gc. 1,)? " ‘47. ' LIBRARY MichiganState University m lllllllujfllflllll llll'l l'l‘l‘l'l“ r, This is to certify that the thesis entitled The Effects of Change in the Physical Environment Upon Elderly Patients During and Following an Institutional Relocation. presented by Gail Lynn Hartwigsen has been accepted towards fulfillment of the requirements for __Eh‘D_.__degree in Mlogy {s_l._\ 7L‘_\_ ) \‘J ‘.___.—. ——' "' x . t .. fir , . " ‘- K47 A X. lo LL” / V T Major professor , Date 21 February 1980 0-7 639 «g é‘\ MSU M . OVERDUE FINES ARE 25¢ PER DAY PER ITEM Return to book drop to remove this checkout from your record. THE EFFECTS OF CHANGE IN THE PHYSICAL ENVIRONMENT UPON ELDERLY PATIENTS DURING AND FOLLOWING AN INSTITUTIONAL RELOCATION by Gail Lynn Hartwigsen A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Family Ecology 1979 ABSTRACT THE EFFECTS OF CHANGE IN THE PHYSICAL ENVIRONMENT UPON ELDERLY PATIENTS DURING AND FOLLOWING AN INSTITUTIONAL RELOCATION BY Gail Lynn Hartwigsen In a society where the numbers of older citizens continue to increase, attention must be focused upon environments that will support their physical and emotional needs. This becomes especially critical in institutional settings where people are separated from the familiarity so essential to their well-being. Relocation of the institutionalized elderly is thought by some to be characterized by higher than normal mortality rates, or "relocation trauma." This exploratory study was undertaken to expose specific aspects of the physical environment that might affect patients either positively or negatively during and following an institutional relocation, with the data ultimately intended to be used as input for the design of facilities for the elderly who require regular, daily medical care. The nature of study of the elderly and of the environment in general necessitates that many factors be investigated. The instru- ments reflect this complexity. The Mental Status Questionnaire (MSQ) was used to determine patient alertness to orientation in time, place, and person. The Activities of Daily Living Scale (ADL) measures the sociobiological behavior of the patient in six basic functions: bathing, dressing, toileting, transfer, continence, and feeding. The Physical Environmental Checklist (PEC) is designed to measure objective characteristics of the immediate physical environment along with obtaining the patients' subjective rating of satisfaction with the seventeen physical environmental aspects in question. The "before and "after" physical environments provided extreme contrasts for the patients, and, since this change was accompanied by little social change, this study has treated the entire relocation experience as a physical environmental change only. Questions guiding the research were organized to crosstabulate the independent variables of mental status, physical health, amount and type of physical environmental control exerted, and amount and type of physical environmental changes perceived by the patient with the dependent variables of nonsurvival, survival, and satisfaction fol- lowing the move. Six specific questions guided the research: 1. Are patients who are more mentally alert, as measured by the Mental Status Questionnaire, more likely to survive relocation than those who are shown to be less alert? 2. Are the more mentally alert patients, as measured by the Mental Status Questionnaire, more likely to be satisfied with their new environments? 3. Do patients who exert control (option of choice) over their new environments prior to relocation survive reloca- tion better than those who do not? 4. Are patients who exert control (option of choice) over their new environments prior to relocation likely to be more satisfied following relocation? 5. Do the number of physical environmental changes, as perceived by the patient during an institutional relocation contribute to the elderly institutionalized patients' mortality, morbidity, or satisfaction? 6. Are there some types of physical environmental changes that are perceived by the patient during an institutional relocation that will contribute more to the elderly patients' mortality, morbidity, or satisfaction? Thirty-seven patients were each interviewed three specific times during the study. The findings as suggested by the data were: 1. Patients scoring higher on the MSQ reported a higher level of satisfaction with the physical environment following the relocation. 2. The survivors who exercised more control over their physical environments prior to the relocation reported a higher level of satisfaction following the relocation. 3. Women expressed satisfaction more often and exhibited greater independence than the men. From these responses, it was believed that the women responded more positively to the relocation than did the men. 4. The patients gave more positive ratings to all but one aspect of the new physical environment in question. Generally, it can be concluded that the relocation was a positive experience. Overall mortality rates for the year preceding the relocation did not differ, and the patients indicated increased satisfaction with the new structure. ACKNOWLEDGMENTS I would like to thank Dr. Gertrude Nygren for her friendship, leadership, and unfailing objectivity throughout this venture. I hope that I will be able to repay her for her efforts by guiding someone else through a project of similar scope in the future. Dr. Beatrice Paolucci provided many suggestions regarding the direction of this research, along with giving encouragement and support throughout its duration. For this I am grateful. Her questions and comments opened some "doors" to ideas that proved essential to this study. Dr. Jane Oyer provided an infinite amount of encouragement along the way, both in classes and as a committee member. Her calm reassurances were most appreciated, as was the kindness she gave continually. Dr. Erwin Bettinghaus made many excellent suggestions regarding the reporting of the findings, and helped to clarify the results of this research. For the first time through with this type of venture, his suggestions to me were most welcome. I would like to thank the patients at the Ingham County Medical Care Facility for their cooperation, and particularly thank Mr. Louis Crowe for his friendship and insight during the project. Mrs. Barbara Thorburn, Ingham County Medical Care Facility Administrator, and Mrs. Carol Kennedy, ICMCF Social Wbrker, also deserve a great deal of thanks for their cooperation, time, and patience. Without them, this project would not have been conducted as positively as it was. Dr. Howard Teitelbaum must be thanked for the unselfish giving of his knowledge, encouragement, and friendship. His special brand of "magic" will always-be remembered and appreciated. I cannot thank him enough for the lights he turned on along the way. To everyone who supported me throughout this project, I give my sincere thanks. TABLE OF CONTENTS LIST OF FIGURES . . . . . . . . . . LIST OF TABLES . . . . . . . . . . Chapter I. INTRODUCTION . . . . . . . . Problem Statement and Purpose of the Study . . . . . . . . . Significance of the Study . . . Conceptual Framework . . . . . Specific Objectives of the Study . Assumptions . . . . . . . . Definitions . . . . . . . . II. REVIEW OF THE LITERATURE . . . . Introduction . . . . . . . . Survival in Relocation . . . . Effects of Physical, Social and Psychological Change . . . . Locus of Control and Assertiveness Attitude Toward Relocation . . Voluntary Versus Involuntary Relocation Communication with the Relocatee . Sensory Loss . . . . . . . Preparation Prior to Relocation . Summary . . . . . . . . . III. STUDY METHODOLOGY AND PROCEDURE . . Sample Selection and Description . Description of the Settings . . . Instrument Selection and Description Mental Alertness and Physical Independence Physical Environment . . . . Procedure . . . . . . . . . Data Gathering Techniques . . . Data Analysis Techniques . . . iv Page vi vii 000301.500 12 12 12 15 18 20 21 24 25 26 28 32 32 34 37 38 39 40 40 46 Chapter IV. RESULTS AND DISCUSSION Presentation of the Research Questions, Findings and Implications . Research Question Research Question Research Question Research Question Research Question Research Question Summary . . . . V. :SUMMARY, CONCLUSIONS?INDIRECOMMENDATIONS 1 001wa Summary and Conclusions Recommendations for Future Research ”PENDIES O O O O O O O A. General Patient Information Form B. Physical Environmental Checklist . C. Mental Status Questionnaire D. Activities of Daily Living Scale and Description of Patients' Physical Health Form BIBLIOGRAPHY . . . . . . Page 50 50 50 SI 58 59 75 83 96 98 98 108 112 113 115 117 119 122 Figure 10. 11. LIST OF FIGURES Basic Interaction Between Man and the Physical Environment as Implied by the Ecological Theory 0 O O O O O O O O O C O O O Conceptualization of Physical Environmental and Patient Factors That Could Affect Institutional Relocation Outcome . . . . . . . . . . Direct and Indirect Determinants of a Patient's Health and Longevity . . . . . . . . . Floorplan of the New Ingham County Medical Care Facility . . . . . . . . . . . . . Instruments Utilized in the Study . . . . . All Patients' Positive Perceptions of Physical Environmental Aspects Prior to and following Relocation . . . . . . . . . . . . All Patients' Negative Perceptions of Physical Environmental Aspects Prior to and following Relocation O O O O O C O O O O O 0 Male Patients' Positive Perceptions of Physical Environmental Aspects Prior to and following Relocation O O O O O O O O O I O 0 Male Patients' Negative PerCeptions of Physical Environmental Aspects Prior to and following $10 cat ion 0 O O O O O O O O O O 0 Female Patients' Positive Perceptions of Physical Environmental Aspects Prior to and following Relocation . . . . . . . . . . . . Female Patients' Negative Perceptions of Physical Environmental Aspects Prior to and following Relocation . . . . . . . . . . . . vi Page 17 36 47 88 89 9O 92 94 95 Table 10. 11. LIST OF TABLES Age and Gender Characteristics of the Thirty-seven Patients Who Participated in the Study . . . . . Specific Combinations of Dependent and Independent Variables Compared in Two-by-Two Contingency Tables as Created by the Process of Crosstabulation . . . . . . . . . . . . Average MSQ Scores for Patients Who Survived or Did Not Survive the Relocation at the Pre-move, Three- month, and Six-month Interview Periods . . . . . Age and Gender Characteristics of Patients Who Survived or Did Not Survive the Relocation . . . All Patients' Reported Satisfaction as Related to Their MSQ Scores . . . . . . . . . . . . Male Patients' Reported Satisfaction as Related to Their MSQ Scores . . . . . . . . . . . . Female Patients' Reported Satisfaction as Related to Their MSQ scores 0 O O O O O O O O O O O Survivors and Nonsurvivors as Related to Their Participation in a Total of Four Possible Areas of Control: Roommate, Room, Room Color, and "Other" Selection . . . . . . . . . . . . . . All Patients' Reported Satisfaction as Related to Their Participation in a Total of Four Possible Areas of Control 0 O O O O I O I O O O O O - O 0 Male Patients' Reported Satisfaction as Related to Their Participation in a Total of Four Possible Areas of Control . . . . . . . . . . . . . . . Female Patients' Reported Satisfaction as Related to Their Participation in a Total of Four Possible Areas of Control . . . . . . . . . . . . vii Page 33 49 51 51 53 55 57 59 6O 62 63 Table 12. l3. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. All Patients' Reported Satisfaction as Related to Their Participation in Roommate Selection . . . . Female Patients' Reported Satisfaction as Related to Their Participation in Roommate Selection . . . . Male Patients' Reported Satisfaction as Related to Their Participation in Roommate Selection . . . . All Patients' Reported Satisfaction as Related to Their Participation in Room Selection . . . . . Female Patients' Reported Satisfaction as Related to Their Participation in Room Selection . . . . . Male Patients' Reported Satisfaction as Related to Their Participation in Room Selection . . . . . All Patients' Reported Satisfaction as Related to Their Participation in Room Color Selection . . . Female Patients' Reported Satisfaction as Related to Their Participation in Room Color Selection . . . Male Patients' Reported Satisfaction as Related to Their Participation in Room Color Selection . . . Average Number of Changes Noted in the Pre- and Post- Relocation Immediate Physical Environments by Survivors and Nonsurvivors . . . . . . . . . All Patients' ADL Scores as Related to Total Number of Changes Perceived in the Physical Environment . . Male Patients' ADL Scores as Related to Total Number of Changes Perceived in the Physical Environment . . Female Patients' ADL Scores as Related to Total Number of Changes Perceived in the Physical Environment . . All Patients' Reported Satisfaction as Related to Total Number of Changes Perceived in the Physical Environment . . . . . . . . . . . . . . Male Patients' Reported Satisfaction as Related to Total Number of Changes Perceived in the Physical Environment . . . . . . . . . . . . . . viii Page 64 65 67 68 69 71 72 73 74 75 77 79 80 81 84 Table Page 27. Female Patients' Reported Satisfaction as Related to Total Number of Changes Perceived in the Physical Environment . . . . . . . . . . . 85 28. Comparison of Mortality Rates at the ICMCF for the Year Preceding the Relocation (1977-78) and the Year of the Relocation (1978-79) . . . . . . . 106 ix CHAPTER I INTRODUCTION Although a substantial amount of study has dealt with the effects of relocation upon elderly individuals, results have been di- verse. Attempts to learn if environmental changes contribute to the survival or nonsurvival of the relocatees have not been conclusive, but literature has suggested a number of factors as being worthy of study. The effects of inter-institutional moves on the involved pa- tients appear to indicate that predictable and controllable environ- ments are associated with relatively less physical and psychological deterioration. Interinstitutional moves, however, vary widely in the numbers and degrees of changes an elderly patient is forced to undergo. The identification of specific factors that prove significant to relo- cated patients, either in the positive or negative sense, is critical. Pablo (1977) found that in an institutional move where the physical and social environments underwent little change, the reloca- tion was successful because the similarity of the "before" and "after" environments helped reduce the trauma associated with change among elderly patients. Schultz and Brenner (1977) and Pastalan and Bourestom (1975) found that pre-relocation preparation program participation increased the predictability of the new environment and effectively reduced mortality rates. Providing patients the opportunity to choose certain I aspects of their changed environment, in part through site visita- tion, is believed to improve the patients' survival rate. There is support for the idea that the design of the physical environment should be considered as an intrinsic goal in its own right regardless of whether other measures of psychological and social functioning are improved. In non-institutional relocations, Lawton and Cohen learned that a relative decline in physical health was associated with new housing, but that the "relative improvement (or lesser decline) in other criteria despite the decline in health . . . points to a buffering effect of the housing environments in keeping tenants' psychological status buoyed up" (1974, p. 204). Relocation has been conceptualized by Markus et a1 (1972), as having two separate stages requiring adjustment: 1) a deprivation of familiar cues and environmental supports, followed by, 2) the necessity to cope with a new set of stimuli in the unfamiliar, new environment. They also feel that field approach and mental status are both implied in the adjustment to a new environment. They contend that field-depen- dent perceivers will suffer from initial deprivation, lacking the abil- ity to "impose structure upon the unfamiliar environment" (1972, p. 377). They also feel that those with low mental status would have difficulty in coping with the new stimuli. Lieberman (1969) feels that specific, detailed information about the disruptiveness of the environmental change could be instru- mental in the development of procedures to lessen the discontinuities in the environment along with the negative effects of institutionaliza- tion. Few studies have been ecological in nature, considering the interdependent relationship of the person/organism to his/her physical environment. A primary purpose of this study is to learn if it is possible to identify environmental predictors affecting an indi- vidual's response to relocation. This study concerns itself with changes in the physical environment and the effects that these singu- lar and cumulative changes can have upon institutionalized older people. Problem Statement and Purpose of the Study This exploratory study is concerned with the identification of factors that positively or negatively affect elderly patients during and following an institutional relocation. Factors that would shed light on the evolving definition of an "improved environment" for these people are demanding study more and more. Given the current feeling that health care facilities, such as the Ingham County Medical Care Facility, hereafter referred to as the ICMCF, should satisfy the residential as well as the health care needs of their inhabitants (Koncelik, 1976), information gathered directly from the patients re— garding their satisfaction with the physical environment appears to be a necessity. In the past, research in this area has often acquired its information vicariously: through nurses, aides, doctors, social work- ers, administrators, and other sources, such as volunteers. The primary purpose of this study is to learn whether or not changes in the actual physical environment affect the involved patients and, if so, if correlations can be made between specific characteris- tics of patients and particular changes that have taken place in the physical environment. In this respect, the factors that will be investigated for comparative purposes are the number and type of physical environmental changes undergone as perceived by the patients, the patients' mental alertness, physical independence, and control exerted prior to relocation. These factors, when correlated with pa- tient mortality, morbidity, and satisfaction, should provide insight into the residents' immediate and eventual relocation pattern within the physical environment. It is felt that if findings in the area of institutional satisfaction were to be more conclusive than they have been, the amount of research and consideration directed toward the design of institu- tions for the elderly would increase. Significance of the Study Unconfirmed information on the effects of specific aspects of the physical environment upon elderly institutionalized patients exists. The relocation described in this study lends itself to this type of investigation, since a change in the structured physical environment occurred accompanied with a minimum of social change via personal con- tacts. Thus, it can be assumed that patient reactions, in terms of mortality, morbidity, and satisfaction with the new surroundings would be more likely to be attributable to the physical changes of the medi— cal care facility than to any other circumstances. An increased knowledge of physical environments that are supportive of human life and satisfaction, particularly in health care facilities, should help contribute to the design and construction of structures that will aide in the healing and caring processes associa- ted with such facilities, not hinder it. It would appear that a more satisfied patient would also feel more cooperative toward acute and chronic health care. Knowledge gained from this study would also identify various patient characteristics that aided or deterred the successful reloca- tion of the individuals. This information would be valuable to administrators of similar facilities when preparing patients for relocation. Conceptual Framework Inherent in the ecological theory is the reciprocal inter- action between man and his environment. Existing as two separate systems, each receives input, is to some degree transformed, and pro- duces output. This output, be it in the form of human behavior or a particular form of the physical environment, impacts upon the inter- acting system, as shown in Figure 1. This concept is an underlying one for this research, although the reciprocal process between man and his environment is not considered in this study. However, it is implied. physical environment FIGURE 1.--Basic Interaction Between Man and the Physical Environment as Implied by the'Ecological Theory. Beacuse of this implication, this study has been conducted within an ecological framework. This framework was also implemented due to the variety of factors that were studied. Indicators of patient nonsurvival, survival, and satisfaction following an institutional relocation are sought, and two primary areas of investigation were perceived as being most influential in their determination: the immediate physical environment, and the patient him/herself. Relocation can be a traumatic experience, especially for an institutionalized elderly person. It requires drawing upon inner re- sources of physical and mental health, and also upon individual per- sonality: the way in which one handles potentially traumatic situa- tions. An individual's ability to recognize, organize and utilize his or her own personal resources during an institutional relocation may spell the difference between nonsurvival, survival and satisfaction following the relocation. The immediate physical environment is defined, for the pur- poses of this study, as the patient's own room and the personal pos- sessions within that room. The extent to which the patient perceives his immediate environment as being a supportive unit and utilizes it as such can also influence his or her eventual relocation. Aspects of the immediate physical environment that were tested for in this study consisted of seventeen specific architectural features or personal touches by the patient that describe the patients' rooms. These aspects are detailed in figure 2, where they are depicted as "filtering through," or impacting upon, the patient, from whence a relocation outcome (nonsurvival, survival, or satisfaction) will result (see figure 2). IMMEDIATE PHYSICAL ENVIRONMENT Hmuocom :4 unuscoua>cm Hmowmanm mouossoou mo homes: tuxedmmwo muoofino Hmcomuom Econ cw woman moououm soon cw canon soon cw cofiwfl>mamu soon ow Ho>oa undo: waauw ououficuom ucoEumwuu uoodm uoHoo noon Hoaoo Soon usuaumouu 3oocw3 ouwm 3ooow3 EOOH ca Boocaz scum 3ow> 58H MO COMUGUCwfiHO numb o» suaaanmmmwoum noon Econ onwm Soon as a. an t... e n.l .l.n e a a .1 n 0.1 t 0 .13 as s t D.r s. a. pm m E m“ m non- satisfaction satisfaction nonsurvival v survival FIGURE 2.—-Conceptualization of Physical Environmental and Patient Factors That Could Affect Institutional Relocation Outcome Specific Objectives of the Study The purpose of this study is to investigate the phenomena of relocation among elderly institutionalized patients. The ecological framework employed scrutinizes the physical environment and the per- sonal resources of the involved individuals, explicitly striving to answer questions related to the amounts of physical environmental change tolerable to the subjects. Specifically stated, the objectives are as follows: 1. To determine whether any specific changes undergone by the patient during relocation affect him/her either positively or negatively. 2. To determine whether specific patient characteristics will be predictive of the patient's susceptibility to the trauma of institutional relocation. "Personal resources" include the individual's mental alert- ness, physical independence, personality, and various demographic characteristics. Mortality rates will be measured against mortality figures at the same facility during the preceding year. Survivors will be analyzed according to their relative degree of adaptation to the new environment and how satisfied they are with the adaptation. The concept of "satisfaction" is an important one. ‘Mandatory preparation of patients prior to relocation has introduced the proba- bility that fewer deaths can be expected following relocations than previously. Because patients may be living longer while in poorer health, rather than dying during relocation, increased attention must be given to the health care facility as a residence as opposed to strictly an acute physical health care establishment. Questions that focus around the physical environment, mental alertness, and control as they relate to satisfaction guide the research. 1. They are: Are patients who are more mentally alert, as measured by the Mental Status Questionnaire, more likely to survive relocation than those who are shown to be less alert? Are the more mentally alert patients, as measured by the Mental Status Questionnaire, more likely to be satisfied with their new environments? Do patients who exert control (option of choice) over their new environments prior to relocation survive re- location better than those who do not? Are patients who exert control (option of choice) over their new environments prior to relocation likely to be more satisfied following relocation? Is there an identifiable pattern in the number of changes in the physical environment that elderly institutionalized patients can experience before their mortality, morbidity, or satisfaction will be influenced? Are there some types of physical environmental changes that are perceived by the patients during an institutional relocation that will contribute more to an elderly patient's mortality, morbidity, or satisfaction? Assumptions The following assumptions underlie this study: 1. 2. All patients included in this study will have been provi- ded with the same pre-relocation preparation program opportunities. There will not be an appreciable decline in mental or physical status due to the natural process of aging during the period of this study. Definitions For the purposes of this study, the following operational definitions are used. Control: The willingness of the patient to select among the options available for his/her room, roommate, and room color in the new ICMCF. Other undefined opportunities were also available for 10 patient input. Dependence: Being unable to carry out all necessary daily activities in one's accustomed life, according to one's established standards. Environmental Change: Any object or event that can stimulate or affect a patient during an institutional relocation, be it positive or negative. Field Dependence: Reliance upon familiar supports in the physical environment. Individuals can be judged to be field dependent or field independent. Independence: Being able to care for one's physical and so- cial needs completely, including all activities concerned with nutri- tion, cleanliness, transportation, living environment, purchasing of goods, and other individually required daily activities. Immediate Physical Environment: That part of the patient's immediate surroundings that are physically visible. It includes the patient's room and its actual architectural features, contents, and design elements. Institution: A health care facility for those individuals who require skilled medical care. Interviewable Patient: Those patients who can readily hear and respond to questioning. ‘ Locus of Control: According to Reid, Haas and Hawkings, locus of control refers to the "extent to which a person sees his out- comes (events he experiences and reinforcements he perceives) as being contingent upon his own efforts and abilities (internal) or as being determined by chance, fate, or powerful others (external)" (1977, 11 p. 441). Mental Status: A measurement, taken by the Mental Status Questionnaire, of the patient's alertness to current events. Personal Control: The ability and permission to exert indi- vidual choice involving personal concerns. Personality: The tendencies of the patient as revealed in the amount and type of control he/she assumes over his/her physical environment in the new ICMCF. Satisfaction: An individual's perception of how the problem in question fulfills his or her needs. The notion of "happiness" is not necessarily implied. CHAPTER II REVIEW OF THE LITERATURE Introduction Literature relevant to the relocation phenomenon that has been associated with elderly institutionalized patients is discussed in this chapter. Specifically, research in the fields of survival in reloca- tion, effects of physical, psychological, and social change, locus of control (including patient satisfaction), and communication with the relocatee will be discussed. Survival in Relocation Brand and Smith have found that, "In general, older persons seem to gain satisfaction and support from association with familiar objects and places and from association with persons living in the same environment" (1974, p. 336). The relocation of the individual implies a disruption of this familiarity, thereby producing stress. Any type of environmental change can be harmful to the relocatee, and its source, whether pleasant or unpleasant, appears to be immaterial. Selye (1974) reports that it is the degree of change, or the demand for readjustment or adaptation, that will produce stress in the individual. Pastalan and Bourestom have found that "more radical environmental changes are associated with both higher mortality rates and with more negative changes in adjustment and life patterns. It would appear then that the sheer amount of forced change overloads the organism to 12 13 such an extent that negative consequences can be anticipated" (1975, p. 139). Slobogin (1977) says that change has been termed the common denominator of stress since it is a threat to the methods people have developed to handle their dependency needs. In change, familiarity is always lost to some degree. A major theme that Dohrenwend (1974) found common to many stressful events is the ability of the individual to adapt to or to cope with the changes that have occurred. Successful dealings with stress seem to demand these behaviors. Four characteristics of older, non-institutionalized people that have tended to indicate more successful relocations have been identified by Carp (1974), three of which can be associated with institutional relocation: 1) that the residents did not expect Utopia upon moving; 2) that the move had been voluntary; and 3) that the relo- catees were in good mental and physical health. In addition, good adjustment to the new surroundings was favored by intelligence, good physical and mental health status, living with the spouse, good socia- bility, and good levels of activity, self-esteem, optimism, present income, and socio-economic status of earlier years. Pablo asserts that the outcome potential of relocation "has consistently been associated with the following: degree of choice, degree of environmental change, degree of preparation, degree of health, or any combination of these factors" (1977, p. 426). Markson and Cumming (1974) found that a relocation of elderly chronic patients does not seem to subject them to a higher risk of dying. Lawton and Yaffe (1969) found similar results in studying a relocation of healthy elderly people. l4 Pastalan and Bourestom (1975) note that female patients relocated less successfully than men. Women tended to personalize their spaces much more than men, and they also formed more social ties, thereby having much more to lose upon relocation. Because of their higher degree of identification with the immediate environment, women were judged more dependent upon it as well. However, in separate studies, Davis and Haueisen (1976) and Schwartz and Karp (1967) reported no significant difference in field dependence between elderly male and female subjects. Davis and Haueisen found that field depen- dent subjects generally tended to be less efficient learners than were their field independent cohorts. In another study, Harel (1979) found that functional health and field dependence/independence played an important part in the survival of elderly non-institutionalized residents. He feels that the more functionally dependent and impaired individual is more risk- prone among older people. Similar "before" and "after" physical environments, accommo- dations, staff, and occupational therapy or physiotherapy treatments are believed to be factors important to lessening inter—institutional relocation mortality rates. Rodstein, Savitsky, and Starkman (1976) found that the patients most susceptible to initial relocation diffi- culties are those who: 1) had a poor capacity for interpersonal rela- tionships; 2) were socially isolated; 3) were either single or divorced; 4) had a dependent personality; 5) had severe chronic brain syndrome; 6) had a negative or ambivalent attitude toward admission; and 7) had often been referred for psychiatric evaluation. Borup, Gallego, and Heffernan (1978) concluded that mortality 15 rates for institutional relocatees are a function of age rather than the influences of relocation. Thus, some predictors clearly emerge, but among others there is a necessity to investigate further and more accurately delineate the causes and results of institutional relocation. The major factors involved are discussed next. Effects of Physical, Social and Psychological Change Institutional relocation seems to affect older, non-ambula- tory patients most. It is felt to be most harmful for those at least seventy-eight years of age, while a mean age of eight to ten years elder than the survivors has been suggested as being particularly predictive of nonsurvival. However, Markus et a1 (1972) found no significant differences among patient age or sex in relocation. Pastalan and Bourestom (1975) found that over half of the patients aged at least seventy-eight years who experienced a "radical" change relo- cation died, compared to 28 percent of their control group counterparts. Lawton and Yaffe concluded that the mortality rate is also thought to increase among patients with "moderate physical impairment, severe brain syndrome, and severe motor impairment" (1969, p. 824). There is suggestive evidence that physical illness affects an individual's psychological status and leads to maladjustment. The relocation of physically or mentally ill patients is comparatively unsuccessful when compared to healthier cohorts. Wittels and Botwinick observed that healthy community residents who have been found to make voluntary moves benefitted, whereas the 16 "relocation of sick people requiring nursing home care, especially when the move is involuntary, is detrimental to longevity" (1974, p. 440). In general, relocated individuals can expect a change in health following the move: health has been shown to both improve and decline more often among relocatees when compared to control groups. Lawton espouses the view of "environmental docility,“ that the more competent the individual, the less will be the "proportion of variance in behavior due to environmental factors" (1970, p. 40). He points out that the older person is more sensitive to change in his new environment because he is likely to have had some type of compe- tence reduction, perhaps through illness or perceptual capability. His is an ecological theory of aging, in which two components of study, the individual and the explicit or the implicit physical environment, are always necessary, and three others, the personal, suprapersonal, and social environments, may be present. He feels that "limitations in health, cognitive skills, ego strength, status, social role perfor- mance, or degree of cultural evolution will tend to heighten the docility of the person in the face of environmental constraints and influences" (1970, p. 40). Additionally, helpless and psychotic or near-psychotic pa- tients have been noticed by Aldrich and Mendkoff (1963) to have the highest death rates during the first year following relocation. It appears that older patients and those who are unaware of events happening around them suffer most. In contrast, Borup, Gallego, and Heffernan (1978) state that the non-interviewable (handicapped, in their terminology) did not have a higher probability of death during and following a relocation than 17 did interviewable (nonhandicapped) patients. Markson and Cumming (1974) feel that mortality is concentrated predominately in the six months surrounding relocation. There is some evidence that the first month following relocation serves to weed out those who were poor relocation risks because of underlying physical illness, mental confusion, or dependence upon the familiar institu- tional environment. On the brighter side, they feel that a mass relo- cation of relatively physically healthy patients has no demonstrable effect on their chances for survival, and that it may in fact be positive. The length of institutionalization seems to affect adjustment to relocation. Patients who have been hospitalized for a shorter period of time have been found to be more vulnerable to the effects of relocation, probably because of their recent move into the facility. Again, the amount of change is critical, according to Pastalan and Bourestom (1975). This may imply that in some cases the person's actual physical health may be precluded by other circumstances. Carp has developed a model illustrating the direct and in- direct determinants of a patient's health and longevity (see Figure 3). genetic factors activity, health and social environment1 social contact.) longevity morale physical environment 4‘—""’/7“ FIGURE 3.--Direct and Indirect Determinants of a Patient's Health and ‘ Longevity (Carp, 1977, p. 248) This model implicates factors other than physical health that can influence longevity: it proposes an ecological approach to the 18 patient's care in an institution, something which has oftentimes been lacking in health care facilities, where acute care only is the norm. Locus of Control and Assertiveness Carp reports that "one indicator of an unresolved adjustment problem, ladk or equilibrium, or stress is a feeling of being upset or unhappy" (1974, p. 445). Wolk and Kurtz (1975) have found that a correlation exists between adaptive behavior and the presence of high expectancy for personal control. Similarly, Palmore and Luikart (1972) found that beliefs in personal control are associated with greaterilife satisfaction. And, Reid, Haas, and Hawkings feel that ". . . losing personal control can lead to dysfunctional behaviour and emotional upset" (1977, p. 441). Based on this literature review, it would appear that an individual's satisfaction with the environment and his/her eventual relocation outcome would depend, at least in part, upon his exertion of personal control regarding the environment. Thus, control, or the ~degree to which an individual attempts to exercise options of choice in the selection of a new environment, could be a powerful predictor of relocation success. Wolk and Kurtz found that "a fairly substantial segment of locus of control research has verified a correlation between adaptive behaviors and the presence of high expectany for personal control" (1975, p. 120). They also concluded that the "internal" individual, one who makes an active attempt to control his/her environment, will relocate more successfully than the "external" person, who believes that very little he/she does will directly affect imminent changes. 19 The internal person, who is generally more striving, self-confident, and less anxious and apathetic, will attempt to become involved in the event, and this is believed to be a positive determinant in his/ her future success in relocation. Schultz and Brenner (1977) and wolk (1976) found that events that are predictable and desired have a powerful positive impact upon the well-being of the institutionalized aged. According to Walk (1976) locus of control was found to be independent of an individual's health status in consideration of pre- dicting adjustment behaviors. Thus, apparently as social and psycho- logical factors, they could significantly affect the person's adjust- ment to the new environment alone. Inrgeneral, the sense of control, the illusion that one can exercise personal choice, has a definite and positive role in sustaining life, according to "Old Age: Personal Control Is Important to the Elderly" (1976). Losing personal control, concluded Reid, Haas, and Hawkings (1977) can lead to dysfunctional behavior and emotional upset. A central effect of many of the physical and social changes that is known to occur is to reduce the sense of control and effectiveness that an elderly person may desire in his everyday life. Schultz and Brenner (1977) note that depression, helplessness, and physical decline have been linked to the patient's perceived loss of control. Belief in one's personal control has been correlated with greater life satisfaction: those who possess it have been found to be more active and to have greater differentiation, complexity, and adaptability. Social isolation, common in institutional settings, can also lead to disorientation in space and time, and to anxiety and depression. It would appear that a potentially lethal situation 20 could result: a social isolate, becoming anxious about an impending relocation may become depressed, believing that he has lost control over his life. This could cause further isolation and a worse progno- sis for the move. Lawton (1970) concludes it possible that the social isolation of an individual who is institutionalized may be a substi- tute for the loss of physical privacy in the setting, and this may be an inevitable consequence. Schwartz and Karp (1967) found that self-esteem influences a person's perceived locus of control. Positive self-regard is a key to successful aging, and plays a critical part in an individual‘s life satisfaction. Internal locus of control is believed by some to be the second best predictor of satisfaction among people who are over the age of 60. Those with internal control cope better and are less defensive than externally oriented people. Attitude Toward Relocation A patient's attitude toward the actual relocation has been found to be critical. Lawton and Yaffe (1969) learned that patients who deny the move or have a negative feeling toward it are predictive of a higher mortality rate than those whose response is satisfactory, angry or demanding. Those who express their anger, accepting the relocation philosophically, are more likely to survive than those who direct their anger against themselves and become depressed as a result, according to Aldrich and Mendkoff (1963). Pastalan and Bourestom (1975) found that patients who retreated from conflict situations by denying their anger subsequently died, and that their rate was twice that of those who expressed their anger openly. They also found that 21 patients who had a positive attitude toward the move relocated most successfully while those who were most negative had a good chance of initial survival following the move but then died at higher rates than other groups soon after the move. Also related to this, Pastalan and Bourestom feel, is the patient's "style of handling problems and feelings, particularly in regard to his assertiveness or lack of it. Patients who adopted a passive stance in regard to problems died at a rate over three times greater than patients who adopted a more assertive stance. The impli- cation is that the patient who perceives locus of control, at least in part, with himself, is better able to deal with relocation stress than is the patient who believes himself to be helpless in the face of problems and challenges" (1975, pp. 141-142). Aldrich and Mendkoff (1963) studied mortality rates during a relocation and related patient survival to their philosophical outlook. They concluded that patients who approached the situation in a philo- sophical manner had the lowest mortality rate (zero percent), followed, in order, by feelings of anger (6 percent), anxiousness (15 percent), regression (27 percent), depression (41 percent), and denial (71 percent). Voluntary Versus Involuntary Relocation The nature of the relocation is a strong determinant in patient mortality. In a study of voluntary versus involuntary moves, Schultz and Brenner (1977) found that sixteen of seventeen involuntary movers died in the first ten weeks of relocation, compared to one of thirty-eight voluntary patients. Brand and Smith (1974) discovered 22 that death rates are higher for those who had no choice but to be placed in an institution when compared to those who had other options. The lack of environmental choice contributes to the patient's locus of control and is predictive of a potentially unsuccessful move. On the other hand, Lawton and Yaffe (1969) say that a voluntary move may re- move some of the negative relocation side effects that normally would be expected. Those who move from home to institution, where they give up a degree of their independence, suffer more than those who move inter-institutionally, where the loss of control may already have been adjusted to. Environments that permit greater control result in greater life satisfaction for the relocatees. Those patients with the least amount of environmental control have been shown to have the highest mortality rates. However, Reid, Haas, and Hawkings (1977) report that there is usually no relationship found between morale and locus of control, although at one time internality was associated with a greater increase in morale. It is believed that one's sense of control and effectiveness are core components of the patient's relocation adjustment and the well-being of the elderly person. Wolk (1976) feels that an elderly person responds to his environment in stages: 1) active involvement; 2) adjustive behavior; 3) expressed satisfaction; and 4) a positive self-concept. He further states that, in an institutional setting, control of the environment would probably appear to be a potentially successful strategy for a patient's positive adaptation. Kahana and Kahana found that impulse control has also been 23 influential in relocation adaptation. Defined as "the ability and willingness to delay gratification," (1975, p. 685) that is central to concepts of ego strength, it also involves the patient's ability toward reflective thinking and his apparent motor control, noting that the development of motor control and delay of gratification are necessary prerequisites for the emergence of higher levels of thought. Impulse control has a consistent and significant relationship with the various indices of adaptation. Walk (1976) feels that internal locus of control is positively linked to a more positive lifestyle, and has also been found to lead to a higher level of adaptation to the new environment. A pre-move condition including depression often presages negative post-relocation psychological changes. Locus of control is believed to be more important for a man's self-concept than for a woman's, say Reid, Haas and Hawkings, and it may be concluded that this relationship is "made manifest in an institutionalized setting where it is likely that fewer avenues of personal control are available" (1977, p. 449). Wolk (1976) also feels that the exact implicationzof locus of control upon institutional relocation is only one of the stressors placed upon the patient, yet much research tends to evaluate it as though it were the only variable that should or could predict a par- ticular behavior or attitude. Little documentation has been found in the satisfaction levels of patients regarding their physical environments. Borup, Gallego, and Heffernan (1978) report that patients generally are satisfied with the facilities' health services, locations, room colors and 24 furnishings, and their roommates. A sizeable number of the subjects expressed dissatisfaction with the dining facilities, cost of the facilities, bathroom facilities, and activity programs. Communication with the Relocatee Considering the general reaction of aged patients to inter- institutional relocation, a number of experimenters have suggested that preparatory programs for patients be mandatory for all such moves. Communication with the individual is critical: Hess and Day (1977) feel that an adequate therapeutic relationship with the patient can- not occur without it. Communication may be difficult to establish with those afflicted with blindness, deafness, or aphasia, but efforts must be made to keep the patient informed of developments during the relocation. Weinberg believes that communication between the elderly person and his environment is important in order to prevent or reduce the ”state of reciprocal withdrawl, which is all too common among the aged and enhances the feeling of alienation and despair" (1970, p. 681). Pathological disorders have at times resulted from communica- tion abuse or absence. Berger and Rose (1977) found that elderly patients may infer that the staff of an institution prefers quiet patients to more demanding ones, and so will limit their interaction, withdrawing from the social life to varying degrees. Previous litere ary citations in this review note the dangers of patient nonpartici- pation within an institutional setting. Cicirelli (1977) has found the elderly have a great need for comunication. They have many concerns and feelings as they face 25 the problems of their age group, problems such as a loss of attractive- ness, loss of sexuality, and the onset of physical limitations. He feels that these feelings and concerns would increase in kind and intensity to the extent that the individual must face them without the emotional support of significant others. . Brand and Smith (1974) have noted that relocated patients generally are less active and have fewer social contacts than their control cohorts. Involuntary relocation, especially, appears to be a major cause for the disruption of social networks, leading to deleteri- ous consequences in the life adjustment of the individual. Sensory Loss Sensory deprivation can be a major hindrance to communication, especially among the aged. Oster says that deafness, blindness, and aphasia can discourage therapeutic attempts by medical facility staff. Common characteristics of sensory deprivation are "reduction of stimulus input levels, reduction of stimulus variability, social iso- lation, and confinement"(l976, p, 461). It is felt that communication must be established with patients with any of these afflictions in order to restore locus of control to the individual. Oster also reports that the environment can participate in producing isolation through its sensory-depriving characteristics. Geriatric patients are often "warehoused" in settings where physical inactivity, along with sensory and perceptual deprivation, are imposed. These design flaws can accelerate the aging process, and increase social isolation and regression of the patient's physical, intellectual, and emotional functioning. 26 Preparation Prior to Relocation Schultz and Brenner (1977), Aldrich and Mendkoff (1963), and Pastalan and Bourestom (1975), believe that the effects of institu- tional relocation are sufficiently severe to require pre—relocation preparation. Pastalan and Bourestom feel that the anticipation of relocation and the initial disorganization that follows the move can be as lethal to the patient as the actual move itself. They recommend that the planning and preparation of patients for relocation begin as soon as possible prior to the move and continue for a minimum of three months following. Mass movers suffer more than those who are individually prepared. Schultz and Brenner (1977) did not, however, note that this was due either to the amount orIquality of preparation givenuthe3mass- movers, although it is a possibility. Aldrich and Mendkoff (1963) agree with Pastalan and Bourestom, saying that individual casework has also helped patients involved in institutional relocations. Pre-move preparation, they feel, is help- ful in encouraging patients to recognize and accept rather than conceal their anger at moving. Pastalan and Bourestom (1975) note that casework does not replace actual site visits to the new facility by the patients. They advocate site visits.continually prior to relocation to familiarize patients with the new environment. They also note that this practice is important to the maintenance of staff morale and unity, which is a necessary input at this time for the patients' feelings of security. In contrasting fingings, Kowalski (1978) reported no ill effects from a forced relocation of institutionalized elderly people 27 following a fire in which the circumstances precluded any pre- relocation preparation. Her findings state that a high mortality rate was upheld for those patients who were in poor health, but not for those who were very old or who were male. Similarly, Borup, Gallego and Heffernan (1978) feel that pre- relocation preparation activities are useless. In their study, findings indicate that relocation did not increase the probability of mortality, and therefore concluded that such programs were not necessary in accomplishing the goal of reducing relocation-caused mortality. They add, however, that this does not exclude the pos- sibility that such activities may indeed extend the patients' lives. Pablo believes there are several commonalities found with respect to minimizing mortality during institutional relocation. They are: "(a) the careful planning of the move and the appreciable casework involved in the patients' preparation for relocation: (b) the nature and degree of environmental change involved: (c) and the voluntariness of the change" (1977, p. 434). Specific measures recommended are: 1) preservation of satisfying relationships: 2) maintenance of familiar surroundings through arrangement of the space and furniture in the new ward rooms: and 3) scheduling transfers so that the disruption of everyday routines and family visitation patterns are kept to a minimum. Support for ecological studies of the environments affecting individuals is growing. Moos et a1 state that it is necessary to study the "socio-ecological setting" within which older people func- tion, since it can influence their "attitude and moods, their behavior, their health, and their overall sense of well-being" 28 (1979, p. 74). Koncelik feels that openness in health care facilities is desired. The key to this, he says, "is to focus upon the needs, general requirements, and desires of this population from the begin- ning of the design process. One important facet is to express appropriate concern for the residential qualities of the physical environment, as well as the health care service aspects of the setting. It would be better to overstress residency vis-a-vis health care in the general qualitative atmosphere" (1976, p. 40) in order to prevent the medical or aesthetic aspects of the institution from predominating during and following a relocation. Predictors characteristic of survival and design specifica- tions for institutionalized settings are indicated as being necessary for the improvement of the welfare of those who reside in health care settings. Narrowing the field of possible significant attributes of the physical environment and its inhabitants to more closely identify appropriate procedures to be followed during a relocation is suggested by the literary findings. Based in part upon the writing of Trippett, the concept of "satisfaction" with the environment is suggested as a research direction more strongly than "happiness” because "young people tend to report more happiness than satisfaction, while older people tend to say that they are more satisfied than they are happy" (1979, p. 100). M Survival following an institutional relocation appears to be a function of many interdependent factors, as cited in this review of 29 literature, the influence of which are of varying levels of impor- tance, as felt by the respective researchers. It is impossible at this point to identify a particular aspect of an impending relocation, or of a patient who will be relo- cated, as being most predictive of the relocation outcome (i.e.: nonsurvival, survival, or satisfaction level). The literature cites what appear to be the factors most in need of investigation, and they can be divided into five categories: change undergone; physical and mental health; control exerted; personality type: and the communication with the patients prior to relocation in preparation for the move. There is a general agreement that the degree and type of change involved will affect the patients. A consensus of opinion regarding the critical amounts of change tolerable to an older, institutionalized person, as well as the identification of particular changes that may be more detrimental to the patient, is unavailable. This area, especially as it relates to the patient's interface with the physical environment, is in particular need of study. The effects of the physical and mental health status upon the patients are unclear from the literature. Research generally indicates that younger, healthier patients tend to relocate better, but contra- dictory findings cloud a definitive consensus. Locus of control research seems to be quite clear. It is widely believed that individuals who assert more power over choice, when it is presented to them, generally possess a higher sense of self-esteem, which, in turn, would help them in their readjustment to a new location. However, research directly relating to institutional 3O relocations is needed. Personality type, as reflected in the manner in which a patient views an impending move, is felt to be predictive of his eventual relocation. Literature relative to this subject was found to be highly in agreement. Most research concerning communication with institutionalized patients prior to a relocation concludes that lengthy, detailed pre- paration of the patients for the move is necessary and positive both prior to and following the event. However, contrasting findings again impede the conclusiveness in this area. Other factors may impinge upon the individual during a relo- cation, as discussed in this review of literature. Predictors characteristic of survival and design specifications for institutional settings are indicated as being necessary for the improvement of the welfare of those who reside in health care settings. Narrowing the field of possible significant attributes of the physical environment and its inhabitants to more closely identify appropriate procedures to be followed during a relocation is suggested by the literary findings. The concept of "satisfaction" with the environment is suggested as a research direction more strongly than "happiness," since happiness would appear to be a more elusive, less critical factor at this stage of investigation. The research reviewed indicated a definite lack of under- standing between the individual and the physical environment, specifi- cally in dealing with the possible effects that the physical environ- ment can have on modifying the quality of health care in a medical 31 care setting. Questions unanswered center around the effects of the physical environment on both patients and the staffs in medical care facilities, as both are concerned with patient care. CHAPTER III STUDY METHODOLOGY AND PROCEDURE The procedures used in this study are presented in this chapter and consist of sample selection and description, a description of the "before" and "after" settings, instrument selection and description, data collection and data analysis. Sample Selection and Description The population at the ICMCF in June, 1978, totaled 177. The study sample was selected from this population based on the following qualifications: 1) the patient was at least 55 years of age; 2) the patient was judged to be interviewable; 3) the patient had resided at the ICMCF prior to the move and planned to remain in the ICMCF at least until the second interview three months after the relocation: and 4) the patient or his/her family had previously given written permission to the ICMCF for participation in academic studies. A list of fifty possible patients was suggested by the ICMCF staff, and from this list thirty-seven subjects who met the above criteria were eventually selected. Several who were originally selected for inclusion in the study were eliminated due to their reluctance to answer the questions and their extreme suspiciousness of the nature of the study. Two patients specifically cited their having "to answer too many questions around this place" as the reason for their disinterest with the study and the researcher. The average age of all subjects at the time of relocation 32 33 was 76.5 years, with women averaging eighty years and men sixty-nine years. Table 1 shows the patients' age and gender characteristics. TABLE l.--Age and Gender Characteristics of the Thirty-seven Patients Who Participated in the Study. Age Gender 55-64 65-74 75—84 85-94 95+ Total male 3 8 3 - - 14 female 2 4 7 s 2 23 total 5 12 10 s 2 37 Sensory loss severe enough to inhibit conversation was not a factor with any patient. Several patients had visual or auditory loss- es, but none interfered with the administration of the instruments. Indeed, visual losses discouraged close visual handwork by a few women, and appeared to incline them toward more conversation during the inter- views. Field notes taken at the time proved helpful in later analyses. In order to lessen the negative effects of relocation, all of the patients were nurtured by the ICMCF staff prior to and following the relocation. Anxieties were soothed and questions regarding the impending move and subsequent new environment were answered by the staff as often as possible on a continual basis. Although many of the patients said they would prefer living in their own homes and may not have volunteered to move to the original ICMCF in the first placel, most made the move to the new building positively. 1It must be qualify for the Greater information the patient, and a social history. for admittance. Michigan. As noted in Chapter II, the Review of the Literature, noted that the ICMCF is a skilled nursing facility. To admittance, the patient's physician is required to complete Lansing 3-Page Referral, a document including medical from the attending physician, nursing care required by This is the only document required All patients must be residents of Ingham County, 34 this is an important step toward a successful relocation experience for the patients. Eighty-four percent of the patients in this study were non- ambulatory. Also, at any one time, the vast majority of the patients at the ICMCF are not self-supporting, most relying upon Medicare or Medicaid for their payment to the facility. Description of the Settings Prior to Relocation - The old ICMCF resembled what one might call a "county home." Multi-storied, red brick, and with a white por- tico in front, the building rested back a few hundred feet from the road, and the expansive lawn separating it from the road decisively indicated that this place was "different." Upon driving closer to the structure, you could see that it was a well-tended place, and had a ubiquitous staff that worked hard to keep the patients comfortable. But still, it was different. Inside, the building took some getting used to. First, the antiseptic odor pervaded the glossy hallways, and any sound reverbera- ted off their tiled walls. Isolated from fenestration and illuminated only by occasional but regularly suspended flourescent lights, the hallways were narrow, relatively dark, and claustrophobic. Yet, they were populated by patients in wheelchairs who said they were there due to a lack of anywhere else to go. ' Patient rooms ranged from housing one to eight people. Most housed four or more, and, in these cases, the patients could rightly identify as their territories their bed, the few feet next to their bed, and the adjacent nightstand. Some of the less fortunate who were 35 situated on the inside of the rooms could not call a window "theirs." All color in the rooms was barely perceptable. Participation in activities meant trips up and down the single disreputable and undependable elevator: many patients voiced an insis- tent hatred of that which they felt was an adversary to their indepen- dence. And, when they did venture on that elevator to attend classes, such as in handicrafts or horticulture, or to participate in church services, their destination was the dark, dank, crowded basement. The saving grace, according to many patients, was the staff. Their interest, morale, and skill impressed the patients and was often the subject of their praise. Following the Relocation - When July 31 and August 1, 1978, came, the patients were moved into the new ICMCF, a low, complex structure that seemed to reach out to the road upon which it was located. Since this building was built next door to the old ICMCF, the patients watched its progress until.they moved in. Constructed on one level, the building is comprised of a central diamond attached to two four-pronged spokes which contain the patient rooms (see figure 4). It is a wide-open appearing building, with many low, large windows that help project the feeling of airiness. The highlight of this aspect of the facility is the greenhouse which is visible as the individual enters through the front door and proceeds down the main hallway. One of the primary components of the solar energy system for the facility, the greenhouse measures approximately forty feet at its widest point, and is a virtual jungle of color, size, and shape. 36 muflflomm oumu Hmufiooz aucooo EmnmcH 3m: on» no :mHmuoloIné $5on 37 This area provides an interesting view, opportunities for incidental companionship, and, because of the sunshine and warmth, a soothing area for patients to spend their time. Because it is all on one level, the patients have great free- dom to wander around the facility, and naturally are more independent than they were in the old building. Bright colors of yellow, orange, blue, green, and red flourish and, it seems, serve two purposes: they create exciting, interesting interior spaces, and they also serve to distinguish the patients' own rooms ("I live on the green hall.") from the rooms of others. Activity rooms, physical therapy facilities, medical services, and dining areas are located centrally, so, while the occupants may have to travel a considerable distance from their rooms in order to visit these places, the way is unimpeded by architectural barriers. Additionally, and gratefully for the patients' convenience, no elevator is on the premises. The relocation from the "before" to the "after" physical set- ting provided a number of changes for the patients. For the reason that the personnel did not change substantially, the relocation is being treated as a physical environmental change only in this study. Instrument Selection and Description Instruments were selected that would measure the mental alert- ness and physical independence of the subjects, and also the actual characteristics of the immediate physical environments along with the patients' reactions to them. Copies of all instrumentation appear in the appendices to this study. 38 Mental Alertness and Physical Independence Mental Status Questionnaire - The Mental Status Questionnaire (MSQ) is a ten-item questionnaire which tests for alertness to orientation in time, place, and person. Scores obtained are based upon the number of incorrect responses to the questions, giving a "quantitative index of mental functioning," according to Kahn, Gold- farb, Pollack and Peck (1960, p. 236). The developers of this test feel that the brevity and objectivity of this measure lend themselves to rapid clinical screening and research. It has been especially useful in studies of institutionalized patients when a measure of mental functioning has been required. Activities of Dsily Living Scale - As developed by Katz, the Activities of Daily Living Scale (ADL) is a "scale whose grades reflect profiles of behavioral levels of six sociobiological functions, namely bathing, dressing, toileting, transfer, continence, and feeding. Its hierarchical nature makes it possible to rank the overall functional status of people in an ordered manner, to make comparisons among them as individuals or groups, and to detect changes over time" (Katz and Akpom, 1976, p. 493). In use and evolution for over twenty years, it has been helpful in contributing information concerning health needs and outcomes that are beneficial for management, planning, policy- making, research and teaching. Patients are graded according to the total number of activi- ties in which they are judged to be independent, as defined by the ADL form. Grading is as follows: "A - Independent in feeding, continence, transferring, going to toilet, dressing and bathing 39 B - Independent in all but one of these functions C - Independent in all but bathing and one additional function D - Independent in all but bathing, dressing and one additional function E ~ Independent in all but bathing, dressing, going to toilet and one additional function F - Independent in all but bathing, dressing, going to toilet, transferring, and one additional function G - Dependent in all six functions Other - Dependent in at least two functions, but not clas- sifiable as C, D, E, or F." (1976, p. 496) Physical Environment Physical Environmental Checklist - The Physical Environmental Checklist (PEC), developed by the researcher for this study, is de- signed to observe both the actual physical characteristics of the inmediate environment and the patients' subjective rating of satisfac- tion with the various environmental aspects in question. The items chosen for the PEC were those that were felt might impact upon the patient. Additionally, several questions of a summarizing nature are included to ascertain overall satisfaction with the immediate physical environment. The "immediate physical environment" is defined as the pa- tient's own room at the ICMCF: the space the patient occupies, be it in a single or multi-bedded room, extending to the doorway leading to the hall. In its development, physical characteristics of the immedi- ate environment were selected that were thought to have influence upon individual taste, preference, and comfort. They dealt with size, 40 design materials, color, and orientation as reflected in the room. The PEC's purpose is to identify which, of any, aspects of the physi- cal environment in the institutional setting significantly affect the patients. Frequency counts of environmental aspects receiving positive or negative ratings will indicate those aspects which were received favorably or unfavorably by the patients, and an overall score for each patient prior to the move, combining positive, negative, and neu- tral responses, will be compared to an identically obtained score fol- lowing the move to determine general environmental satisfaction. Procedure Data Gathering Techniques Permission to undertake this study was obtained from the ICMCF in the spring of 1978. This permission was granted following a verbal description of the objectives of the research and assurances to the administrative staff that interference with neither the operation of the facility nor the treatment of patients would occur. The admini- strators contacted at the time were acutely aware of mortality rates that were said to be associated with institutional relocations, and were extremely curious to see if their efforts to prepare their pa- tients would prove to be beneficial. They were particularly interes- ted in the possible documentation that this research might provide so that in the future they might advise other hired personnel in institu- tions considering relocation. It is noted that the cooperation of the administrator and social worker most closely associated with the study was exemplary. Their time and informed concerns afforded invaluable insight into aspects of the facility's operation and policies, along 41 with providing a supportive environment within which to conduct the study. Their obvious interest in the patients and the findings of the research aided the progress of the study. The list of possible study subjects was prepared by an administrator from the names of patients who had agreed to cooperate in research projects. The ICMCF had on file, as part of their standard operating procedure, signed forms by the patients or their families indicating whether they would or would not consent to be included in academic studies. For this reason, a great deal of time was saved by not having to request this permission of the individual patients. Demographic information from the files of the ICMCF was also obtained. Patient gender, birthdate, marital status and educational level were recorded for each subject, along with their date of admit- tance to the ICMCF and their anticipated length of stay. In the pro- cess of obtaining this information, it was noted that the educational level and marital status data for the patients was changed several times on the record cards, and thus the reliability of this informa- tion was questionnable. Thus, it was felt that these two variables would not be included in the analysis. Information regarding the patients' pre-relocation participa- tion in activities designed to prepare them for their new environment was obtained from the conferring social worker at the ICMCF. The activities made available to the patient for participation consisted of selecting roommates, rooms, and room colors. The opportunity for further participation in areas undefined by the staff was assumed by only two patients. One patient helped select paintings for the facility's public spaces, and another helped determine the 42 size of the new single rooms by maneuvering his electric wheelchair within the outlined space of the proposed area. The area size was suggested by federal guidelines, but as a result of this effort, the size of these rooms was increased to reflect his movement. The re- cording of this data provided the amount and type of "control" which was exerted by each patient. The next step in the data gathering stage of the research was the actual interviewing of the patients. It was felt that no interviews could be scheduled that would conflict with any ongoing programs of the ICMCF. Furthermore, it was impossible to arrange a standard interviewing time for these patients. As a result, interviews had to be conducted on a "whenever possible" basis. This meant that the interviewer had to be available on a continual basis_seven days a week during the interviewing periods, and contributed to the fact that the three interviews with each patient were each approximately three months apart. These constraints made the interviewing stage of data gathering a highly labor and time intensive effort. During the first interview, the subjects were told about the study: that their reactions to the new and old ICMCF buildings were being solicited in order to better plan similar structures in the future. Following the outline of the problem, the patients were asked if they would like to participate, and those who agreed and met the previously mentioned qualifications comprised the study sample. Interviews were then begun with the patients prior to the move, and were repeated three months following the actual move, and again six months following the move. This time frame, as suggested by the literature, is believed to include the period during which the 43 patients would be most affected by the relocation trauma. A special note regarding the actual interview procedure is necessary here. Data were collected from June, 1978, until March, 1978. Lengthy periods of time were devoted to and particular atten— tion and care were given to each individual during the interview period in order to establish a sincere rapport between subject and interviewer. Three specific conditions were noted that called for special effort during the interviews: 1) The elderly patients in this institution were separated from their families, which tended to cause extreme loneliness at times; 2) most had chronic physical ailments; and 3) because of the facility's proximity to Michigan State University (making it a natural "laboratory" for academic projects) some patients were wary of outsiders coming in to ask them questions. Indeed, two patients who were originally suggested as possible participants in the study, as mentioned earlier, were eventually eliminated for reasons directly related to this fact. Taking these factors into consideration, the interviews were conducted in a conversational tone. It was necessary to convey the genuine interest that the researcher had in each patient in order to cultivate the trusting relationship necessary for obtaining the answers requested in the interviews. Interviewing elderly patients in situations such as this tended to suggest the usage of a non-schedule standardized interview, a method which allows freedom to the inter- viewer and respondent while also providing a framework for the collec- tion of comparable and classifiable data. According to Richardson, Dohrenwend and Klein, "Where the respondents are heterogeneous and the study deals with sensitive topics which are not discussed widely and 44 openly, the non-schedule standardized interview appears more appropri- ate" (1965, p. 52). The individual interviews lasted from a minimum of ten min- utes to a maximum of one and one-half hours, averaging approximately thirty minutes. Specific patient responses to questions sought by the instrumentation was recorded during the individual patient interviews. Field notes were added following the interviews if noteworthy observa- tions pertaining to the patients' behavior (i.e.: a behavior change from earlier interview periods) occurred. The interpersonal relation- ships developed during this time period often helped explain why certain trends or responses occurred with particular individuals. For example, one woman who was severly crippled with arthritis and in great pain initially responded negatively toward attempts at conversa- tion and interviewing by the researcher. However, after rapport and trust were established she proved to be an excellent subject. In addition to improving the quality of the respondents' answers, noted by their comparative completeness, the degree of acquaintence helped produce a challenging, enjoyable atmosphere for which to conduct the study. The desire to know how these people felt and how they would eventually relocate sustained the researcher's interest for the duration of the data collection period. The initial interview schedule consisted of three sections and only two sections were included in the second and third interviews. The first interviews were conducted prior to June, 1978, and the pa- tients were initially questioned regarding their satisfaction with the old facility. Specifically, they were asked to rate their satisfaction with their rooms and with the imminent prospect of relocation to the 45 new building. A single question inquiry into the self-assessed health of the patients was then asked. A five-point Likert-type scale was used with three questions, with the following classifications being used: very satisfied; quite satisfied; satisfied; not very satisfied; and not satisfied at all. In the second and third interviews, this section was necessarily eliminated. The questions of room satisfaction were covered with the completion of the PEC. The second step of the patient interviews consisted of recording the objective physical characteristics of the room on the PEC. In both ICMCF buildings, this included actually measuring the room sizes and the personal patient territories within those spaces. During the interview, patients were asked their feelings of satisfac- tion with the various physical characteristics that were being investi- gated, and their responses were classified as being positive (satisfied) or negative (not satisfied or not caring). The last step included the administration of the MSQ. Depending upon the perceived alertness of the patient, various verbal introductions to the instrument were used so as to elicit appropriate responses. However, the ten questions of the MSQ were worded identi- cally throughout. For example, very alert patients were advised "Now I have some questions for you that are different, maybe even a little silly." Less alert patients were made aware of the different nature of the questions, with no further explanation. These techniques were utilized to prepare the patients for the type of questions in the MSQ and to affirm the fact that the administration of the test was essential to the study as an objective measure. 46 The ADL forms were distributed at the beginning of each of the three interview periods, and were collected following their com— pletion. The nursing staff at the ICMCF voluntarily completed the ADL forms for each patient, along with anwering questions concerning the seriousness of the patients' illnesses and projections of their life expectancy for the next year were a relocation not occurring. Informal field notes were taken at the times of the inter- views. These concerned noting the mood and personality of each pa- tient at the time of each interview, and proved to be helpful in a general understanding of patient responses. For example, during the last interview, one of the women was extremely talkative, although somewhat removed, and did not want to end the session. The fieldnotes indicated that in the two previous interviews she had.made it clear that she would participate, but really did not care about the study. These interviews were extremely short. At the last interview her behavior indicated that something had happened. It was soon learned from her that her roommate had died the night before, and this event was having a definite effect upon her attitude, at least for the time being. The notes proved to be helpful several other times in similar ways. Figure 5 details the administration periods for each instru- ment used in the study. Data Analysis Techniques The data analysis techniques had to satisfy two conditions as set by the data gathered: l) the research questions asked, and 2) the level of measurement of the independent and dependent variables. 47 .co«umuau«:.m§oo mo woodman .mcoomua sauna. .coEmEuOuca no noogom use .swsum we» as emuaueua aucuasuuucnun.m assume Discuss :o—uIUOuou ca nouscso eunuch o» as: .ousolsouueso 2: Essay 98:8. 339.3... .eu=o~uoa canoes cu .auscl acesqaso uncuuagn saunas: ecu concave: moo-no hqosuauonao ca monocuso scuaaOOuou can ya savanna adsocoqacuoa causueeo be t cool canton veg-ous .aacouuoa ouosua>o cu sciences concave—on use ass-us cause: no aqzoco«ao—oa evacuees ca senescence no sleeves and: assuaoduonno menu ca clan unto sands: usuuauga cu nous-:0 oceans old» uses oucoesunoe\ooeoosoaoocu .oacoqaoa on concern ascend use» cadence—on use: a nausea scuasuuuacu one. a: had—ouuol gun: sodas-:aoa oeuQUOqou no aauqouuol aaauucoo 31!. use-lacuna a-uuu a... 2.283 an condoned an acumen consume-no :8. e..- 8283 a. 2.22:... a. season aeolian-an £000 .oc—uoaaa an ocuuoa acoluaoaao zoos .osquouca an 31.x. acollaouno £000 a: a... .2283 as 202!— ocu nosoaueaou «sewage £33.... monsoon haunnoau nasal mucu- huqquulu unquaooau uuaaoscoouesu «cud-azh sous-ass causesoquuosa tau-um ~35: .xue .09- aoaaooa hauuuoou canon usueua huuoa no oeuauauuu‘ tenuous hauuqocu nauseouueso ..u...es coda-oo~ou 22.3 8.53». 233- «Baal oqaacuanlou saunas assuage nuances suaquuOI 523.8.- .v .n .n .ucoo .hbt0990uh .oousoo .ucolouuasn .uoasueo: cost 48 This latter point is very important since it divides, generally speak- ing, the set of possible analytic techniques into two domains, non- parametric and parametric. As noted earlier, this is an exploratory study. This suggests among other things, that the opportunities to judiciously introduce, delete and combine variables need to exist to lay bare any underlying structure to the data. Subtle shifts also need to be detected. Be- cause of these needs and because most of the variables were felt, most defensibly, to be at best ordinal, a crosstabulation of the data, independent by the dependent variables, was determined to be the most appropriate technique. A Pearson Correlation was done, but other than providing, in a most general sense, a direction within which to pursue certain variable combinations, the results obtained were not helpful. The findings of this study suggest an ordering of aspects of the physical environment that could be interpreted as interval data, and this could be built upon in future studies, perhaps utilizing a multiple regression. Crosstabulation - Specific comparisons for the analyses of the data were created by crossing the dependent variables (non-survi- val, survival, and satisfaction) with the independent variables (men- tal status, physical health, total physical environmental control exerted, specific physical environmental control exerted, total physi- cal environmental changes perceived, and specific physical environ- mental changes perceived). Table 2 illustrates these combinations. 49 TABLE 2.--Specific Combinations of Dependent and Independent Variables Compared in Two-by-Two Contingency Tables as Created by the Process of Crosstabulation. Independent Dependent variables variables non-survival survival' satisfaction mental status X X X physical health X X X control exerted: total specific physical environ- mental changes perceived: total specific Details summarizing the two-by-two contingency tables created by the process of crosstabulation appear in Chapter IV, Results and Discussion. CHAPTER IV RESULTS AND DISCUSSION The analyses and discussion of the data will be presented in this chapter in the following manner. First, the research question under consideration will be stated, with the individual research ques- tions addressed separately. Each of these sections will consist of four subsections: the presentation of the research question, a state- ment of the findings, the necessary statistical analysis, and a discus- sion of the findings as related to the research question. An overall summary of the findings will conclude the chapter. Presentation of the Research Questions, Findings and Implications Research_guestion 1: Are patients who are more mentally alert, as measured by the Mental Statusygpestionnaire, more likely to survive relocation than those who are shown to be less alert? The low number of patients who died following relocation inhibits the results in this case, and caution must be heeded. The patients who died had consistently lower MSQ scores than those who survived. Table 3 illustrates the average MSQ scores for the patients who died following, or survived the relocation at the pre-move, three- month, and sixrmonth interview periods. 50 51 TABLE 3.--Average MSQ Scores for Patients Who Survived or Did Not Survive the Relocation at the Pre-move, Three-month, and Six-month Interview Periods. Pre-move Three-month Six-month interview interview interview survived 6.9 6.9 6.9 patients‘ did 0 . f t 6.0 6.5 4.0 surv1ve Table 4 details the confounding variables of age and gender, and again describes all of the patients in the study, illustrating the average age of the groups that died and survived following relocation, according to gender. TABLE 4.--Age and Gender Characteristics of Patients Who Survived or Did Not Survive the Relocation. Age Gender 50-59 60-69 70-79 80-89 90-99 Average male 1 6 3 - - 67.4 pa- surVived female - 3 5 10 4 80.8 tient did not male - l 2 l - 73.25 survive female - - - l - 85 Predictors of death cannot be inferred from these data, only the concept that several causes may be involved, including acute physical disability. Research Question 2: Are the more mentally alert patients, as measured by the Mental Status Questionnaire, more likely to be satisfied with their new environments? 52 In order to judge the effect of the MSQ on satisfaction, a summary of the crosstabulation of these scores is presented in Table 5. The MSQ scores tended to cluster at the upper end of the scale. Accordingly, the distribution had to be "collapsed" so as to get an accumulation of scores that could descriptively discriminate between patients. The decision was made to divide the scale at its midpoint and to arbitrarily call the upper half "high" and the bottom half "low." It thus appears that the patients who ranked in the upper half of the MSQ (scoring a six or better) were indeed more satisfied with their new environments following the relocation. Table 5 illustrates that prior to the move, 63.8 percent of the patients were satisfied with their rooms -- with those patients scoring six or more on the MSQ accounting for 78.3 percent of the total satisfaction. Of those people scoring a six or above on the MSQ, a higher proportion, 13.9 percent, were dissatisfied with their old ICMCF rooms, compared to only 2.8 percent of those judged less alert. Following the move, Table 5 shows that the more mentally alert patients accounted for 96.2 percent of the total satisfaction at the three-month followbup period, and 79.3 percent of it at the six- month interview. Overall, these patients were consistently more satisfied. The patients scoring at least six on the MSQ show a more changeable level of satisfaction than the less alert patients, indicat- ing that they are more sensitive to their immediate environments. These findings suggest that both positive and negative reactions should be taken into account when preparing patients for relocation. 53 o.ooa H.w> m.am o.ooa m.mm v.0 o.ooa m.mm 5.0H mm mm h an mm N mm on w muaomom ceoaou Hmuoa v.m ~.m H.m H.ma m.ma N.m H.om m.mm m.~ o.m m.va m.ma 0.0m o.ov 5.0H >.oo m.mm 0.0m 0.0m m.~m >.h m m a m v H ma ma H oceuoommeumw mouuomom m>eummoz o.om m.Hh m.ma m.mm 0.0m m.m m.mo o.om m.ma o.mm >.mm ~.ow 0.0m o.oo m.mm m.mh n.0N m.om m.m m.mh >.Hm mm mm o mm mm H mm ma m coauomwmwumm oouuomom m>wuwmom GM 3 GM 9 GM. 8 .292. um: um: .2 am: am: .289 am: om: ommucoouom,amuou uoooo cacaoo Homo» mmmucoomwm Homo» oomucooucm cfioaoo omoucoouom 30» canon Haoo ommucoommm HmDOD ommucmouom :anoo mmmucoouom 30H poooo Haoo monsoHHOM nucoslxwm moIBOHHom moccaloouna GOHHMUOH OH OH HOflHm .mououm am: Hausa OB ooumflom mm :owuomwmwumm omuuomom .mucmwumm HHdll.m mqméfi 54 These findings may be clarified by inspecting both the "total" percentages and the percentages found in the individual cells. Total column percentages dropped 16 percent (from 93.5 percent to 78.1 percent) between the three-month and six-month interview periods, suggesting there is a shift toward lower MSQ scores. The overall satisfaction reflected in the row totals increased by approximately 7 percent (from 83.9 percent to 90.6 percent). The notion of the process of crosstabulation must be recalled at this point and, in particular, how the relative distribution of scores across all cells contributes to these row and column percentages. Thus, while it is true that those who reported satisfaction with their environments also scored a six or better on their MSQs, it is also interesting to note that over time there is a meaningful shift among the less alert toward more satisfaction and that among the more alert there is a shift toward less satisfaction. Environmental Satisfaction and Mental Alertness as Related to Gender - Generally speaking, men expressed satisfaction with their immediate physical environments following the relocation. Table 6 shows that prior to the move, the greatest percentage of men was that which expressed satisfaction with their rooms and also scored at least six on their MSQs. Fewer men than women expressed satisfaction with their rooms at the old ICMCF (see Table 7 for the womens' reactions) but Table 6 shows that at the three-month follow-up the percentage of men who reported satisfaction increased, with 84.6 percent of those scoring at least six on the MSQ. By the six-month interview period, the general satisfaction level for men had dropped, with 55 c.00H 5.~5 m.5m c.00H m.vm v.mH 0.00H o.vm v.mH HH w m MH HH N mH HH N muHomom :ESHOU Hmuoa «.mH H.m H.m 5.5 o 0.5 N.ov m.mm 5.5 m.NH m.mm o 0.0m m.¢m 0.0m 0.0m o.om o 0.00H m.mm 5.mH m H H H o H m m H :oHuommeumm oouHmmum o>Hummoz m.Hw m.mo «.mH m.mm m.vm 5.5 m.mm H.mv 5.5 m.5m 5.mo 0.00H 0.0m m.vm 0.0m m.55 m.- 5.Hm m.m 5.mm m.vH m 5 m NH HH H 5 o H GOHuommeumw mouuomom m>HuHmom on ov on 3 GM 3 Babe as. 9.: e52. as. am: .52 am: as. ommucouuomlHouou ucooo chHoo Hmuou oomucooumm Houou ommucmouom oEoHoo monocoosom 30H ucooo HHoo mmmucoouom Hmuou wmmuccouom :EoHoo ommucoosoQV3ou ucoou HHoo monsoHHom mucoslem monsoHHom mucosuomuna cOHumcoHcH on scene .mououm Om: Hcha ou ooDMHom mo coHuoownHumm omuuomum .mucoHumm onzla.m names 56 the number of patients reporting satisfaction and scoring six or better on the MSQ 21 percent fewer in number than at the three-month interview. Prior to the relocation, women reported more satisfaction with their rooms, with 75 percent of those who reported satisfaction belonging to the more mentally alert group. Table 7 shows that, over- all, the women who were more mentally alert reported more satisfaction at the three-month and six-month interview periods than did those who were less alert. The reaction of the women at the three interview periods more closely reflects that of the patients as a whole, as illustrated in Table 5. Again, it would appear that the individuals who scored higher on the MSQ would be better equipped to notice change, both of a positive and negative nature and thus would be more prone to express satisfaction when relocated to an improved physical space. Following the move, the men seemed to be influenced by a halo effect around the three-month interview period that receded somewhat by the six-month follow-up. WOmen maintained a more steady and positively skewed trend of satisfaction following the move, indicating that they probably are better suited for living in an environment of this type at this time than the men are. Their relocation pattern did not seem to be as volatile. This sheds some light on techniques that may be utilized to prepare patients for relocation, implying that men require different types of measures be used not so much to diminish the apparent halo effect at the three-month follow-up period as to lessen the subsequent sixrmonth downturn. 57 0.00H o.Hm o.mH o.ooH c.00H o 0.00H @.Nm v.5H HN 5H m mH mH 0 MN 0H v «moucouuom.Hmuou ucooo ceoHoo Hmuou muHomom asoHou Hmuoe m.e m.v 0 ~.- «.mm o v.om v.0m o mmmucmoswo Hmuou m.m o ~.~m o m.om o mmmuemoumo essHoo o.ooH o c.00H o o.o0H o wmmuewoswm sou H H o v e o s s o meson HHmo COHuommmHumm pouuomom o>HuMMmz ~.mm ~.oh H.mH m.s> m.>s o o.mo «.mm e.>H memucmusmm Hmuou H.vm 0.00H w.55 o N.@@ o.o0H ommucoonom :EoHou o.om o.om c.00H o o.mn o.mm mmmucmouwo 30» ON 6 v «H eH 0 6H NH v assoc HHmo fiOMuomm mmnubm COHHOQOK w>..nu.m mom QM av fine em ev “Ha am my as am: om: am am: am: q< om: om: monsoHHom aucoEIXHm molsoHHOm apocaloouna cOHumooHoH ou MOHHm .monoum 0m: HHosa ou ooumHom mm ooHuommmHumm owuuommm .mucoeuwm mHmEomun.5 mamas 58 The fact that the mens' performance on the MSQ drops places additional concern on this issue, ramifications of which are unex- plained by the data presented here. Researchfguestion 3: Do patients who exert control (Option of choice) over their new environmentsyprior to relocation survive relocation better than those who do not? Again, in order to produce an accumulation of scores that might descriptively discriminate the sample, the distribution of patients had to be "collapsed." The decision was made to divide the scale of possible control choices exerted at its midpoint and to arbitrarily call three or four controls exerted "more" and one or two controls exerted "less." Patients were provided with four categories of opportunities to exert control over their future environments: choice of roommate, choice of room, choice of room color, and other undefined patient contributions, such as suggestions relating to the paintings that were placed in the facility. Table 8 shows that of the five patients who died, four partici- pated in more than two of the control categories. From the information available, these individuals participated at a proportionately higher rate than those who survived. Again, caution must be stressed because of the small cell sizes. 59 TABLE 8.--Survivors and Nonsurvivors as Related to Their Participation in a Total of Four Possible Areas of Control: Roommate, Room, Room Color, and "Other" Selection. Six-month follow-up Control Control <3 2} Total Survivors cell count 10 22 32 row percentage 31.2 68.8 column percentage 90.9 84.6 total percentage 27.0 59.4 86.5 Nonsurvivors cell count 1 4 5 row percentage 20.0 80.0 column percentage 9.1 15.4 total percentage 2.7 10.8 13.5 Total column results total column count 11 26 37 total percentage 29.7 70.3 100.0 Therefore, from this limited data, greater amounts of control exerted prior to relocation would not appear to improve survival rates. Research Question 4: Are patients who exert control (option of choice) over their new environments prior to relocation likely to be more satisfied followinggrelocation? Overall, it appears that those patients who exerted more control, participating in at least two of the available categories men- tioned in Research Question 3, expressed satisfaction following the relocation (see Table 9). At the three-month follow-up period, there was an approximate 24 percent increase in overall positive satisfaction, which increased o.OOH m.mo N.Hm 0.00H 0.00 v.Hm 0.00H n.05 5.mN uwmucmohwmleuou 6O mm «N CH mm on HH 5m on HH ucooo csoHoc Hmuou muHomom caoHou Hmuoa e.m v.m o H.sH v.HH s.m m.oe m.em ~.oH mmeucmosmm Heuou , m.MH o 5.0H ~.mH o.vm m.¢m ommuoooucm cfioHoo o.ooH o e.oo m.mm o.oo o.oe ammuemoumm sou m m o o v m mH m m assoc HHmo cOHuommeuom oouuommm o>Hummoz o.om v.mm ~.Hm m.~m H.>m s.m~ v.mm m.o> m.MH mmmucmosmo Hmuou v.mm o.ooH m.mm m.Hm «.mo «.mv commemoumm chHoo m.mo m.vm o.mo o.Hm m.ss s.- commemosoo son mm mH OH on om m mm 5H m 9:900 HHmo COHuomumHumm omuuomum w>Hunom mm mv mm mv mm mv Hmuoe Houucou Houucoo Hmuoa Honucou Homecou Hmuoa Honucou Houucoo monsoHHow :DCOEIme mol3oHHom sucoslmmuna :OHumooHoH ou HOHHm .coHuooHom :uosuog one HOHOU Boom .Eoom .ouoEEoom “Houusoo mo mmmufi anHmmom moon mo Hmuoa m cH :OHummHOHuHmm HHmna ou ooumHom mm cOHuommmHumm pounommm .mucoHumm HH.Hm momuemuswm sou N N o N H H 5 n v £300 HHmO GOHuomumHumm omuuomwm o>Hummmz m.Hm ~.mH m.mo o.om m.0m m.mm 0.0m v.H~ m.m~ ommucounom Hmuou 0.0m 0.00H 0.0m m.5m 0.0m 0.0m ommucoouom chHoo ~.- m.ss v.om o.mo m.~e H.sm mmmucmoumm 30» m m 5 HH o 5 5 m e assoc HHmu ooHuommeumm ocuuommm o>HuHmom mm mv am my mm mv Hmuoa Honucou Houucoo Hmuoe Houucoo Homecou Hmuoa Homecoo Honucoo mousoHHom scoofilem mo|3oHHom sucoaloousa cOHuoooHoH on HoHHm .coHuomHmm :Honuo= pom HOHOU 500m .200“ .mumEEoom “Houucou mo nomad mHonmom Hoom mo Hmuoe m cH COHquHoHuumm HHonB on ooumHom mm cowuommmvam pouuomom .mucoHumm mHm 1|.oH mqmee 63 0.00H 5.m0 m.vH 0.00H 0.0m 0.mH 0.00H 0.50 0.MH Hm 0H m mm 0H m mm 0m m muHomom cezHou Hmuoa 0.v 0.v 0 ~.0H 0.mH m.v 0.vm H.0m 5.0 0.m 0 m.mH m.mm 0.0m 5.00 0.00H 0 0.05 0.0m 0.05 0.0m H H 0 v m H m 0 m GOHuommeumm ocuuomom o>Hummoz m.mm 0.Hm m.¢H 0.H0 5.~5 H.m ~.m0 0.00 m.v v.00 0.00H N.e0 5.00 0.05 m.mm 0.00 0.mH 0.00 H.HH m.mm 5.0 on 5H m 0H 0H N mH vH H cOHuommmHumm oouuomom m>HuHmom m o I. I: I. H u 9 mA mv Hmuoe mA mv Hmuoa m4 mv Houucoo Houucou Houucou Honuooo Houuooo Houucou mmmucmonmmleuou ucooo chHoo Hmuou omnucouuom Hmuou mmmucocnwm csoHoo momucoouom 30H assoc HHmo cmmucmouom Hmuou ommucoouom chHOo oomucounom 30H ucooo HHoo monsoHHow nu:OEIXHm molonHom sucoaimouna COflUMOOH GM 0“ HOHHQ .coflufiom 2930.. can uoHoo 200m .500m .oumEEoom soom mo Hmuoa m :H :OHuomHoHuHmm HHonB ou ooumHom mm :oHuommmHumm oouuomom .musmHumm oHMEomln.HH mqmda «Houucoo mo moose oHnHmmom 64 0.00H 0.00 H.0H 0.00H 0.50 H.NH 0.00H 0.00 v.HH Hm 0m 0 mm mm v mm Hm v mUHomom :EoHou Hmuoa ommucoouom Hmuou ucooo :EsHoo Hmuou 5.0 5.0 0 N.0H N.0H 0 H.5m e.Hm 5.0 monocoouoofidmuou 0.HH o N.5H o 0.0m o.om mmmuewoumm essHoo 0.00H 0 0.00H 0 0.v0 v.0H omeucoosom 30H m m 0 0 0 0 0H HH N ucoou HHmo GOHuommeumm commemom m>Hummoz 0.00 N.v5 H.0H 0.00 5.N5 H.NH m.N0 H.50 5.0 ommucoosmo.douou 0.00 0.00H 0.N0 0.00H 0.00 0.00 wmmucoouom chHoo H.Nm m.5H 5.00 m.eH m.om H.m mmmuemoumo sou 0N MN 0 0N vN v NN 0N N assoc HHoo cOHuommeumm pouuomom o>HuHmom muoa no» on once mm» o: m 0 mom 0: H Honucou Houucoo H Houucoo Houusou H u a Houucoo Houucoo mononHow mucoslem moI3oHHOM nucoslmouza :oHumooHoH on MOHHm .ooHuooHom mamasoom oH COHummHOHuHmm HHmna ou ooDMHom mm coHuommmHumm pouuommm .mUGmHumm HHdII.NH mqmda 65 0.00H 0.00H 0 0.00H 0.00H 0 0.00H 0.00H 0 cmmucoouom Homo» ON ON o Hm Hm 0 mm mm o u:500 GESHOU Hmuou muHomom chHoo Houoa 0.0 0.0 o o.mH o.mH o 0.Hm 0.Hm o mmmucmoswo Hmuou 0.0 0 0.0H 0 0.H0 0 monocouuom :EzHou o.ooH o o.ooH o o.ooH o ammucmosmm sou H H o v v o 5 5 o ucsoo HHmo coHuommmHumm oopuomom o>Hummmz 0.00 0.00 0 0.H0 0.H0 0 N.00 N.00 0 mmmucoouom Hmuou 0.00 0 0.H0 0 N.00 0 ommucwouwm osoHoo 0.00H 0 0.00H 0 0.00H 0 oomucmosom 30H 0H 0H 0 5H 5H 0 0H 0H 0 Doooo HHec coHuommmHumm oouuomom o>HuHmom m 0 new 0: m 0 mom 0: m o no» 0: H u a Houucou Houucoo H u a Houucou Houucou H p B Houucoo Houucou mononHow SDGOEIXHm mzasoHHow nucofiuoouna GOHumooHoH ou MOHum .:oHuomHmm mumseoom :H :oHummHoHuumm uHmse o» omumHmm mm coHuommmHumm couscous .muemHumm mesomsa.MH mamas 66 at the six-month period is in fact up 14 percent over the three-month follow-up. The pattern for men, however, is different. Table 14 shows that 69.2 percent of the men participated in roommate selection, while 30.8 percent chose not to. At the three-month interview period, 58.3 percent of those who chose their roommates were satisfied with the relocation, but by the six-month follow-up, this had dropped to 36.4 percent. Their nonparticipation suggests that this is probably not an important consideration to the men, at least in the positive sense, and the fact that their overall level of satisfaction at the six—month period was down accentuates this finding. Room Selection - Following relocation, the patients who exerted control over the selection of their room appeared to be satisfied with the move. Table 15 shows a steady increase in the percentage of patients who reported satisfaction and who also partici- pated in the selection of their rooms. This again may be a function of gender. Table 16 indicates that 95.5 percent of the women participated in selecting their rooms prior to the relocation, and that 76 percent of those individuals were satisfied with the relocation at the three-month follow-up period, with this percentage rising by the six-month interview. On the other hand, 46.2 percent of the men participated in the selection of their rooms and while most reported satisfaction with the relocation in general, the highest percentage of the two groups of men who were satisfied was the one in which the patients did not 67 0.00H 0.v0 0.0m 0.00H 5.00 0.00 0.00H N.00 0.00 .wmuucmoumm‘Hmuou HH 0 0 NH 0 v HH m e assoc cesHoo Hmuou mflflfimmflm CEDHOU HMUOB N.0H N.0H 0 0.0 0.0 0 N.0v 0.0m v.0H omcucooumm Hmuou m.mm 0 0.NH 0 v.0v 0.00 comucooumm c=5Hoc o.ooH o o.ooH o 5.00 m.mm wmmucmosma sou N N 0 H H 0 0 v N u:500 HHeo coHuommeumm oouuomom m>Hummoz 0.H0 v.00 0.0V 5.Hm 0.00 0.00 0.00 0.00 «.0H mmmucoouom Hmuou 5.00 0.00H 0.50 0.00H 0.00 0.00 ommucoouom :EoHoo v.vv 0.00 0.H0 v.0m v.H5 0.0m wmmucmonmm 30s 0 o 0 HH 5 v 5 0 N ucooo HHcc coHuommmHumw pousommm o>HuHmom 0908 005 on once mom on ouoa 005 o: H Houucou Houucou H Houucou Houucou H Houucoo Houucoo molonHOM SDGOEIme mdlsoHH00 nucoelomusa :oHumooHoH ou HoHum .coHuooHom mumssoom :H GOHquHoHuHmm HHoAB ou ooumHom mm COHuommeumm omuhomom .nucoHumm oHMZnI.vH 04009 68 0.00H N.¢5 0.0N 0.00H 0.05 N.vN 0.00H H.55 0.NN Hm MN 0 mm 0N 0 0m 5N 0 muHomom cEsHoo Hmuoe omwucmosomlHouou ucnoo chHoo Hmuou 5.0 5.0 0 N.0H N.0H 0 H.5m 5.0N v.HH o0oucouswm Hmuou 0.0H 0 0.0N 0 m.mm 0.00 m0mucoouom :EoHoo 0.00H 0 0.00H 0 N.00 0.00 ommuooosmm 30H m m 0 0 0 0 0H 0 o ucooo HHoo coHuommeumm mousomom o>Hum0oz 0.00 0.00 0.0N 0.v0 0.00 N.¢N 0.N0 0.H0 v.HH momucoouom Home» 0.50 0.00H 0.00 0.00H 5.00 0.00 o0mucoouom SesHoo v.H5 0.0N v.H5 0.0N 0.H0 N.0H senescence sou 0N 0N 0 0N ON 0 NN 0H v uoooo HHoo coHuommmHumm mouuomom o>HuHmom m o mm» o: muoa 005 o: 0909 00> o: H u 9 Houucou Houucou H Honucou Houucou H Houucou Houucoo molsoHHom smooslem mmlsoHHom nuoosucousa coHumooHou ou HOHHm .coHuooHom 5000 :H cOHummHoHuHom HHons on mmumHom mm coHuomMmHumm pouuomom .muomHumm HH4|I.0H 04008 0.00H 0.00 0.0 0.00H N.00 0.v 0.00H 0.00 0.0 ommucmoumm,HmuOu ON 0H H HN 0N H NN HN H unmou CESHOO Hmuou muHsmom CESHOU Hmuoa 69 0.0 0.0 0 0.0H 0.0H 0 0.H0 m.5N 0.0 wmmucwosmm Hmuou 0.0 0 0.0N 0 0.0N 0.00H omoucmouom :EsHoo 0.00H 0 0.00H 0 5.00 m.vH oomucmouom 30H H H 0 v v 0 5 0 H assoc HHmu coHuomumHumm oouuommm o>Hummoz 0.00 0.00 0.0 0.H0 N.05 0.v N.00 N.00 0 o0mucousmm chou 5.v0 0.00H 0.00 0.00H v.H5 0 o0mucwouom :EoHoo 5.vm m.m H.v0 0.0 o.ooH o mmmucmusmm 30s 0H 0H H 5H 0H H 0H 0H 0 pcoou HHwo :oHuommmHumm pounomum o>HuHmom m 09 005 o: m o 00% o: m 08 005 o: H u Houucou Houucou H u a Honucou Houucou H u Houusoo Houucoo molonH00 mucosime monsoHHom spoofilowuoa cOHuoooHoH on HoHum .:0HuomHmm 6000 :H coHummHoHunmm “Hosfi ou poumHom mm :OHuommeucm oouuomom .muooHumm onEomll.0H names 7O participate. This is shown in Table 17. Again, it appears that room selection is not an important option for men, while it is for women. This may be a function of time with these particular individuals. Women seem to be exhibiting a common trend toward "nesting" while men have other defined interests. Room Color Selection - Overall, following the relocation, people who assumed control over the selection of the color of their room were slightly more satisfied than those who did not. Table 18 shows the results for men and women. In general, room color selection does not appear to be one with which patients concerned themselves to a great extent, but their lack of participation in its choice does not seem to have affected their satisfaction with the relocation. Once again, the results differ according to gender. Table 19 indicates that 86.4 percent of the women participated in the selection of the color of their room, and that following the move they were quite satisfied. The largest groups of women in the three-month and six-month follow-up interview periods were those who had chosen their room colors and were generally satisfied with the relocation. Table 20 shows that 46.2 percent of the men chose the color of their room prior to relocation. Following the relocation, 33.3 percent who chose their room color reported satisfaction at the three- month interview period, but only 18.2 percent were in this group at the six-month follow-up. Again, it appears that the halo effect could be playing a part in this pattern of settlement. Control over Other Aspects of the Environment - Because only two patients assumed control over their environments in ways other than roommate, room and room color selection, meaningful results for this 71 0.00H v.00 0.00 0.00H 5.Hv 0.00 0.00H N.00 0.00 omoucoouom Hmuou HH 0 5 NH 0 5 MH 0 5 pcoou :EoHoo Homo» muHomom :EsHoo Hmuoa N.0H N.0H 0 0.0 0.0 0 N.00 H.mm H.HN moeuewosmo Hmuou 0.00 0 0.0N 0 0.00 0. Ne 003:8qu EBHoo 0.00H 0 0.00H 0 0.00 0.00 womucmosmo sou N N 0 H H o 0 m m ucooo HHmo cOHuommmHuom oouuomem m>Hum0mz 0.H0 N.0H 0.00 5.H0 0.00 0.00 0.00 H.0N 0.00 ommucoouom Houou 0.0m 0.00H 0.00 0.00H 0.0m H.5m 0000200000 essHoo N.NN 0.55 0.00 0.H0 0.N0 H.5m mmmucmoumo son 0 N 5 HH 0 5 5 m w 0:900 HH00 coHuommeumm oouuomom o>HuHmom m o 005 o: m o 005 o: m o mom 0: H u E Hosucou Houucoo H u E Hosucoo Houucoo H u a Houucoo Houucou molsoHHom cancelem molsoHHou succeloouaa COHUMUOHoH on HOHHm .COHHOOHOW 500“ CH fiOHHfiQHUflHHGQ HHOr—B 0U OOHMHOM mm COflUOMHmfiumw UOQHOQOM .WHCOHUMQ OHmzllofifl Sgfi 0.00H 5.50 0.N0 0.00H 5.00 0.00 0.00H v.H5 0.0N mmmucmouwm Hmuou 72 Hm HN 0H Hm MN 0H mm 0N 0H ucooo :EoHou Hmuou muHomom qfioHOU Hmuoa 5.0 5.0 0 N.0H H.NH 0.m H.5m 0.NN 0.0H o0mucooumm Hmuou 0.0H 0 0.5H 0.0H 0.NH 0.0m mmmucmosmo :ssHoo 0.00H 0 0.00 0.0N 0.H0 0.0m wmmucoouom 30H m m 0 0 v H 0H 0 0 ucoou HH8 :oHuummmHumm omuuomom w>Huo0mz 0.00 H.00 0.N0 0.00 0.50 m.5N 0.N0 0.0v 0.0H ommucoouom Hmuou 5.00 0.00H 0.N0 0.00 0.00 0.00 ommucmuuom CEoHoo 0.00 5.00 0.50 H.Nm 0.55 5.N~ momucmoswo sou 0N 0H 0H 0N 0H 0 NN 5H 0 pence HHmo COHuommmHumm oouuomom o>HuHmom 0009 005 0: once 005 o: 0009 no» on H Houucou Houucou H Houucoo Houucoo H Houucoo Houucoo moI3oHHow nucosume monsoHHOM sucofiloouna :0HumooHou on HoHum .cOHuooHom uoHou Boom cH coHummHOHuHmm HHoSB on omuoHom mm cOHuommmHumm pounommm .mucoHumm HH¢II.0H mqmda 73 0.00H 0.00 0.0H 0.00H 5.00 m.vH 0.00H v.00 0.0H mmmucmuummleuou 0N 5H m HN 0H m NN 0H m 0:500 :EoHoo Hmuou muHomom ceoHoo Hmuoa 0.0 0.0 0 0.0H 0.0H 0.0 0.H0 5.NN H.0 o0mucoouom Hmuou 0.0 0 5.0H 0.00 0.0N 5.00 c0mucoosom :EoHoo 0.00H o 0.05 0.0N v.H5 0.0N ommuooouwm 30H H H 0 v m H 5 0 N ucooo HHoo :oHuommmHumm pouuomom o>Hummoz 0.00 0.00 0.0H 0.H0 v.H5 0.0 N.00 0.00 0.0 m0cucmouom Homo» H.00 0.00H 0.00 5.00 5.05 0.00 wmmucmoumo cesHoo 0.40 0.0H N.00 0.HH 0.00 5.0 mmmucwosma 3o» 0H 0H m 5H 0H N 0H vH H 0:500 HH8 COHuuommHumm omuuomom m>HuHmom m o 005 o: o c we» on o o 005 on H u a Houucoo Houucou H u a Houucoo Houucou H u a Honucoo Houucou 05l30HH00 Buooslem molsoHH00 cocoauoousa coHuoooHou cu HoHum .COHUUQHOw HOHOU 500m EH COflHMQfiOfiUHMQ HHOSH. 0U mvmumHmm mm COfiUOflmmflumm VGUHOQQM .muGGflUMm @Hgmhllomfl SMCB 74 0.00H n.0m 0.00 0.00H 5.H0 0.00 0.00H N.0v 0.00 mmmucmoumm Hmuou HH 0 5 NH 0 5 0H 0 5 0:000 :ssHoo Hmuou muHomum chHoo Hmuoa N.0H N.0H 0 0.0 0.0 0 0.00 H.HH H.HN mmmuemoumo Hmuou 0.00 0 0.0N 0 0.00 0.N0 cmmucmouom :EoHoo 0.00H 0 0.00H 0 0.00 0.00 ammucoouom 30» N N 0 H H 0 0 m m 0:000 HH00 :oHuommmHumm oouhommm o>Huomoz 0.H0 N.0H 0.00 5.H0 0.00 0.00 0.00 H.0N 0.00 w0ouoouuom Houou 0.00 0.00H 0.00 0.00H 0.00 H.50 0000000000 cesHoo N.NN 0.55 0.00 0.00 0.N0 H.50 o0mucwouoo 30H 0 N 5 HH v 5 5 m v DGSOO HHmo coHuoommHumm oouuomum o>HuHmom m o 005 o: m o 005 on m o 005 on H u E Houucoo Houucoo H u 9 Houucoo Houucoo H D B Houucoo Hosucoo mousoHHom zucoEIme monsoHHOM zucoEImouna :oHumooHon on HOHHN .eoHuomHmm uoHoo eoom :H :oHumoHoHuuma “Here on emumHem mm :oHuomemHumm omusoomm .mucmeumm «Hazlu.om 00009 75 aspect of potential control cannot be reported here. The two patients who did exert control in ways other than those suggested by the ICMCF were discussed earlier: one helped select the paintings for the public areas of the facility, while another helped determine the eventual size of the single patient rooms by maneuvering his electric wheelchair within an outlined area, the size of which was later en- larged to reflect his movement. Research Question 5: Is there an identifiable pattern in the number of changes in the physical environment that elderly institutionalized patients can experience before their mortality, morbidity, or satis- faction will be influenced? Patient Mortality - Because of the small number of patients who died during the period of this study (n = 5), a definitive state- ment cannot be made. However, it was found that those patients who did not survive noticed significantly fewer changes in their immediate physical environments than those who survived, as shown in Table 21. TABLE 21.--Average Number of Changes Noted in the Pre- and Post- Relocation Immediate Physical Environments by Survivors and Nonsurvivors. Average number of changes noticed survivors 7.66 nonsurvivors 4.75 The five patients who died following the relocation were assessed to be in poorer health than those who survived. Four of them were quite physically dependent upon the staff, as measured by their ADL scores, while one scored at the mean of the survival group. It is possible that the physical or mental condition of the patient and the 76 accompanying medical care would detract from the patients' realization of the physical environment at this point. Patient Morbidity - Patient Morbidity, as indicated by ADL scores, appears to be affected by the relocation when it is cross- tabulated with the total number of relocation changes that were per- ceived by the patient. Patient morbidity did not change appreciably between the pre-move and the three-month follow-up periods, but did improve by an overall 7.6 percent by the six-month follow-up visit (see Table 22). The frequency counts indicate that prior to the move, twenty-three patients were ranked in the lower half of the ADL scale (they were more physically dependent), and at the three-month follow-up twenty-four were ranked as being dependent. But, by the six-month interview period, this number had decreased to eighteen. Statements about the classification of ADL scores and the physical environmental changes perceived by the patients are necessary here. Again, to produce an accumulation of scores that might descriptively discriminate the sample, the distribution of patients was "collapsed." The decision was made to divide the possible categories of the ADL at their midpoint, and to arbitrarily call A - D the "upper" or more independent patients, and E - Other, the "lower“ or more dependent patients. Similarly, the highest number of physical environmental changes noticed by any patient was fourteen, and this number was divided at its midpoint, with the perception of fewer than seven changes arbitrarily called "fewer" and the perception of seven or more changes "more." Patient Morbidity as Related to Gender - Because of the small cell sizes, conclusive results of the influence of total changes upon 0.00H 0.v0 0.00 0.00H 0.N0 H.50 0.00H 0.N0 H.50 wmoucmoumm,HmaOu 77 H0 00 HH mm «0 HH mm mm 0H 0:000 cesHoo Hmuou muHomom :EoHou Hmuos 0.H0 0.NN 0.0H 0.Hm H.5H 0.0H 0.00 H.5H H.5H ammucmosmo Hmuo» 0.00 0.00 H.5N 0.00 0.50 N.00 o0mucoouma cesHoo 0.00 N.00 0.00 0.00 0.00 0.00 mmmucmosmo 300 HH 5 0 HH 0 0 NH 0 0 peace HHmu Aon: Hammoc 0-4 mmuoom 000 H.0m 0.H0 H.0H 0.00 5.00 0.NN 5.00 5.00 0.00 mmmuemuumo Hmuou 0.00 0.00 5.N5 0.H0 5.05 0.00 mmmuemosmo assHou N.05 0.50 5.00 H.HH 0.00 0.0m ommucmoumm 30H 0H HH 0 am 0H 0 mm 0H 5 0:000 HH00 HuHmn umsooo seasons mmuoom 000 5N 5v 5M 5v 5M 5v H0009 0000050 000cmno Hmuoa mmmcmno momcozu Hmuoe 000:0:0 000cmnu mouonHOM nucoEIme mousoHH00 apocaloouna coHumooHQH on HoHnm .ucmEcouH>om HMUHm5nm on» CH oo>HooHom momcmsu mo Hwofioz Hmuoe on ooumHom mm mmuoom Had .mucmHumm HHdut.NN mqmds 78 the morbidity of men are tentative, but a certain trend was noted (see Table 23). Following the move, the percentage of males in the more dependent half of the ADL scale was up approximately 23 percent, and at the six-month follow-up had lowered 8.3 percent. This appears to indicate that as time went on, the mens' physical independence was impaired. On the other hand, the female patients appeared to have benefitted from the relocation in this respect. Table 24 shows that the percentage of women who were in the upper half of the ADL scores increased in each successive interview period. The more accessible environment may be encouraging the women to become more independent. For example, the fact that clothing storage is now located in their own rooms rather than in the hallway may facilitate the task of dressing, a consideration in the ADL. Also, the proximity of the toilet now encourages its use as opposed to when the patients were required to use community toilet facilities located off the hallways in the old structure. Another explanation may exist in the change of the physical environment alone. The more pleasant surroundings, as suggested by several subjects, makes the patients feel better about where they now live. Since the ADL is not solely a measure of physical capability but also considers the sociological desire of the patients to complete a task, the motivation provided by the new environment could also account for their increased independence. Patient Satisfaction - Patients who perceived more changes in their immediate physical environments reported a higher level of satisfaction following the relocation. Table 25 illustrates a 31.2 79 o.oo~ 5.~5 m.5~ o.ooH m.mo m.0m o.ooH ~.mo m.om mompcmoumm,flmuou HH m n ma m v ma 0 v pesoo season Hugo» muasmmm casaoo Hmuoa v.0m «.mH «.ma H.mm v.mH 5.5 N.0v H.mm H.m~ mmmucmoumm Hmuou o.m~ 5.9m N.NN o.m~ m.mm o.m5 wmmucmonmm assaoo 0.0m 0.0m 5.oo m.mm o.om o.om momucwoumm 30H v a m m m a o m m assoc Hamo “mam; madame Qua mmuoom doc o.mo m.vm H.m m.05 m.mm H.mm m.mm N.0v 5.5 monocoouwm Hmuou o.m5 m.mm m.55 o.m5 5.00 o.mm ommucmonmd assaou 5.mm m.va o.O5 0.0m 5.mm m.ea mmmucmoumo son 5 o H OH 5 m 5 o a unsoo Hamo imam: umzoqv umnuOum mmuoom ace mm 5v 5M 5v mm 5v Hmuoa momcmno momcmno Hmuoa momsmsu mmmcmsu Hmuoe wwmcmau mwmcmsu msIBOHHom nucoalxwm maisoaflom SUGOEImmusa coaumoonu on Hofium '1 Ill Hmo«m>sm on» Ca ©m>flmoumm mmmcmno no Hmnfisz Hmuoa " «IL .ucmficouw>cm on owumem mm mmuoom and .mucmwuwm wamzvu.mm wands 80 o.ooa o.oo o.ov o.ooH H.mm m.ov o.o0H a.am m.oe manuamouwm Hmuou ow «H m «N ma m «N ma m assoc season Hmuou myasmmm cesaoo Hayes o.mv o.m~ o.om q.om ~.mH «.ma m.5~ o.MH m.ma momucmoumg Hmuou 5.Hv o.om m.om v.qe H.m~ m.mm mumucmouwm season o.mm q.vv o.om o.om 0.0m o.om oomucmoumm 3cm m m v m e v m m m assoc Hamo roam: umamoo mum mmuoom mom o.mm o.mm o.o~ m.mm m.ov 5.NN 5.N5 m.mq n.5m momucmouwm Hugo» m.mm o.om ~.mo o.mm m.o5 5.mo momucmuumd cesaoo o.mo v.om m.vo 5.mm m.~m m.5m momucmouwm sou HH 5 v «a m m ma 0H m unsoo Hamu roam: uwzoao umnuonm mmuoom qua mm 5v mm 5v mm 5v Hmuoa mwmcmso mmocmcu Hmuoa momcmsu mwmcmcv Hmuoe momcmnu mwmcmnu mousoaaom cucOEnxwm asuzoaaom cucosnmwuna cofiumoodwu on uofium .ucmficoufi>cm Hmowmanm mcu ca om>flmouom momcmnu mo umnfisz dance on pmumHmm mm mwuoom and .mucwwumm mamammcu.vm wands 81 o.ooH m.ao 5.mm o.oOH 5.om m.mm o.ooa 5.vm m.mm mmwucoouomjamuou Hm ma «H mm mm HH em mm «H assoc assaoo Hmuou muaswmm canaou Hmuoa 5.m ~.m m.o «.ma o.m H.NH «.mm v.~m m.m wmmucmoumm Hmuou m.m 5.oH m.v v.om o.om 5.0a mumucmoumo essaoo m.mm 5.00 o.o~ o.om m.vm v.ma wmmucmuumm gou m H N m H w ma HA m ucsoo HHmo dofiuommmflumm cmuuommm w>wummwz m.om H.mm m.~m m.vm o.mm ~.H~ m.Hm «.mm v.m~ momucmonmm Hmuou 5.vm m.mm m.mm o.mo 0.0m m.mm mmmucmoumm assaoo m.¢© 5.mm o.mb o.mm v.Nm c.5v mmmucmoumm 30H mm ma OH on am 5 am ea oH assoc Hamo cowuomumfiumm owuuommm m>fluwmom 5M 5v 5M 5v 5M 5v Hmuos mamamao mmocmso sauce mwmqmso mmmcmno Hmuoa mmmcmso momcmgo msnzoaaom suGOEwam malzoaflou nucoelmmune coflpmoonH o» Hofium .ucmEcouw>:m Hmowm>nm on» ca Um>floouom mmocmsu mo Hmnfisz Hopes ou cmumem mm cOwuommmfiumm vouuommm .mucmwuom admin mm wands 82 percent improvement for this group at the three-month follow-up, with a 5.5 percent reduction in that percentage at the six-month follow— up. Only one of these patients eventually reported dissatisfaction with the new environment. Conversely, among the patients perceiving fewer than seven changes in the physical environment, a relatively small 2.9 percent change in their positive satisfaction was indicated between the pre- move and the six-month follow-up periods. However, an 8.2 percent reduction in environmental satisfaction was noted at the three-month follow-up period. The fact that this loss was more than recovered by the six-month follow-up is worthy of note, indicating that this group appears to have benefitted from the relocation over time. It would appear then that the patients who noticed at least the median number of changes were more satisfied following their relocation. Judging from their reported dissatisfaction with the old ICMCF environments, these individuals would seem to be those who are more discriminating in the evaluation of their environment, thereby also being those more likely to respond to a drastic improvement in their surroundings. Patient Satisfaction as Related to Gender - Prior to the relocation, 50 percent of the male patients reported dissatisfaction with their immediate physical environments, with those patients who eventually perceived more changes in the environment accounting for 66.7 percent of the dissatisfaction. Following the move, 41.7 percent more of the men reported satisfaction with their surroundings with those noticing the greater number of changes accounting for most of the satisfaction. At the six-month follow-up, 81.8 percent of all 83 males reported satisfaction with their environment, a decrease from the three-month interview but still an overall positive change in satisfaction. However, among those males perceiving the most changes in the physical environment, four percent fewer reported satisfaction at the six-month follow-up than did at the three-month interview. The male patients perceiving the median or greater changes appear to be more reactionary toward the relocation than those notic- ing fewer than the median (see Table 26). However, the low number of patients in the cells, particularly in those where patients perceived fewer than the median changes precludes definitive comment. Among the females, general overall satisfaction was reported at each interview period, suggesting that the possible halo effect present with the men at the three-month followbup probably was not a factor. Table 27 indicates that the women responded in a less re- actionary fashion than did the men, but eventually more proved to be satisfied with the relocation. It appears that the women required more time in order to express satisfaction with their environments. Again, the patients who perceived seven or more environmental changes reacted more to the relocation than those noticing fewer than seven. Discussions with women at the six-month interview period revealed that although the ICMCF still was not "home," they generally made more positive comments about their living accommodations than they had at the three-month follow-up. Researchyguestion 6: Are there some types of physical environmental changes that are perceived by the patient during an institutional relocation that will contribute more to an elderly patient's mortality, morbidity, or satisfaction? 84 0.00H 5.N5 n.5m 0.00H o.m5 o.mm 0.00H o.m5 o.mm ommucwonmm Hmuou HH m m NH m m NH m m uczoo cscHoo Hmuou muHDmmm cEDHoo Hmuoa m.mH H.m H.m m.m o m.m 0.0m m.mm 5.mH mmmucwoumm Hmuou m.~H m.mm o m.mm v.vv 5.oo womucmoumm cesHoo 0.0m o.om o o.ooH 5.90 H.HH mamucmouwd so» m H H H o H o e m ucsoo HHmo coHuommeumm pmpuommm m>Hummmz m.Hm m.mm m.mH 5.Hm o.m5 5.0H 0.0m 5.Hv m.m wmmucwoumm Hmuou m.5m 5.00 o.ooH 5.0m w.mm m.mm wmmucwouwm cEsHoo m.55 N.NN m.Hm ~.mH m.mm 5.0H momucmoumm 30H m 5 N HH m N m m H assoc HHmo -..‘c0HuommmHumm pmuuommm w>HuHmom mN 5v mN 5v NM 5v Hmuoa mmmcmco woodman Hmuoa momcmno momcmno Hmuoa mwmcmco momcmzu donsoHHOM cucoelxfim malonHOH nucoEImmusa coHumooHoH ou uoanm on» :w ow>wmouwm moosmau mo Honssz Hmuoe ou wouMHmm .ucmficouw>cm Hmowmmsm mm coHuomumHumm pouuomom .mucoHumm mezul.mm mqmda o.ooH o.mm o.me o.oOH m.Ho H.mm o.ooH H.mm m.oq mmaucmoumm Hmuou on HH m Hm mH m mm HH m unsoo aesHoo Hmuou muHammm :EcHOU Hmuoa 85 o.m o o.m o.mH m.v H.HH m.Hm m.Hm o mmmucwuumd Hmuou o H.HH 5.5 m.5m m.mm o mmwucmoumm cEHHHOU o c.00H o.mm o.m5 0.00H o mmmucooumm 30H H o H v H m 5 5 o ucdoo HHmo GOHuommmHumm pouncMmm m>Hummmz o.mm o.mm H.ov 0.Hm H.5m m.m~ N.mo m.5m m.oe mmmucoonwm Hmuou 0.00H m.mw m.mm m.mw N.0v c.00H momucmoumm cssHoo m.5m H.Nv $.05 v.0m o.ov 0.00 wmmucmoumm 30H mH HH m 5H NH m mH w m unsoo HHmo cOHuommmHuwm pwuuommm m>HuHmom Hmuos mm 5v. Hmuos 5N 5v Hmuos mm 5v mmmcmnu mwmcwcu mwmcmso mwmcmnu momcmnu momcmnu mal3oHH0m sucofilem msn3oHHOm nucoslmwuna cOHumoonH on MOHum .quEcouH>cm HMOHmanm ecu cH om>Hmouom mwmcmco mo uwbssz Hmuoa Ou omumHmm mm coHuommeumm pwuuommm .mucoHumm mHmsmmsl.5m mamas o.o0H o.mm o.mv o.OOH m.Ho H.mm o.OOH H.mm m.oq ammucmoummemuou on HH m Hm MH m mm mH m assoc cesHoo Hmuou muHsmmm :EsHoo Hmuoa 85 o.m o o.m o.mH m.v m.vH m.Hm m.Hm o ammuamouwm Have» 0 H.HH 5.5 m.5m m.mm o mmmucmouom cEsHoo o o.ooH o.m~ o.m5 o.ooH o wmmucmoumm sou H o H v H m 5 5 0 £800 :8 cOHuommmHumm oouuommm w>Hummwz o.mm o.mm H.ov o.Hw H.5m w.mm N.mo m.5m m.ov monocoouwm Hmuou o.ooH m.mm m.~m m.~w N.0v c.00H ommucmouom GEsHoo m.5m H.Nv $.05 v.mm o.oe 0.0m mmmucmouwa 30H mH HH m 5H NH m mH o m ucsoo HHmo coHuommmHumm pwuuomum m>HHHmom mm 5v mm 5v NM 5v Hmuoe momcmcu mwmcmcu Hmuoa momcmno mwmcmco Hmuoa momcmco momcmco mal3oHHow sucosume mansoHHOH cascanomuna coHumoonu on uoHum .ucmficouH>cm HMOmecm mzu CH pm>Hwoumm mmmcmso mo umnsoz Hayes 0» omumem mm coHuomumHumm pmuuommm .mucmHumm wHMEmmsl.5m mqmoz .uoO .umom mHno mono new» coco: .im5nm5mH. :oHumoonm may no anus man can im5-55ch coHumoonm was schmomna now» may now noon was an manna suHHmuuoz no comHumasoouu.m~ mamas 107 substantiate those of Borup, Gallego and Heffernan (1978), and Kowalski (1978). Communication with patients in relocation situations must be of a close, considerate manner, and cannot be emphasized enough. The apprehension exhibited by the patients in this study in formal and informal conversations regarding the move, both before and after, indicates that they need a listening ear: someone who will just listen and try to allay their fears. In this case, the ICMCF did encourage their staff to do this, and for many patients it appeared to help. But, some patients required extra consideration, and others were unsure of what the official staff told them. It might be the case that the less alert patients are especially in need of this type of communication. It may be the difference between understanding what the relocation is for, and hence the difference between nonsurvival, survival, and satisfaction following a relocation. Generally, it does appear that the degrees of change, pre- relocation preparation, choice (both available to and exerted by the patient), physical health, and any combination of these factors, as noted by Pablo (1977) are the most influential of the traditionally studied factors associated with relocation. From this ICMCF study, patient satisfaction with the physical environment, and how this factor can aid in the relocation process, appears to be a valuable addition to the list of concerns, particularly considering the design of such facilities in the future. Ten hypotheses have been suggested from the findings of this study, and have been grouped into two categories: primary and secondary. 108 Primary: 1. There is an identifiable significant range in the number of changes in the physical environment that elderly institutionalized patients can experience before their mortality will be influenced. 2. There is an identifiable significant range in the number of changes in the physical environment that elderly institutionalized patients can experience before their morbidity will be influenced. 3. There is an identifiable significant range in the number of changes in the physical environment that elderly institutionalized patients can experience before their satisfaction will be influenced. Secondary: 4. Patients who are more mentally alert, as measured by the Mental Status Questionnaire, are more likely to survive relocation than those who are shown to be less alert. 5. The more mentally alert patients, as measured by the Mental Status Questionnaire, will relocate more successfully. 6. Patients who exert control (option of choice) over their new environments prior to relocation will be more satisfied with the relocation than those patients who do not. 7. Patients who exert control (option of choice) over their new environments prior to relocation will survive the relocation better than those who do not. 8. Some types of changes that occur in the physical environ- ment during an institutional relocation will contribute more to the elderly patients' mortality than others. 9. Some types of changes that occur in the physical environ- ment during an institutional relocation will contribute more to the elderly patients' morbidity than others. 10. Some types of changes that occur in the physical environ- ment during an institutional relocation will contribute more to the elderly patients' satisfaction than others. Recommendations for Future Research Whereas this research answers some questions, it certainly prompts others. Three categories of future research are suggested, 109 involving the degree of environmental change that is tolerable to the patient, the effects of the physical environment upon the patient, and concerns related to male survival and satisfaction. Prefacing all suggestions is the recommendation that longitudinal study be the context within which all research in this area is conducted. As an example of the advantages of a longitudinal study, the present study benefitted from the six-month follow-up, the results of which are felt to more accurately reflect the long-term relocation status of the patients, especially the male patients. Although this study does not qualify for longitudinal status at the present time, its limited time span did benefit from the spirit of that concept. Relying solely upon results provided by a preliminary three-month follow-up could have prejudiced the outcome report. The relocation of any person, particularly an older one, takes time. Thus, the literature addressing time lines for such studies should be amended to include more follow-up study time after the relocation in order to more closely determine the true effects that occur . Degree of Environmental Change More work concerning the degree of environmental change that is tolerable to institutionalized patients is needed. Research can be oriented toward physical and/or social conditions of patients and their physical environments, and combinations of these factors that could influence relocated patients either positively or negatively should also be investigated. It is reasonable to assume that the discovery of 110 characteristics that are predictive of patients' vulnerability to an unsuccessful relocation should be pursued. The value of this type of 3, whose purpose study is inherent to mandatory pre-relocation programs is to reduce the mortality rate during and following institutional relocation. The identification of predictors that would accurately characterize successful or unsuccessful relocations of patients would be helpful in selecting the type of preparatory program that should be initiated for the various patient types. Larger study samples are recommended to more accurately verify findings, along with replications of previous research concern- ing environmental change. Effect of the Physical Environment Increased study should be focused upon the "well" patients in medical care facilities since they are often the individuals who are in most need of a truly habitable environment: they are the ones who notice their surroundings most, who potentially can be most hurt by them, and who potentially can benefit most from them. The increased lifespan that can be expected, especially by women, places more importance upon the concept of the "medical care facility as a residence" rather than only an acute or chronic care facility, since, for many people, it is their home. The continuation in the development of instruments that would evaluate the physical environment is encouraged. Accurate research in ZSenate Bill 3503, 93rd Congress, 2nd Session, amended "Title XIX of the Social Security Act to impose certain requirements relating to the discharge of transfer of medicaid patients from skilled nursing homes or intermediate care facilities, and for other pruposes. July 30, 1974." (Pastalan and Bourestom, 1975, p. 150) 111 this area will benefit from instrumentation that has proven validity, reliability, and relatedness to the subject at hand. The difficulties encountered in data collection in a study of this type result in part from the lack of appropriate instrumentation, particularly involving measures of satisfaction with the physical environment. Factors in the physical environment that are associated with satisfaction or dissatisfaction following an institutional move continue to require investigation. Their identification would provide invaluable design detail information to planners of such facilities as the ICMCF. Male Survival and Satisfaction The results of this study indicate that much study is needed regarding male satisfaction in medical care facilities. The research methods in the present study did not provide for a comprehensive investigation regarding the social and physical conditions of the male subjects, but the inclusion of such instrumentation is recommended for future study. Expectations of their new surroundings, as well as purposes they would like their new surroundings to fulfill would shed considerable light in this area. Following these research suggestions should help to expand the body of knowledge relative to institutional relocation in specific and in institutional living for the elderly in general in a meaningful way. As mentioned earlier, the research should be conducted within a longitudinal context for best results. APPENDICES 112 APPENDIX A GENERAL PATIENT INFORMATION FORM 113 Check # Date Patient : general statement about the patient's personality, as observed by the interviewer on the date noted Demographic Information: l. male/female 2- birthdate 3. age at time of relocation 4. marital status (S,M,W,Sep) 5. education - highest grade attended 6. date of admittance to ICMCF 7. anticipated length of stay 8. time spent at ICMCF prior to relocation Participation in Pro-relocation Program Preparation: 1. roommate selection 2. room selection 3. room color selection 4. other - specify Attitude Toward the Relocation: on a 1 (low) to 5 (high) scale 1. How satisfied are you now with your room? 2. How do you feel about the move? 3. How do you feel about your health? 114 APPENDIX B PHYSICAL ENVIRONMENTAL CHECKLIST 115 PHYSICALdSOCIAL ENVIRONMENTAL INDEx: Total number of changes: physical changes: social changes : Questions: (According to a 'l-very satisfied, 2, 3, 4. Sovery dissatisfied” scale.) Prior to relocation: How do you feel about your room? Probes: How do you feel about the: 1. size of your room? 2. placement of the bathroom? 3. view from your window? 4. windows in your room? 5. color of your room? 6. storageinyourroom? 116 APPENDIX C MENTAL STATUS QUESTIONNAIRE 117 MENTAL STATUS QUESTIONNAIRE Patient: Date: Check # Score: 1. Let's see. What is the day today? 10. (Ask only if not given in answer to "1" above.) What month is it now? What year is it now? How old are you? What month were you born? What year were you born? What is the name of this place? (Probe: What do you call this place?) (Write out name of hospital.) Where is it located? (Write out city, street, or address given.) Who is president of the United States? Who was president before him? 118 We APPENDIX D ACTIVITIES OF DAILY LIVING SCALE AND DESCRIPTION OF PATIENTS' PHYSICAL HEALTH FORM 119 Phraluatimfomforlndexofm Mane Dayofovaluatim Panamaofhrsctiminglistodbelon,d1cdcdescriptimmatapplies. (Ihewoni "assistance” mayorvision, directim, orperamalassistanoe.) Hedwig-eitherspa'mbath, whatnot-shaver [—1 fl InceivesmassistanoeTgcts maimassistameinbathfixg maivosauistmxoaih inmadoutoftxbbyselfif auyaaepartofthebody battungnoaethanampart uabisusualumansof (michasbackoraleg) ofthebodywrmtbathed) bathing) musing-gumfrmclmeumfidrmn-mcludmgmlofims,murganmts andusingfasuaners (includingbraoesifwom) Gtsclotheamdgtson- Catsclothosandgtsdressed Thoeivesassistancein pletelydrcsaadwithout witlmtassistanoaeamaptfor Qttingclottnsorin assistancm ’ $jectforsupportsudzas ingclothcsafberelim- mammnigathedpm bedpanoromnoa naming) Transfer- Mcvesinandoutofbaas mvesinandoutofbodor Doem'tgtoutofbed wellasinandoutofduair daairwithoutassistanoa Omtinence- Omtrolsurirmtimandbouif ficocasicrml‘acad’ents' Superfisimlmlpskeep mtoamletclybyaelf urineorbowalcmtrol; counterisusd.oris iromtimt Feeding- ?Esselffithmtassis— fifecdssclferocptforgttim mmmmm tance assistmxocincuttingnmator ficcdingorisfedpartly hatter-inquest! orompletclybyusin; tubesorintravenms fluids 121 Description of Patient's Physical Health: Please use the following three descriptions to answer "A" below. Mild is defined as minor conditions or cases of angina, congestive heart failure, diabetes or hypertension, and transient mild cerebral insufficiency, infections or gastrointestinal symptoms. Minor ECG includes low or isoelectric T waves, mild S-T depression, P-R interval prolongations of less than .23 sec., a QRS width of less than .12 sec., slurring or notching of the QRS complexes, unifical atrial or ventricular extasystoles less than 6 per mdnute, and regular sinus rhythms over 50 but under 100. Moderate is defined as ECG T-wave inversion, bundle-branch block, dropped beats, a P-R over .22 sec., S-T depression of 1-2 mm, sinus bradycardia between 40 and 50, sinus tachycardia between 100 and 150, a significant increase in angina, hypertension or congestive heart failure, exacerbation of asthma, diabetes out of control, moderate bleeding from a duodenal ulcer, complex extrasystoles, bigeminal or trigeminal pulse, and post extrasystolic T-wave inversions. Severe is defined as acute coronary insufficiency of myocardial infarction, a hypertensive crisis with cerebral encephalopathy, diabetic coma, acute gastrointestinal bleeding from an old duodenal ulcer, acute pulmonary edema, tachyarrhythmia, sinus tachycardia over 150, sinus bradycardia under‘40, and multiple extrasystoles’(more than 10 per minute). ***Questions*** A. This patient's physical condition would be described as being: 1. better than any of the above classifications 2. "mild" 3 . "moderate" 4. "severe" 5. worse than any of the above classifications B. If this relocation to the new facility were not taking place, would this patient reasonably be expected to live: (check the longest period expected) 1. less than three months 2. 3 to 5 months 3. 6 to 8 months 4. 9 to 11 months 5. longer than one year C. Physical limitations of the patient: Blindness: Deafness: 1. partial 1. partial 2. complete 2. complete Other physical limitations: BIBLIOGRAPHY 122 REFERENCES CITED Aldrich, C. Knight, and Mendkoff, Ethel. "Relocation of the Aged and Disabled: A Mortality Study." Journal of the American Geriatrics Society 11 (March 1963): 185-194. Berger, Raymond M., and Rose, Sheldon D. ”Interpersonal Skill Training with Institutionalized Elderly Patients." Journal of Gerontology 32, No. 3 (1977): 346—353. Borup, Jerry H.; Gallego, Daniel T.; and Heffernan, Pamela G. Geriatric Relocation. Ogden, Utah: Weber State College Press, 1978. Brand, Frederick, and Smith, Richard T. "Life Adjustment and Relocation of the Elderly." Journal of Gerontology 29 (1974): 336-340. Butler, Robert N. Why Survive: Being Old in America. Evanston: Harper and Row, Publishers, 1975. Butler, Robert N., and Lewis, Myrna I. Aging_and Mental Health, Positive Psychosocial Approaches. 2nd ed. Saint Louis: C.V. 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Office of the Graduate School Michigan State University East Lansing, MI 48824 Dean Guido Weigand College of Liberal Arts Arizona State University Tempe, AZ 85281 Dean Weigand: This is to acknowledge receipt of Gail Hartwigsen's dissertation in this office as of the date noted below. Signed: Date: . y" HICHIGQN STQTE UNIV. LIBRARIES llHIMIIIN4||lfl|H||l||||l|lHflHIMth‘lllllllHIIHII 31293100642887