressful or traumatic life event, more
research regarding the issue of interinstitutional relocation is
needed to ascertain the effects of the relocation event on the
elderly individuals who are experiencing the move.

In 1982, there were approximately 1.3 million nursing home
residents in the U.S. (Butler 8 Lewis, 1982). In 1985 ”an estimated
1.4 million elderly Americans lived in nursing homes, and
approximately 6.6 million Americans aged 65 and older were in need of
long-term care indicating a 14% increase since 1980” (Day, 1985, p.
6). According to Day (1985), "the number is expected to grow at an
even faster rate in the 1990's“ (p. 6), and the number of elderly
requiring institutional care can be expected to rise.

One possible explanation for the increased utilization of
long-term care facilities by the elderly is the advent of DRG's

(diagnosis-related groupings). As of 1984, hospital patients are

classified on the basis of diagnosis and the hospitals are
concurrently paid a fixed amount per discharge based on the diagnosis
of the patient. The DRG system is the basis for the concurrent
payment method (known as the prospective payment system -- PPS) and
is a method which "radically restructures the manner in which
hospitals are paid for inpatient services provided to Medicare
beneficiaries” (AMA, 1986). The DRG/PPS system's major objective “is
to establish the government as a 'prudent buyer' of health care while
maintaining beneficiaries' access to quality care" (AMA, 1986).
However, an outcome of the DRG/PPS system is often a shortened length
of stay in the acute care setting. Many of the elderly patients are
too ill to return to their homes after a shortened hospital stay and
may, therefore, be referred for nursing home placement.

Also reported in the literature is the phenomenon of the
increased utilization of long-term care institutions by elderly
individuals who are 85 years and older (Day, 1985; U.S. Senate,
Special Committee on Aging, 1985). The population, 85 years and
older, are those elderly individuals who are I'most likely to suffer
severe mental and physical impairments that are difficult for
unskilled family members to care for at home" (Day, 1985, p. 7).

One of the major traumas of the last stage in the life cycle is
the realization that the elderly individual can no longer
independently care for himself/herself and must be relocated to an
alternative living arrangement. According to Rowles and Ohta (1983)
”much discussion has evolved on the notion of 'transplantation shock'

or the 'relocation effect' eXperienced by elderly individuals upon

 

 

 

2'“ -' huh

changing living environments“ (p. 189). Two questions arise: Do all
older people under all conditions experience negative consequences
following a move, or are certain types of individuals more
susceptible to a move under certain conditions? What, if anything,
can be done to facilitate adjustment in a new setting and reduce the
potential ”transplantation shock“?

According to Engle (1985) ”relocation, or moving from one
environment to another, is potentially traumatic for the aged”

(p. 355). Yurick, Robb, Spier and Ebert (1985) report that
”relocation is a life change experienced by many aged persons and
studies of the long-term effects of relocation on the mortality,
health and well-being of the aged person have produced conflicting
results” (p. 254).

Nirenberg (1983) reports that there are many inconsistencies
among studies regarding the issue of relocation of elderly
individuals to institutions. Such reported inconsistencies of the
effects of relocation are related to “mortality rates, increase in
disease, general physiological decline and signs of depression and
withdrawal“ (p. 673). Nirenberg also reports methodological
difficulties in studies of the effects of relocation on the elderly,
i.e., ”inadequate control groups, non-random subject selection and
use of mortality rate as the sole dependent variable” (p. 673).
Therefore, Nirenberg concludes that there is a need for additional
research in the area of relocation and its effects on the elderly

population.

 

 

In reviewing the research regarding the effects of relocation on
the elderly, it is evident that additional study is needed in this
area. Further investigation must be pursued to define the effects of
relocation on the elderly population and to delineate possible
alternatives for addressing the issue in order to prevent unnecessary

problems in relocation.

Purpose

Many of the research studies which have been completed regarding
the effects of relocation on the elderly individual show that
relocation is related to an increase in morbidity and mortality
(Pastalan 5 Bourestom, 1977; Thomas, 1979). Fewer negative effects
have been identified in other studies regarding the elderly
individual who is experiencing relocation (Borup, Gallego 8
Heffernan, 1979; Pino, Rosica 8 Carter, 1978). The effects of
relocation on the elderly are as follows: increases in disease,
general physiological decline, depression and withdrawal (Nirenberg,
1983).

The idea for this study evolved from the premise that since
researchers indicate that relocation often results in negative
experiences for the elderly individual, use of a positive approach
when dealing with an elderly client experiencing relocation could
possibly reduce the negative consequences. In other words, the
experience of relocation could be viewed as a positive experience if
the approach to the relocation was positive. The positive approach

to relocation was designed in this study as an orientation program.

 

 

 

However, due to a limited number of eligible subjects for the study,
the orientation program was not completed on a significant number of
participants. An additional research question was raised relative to
the description of the characteristics of the skilled nursing
facility population and a descriptive study was completed regarding
those elderly individuals who are relocating to the skilled nursing
facility from the acute care setting.

The effects of relocation of an elderly individual from the acute
care setting to the extended care facility has been selected for
study. Relocation from acute care to extended care is a common
occurrence in which the elderly individual is perceived by others as
experiencing a great deal of stress (Yurick, Robb, Spier, 8 Ebert,
1984).

Therefore, the purposes of pursuing the more specific issues
involved in relocation of an elderly individual from the acute care
setting to the extended care facility were:

1. To investigate the effects of relocation on an elderly
individual's ability to adapt to the new environment when moving
from an acute care setting to an extended care facility in terms
of the patient's general well-being, both objectively and
subjectively.

2. To investigate the feasibility of the introduction of an
orientation program by a registered nurse to elderly individuals
relocating from the acute care setting to the extended care

facility.

 

3. To determine the effectiveness of an orientation program by a
registered nurse for the elderly individual who is experiencing
relocation from an acute care setting to an extended care

facility.

Problem Statement

Relocation to alternative environments encompasses several types
of moves, i.e., home to institution, institution to home, or
lnterinstitutlonal moves. In order to narrow the focus of this broad
concept, one issue has been selected for discusSion. The issue is
relocation from the acute care setting to the extended care setting
or facility; more specifically: ”What is the effect of an
orientation program by a registered nurse from an extended care
facility upon an elderly individual's adaptation to that facility

upon being admitted from an acute care setting”?

Definition of Variables

The independent variable ”orientation program“ was defined by
providing a definition of “orientation” and ”program.” ”Orientation”
was defined as ”an adjustment or adaptation to a new environment,
situation, custom, or set of ideas” (Morris, 1973, p. 926).
”Program“ was defined as ”a plan of procedure: a schedule or system
under which action may be taken toward a desired goal; a proposed
project or scheme” (Gove, 1961, p. 1812). “Orientation program” was
defined as a plan of procedure to assist a person in an adjustment or

adaptation to a new environment or situation. The orientation program

provided to the elderly individuals who were relocating from the
acute care setting to the extended care facility included an
introduction to the facility's policies and procedures, a tour of the
facility, and answering the patient's questions regarding the
facility.

The dependent variable “more positive adaptation” was clarified
by the definitions of ”positive” and ”adaptation.” Adaptation was
defined as ”anything that is changed or changes so as to become
suitable to a new or special use or situation (Morris, 1973, p. 14).
Positive was defined as “characterized by or displaying certainty,
acceptance or affirmation” (Morris, 1973, p. 1022). Therefore, “more
positive adaptation” was defined as a certain, accepted or affirmed
change which is accomplished so as to become suitable to a new
situation. The patient who experiences ”more positive adaptation”
upon relocation will exhibit a change which is suitable to adapting
to the new environment. The adaptation was viewed as an outcome of
the process of moving and preparing for the move to the new
location. The outcome of adaptation can be measured.

Since adaptation is viewed as an outcome, the outcomes which
were to be measured to indicate whether the elderly patient had
experienced a positive adaptation from the acute care setting to the
extended care facility were:

1. Knowledge
2. Socialization
Mental status was to be measured upon admission and at one month

after admission using the Short Portable Mental Status Questionnaire

(SPMSQ). In utilizing this tool to measure mental status, the
researcher examined the elderly patient's mental status within 48
hours of relocation from the hospital to the extended care facility
and again one month later to determine any change in status during
this time. The researcher also noted any differences in change in
mental status between the treatment group (those patients who
participated in the orientation program) and the control group from
measures taken upon admission and one month after admission.

Knowledge was to be measured by determining the knowledge level
of the elderly patients upon admission and one month post-admission
regarding the policies and procedures of the extended care facility.
The elderly patients were tested utilizing a short questionnaire
which addressed the knowledge level of the patient regarding the
Specific policies and procedures of the extended care facility to
which they were transferring. The researcher examined any
differences in knowledge level regarding the facility's policies and
procedures between the treatment group and the control group. The
treatment group participated in an orientation program which was
developed to present the facility's policies and procedures and the
control group did not.

Socialization was to be measured for both the treatment and
control groups by examining the patient activity records at the
facility for number of social activities attended by each patient in
one month. The researcher was to examine the activity records for
any differences in number of activities between the treatment and

control groups. The social activity was to be measured from

 

admission until one month post-admission and the researcher was to

review the records for changes in amount of socialization.

A positive adaptation for the elderly clients in this study was

measured as:

1.

An increased knowledge level as evidenced by the elderly
client's improved performance on the knowledge questionnaire
pretest to posttest.

An increase in socialization as evidenced by the elderly

client's increase in social activity pretest to posttest.

Therefore, the hypothesis for the study was stated as: an elderly

individual from an acute care setting who is provided an orientation

program to an extended care facility by a registered nurse from that

facility will experience more positive adaptation than an elderly

individual from an acute care setting who is not provided an

orientation by a registered nurse from that facility.

1.

The more specific hypotheses for this study were:

An elderly individual from an acute care setting who is provided
an orientation program to an extended care facility will
demonstrate a higher level of knowledge regarding the facility's
policies and procedures than an elderly individual from an acute
care setting who is not provided an orientation program.

An elderly individual from an acute care setting who is provided
an orientation program to an extended care facility will
demonstrate a higher level of social activity than an elderly
person from an acute care setting who is not provided an

orientation program.

 

10

Assumptions and Limitations

 

Assumptions

 

1.

The following assumptions were made in this study:

It was assumed that elderly individuals who were relocating from
the acute care setting to the extended care facility were
required to respond to change as a result of the relocation
experience.

It was assumed that the effects of the relocation experience
from the acute care setting to the extended care facility were
different upon admission to the extended care facility than the
effects 30 days after admission.

It was assumed that the elderly individuals who participated in
the study were capable of responding cognitively to the
questionnaires which were used as the measurement instruments.
It was assumed that the elderly individuals experiencing
relocation from the acute care setting to the extended care
facility viewed the relocation event as a significant and
important life event involving adaptation.

It was assumed that changes in adaptation could be determined

and assessed by measurement of knowledge and socialization.

Limitations

 

1.

The following limitations were acknowledged in this study:

The elderly individuals who were relocating from the acute care
setting to the extended care facility experienced differing
lengths of stay in the acute care setting before transferring to

the extended care facility.

 

 

11

The individuals who agreed to participate in the study did so on
a voluntary basis and were randomly assigned and, therefore, the
study results were not generalizable to non-volunteers.

The study participants were discharged from the acute care
setting much sooner under the new procedure utilizing diagnosis
related groups (DRG's) than clients who were subjects of related
research in past years. Therefore, comparisons to past research
regarding relocation from acute care to extended care settings
may not be consistent. Also, study participants may have been
too ill to complete the orientation program.

The participants who agreed to take part in the study initially
may not have been available at the time of retest due to
attrition.

The Director of Nursing of the extended care facility visited a
small percentage of the clients in the acute care setting who
were being transferred to the extended care facility. The
Director of Nursing provided an informal orientation to the
extended care facility to those patients who were visited.

The study participants may have experienced other losses in
addition to the losses involved with relocation and may have
reacted differently.

The level of accuracy of the social activity director was
variable when she was recording daily activities.

One month may not have been long enough to make a positive

adaptation to the extended care facility.

1.

12

There was no control for physical health, i.e., more debilitated

patients may have made a poorer adjustment.

Criteria for Inclusion in the Study

 

Age limitation. The participants in the study were 55 years of

 

age or older.

Presence of family/significant other. All patients who were

 

admitted to the extended care facility were required to
designate a “responsible party“ (a family member or significant
other who is responsible for the patient's affairs).

Terminal illness. Presence of a terminal illness was considered

 

in selection of patients in the study, but only as related to
the inability of the patient to participate due to communication
problems, physical weakness/deterioration or unwillingness to
participate.

Diagnosed Alzheimer's or dementia patients were not included in
this study.

Ability to speak and understand English was mandatory for
participation in the study as the questionnaires were
administered in interview format. Also, the respondents were
capable of hearing or of having an interpreter available if
deafness was an issue.

The participants were able to respond to the sociodemographic
questionnaire and to the Short Portable Mental Status
Questionnaire (SPMSQ) in interview format for determination of

cognitive impairment.

13

Overview

This thesis is composed of six chapters. In Chapter I, the
introduction, purpose, problem statement, hypothesis, definition of
variables, and assumptions and limitations of the study are
presented. The conceptual framework is presented in Chapter II, to
include the definition and development of each concept.

Included in Chapter III are the purpose of the literature review
(sectioned according to variables and/or major topic areas related to
nursing and the study), and a summary of the literature.

In Chapter IV, Methodology and Procedure to include an overview,
population, subjects, sampling technique, operational definition of
the variables, instruments, data collection procedures, scoring of
measures, a statement about protection of human subjects and data
analysis techniques to be used are presented.

Data Presentation and Analysis are presented in Chapter V, to
include a chapter overview, general descriptive data, data
presentation for the hypothesis and summary of the findings. In the
final chapter, Chapter VI, are the summary and interpretation of
inferential findings, other findings, conclusions, to include
implications for advanced nursing practice and primary care,
recommendations, and tying of the research problem to the conceptual

framework and previous research.

 

 

CHAPTER II
Conceptual Framework
Overview
lnterinstitutlonal relocation from the acute care setting to the
extended care facility will be the focus of the following discussion.
The format for the discussion encompasses a definition of the
concepts, a statement regarding conceptual relationships, and
development of a conceptual framework which integrates the Roy

Adaptation Model of nursing.

Relocation

 

Relocation is defined as ”moving from one environment to another”
(Rowles 8 Ohta, 1983, p. 189) and ”to establish in a new place''
(Morris, 1983, p. 1099). Relocation also means I'any change in the
residential environment from one home or apartment in the community
to another, from a community home or apartment to an institutional
environment, and from one institutional setting to another” (Forbes 8
Fitzsimons, 1981, p. 263). Relocation is defined for the purposes of
this discussion as moving from one environment (the acute care
setting) to another (the extended care facility).

Volanin (1978) describes ”a study of a small hospital, who moved
an elderly group (average age in the 80's and were defined as very
frail)” who could not live without assistance to a new extended care
facility which was connected to the hospital (p. 47). The nursing

staff were provided a continuing education course on nursing care of

14

 

15

the geriatric patient which was completed prior to the move. The
patients were provided an orientation program of two months duration
prior to the move. The orientation program included taking the
patients who were being transferred to lunch in the dining room of
the new extended care facility every day. The patients were allowed
to browse around the facility before and after lunch, to choose the
room to which they would be moving, and to communicate freely about
the move.

The move was very well planned and on the day of the move the
patients were allowed to have breakfast, bathe and dress. Their
families came in and participated in the moving process and the move
was accomplished in time for lunch in the main dining room.

The success of the move was gauged by the patients' nighttime
behaviors. The behaviors measured were: 1) sleeplessness; 2)
confusion; 3) incontinence; and 4) wandering.

The results which were reported were: no sleeplessness,
confusion incontinence or wandering. The move was considered to be a
great success. The conclusions drawn by the researchers were that in
relocation of the elderly, the patients must be informed, must
participate in planning, must make choices, if possible, and the
family and staff should be included in the move (Wolanin, 1978).

Nirenberg (1983) completed an experimental study which
investigated lnterinstitutlonal relocation effects on forty subjects
in a nursing home in North Carolina. The subjects were moving from
an old facility to a new facility and Nirenberg viewed the relocation

experience as a stressful life event for the subjects. The results

 

16

of Nirenberg's study indicated that administration of an orientation
program in conjunction with a behavioral skills program (consisting
of meetings with the subjects to teach them how to effectively deal
with the relocation experience) led to a favorable relocation
experience.

Pino et al. (1978) completed a study regarding the differential
effects of relocation on nursing home patients. Pino et al. (1978)
hypothesized that the patients who are relocated from another
institution ”will have more difficulty in readjusting than the
transferred patient who has been prepared for the move, or the
unprepared transferred patient” (p. 187). The result of the study by
Pino et al. (1978) indicated that ”prepared patients demonstrated
less decline in mental alertness than other groups” (p. 172).

In the studies by Nirenberg (1983) and Pino et al. (1978),
relocation, its effect on the elderly and prior preparation for the
move are important considerations for a positive relocation
eXperience. Also, the issue of relocation and its effect upon the
elderly is discussed as a positive experience as opposed to a
negative experience as the earlier studies on relocation indicated.

To further support the concept of more positive relocation
effects, Giorella and Bevil (1985) reported that "relocation to a
nursing home frequently involves the frail or ill old-old, making
outcomes less certain” (p. 159). These authors suggest that if the
relocation from facility to facility is well-planned, relocation is

less likely to have ill effects.

17

Ebersole and Hess (1985) state that “the aged are more apt to be
relocated than any other population segment'l (p. 235). Therefore,
these authors conclude that significant variables should be
considered which relate to positive outcomes of relocation when
relocation is defined as moving from one environment to another. For
the purposes of this study, relocation is defined as moving from the
environment of the acute care setting to the environment of the
extended care facility.

In order to clarify the concepts of acute care setting and
extended care facility within the definition of relocation, acute
care setting is used synonymously with hospital and means a setting
where the acute or immediate medical needs are met. Extended care
facility is used synonymously with long-term care facility and means
a setting where the recuperative, rehabilitative and supportive

medical needs are met.

Orientation

 

The concept of orientation can be defined simply as ”an
adjustment or adaptation to a new environment, situation, custom, or
set of ideas“ (Morris, 1973, p. 926). The concept "orientation
program” is defined as ”a plan of procedure to assist a person in an
adjustment or adaptation to a new environment or situation.” The
”orientation program” provided to the elderly individual who is
entering the extended care facility includes a program provided on a
one-to-one basis by a registered nurse who is familiar with the

facility. The orientation program includes information about the

18

general operations of the extended care facility, and a review of the
policies and procedures inherent to that facility. The categories of
information include: type of organizational structure, political
structure, type of nursing care delivery system, daily routine (as
established by the facility), types of recreational programs, types
of rehabilitative/restorative programs, Patients Rights, expectations
of the patient/family and patient's expectations of the facility.

”Orientation” also refers to discussing concerns and answering
questions which the elderly person may have about the facility. This
type of discussion should include family members and/or significant
others as appropriate. The orientation should be viewed as a
”getting acquainted” period for both the individual and the nurse.
The encounter should conclude with a feeling of mutuality about the
exchange which has taken place. The elderly individual should view
the encounter as a meaningful interaction in which all of his/her
questions have been answered, and should be left with the feeling
that he/she may call upon the nurse with further questions and/or
concerns.

In order to view the concept of orientation as a measurable
phenomenon and further define its use, specific measurement
instruments must be utilized. According to the definition given
earlier, orientation is defined as ”an adjustment or adaptation....“
(Morris, 1973, p. 926). Therefore, the tools which assess the
elderly person's capability to adapt are those instruments which
assess the process of adaptation. The elderly individual will adapt

post-relocation by increasing his/her knowledge about the facility

 

 

 

l9

and its operations and by socializing with family and the other
residents at the facility.

In this study, the orientation program will be introduced. The
effect of the orientation program on the elderly client will be
determined by the measurement of how well the client has adapted.
Adaptation will be measured in terms of the client's knowledge level
before and after presentation of the orientation program and by

amount of socialization post-relocation.

Orientation Programs

Prior to discussion of the measurement instruments, 3 discussion
of the literature regarding the usefulness of orientation programs
when dealing with the relocation of the elderly will be presented.
Information is available in the literature regarding the issue of
orientation of the elderly individual in preparation for admission to
an extended care facility. For example, Ebersole and Hess (1985)
found that among high-risk groups (those who are very old, with
severe disabilities and apathetic affect), adaptation is enhanced by
positive staff attitudes and morale and prior preparation for the
move.

Mullen (1977) identified several other critical factors that
reduce relocation or ”transplantation shock.“ These factors include:
1. Prior cognitive mastery through tours, audiovisual presentations

and a detailed advanced plan for the move.
2. A clear understanding of the extent of family involvement by the

aged person, staff and family.

 

20

3. Joint decision making with the family and the aged individual.
4. Communications geared to the client's mental and sensory status.
According to Yurick, Robb, Spier and Ebert (1984) the steps which are
identified when dealing with relocation trauma in the elderly are to:

1. Give the individual the opportunity for choice.

2. Give individualized preparation.

3. Do premove orientation to the new location.

4. Allow the person to participate in the decision making process.
Liben, Patterson and Newcombe (1981), in working with spatial
relationships and the elderly, found that ”'get acquainted' visits to

the new environment did diminish the negative effects of forced
relocation“ (p. 364). Since there is support in the literature that
“prior preparation” or ”orientation” assists in promoting positive
outcomes in relocation, it is important for those professionals and
others (nurse aides, family members, trust officers, admission office
personnel in the extended care facilities) who work with the elderly
to further test and validate this premise. More specifically, for
the purposes of this study, it is important to test the effectiveness
of an orientation program in providing more positive adaptation for
an elderly population who is being relocated from an acute care
setting to an extended care facility. In this study, the orientation
program will include:

1. A review of the Patient Bill of Rights.

2. A tour of the facility.

 

 

 

 

21

3. A review of the current policies and procedures of the facility
(i.e., visiting hours, meal times, activity times, types of
activities which are offered, etc.).

4. An opportunity for the participant to review any questions or

concerns about the relocation experience with the researcher.

Adaptation

The researcher will attempt to determine whether or not
presentation of the orientation program affects the adaptation of the
elderly individuals. Whether or not the individual has adapted will
affect the individual's relocation experience.

To define the concept of adaptation as it relates to the patient
role in the new environment, Burnside (1980) addresses the issue in
speaking about the “Fight Phenomenon." Burnside states that “the
institutionalized aged persons are forced to learn to survive in a
new setting at a point in time when they do not adapt readily; they
become frustrated and angry“ (p. 32). She goes on to say that it is
the professional nurse's place to intervene before this phenomenon
occurs by preventing anger, frustration and feelings of hostility
from accumulating. Therefore, the older person seems to feel that
"to pick a fight with or to complain belligerently to a truly
powerful nonretaliatory person who will do something remedial does
appear to enhance the ability of certain aged persons to c0pe with
living in institutional settings” (Burnside, 1981, p. 53).

Ebersole and Hess (1985) also speak to the issue of the elderly

person's adaptation to the patient role when relocating and they

 

 

 

22

identify ten variables which relate to positive outcomes of

relocation. Five of these variables deal with assisting the

individual to adapt to the new role, and the variables are:

1. Decision-making power is present.

2. Adequacy of new living situation including convenience to needed
services.

3. Prior preparation to move.

4. Few concomitant stresses experienced.

5. Involvement of family or significant others (Ebersole 8 Hess,
1985, p. 235).

Grey (1978) found that "among high risk groups (those who are
very old, with severe disabilities and apathetic affect) adaptation
is enhanced by positive staff attitudes, morale and prior preparation
for the move” (p. 38). Mullen (1977) also identified several factors
which enhance adaptation and reduce “transplantation shock.“

As previously discussed, the measurement of the patient's
adaptation upon admission to the facility was accomplished using
tools to measure adaptation ability. The measurement tools which
were selected for this study were to measure adaptation abilities of
the elderly individual by measuring knowledge about the extended care
facility and socialization to the environment of the extended care

facility.

23

Conceptual Framework

 

The Roy Adaptation Model of Nursing is the basis for the
conceptual framework of this study. Briefly, the Roy Adaptation
Model of Nursing can be explained as a model which ”identifies the
recipient of nursing care as an adaptive system” (Roy 8 Roberts,
1981, p. 43). Roy views this system as a composition of inputs,
internal and feedback processes and output. The inputs are defined
as stimuli which are fed into the adaptive system. The stimuli are
processed in the regulator and cognator which are the two internal
processor subsystems which deal with coping. The coping process is
then effected through the four adaptive modes: physiological needs,
self-concept, role function and interdependence. These modes are the
mechanisms which “provide the particular form or manifestation of
cognator and regulator activity" (Roy 8 Roberts, 1981, p. 43).

The physiological needs are defined as ”the body's basic needs”
(Roy 8 Roberts, 1981, p. 43); self-concept is “the composite of
beliefs and feelings that one holds about oneself at a given time”
(Roy 8 Roberts, 1981, p. 43); role function is “performance of duties
based on given positions in society” (p. 44); and interdependence
”involves one's relations with significant others and support
systems“ (Roy 8 Roberts, 1981, p. 44). These adaptive modes effect
coping behaviors through physiological and psychological functions.

After the coping mechanism is effected through the four adaptive
modes, which is the process phase of the system, the process ends
with outputs or outcomes. The outcomes are expressed in Roy's Model

as adaptive responses or ineffective responses. The adaptive

 

24

responses are those responses in which the individual has coped
(process) and then adapted (outcome). The ineffective responses are
those in which the individual has not coped (process) and, therefore,
has not adapted (outcome).

In viewing the elderly individual who is involved in the
relocation process, the person is viewed as an adaptive system.
Burnside (1980) contends that upon relocation ”the older patient
usually has increased difficulty in adapting and adjusting to the
rapidly changing environment, not only to the physical environment,
but to the psychosocial one as well” (p. 103). Also, Burnside states
that ”the provision of a supportive environment in which patients are
able to plan for their future helps them feel that they control their
destiny" (p. 103), which again assists the individual to adapt.

An adaptive system is defined by defining the concepts of system
and adaptation. System is defined simply as ”a mechanism involving
input, internal and feedback processes and output” (Roy 8 Roberts,
1981, p. 43). Adaptation is defined as "something that is done by
living systems in interaction with their environment” (Roy 8 Roberts,
1981, p. 32). Adaptation may be viewed as an outcome or a process.
Therefore, an adaptive system is a mechanism involving inputs,
internal and feedback processes and output which is in constant
interaction with its environment (Figure 1).

In Figure 1, Roy's conceptual model of nursing is represented.
The items which are demonstrated as input are both internal and
external stimuli. More specifically, these stimuli are the elderly

individual's feelings regarding the move to the extended care

 

 

 

25

 

 

Cognator

 

(Coping

INPUT -——f3> A
I

Mechanisms)

 

 

Regulator

 

 

 

 

(Stimuli Adaptation Level:)

1. The elderly individual's
feelings regarding the move
to the extended care
facility.

2. The reaction by the elderly
individual to the family's
and staff's attitudes about
the move.

3. The physical effects of the
move:

a. Presence of pain upon
movement.

b. Weakness/fatigue.

c. Changes in bodily
functions.

4. The mental status of the
elderly individual.

Effectors,
Adaptive Modes

Coping is

Effected ‘-—~—%> OUTPUT

Through the
Four Modes

 

 

(Adaptive and Ineffective
Responses:)

1. Adaptation to the move.

Increased knowledge and
social activity.

Failure to adapt (to the
move). Decreased knowledge
and social activity.

Figure 1. The Person as an Adaptive System, adapted from Roy, C. 8

 

Roberts, 5. (1981). Theory construction in nursing: An

adaptation model, p. 58.

 

Englewood Cliffs, NJ.

 

 

26

facility, the reactions by the elderly individual to the family's and
staff's attitudes about the move, the physical effects of the move,
(presence of pain upon movement, weakness and fatigue, and changes in
bodily functions) and the mental status of the elderly individual.

The cognator and regulator are represented as the coping
mechanisms and the adaptive modes are the effectors of the elderly
individual's coping skills. The coping skills are then represented
as effective or ineffective in the output phase. The outcome of the
effective or ineffective coping by the individual is positive or
negative adaptation to the move.

The elderly individual who is relocating from the acute care
setting to the extended care facility is an adaptive system. The
elderly individual as an adaptive system is very much affected by
changes in environment and must constantly adapt in order to deal
with the changes.

One disadvantage in the outcome upon relocation of the elderly
individual is that his/her health is compromised in some way. As is
suggested in the literature (Ebersole 8 Hess, 1985; Pino et al.,
1978; Pastalan 8 Bourestrom, 1977; Wolanin, 1978), this compromise
weakens the coping and adaptation capability of the elderly
individual. Therefore, the individual is not functioning at his/her
normal adaptive potential.

According to Mullen (1977), ”adequate medical treatment before,
during and after the move may mitigate some of the stressful effects

of the move” (p. 13). Striving to achieve an optimal level of health

 

 

27

for the elderly individual will provide for more positive adaptation
upon relocation.

The intervention by Mullen (1977) is viewed as input when
applying it to the Roy Model. The intervention of "medical
treatment" is seen as input from external stimuli (Roy 8 Roberts,
1981). The medical care team is viewed in this situation as
manipulating the external variables and the individual is seen as
providing internal stimuli In regard to his/her reaction to his/her
current health status.

Roy, according to Fitzpatrick and Whall (1983) further defines
stimuli and speaks of focal, contextual and residual stimuli. Focal
stimuli is ”the stimuli immediately confronting the person” (p.
159). Contextual stimuli is ”all other stimuli which are present”
(p. 159), and residual stimuli is ”factors from past experiences
which may be relevant to the present situation but whose current
effect cannot be validated. These factors include beliefs and
attitudes” (Fitzpatrick s vhaii, 1983, p. 159).

In dealing with relocation from the acute care setting to the
extended care facility, the elderly individual is dealing with
several other types of stimuli as well as the issue of compromised
health. He/she is dealing with such stimuli as past experience with
relocation (residual stimuli), coping ability in dealing with change
(contextual stimuli) and feelings and emotions about his/her current
situation (focal stimuli). All of these stimuli affect the way in

which the elderly individual will deal with the issue of relocation.

 

28

According to Mullen (1977) and Ebersole and Hess (1985), there
are many significant variables which affect how the elderly adapt to
the relocation process. First, the elderly must process the stimuli
and accept those stimuli in the form of input, according to Roy's
model. Next, the input is dealt with in the primary subsystems of
the regulator and cognator, and in the secondary effector or
subsystems (Fitzpatrick 8 Whall, 1983).

The regulator is related predominantly to the model of
physiological needs and the major parts of the subsystem are the
neural, endocrine and perception-psychomotor portions (Roy 8 Roberts,
1981). The cognator subsystem relates to all four adaptive modes and
the major parts are ”the psychosocial pathways and the apparatus
for: 1) perceptual/information processing; 2) learning; 3) judgment;
and 4) emotion” (Roy 8 Roberts, 1981, p. 62).

The processes of both the cognator and regulator are identified

in propositions which depict the relationships between the individual
and each of the subsystems. ”The two systems are linked together in
the process of perception” (Roy 8 Roberts, 1981, p. 67). The
secondary effector subsystems consist of the four adaptive modes:
1) physiological needs; 2) self-concept; 3) role function; and 4)
interdependence. ”These modes will provide the particular form or
manifestation of cognator and regulator activity” (Roy 8 Roberts,
1981, p. 66-67).

Therefore, the elderly individual processes all of the input

information into the cognator and regulator subsystems. The

 

 

 

29

manifestation of the response to this processing of information will

be seen in the adaptive modes.

The elderly individual who is relocated from the acute care

setting to the extended care facility will deal with the input

information through mental and physical processes. The perception

process will then effect the adaptation.

The elderly individual generally perceives the issue of

relocation as stressful and will effect this perception of relocation

as a stressful event through the four modes:

1.

Physiological needs. According to Burnside (1980), to help
persons with limited neurological functioning (such as the
elderly) to adjust and accept change, we would have to retain
much of what was familiar. Or, according to Wolanin (1978),
such physiological issues as vision must be taken into
consideration when relocating the elderly, and plans to
compensate must be formulated when function is poor.

No matter what the physiological problem is, the elderly
individual should be assisted in adaptation to the physical
problem first and then assisted with the adaptation to the new
environment.

Self-concept. According to Burnside (1980) ”the elderly
institutionalized patient is often unable to cope with all of
the stimuli within the environment and has a low self-esteem”
(p. 103). The elderly individual in the acute care setting who
is transferring to the extended care facility is often

functioning at this level.

 

 

 

30

3. Role mastery. According to Burnside (1980), the newly admitted

nursing home resident is faced with new role challenges:

a. Orienting himself or herself to the facility.

b. Living in a group.

c. Coming to grips with loneliness and dependency.

The elderly involved in relocation will experience adjustment to
acquisition of an entirely new role.

4. Interdependence. When an elderly individual is confronted with
the issue of relocation, the relocation process is viewed as a
multifaceted one in which the individual experiences dependency
and interdependency, but experiences little independence.

According to Lesnoff-Caraveglia (1980), "the process by which the
environmental change is effected and the nature of the environment
are as important as the change itself'I (p. 185). Therefore, the
elderly are bombarded by several changes which evoke dependency needs
which are often seen as negative behaviors by the elderly. These
needs can take on a more positive focus by becoming interdependent
needs, whereby the patient, family and professional are all working
together toward a positive relocation experience.

According to Roy (Roy 8 Roberts, 1981), after the four adaptive
modes ”interact” with the regulator and cognator, responses are
effected which are either adaptive or ineffective and are termed
output. These responses, whether negative or positive, are fed back
to the input for further processing and are added to the adaptation

level as stored knowledge.

 

 

 

31

The elderly individual will exhibit responses to the relocation
from the acute care setting to the extended care setting. The
responses may be adaptive or ineffective in nature. An adaptive
response would be a quick and positive adjustment to the move which
promotes the integrity of the individual. In this type of response
the individual will exhibit positive adaptation.

An ineffective response can be manifested in a number of ways,
i.e., the ”Fight Phenomenon," depression, withdrawal, death, etc.
This type of response disrupts the integrity of the individual and
the individual exhibits negative coping behavior, and maladaptation.

Both types of responses will influence the elderly individual's
adaptation to the new environment. When unusual stressors or
weakened coping mechanisms make a person's usual attempts to cope
ineffective, then the person needs a nurse. Therefore, it is the
responsibility of the nurse to intervene and ”manipulate the stimuli
so that they fall within the patient's zone of positive coping” (Roy
8 Roberts, 1981, p. 47).

In dealing with the issue of relocation and the elderly, ”the
professional nurse is the appropriate person to assess the situation
of the elderly patient and to plan appropriate interventive strategy'I
(Burnside, 1980, p. 32). Therefore, the nurse can assist with the
adaptation to the relocation process through interventions which will
enhance the elderly individual's coping capabilities. One method of
intervention is the provision of an orientation program to the
extended care facility by a professional nurse who is familiar with

that facility. In providing an orientation program to the extended

 

32

care facility, the professional nurse is manipulating the type and
amount of stimuli which is provided for the patient. By manipulating
the stimuli the professional nurse is able to affect the type of
input which the individual receives.

In accordance with Roy's Adaptation Model, the orientation
program will be administered as an external stimulus. The elderly
individual will accept the program as input and process it through
the cognator and regulator subsystems. The processed information
will be perceived by the individual and effected in the four adaptive
modes:

1. Physiological needs. The person's neurological system will
respond to the orientation program as presented by the
professional nurse, and a body response will be effected.

2. Self-concept. The elderly individual will view the new
information from the orientation program and will experience a
change in self-esteem and self-awareness.

3. Role mastery. The elderly individual will process the new
information from the orientation program and will integrate the
information in preparing his/her new role.

4. Interdependence. The elderly individual will recognize the
reciprocal nature of this relationship with the professional
nurse through participation in the orientation program. The
nurse can reinforce this relationship through effective
communication.

After the orientation program is presented, the output will be

viewed as positive adaptation or as negative adaptation to the newly

 

 

33

acquired patient role after relocation. The output will then be fed
back to the input component in the form of newly obtained knowledge.
The model is developed in such a way that when the output
information is fed back through the feedback process, the
professional nurse can make an assessment at that point and provide
another intervention as needed. At this point, the interventions of
the nurse become part of an ongoing process. The ongoing process in
the model is easily assimilated with the nursing process (Figure 2).
In Figure 2, a flow chart illustrating the nursing process based
on the Roy Adaptation Model of Nursing is represented. Application
of the nursing process to the issue of relocation from the acute care
setting to the extended care facility by an elderly individual is
applicable to this representation. The first level assessment is
representative of the client's behavior in each adaptive mode and the
second level assessment is representative of the focal, contextual
and residual stimuli (see examples, Figure 2). Problem
identification is represented by a statement that the elderly
individual has adapted effectively/ineffectively to the move. Goal
setting is explained as the behavioral outcome for the client. The
elderly individual will effectively adapt to the relocation from the
acute care setting to the extended care facility. The intervention
is represented by the orientation program and the evaluation is
represented by measurement of adaptive behaviors: sociability and
knowledge. The adaptive behaviors are outcomes of the effects of

relocation and/or the orientation program on the elderly individual.

 

 

 

First Level Assessment
(client behavior in each
adaptive mode).

1. Physical needs - visual/
hearing problems, medical
diagnosis.

2. Self-concept - low self-
esteem, feelings of
inadequacy.

3. Role mastery - adjustment
to the new role at the ECF.

4. Interdependence - the
elderly Individual, the
family and the nurse work
together.

34

 

 

 

Second Level Assessment
(focal contextual and residual
stimuli).

Focal - present situation
(where he/she now resides).

Contextual-other stimuli
(family's feelings about move,
staff attitudes).

Residual-past experience (past
experience with moves/reloca-
tion; hospitalization In past).

 

 

 

 

 

 

Figure 2:

 

Problem Identification
(statement of adaptive/
maladaptive behavior with most
relevant influencing factors).

I. The elderly Individual has
adapted to the relocation
from the acute care setting
to the ECF with/without
family support, staff
support and an orientation
program.

2. The elderly individual has
not adapted to the reloca-
tion from the acute care
setting to the ECF with/
without family support,
staff support, an orienta-
tion program.

 

 

I

 

 

Goal setting (behavioral
outcome for the client).

The elderly individual will
experience a positive adapta-
tion to the relocation from
the acute care setting to
the extended care facility.

 

 

Evaluation (judgment of
as measured by comparison of

knowledge and sociability.

 

 

y

 

effectiveness of intervention)

 

the pretest/posttest scores on

 

 

 

Intervention (approach to
promote adptatlon by manipu-
lation of stimuli) provision
of an orientation program by
an R.N. from the ECF.

 

Flow Chart Illustrating the Nursing Process Based on the

Roy Adaptation Model of Nursing, adapted from Roy, C.

(1976), Introduction to nursing:

38. Englewood Cliffs, NJ.

An adaptation model, p.

 

 

 

 

 

35

Therefore, the model is easily applied to professional nursing
practice through application of the model to the nursing process.

The professional nurse can assist the elderly individual who is
relocating from the acute care setting to the extended care facility
through adaptation of the conceptual framework which has been
developed in this discussion.

In the primary care setting the Clinical Nurse Specialist can
utilize the model directly by addressing the elderly client's and the
family's needs when faced with relocation from the acute care setting
to the extended care facility. The Clinical Nurse Specialist's role
is to identify the client's and family's needs through assessment of
the adaptive modes and the various stimuli which are present. The
Clinical Nurse Specialist also identifies the problem(s) associated
with the relocation event, provides assistance in goal-setting for
the client and significant others, provides intervention strategies,
i.e., the orientation program to the extended care facility and
evaluates the effectiveness of the intervention in the relocation
event.

The Clinical Nurse Specialist in the primary care setting may
also effect several role characteristics to enhance the relocation
experience for the client. The Clinical Nurse Specialist may broaden
the scope of the event through education of other health team members
from the acute care setting and extended care facility who are
involved in the event.

One of the roles of the Clinical Nurse Specialist during the

relocation of an elderly client from the acute care setting to the

 

 

 

 

 

36

extended care facility is the role of advocate. The Clinical Nurse
Specialist functions as an advocate "by creating a climate of
mutuality in which the nurse assists the client in exercising his/her
rights and in improving self-care abilities'I (MSU Graduate Student
Handbook, 1980, p. 22). In the relocation situation the nurse
encourages the client to exercise his/her rights to identify factors
which will make the move a more positive experience. In doing so,
the Clinical Nurse Specialist functions also as an educator.

Other role characteristics exhibited by the Clinical Nurse
Specialist in the primary care setting when dealing with an elderly
client who is experiencing relocation are the roles of assessor,
planner, counselor, collaborator and coordinator. Utilization of
these role characteristics serve to enhance the relocation experience
for the client.

As assessor, the Clinical Nurse Specialist ”utilizes a data base
to identify health care needs” and as a planner ”develops
goal-directed strategies in collaboration with the client to
facilitate maintenance and achievement of health-oriented goals“ (MSU
Graduate Student Handbook, 1980, p. 23). The Clinical Nurse
Specialist would coordinate and direct the relocation experience with
the elderly client and the client's family providing the necessary
input to accomplish the client-centered relocation experience
effectively.

Similarly, the Clinical Nurse Specialist as consultant and
collaborator would enhance the elderly client's relocation

experience. The Clinical Nurse Specialist would educate the nursing

 

 

 

 

37

staff regarding the effects of relocation from an acute care setting
to an extended care facility on the elderly client. As collaborator,
the Clinical Nurse Specialist would work with the acute care and
extended care health team members ”to achieve joint responsibility
and accountability for planning and for decisions made regarding
client needs and outcomes” (MSU Graduate Student Handbook, 1980, p.
22).

The framework which has been deveIOped in this paper is easily
applied to the primary care setting. The framework is applied to the
conceptual model through synthesis with the Roy Adaptation Model and
the model can then be integrated and applied to the nursing process
for use in professional nursing practice (Figure 3).

Figure 3 is representative of Figures 1 and 2 in combined form.
The Roy Adaptation Model of nursing and the illustration of the
nursing process based on the Roy Adaptation Model of Nursing can be
presented through integration of the individual representations. The
outcome is the model for the effect of orientation on the elderly
individual in relocation from the acute care setting to the extended
care setting as applied to the Roy Adaptation Model of Nursing and as

integrated with the nursing process.

 

 

38

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The Effect of Orientation on the Elderly Individual

ure 3

Fi

Relocation from the Acute Care Setting to the Extended

Care Facility as applied to the Roy Adaptation Model of

Nursing and integrated with the nursing process.

 

 

 

 

CHAPTER III

Review of the Literature

Introduction

 

The purpose of this chapter is to present a scholarly review of
the literature regarding the major variables in this study. The
studies which will be identified are related to: interinstitutional
relocation of the elderly, adaptation and orientation programs for
elderly individuals who are experiencing relocation. Also discussed
are the concepts of knowledge and socialization as a part of
adaptation. Included in the review will be discussion of both the
content and the limitations of the studies, discussion regarding how
the literature is related to nursing, and summarization of the
literature which has been reviewed. The literature review will
consist of three sections: interinstitutional relocation of the

elderly, adaptation and orientation programs.

lnterinstitutlonal Relocation of the Elderly

 

Several studies have been completed regarding the issue of
interinstitutional relocation of the elderly. Basically there are
two conclusions which have been formulated from the studies which
have been completed. The first conclusion indicates that relocation
of the elderly to an institution is a negative experience which
results in increased morbidity and mortality of elderly individuals
(Pastalan 8 Bourestom, 1977; Thomas, 1979). The second conclusion

indicates that interinstitutional relocation of an elderly individual

39

 

 

 

 

 

 

40

has little or no effect on the morbidity or mortality of the elderly
individual (Borup, Gallego 8 Heffernan, 1979) and the relocation is
not viewed as a negative experience. Due to the discrepancy in the
findings of the studies regarding interinstitutional relocation of
the elderly, according to Mirotznik and Ruskin (1984) ”it is
imperative that we continue to expand our knowledge to better

understand the consequences of relocation for the elderly” (p. 286).

Effects of Relocation on Mortality Rates

 

In studying the effects of interinstitutional relocation from the
perspective of the effects of the relocation experience on mortality
rates, Pastalan and Bourestom (1977) studied two groups of elderly
nursing home patients (N = not reported) who were being relocated to
different nursing homes. The study was initiated in 1971 and the
patients were matched in age, sex, physical and mental health. One
group was relocated after four preparatory visits to their new home
and the other was moved after only one preparatory visit to their new
home. Within one year, 27% of the first group had died and 52% of
the latter group had died.

The small study completed by Bourestom and Pastalan (1977) lead
Pastalan and a team of researchers in Pennsylvania to study a larger
group of elderly individuals who were experiencing interinstitutional
relocation from one nursing home to another (N = 400). The study was
completed in 1974. The elderly individuals were prepared by the

nurses and social workers from their nursing home and were

 

 

 

in

familiarized with the new environment utilizing counseling sessions,
group discussions and visits to the new homes (Pastalan 8 Bourestom,
1977).

The study group in Pastalan and Bourestom's (1977) study was
evaluated at the end of one year and, upon measuring the annual
mortality rate of the 400 elderly individuals, the annual mortality
rate was measured at 22%. In summarizing Pastalan's (1977) study,
the 22% annual mortality rate experienced in the study was compared
to the 27% annual mortality rate for elderly individuals in
Pennsylvania, and to the national mortality rate of 28% for elderly
individuals. Pastalan and Bourestom (1977) established that the 22%
annual mortality rate showed an improvement in mortality rate and
related the improvement to prior preparation for the move.

Pastalan (1977) and the other researchers established that if an
elderly individual was moved more than 45 miles, the mortality rate
was higher than for those individuals who were moved a shorter
distance. Another conclusion made by Pastalan (1977) and the other
researchers was that ”those who definitely accepted or rejected the
move died at a lower rate than those who did not seem to care” (p.
32).

In reviewing the results of Pastalan's (1977) Pennsylvania study,
it is not clear whether or not the mortality rates were truly
affected by the relocation experience or if the mortality rates were
caused by other factors, such as illness, frailty, stage of disease,
or type of diagnosis. However, the pervading message in Pastalan's

(1977) program is that preparing the elderly individual prior to the

 

 

 

 

 

 

42

relocation experience seemingly positively affects the adjustment to
the new setting and decreases the mortality rate.

In studying the issue of mortality as related to interinstitutional
relocation of the elderly, Butler and Lewis (1983) report that 85-90%
of persons who enter nursing homes do not leave them alive.

According to Butler and Lewis (1982), the average length of stay is
1.6 years, one-third of the residents die within the first year of
relocation to the nursing home, and another one-third die between the
first and third years post-relocation.

In 1983, Chenitz completed a qualitative study of two groups of
elderly individuals who experienced difficulty in making the
transitions to nursing homes upon relocation (N = 30). The
individuals were studied from admission to six to nine months after
admission and were interviewed several times each week during that
time.

Chenitz (1983) used grounded theory methodology and analyzed the
data from the actual experiences of those persons who were
relocated. The group of elderly individuals studied were compared to
a similar group of elderly who were receiving home care (N = 30).
Also interviewed were staff, physicians, and other elders in nursing
homes in the area, and those subjects were used as a basis for
comparison.

The elderly individuals who were experiencing relocation in
Chenitz's (1983) study displayed several types of reactions to the
move from acceptance to resistance. Resistance was demonstrated by

”giving up the will to live” or ”just waiting to die” (Chenitz, 1983,

 

 

 

43

p. 85). Chenitz also explains the relocation process as a ”status
passage" or a movement from one life experience to another to include
moving from life to death. In other words, mortality can be viewed
as a result of the relocation process.

Pino et al. (1978) completed an experimental study of elderly
individuals (N = 100) who were relocated. The participants were
subdivided into four groups of twenty-five participants each:
relocated patients, prepared transfers, unprepared transfers and
control group. The instruments used for measurement in the study
were the Life Satisfaction Scale, the Personality Adjustment Scale,
Raven's Progressive Matrices, Activities of Daily Living and the
Mental Status Questionnaire. The data was gathered one week prior to
transfer to one week after admission and again after nine months.

Analysis of the data included analysis of variance of pre- and
post-measurements for the four groups. The results of the measures
on the Life Satisfaction Scale were reported as significant
differences (at the .005 level) which ”demonstrated the superiority
of the transferred groups to the relocated control groups on this
test” (Pino et al., 1978, p. 170). The results were found to be
nonsignificant when testing group differences on the Personality
Adjustment Scale and on the Raven's Progressive Matrices (a
nonverbal, culture-free IQ test). All groups performed significantly
better than the control group on the Activities of Daily Living Scale
and on the Mental Status Questionnaire. Therefore, since the

“prepared“ patients performed at a more successful level, it has been

 

44

postulated by the authors that the mortality rates of the prepared
groups was lower than the rates of the unprepared group.

A descriptive study investigating the effects of the
interinstitutional relocation was completed by Mirotznik and Ruskin
(1984) on the health of chronically ill patients (N = 306) and the
authors determined that ”relocation had no positive or negative
effect on 13 of 18 health measures investigated” (p. 286). The
instruments which were used in the study were the Albert Einstein
College of Medicine Depression Scale (AECMDS) to measure
post-relocation morale, a questionnaire measuring patient
satisfaction with the move, a medication review instrument and a
review of the number of specialist consultations. Data were analyzed
and the results of the study indicated that relocation had no effect
on 13 of the 18 health measures. ”The five measures which exhibited
significant main and/or interaction effects were Pulse Intensity,
Respiration Frequency, Respiration Intensity, Sedatives and
Tranquilizers and Specialist Consultations'l (Mirotznik 8 Ruskin,
1984, p. 288). Four of the five measures were reported by the
authors to show positive effects post-relocation and one of the
measures was reported to show a negative effect. A negative effect
was experienced by elderly patients who exhibited a decrement in
health as measured by Specialist Consultations.

Mirotznik and Ruskin (1984) concluded that “the study's findings
suggest that several of the factors which mediate mortality during
relocation also mediate the impact of relocation on health”

(p. 291). The factors which Mirotznik and Ruskin (1984) referred to

 

 

 

45

as mediating the impact of relocation are: 1) interest and concern
by the administration and professional staff of the nursing home;
2) an extensive relocation plan to minimize relocation trauma;

3) formation of an “Interdisciplinary Relocation Team” to provide
emotional and social support to the patients; and 4) patient
involvement in decision making regarding the move.

According to Horowitz and Schultz (1983) ”40 empirical studies
have been completed regarding interinstitutional or intrainstitutional
relocation of the elderly and 32 of these 40 studies report mortality
comparisons” (p. 232). Horowitz and Schultz's article is a critique
of the relocation literature regarding interinstitutional and
intrainstitutional relocation of the elderly. The authors report
that the articles which accept the null hypothesis that relocation
has no effect on mortality rate are invalid and unreliable.

Borup (1983) responded to Horrowitz and Schultz (1983) and
continues to propose that interinstitutional and intrainstitutional
relocation has no effect on mortality rates of elderly individuals.
Borup (1983) proposes that ”we need now to direct our attention to
possible adverse conditions that are causal to an individual's
vulnerability to mortality when relocating” (p. 241). The possible
adverse conditions deal with morbidity.

In reviewing the literature on the issue of the effects of
relocation on mortality rates of elderly individuals, Borup's
statement regarding the need to direct attention away from the
mortality issue is justified. Due to the discrepancies in the

findings after each attempt to attribute increases in mortality rates

 

 

46

to relocation effects, it becomes obvious that another method for
measuring relocation effect is needed. All of the studies, including
the studies of Pastalan and Bourestom, indicate that issues such as
preparation for the move, orientation to the new location and
allowance for patient involvement in decision-making positively
affect the relocation experience. Therefore, it seems more feasible

to investigate those more positive issues in studying relocation.

Effects on Morbidigy

 

Pastalan and Bourestom (1977) investigated the effects of
relocation of the elderly on mortality rates and several others
investigated the effects of relocation of the elderly on morbidity
rates. In reviewing the literature regarding the perspective that
morbidity rates are affected by relocation of elderly individuals,
Thomas (1979) completed a descriptive study of elderly residents in
six skilled nursing homes in a three county area (N = 30) focusing
upon the morbidity rate post-relocation for the elderly population
who was studied. The tools used in the study were the Cornell
Medical Index Health Questionnaire (CMI) which was used to elicit
medical and psychiatric information and the Geriatric Social
Readjustment Rating Scale (GSRRS). The GSRRS measured the amount of
stress undergone by the patient within the past five years (Thomas,
1979). Also utilized was the Signs and Symptoms of Stress Checklist
(SOS) which is Thomas' own instrument. The data analysis was

completed by classification of symptoms by body systems to identify

47

morbidity patterns and trends. The Spearman rank order correlation
coefficient was used to analyze the data (Thomas, 1979, p. 267).

The elderly subjects in Thomas' (1979) study were observed for 28
days and the results from the CMI indicated that 41% of the relocated
elderly were reported to be angry and 27% were depressed. The
physical symptoms reported in order of frequency were: 1)
cardiovascular system problems; 2) digestive system problems; 3)
confusion; 4) sleeplessness; 5) fatigue; 6) crying; and 7) feelings
of hopelessness (Thomas, 1979, p. 267). Every subject reported
significant emotional disturbance according to the GSRRS.

Thomas (1979) concludes that relocation affects morbidity but
cites the limitations of her study as ”a small population,
insufficiently trained data collectors, a short observation period
and the need for modification of the data collection tools“ (p.

271). As in Pastalan's (1977) study, it is difficult to state that
the reason for the change in morbidity rate was due to the effects of
relocation only. Several other factors such as type of diagnosis
frailty and mental status could affect the results of the study.

In relationship to morbidity as related to relocation of the
elderly, Rodstein et al (1976) completed a descriptive study of
elderly individuals admitted to the Jewish Home and Hospital for Aged
(N = 100). The participants were studied for one month post-
relocation. The physical health factors and behavioral changes were
analyzed independently and then correlated. Fifty subjects did not
show any significant changes in medical status, 14 had minor changes,

15 had moderate changes and 21 had severe changes in medical status.

48

The majority of the changes which were significant in relationship to
medical status were cardiovascular changes. After six months the
medical status changes were re-evaluated and 25% of the patients with
moderate or severe medical changes showed improvement or complete
resolution of the changes.

Fifty subjects in the study by Rodstein et al. (1976) showed
significant difficulties in adjustment as measured by evaluation of
the quality of adjustment. The quality of the adjustment was
measured in terms of mood, anxiety, orientation, personality
characteristics, interaction with staff and residents and family
relations.

The conclusion which was drawn by Rodstein et al. (1976) in
regard to morbidity rates as related to relocation was that the
initial period post-relocation is a stressful experience. However,
among those elderly who manifested problems of adjustment, the
majority improved within six months after admission.

In reviewing the literature regarding the effects of relocation,
it is initially a stressful experience which has some negative
effects on physical health. However, after one to six months when
the relocated elderly are re-evaluated, there is improvement in the
individual's physical health. Therefore, effects of relocation on

morbidity are short-lived.

49

Lack of Effect on Morbidity/Mortality

The improvement in adaptation after a longer term of adjustment
indicates that the effects of relocation on morbidity and mortality
are not as significant as appearances indicate. Borup et al. (1979)
studied the effects of interinstitutional relocation on mortality of
elderly individuals (N = 982) and determined that relocation had no
effect on mortality. Borup et al. (1979) studied 30 nursing homes in
Utah. An experimental-control research design was utilized. The
experimental group consisted of all patients residing in 30 nursing
homes and the control group consisted of all patients residing in 19
randomly selected homes. Both groups were contacted during the
course of the study. The experimental group was contacted on four
occasions and the control group was contacted on two occasions.

The mortality rates were calculated for the two groups, and data
were analyzed using the Chi square technique. The findings of the
study indicated that the mortality rates for those patients in the
experimental group were lower than for those in the control group.
Further analysis of data indicated that the control group contained
more old-old patients, and the difference in the mortality rates in
the two groups was apparently due to the large number of old-old
patients in the control group, not due to relocation effects.
Therefore, Borup et al. (1979) concluded that relocation has no
influence on mortality of elderly individuals who are relocated.

Engle (1985) completed a descriptive study of elderly individuals
who were relocated from a hospital to a nursing home (N = 55). The

participants were 60 years old and older and were evaluated for level

 

 

50

of consciousness, attention, concentration, orientation, memory, and
higher cognitive function using the Mental Status Examination. Six
activities of daily living were also evaluated using the Scaled
Outcome Criteria.

Data were collected over a four day period and data were analyzed
using a matched pairs gftest which demonstrated no significant
differences in the mean scores of the participants' functional status
over the four day period. There was no significant difference
between Day 1 and Day 4 for level of consciousness, attention/
concentration, orientation or higher cognitive function (Engle,
1985). However, a significant finding was reported regarding
memory. There was significant improvement in memory, both short- and
long-term from Day 1 to Day 4. No deterioration in functional or
mental status was determined in Engle's study. The study results
were reported to demonstrate either no change or slight improvement
in status. Therefore, the findings in Engle's study are reported
indicating that interinstitutional relocation of the elderly has no
effect on morbidity or mortality.

Nirenberg (1983) completed an experimental study of cognitively
low-functioning and high-functioning subjects (N = 40) who
experienced interinstitutional relocation from an old, deteriorating
facility to a new facility. Nirenberg tested the participants two
weeks prior to relocation, three weeks following relocation and three
months post-relocation. The instruments utilized in the assessment
of the elderly were the Short Portable Mental Status Questionnaire,

the Philadelphia Geriatric Center Morale Scale, the Physical

51

Self-Maintenance Scale, the Face-Hand Test, and the VIRO Assessment
Scale. The treatment of the participants involved a basic relocation
preparatory program which involved all subjects. One-half of the
low-functioning group was assigned to a behavioral skills program and
one-half of the high-functioning group was assigned to a cognitive
skills program. The control groups consisted of one-half of the
low-functioning and one-half of the high-functioning groups and were
visited by volunteers on the same days that the treatment groups
received training.

Nirenberg (1983) analyzed data from the study utilizing the
techniques of multivariate analysis of variance (MANOVA) and Post hoc
Scheffe' means comparisons. The results indicated the ”the
behavioral skills program led to favorable post-relocation changes,
but the cognitive skills program did not” (p. 693). Overall, the
experiment showed that the relocation experience had no effect on the
morbidity or mortality rates of the individuals studied. The results
indicated differences in adjustment or adaptation as evidenced by an
increase in passive-withdrawn behaviors in low-functioning subjects
and an increase in active-outgoing behavior in high-functioning
subjects.

Stein, Lynn and Stein (1985) reported a descriptive study of
elderly individuals who were newly admitted to ten nursing homes
(N = 223). The study took place over a two and one-half year period
and "the purpose of the study was to explore the dimensions of
anticipated stresses of institutionalization in a newly admitted

group of nursing home residents, and to determine the relationship of

52

these anticipated problems to demographic and attitudinal variables
as well as to psychological and physical function” (p. 89).

The instruments used in Stein's (1985) study were a 20-item
Stresses in Institutional Care Scale (SIC), a five-point scale to
measure attitudinal variables, Rotter's Scale, the POMS, Sherwood's
Self-Esteem Scale and the Rapid Disability Rating Scale. Data were
analyzed utilizing correlations and factor analysis. The results
from the SIC scale indicated that identifying stresses which the
elderly experience related to relocation to a nursing home provides
the staff with information regarding the patient's specific concerns.
The identification of the stressors which are defined by the patient
(severance anxiety, medical concerns, tender loving care, relocation,
orientation and individual space) allows the staff the opportunity to
address the patient's concerns. Addressing the patient's concerns
lessens the stress and improves the outcome of the relocation
experience. Therefore, relocation of the elderly when accomplished
in this manner does not negatively affect morbidity and mortality

rates.

Summary Morbidity/Mortality

 

In reviewing the literature regarding the issue of the effect of
interinstitutional relocation on the morbidity and mortality rates of
elderly individuals, it is indicated by the findings that there is
disagreement regarding this issue. The authors of the research
studies regarding interinstitutional relocation of the elderly

conclude either that: 1) morbidity and mortality rates are

53

negatively affected by the move; or 2) there is no effect on
morbidity and mortality rates post-move. Therefore, the focus in
this study does not deal with the issues of mortality and morbidity
but deals with the broader issue of whether or not the elderly can

effectively adapt upon relocation from one institution to another.

Adaptation

Adaptation is defined as ”anything that is changed or changes so

 

as to become suitable to a new or special use or situation” (Morris,
1973, p. 14). According to Roy (1981) adaptation is defined as “the
person's reponse to the environment which promotes the general goals
of the person including survival, growth, reproduction and mastery“
(p. 53). McGlynn (1983) reports that adaptation is “the way a person
responds to focal, background or internal stimuli if the behavior
remains constant" (p. 32). For the purposes of this study adaptation
is viewed in terms of an outcome which is expressed as "more positive
adaptation." “More positive adaptation” for the purposes of this
study is defined as certain, accepted or affirmed change which is
accomplished so as to become suitable to a new situation. The
concept "more positive adaptation” is defined as a positive change
for the individual post-relocation, whereas morbidity and mortality
denote a negative change for the individual as a result of the
relocation experience.

Farkas (1981) completed an experimental study ”to identify
adaptation problems on the part of elderly persons and significant

others that were associated with nursing home applications for

 

54

elderly persons in Canada” (p. 363). The group studied (N = 44)
included both elderly individuals applying to nursing homes, their
families and significant others and a control group. The conceptual
framework for the study was based on the Roy Adaptation Model
(Farkas, 1981).

Farkas (1981) utilized ”face-to-face interviews” in the elderly
subjects' homes to collect data. “Scales for powerlessness as well
as knowledge and utilization of services were developed'I (p. 364).
Data were analyzed utilizing Chi square technique.

Farkas (1981) indicated that the original reason for a nursing
home referral is a problem of adaptation in the physiological mode.
However, the problems of adaptation in the physiological mode were
viewed by the patients' significant others as within the coping
capabilities of the elderly subjects. The significant others'
concerns regarding problems of adaptation dealt more specifically
with the self-concept and role function modes. The specific
adaptation problems which the elderly individuals experienced were
specific to the interdependence and the physiological modes of Roy's
Model. Therefore, the elderly in Farkas' study viewed dependency and
physiological problems, i.e., hearing loss, incontinence, difficulty
climbing stairs as a greater problem than the issues of self-concept
and role function.

The significant others in Farkas' (1981) study felt that the
physiological problems as well as the issue of dependency could be
overcome. The significant others viewed the issue of the elderly's

concept of his/her capabilities and self-concept as well as the

 

55

elderly's role function as the areas of greatest concern regarding
adaptation to the need for nursing home placement. The difference in
the feelings of the significant others as compared to the feelings of
the elderly regarding the adaptation problems in considering the need
for a nursing home admission play a significant role in how well the
elderly person adapts.

Craig (1983) developed a conceptual model for adaptation in
chronic illness. Craig (1983) defined adaptation as ”coming to terms
with the reality of chronic illness as a stage of being, discarding
false hope and destructive hopelessness, and restructuring the
environment in which one now functions" (p. 399). Craig's framework
could easily be applied to adaptation to any major life change such
as relocation.

Craig (1983) describes adaptation as the goal or outcome to the
event of chronic illness which is accomplished through utilization of
the process of appraisal and reappraisal. The process of
appraisal-reappraisal consists of problem-solving techniques and
coping. Craig's framework purports that through utilization of
problem-solving and coping techniques, the person eventually adapts.

Janelli (1980) reports the use of Roy's Adaptation Model in
gerontology, especially when dealing with the elderly when they are
facing life transitions or changes. According to Janelli, ”change is
seen as an adaptive process” (p. 140) involving interactions among
psychological and biological elements.

In discussing Roy's Model of adaptation, Janelli (1980) reports

that "the dynamic force of the model rests in man's ability to adapt

56

to an ever-changing environment” (p. 140). Janelli discusses the
application of Roy's Model to hypothetical elderly patient situations
to emphasize the point that the elderly's needs in any situation can
be met by viewing them as adaptive individuals. Janelli points out
that because of the elderly's state of developmental process, they
are experiencing major changes rapidly and must learn to adapt in
order to survive.

Chenitz (1983) views nursing home admission as a crisis for the
elderly individual and states "if the crisis is not resolved, the
elder continues to function maladaptively” (p. 97). Chenitz studied
elderly individuals who were admitted to two nursing homes in the San
Francisco Bay area (N = 30) and compared their experiences to a group
of elderly individuals receiving home care from visiting nurses
(N = 30) in a qualitative study. Chenitz reported that the elderly
individuals' reactions to relocation resulted in various displays of
behavior from acceptance to resistance, and that the elderly view the
relocation experience as one of the many passages which an individual
experiences during life.

Moos, David, Lemke, and Postle (1984) studied elderly individuals
in an older nursing home who were relocated to a new building (N = 98)
and examined behavioral patterns of residents and staff who were
involved in the move. The study was descriptive and the measurement
instrument which helped describe the changes post-relocation was the
Multiphasic Environmental Assessment Procedure (MEAP). The MEAP
assessed the facility's physical features, policies and programs,

resident and staff characteristics and social climate.

57

Data in Moos' et al. (1984) study was analyzed utilizing
percentages and analysis of variance techniques. The result of the
findings was that the residents utilized the new building living
space differently then they had utilized space in the old structure
i.e., spending more time in the halls of the new structure and less
time in lounge areas. These types of behavioral changes were
”conceptualized as attempts to adapt to the larger design and altered
layout of the new facility" (p. 495). According to Moos' et al.
study, the elderly who are faced with the experience of relocation
experience adaptation as measured by behavioral changes i.e., passive
behavior, active task-oriented behavior, and interpersonal and social
behavior as a result or outcome of the move. Interactions between
residents and staff increased post-move as well as interactions with
individuals from outside the facility. Also, the residents'
participation in organized activities at the institution increased
dramatically from before the move to two months post-move (Moos et
al., 1984).

King et al. (1987) completed a descriptive study of 37 relocated
elders who were forced to move from a small rural mining town in Utah
to other communities. The subjects were interviewed and categorized
according to how well they adjusted to the move. Presence of a
confidant, self-esteem, the amount people worry, and perceived health
were all cited as factors relative to type of outcome post-move.

King et al. (1987) concluded that the risk of relocation trauma
must be assessed and concern and support by professionals are

important to the client. Another conclusion of King et al. is that

58

the relocation experience and the outcomes are individualized
experiences and ”nurses can use a continuum of care to develop

interventions that match the individual needs of relocationg clients“

(p. 261)

Summary - Adaptation

 

In reviewing the literature, adaptation is viewed as a method by
which the elderly deal with change. A great deal of the literature
regarding the concept of adaptation discusses the concept of coping.
It is imperative, however, that the concepts are clearly defined and
that they are not used interchangeably. Coping and adaptation are
very different concepts.

Coping is defined as a process and adaptation is defined as an
outcome. According to Roy (1981), coping is the process which the
individual internalizes in the cognator/regulator process subsystems
and the response to or outcome of the coping process is positive or
negative adaptation. Adaptation can be measured in terms of outcomes
which can be identified by the professional nurse during his/her
assessment of an individual.

Adaptation is the concept which has been selected as the method
by which the elderly deal with change. Adaptation is viewed as an
outcome and the processes of coping, adjustment and problem-solving
are utilized as means to accomplishing the outcome of adaptation.

In order to accomplish positive adaptation, for the purposes of

this study, an orientation program was introduced. The orientation

 

59

program positively affected the adaptation experience of the
individual.

The outcome of adaptation was to be measured by the elderly
individual's performance on a test of knowledge about the nursing
home pre- and post-orientation and the level of socialization 30 days
post-admission was to be measured by review of social activity
attendance records, staff perception of socialization and the social
worker's perception of his/her socialization. High levels of
performance on the knowledge examination as well as a high level of
socialization were to be indicators of positive adaptation to the
nursing home.

Knowledge

The concept of knowledge was to be measured in this study as a
determinant of the amount of adaptation experienced by the elderly
individuals. Knowledge has been measured in the relocation
literature (Amenta et al., 1984; Engle, 1985; Nirenberg, 1983; Pino
et al., 1978) as an indicator of successful adaptation. Knowledge is
generally measured in relationship to the change in knowledge level
after prior preparation for the move. Knowledge levels are higher
for those elderly individuals who are prepared prior to the move as
compared to those individuals who are not prepared for the move.

Socialization

 

In addition to improving knowledge with prior preparation for the
move, social activity status is also improved with prior preparation
for the move (Engle, 1985; Grey, 1978; Moos et al., 1984; Nirenberg,

1983). Social activity is measured as the amount of social

 

 

 

60

interaction which is exhibited by the elderly individual
post-relocation. For the purposes of this study, the provision of
the orientation program to the extended care facility by the
registered nurse was to be the stimulus which affected the amount of
social activity which is exhibited by the elderly individual
post-relocation. However, social activity is an individualized type
of experience in which the amount of social activity which is
exhibited prior to institutionalization, must be taken into
consideration when evaluating the individual's social behavior

post-institutionalization.

Orientation Program

In looking more closely at the issue of relocation involving
elderly individuals who are moving to institutions, researchers in
relocation have been able to agree upon one issue: Prior preparation
for the move positively affects the elderly individual's adaptation
to the move (Borup, Gallego, 8 Heffernan, 1979; Burnside, 1981;
Ebersole 8 Hess, 1981; Giorella 8 Bevil, 1985; Hunt 8 Roll, 1987;
Nirenberg, 1983; Pastalan 8 Bourestom, 1977; Wolanin, 1978; Yurick,
Robb, Spier 8 Ebert, 1984). Despite the difference in opinion in the
literature regarding the effect or lack of effect of relocation on
morbidity and mortality rates, the issue of prior preparation for the
move as a factor in the elderly person's positive adjustment to an
institution is supported in the literature.

One method of preparing an elderly individual prior to relocation

is by providing an orientation program for the individual. Several

 

61

studies have been completed which have incorporated an orientation
program prior to or at the time of the move. Kennedy et al. (1987)
reported effective comprehensive discharge planning as one method of
prior preparation to moving the elderly from the acute care setting.
In an experimental study of 80 elderly, acute care patients, Kennedy
et al. report that for those in the treatment group, ”length of
hospital stay was reduced by two days and the average time between
discharge and readmission was increased by 11 days utilizing
comprehensive discharge planning.‘I

Hunt and Roll (1987) reported environmental simulation as an
effective technique in preparing the elderly individual for a move to
an unknown building. In a field experiment of 60 elderly
individuals, there were three evenly divided groups of participants:
site visit group (20); simulation group (20); and control group
(20). The findings were indicative that enviornmental simulation is
comparable to site visits in instilling confidence and improving
efficiency in way-finding in the new setting. In other words, prior
preparation to the move is beneficial in assisting elderly
individuals in their adaptation to the new surroundings.

Pino, Rosica and Carter (1978) completed a study regarding the
differential effects of relocation on nursing home patients with the
hypothesis that the patients who are relocated from another
institution ”will have more difficulty in readjusting than the
transferred patient who has been prepared for the move, or the
unprepared transferred patient” (p. 167). (Transferred is defined as

an intrainstitutional move.) The patients in this study were divided

 

62

into four groups: ”relocated patients, prepared transfers,
unprepared transfers and the control group. (A stationary group of
aged patients at a neighboring institution within the same
geographical area.) (p. 167). As in the the study by Nirenberg
(1983), a battery of tests were used to assess the patients'
psychological status and to assess "their reported sensitivity to
change” (Pino, Rosica, 8 Carter, 1978, p. 169).

The result of the study by Pino, Rosica and Carter (1978) showed
that ”prepared patients demonstrated less decline in mental alertness
than other groups, but only slightly less than the unprepared
transfers; the relocated subjects declined slightly less than the
unprepared transfers; and the relocated subjects declined
significantly in Life Satisfaction and Personality Adjustments“ (p.
172). The recommendations made after completion of the study
include: 1) extensive preparation for relocation should focus on the
positive aspects of the new environment; and 2) an assessment measure
should be administered prior to the move to help identify the
patients most susceptible to relocation trauma.

Grey (1978) completed a study of residents of the Jewish Home for
the Aged in New Haven (N = 137) who were moved from an old building
to a new building. The planning for the move was initiated one year
previous to the move. A ”move committee" was formed and the task for
the committee was to accomplish proper placement of patients. A
written plan for the move was completed for each department. The

plan was very detailed and well-organized.

 

 

63

The orientation program involved nine months of staff orientation
including informal discussions, development of the concept of team
nursing, involvement in patient placement and formal tours of the new
facility to include new equipment and systems review. The patient
orientation was directed by the Recreation Department. Four weeks
were allotted for orientation of patients (Grey, 1978).

Patient orientation included visitation of their new rooms, if
possible, involvement in decisions regarding the move, casual talks
and discussions, distribution of drawings of the new facility and
formal discussions by administrative staff regarding the move (Grey,
1978). The patients' orientation generally was accomplished
utilizing small group sessions.

In Grey's (1978) study, the families and volunteers were also
prepared for the move. Therefore, both volunteers and family members
assisted with and participated in the move.

The post-move changes as a result of the study showed ”comparison
of the patient profiles prior to the move and the post-move profiles
done 90 days after the move” (Grey, 1978, p. 36-37). The results
indicated that 59 residents actually showed an improved status
post-move and the mortality rates for the patients post-move were at
a “remarkably low rate“ (p. 37). When speaking of improved status,
Grey indicated that the patients showed an improvement in
incontinence, locomotion and/or behavior as measured by a comparison
of the profiles of patients pre- and post-move.

According to Grey (1978), by providing an orientation program

prior to the move, the indication is for "successful moves with less

 

 

 

64

mortality" (p. 38). Also, the orientation program provided a means
by which, through involvement in decision making, the elderly may
play an important role in the relocation event.

Amenta, Weiner and Amenta (1984) studied a 97-year old private
nursing home which was closing. The residents (N = 47) of the
nursing home were relocated to a neighboring facility. The length of
stay of the residents being moved was one year to 25 years at the old
facility.

According to Amenta, Weiner and Amenta (1984), ”to reduce the
trauma of relocation as much as possible, an extensive preparation
program for these people and their families was begun seven months
before the move” (p. 356). The residents were all notified of the
move on the same day by letter.

The preparation program consisted of: 1) a film-strip about the
new location three weeks after initial notification; 2) visits by the
new facility's staff; 3) inventories of patients' personal possessions;
4) visits from a program director from the new facility on a
one-to-one basis to every resident; and 5) exploration of the issue
of compatible roommates (Amenta et al., 1984).

Within the new facility were two groups: one group who agreed to
move to accommodate the incoming group from the old facility which
was closing and one group who chose not to move. Thus, the study
included observation of three groups who were involved differently in
the relocation experience. Those patients moving to the new facility

from the old nursing home and the two groups within the new facility.

 

 

65

The measurement tools which were utilized by Amenta et al. (1984)
were: 1) an assessment form incorporating ”the five goals of
long-term care distinguished by Bloom: physical, mental, affective
and interpersonal functioning; and influence on the social
environment (p. 358); 2) the NOSIE scale which tested for affective
function; 3) the Geriatric Rating Scale of Plutchick et al.; 4) the
ADL Scale of Katz. The residents were assessed and then reassessed
at intervals of one, three, eight and 12 weeks and at six months
(Amenta et al., 1984).

The scores on the measurements were analyzed for change in
general condition and for differences in decline between grOUps.
Significant differences were noted in which the stationary group
performed less well on all measures of general condition and fine
symptom scores than did the relocated group. However, the relocated
group fared less well than the transferred group on the same
measures.

According to Amenta et al. (1984), although the findings were not
as dramatic as the authors had anticipated, the groups which were
prepared for relocation (the relocated and the transferred groups)
fared better due to the prior preparation for the move. The
relocation group basically viewed the move as a positive experience
and the transferred group enjoyed being hosts to the newly relocated
group. The stationary group had no preparation for or participation
in the move and fared least well.

Livy (1979) addresses the issue of “admission trauma” when a

patient is admitted to a nursing home. Livy discusses a program to

66

provide for ”more humanized admission procedures” (p. 11) entitled
”Social Adjustment Program.“ The goals of the program are to:
“1. Reduce admission and transfer trauma.
2. Increase patient and family involvement in the admission and
transfer procedures.

3. Provide a smoother transition between injury or illness and

recovery.
4. Humanize admission and transfer procedures.
5. Improve community relations.
6. Increase patient screening.

\1
0

Build rapport between patients, family and health care facility.
8. Make staff more aware of patients' needs” (p. 11).

The ”Social Adjustment Program” involves three parts (Livy,
1979). Part I involves visiting the patient in the hospital and
orienting him/her to the facility. Part II involves visitation by
the nursing staff, therapists and social worker, ordering of all
personal services and initiation of the interdisciplinary plan of
care. Part III involves a welcome by a member of a committee of
alert patients who invites the patient to activities, meals and a
tour of the facility. Livy proposes the "Social Adjustment Program'I
a type of orientation program, as "a possible solution to admission
trauma” (p. 10).

Palestis (1986) proposes that ”the admission ward concept'I is a
type of orientation program for elderly individuals who are newly
admitted to a nursing home. The Admission Ward is a 25-bed unit

where the new patients are admitted and a comprehensive assessment is

 

67

completed. The assessment involves a physical and social assessment
as well as a determination of the patient's ability to accomplish
activities of daily living. The assessment is accomplished by an
interdisciplinary team of health care professionals. ”The average
length of stay on the Admission Ward is three to four weeks”
(Palestis, 1986, p. 40). The patient is then moved to a ”home unit
where he/she will remain unless there is a significant change in
status and a need for a different type of care“ (p. 40).

Palestis (1986) reports that ”The Admission Ward concept reduces
the incidence of inappropriate assignment of residents and, thus,
reduces the frequency of interunit transfers” (p. 41). The concept
of an Admission Ward also allows the patient time to become oriented
to his/her new role of nursing home resident.

Petrou and Obenchain (1987) completed a study of 101 patients who
were relocated to a newly constructed 120-bed nursing home care unit
(NHCU) to determine ”to what extent planned nursing interventions
prior to relocation reduced physical health problems after patients
were transferred to the new unit” (p. 264). The findings which were
reported by Petrou and Obenchain were that the prepared group in this
experimental study ”experienced fewer incidents of negative health
indicators than the group who were admitted to the nursing home

without any known preparation” (p. 266).

68

Summary - Orientation Program

 

It is evident by the numerous reports in the relocation
literature that prior preparation for the move or orientation
programs are an integral component for a positive relocation
experience for an elderly individual who is being admitted to a
nursing home. There is a discrepancy in the literature regarding the
effects of relocation on mortality and morbidity in the elderly, but
the authors of relocation literature generally agree that prior
preparation for the move positively impacts the relocation

experience.

Relationship of Literature to Nursing

 

It is apparent in the relocation literature that the more
positive the relocation experience for the elderly individual when
moving to a nursing home, the better the chances for the elderly
individual to adapt to the new location. The relationship of a
positive adaptation by an elderly individual to a nursing home to
nursing is that the professional nurse is capable of affecting the
patient's relocation experience by:

1. Providing prior preparation for the move.

2. Providing an orientation program for the individual.

3. Providing support to the family and patient.

4. Answering the patient's and family's questions.

5. Introducing the patient to other patients and to the staff.

According to Weiner (1978) the professional nurse should play an

integral role in orienting the elderly patient to the nursing home.

 

69

Weiner (1978) reports that the nurse should ”listen to the patients”
(p. 5) and prepare them with an orientation program which builds
trust in the patient as he/she can see that the nursing home staff
are caring people.

In applying the findings in the literature regarding
interinstitutional relocation, adaptation and orientation programs to
the role of the professional nurse, the professional nurse should
consider three areas. The professional nurse should assess the
effects of the relocation experience on the elderly individual,
taking into consideration any effects regarding morbidity and
mortality rates. The professional nurse should also consider
presentation of an orientation program as an integral component of
the relocation experience for all elderly individuals who are

experiencing interinstitutional relocation.

Summary of Literature

The implications for the professional nurse dealing with patients
who are experiencing interinstitutional relocation are enumerated as
implications for: 1) assessment of the interinstitutional relocation
experience; 2) identification of the types of adaptation; and 3) the
necessity of orientation programs. In reviewing the relocation
literature the themes of the nursing implications as identified are
favorably supported.

Since the literature favorably supports the concepts of
interinstitutional relocation, adaptation and orientation programs as

major concepts related to interinstitutional relocation of the

70

elderly, it is imperative that these concepts are examined more
closely. From a nursing perspective, the concepts can be examined
more closely to demonstrate the relationship of the effectiveness of
the professional nurse's role to the relocation experience of the
elderly individual.

Therefore, after review of the literature it has been determined
that the relationship between the interinstitutional relocation of
the elderly individual and the type of adaptation experienced by the
individual is determined by the presence or lack of preparation for
the move, i.e., an orientation program. In this study the
relationship of the concepts will be addressed as a directional
hypothesis which states that an elderly individual from an acute care
setting who is provided an orientation program to an extended care
facility will experience more positive adaptation than an elderly
individual from an acute care setting who is not provided an
orientation program by a registered nurse from that facility.

In reviewing the relocation literature there is clearly a
discrepancy in opinion regarding the effects of the interinstitutional
relocation experience on the morbidity and mortality rates of elderly
individuals. Also, there is a great deal of support regarding prior
preparation for the move and the use of orientation programs.
Therefore, Borup (1983) states "guidelines should now be incorporated
that will promote the transfer of patients with the greatest possible
care and sensitivity" (p. 24). In other words, it is time to cease
arguing about whether or not it can be proven that more people die as

a result of interinstitutional relocation than would normally die,

71

and it is time to look at programs which will improve the quality of

the relocation experience for the elderly individual. One program

which has the potential to effect a more positive interinstitutional

relocation experience for the elderly is proposed in this study.

CHAPTER IV
Methodology and Procedure
Overview
The purpose of this chapter is to present the methodology which

was utilized and the procedures which were instituted in order to
accomplish a study involving the effects of relocation on the elderly
individual who is transferring from the acute care setting to an
extended care facility. The content of this chapter includes: the
design of the study, population studied, the subjects who were
selected and the sampling technique which was utilized. Included
also are: 1) operational definitions of the concepts and variables
in the study; 2) the instruments which were used; 3) the data
collection procedures and analysis techniques; 4) scoring of the
measures; 5) a statement about Protection of Human Rights; and

6) reliability and validity of the measurement instruments.

Design

Experimentallguasi-Experimental

 

The design which was utilized in this study was the quasi-
experimental type of research design. The experimental design was to
be utilized in observing the effects of the orientation program by
the registered nurse on the knowledge level of the patient at the
extended care facility post-relocation. The quasi-experimental

design was to be utilized to observe the effects of the orientation

72

73

program by the registered nurse on the amount of socialization
post-relocation.

The experimental design is characterized by the following
properties (Polit 8 Hungler, 1983, p. 142):

1. Manipulation. The experimenter does something to at least some
of the subjects in the study.

2. Control. The experimenter introduces one or more controls over
the experimental situation, including the use of a control or
comparison group.

3. Randomization. The experimenter assigns subjects to a control
or experimental group on a random basis.”

For the purposes of this study, the experiment was designed to
consist of:

1. Manipulation. The registered nurse will provide an orientation
program to one-half of the subjects.

2. Control. The researcher will assign one-half of the subjects to
a control group which will not participate in the orientation
program which is provided by the registered nurse. The control
group will receive the usual treatment which is afforded a newly
admitted patient in the extended care facility.

3. Randomization. The researcher will assign all subjects to a
control or experimental group.

The quasi-experimental design was designed for comparison of the
subject's knowledge pretest to posttest. The experimental design was
designed for comparison of experimental and control group differences

related to knowledge level.

 

74

In utilizing the experimental design, the study participants were
to be pretested for knowledge after randomization utilizing a short
questionnaire which tests the knowledge level of each participant
regarding the policies and procedures of the extended care facility.
After the pretest had been completed by a trained volunteer, the
orientation program was introduced to the experimental group by the
registered nurse. One month after admission to the extended care
facility, the knowledge questionnaire was to be readministered by the
volunteer as a posttest. The scores on the questionnaire were to be
analyzed and compared.

Also, at one month post-admission the social activity records of
each participant were to be reviewed, and the staff's and social
worker's perception of socialization were to be reviewed.

Differences in socialization between the experimental and control
groups were to be noted. The amount of socialization of both groups
would be analyzed.

The posttest design, which is a type of quasi-experimental
design, was to be utilized when examining the subjects' level of
socialization. The social activity of the study participants was to
be measured at posttest only to determine differences in level of
socialization between the experimental and control groups. Since all
study participants were newly admitted to the extended care facility,
the level of socialization at the time of pretest for all participants
was fairly low. Therefore, measuring socialization at posttest
retrospectively would allow for examination of differences in amount

of socialization experienced by each group over a one month period.

75

Threats to Internal Validity
The threats to internal validity in this study were the
following:

1. Maturation. Participants in this study would adapt somewhat
after staying one month at the extended care facility with or
without the intervention of an orientation program.

2. Testing. The participants in this study were to be tested and
then retested utilizing the same instruments after only a
one-month duration. Therefore, the participants could remember
the questions and/or their responses.

3. Mortality. There was a potential for attrition of participants
in this study due to loss of interest, illness, death, etc.

4. Spill over of information. The participants in the experimental
group in this study could potentially inform the participants in
the control group about the information which they had obtained
in the orientation program.

In order to determine the occurrence or presence of extraneous
variables which may affect the participants' adaptation to the
extended care facility in this study, a chart review was completed
after the posttests wre finished. The chart review was accomplished
after obtaining permission on the individual consent forms from the
participant and/or responsible party. The researcher utilized
standardized chart audit forms to obtain information from each
medical record related to: physical changes/events, social changes/
events, presence of chronic illness(es), physical disabilities,

assistive devices used, speech/communication patterns and occurrence

76

of death post-relocation. The chart audit was completed on all study
participants. Charts were reviewed by two auditors; the first person
to audit the charts was a reviewer who is a trained volunteer in a
profession other than nursing and the second person to audit the
charts was the researcher. The charts were reviewed at two intervals
not more than two weeks apart. One-half of the charts were reviewed
at the first audit period and the other one-half of the charts were
reviewed at the second interval. The reviewers audited the charts at
different times with the trained volunteer reviewing the charts
first. The researcher reviewed the same charts within one week of

the student's review.

Population, Supjects, Sampling Technigue

 

The population which was selected for the study of relocation of
the elderly from the acute care setting to the extended care facility
was those elderly individuals (55 years and older) who were admitted
to the extended care facility for the first time. The individuals
included in the study had not experienced a previous nursing home
admission.

The study participants were selected from all new admissions to
the nursing home and were screened utilizing the sociodemographic
questionnaire and assigned to either the experimental group or the
control group. The subjects who were included in the study met the

following criteria.

10.

11.

77

The subjects:

were transferred from the acute care setting to the extended
care facility.

had experienced no previous admissions to an extended care
facility.

planned to stay at the facility for at least one month.

if diagnosed as having dementia, Alzheimer's disease or organic
brain syndrome were unable to respond to the screening items on
the Sociodemographic questionnaire.

were able to speak, understand, read and write English.

were capable of answering questions coherently.

were 55 years of age or older.

voluntarily agreed to participate and cooperate in the study and
were willing to participate upon request in a brief orientation
program to introduce him/her to the facility.

were able to communicate his/her responses to the researcher if
he/she was aphasic, blind or hearing impaired.

were mobile so that they were able to complete the tour of the
facility (ambulatory, wheelchair bound).

identified a family member/significant other who was responsible

for their care.

The subjects in the study were required to meet the study

criteria and were assigned to the study from the population of

individuals who were being transferred from the acute care setting to

the extended care facility for the first time. The subjects were

screened from the sample utilizing a sociodemographic instrument as a

78

screening tool (see Appendix A). The sociodemographic questionnaire
was given to the participant in interview format by the researcher.

The items on the sociodemographic questionnaire which which were
utilized for screening purposes were:

1. Age and birthdate.

2. Languages spoken.

3. Medical diagnosis.

4. Expected length of stay.

5. Number of prior nursing home admissions.

6. Whether the participant had a tour of the nursing home.
All other items on the sociodemographic questionnaire were designed
to be exploratory in nature.

The study participants had to be able to answer the items on the
sociodemographic questionnaire related to age/birthdate, languages
spoken, number of prior nursing home admissions and whether the
participant had a tour of the nursing home for purposes of screening
for mental awareness. If the participants were unable to respond to
the screening items, they were considered ineligible for the study.
As many of the participants who were transferred from the acute care
setting were acutely 111 and/or were experiencing a decrease in
mental status, it was anticipated that the percentage of participants
who were unable to answer the screening items on the sociodemographic
questionnaire would be higher than for previous admissions.

Sampling
The sampling technique which was selected for use in this study

was an accidental sampling or sample of convenience. Convenience

 

 

 

79

sampling was a nonprobability sampling method (Polit 8 Hungler,
1983). The participants were selected from those individuals who
were newly admitted to the extended care facility.

Assignment to Experimental/Control Group

 

The individuals who participated in the study met the criteria of
the study and identification numbers were assigned to the selected
participants. Starting with the first admission upon the onset of
data collection, the admissions were numbered in order of admittance,
starting with number one. The odd numbered participants were
assigned to the control group and the even numbered participants were

assigned to the experimental group.

Operational Definition of Major Concepts

 

One of the major concepts in this study was the concept of the
orientation program. The other major concepts included
interinstitutional relocation and elderly adaptation. The major
concepts in this study have been conceptually defined in the
discussion regarding the conceptual framework, however, the concepts
require operationalization in order to describe how they were
utilized specifically in this study.

The orientation program was conceptually defined as ”a plan of
procedure to assist a person in an adjustment or adaptation to a new
environment or situation.“ The orientation program was operationally
defined as a program presented by a registered nurse to introduce the
experimental group participants to the extended care facility within

48 hours of admission. The orientation program consisted of:

80

1. An introduction to the facility's policies and procedures
regarding: 1) the Patient Bill of Rights; 2) times of daily
routines (meals, medications, bedtime activities); 3) activities
and services which are available (recreational activities,
therapies, beauty/barber shop, library, consultants, i.e.,
podiatrist, dentist, psychiatrist); 4) visiting hours; and
5) ancillary services (laundry, maintenance, dietary,
housekeeping).

2. A tour of the facility.

3. Answering any questions which the patient may have regarding the
facility.

The orientation program consisted of a comprehensive introduction
to the facility utilizing a brochure containing the Patient Bill of
Rights and a handout identifying the times of the daily routines, the
activities and services which were available, the visiting hours, and
the ancillary services which were provided by the facility. Also
included in the program was a tour of the facility. The orientation
program was administered by the researcher and was initiated by the
researcher within 48 hours of admission to the facility. The
orientation program was administered at one sitting on a one-to-one
basis with each participant in the patient's room or in the lounge
area.

The tour of the facility was also given by the researcher within
48 hours of admission. The entire program was completed within 48
hours after initiation. The orientation program was completed when

the brochure and handouts were distributed to the participants and

81

reviewed by the researcher, when the tour was completed and when all
of the patient's questions were answered. The total time involved in
the program was approximately two to two and one-half hours.

The second major concept in the study was interinstitutional
relocation which is conceptually defined as ”moving from one
environment (the acute care setting) to another” (the extended care
facility) (Rowles 8 Ohta, 1983, p. 189) or moving from one institution
to another. In operationalizing this concept, interinstitutional
relocation was defined as moving or transferring from the hospital
setting to the extended care facility. For the purposes of this
study only those individuals who were moving from a hospital to an
extended care facility for the first time were included in the
study. The participants arrived by ambulance or private car and may
have been or may not have been ambulatory.

The third major concept included in this study was the concept of
adaptation. Adaptation was defined conceptually as ”anything that is
changed or changes so as to become suitable to a new or special use
or situation” (Morris, 1973, p. 14). In operationalizing the term
adaptation for this study, the concept was expanded to identify a
type of adaptation, in this case ”more positive adaptation.“ It was
hypothesized that the elderly individual who participates in the
orientation program experienced ”more positive adaptation”
post-relocation than the study participant who was not exosed to the
orientation program. Adaptation was to be measured utilizing:

1. A short questionnaire to measure knowledge of the facility's

policies and procedures.

82

2. Social activity records to measure amount of patient
socialization.

3. A statement regarding the staff's and the social worker's
perception of socialization.

”More positive adaptation” was to be indicated by:

1. An increase in knowledge of the facility's policies and
procedures pretest to posttest.
2. The amount of social activity at posttest.

It was hypothesized that the participants who were members of the
experimental group would perform higher or at the same level as the
control group members on the knowledge test pretest to posttest and
would exhibit greater social activity than the control group
members. The higher predicted performance of the experimental group

was to be attributed to the effect of the orientation program.

Instruments
The instruments which were to be utilized in this study were

identified as:
1. The Short Portable Mental Status Questionnaire.
2. A short questionnaire regarding knowledge of the extended care

facilities and procedures.
3. A Social Activity Record.
4. The Socioeconomic and Demographic Questionnaire.

Pilot Testing of Instruments

 

The SPMSQ and the knowledge questionnaire were pilot-tested for

readability with three to four elderly nursing home residents. The

 

83

questionnaires were piloted by both the researcher and the trained
volunteer who were administering the instruments for the study. The
residents were selected by the Director of Nursing for the pilot
group and were alert, oriented and 55 years of age or older.

seas;

The Short Portable Mental Status Questionnaire (SPMSQ) is a
standard test of mental status which is used to assess memory,
orientation and calculation (Winograd, 1984) (see Appendix B). It is
a ten-item test of orientation, recent memory, long-term memory and
capacity for serial calculation (p. 50). The SPMSQ is a short
portable, reliable and valid standardized instrument and clinicians
whose practice includes any significant number of elderly patients
need such an instrument (Pfeiffer, 1975, p. 433).

The Short Portable Mental Status Questionnaire (SPMSQ) Was to be
utilized to measure the participants' mental status 48 hours
post-relocation and again at one month post-relocation. The SPMSQ
was to be utilized: 1) to indicate initial differences which were
present between the experimental and control groups; and 2) to
provide a description of the characteristics of the sample. The
SPMSQ was to be utilized at posttest in one month to note any changes
in the participants performance from admission to one month post-
relocation.

The SPMSQ was administered by a trained volunteer and the scoring
was accomplished by the researcher. According to Winograd (1980),
the SPMSQ is scored on the number of correct responses adjusted for

years of education and race:

84

0 to 2 errors are presumed to correlate with intact

intellectual function.

3 to 4 errors with mild intellectual impairment.

5 to 7 errors with moderate intellectual impairment.

8 to 10 errors with severe intellectual impairment.
"The total sum of the errors, adjusted for educational level,
provides a benchmark for determining the level of intellectual
functioning of the client“ (Cairl, Burton, Keller, Kosberg, Pfeiffer,
1985, p. 10).
Knowledge Questionnaire

The knowledge questionnaire regarding the participant's knowledge
of the policies and procedures of the extended care facility is a
ten-item questionnaire which was to test the knowledge level of the
participant at pre and posttest. The questionnaire was to be
administered at admission and at one month post-admission. The
questionnaire was designed to test the participants' knowledge
regarding the content in the orientation program, i.e., meal time,
services offered by the facility, and layout of the facility (see
Appendix C). The questionnaire was given after the SPMSQ and was
administered utilizing an interview format.

Social Activity Record

 

The Social Activity Record is a tool which was established by the
individual facility as a document on which the residents' social
activities can be recorded on an individual basis (see Appendix D).
The Social Activity Record was completed by the Activity Director and

the day-to-day social activities were recorded for each resident.

 

85

Participation in formal social activities was not a requirement for
inclusion in this study. For example, the participants may have
socialized by attending meals in the dining room or by visiting a
friend. The researcher was to review the Social Activity Records for
each study participant at posttest one month post-admission. The
researcher met with the Activity Director prior to the study to
discuss the method for recording the social activities of the
participants.

The social activity was to be scored by tallying the number of
times the patient participated in formal social activities in a one
month period. The number of times the participants in the
experimental group participated in social activities was to be
compared to the number of times the control group participated in
social activities in a one month period post-relocation. The results
were to be compared and differences reported.

Social activity was also to be evaluated by logging the social
worker's and the charge nurse's assessment of the patient's social
activity. The social worker's notes were to be checked and the
patient's social activity was to be noted. The charge nurse's
perception of the amount of social activity experienced by the
participants was also to be recorded.

Socioeconomic and Demographic Questionnaire

The Socioeconomic and Demographic Questionnaire is an 18-item
questionnaire. The first 14 items were obtained from the study
participants. The researcher administered the Socioeconomic and

Demographic Questionnaire utilizing an interview format after

 

 

 

86

explaining the study on a one-to-one basis and after obtaining
consent from the participant. The responses to items 15 to 18 on the
questionnaire were obtained from the client's record from the social

worker or from the admission secretary.

Data Collection Procedures

The researcher was notified by the agency regarding all newly
admitted patients, and the researcher explained the study on a
one-to-one basis, obtained consent and administered the
sociodemogrpahic questionnaire with the participant. The researcher
assigned the participants an identification number. Every other
admission went to the control group. Even numbers were assigned to
the experimental group and odd numbers to the control group. The
researcher notified the trained volunteer to administer the pretest
instruments: The Short Portable Mental Status Questionnaire (SPMSQ)
and the knowledge questionnaire.

The SPMSQ and the knowledge questionnaire were administered by a
trained volunteer. The social activity data retrieval was to be
accomplished by the researcher. The volunteer administered the SPMSQ
and the knowledge questionnaire. The volunteer administered both
measurement tools within "24” hours of admission in either the
patient's room or another private, quiet, well-lighted area. The
administration of the instruments was accomplished in an informal,
relaxed manner utilizing an interview format. The volunteer
administered the SPMSQ to the patient and the volunteer wrote in the

responses. The volunteer administered the knowledge questionnaire

 

87

which tests the participants' knowledge of items regarding patients'
rights, visiting hours, services, social activities, meals and
medications. The volunteer read the items to the participant and
recorded the participant's responses.

The volunteer was to administer the measurement tools at both
pretest and posttest and the researcher was to code and record the
data. The researcher was to gather and code the data regarding the
participants' social activity and/or level of socialization. The
formal social activity was recorded on a daily basis by the Social
Activity Director from admission and the data was to be collected at
one month post-admission by the researcher.

In order to provide an accurate measurement of the concept of
adaptation, the participants were requested to hold any questions
which did not relate specifically to the testing procedure until
after administration of the instrument. Reassurance about or
guidance of the participant regarding their relocation experience
could have biased the study results.

Confidentiality was assured for each study participant and the
researcher addressed the issue of confidentiality with each subject
individually. The issue of confidentiality was also addressed in the
Patient Bill of Rights and each participant in both groups received
the Patient Bill of Rights brochure upon admission.

Each participant was expected to complete the sociodemographic
questionnaire and the pretests within 24 hours of admission and the
posttests one month after admission. If any of the participants were

unable to complete the program for any reason the researcher or the

 

 

 

88

volunteer would have stopped the program at that point. If the
participant was able to resume his/her participation in the program,
the researcher would have determined if the participant was within
the time restrictions which had been set for administering the
questionnaires and if so continued the program with the participant.
If the participant was unable to continue within the time frame for
the questionnaire administration or was unable to continue for any
reason, the participant was to be removed from the study.

Each participant was required to remain in the study for one
month after enrollment in the study. At the end of one month, the
posttests were to be administered. If the participants did not
remain in the study for one month or were not capable of
participating in the administration of the questionnaires at one
month post-relocation, those participants were to be automatically
removed from the study.

Chart Audit

 

In order to determine the occurrence or presence of extraneous
variables which may have affected the participant's adaptation to the
extended care facility or participation in the study, a chart review
was completed. The chart review was conducted by the trained
volunteer and the researcher, utilizing: 1) a list of common events
or condition changes which may have influenced the resident's
adaptation to relocation from the hospital to the extended care
facility; and 2) a list of items related to the overall physical
condition of the participant (see Appendix E). The items were marked

as conditions which had occurred or changed or conditions which had

 

 

 

89

not occurred or changed from admission to one-month post-relocation
by marking the items "yes'I or "no.” The data was to be retrieved on
each participant and the results of the audit were to be reported in

conjunction with the data analysis.

Reliability and Validity of Study Measures
SPMSQ

Reliabiligy

 

Reliability of a measurement instrument is defined as "the degree
of consistency or dependability with which an instrument measures the
attribute it is designed to measure" (Polit 8 Hungler, 1983, p. 621).
The SPMSQ is described in the literature as a reliable instrument for
assessment of an elderly client's level of intellectual functioning
(Cairl et al., 1985; Gurland, 1980; Pfeiffer, 1975; Winograd, 1980).

According to Pfeiffer (1985) “a four-week test-retest of the
SPMSQ produced a reliability coefficient of .82 and .83 for two
groups of aged subjects” (p. 712). The SPMSQ is also viewed as a
reliable instrument in differentiating organic and functional
disorders according to Wolber, Romaniuk and Eastman (1984).

Gurland (1980) reports that the SPMSQ is a reliable and valid
tool in a report of mental health status assessment of older adults.
Gurland (1980) reports that the SPMSQ is a reliable tool for
assessing both degree of mental impairment and ability to carry out
activities of daily living (ADL).

Pfeiffer (1975) described the SPMSQ as a short, reliable

instrument which detects the presence of intellectual or cognitive

90

impairment. Reliability for the SPMSQ was established utilizing two
groups aged 65 and older (N = 30 and N = 29) who were given the SPMSQ
twice at four week intervals to determine stability of response. The
test-retest correlations were reported as .82 and .83, respectively.
“The findings from these studies indicate that the responses to
individual questions and the total error score on the SPMSQ are
remarkably stable, indicating no significant practice effect or
deterioration in performance over this length of time” (Pfeiffer,
1975, p. 439).

Validity

Validity of a measurement instrument is defined as ”the degree to
which an instrument measures what it is intended to measure" (Polit 8
Hunger, 1983, p. 624). The validity of the SPMSQ has been
established by several researchers (Gurland, 1980; Pfeiffer, 1975;
Wolber et al., 1984). The SPMSQ is considered to be valid in
differentiating organic and functional disorders as well as level of
intellectual functioning.

The validity of the SPMSQ was established by Pfeiffer (1975) when
it was administered to "two non-random populations of the elderly:
1) 141 subjects aged 50 or over referred for evaluation to the OARS
clinic at the Duke University Center OARS clinic for the Study of
Aging and Human Development; and 2) 102 subjects aged 65 or over from
the same county as a community survey population, who were already
living in institutions (p. 438).

In the two non-random populations of elderly, face validity was

established for the SPMSQ in relation to organic impairment. There

91

was 92% agreement between diagnoses of organic brain syndrome (OBS)
and the SPMSQ score for 133 out of 141 subjects in the OARS clinic at
Duke University when definite impairment was indicated. Also, there
was 82% agreement when the SPMSQ indicated mild or no impairment
related to 08$.

Knowledge Questionnaire

 

Reliability

 

Reliability was established in this study for the SPMSQ by
further assessment of the tool for stability, however reliability for
the knowledge questionnaire has not been established at this time.
The readability of the knowledge questionnaire was assessed from a
pilot test of the instruments on a small population of elderly
individuals who are currently institutionalized (three to four
subjects).

Validity

The content validity of the knowledge questionnaire regarding the
extended care facility's policies and procedures was established.

The content validity of the measure was established by the thesis
committee. Criterion-related and construct validity will not be
established for the knowledge questionnaire during the course of this
study.

Social Activity Record

Reliability

 

The accuracy of the reporting of the participants' social

activity depended on the accuracy of the recording by the Social

92

Activity Director. Therefore, the reliability of the report depends
upon the reliability of the rater(s) whose reliability is unknown.
Validity
The content validity of the Social Activity Record was established
by the thesis committee. Criterion-related and construct validity was
not established for the Social Activity Record during the course of

this study.

Scaling

After testing the participants' mental status and knowledge at
pretest and posttest and the social activity at posttest, the measures
were to be scored. The SPMSQ was scored by summation of the errors
and was adjusted for educational level (see Table 1).

The knowledge questionnaire was to be scored at pretest and
posttest by summation of incorrect responses and reporting of the
number of incorrect resposnes out of a possible score of 15. The
Social Activity Record was to be scored at one month post-admission by
summation of the number of social activities in which each participant
was involved.

Data Analysis

 

The technique of analysis which was to be utilized in this study
was a t-test. A t-test was to be utilized to analyze the differences
between the experimental and control groups after the orientation
program. The difference in knowledge between the experimental and
control groups pretest to posttest was to be compared. A t-test was

also to be computed for the difference in scores of the treatment and

93

Table 1: Short Portable Mental Status Questionnaire Summation

 

 

Adjusted Score Clinical Sigpificance
0-2 errors Intellectually intact.
3-4 errors Mild cognitive impairment. Client is some-

what forgetful and may need to depend on
memory aids such as calendars, memos, or
lists to facilitate functioning.

5-7 errors Moderate cognitive impairment. Client may
have problems functioning totally indepen-
dently, forgetting to take medications, to
turn off stove after cooking, or to pay
monthly bills.

8-10 errors Severe cognitive impairment. Client is
unable to function without assistance and is

likely to need almost constant supervision.

 

control groups regarding the amount of social activity the participants
experienced. The level of statistical significance which was to be
considered acceptable was .05 for both knowledge and social activity.
Reporting t-tests results would have indicated the statistical
significance of the questionnaire results. After analyzing the
significance of the knowledge questionnaire and social activity
results, the effectiveness of the orientation program could have been

determined.

94

An alpha coefficient was to be utilized to determine the
correlation between items on the knowledge questionnaire, or to
determine the internal consistency of the knowledge measure. The
alpha coefficient was to be determined after the pre and posttest
measures were completed for the knowledge questionnaire.

Simple means were reported for the categories which were
extrapolated from the chart audit report. The mean measures were
determined to be a method by which the types of categories (i.e.,
number of certain diagnoses, physical disabilities, condition changes)

could be reported.

Protection of Human Subjects
After the data analysis had been completed, the results were
reported. Protection of the anonymity of the participants was
mandatory. Protection of the participants' rights throughout the
entirety of the study was also a necessity. Specific guidelines
regarding participants' rights should be adhered to in order to assure
anonymity and confidentiality.
In this study, the rights of the participants were protected by:
1. Obtaining informed consent from each participant which was
witnessed by another party. If the participant had a legal
guardian, the guardian signed for the participant.
2. Assuring freedom from harm, privacy, anonymity and
confidentiality.
3. Submitting the research proposal for approval to the University

Committee on Research Involving Human Subjects.

95

4. Assuring that the control group received the usual treatment upon
relocation; nothing was to be deleted from their treatment.
The records which were kept on each participant were confidential
and the researcher had access to them. The trained volunteer had
access to the medical records of the participants in assisting with

the chart audit.

M

The methodology which was utilized and the procedures which were
instituted in order to accomplish a study involving the effects of
relocation on the elderly individual who is transferring from the
acute care setting to an extended care facility have been defined.
The data collection procedures and the data analysis techniques have
been prepared and after collection and analysis of the data was

completed, the data was presented and analyzed.

CHAPTER V
Data Presentation and Analysis of Results
Overview
The purpose of this chapter is to present the analysis of the

data and a discussion of the interpretation of the results.
Additionally, the researcher will report the difficulties which were
encountered during data collection, the resultant procedural changes
which occurred, and questions which arose related to the collection
of data. The content of this chapter includes (1) the study findings
and (2) a discussion of the reported findings relative to study

hypotheses.

Study Findingg

 

The focus of the study was on the feasibility and effectiveness
of an orientation program by a registered nurse within 48 hours of
admission for newly admitted elderly patients at a nursing home in
the Midwest. The study was an experimental study of 66 subjects who
were admitted from an acute care setting to a 167 bed skilled nursing
facility. The study was conducted over a four month period from
January 1, 1987 to May 1, 1987.

Sample Characteristics

Eligibility Criteria

 

Out of 66 admissions over the designated four month period of
study, eight subjects were eligible for enrollment in the study

according to the study criteria. The study criteria were:

96

 

10.

11.

97

The subjects were transferred from the acute care setting to the
extended care facility.

The subjects had experienced no previous admissions to an
extended care facility.

The subjects had planned to stay at the facility for at least
one month.

The subjects, if diagnosed as having dementia, Alzheimer's
disease or organic brain syndrome were able to respond to the
screening items on the Sociodemographic Questionnaire.

The subjects were able to speak, understand, read and write
English.

The subjects were capable of answering questions coherently.
The subjects were 55 years of age or older.

The subjects voluntarily agreed to participate and c00perate in
the study and were willing to participate upon request in a
brief orientation program to introduce him/her to the facility.
The subjects were able to communicate their responses to the
researcher if they were aphasic, blind or hearing impaired.

The subjects were mobile so that they wre able to complete the
tour of the facility (ambulatory/Wheelchair bound).

The subjects identified a family member/significant other who

was responsible for their care.

The subjects in the study were assigned to the study from the

population of individuals who were being transferred from the acute

care setting to the extended care facility for the first time. The

98

subjects were screened from the sample utilizing the Sociodemographic
Questionnaire (see Appendix A).
Number of Participgnts

Of the 66 individuals who were admitted to the skilled nursing
facility over the period of four months in which the study was being
conducted, eight subjects were eligible for enrollment in the study
according to the study criteria. Of the eight subjects who were
eligible for enrollment in the study, three remained eligible to
participate in the study at the time of the posttest which was one
month post-admission. Of the three participants who remained in the
study, two subjects were members of the control group in which no
orientation program was completed, and one subject was a member of
the treatment group.

The remaining five subjects were unable to complete the
requirements of the study for the following reasons:

1. One participant was discharged home before the posttest was
completed.

2. One participant's mental status deteriorated to a point at which
the participant was too confused to respond to the posttest
questionnaire.

3. Two participants were discharged to the hospital before
completion of the posttest.

4. One participant died prior to the posttest.

99

Pretest Findings

 

Pretest information was gathered on eight subjects. The ages of
the subjects ranged from 74 to 90. The mean age of the pretest group
was 85.

The physical status of the eight subjects who participated in the
pretest was variable. Seven of the eight subjects were females.
Their physical disabilities were listed as:

1. Parkinsonism

2. Post-coronary bypass

3. Dementia

4. CHF with permanent pacemaker
5. Cerebral ischemia

6. Fractured left hip

7. Pneumonia

8. Metastatic carcinoma

None of the participants for the pretest were ambulatory on
admission and all required assistance in activities of daily living.
The reasons for admission for each member of the pretest group varied
according to their medical diagnosis, but all of the individuals had
been admitted to the skilled nursing facility because they were not
able to be in their own home at the time of their admission for one
reason or another.
acres

The Short Portable Mental Status Questionnaire (SPMSQ) was
administered to each of the eight pretest participants. Four of

those participants scored 0-2 errors, (intact intellectual function),

 

100

three scored three to four errors (mild intellectual impairment), one
subject scored 5-7 errors (moderate intellectual impairment), and no

subjects scored 8-10 errors (severe intellectual impairment).

Table 2: Short Portable Mental Status Questionnaire Scoring

 

 

 

SPMSQ Number of Subjects Percent of Subjects
0-2 errors 4 50%

3-4 errors 3 38%

5-7 errors 1 132

8-10 errors 0

 

Knowledge Questionnaire

The Knowledge Questionnaire was also administered to the pretest
group. The knowledge questionnaire was designed to test the
participants' knowledge regarding the content of the orientation
program, i.e. mealtimes, services offered by the facility (see
Appendix C). The questionnaire was a ten-item questionnaire.

None of the pretest group answered all of the questions correctly
on the pretest. When reviewing the pretest item by item, the
following results were obtained from the ten questions in the
Knowledge Questionnaire (see Appendix C).

According to the results of the pretest knowledge questionnaire
(see Table 3), the questions which were answered correctly most
frequently were related to obtaining the services of a dentist,

podiatrist, barber and/or beautician. The item on the pretest

 

 

101

knowledge questionnaire which was most frequently incorrect was the item
related to the patient's Bill of Rights. All of the pretest group members
missed the item related to the Bill of Rights for residents of nursing

homes scoring zero on that item.

Table 3: Knowledge Questionnaire Scoring

 

Percent of

 

Item Number Correct Subjects
1. Two Rights (Bill of Rights) 0 0
2. Visiting Hours 2 25%
3. Departments which provide service 3 38%
4. Dental/Podiatry Services 5 63%
5. Beautician/Barber Services 5 63%
6. Location of Beauty Shop 2 25%
7. Activities available 4 50%
8. Location of activities 2 25%
9. Mealtimes 3 38%
10. Medication times _1_ 13%

TOTAL 27

 

Posttest Findings

 

There were no posttest results to report in this study.
Therefore, tests of significance were not performed relative to the
hypotheses of this study. Tests of significance were not

accomplished due to limitations in this study which were identified

102

as insufficient numbers of study participants, lack of access to
additional skilled nursing facilities in the area, and lack of
uniformity among skilled nursing facilities which would have
confounded the study results.

The acuity level of the patients who were being admitted from the
acute care setting was high. Acuity level is defined as the amount
of or level of nursing care which is required to be carried out for
an individual patient.

The patients who were being admitted to the skilled nursing
facility as potential candidates for the study repeatedly failed to
meet the study criteria for various reasons, i.e., mental confusion,
physical deterioration, inability to communicate. As a result of the
small number of study participants, the experimental intervention was
stopped at the end of four months.

The researcher was not able to fulfill the requirements of the
design of the study due to lack of subjects, and therefore, (1) the
socialization records were not reviewed, (2) the charge nurses' and
social worker's impressions related to social activity were not
recorded, (3) the amount of social activity at posttest could not be
measured on a Likert type scale as intended and (4) the experimental
and control group's ratings on the knowledge questionnaire and SPMSQ
could not be compared at pre and posttest for any differences.

Therefore, the findings of the experimental study lead the
researcher to an additional research question relative to the

characteristics of the nursing home population. The additional

103

question became: What are the characteristics of the skilled nursing

facility population at the time of admission to the setting?

Additional Findingg

 

In an effort to answer the additional research question regarding
the characteristics of the nursing home population, the following
analyses were conducted.

Methods

A medical record audit on an independent sample of 22 subjects
who were admitted to the skilled nursing facility from January 1,
1987 to May 1, 1987 was accomplished. The researcher sent a letter
to each of the 66 persons who were admitted to the skilled nursing
facility from January 1, 1987 to May 1, 1987. Permission was
requested from each individual or from that individual's responsible
party in the event that they could not give permission themselves to
audit the patient's medical record and 22 persons responded that they
would be willing to participate in the medical record audit.

The researcher obtained written consent from the patient or
responsible party to complete the medical record audit. The audits
were completed by a trained volunteer who was in a non-nursing
profession and by the researcher within two weeks of obtaining
consent. The findings of the medical records audits are
representative of a population of elderly individuals who were being
transferred from the acute care setting (hospital) to the skilled

nursing facility.

104

Two chart review forms were utilized for the audit of each
subject's medical record in addition to use of the sociodemographic
questionnaire for data retrieval. The purpose of the chart review
forms was to provide a standardized format for retrieval of data
which was related to the physical status of each of the subjects, to
any assistive devices which were utilized by the subjects throughout
their stay at the facility, speech and communication abilities of the
subjects, and occurrence of death, and/or discharge post-relocation.
The medical record audit also was utilized to retrieve data related
to social and physical changes or events which occurred during the
subjects' stay at the skilled nursing facility. The data was
retrieved during the period from admission to the facility to 30 days
post-admission. The 30 day period for data retrieval was the same as
the length of time between pretest and posttest for the original
designed planned experimental study.

Independent Sample

 

The audit sample is comprised of 22 individuals who ranged in age
from 57 to 94. The mean age of the group was 80. Nineteen
individuals in the sample were females and three individuals were
males. The mean age of the male population was 83, and the mean age
of the female population was 79 (see Table 4).

According to the audit of the records utilizing the
sociodemographic questionnaire, within the female group there were 11
who were widowed, six who were married and one who was single. There
was one widowed male and two married males in the population. All

subjects were Caucasian and all but one individual spoke English as

105

Table 4: Summary of Sociodemographics of Chart Audits

 

FEMALE MALE TOTAL

Age Range: 57-94 Range: 75-91 Range: 57-94
Mean Age: 79.6 Mean Age: 83 Mean Age: 80

Race All Caucasian All Caucasian 22

Marital Status

Married 2 8

Widowed 11 1 3

Single 0 1

Divorced 1 0 1
Education

< High School * *

High School * *

> High School 1 0 1
Familiarity with Nursing Homes

Resident Before 10 2 12

Family Member In 1 -- I

Told About 1 -- 1

Toured 1 -- 1
Medical Insurance

Medicare l7 3 20

Medicaid 1 0 1

Blue Cross 15 3 18

Health Plus 3 0 3
Responsible Party

Friends 2 -- 2

Family 16 3 19

Trust Officer 1 -- 1
Length of Stay

Indefinite 15 2 17

Short Term 4 1 5

 

*not documented in record

106

the primary language spoken. There was no indication on one
individual's medical record as to language(s) spoken (see Table 4).
The individuals' medical records were audited for educational
level (highest grade completed) and religious preference.
Information relating to educational level was available on only one
subject's medical record and the individual whose educational level
was indicated was a college graduate (see Table 3). According to the
sociodemographic screening, there were 15 individuals who were
Protestant and seven who were Catholic in the sample.

Hospitalizations

 

The number of prior hospitalizations in the past five years
(1981- 1986) was noted for each subject. Fourteen subjects had
experienced one to five prior hospitalizations in the past five
years, ”multiple” or ”numerous” hospitalizations were recorded for
three of the study participants and the number of prior
hospitalizations was not noted for five of the subjects. The number
of prior nursing home admissions was also noted on each subject.
Four of the subjects had no prior nursing home admissions, ten of the
subjects had one prior nursing home admission and eight of the
subjects' records had no notation regarding prior nursing home
admissions.

Familiarity with Nursing Home Procedures

Familiarity with nursing home procedures was noted for each
subject in the study. Ten subjects were familiar with nursing home
procedures (had been a resident in a nursing home before). One

subject was familiar with nursing home procedures (had a family

107

member in a nursing home). One subject was familiar (had been told
about this nursing home) and one subject was familiar (had toured
this nursing home). Familiarity with nursing home procedures was not
recorded on nine of the medical records which were audited (see Table
4).
Medical Insurance

The type(s) of medical insurance(s) which the study participants
carried was summarized. All 22 subjects carried some form of medical
insurance. Twenty of the subjects carried Medicare, three subjects
carried Health Plus (HMO), one subject carried Medicaid and several
subjects carried another commercial insurance in addition to Medicare
(see Table 4).
Responsible Party

All study participants identified a responsible party and 19 of
the responsible persons were family members. Two of the responsible
parties were identified as friends of two of the subjects and one was
identified as a trust officer. Legal guardianship was not identified
in the medical record, so it is not known how many of the responsible
parties were also legal guardians or had durable power of attorney
(see Table 4).
Admission Diagnoses

The current admitting diagnoses which were observed for the study
participants are listed in Table 5. The most frequently noted
admitting diagnosis was cerebrovascular accident or post-cerebrovascular

accident and there were 23 diagnoses that were noted once only.

 

108

Table 5: Admitting Diagnoses

 

mNO‘UT-E'UJN-t
00-.

I8.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.

CVA/Post CVA (7)

Dehydration (4)

Organic Brain Syndrome (3)
Hypertension (2)

Congestive Heart Failure (2)
Diabetes Mellitus (2)
Parkinson's Disease (2)
Pneumonia (2)

Severe Hypoglycemia

Above the Knee (L) Leg Amputation
Atrial Fibrillation

Mitral Valve Replacement

Cancer of Colon

Transient Ischemic Attack
Arteriorsclerotic Heart Disease
Multiple Fractures
Post-Subdural Hematoma

Urinary Tract Infection
Gastrointestinal Bleeding
Contusion Lumbar Spine
Osteoporosis

Cerebral Ischemia with Left Hemiplegia
Arthritis

Hip Replacement (left)
Fractured Hip

Post-Colostomy; Flaccid Bowel
Dementia

Cancer of Prostate
Sacrococcygeal Decubitus Ulcer
Anemia

Pulmonary Edema

 

109

Physical Status

The physical status of the individuals was obtained utilizing a
standardized review form. Each subject's vision, hearing, chronic
illness and other physical problems/illnesses, physical disabilities,
assistive devices, speech/communication, death, discharges, social
and physical changes or events was noted.

The subjects' vision was recorded as: poor (4); blind left eye
(2); adequate with glasses (2); adequate (2); blind right eye (1);
comatose (1); not recorded (10). The subjects' hearing was reported
as adequate (8); poor (3); fair (1); excellent (1) and not recorded
(9).

The most frequently reported chronic illness was CVA
(cerebrovascular accident/stroke)(10); followed by hypertension (7);
arthritis (5); kidney/urinary tract disease (5); glaucoma/cataracts
(3); diabetes mellitus (3); cancer/leukemia (2); Parkinson's disease
(2); and fractured hip (1). Other physical problems/illnesses were
listed as congestive heart failure (4); dehydration (4);
arteriosclerotic heart disease (3); organic brain syndrome (3); fecal
impaction (2); artial fibrillation (2); decubltus ulcer coccyx (2);
osteoporosis (2); urinary tract infection (2). Several other
physical problems/illnesses were listed once.

The chronic illnesses which were identified in the medical
record audit are cited in Table 6.

The most frequently cited chronic illness was stroke and the
least frequently cited chronic illnesses were emphysema/chronic

bronchitis, nervous disorders and Alzheimer's Disease in this

 

110

Table 6: Summarization of Chronic Illness Scoring

 

 

Female Male Total
Chronic Illness(es) N = 19 N = 3 Number
Arthritis 5 0 5
Glaucoma/Cataracts 3 0 3
Emphysema/Chronic Bronchitis 0 0 0
Hypertension 7 0 7
Diabetes Mellitus 2 1 3
Kidney/Urinary Tract Disease 4 1 5
Cancer/Leukemia 1 1 2
Stroke (CVA/TIA) 10 0 10
Parkinson's Disease 1 1 2
Nervous Disorders 0 0 0
Broken (fractured) Hip 1 0 1
Alzheimer's Disease 0 0 0
Other -- -- 52

 

population. All of the male subjects were noted to have two or more
chronic illnesses, and 16 out of 19 of the female subjects were noted to
have two or more chronic illnesses. The highest number of chronic

illnesses was noted to be ten chronic illnesses for one female subject.

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Disabilities

The physical disabilities which were reported were total paralysis
(0); partial paralysis (4); missing/nonfunctional limbs (2); broken bones
(2). Assistive devices which were recorded as utilized by the subjects
were: wheelchair (18); cane/walker (11); catheter (11); feeding tube (8);
intravenous (3); tracheostomy (1); leg brace (1); and other: restraints
(physical) (3); oxygen (1); water mattress (1); air mattress (1); suction
machine (1); and dressings (1) (see Table 7).

Speech and communication patterns of the subjects were recorded as:
speaks normally (15); unable to speak, but communicates (5); and unable to
communicate (2) (see Table 7).

Course of Institutionalization

 

There were no reports of any deaths post-relocation from admission to
one month post-admission, however, several discharges from the skilled
nursing facility were noted. The length of stay at the skilled nursing
facility ranged from six days to indefinite in the study population. Four
of the subjects returned to their homes upon discharge; six subjects were

discharged to the hospital including one male subject who was discharged

 

to the hospital 11 days post-admission, was readmitted within five days,
and was discharged again after a ten day stay at the skilled nursing
facility; and one subject was discharged to Adult Foster Care. Seven of
the subjects who were discharged left within 30 days of admission (see
Table 7).

Seven of the subjects had discharge plans in place and 15 subjects had
no record of discharge plans. Eleven subjects (50%) moved from one room

to another but none of the subjects were found to have a room rate change.

112

Table 7: Summarization of Physical, Communication and Discharge
Status (Form 1)

 

 

Male Female Total
Physical Disabilities
Total paralysis -- -- 0
Partial paralysis -- 4 4
Missing limbs -- 2 2
Broken bones -- 2 2
Assistive Devices
Cane/Walker 2 9 11
Wheelchair 2 16 18
Leg brace -- 1 1
Back brace -- --
Artificial limb -- --
Catheter 2 9 11
Respirator/Ventilator -- -- 0
Trach -- 1 1
Feeding tube 1 7 8
IV -- 3 3
Other: oxygen 1 -- 1
air/water mattress -- 2 2
restraints 1 2 2
suction -- 1 1
dressings -- 1 1
Speech/Communication
Normal 2 13 15
Unable to speak -- 5 5
Unable to communicate 1 1 2
Deaths -- post-relocation -- -- 0
Discharge*
To hospital 2 4 6
To home -- 4 4
Other: Adult Foster Care -- 1 1

 

*indicates that not all discharges were completed in one month

113

There were no recordings on any of the subjects related to death of a
loved one or private duty nurses present.

Fourteen subjects attended physical therapy, eight subjects
attended occupational therapy and four subjects attended speech
therapy of the 22 subjects whose records were audited. Attendance in
therapy was recorded if the subjects attended the therapies at any
time during the 30 days from admission to 30 days post-admission (see
Table 8).

The physical changes or events which were audited utilizing the
second audit form were occurrence of: 1) infection(s); 2) pain;

3) bleeding; 4) medication reactions; 5) falls; 6) post-operative
complications; 7) complications of bed rest; 8) change in level of
responsiveness; and 9) alteration in nutrition (see Table 8).

The physical changes or events were audited and the number of
subjects experiencing infections during the first 30 days
post-admission was eight and the number of subjects experiencing pain
which was reported and documented by the nurse was eight. There was
one subject who experienced bleeding (hematuria); there were no
recorded medication reactions and no recorded falls. The number of
post-operative complications noted were two and there were 11
subjects (50%) who experienced complications of bed rest. Three
subjects experienced change in level of responsiveness: 1) from
responding completely to no response during the one-month period
post-admission; 2) frequent change in responsiveness; and 3) becoming

restless and confused at times.

 

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Table 8: Summary of Medical Record Audit (Form 2)

 

 

 

 

Male Female Total

Social and Physical Changes or Events
Presence of Family Support

Daily -- 10 10

More than one time weekly 2 3 5

Weekly -- 1 1

Support, but no visits 1 2 3

No support, no visits -- 3 3
Discharge Plans -- 7 7
Moved Room to Room 1 10 11
Room Rate Change -- -- 0
Death of a Loved One -- -- 0
Private Duty Nurse(s) -- -- 0
Therapy

Physical therapy 3 11 14

Occupational therapy 8

Speech therapy --
Social Worker Involvement 3 18 21
Physical Changes or Events
Infections 1 8
Pain 1 8
Bleeding 1 1
Medication Reactions -- -- 0
Falls -- -- 0
Post-Operative Complications -- 2 2
Complications of Bed Rest 2 9 11
Change in Level of Responsiveness 1 2 3
Alteration in Nutrition 2 4 6

 

115

The final item which was audited relating to physical changes was
nutritional alterations. Alterations in nutrition were recorded on
six subjects with the alterations noted as jejunostomy, gastrostomy,
nasogastric tube feeding, loose fitting dentures, dysphagia with
decreased intake and poor appetite (see Table 8).

Social Activity/Social Events

 

The social changes or events which were audited on the second
audit form were: 1) presence of family support; 2) presence of
discharge plans; 3) movement from one room to another; 4) occurrence
of room rate changes; 5) death of a loved one; 6) presence of private
duty nurses; 7) attendance at therapies; and 8) social worker
invovlement on a regular basis (see Table 6).

Twenty-one of the 22 subjects were reported to have had social
worker involvement on a regular basis. Involvement on a regular
basis by the social worker was defined as visits from the social
worker at admission and at least monthly thereafter.

Nineteen subjects were identified as experiencing presence of
family support. Ten subjects received visits daily; four subjects
received more than one visit weekly; one subject received visits
weekly; one subject received visits three times weekly; three
subjects were identified as having support, but the frequency of
visits was not recorded; and three subjects were identified as having
no support and no visits (see Table 8).

The findings of the medical record audit were summarized. The
results of the audit were reviewed and conclusions regarding the

reasons the newly admitted patients to the skilled nursing facility

 

 

116

did not meet with the criteria for inclusion in the experimental
study regarding the effects of and feasibility of an orientation
program by a registered nurse upon newly admitted patients to a

nursing home were determined.

Discussion

 

After summarizing the findings from the medical record audit
which was accomplished for 22 subjects who were admitted to the
skilled nursing facility in the study during the period from January
1, 1987 to May 1, 1987, it has been determined that there were
multiple reasons for the alteration of the study plan. Of the 22
medical records audited, there were clearly defined recorded
responses relating to the subject's potential for study participation
based on the stated criteria. The reasons for ineligibility for the
study are as follows:

1. Twelve of the subjects (552) had been a resident of a nursing
home before. According to the study criteria, in order to be
eligible for the study the individual must not have experienced
any previous admission to an extended care facility (nursing
home).

2. Seven of the subjects (32%) were discharged from the facility
prior to one-month post-admission. The study criteria was
written such that individuals who participated in the study
planned to stay at the facility for at least one-month.

3. Three of the subjects (14%) were diagnosed as having organic

brain syndrome and dementia and were unable to respond to the

117

screening items on the Sociodemographic Questionnaire.

According to the criteria for inclusion in the study, the
participants who were diagnosed with dementia, Alzheimer's
disease or organic brain syndrome and were unable to respond to
the screening items on the Sociodemographic Questionnaire were
ineligible for inclusion in the study.

Seven of the subjects (32%) were unable to communicate responses
to the researcher; five of the subjects were unable to speak and
two were unable to communicate at all. According to the
inclusion criteria for the study, the participants must have
been able to communicate responses to the researcher if he/she
was aphasic, blind, or hearing impaired. There were no blind
subjects noted in the audit, but three of the subjects were
noted to hear poorly.

Four of the subjects (18%) were identified as having partial
paralysis and two subjects were identified as having missing/
non-functional limbs. Eighteen subjects were wheelchair bound,
11 subjects used a cane or walker for mobility, and one subject
used a leg brace. Eight subjects had feeding tubes, one subject
used oxygen, three subjects utilized physical restraints and one
subject had dressings which were conditions which limited the
range of their mobility status. According to the study
criteria, the participants were to be mobile so that they were
able to complete the tour of the facility (ambulatory or via

wheelchair).

118

The total number of subjects out of the 22 subjects who
participated in the medical record audit who were ineligible
according to the inclusion criteria to participate in the
experimental study was 20. Of the remaining two subjects, one was
recovering from pneumonia upon admission to the skilled nursing
facility and was either too weak or too confused to particiapte in
the study as required during the first 48 hours of admission. The
other subject was experiencing pain and limited activity due to her
post-operative status post-admission, and, therefore, was not
eligible to participate in the tour of the facility.

The entire 22 subjects whose medical records were audited to
determine their status regarding inclusion in the experimental study
were ineligible for one or more reasons according to the study
criteria. Also, of the eight participants who were initially
enrolled in the study, only three remained eligible for inclusion in
the study at one-month post-admission. Therefore, the feasibility of
a registered nurse providing an orientation program for the 30
subjects who were either enrolled in the experimental study or who
participated in the audit was very poor. It was not feasible for a
registered nurse to successfully provide an orientation program to
those subjects who participated in the study during the period from
January 1, 1987 to May 1, 1987. Additionally, the effectiveness of
an orientation program provided to the 30 subjects who were either
enrolled in or audited during this study could not be measured.

Neither the feasibility of an orientation program nor the

effectiveness of an orientation program by a registered nurse to

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elderly individuals relocating from the acute care setting to the
extended care facility can be determined due to the limitations of
this study to include the inadequacy of the medical records related
to communication status, discharge status, physical status and
general well-being which were noted during the medical record audit.
Therefore, the effects of relocation on an elderly individual's
ability to adapt to the new environment when moving from an acute
care setting to an extended care facility in terms of the patient's
well-being, both objectively and subjectively could not be determined

during the course of this study.

Summary

Due to the lack of available participants in the experimental
study in this research, the study could not be completed as
designed. The hypotheses which were tested in this study were
neither accepted nor rejected as the study was not completed. The
hypotheses which could neither be supported/accepted nor rejected
were:

1. An elderly individual from an acute care setting who is provided
an orientation program by a registered nurse from that facility
will experience more positive adaptation than an elderly
individual from an acute care setting who is not provided an
orientation program by a registered nurse from that facility.

2. An elderly individual from an acute care setting who is provided
an orientation program to an extended care facility will

demonstrate a higher level of knowledge regarding the facility's

120

policies and procedures than an elderly individual from an acute

care setting who is not provided an orientation program.

3. An elderly individual from an acute care setting who is provided
an orientation program to an extended care facility will
demonstrate a higher level of social activity than an elderly
person from an acute care setting who is not provided an
orientation program.

As the researcher was able to complete the intervention of the
orientation program with only one subject, the number of participants
was not sufficient to report significant study findings. However,
the medical record audit which was accomplished retrospectively with
22 subjects was an attempt to examine the reasons for subject
ineligibility and inability of the researcher to carry out an
orientation program. Several conditions which caused the subjects to
be determined ineligible for the study were identified and the

hypotheses were neither rejected nor accepted.

CHAPTER VI
Summary and Conclusions
916.2491
The purposes of this chapter are to present: 1) a summary of the
research findings; 2) recommendations based on the findings; and 3)
conclusions which have been derived from the research. The content
of this chapter includes three sections: summary of findings,

recommendations and conclusions.

Summary of Findipgs

 

Description of Study

 

In an experimental study of elderly individuals who were being
relocated from the acute care setting (hospital) to an extended care
facility (nursing home), the effects and the feasibility of an
orientation program upon the relocated individual's adaptation were
determined. The study was conducted at a 167-bed skilled nursing
facility in the Midwest. The facility's policy was to accept newly
admitted individuals from four large community hospitals in the
area. The subjects for this research study who were enrolled in the
program were admitted from one of the four community hospitals.
Purposes

The study was designed to determine the effect(s) and/or
feasibility of an orientation program by a registered nurse upon the
adaptation of the newly admitted elderly individuals. The idea for

the study was derived from the researcher's long-term interest in the

121

122

differences between those elderly individuals who were admitted to

the extended care facility for the first time who adapted very poorly

and those elderly individuals who adapted very well to the new
setting.
The specific purposes of the study were:

1. To investigate the effects of relocation on an elderly
individual's ability to adapt to the new environment when moving
from an acute care setting to an extended care facility in terms
of the patient's general well-being, both objectively and
subjectively.

2. To investigate the feasibility of the introduction of an
orientation program by a registered nurse to elderly individuals
relocating from the acute care setting to the extended care
facility.

3. To determine the effectiveness of an orientation program by a
registered nurse for the elderly individuals who were
experiencing relocation from an acute care setting to an extended
care facility.

Conceptual Framework
The purposes and hypotheses of the study were related to the

effectiveness and feasibility of an orientation program for an

elderly individual who was relocating from the acute care setting to
the extended care facility, and to the concept of adaptation
post-relocation. Therefore, the conceptual framework which was
utilized in this study was based upon the Roy Adaptation Model of

Nursing and the nursing process. The concepts within the framework

123

which have been defined are relocation, orientation, orientation
program and adaptation.

In brief, the Roy Adaptation Model of Nursing is a model which
“identifies the recipient of nursing care as an adaptive system" (Roy
8 Roberts, 1981, p. 43). In applying the Roy Adaptation Model of
Nursing to the issue of relocation of the elderly individual, the
relocation event is viewed as the stimuli/input. The elderly
individual c0pes with the event, the individual's coping is effected
by feelings, reactions, physical effects and mental status and
output(s) are achieved. The output is either adaptation to the event
or failure to adapt to the event. The response(s) are fed back
through the system in the form of input and the system recycles (see
Figure 1).

The Roy Adapatation Model of Nursing was the framework for the
client's reaction to the relocation event and the nursing process
became the vehicle by which the professional nurse could intervene in
the relocation event. In providing an orientation program, the
professional nurse was able to manipulate the stimuli and affect the
type of input the individual received. As the individual takes in
the orientation program as part of the input, he/she copes, effects
his/her coping in the four adaptive modes and either adapts or fails
to adapt (output). The professional nurse can make an assessment at
the point at which the output information is fed back through the
feedback process and provide another intervention as needed.
Therefore, the nursing process is applied by the professional nurse

to the Roy Adaptation Model of Nursing.

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Problem Statement
The experimental intervention was designed to answer the question
regarding the effect(s) of an orientation program upon the elderly
individual's adaptation to the extended care facility. The elderly
individuals were admitted from the acute care facility.

Variables
The variables in the study were identified. Orientation program

was the independent variable and more positive adaptation was the

dependent variable. ”Orientation program“ was defined as a plan of
procedure to assist a person in an adjustment or adaptation to a new

environment or situation. More positive adaptation was defined as a

certain, accepted or affirmed change which is accomplished so as to

become suitable to a new situation.
Therefore, the positive adaptation was to be measured as:

1. An increased knowledge level as evidenced by the elderly client's
improved performance on the knowledge questionnaire pretest to
posttest.

2. An increase in socialization as evidenced by the elderly client's
increase in social activity at posttest.

Hypotheses
The hypotheses which were formulated for this study were:

1. An elderly individual from an acute care setting who is provided
an orientation program to an extended care facility by a
registered nurse from that facility will experience more positive

adaptation than an elderly individual from an acute care setting

 

 

 

 

125

who is not provided an orientation by a registered nurse from

that facility.

2. An elderly individual from an acute care setting who is provided
an orientation program to an extended care facility will
demonstrate a higher level of social activity than an elderly
person from an acute care setting who is not provided an
orientation program.

3. An elderly individual from an acute care setting who is provided
an orientation program to an extended care facility will
demonstrate a higher level of knowledge regarding the facility's
policies and procedures than an elderly individual from an acute
care setting who is not provided an orientation program.

The hypotheses for this study were neither accepted nor rejected,
as the researcher was unable to carry out the intervention due to
lack of eligible participants for the study. Sixty-six individuals
were admitted to the extended care facility over a four month period,
but only eight individuals were eligible for participation in the
study according to the study criteria. Of the eight individuals who
were eligible upon admission for participation in the study, only
three remained in the study at the time of the posttest. Of the
three participants who remained eligible at the time of the posttest,
one individual was a member of the experimental group and two were
members of the control group. The number of participants was
insufficient to report any significant findings.

Due to the findings of the study, an additional research question

was raised relative to the characteristics of the population at the

126

skilled nursing facility. Therefore, permission was obtained from 22
subjects of the 66 individuals who were newly admitted to the newly
admitted skilled nursing facility over a four month period to
accomplish a medical record audit. The purpose of the audit was to
describe the characteristics of the skilled nursing facility
population. The results of the medical record audit were indicative
of a population of elderly individuals who were ineligible for the
experimental study related to the criteria. The findings of the
medical record audit were that 12 of the 22 subjects had experienced
one prior nursing home admission; five of the subjects were unable to
communicate; seven subjects were discharged from the facility prior
to one month post admission; three subjects were diagnosed with
organic brain syndrome; and eight subjects were too physically
debilitated to participate. These data were characteristic of
one-third of the elderly population who were being admitted to the
skilled nursing facility over a four month period. All of the
individuals who were described were admitted to the skilled nursing
facility from the acute care setting.

Of the total 30 subjects studied, eight subjects from the
original experimental study were described based upon the pretest
data. The eight subjects from the original study were also admitted
from the acute care setting to the skilled nursing facility.

By describing 30 subjects who were transferred from the acute
care setting to the skilled nursing facility, the researcher was able

to identify several characteristics which have vital implications for

127

long-term care and which guide recommendations for future research

related to relocation of the elderly to long-term care institutions.

Recommendations

Recommendations for Future Research

 

In lieu of the design in this research study, an alternate type
of design would be recommended for future research regarding the
topic of relocation of the elderly from the acute care setting to the
extended care setting. Initially a pilot study would be appropriate
which would describe the population which is being admitted from the
acute care setting to the extended care facility. The population
which would be described could be composed of those elderly
individuals who were currently in the acute care setting who were to
be placed in an extended care facility. By identifying the
population at the acute care setting, the acuity level of the patient
could be ascertained prior to the relocation so that the orientation
program to the extended care facility could be planned according to
the patient's capability. Also, by obtaining the study sample at the
acute care setting, the researcher would be able to follow the
individuals to several different facilities rather than to only one
facility as in this study.

After assessing the population in the acute care setting during
the pilot study, it would be determined whether or not the population
was variable and whether or not there were a significant number of
eligible participants so that it was feasible to attempt a

descriptive study. If it was feasible to attempt a descriptive

 

 

128

study, it is recommended that all elderly individuals in the acute
care setting who were being transferred to an extended care facility
be provided an orientation program to prepare them for the move. The
content of the orientation program would be dependent upon the type
of facility to which the individual was being transferred. However,
all individuals who participated in the study would be screened
utilizing a standardized Sociodemographic Questionnaire.

Criteria for Future Study

 

The criteria for the study should be less restrictive in regard
to mobility status, mental status, and communication status. Also,
the subjects who had experienced previous admissions to an extended
care facility should be eligible for participation since every new
admission for the individual is a new experience and those
individuals would also benefit from an orientation program.

The study criteria related to each participant staying at the
facility for at least one month would not be necessary. The purpose
of the study would be to observe the individual's adaptation
post-relocation to the new facility, and duration of stay would not
be a criterion.

The necessary criteria for the study would be:

1. The subjects would be transferred from the acute care setting to
the extended care facility.

2. The subjects would be 55 years of age or older.

3. The subjects would voluntarily agree to participate and cooperate
in the study and would be willing to participate upon request in

a brief orientation program to introduce him/her to the

129

facility. In the event that the subject was diagnosed as having
organic brain syndrome, Alzheimer's disease or dementia or was
unable to communicate and was unable to respond to the screening
items on the Sociodemographic Questionnaire, a family
member/significant other could be identified who was responsible
for their care and that individual would participate in the
study.
The criteria for future study of elderly individuals who are
relocated from the acute care setting to the extended care facility
would be less rigid than the criteria proposed in this study. The

orientation program would be also less rigid and more individualized.

Orientation Program

 

After identifying the population at the acute care setting with
the assistance of the social services department regarding those
elderly patients who were being transferred to an extended care
facility, the researcher could implement the orientation program.
The orientation program would be implemented before the elderly
individual was discharged from the acute care setting. The
orientation program would include familiarizing the patient and/or
family with the extended care facility and answering any questions
which the patient and/or family raised regarding the transfer. Part
of the preparation for the move would involve provision of a familiar
person i.e. the researcher who would be available to the patient
and/or family both prior to the move and post-transfer to provide

continuity and support throughout the relocation experience.

130

In order to accomplish the change in design so that the patients
and/or families could be prepared prior to the relocation at the
acute care setting, the researcher would be required to obtain
permission from all of the involved facilities in order that he/she
could accomplish the research. However, although it would be a
greater task to gain entry into several facilities than it would be
to function at one facility post-relocation as was done in this
study, the opportunity for gaining greater participation in the study
would occur.

It is recommended that the research question or problem statement
could remain the same as the question which was identified in this
study if the focus of the prior preparation for the move became the
acute care setting instead of the extended care facility. The
question would remain as: “What is the effect of an orientation
program by a registered nurse from an extended care facility upon an
elderly individual's adaptation to that facility upon being admitted
from an acute care setting?” The change in preparation for the
relocation experience from the extended care facility to the acute
care setting would change the timing of the orientation program but
not the measurable outcome. The outcome which would be measured
would be adaptation.

The patient's adaptation was to be measured in terms of knowledge
and social activity in this study, but due to the attrition rate, the
measurements were never obtained. Therefore, it is recommended for
future research that knowledge and social activity are measured as

indicators of level of adaptation. However, instead of measuring the

 

 

131

individual's knowledge and social activity post-relocation at a
facility in which the level of acuity of care of the newly admitted
patients was extremely high, it is recommended that the individuals
are screened utilizing the Sociodemographic instrument while in the
acute care setting. By screening the individuals at the acute care
setting, the chances of the level of acuity being more variable would
increase and therefore the number of eligible participants could
increase. The variability in the level of acuity of the patients
would be determined in the initial pilot study describing the
population of elderly individuals in the acute care setting who were
being discharged to extended care facilities.

The functional level of the participants in the study would be
determined and the orientation program would be based on the acuity
level of the patient. The ambulatory individuals and more mobile
individuals would participate actively in a tour of the facility
whereas the less mobile patients would view a videotape of the
facility layout. The most severely impaired individuals, both
mentally and physically who met the study criteria would be provided
a simple orientation program and/or their family member/significant
other would participate in the orientation program. Family
members/significant others of all participants would be encouraged to
participate in the orientation program.

It is recommended that those elderly individuals in the acute
care setting who met the screening criteria would be given a
knowledge pretest within the first week of discharge from the acute

care setting and the Short Portable Mental Status Questionnaire

 

132

(SPMSQ) would also be administered. The knowledge questionnaire and
the SPMSQ would be repeated at posttest one month post admission or
at discharge from the facility whichever occurred first. The purpose
of the SPMSQ would be to evaluate mental status prior to admission
and then to observe for any changes at posttest. The mental status
assessment at pretest and posttest would possibly address the issue
of mental status changes over time which could potentially impact the
participant's performance on the knowledge questionnaire or upon
his/her social activity over time. The individual's mental status
could potentially influence the individual's adaptation to the new
setting.

The knowledge questionnaire would be scored by summation of
incorrect responses and reporting of the number of incorrect
responses out of a total possible score. The number of correct
responses by each participant in the group would be recorded and
pretest to posttest differences would be compared in order to
describe the effectiveness of the orientation program.

The social activity of the individuals who were relocated to the
extended care setting would be monitored from admission to one month
post-admission. The number of formal and informal social contacts
would be recorded.

The Social Activity Record would be scored at one month
post-admission by tallying the number of times the patient
participated in formal social activities in a one month period. The
number of times each participant attended formal social activities

would be recorded and pretest to posttest differences would be

133

compared. The results would be compared and differences noted in
order to describe the effectiveness of the orientation program.

Social activity would also be evaluated by logging the social
worker's and the charge nurse's assessment of the patient's social
activity. The social worker's notes would be checked and the
patient's social activity would be noted. The charge nurse's
perception of the amount of social activity experienced by the
participants would also be recorded. The researcher would interview
the charge nurses and record their perceptions and observations
regarding the types of social activities in which the study
participants would be involved.

The social worker's and charge nurse's reports and comments, and
the recording on the formal activity record would provide an overall
picture of the participant's social activity to include 1)
participation in formal social activities and 2) participation in
informal activities i.e. family visitation, visitation by other
residents of the facility. The amount of participation could be
measured and scored on a Likert-type scale with a scoring of (0-10)
little social activity to (20 +) a great deal of social activity.

Social activity varies from individual to individual and the
researcher should note the amount and type of social activity in
which the individual was involved prior to institutionalization. The
former pattern of social activity could be noted in a brief statement
after obtaining the social activity history from the participant
and/or his/her family/ significantly other. In order to describe and

compare social activity of several elderly individuals, it is

134

important to allow for individual differences and to describe those
differences upon reporting the study findings.

Another important issue related to amount of social activity is
to be sure to note physical limitations of the individual, i.e.,
acuity of illness, sensory/perceptual deficits. In order to
accurately describe and compare social activity as an indicator of
successful adaptation, it is important to correlate and/or describe
the types of physical limitations which may hinder participation in
social activity by an elderly individual.

The adaptation of the study participants could be described
utilizing the data related to knowledge about the facility pretest to
posttest and amount of formal/informal social activity experienced by
the participants. Data analysis would include mean scores and
frequencies related to social activity and t-tests related to pretest
to posttest differences in knowledge about the facility.

Correlations could also be done utilizing alpha coefficients
relative to comparison of mediating factors to the results i.e.
severity of illness, mental status, age, functional status and family
support. The mediating factors which significantly affected the
study results would be reported with p < .05.

It is recommended for future research that an experimental study
related to interinstitutional relocation of the elderly from the
acute care setting to the extended care setting is to be attempted
only after: 1) a pilot study is accomplished to determine the
feasibility of this type of study and 2) a descriptive study of the

issue is accomplished in order to describe the population and to

 

135

determine the effectiveness or ineffectiveness of an orientation
program. If the orientation program can be described as
significantly effective for elderly individuals who are relocating
from the acute care setting to the extended care facility, an
experimental study could be designed to test the effectiveness of an
orientation program.

The effectiveness of the orientation program would be measured by
the experimental group's performance on the knowledge questionnaire
compared to the performance of the control group. Also, the amount
of social activity recorded for the members of the experimental group
compared to the amount of social activity of the control group,
taking into account individual differences, would determine the
effectiveness of the orientation program and, thus, the patient's
adaptation to the extended care facility would be determined.

One question which was raised during the course of this study
which should be pursued is: “What role does the family/significant
other play in the elderly individual's adaptation post-relocation
upon being transferred from the acute care setting to the extended
care facility?” It is recommended that this issue should be pursued
in any future studies related to interinstitutional relocation of the
elderly. By measuring the individual's informal social activities,
the family or significant other's visits will be documented. Also
the charge nurse's and social worker's perceptions of the elderly
person's social activity will provide information regarding social
contacts by the family and/or significant other(s). However, the

question of the role of the family and/or significant other(s)

136

related to the patient's adaptation post-relocation should be pursued
in greater depth. The family/significant other(s) should be
interviewed and areas related to relationships, decisions, influence,
financial assistance and past caregiving should be addressed.

Due to the limitations of this study related to recruitment of
adequate numbers of participants after a four month period of study,
the recommendations which have been made for future research are to
attempt to redesign the study so that a significant number of
participants may be recruited. Also, the recommendations include a
stepwise approach to the experimental design in lieu of starting with
an intervention study without piloting for feasibility. Lastly, it
is recommended that the family and/or significant other's involvement

related to impact upon the individual's adaptation should be pursued.

Recommendations for Nursing Practice

The concept of relocation related to moving the elderly from one
place to another has been discussed in the literature at great length
over several years. The only conclusion which has been agreed upon
in the findings is that prior preparation to the move is a key factor
in an elderly individual's positive adaptation to the move. The
implications for nurses related to the issue of prior preparation to
the move are that the professional nurse is in a key position to
provide the prior preparation for the move to the client. Therefore,
it is recommended that professional nurses who practice in both acute
care and extended care settings could play a major role in assisting

an elderly individual and family in the relocation experience from

137

acute care to extended care. An increase in communication between
the nurses in acute care and extended care is needed in order that
each one understands the other's setting. By understanding the
operation of each type of setting regarding routines, policies and
procedures, the patients can be prepared prior to moving from one
environment to the other. Also, if the extended care facility nurses
are more familiar with the acute care setting, they will have an
increased understanding of the patient's experiences prior to
relocation. The extended care facility nurses can also assist the
patients who are newly admitted to the extended care setting
post-relocation by providing information about the facility, its
policies and procedures and daily routines. The extended care
facility nurses can also perform a functional assessment on each
patient who is newly admitted and determine his/her plan of care
based upon nursing diagnoses, goals for treatment and expected
outcomes.

Based upon the data which was retrieved from the medical record
audit, the nurses in both acute care and extended care settings can
expect that the patients with whom they work will be more acutely ill
than in the past several years due to DRG's, and they will present to
the extended care setting after a shorter acute care stay. The
elderly patients in this study had multiple care needs upon admission
to the skilled nursing facility and were fairly dependent in most
cases. Therefore, it will be very important to develop a
comprehensive plan of care upon the first day of admission and to

continue to update the plan of care as the patient's condition

 

138

changes. Ongoing assessment from the time of admission to the acute
care setting which could be communicated to the skilled nursing
facility would be a most comprehensive means of caring for the
elderly individual and ”bridging the gap” throughout the relocation
process.

Another recommendation for nursing practice is to incorporate the
concept of an orientation program for all elderly patients who are
being discharged from the acute care setting or for those elderly
individuals who are being admitted to the extended care facility into
the discharge and/or admission policies respectively. If prior
preparation for the move was a routine procedure upon discharge from
the acute care setting and if an orientation program was presented by
the nursing staff to each newly admitted elderly individual and their
family or significant other, preparation for relocation could become
a policy and procedure from which all elderly individuals would
benefit.

Discharge planning nurses who would participate in preparation
for relocation to alternative living environments, i.e., extended
care facilities would be in a strategic position to impact the
elderly individual's relocation experience. Creative techniques,
i.e., video cassette recordings of the routines and surroundings of
the facility which the patient is transferring to and brochures which
are designed to describe the policies and routines of the extended

care facility could be implemented.

139

Relationship to Theoretical Model

In order to relate theory to practice regarding the relocation of
the elderly individual from the acute care setting to the extended
care setting, the conceptual framework for this study could be
utilized to direct the acute care and extended care nurse's
interventions. The elderly patient who is being relocated could be
assessed regarding inputs, i.e., his/her feelings regarding the move;
his/her reaction to the family and staff's attitudes about the move;
the physical effects of the move and the patient's mental status at
the time of the move. The nurses in both settings could then plan
the individual's care and observe measurable outcomes, i.e., mood,
demands for attention, confusion, appetite, mobility status, etc.
The nurses could manipulate the stimuli through further nursing
interventions to work toward positive outcomes for the patient.

Nursing Education

 

In regard to nursing education, there are several opportunities
for the professional nurse to provide input into the elderly
individual's relocation experience. Nursing educators could initiate
the education of professional nurses regarding relocation of the
elderly. Relocation and its effects upon the elderly population
could be presented in the didactic portion of the student nurse's
course work, and the theory related to relocation of the elderly and
its effects could be operationalized in the clinical portion of the
nurse's education experience.

The recommendations for nursing education based upon the content

of this study are that nurses could be introduced to the concept of

140

relocation of the elderly during their educational experience and
could incorporate that knowledge as a part of routine practice when
working with the elderly who are being relocated. Programs regarding
relocation of the elderly could be presented in educational seminars
for the nursing staff of both acute care and extended care settings.
Workshops regarding the issue of relocation of the elderly could also
be presented in the community for professionals and non-professionals
who are involved in caring for the elderly.

Nursing leaders could reinforce the need for support for the
elderly and their families/significant others during the relocation
experience through seminars and workshops. Nurses who are employed
by institutions in health care which deal with the care of the
elderly could be very influential in impacting facility or
institutional policies and procedures related to nursing care of the
relocated or soon to be relocated elderly.

Nursing Service

Implications for nursing service related to relocation of the
elderly and prior preparation for the move can be identified as: 1)
impacting policy-making related to relocation issues; and 2)
enforcement of policy which has been set related to relocation of the
elderly. Other service-related issues regarding relocation of the
elderly involve community awareness related to the impact of
relocation upon the elderly and provision of information to
non-nursing disciplines who are involved with care of the elderly.

Implications which the results of this study have for nursing

practice, education and service have been identified as practical

141

measures which any professional nurse could utilize in any setting

regarding preparation of the elderly individual for a relocation

experience. Creativity in formulating means to assist the elderly is
imperative in order to address the multiplicity of physical
disabilities versus learning needs of the elderly population.

Implications for Advanced Practice in Nursing
There are also implications in nursing related to the nurse in

advanced practice related to relocation of the elderly. The

implications for the advanced nursing practitioner in primary care
are related to the many role characteristics which are identified in
the advanced practitioner's role. The implications which are
indicated as a result of this study related to the Clinical Nurse

Specialist's role in relocation of the elderly are that the Clinical

Nurse Specialist will function as:

1. An assessor collecting subjective and objective data related to
the individual who is being relocated in order to form a data
base to assist in the formation of tentative nursing diagnoses
which may impact the relocation experience. The Clinical Nurse
Specialist will initiate the assessment and work with the client
in the primary care setting.

2. A change agent utilizing relocation theory and the findings in
the literature related to relocation of the elderly and prior
preparation for the move in order to impact policy/procedural
issues. The Clinical Nurse Specialist can function to provide
education and anticipatory guidance related to relocation of the

elderly in the primary care setting as a part of an examination.

3.

142

A client advocate by working with the client and/or family to
promote a more positive relocation experience.

A clinician in formulating nursing diagnoses and managing
disabilities or difficulties related to the relocation
experience. Also, the Clinical Nurse Specialist in primary care
will function as a clinician in collecting data to determine the
need for relocation for an elderly client.

A collaborator working with the physicians, social workers and
other members of the health care team in effecting the relocation
of the client. The Clinical Nurse Specialist can collaborate
with the primary care team when a determination for relocation
for an elderly client is necessary.

A consultant to the acute care or extended care nursing staff or
other health professionals regarding interinstitutional
relocation and its impact upon the elderly as well as functioning
as a consultant to nurses and other professionals in the primary
care setting.

A coordinator by facilitating and coordinating the
interinstitutional move for the elderly individual and family.

A counselor to the client and/or family regarding concerns
related to the relocation experience especially in the primary
care setting as primary or secondary prevention for the
experience.

An educator to the community, to other nursing professionals, and
to other health care professionals regarding interinstitutional

relocation of the elderly.

143

10. An evaluator who appraises the effectiveness of the program
which is designed to assist the elderly client and/or family in
the relocation process.

11. A leader by directing others and facilitating the preparation of
the elderly individual for the relocation experience. The
Clinical Nurse Specialist also can function as a leader in
primary care by introducing the concept of relocation and its
impact upon the elderly.

12. A planner by developing a plan or program related to ways in
which to deal with the relocation of the elderly individual
which are more supportive than the current practice in primary
care and also to plan ways in which to inform the community
regarding the issue of relocation of the elderly and its impact
especially as related to the effects on the family and/or
significant others.

13. A role model to others in the way in which he/she deals with the
client, family, and staff regarding the Issue of relocation.

14. A researcher/inquirer by pursuing further study regarding
interinstitutional relocation of the elderly in order to advance
nursing knowledge. Also, by presenting the findings of this
research study at professional nursing seminars.

Therefore, since the results of the study were unable to be
analyzed due to the lack of study participants, it is imperative that
further research is pursued regarding relocation of the elderly and
more specifically interinstitutional relocation of the elderly. Due

to the findings in the literature related to the importance of prior

144

preparation for a move when relocating the elderly, several
implications were identified related to nursing theory, education,
practice and service. Since DRG's have become an additional concern
regarding more rapid discharge of elderly individuals from the acute
care setting with less time for adequate preparation for the move, it
is important that nurses are aware of the implications related to
their role in moving the elderly from one setting to another.

Implications for the Clinical Nurse Specialist in caring for the
elderly, other than those which are specifically related to
operationalizing the role characteristics, are related to the
Gerontological Clinical Nurse Specialist having more knowledge about
issues in caring for the elderly than other health care
professionals. The Clinical Nurse Specialist has more knowledge of
resources which are available to the elderly individual in assisting
them with relocation. The Clinical Nurse Specialist can provide the
elderly individual with available options for placement post-
institutionlization and can assess the elderly individual and plan
with him/her regarding the best alternatives for living arrangements
related to their situation. Primary care placement opportunities for
the elderly individual, i.e., Adult Foster Care, Home Care or
Congregate Living can be recommended as alternatives to nursing home
placement whenever feasible.

The Clinical Nurse Specialist in Primary Care can also provide
education, family support and continuity of care in providing care to
the elderly individual and/or family who is faced with relocation.

Mobilization of resources can also be accomplished by the Clinical

 

 

 

145

Nurse Specialist in the primary care system in order to look at the
whole person rather than the physical defects only.

In the long-term care arena, the Clinical Nurse Specialist can
recommend alternative types of placement, provide education and
mobilize resources, and can also listen to the client's concerns and
work with the nursing staff to inform them of the client's needs. If
the Clinical Nurse Specialist is working in the nursing home setting
in long-term care, the staff can be made aware of the acuity of care
required by the elderly client(s) and can assist in preparing the
nursing staff and the families.

Physicians and other health care professionals can be assisted by
the Clinical Nurse Specialist in Primary Care regarding concerns
related to appropriate care for the elderly regarding relocation
issues. In the event of nursing home placement, the Clinical Nurse
Specialist in Primary Care can assist physicians and other health
care professionals to understand how the system works, i.e., the
requirements imposed by regulatory agencies, the policies and
procedures of the institution, the alternatives which are available
in the event that the elderly individual is discharged from the
nursing home setting.

Regarding discharge from the nursing home setting, the Clinical
Nurse Specialist can begin discharge planning with the client soon
after admission if appropriate, and can share with the client and/or
family the percentage of individuals who go home from the facility.
The Clinical Nurse Specialist could plan and contract with the client

and/or family to go home or to an alternative living arrangement.

146

Based upon the data from this research, it was noted that 232 of the
elderly individuals who were admitted to the facility were discharged
to their home or to alternative living arrangements. Therefore, it
is important to note that persons do go home and inform clients and
families that the nursing home setting is not necessarily the final
placement alternative.

The Clinical Nurse Specialist in Gerontology can utilize a
conceptual framework such as the one utilized in this study upon
which to base his/her practice in the care of the elderly who are
experiencing interinstitutional relocation. Based upon such a model
the issues which are related to interinstitutional relocation of the
elderly can be explored and interventions can be planned with the
client, family and/or significant other utilizing the expertise of
the Clinical Nurse Specialist. The Clinical Nurse Specialist is the
primary gatekeeper in affording the client the most continuous,
comprehensive and coordinated care possible given the circumstances

surrounding the relocation event.

Conclusions

 

The following conclusions have been formulated as a result of the
findings of this study:

1. It was not feasible to complete an orientation program for
elderly individuals who were relocated from the acute care
setting to 167 bed extended care facility in the Midwest due to
the acuity level of the individuals who were being admitted to

the facility and to the number of individuals who were residents

147

of an extended care facility prior to admission to this facility
so that the individuals failed to meet the study criteria.

2. It was not possible to investigate the effects of relocation on
an elderly individual's ability to adapt to the new environment
when moving from the acute care setting to the extended care
facility due to the lack of participants.

3. It was not possible to ascertain the effectiveness of the
orientation program which was designed in this study upon the
newly relocated patient's adaptation to the 167 bed extended care
facility due to the lack of participants.

4. It was possible to describe the characteristics of the newly
admitted elderly population in a skilled nursing facility.

Discussion of Conclusions

 

The conclusions which have been drawn from the findings of this
study are directly related to the original purposes which were
identified for the study. The original purposes were not met due to
the lack of eligible study participants. The effectiveness and
feasibility of an orientation program by a registered nurse from an
extended care facility could not be ascertained during the course of
this study nor could the elderly individual's adaptation
post-relocation be measured. The acuity level of the patients who
were admitted over the four month period of study was high and only
eight participants out of 66 newly admitted patients were eligible
for the study according to the study criteria. Of the eight eligible
participants, three participants were available at posttest to

complete the study.

148

The hypotheses for the study were neither accepted or rejected

due to the lack of participants. It was not possible for the

desearcher to determine whether or not:

1.

An elderly individual from an acute care setting who is provided
an orientation program to an extended care facility by a
registered nurse from the facility will experience more positive
adaptation than an elderly individual from an acute care setting
who is not provided an orientation by a registered nurse from
that facility.

An elderly individual from an acute care setting who is provided
an orientation program to an extended care facility will
demonstrate a higher level of knowledge regarding the facility's
policies and procedures than an elderly individual from an acute
care setting who is not provided an orientation program.

An elderly individual from an acute care setting who is provided
an orientation program to an extended care facility will
demonstrate a higher level of social activity than an elderly
person from an acute care setting who is not provided an
orientation program.

According to the literature (Pastalan 8 Bourestrom, 1977; Petrou

8 Obenchain, 1987; Pino et al., 1978; Kennedy et al., 1987;

Mirotznik 8 Ruskin, 1984) prior preparation for the move i.e.

provision of an orientation program for elderly individuals who are

relocating from one institution to another provides for a more

positive adaptation. Therefore, the literature is supportive of the

original intent of this study which was to determine the feasibility

149

and effectiveness of an orientation program upon the elderly
individual's adaptation post-relocation. The literature was found
also to be in favor of the hypotheses of this study which indicated
that the elderly individuals who were involved in an orientation
program post-relocation would experience more positive adaptation
than those who did not. However, since the study was not completed
as designed due to lack of participants, the hypotheses can neither
be supported nor rejected.

The literature related to relocation of the elderly and
orientation programs for the elderly who are being relocated did not
contain evidence of relocation of the elderly from the acute setting
to the extended care facility since the advent of DRG's
(diagnosis-related groups). Therefore, it was not possible to rely
on the studies in the literature regarding the outcome of this
experimental study as there are few similar studies which have been
reported.

It has been recommended in this study that due to the support in
the literature for the issue that an orientation program prior to the
move can be a positive experience, a study could be designed to
obtain participants at the acute care setting. The study would be
designed to screen the potential subjects at the acute care setting
in order that a more variable population could be identified compared
to the limited population which was identified at one skilled nursing
facility in this study.

In planning the orientation program at the acute care setting,

issues such as (1) client expectation regarding the move, (2) forced

150

choice, and (3) client's sense of control relative to the move should
be taken into consideration. The client's expectation(s) about the
move can be ascertained upon interview of the client or upon initial
assessment. The client's questions and/or concerns can be answered
and the client and/or family/significant other can participate in a
mutual planning process.

The client's feelings regarding relocation as a ”forced choice”
issue could also be explored upon initial assessment. The ”forced
choice" issue can be discussed with the client and/or family/
significant other and the client can become a part of the planning
process in order that he/she and/or his family/significant other do
not feel as though they are being forced into the relocation.

The client's sense of control relative to the move is of vital
importance in the relocation process, and by identifying areas in
which the client/family/significant other can make choices related to
the move, they can feel more a part of the process. The
interventions dealing with control or "forced choice" issues may be
as simple as listening to the client's or family's concerns and
keeping them informed regarding the relocation process.

Most of the studies in the literature (Pastalan 8 Bourestom,
1977; Petrou 8 Oberchain, 1987; Pino et al., 1978; Kennedy et al.,
1987; Mirotznik 8 Ruskin, 1984;) were performed utilizing an
orientation program prior to the relocation experience as compared to
the orientation program which was to be offered in this study within
48 hours of admission to the skilled nursing facility. Therefore, it

has been recommended by this researcher that the original intent

151

and/or purposes of the study remain the same, but the design could be
rewritten and a study could be carried out at the acute care setting
as the initial site for screening potential subjects and implementing
the orientation program.
Theoretical Implications

The hypotheses in this study were neither supported nor rejected
and therefore the findings are not identifiable as lending strength
or modifying existing theory. However, since the restrictiveness of
the study criteria combined with the high acuity level of the newly
admitted patients were the main factors which minimized eligibility
for the study, if the study was replicated utilizing the acute care
population in conjunction with a new design, the opportunity for
completion of the study is a feasible one.

The variables in a replication study regarding relocation of the
elderly from acute care to extended care would remain as knowledge
and social activity as indicators of the variable of adaptation.
Additional concepts which would be discussed in a replication study
would be functional status of the participants, involvement of family
and/or significant others and social support.

The theoretical implications related to the idea for a
replication study with a modified population and modified design are
that relocation of the elderly is viewed by this researcher as a
major life event which could be explored more fully. Also, since
there is a strong indication in the relocation literature that prior
preparation for the move, i.e. orientation programs, are supportive

and assistive measures which can be implemented to assist the elderly

152

individuals to experience more positive adaptation upon relocation,
further research related to the topic should be pursued. According
to Mirotznik and Ruskin (1984) ”it is imperative that we continue to
expand our knowledge to better understand the consequences of
relocation for the elderly" (p. 26).

With the advent of DRG's (diagnosis related groupings) it is
imperative that the issue of relocation of the elderly be examined
further. Due to shorter acute care stays and earlier discharge, the
elderly are being relocated more rapidly from the acute care setting
to alternative living arrangements to include extended care
facilities. Since most of the studies related to relocation of the
elderly which were cited in this study were completed prior to the
advent of DRG's, it is important that further studies are
accomplished which describe the situation and add to the literature
regarding feasible intervention and/or proposals related to
interinstitutional relocation of the elderly.

Study‘Contributions

 

The contributions which this study has made to the concern
regarding relocation of the elderly from the acute care setting to
the extended care facility are:

1. The identification of a low success rate related to orientation
of the elderly individual at post-relocation.

2. The realization that the family and/or significant other(s) must
be targeted in preparation for the move in the event that the
elderly individual is unable to participate or cooperate in the

move a

153

The recognition that shorter acute care stays are creating a need
for prior preparation for the relocation to the extended care
facility as soon as possible at the acute care setting.

The identification of a need for a pilot study regarding the
issue of relocation of the elderly in order to better define the
problem.

The notion that increased severity of physical status requires
increased acuity of nursing care which identifies a need for
increased nursing staff, especially an increase in registered
nursing coverage on a 24-hour basis.

The recognition that there is a need for multidisciplinary
intervention and collaboration in order to address the
multiplicity of needs of the institutionalized elderly.

The issues of concern in the nursing profession related to the

relocation of the elderly from one institution to another are

becoming more visible, but more up-to-date research is needed in

order to more clearly define the problem. Also, more research is

needed as has been indicated by this study in order to assist others

regarding design and methodology which is workable when addressing

the issue of interinstitutional relocation of the elderly.

REFERENCE S

REFERENCES
Amenta, M., Weiner, A., 8 Amenta, D. (1984, November/December).
Successful relocation. Geriatric Nursing, 356-360.

American Medical Association. (1986). DRG's and the prospective

 

payment system: A guide for physicians. Chicago: American
Medical Association.
Borup, J. (1983). Relocation mortality research: Assessment, reply

and the need to refocus on the issues. The Gerontologist, 23(3),

 

235-242.
Borup, J., Gallego, D., 8 Hefferman, P. (1979). Relocation and its

effects on mortality. The Gerontologist, 19, 135-139.

 

Burnside, I. (1980). Psychosocial nursing care of the aggd (2nd ed).

 

New York: McGraw-Hill Book Co.

Burnside, I. (1981). Nursing and the aged (2nd ed). New York:

 

McGraw-Hill Book Co.
Bush, S. (1977). Newsline. Psychology Todgy, 10(9), 32.

Butler, R., 8 Lewis, M. (1982). Aging and mental health (3rd ed).

 

St. Louis: C.V. Mosby.

Cairl, R., Burton, 8., Keller, 0., Kosberg, J., 8 Pfeiffer, E. (1982).
Geriatric Assessment Testing and Evaluation system trainigg_manual
(GATES). Durham, NC: Duke University Center for Aging.

Chenitz, W.C. (1983, March/April). Entry into a nursing home as
status passage: A theory to guide nursing practice. Geriatric

Nursin , 92-97.

154

155

Craig, H.M., 8 Edwards, J.E. (1983). Adaptation in chronic illness:
An eclectic model for nurses. Journal of Advanced Nursing, 8,
377-404.

Day, A.T. (1985, September). Who cares? Demographic trends challeng
family care for the elderly. Population Trends and Public Policy,
#9.

Ebersole, P., 8 Hess, P. (1985). Toward healthy aging: Human needs

and nursing response. St. Louis: C.V. Mosby.

 

Engle, V. (1985). Mental status and functional health four days
following relocation to a nursing home. Research in Nursing and
flgglgfl, g, 355-361-

Farkas, L. (1981). Adaptation problems with nursing home application
for elderly persons: An application of the Roy adaptation nursing

model. Journal of Advanced Nursing, 6, 363-368.

 

Feiger, J. (1983, September/October). Divided loyalties. Geriatric
Nursin , 298-300.

Fitzpatrick, J., 8 Whall, A. (1983). Conceptual models of nursing:

 

Analysis and application. Bolvie: Robert J. Brady Co.

 

Forbes, E., 8 Fitzsimons, M. (1981). The older adult: A_process for

 

wellness. St. Louis: C.V. Mosby Co.
Garland, J. (1985). Adaptation skills In the elderly, their supporters

and carers. British Journal of Medical Psychiatry, 58, 267-274.

 

Giorella, E.C., 8 Bevil, C.W. (1985). Nursing care of the aging

 

client: Promoting_healthy adaptation. Norwalk: Appleton-

 

Century-Crofts.

156

Gordon, G. (1985). The social readjustment value of becoming a nursing

home resident. The Gerontologist, 25(4), 398-402.

 

Gove, P. (Ed.) (1961). Webster's third new world international

dictionar . Springfield: G 8 C Merriam Company.

 

Grey, C. (1978). Moving 137 elderly residents to a new facility.
Journal of Gerontological Nursing, 4(6), 34-38.

Helmes, E., Kalman, G., 8 Short, J.A. (1987). Standardization and
validation of the multidimensional observation scale for elderly
subjects (MOSES). Journal of Gerontology, 42(4), 395-405.

Hing, E. (1987). Use of nursing homes by the elderly: Preliminary

data from the 1985 National Nursing Home Survey. Advance Data,

 

National Center for Health Statistics, #135, 1-12.

Horowitz, M., 8 Schulz, R. (1983). The relocation controversy:
Criticism and commentary on five recent studies. 1gp
Gerontologist, 23(3), 229-233.

Hunt, M., 8 Roll, M. (1987). Simulation in familiarizing older people

with an unknown building. The Gerontologist, 21(2), 169-175.

 

Janelli, L.M. (1980). Utilizing Roy's adaptation model from a

gerontological perspective. Journal of Gerontological Nursing, 6,

 

140-142.
Kennedy, L., Neidlinger, S., 8 Scroggins, K. (1987). Effective
comprehensive discharge planning for hospitalized elderly. IDS

Gerontologist, 21(5), 2, 577-580.

 

Kent, 0., Kastenbaum, R., 8 Sherwood, S. (1972). Research planning

 

and action for the elderly: The power and potential of social

 

science. New York: Behavioral Publications.

 

157

King, K., Oimond, M., 8 McCance, K. (1987, September/October). Coping

with relocation. Geriatric Nursing, 258-261.

 

Lesnoff-Caraveglia, G. (1980). Health care of the elderly: Strategies
for prevention and intervention. Human Sciences Press.

Liben, L., Patterson, A., 8 Newcombe, N. (1981). Spatial
representation and behavior across the life span: Theory and

application. New York: Academic Press.

 

Lieberman, M., 8 Tobin, S. (1983). The experience of old age. New
York: Basic Books, Inc.

Livy, D. (1979, May). A possible solution to admission trauma.
American Health Care Association Journal, 5, 10-11.

Mangen, 0., 8 Peterson, W. (Eds.) (1982). Research instruments in
social gerontology. In Clinical and social gerontology (Vol. 1).
Minneapolis: University of Minnesota Press.

McGlynn, J. (1983). Adaptation theory...behaviorists have constructed

a model. Nursing Mirror, 156(26), 31-32.

 

Mirotznik, J., 8 Ruskin, A. (1984). Inter-institutional relocation

and its effects on health. The Gerontologist, 24(3), 286-291.

 

Moos, R., David, T., Lemke, S., 8 Postle, E. (1984). Coping with an
intra-institutional relocation: Changes in resident and staff

behavior patterns. The Gerontologist, 24(5), 495-502.

 

Morris, W. (Ed.) (1973). The American heritage dictionary of the

English Iangugge. Boston: American Heritage Publishing Co., Inc.

 

Mullen, E. (1977, July/August). Relocation of the elderly:

Implications for nursing. Journal of Gerontological Nursing, 3(4),

 

13-16.

158

National Center for Health Statistics. (1979). The national nursing
home survey: 1977 summary for the U.S. Vital and Health

Statistics, Series 13, #43, DHEW Pub. No. (PHS) 79-1794.

 

Nirenberg, T. (1983, October). Relocation of institutionalized
elderly. Journal of Consulting and Clinical Psychology.
Palestis, E. (1986, January/February). The admission ward concept.

Geriatric Nursing, 2(1), 40-41.

 

Petrou, M., 8 Obenchain, J. (1987, September/October). Reducing

incidents of illness posttransfer. Geriatric Nursing, 264-266.

 

Pfeiffer, E. (1975, October). A short portable mental status
questionnaire for the assessment of organic brain deficit in
elderly patients. Journal of the Emerican Geriatrics Society,
‘23(10), 433-441.

Pino, C., Rosica, L., 8 Carter, T. (1978). The differential effects

of relocation on nursing home patients. The Gerontologist, 18(2),

 

167-172.

Polit, D., 8 Hungler, B. (1987). Nursing research: Principles and

 

methods (3rd ed). Philadelphia: Lippincott.

 

Rodstein, M., Savitsky, E., 8 Starkman, R. (1976). Initial adjustment
to a long-term care institution: Medical and behavioral aspects.

Journal of the American Geriatrics Society, 24(2), 65-71.

 

Rowles, G., 8 Ohta, R. (Eds.) (1983). Agjng and milieu:

 

Environmental perspectives on growing old. New York: Academic

 

ress, Inc.

Roy, C. (1976). Introduction to nursing: An adaptation model.

 

Englewoods Cliffs: Prentice-Hall, Inc.

159

Roy, C., 8 Roberts, 5. (1981). Theory construction In nursing: An

 

adaptation model. Englewood Cliffs: Prentice-Hall, Inc.

 

Stein, 5., Linn, M., Stein, E. (1985). Patients' anticipation of

stress in nursing home care. The Gerontologist, 25(1), 88-94.

 

Thomas, E. (1979). Morbidity patterns among recently relocated
elderly. Kansas City: ANA Publications.

U.S. Senate (1985, October). How older Americans live: An analysis

 

of census data. Special Committee on Aging #990.

 

Weiner, M.B. (1978, September). Caring for the elderly: Orienting
the new admission elderly patient to the long-term care facility.

Journal of Nursing Care, 5.

 

Winograd, C.H. (1984, January). Mental status tests and the capacity

for self-care. Journal of the American Geriatrics Society. 22(1),

 

49-55.
Wolber, G., Romaniuk, M., Eastmen, E., 8 Robinson, C. (1984, August).
Validity of the short portable mental status questionnaire with

elderly psychiatric patients. Journal of Consulting and Clinical

 

Psychology, 52(4), 712-713.
Wolanin, M.O. (1978, May/June). Relocation of the elderly. Journal

of Gerontological Nursing, 4(2), 47-50.

 

Yurick, A., Robb, S., Spier, B., 8 Ebert, M. (1984). The aged person

 

and the nursing process. Norwalk: Appleton-Century-Crofts.

 

 

APPENDICES

APPENDIX A

Socioeconomic and Demographic Questionnaire

160

Socioeconomic and Demographic Questionnaire

 

 

Date:
10 #:
Birthdate: Age:
Sex: Male ___ Female
Marital Status: ___ Single

___ Married

___ Widowed

Divorced
___ Separated

Ethnic background (optional): (CHECK MORE THAN ONE IF APPLICABLE)

Caucasian
Hispanic

Afro American
Native American

Other
Languages spoken (check one): ___ English
French
___ Spanish

Other (please specify

 

Education level (highest grade completed):

Elementary school (0-6th grade)
Junior High School (7 - 9th grade)
Some high school
Completed/graduated high school

College (number of years attended: )
Religion (check one): ___ Protestant
___ Catholic

___ Other (please specify

 

Employment status:

Place of employment (currently or formerly

 

Job title:

 

Chronic illnesses: 1.

 

 

 

 

 

12.

13.

14.

16.

17.

18.

-2- 161

Number of prior hospitalizations in past five years (1981-1986):

__ 1-5
6-10
7-15

Number of prior nursing home admissions: 0
1

Familiarity with nursing home procedures:

Not familiar at all

Familiar (have been a resident of nursing home before)
Familiar (have had a family member in a nursing home)
Familiar (have visited a nursing home)

Familiar (have been told about this nursing home)

Familiar (have toured this nursing home)

Familiar (the Director of Nursing has visited me prior to my
admission here)

Unfamiliar (have never visited or been in a nursing home and
know very little about nursing homes)

DO NOT WRITE BELOW THIS LINE

Medical insurance: YES NO

Type(s):

 

 

Responsible party name:

 

Relationship:

 

Medical diagnosis (current):

 

 

Name of facility transferring to:

 

Expected length of stay (number of days):

 

10/20/86

APPENDIX B

Short Portable Mental Status Questionnaire (SPMSQ)

 

162

Pfeiffer
Short Portable Mental Status Questionnaire (SPMSQ)

INSTRUCTIONS: Ask the subject questions 1-10, record answer, and enter
as ”1” under appropriated column (correct/error). All responses to be
scored correct, must be given by subject without reference to calendar,
newspaper, birth certificate or other memory aid.

CORRECT ERROR
1. What day is it?

Month Day Year
(Score correct only when the exact month, day year are given correctly.)

2. What day of the week is it? Day

 

3. What is the name of this place?

 

(Score correct if any correct description of the location is

given: “My home,” accurate name of town, city, or name of rsidency
hospital, or institution (If subject is institutionalized) all are
acceptable.)

4. What is your telephone number?
(If none, see 4A below.)

 

(Score correct when the correct number can be verified or when
subject can repeat the same number at another point in questions.)

4a. What is your street address? (Ask only if subject does not
have a telephone.)

 

 

5. How old are you? Age
(Score correct when stated age corresponds to date of birth.)

6. When were you born?

Month Day Year
(Score correct only when exact month, date and year are all given.)

7. Who is the president of the United States now?

 

(Only the last name of the president is required.)

8. Who was the President before him?

 

(Only last name of previous President:)7

SPMSQ 163
Page 2

9. What is your mother's maiden name?

 

(Does not need to be verified. Score correct if female name plus
last name other than subject's last name is given.)

10. Substract 3 from 20 and keep subtracting 3 from
each new number all the way down?

(The entire series must be performed correctly in order to be
scored correct. Any error in series or unwillingness to attempt
series is scored as incorrect.)
TOTAL ERRORS
Adjustment Factors:

A) Subtract 1 from ERROR SCORE if subject has had

only a grade school education. -
8) App 1 to ERROR SCORE if subject has had education
beyond high school. +

TOTAL ADJUSTED ERRORS

© COPYRIGHT E. Pfeiffer, 1974. Reference: E. Pfeiffer (1975). A
short portable mental status questionnaire for the assessment of organic

brain deficit in elderly patients. Journal of the American Geriatrics
Societ , 23(433).

APPENDIX C

Knowledge Questionnaire

164

Knowledge Questionnaire
(Ten Items)

Identify two of the rights which patients have
at this facility according to the Patient Bill
of Rights?

What are the visiting hours at this facility?
What departments other than the nursing
department provide services for the residents
of this facility? (List two.)

How do you obtain the services of a dentist or
a foot doctor if you need them?

How do you obtain the services of a eautician
or barber if you need them?

Where is the beauty/barber shop located?

What type(s) of social activities are available
at this facility? (List three.)

Where are the group social activities held?
What time are your neals served?
What time are medications administered (given)

by the nurse?

TOTAL

10/20/86

CORRECT ERROR

APPENDIX D

Social Activity Record

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APPENDIX E
Chart Review Form

Chart Audit Review Form

 

166
CHART AUDIT/REVIEW FORM
Events or condition changes which may effect the resident's
relocation experience:
Social Changes or Events 12S

1. Presence of family support?

(Number of visits per week? )

N

. Discharge plans in place?
. Moved from one room to another?

3
4. Room rate changed occurred?

5. Death of a loved one? ___
6. Private duty nurses present? ___
7. Attends therapy:
--Physical ___
--0ccupational ___
--Speech ___

O)

. Social worker involvement on a regular basis?

Physical Changgs or Events

1. Infection (5)? (number _____) ___
2. Pain? ___
3. Bleeding .__
4. Medication reations? (number _____) ___
5. Falls? (number _____) ___
6. Post-operative complications?

\l

. Complications of bed rest?

(I)

. Change in level of responsiveness?

Describe:

 

9. Alteration in nutrition?

Describe:

 

10/20/86

APPENDIX F

Routine Services Guide

167

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APPENDIX G

Human Subjects

168

NHCHIGAN STATE UNIVERSYTY

 

UNWERSITY COMMITTEE ON RESEARCH INVOLVING EAST LANSING . MICHIGAN . 48824-1046
HUMAnsumHIsummnn
BBADMDflflRAnONBUHDmG
(517) 355-2186

December 2, 1986

Ms. Janet Elgood
College of Nursing
A230 Life Sciences Building

Dear Ms. Elgood:

Subject: Proposal Entitled, "The Effects of Orientation to an
Extended Care Facility on the Elderly Person's
Adaptation to the Patient Role"

UCRIHS' review of the above referenced project has now been completed. I am
pleased to advise that the rights and welfare of the human subjects appear to
be adequately protected and the Committee, therefore, approved this project
at its meeting on December 1, 1986.

You are reminded that UCRIHS approval is valid for one calendar year. If you
plan to continue this project beyond one year, please make provisions for
obtaining appropriate UCRIHS approval prior to December 1, 1987.

Any changes in procedures involving human subjects must be reviewed by the
UCRIHS prior to initiation of the change. UCRIHS must also be notified
promptly of any problems (unexpected side effects, complaints, etc.)
involving human subjects during the course of the work.

Thank you for bringing this project to our attention. If we can be of any
future help, please do not hesitate to let us know.

Sincerely,

Tile/m.

Henry E. Bredeck, Ph. D.
Chairman, UCRIHS

HEB/jms

cc: Dr. Barbara Given

MSU it an Affirmative Action/Equal Opportunity Institution

169

MICHIGAN STATE UNIVERSITY

 

COLLEGE OF NURSING EAST LANSING 0 MICHIGAN ' 48824-1317

MEMORANDUM
October 16, 1986
T0: Henry Bredeck, UCRIHS

FROM: Barbara Given, Ph.D., R.N., F.A.A.N.
Director for the Graduate and Research Programs

RE: Janet Elgood
Janet successfully defended her thesis proposal. Her committee approved
her proposed research project for her M.S.N. program in the College of

Nursing.

Ipla

MSU is an Affirmative Action/Equal Opportunity Institution

APPENDIX H

Consent Forms

170

Dear

I am a graduate student in nursing at Michigan State University and I
am conducting research at Kith Haven, Inc. My study involves
reviewing the medical records/charts of those elderly individuals who
are admitted to Kith Haven, Inc., from the hospital.

My goal in conducting this research is to determine how the elderly
person who is transferred to the nursing home from the hospital
adapts to such a change. Therefore, I would like to request that you
give me permission to review your relative's/client's medical

record. The time of review would involve a 30 day period, from
admission until one month after admission. The medical record review
would in no way affect your relative's/client's stay at Kith Haven.

If you are willing to grant permission to me to review your
relative's/client's medical records for this research study, please
sign the enclosed consent form and return it in the self-addressed
stamped envelope.

Thank you for your consideration in this matter.

Sincerely,

Janet Elgood, R.N.
Graduate Student
Michigan State University

Enclosure

l7l

CONSENT FORM - MEDICAL RECORD AUDIT

By agreeing to participate in this study regarding the effects of an
orientation program by a registered nurse to an elderly individual
who is moving from a hospital to a nursing home, you will be giving
permission to the researcher to review your relative's/client's
medical record for the purpose of information retrieval. The
information will be retrieved during the period from admission to one
month after admission. If you agree to participate in this study,
please sign the following statement.

By signing this form, I understand that:
l. l have freely given consent to take part in this study.

2. I am free to discontinue participation in the study at any time
without penalty.

3. The information which is retrieved will be treated with strict
confidence and all participants will remain anonymous.

h. I am not guaranteed any beneficial results from participation in
this study.

5. Results of this study will be made available to me at my
request.

6. This research is being conducted as partial fulfillment for the
requirements for the degree of Masters of Science in Nursing,
College of Nursing, Michigan State University.

Because of my relative's/client's medical condition, I realize that
he/she may not be able to participate in this study. Therefore, I
agree to sign on his/her behalf. Also, I understand that
participation in this study will in no way affect his/her medical
care.

 

 

Witness Responsible Party Signature

 

 

Date Date

172

CONSENT FORM

By agreeing to participate in this study regarding the effects of an
orientation program by a registered nurse to an elderly individual
who is moving from a hospital to a nursing home for the first time,
you will be involved in answering two questionnaires and possibly
participating in an orientation program within 48 hours of admission
to the nursing home. Also, your participation will involve answering
two questionnaires one month after admission to the nursing home. If
you agree to participate, please sign the following statement.

By signing this form, I understand that:
l. I have freely consented to take part in this study.

2. The study has been explained to me. Furthermore, I understand
the explanation that has been given to me and what my
participation may involve.

3. I am free to discontinue my participation in the study at any
time without penalty.

A. My responses on the questionnaires will be treated with strict
confidence and all participants will remain anonymous.

5. I am not guaranteed any beneficial results from my participation
in this study.

6. Results of this study will be made available to me at my
request.

7. My medical record will be reviewed by the researcher for the
purpose of information retrieval which relates to the study.
The information which is retrieved will be reviewed and compiled
by the researcher only.

8. This research is being conducted as partial fulfillment for the
requirements for the degree of Masters of Science in Nursing,
College of Nursing, Michigan State University.

 

 

 

Witness Signature

 

 

Date Date

In the event that the participant is unable to sign, the individual
who is designated as the responsible party will sign.

 

 

Witness Responsible Party Signature

 

 

Date Date

 

 

, - IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII