Older adults are increasingly choosing to relocate to congregate-type independent living

feature article Assessing Older Persons Readiness to Move to Independent Congregate Living EILEEN K. ROSSEN, PhD, RN Older adults are increasingly choosing to relocate to congregate-type independent living communities. Relocation to an independent living community is a late-life transition that is considered a stressful life event. Although relocation to an independent living community offers potential benefits, many older persons have difficulties during this transition, including poor adjustment, loneliness, and depression. All of these are associated with poorer health, higher healthcare costs, increased risk of institutionalization, and increased morbidity and mortality. This article provides guidelines for assessing the readiness of an older person to move to an independent living community and implications for advanced practice nurses whose role encompasses promoting the health and well-being of older adults. Using the assessment guidelines, the advanced practice nurse can identify older persons at risk for difficulty during relocation and intervene with guidance and strategies to promote positive KEY WORDS: relocation, assessment, congregate living communities The US population is aging rapidly, and by 2030, approximately 20% or 71 million people are expected to be 65 years or older. 1 With our aging society, an estimated 23% of persons 65 years or older experience relocation, 2 and increasingly, they are choosing relocation to independent congregate living communities (ILCs), where they can continue independent living in a protected setting with supportive services. 3 5 Independent congregate living communities are residential settings of multiunit independent living apartments adapted to meet the special needs of elderly persons with services such as meals, transportation, and housekeeping. When older adults relocate to ILCs, they experience a disruption of their lives. The literature indicates, however, that those older adults who plan well for their move and use strategies to incorporate their new living arrangements into the structure of their Author Affiliations: University of North Carolina, Greensboro, North Carolina. Corresponding author: Eileen K. Rossen, PhD, RN, 107 Pier 33 Dr, Unit 110, Mooresville, NC 28117 (Eileen_rossen@uncg.edu). Clinical Nurse Specialist A Copyright B 2007 Wolters Kluwer Health Lippincott Williams & Wilkins 292

daily lives are more satisfied with their move and experience better quality of life. 6,7 Older adults who plan poorly for the move and give little forethought to the effects of the move on their lives are less satisfied with their move and experience a poorer quality of life. 6,7 This article reviews the literature on factors that influence both positive and negative outcomes of relocation to ILCs. The article also provides 2 assessment tools for determining the readiness of an older person to move to independent congregate living and proposed areas for the older person to think about to promote readiness for the move. Older people s responses to the assessment tools can guide advanced practice nurses (APNs) to identify older persons at risk for difficulty during relocation process and identify the areas that put these older adults at risk. This knowledge will allow APNs to consider ways of intervening to promote positive relocation adjustment and quality of life in older adults. LATE-LIFE RELOCATION Late-life relocation, a transitional process, comprises initiation of the move, the actual move, and subsequent adjustment to the new setting. 6 The reasons older adults give for relocating to ILCs vary, but they include concerns about health of self or spouse, need for help with cleaning and cooking chores, difficulty in maintaining their home and yard, the expenses of living and maintaining their home, safety, and social isolation. 4 Factors that older adults consider in choosing to move to an ILC reflect their reasons for moving and are related to (a) financial capability, (b) amenities provided, (c) relationships, (d) transportation, and (e) healthcare provision. 8 Krout and colleagues 8 report that the financial questions most asked are Can I afford the ILC for my lifetime and how will the financial obligations at the ILC change my lifestyle? The most often asked questions related to amenities of the ILC are Does the ILC have an atmosphere I will like and fit into? Will I like the food served? Do they have activities I will enjoy? Questions related to relationship concerns are Will my relatives and friends visit me, or can I visit them after I move to the ILC? Will I make new friends and feel socially comfortable at the ILC? Transportation concerns are reflected in the question, Will I have transportation to places I will need or want to go to? Finally, healthcare provision is reflected in the question, Will my current and future health-needs be met when I move to an ILC? The literature suggests that older adults respond in varying ways to relocation transition: some are able to adapt effectively to the move with positive outcomes, whereas others have difficulty in adaptation, with subsequent negative outcomes. Positive relocation outcomes include improvements in health and social interactions 7 and psychological benefits such as experiencing unexpected gains, 6,9 finding meaning in the experience, 10,11 and experiencing feelings of safety and security. 12,13 Negative relocation outcomes include declining health, reduced functional independence, social isolation and loneliness, reduced quality of life, and dissatisfaction and depression. 4,6,7,12 16 These negative outcomes are associated with high healthcare costs, increased risk of institutionalization, and increased morbidity and mortality. 4,13,17 Factors found to affect late-life relocation adjustment and physical, psychological, and social well-being include the person s perception about the choice to move, the predictability of the new environment, perceptions of self and others, preservation of relationships, presence of a confidant, maintenance of independence, and depression. 3,6,7,18 Perception of having a choice to move has been positively correlated with psychological adjustment, conceptualized as morale, congruence, and continuity and is a contributing factor to positive 3,6,19 Lack of choice or feeling forced to move has been associated with dissatisfaction with the new home, 6 poorer functional status and self-rated health, and higher levels of depression, loneliness and anxiety, 20 and this is a contributing factor to a poor relocation outcomes. 6 Positive correlations have been found among perceptions of self and others and psychological adjustment to relocation. 9,19 Preserving relationships among family and friends and having a confidant were found to positively influence psychological adjustment to and satisfaction with a new home. 3,6,7 High selfesteem scores and low symptoms of depression were factors contributing to positive relocation adjustment, whereas low self-esteem and higher levels of depressive symptoms contributed to poor 7 According to the nursing model of transitions, relocation is a situational transition. 21 Transitions are defined as complex person-environment interactions embedded in the context and the situation that consist of both the disruption of the person s life and the person s responses to the disruption. Transitions are process oriented. There are 3 major concepts in the transitions model: universal properties, transition conditions, and indicators of healthy transition. Universal properties include the characteristics of the process or movement from one state to another such as changes in identity, roles, relationships, abilities, and patterns of behavior. Transition conditions are personal and environmental factors that influence the transition, such as physical and emotional well-being as well as person-environment interactions. Indicators of healthy transition are factors that indicate the quality of the transition outcome, such as satisfaction with the new home and perceived quality of life. With the increasing numbers of older adults moving to ILCs, there is a need for healthcare professionals to assess the readiness of older adults to go through the situational transition of a move to an ILC, so that those who are at risk for negative outcomes and potentially costly healthcare use can be identified and interventions developed to prevent these negative outcomes. Implementing such interventions can contribute to meeting the Healthy People 2010 objective of increasing older adults quality and years of healthy life. 22 Clinical nurse specialists and other APNs can play an essential role in meeting this need because they are in many settings where older adults seek healthcare and live. 23 27 For example, as healthcare delivery shifts from acute inpatient care to community-based settings, 27 APNs are moving into expanded community-based roles. 26 Many provide direct care to individuals, families, and communities (case management), and they may also be responsible for assessing the needs of populations such as older adults. 26 Thus, they are well positioned to assist elders who are relocating. VOLUME 21 NUMBER 6 293

ASSESSMENT OF READINESS TO MOVE TO AN ILC How does one know what an individual s risks are for negative relocation outcomes? Recent research 6,7,14,15 suggests that the parameters for assessing older persons readiness to move to ILCs include (a) choice in relocation, (b) preparation for the move, (c) congruence between the ILC and the older person s expectations, (d) existence of a confidant, and (e) openness to forming new relationships. Two specific tools can be used to determine the readiness of older adults contemplating moving to an ILC. The first is a set of questions developed based on the review of literature that assess the above 5 factors. The questions in Table 1 can be used in an interview, and older adults answers to the questions will help to assess the individual s readiness to move and provide potential indicators to develop strategies to promote the older person s positive adaptation to relocation to an ILC. Question 1 explores the person s perception of having a choice to move and being an integral part of the decision. The literature points to better psychological adjustment following relocation when persons believe they have a choice about whether to move or not, whereas lack of choice or feeling forced to move has been associated with dissatisfaction with the new home, poorer functional status, and self-rated health as well as higher levels of depression, loneliness, and anxiety. 6,7,28 Therefore, it is important to determine the older person s desire to move. If the person wants to make the move, he or she should be supported; however, if the individual is resistant to the move or says that someone else strongly wants him or her to move, then the older adult should be encouraged to discuss feelings and desires about the move so that the individual can resolve those feelings and have a successful move, or choose not to move. Questions 2, 3, 4, 5, and 6 explore the person s preparedness in many areas that will be affected by a move to an ILC. For example, in one study, women who adjusted well to their relocation to ILCs said that they had planned well for the move, knew what furniture and belongings to take with them, felt they had a good plan for disposing of unnecessary belongings (ie, what to give to children, sell, or throw out) and had planned in detail the progression of activities they needed to make to be ready to move (eg, selling the home with closing date, shutting off utilities, etc), and knew who was going to help them pack, clean, and move. 6 Other women who adjusted well discussed how they had planned to eat dinner at different tables for the first month after they moved so they would meet as many new people as possible. One person planned to attend as many different functions as possible during her first few months at her new home, even those she was less interested in, so she could get better acquainted with her new neighbors. 6 Another person told how she had visited the ILC at different times of the day and evening and had eaten several meals at the ILC before moving to get a feel for the place. 6 The older person s answers to these questions reveal areas that have been thought of and planned for as well as areas that have not. To promote positive adjustment, support and encouragement can be given for those areas that have been well planned, whereas further discussion and problem solving can be used in areas that the older person has not thought of or planned for. Positive psychological adjustment to and satisfaction with a relocation have also been shown to be influenced by preservation of positive relationships, continued social support from family and friends, and the presence of a confidant. 6,7,14,17 Older persons answers to questions 7 and 8 in Table 1 will give a good indication of their thinking and planning in regard to their relationships. If they talk about maintaining ties with family and friends and discuss the ways they plan to do that (eg, have dinner with family every Sunday after church and continue to go shopping with a daughter at least once a week), then their continued relationships are likely to contribute to positive adaptation. If they do not discuss how they will continue relationships, then it may be useful to aid older persons to identify who they would like to remain in contact with and to problem solve ways they can do that (eg, weekly Table 1. Questions Healthcare Providers Can Ask to Assess Readiness to Move 1. How was the decision to move made? Who participated in making the decision? How do you feel about the decision to move? 2. How do you plan to handle the actions necessary for relocating to an independent living community (ILC)? 3. What factors do you think will determine the fit between you and the ILC? For example: a. Is the ILC close to your current home, family, and friends? b. Have your visits to the ILC contributed to your decision to move there? c. What are your thoughts about the people who live there? 4. What kinds of things are you doing to prepare for the move? For example: a. How do you feel about giving up your current home? b. How did you determine what belongings/furniture to move? c. What kinds of plans do you have for the things that you are not taking with you? d. How do you plan to move your belongings? Who will help you? 5. How do you think the move will affect your life? 6. What kinds of things do you think will change? Remain the same? 7. How do you think the move will affect your relationships with family? Friends? Others? 8. Who do you have that you can talk about almost anything with? 294

telephone calls, sending notes/letters, and inviting people to dinner). Older persons answers to the questions in Table 1 can serve as the starting point for discussing and problem solving areas that are known to contribute to positive A second tool to assess readiness for relocation to an ILC is the 32-item Self-Efficacy Relocation Scale. 28 Selfefficacy theory suggests that people are better able to meet challenges such as relocation when they believe that their thoughts, emotions, behaviors, and living situations are within their control and they have the confidence to carry out needed behaviors. 29,30 Beliefs in personal efficacy also contribute to ability to activate the motivation, cognitive resources, and actions necessary to accomplish specific tasks. 29 Therefore, older adults self-efficacy or sense of control over their behavior, their environment, and their own thoughts and feelings can contribute to positive Nurses working with older adults in primary care and community health settings should assess clients planning relocation to determine their relocation self-efficacy. The Self-Efficacy Relocation Scale consists of 3 subscales: transition management efficacy, daily living efficacy, and engagement efficacy. The transition management efficacy subscale is made up of 9 items that refer to the individual s confidence in planning and preparing the activities of moving (eg, hiring movers and unpacking boxes). The daily living efficacy subscale consists of 7 items that refer to the individual s confidence in meeting new and continuing demands of living at the ILC (eg, learning the new address and telephone number and handling mail), and the engagement efficacy subscale is made up of 16 items that refer to the individual s confidence in engaging in social interactions and activities (eg, continue relationships with family and friends and make new friends). 28 The scale factors reflect relocation as process or phases of the move from the actual preparatory and completion actions (transition management efficacy) to consideration of new business and daily living arrangements (daily living efficacy) and to dealing with staying connected with friends and family as well as connecting with the new environment (engagement efficacy). 28 Items are rated on a 5-point scale indicating respondents degree of confidence in their ability to carry out needed relocation behaviors (5 = extremely confident, 4 = very confident, 3 = moderately confident, 2 = a little bit confident, and 1 = not at all confident). Subscale and total scores are calculated by summing the responses, with higher scores indicating greater confidence in being able to carry out the behaviors necessary to move to an ILC. Answers on the tool can be used to guide development of interventions to support positive self-efficacy behaviors and encourage the development of behaviors that support When older adults believe they have made the decision to move, have the confidence to make the move, feel there is a fit between themselves and their new home (ILC), sense that their plans to move are organized and pleasing to them, and know how they will continue relationships and develop new relationships with others, they experience a sense of control over their behavior and environment. 4,6,9,28 This sense of control contributes greatly to their well-being and successful relocation. Thus, nurses who work with older adults need to recognize the role they can play in developing and implementing health promotion and illness prevention activities for those who are contemplating moving to an ILC. Assessment of readiness for this type of move with interventions for specific areas that put individuals at risk for poor relocation adjustment is essential. The problem is how do we get this assessment done? Advanced practice nurses need to identify a point of contact for the assessment. Readiness to move assessments may be made by APNs working in a retirement community during one of the initial visits made by a prospective mover. Community health APNs can provide education and preventive consultations with older adults in senior centers, churches, and other organizations. 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