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Prep : a preperation programme designed to minimize the stress of institutional relocation on the elderly Mills, Sandra Ruth 1978

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PREP: A PREPARATION PROGRAMME DESIGNED TO MINIMIZE THE STRESS OF INSTITUTIONAL RELOCATION ON THE ELDERLY by SANDRA RUTH MILLS B.A., Univ e r s i t y of B r i t i s h Columbia, 1976 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS i n THE FACULTY OF GRADUATE STUDIES Department of Psychology We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA December 1978 (c) Sandra Ruth M i l l s , 1978 I n p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f t h e r e q u i r e m e n t s f o r a n a d v a n c e d d e g r e e a t t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a , I a g r e e t h a t t h e L i b r a r y s h a l l m a k e i t f r e e l y a v a i l a b l e f o r r e f e r e n c e a n d s t u d y . I f u r t h e r a g r e e t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y p u r p o s e s may b e g r a n t e d b y t h e H e a d o f my D e p a r t m e n t o r by h i s r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l n o t b e a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . D e p a r t m e n t o f Psychology T h e U n i v e r s i t y o f B r i t i s h C o l u m b i a 2075 Wesbrook Place Vancouver, Canada V6T 1W5 i i . . ABSTRACT The present study assessed the effectiveness of a preparation programme designed to minimize r e l o c a t i o n stress i n the e l d e r l y by com-paring i t with an att e n t i o n placebo condition and an assessment-only condition. The preparation programme was intended to increase predic-t a b i l i t y of the consequences of moving to an extended care unit (ECU); to enhance personal co n t r o l over environmental events; and to encourage family support. Seventy-four e l d e r l y prospective patients of the University of B r i t i s h Columbia (UBC) ECU i n i t i a l l y p a r t i c i p a t e d i n the study. Patients with severe cognitive, sensory, or communication im-: pairments were not included i n the sample. The mean age of the sample was 80.2 years (S.D. = 11.09). Seventy-eight percent were female, and 79.73% were non-ambulatory ( i . e . , used a wheelchair). Subjects came from pr i v a t e homes and from 41 f a c i l i t i e s i n the Greater Vancouver area representing four l e v e l s of care. F a c i l i t i e s were s t r a t i f i e d on the basis of population s i z e ; f a c i l i t i e s within each s i z e category were assigned to one of three experimental conditions: (1) assessment-only co n t r o l , (2) attention placebo, and (3) preparation programme. Infor-mation relevant to the subjects' s o c i a l , psychological, and ph y s i c a l functioning was c o l l e c t e d at preadmission and three and s i x months follow-ups. Data were obtained from the subjects themselves, the s t a f f who were caring for subjects, and the interviewers. In add i t i o n , behavioural observations were conducted at the two follow-up periods. Subjects i n the assessment-only co n t r o l group p a r t i c i p a t e d only i n the preadmission and follow-up assessment interviews. In addition to the i i i preadmission assessment interview, subjects i n the att e n t i o n placebo group received three v i s i t s by a therapist unfamiliar with the prepara-t i o n programme, who spent time discussing the subjects' move to the ECU and s p e c i f i c concerns r a i s e d by the subject. The preparation programme included three 45 minute sessions i n addition to the assessment i n t e r -view, which were conducted by a therapist two to three weeks p r i o r to re l o c a t i o n . The intervention consisted of three components:, (1) an information slide-tape programme, (2) a stress management t r a i n i n g s lide-tape programme, and (3) sponsor (family) t r a i n i n g and involvement. In the f i r s t preparation session, the subject was shown a 15 minute slide-tape presentation i n which an e l d e r l y woman narrator provided accurate information about the ECU i n order to create r e a l i s t i c expec-tancies about h o s p i t a l i z a t i o n . In the second and t h i r d sessions, the subject was shown two parts of a slide-tape programme i n which the same narrator taught stress-management techniques. The techniques included problem-solving, assertiveness, deep breathing, coping s e l f -statements, and p o s i t i v e thinking. The therapist stopped the s l i d e -tape programme at designated points and reviewed the techniques with the subject. Sponsors attended two 2-hour meetings during which time r e l o c a t i o n s t r e s s , the preparation programme, and the sponsor's r o l e i n the r e l o c a t i o n process were discussed. Sponsors were also shown the slide-tape programmes, given a tour of the f a c i l i t y and a spon-sor's manual. No s i g n i f i c a n t main e f f e c t s or in t e r a c t i o n s were observed on any of the dependent measures. However, a s i g n i f i c a n t time e f f e c t was observed i n mental status scores over the three assessment periods. i v A l l groups showed s i g n i f i c a n t improvement i n mental status at the s i x months follow-up. The apparent ineffectiveness of the programme was at t r i b u t e d to the p o s s i b i l i t y that subjects may not have a c t u a l l y learnt the coping s k i l l s ; that the content and length of the sli d e - t a p e pro-grammes may have been inappropriate; that preparation alone may be i n s u f f i c i e n t to s i g n i f i c a n t l y reduce r e l o c a t i o n s t r e s s ; and that the i n i t i a l operating conditions of the h o s p i t a l may have mitigated the ef f e c t s of the preparation programme. There i s a need for future research on the development of e f f e c t i v e preparation programmes for r e l o c a t i o n i n the e l d e r l y . V Abstract L i s t of Tables L i s t of Appendices Acknowledgements Introduction Method . Results Discussion TABLE OF CONTENTS Page i i v i v i i x 1 36 48 59 References Appendices 67 79 v i LIST OF TABLES Page Table 1 Percentage of Subjects i n Each Group Coming from Priva t e Homes and Personal, Intermediate, Extended, and Acute Care F a c i l i t i e s 38 Table 2 Percentage of Subjects i n Each Group within Each Primary Diagnostic Category 39 Table 3 Number of Subjects i n Each Group at the Preadmission, Three Months, and Six Months Follow-ups. 40 Table 4 Summary of Subject A t t r i t i o n between Pre-admission and Six Months Follow-up. 41 Table 5 Demographic C h a r a c t e r i s t i c s of Subjects i n Each Group. 51 Table 6 Means and Standard Deviations on Measures of the Number of L i f e Stress Events Occurring During the Preceeding Six Months and Number of P o s i t i v e Attitudes Towards the- Forthcoming Relocation. 52 Table 7 Summary Table of Means on Mental Status, Weighted Health Status, L i f e S a t i s f a c t i o n , VIRO, NOS, and ADL Measures at Preadmission. 53 Table 8 Mean scores on Mental Status at Preadmission, Three Months, and Six Months Follow-ups. 56 v i i LIST OF APPENDICES Page Appendix A A p p l i c a t i o n Form for Extended and Intermediate Care i n B.C. 79 Appendix B Informed Consent Form 81 Appendix C Demographic Questionnaire 82 Appendix D Mental Status Questionnaire 83 Appendix E L i f e Stress Events Schedule 84 Appendix F Health Status Questionnaire 85 Appendix G L i f e S a t i s f a c t i o n Index 86 Appendix H Attitudes Towards the Move 87 Appendix I Post Relocation Adjustment Scale 90 Appendix J Interviewer's Observation Scale 91 Appendix K Nurses' Observation Scale 96 Appendix L A c t i v i t i e s of Daily L i v i n g (ADL) Chart 104 Appendix M Planned A c t i v i t y (PLA) Check 107 Appendix N Transcript of Information Slide-Tape Programme: A Time for Change 109 Appendix 0 Transcript f o r Coping-Skills Training S l i d e -Tape Programme: Getting Ready for Moving Day 115 Appendix P Therapist Guidelines for Coping S k i l l s Training Slide-Tape Programme 130 Appendix Q Sponsor's Manual 134 Appendix R Table 1. Analysis of Variance on Age 149 Appendix S Table 1. Analysis of Variance on Number of L i f e Stress Events Occurring within Six Months Before Relocation 150 v i i i LIST OF APPENDICES (continued) Page Table 2. Analysis of Variance on the Number of P o s i t i v e Attitudes Towards the Forthcoming Relocation Stated at Preadmission 151 Appendix T Table 1. Analysis of Variance on Mental Status at Preadmission 152 Table 2. Analysis of Variance on Weighted Health Status at Preadmission 153 Table 3. Analysis of Variance on L i f e S a t i s -f a c t i o n at Preadmission 154 Table 4. Analysis of Variance on VIRO Scores at Preadmission 155 Table 5. Analysis of Variance on NOS Scores at Preadmission. 156 Table 6. Analysis of Variance on ADL Scores at Preadmission. 157 Appendix U. Table 1. Repeated Measures Analysis of Covariance on L i f e S a t i s f a c t i o n Scores at Three Months and Six Months with Preadmission L i f e S a t i s f a c t i o n Scores as Covariate. 158 Table 2. Repeated Measures Analysis of Covariance on VIRO at the Three Months and Six Months Follow-ups with Preadmission VIRO Scores as Covariate. 159 Table 3. Repeated Measures Analysis of Covariance on ADL at Three Months and Six Months Follow-ups with Preadmission ADL Scores as Covariate 160 Appendix V Table 1. Repeated Measures Analysis of Variance on Mental Status Over Preadmission, Three Months, and Six Months Follow-ups 161 Table 2. Repeated Measures Analysis of Variance on Weighted Health Status Over Preadmission, Three Months, and Six Months Follow-Ups 162 Table 3. Repeated Measures Analysis of Variance on NOS Scores over Preadmission, Three Months, and Six Months Follow-ups 163 i x LIST OF APPENDICES (continued) Page Table 4. Repeated Measures Analysis of Variance on Post-Relocation Adjustment over Three Months, and Six Months Follow-ups„ Appendix W Table 1. Repeated Measures Analysis of Variance on Mental Status over Preadmission and Three Months Follow-up Table 2. Repeated Measures Analysis of Variance on Weighted Health Status over Preadmission and Three Months Follow-up Table 3. Repeated Measures Analysis of Variance on NOS Scores over Preadmission and Three Months Follow-up 164 165 166 167 Appendix X Table 1. Repeated Measures Analysis of Variance on Seclusiveness over the Three Months and Six Months Follow-ups 168 Table 2. Repeated Measures Analysis of Variance on Sleeping Behaviour over the Three Months and Six Months Follow-up 169 Table 3. Repeated Measures Analysis of Variance on Time Spent Engaged i n A c t i v i t y over the Three Months and Six Months Follow-ups 170 Table 4. Percentage of Subjects i n Each Group Engaged i n A c t i v i t y During 0%, 25%, 50%, 75%, and 100% of the Observation Periods at Three Months Follow-up 171 Table 5. Percentage of Subjects i n Each Group Engaged i n A c t i v i t y During 0%, 25%, 50%, 75%, and 100% of the Observation Periods at Six Months Follow-up 172 Table 6. Percentage of Subjects i n Each Group Alone During 0%, 25%, 50%, 7.5%, and 100% of the Observation Periods at Three Months Follow-up Table 7. Percentage of Subjects i n Each Group Alone During 0%, 25%, 50%, 75%, and 100% of the Observation Periods at the Six Months Follow-up 173 174 X ACKNOWLEDGEMENT S I would l i k e to express my appreciation to the following people who have aided me i n the present research. Dr. David Lawson, for h i s support and encouragement as my thesis supervisor and major advisor and for h i s help i n the ed i t i n g and re-v i s i o n of t h i s manuscript; Dr. G l o r i a Gutman, for her contributions as a member of the thesis committee, p a r t i c u l a r l y for her expert advice i n the development of the assessment battery; Dr. Park Davidson, for serving as a member of the thesis commit-tee; Dr. Jerry W i l l i s , f o r serving as my thesis supervisor and major advisor from September 1976 to July 1978; Dr. John Campbell, for his contributions to the development of the present study; Elaine Senkpiel,..for her support and encouragement and for her help i n a l l phases of the data c o l l e c t i o n and coding of the data; Jane Buchan, f o r the development of the NOS and help i n the data c o l l e c t i o n ; Kathleen Moorby, the s o c i a l worker at the UBC ECU, for her support and for serving as the l i a s o n person between the h o s p i t a l admissions committee and the present study; Stephen Ho l l i d a y , f or serving as s t a t i s t i c a l consultant for the present study; the students who served as ther a p i s t s , interviewers, observers, x i and coders; the s t a f f and patients at the UBC ECU; the s t a f f at the pre UBC f a c i l i t i e s ; Brian Mchahon and Alan Mason, at Biomedical Communications Department, for t h e i r help i n the production of the slide-tape pro-grammes; t Judy Hawkins, for her expert typing of the manuscript; Don Ramer, for h i s encouragement throughout the w r i t i n g of the manuscript; my family, for t h e i r much needed support, encouragement, and patience. The production costs of the slide-tape programmes were covered by a Woodward Foundation Grant. The present research was supported, i n part, by a grant to Dr. Jerry W i l l i s from Canada Council (No. 66-0294) from May 1977 to December 1977 and to Dr. Jerry W i l l i s / D r . David Lawson from Health and Welfare (no. 65-1745) from January 1978 to the present. 1 INTRODUCTION Within the past decade, the government, health care professionals, and researchers have become increasingly concerned with the problem of housing and caring for the e l d e r l y . One major contribution to t h i s problem i s the s i z e of the e l d e r l y population and the fa c t that i t i s growing fa s t e r than any other age group (Brody, 1971; MacDonald, 1973; Schreiber, 1972). Approximately 8-10% of North America's population i s over 65 years of age (Brotman, 1968), and of t h i s segment of the population, i t i s the group 75 years of age and older that i s increa-sing most ra p i d l y (Spasoff, Kraus, Holden, Rodenburg, & Woodcock, 1978). Furthermore, the growth rate of the e l d e r l y i s expected to increase i n the future (Brody, 1971). The implications of the changing population pattern for today's society are s i g n i f i c a n t , since the e l d e r l y need and consume a d i s -proportionate amount of health care services. Even though they repre-sent only 8-10% of the North American population, persons over 65 years of age u t i l i z e 20-33% of acute h o s p i t a l beds (Weaver, McPhee, & Lambert, 1975) and nearly h a l f of the r e s i d e n t i a l population of mental hospita l s i s over 65 years of age (Tobin & Lieberman, 1976). A s i g n i f i c a n t portion of North America's aged are p h y s i c a l l y or psychologically deteriorated to the extent that they need some type of long-term i n s t i t u t i o n a l care. In Canada, as i n the U.S., nearly 10% of those over 65 years of age reside i n some type of long-term care i n s t i t u t i o n (Spasoff et a l . , 1978; Tobin & Lieberman, 1976). Moreover, the l i k e l i h o o d of i n s t i t u t i o n a l placement increases with 2 age. For example, within an i n s t i t u t i o n , the average age of a r e s i -dent i s 82 years. Furthermore, i t i s not uncommon for more than 20% of i n s t i t u t i o n a l residents to be older than 90 years of age (Brody, 1971). While a major s o c i a l trend i n our society i s the adoption of an i n s t i t u t i o n a l s o l u t i o n to the problem of housing and caring for the e l d e r l y , t h i s approach appears to have some serious shortcomings. A major one i s that the stress associated with r e l o c a t i o n of aged i n d i -viduals may, i n i t s e l f , produce higher morbidity and mortality rates than would be the case i f these i n d i v i d u a l s were l e f t i n t h e i r o r i g i -n a l settings (Pastalan , 1976) . According to Tobin and Lieberman . . (1976), regardless of e f f o r t s made to prevent premature i n s t i t u t i o n a -l i z a t i o n and provide alternate types of services, such as home health care and g e r i a t r i c day care, a s i g n i f i c a n t proportion of the e l d e r l y w i l l s t i l l require i n s t i t u t i o n a l i z a t i o n i n the next 20 years. Since the i n s t i t u t i o n a l s o l u t i o n w i l l be needed for some time, i t i s important for researchers, professionals, and p o l i c y makers to turn t h e i r a t t e n t i o n to the study of r e l o c a t i o n stress and the development of adequate treatment strategies to reduce i t s deleterious impact. The present study concerns i t s e l f with the development of such a treatment programme. To provide the background to the problem and i t s proposed s o l u t i o n , the following l i t e r a t u r e review w i l l focus on r e l o c a t i o n stress i n general, r e l o c a t i o n stress i n the e l d e r l y , treatment programmes for r e l o c a t i o n stress i n the e l d e r l y , and r e l e -vant preventive stress i n o c u l a t i o n approaches. 3 Relocation Stress Relocation i s a s i g n i f i c a n t l i f e event which involves the loss of f a m i l i a r people, objects, a c t i v i t i e s , and f a m i l i a r surroundings. According to T o f f l e r (1961), moving one's home i s a s t r e s s f u l experi-ence which may require a number of d i f f i c u l t psychological adjustments and behavioural changes i n a r e l a t i v e l y short period of time. An i n d i v i d u a l may, for example, be required to modify aspects of his/her l i f e s t y l e such as preferences for food, clothing and f u r n i t u r e , and choice of r e c r e a t i o n a l a c t i v i t i e s without clear guidelines for sanc-tioned behaviours (Seeley, Sim, & Loosely, 1963). Tyhurst (1957) observed a f a i r l y consistent pattern of adjustment following r e l o c a t i o n which can be summarized i n the following manner. Aft e r the fundamental s u r v i v a l needs are met by f i n d i n g a home and employment, in d i v i d u a l s who have relocated become aware of the strangeness of th e i r new sur-roundings. As t h i s happens, they may reduce t h e i r a c t i v i t y l e v e l and withdraw from the larger s o c i a l environment. They may then f e e l helpless and uncomfortable i n the unfamiliar environment and become anxious and depressed. I t may take relocated i n d i v i d u a l s one to several months to adjust to the new surrounding. According to Tyhurst (1957), some i n d i v i d u a l s never adjust adequately. Relocation occurs under a v a r i e t y of circumstances and may be p o s i t i v e l y or negatively valued depending on the meaning of the move. For many middle and upper income f a m i l i e s , r e l o c a t i o n i s p o s i t i v e l y valued, since i t often accompanies s o c i a l and employment advancement. For the poor, however, r e l o c a t i o n i s usually a dreaded necessity re-s u l t i n g from unemployment or other hardships ( I t t e l s o n , Proshansky, 4 R i v l i n , & W i n k e l , 1974; T o f f l e r , 1961). Long-term r e s i d e n t s of Bos ton ' s West End, f o r example, were s t u d i e d f o l l o w i n g t h e i r i n v o l u n -t a ry r e l o c a t i o n due to urban renewal . I t was expected that the r e -l o c a t i o n of the r e s i d e n t s from crowded slum c o n d i t i o n s to b e t t e r housing would r e s u l t i n improved mental and p h y s i c a l h e a l t h . In s t ead , i t appeared to have had the oppos i t e e f f e c t . F r i e d and G l e i c h e r (1961) repor ted that 46% of the women and 38% of the men exper ienced severe depress ion a f t e r r e l o c a t i o n tha t l a s t e d f o r as long as two y e a r s . F r i e d (1963) de sc r i bed the r e s i d e n t s ' depress ion as c h a r a c t e r i z e d by f e e l i n g s of p a i n f u l l o s s , h e l p l e s s n e s s , and anger. I t was suggested tha t a major c o n t r i b u t o r to t h i s depress ion was the d i s s o l u t i o n of s o c i a l networks, such as the l o s s of f a m i l i a r people w i t h p r e d i c t a b l e pa t t e rns of behav iour , and the l o s s of p l a c e i n which those networks opera ted , such as the corner d rugs to re . I n f a c t , Gans (1962) con-cluded tha t the uproo t ing of the a r e a ' s r e s i d e n t s c o n t r i b u t e d more to mental i l l n e s s than the o r i g i n a l crowded and d e t e r i o r a t e d p h y s i c a l environment. S tudies of the e f f e c t s of fo rced r e l o c a t i o n s i n other c i t i e s repor ted comparable f i n d i n g s w i t h s i m i l a r types of popu la t ions ( I t t e l s o n et a l . , 1974). Whi le there i s anecdo ta l data to suggest that even under the most favourab le c i rcumstances , people w i l l exper ience d i s r u p t i o n f o l l o w i n g r e l o c a t i o n , the r e a c t i o n appears to be even grea ter for those who move under l e s s favourab le c i rcumstances . Al though those i n d i v i d u a l s who r e l o c a t e under the most favourable circumstances d i f f e r i n numerous respec ts from those who move because of ha rdsh ips , most i n v e s t i g a t o r s a t t r i b u t e the more severe r e a c t i o n s of the 5 disadvantaged to the f a c t that they t y p i c a l l y have l i t t l e c o n t r o l over the decision to relocate ( I t t e l s o n et a l . , 1974; T o f f l e r , 1961). Relocation Stress i n the E l d e r l y Like the poor, the e l d e r l y usually have l i t t l e c o n t r o l over the decision to move. I t i s generally dictated by health and f i n a n c i a l reasons. Furthermore, the e l d e r l y are also a low status group, which may be f i n a n c i a l l y supported and/or cared for by the government (MacDonald, 1973). Given these s i m i l a r i t i e s , i t should not be sur-p r i s i n g to discover that the e l d e r l y appear to be vulnerable to r e l o -c ation s t r e s s . The apparent v u l n e r a b i l i t y of the e l d e r l y to the adverse e f f e c t s of r e l o c a t i o n i s thought to be l a r g e l y due to a number of changes commonly associated with the aging process i t s e l f . With advancing age, the e l d e r l y are more susceptible to losses of a bio-l o g i c a l , psychological, and s o c i a l nature. Not only i s there an increased p r o b a b i l i t y of chronic i l l n e s s , but i t i s also l i k e l y that sensory c a p a c i t i e s , m o b i l i t y , and cognitive functioning w i l l d eteriorate. Furthermore, established s o c i a l r o l e s such as those of wife, husband, and/or worker may be l o s t as a r e s u l t of a spouse's death and/or compulsory retirement. Such changes may, i n turn, r e s t r i c t the ac-t i v i t i e s of the e l d e r l y and adversely a f f e c t the i n d i v i d u a l ' s s e l f -concept. As a r e s u l t of these age-related changes, the e l d e r l y may be less able to cope with the a d d i t i o n a l losses involved i n a change of environment. Studies of the r e l a t i v e impact of r e l o c a t i o n on d i f f e r e n t age groups, although few i n number, support the notion that the e l d e r l y are most vulnerable to adverse e f f e c t s of involuntary r e l o c a t i o n 6 (Goldscheider, 1966; Neibank & Pope, 1965). Key (1967), for example, reported that older persons, forced to move because of urban renewal and/or highway construction, experienced more negative emotions than younger persons i n the same s i t u a t i o n . Within the past decade, professionals and researchers have become concerned about r e l o c a t i o n stress i n the e l d e r l y , and as a r e s u l t , have begun to assess the e f f e c t s of r e l o c a t i n g them (Leibowitz, 1974; Pastalan, 1976). Investigations have examined the impact of a va r i e t y of relocations on the e l d e r l y : from the community to apartments (Carp, 1966; Lawton & Yaffe, 1970; Storandt & Wittels, 1975; Wittels & Botwinick, 1974); from the community to an i n s t i t u t i o n (Lieberman, 1974; Whittier & Williams, 1956); from one i n s t i t u t i o n to another (Aldrich & Mendkoff, 1963; Jasnau, 1967; K i l l i a n , 1970; Lieberman, 1974; Markson & Cumming, 1974; M i l l e r & Lieberman, 1965); and from one part of an i n s t i t u t i o n to another (Jasnau, 1967; Leibowitz, 1974; Pablo, 1977). Since the present study i s concerned only with i n s t i t u t i o n a l r e l o c a t i o n , that i s r e l o c a t i o n of the e l d e r l y to, from, or within an i n s t i t u t i o n , only studies of these types of r e l o c a t i o n w i l l be reviewed. The E f f e c t s of I n s t i t u t i o n a l Relocation on the E l d e r l y The most dramatic e f f e c t of i n s t i t u t i o n a l r e l o c a t i o n to be re-ported i s that of increased m o r t a l i t y . Increased mortality has been reported i n studies of r e l o c a t i o n (1) from the community to i n s t i t u -t i o n (Whittier & Williams, 1956; Lieberman, 1974); (2) from one i n s t i t u t i o n to another (Aldrich & Mendkoff, 1963; K i l l i a n , 1970; K r a i , Grad, & Berenson, 1969; Lieberman, 1974; Markus, Blenkner, Bloom, & 7 Downs, 1971; M i l l e r & Lieberman, 1965); and (3) from one part of an i n s t i t u t i o n to another (Aleksandrowicz, 1961; Jasnau, 1967). The r e s u l t s of these studies are d i f f i c u l t to i n t e r p r e t , however, because of problems i n methodology and experimental design. According to Kasl (1972) and Rowland (1977), who have extensively reviewed t h i s l i t e r a -ture, the evidence that r e l o c a t i o n increases the p r o b a b i l i t y of death i s more convincing i n studies of i n t e r and i n t r a - i n s t i t u t i o n a l r e l o -cations than i n studies of relocations from the community to i n s t i t u -t i o n s , since mortality i s not counfounded by the e f f e c t s of i n s t i t u -t i o n a l i z a t i o n or-.selection bias as i t i s i n relocations from home to i n s t i t u t i o n . They caution, however, that the r e s u l t s of some of the studies of i n t e r and i n t r a - i n s t i t u t i o n a l r e l o c a t i o n may, i n turn, be confounded by the f a c t that those patients who relocated were probably not chosen randomly. Because of these d i f f i c u l t i e s , and the f a c t that not a l l studies on i n s t i t u t i o n a l r e l o c a t i o n i n the e l d e r l y report increased mortality (e.g., Gutman & Herbert, 1976; Markson & Cumming, 1974), i t i s impossible to determine the extent of the e f f e c t of r e l o -cation on s u r v i v a l . It i s important to note, however, that since i n d i v i d u a l s may experience impairments i n functioning without dying, i t i s unreasonable to conclude that r e l o c a t i o n does not have a dele-terious impact on the e l d e r l y i f an increase i n mortality i s not re-ported i n research that focusses on mortality e x c l u s i v e l y as the dependent v a r i a b l e . Measures of s o c i a l , psycholoigcal, and physio-l o g i c a l functioning may, indeed, be more s e n s i t i v e to changes due to r e l o c a t i o n s t r e s s . Studies examining the impact of r e l o c a t i o n on the i n d i v i d u a l ' s l e v e l of p h y s i o l o g i c a l , psychological, and s o c i a l functioning, although 8 few i n number, provide a d d i t i o n a l evidence of the deleterious e f f e c t of r e l o c a t i o n on the e l d e r l y . Lieberman (1974), for example, reported declines i n p h y s i o l o g i c a l , psychological, and s o c i a l functioning i n 48-56% of relocated patients. Decreased psychosocial a c t i v i t y and increased pessimism following r e l o c a t i o n have also been reported by other investigators (Bourestom & Tars, 1971; Pablo, 1977). The long-term e f f e c t s of r e l o c a t i o n on the psychological func-tioning of r e l a t i v e l y healthy e l d e r l y persons have been most exten-s i v e l y examined by Tobin and Lieberman (1976). Changes i n cognitive functioning, a f f e c t i v e responsiveness, emotional states, and s e l f -perception were assessed during the waiting period p r i o r to r e l o c a t i o n , and two months and one year a f t e r r e l o c a t i o n . During the waiting period, impaired cognitive functioning and decreased a f f e c t i v e res-ponsiveness were observed. Only a few a d d i t i o n a l changes i n the i n d i -vidual's psychological functioning were found within the f i r s t year a f t e r admission. The most s i g n i f i c a n t of these were perceived capa-c i t y for s e l f - c a r e and bodily preoccupation. Patients f e l t that they were less able to do things for themselves and were incr e a s i n g l y concerned with t h e i r health. In addition, patients became les s hope-f u l , expressed le s s need for a f f i l i a t i o n , and became more, h o s t i l e to-wards others. Since control groups were not included i n these studies, i t i s impossible to determine whether these changes i n psychological, s o c i a l , and p h y s i c a l functioning occurred as a r e s u l t of r e l o c a t i o n . Taken together, however, these studies suggest that r e l o c a t i o n may . have deleterious e f f e c t s i n the e l d e r l y . The severity of t h i s 9 apparent e f f e c t , however, i s not uniform. As a r e s u l t , researchers have attempted to define c h a r a c t e r i s t i c s that describe i n d i v i d u a l s most vulnerable to r e l o c a t i o n s t r e s s , that i s , c h a r a c t e r i s t i c s that d i f f e r e n t i a t e deceased .from surviving relocatees. A number of demo-graphic, health, and psychological c h a r a c t e r i s t i c s have been found to co r r e l a t e with patient outcome following r e l o c a t i o n . Patient C h a r a c t e r i s t i c s Associated with Relocation Outcome Evidence suggests that males are generally more vulnerable to re l o c a t i o n stress than females (Kasl, 1972; Markus et a l . , 1971; Pablo, 1977). Contrary to common expectations, however, age was not found to c o r r e l a t e consistently with mortality ( K i l l i a n , 1970; K r a i et a l . , 1968; Markus et a l . , 1971; Pablo, 1977). Rather, health factors such as global prognosis ( K i l l i a n , 1970; Pastalan, 1976), and l e v e l of physic a l functioning are p r e d i c t i v e of r e l o c a t i o n outcome (Kasl, 1972; K i l l i a n , 1970; Lieberman, 1974; Leibowitz, 1974). Several psychological c h a r a c t e r i s t i c s have been found to co r r e l a t e with r e l o c a t i o n outcome. These include depression (Leibowitz, 1974; M i l l e r & Lieberman, 1965), anxiety (Leibowitz, 1974; M i l l e r & Lieberman, 1965), hopelessness (Tobin & Lieberman, 1976), impaired cognitive functioning (Goldfarb, F i s c h , & Berger, 1966; Leibowitz, 1974; M i l l e r & Lieberman, 1965), f i e l d dependency (Bloom, Blenkner, & Markus, 1969; Markus et a l . , 1972), deni a l of the forthcoming r e l o c a t i o n (Tobin & Lieberman, 1976), and p a s s i v i t y ( A l d r i c h & Mendkoff, 1963; Pastalan, 1976; Tobin & Lieberman, 1976; Turner, Tobin, & Lieberman, 1972); a l l of which are p r e d i c t i v e of a poor outcome. The most s i g n i f i c a n t f i n d i n g i n t h i s area of research i s that anger and aggressiveness are 10 associated with s u r v i v a l , while p a s s i v i t y and acceptance are correlated with death and decline. ( A l d r i c h & Mendkoff, 1963; Pastalan, 1976; Tobin & Lieberman, 1976; Turner, Tobin, & Lieberman, 1972). Tobin and Lieberman (1976) suggested that p a s s i v i t y may prevent the development of coping s t r a t e g i e s that f a c i l i t a t e adjustment. Circumstances of the Relocation Associated with Relocation Outcome Research appears to suggest that the e f f e c t of r e l o c a t i o n on the el d e r l y i s also influenced by such circumstances as the degree of choice, the amount of s o c i a l support from the family and f r i e n d s , the degree of environmental, change, the c h a r a c t e r i s t i c s of the receiving f a c i l i t y , the match between the patient's c h a r a c t e r i s t i c s and those of the receiving f a c i l i t y , and the degree of patient preparation (Kasl, 1972; Leibowitz, 1974; Pablo, 1977). Many researchers suggest that the perceived voluntariness of the move i s an important factor i n f l u e n c i n g the impact of r e l o c a t i o n (Brody, 1971; Jasnau, 1967; Leibowitz, 1974; Schulz & Brenner, 1977; Smith & Brank, 1975). The r e s u l t s of several studies of involuntary relocations from home to i n s t i t u t i o n and from one i n s t i t u t i o n to another, which a t t r i b u t e increased l i f e d i s s a t i s f a c t i o n and mortality to the involuntary nature of the move (e.g., Aldrich'& Mendkoff, 1963; Smith & Brank, 1975) and the r e s u l t s of studies of voluntary moves of e l d e r l y community residents from homes to apartments (Carp, 1966; Lawton & Yaffe, 1970) which do not report increased l i f e d i s -s a t i s f a c t i o n and mortality, are c i t e d as support f o r t h e i r hypothesis. The research evidence i s not cl e a r , however, since there i s a lack of comparative studies of voluntary vs. involuntary r e l o c a t i o n s , and 11 since i n i t i a l differences i n health status may account f o r the d i f -ferences i n post - r e l o c a t i o n outcomes. The most frequently c i t e d comparative research i n t h i s area, conducted by F e r r a r i (1963), com-pared pos t - r e l o c a t i o n mortality rates of a group of e l d e r l y women who v o l u n t a r i l y moved to an i n s t i t u t i o n and a group of e l d e r l y women who had no other choice but to seek i n s t i t u t i o n a l i z a t i o n . The higher mortality reported f o r the involuntary group may, however, have been due to a poorer health status. While any i n s t i t u t i o n a l r e l o c a t i o n may be regarded as somewhat involuntary, since the dec i s i o n to seek i n s t i t u t i o n a l i z a t i o n i s usually necessitated by health and f i n a n c i a l f a c t o r s , and influenced by the phy-s i c i a n and/or family members, perceived choice i n the de c i s i o n to move may be enhanced by involving the patient i n the decision-making pro-cess, asking the patient to consent to the move, and/or inv o l v i n g the patient i n the s e l e c t i o n of a f a c i l i t y . Research which would inves-t i g a t e the influence of degree of choice on r e l o c a t i o n stress by com-paring patients who were moved i n v o l u n t a r i l y from one i n s t i t u t i o n to another, patients who gave formal consent to move, and patients who both gave consent to the move, and p a r t i c i p a t e d i n the s e l e c t i o n of a f a c i l i t y would be u s e f u l . Such research would also have to match patients on health status p r i o r to r e l o c a t i o n . There i s also some evidence to suggest that the ef f e c t s of r e l o -cation i n the e l d e r l y are a function of the d i s s i m i l a r i t y of the two environments. Bourestom and Tars (1974), f o r example, found that the post-r e l o c a t i o n mortality rate of a group of relocated patients who experienced a major environmental change involving a new ph y s i c a l 12 environment, new programmes, and new patient population, was s i g n i f i -cantly higher than that of a group of patients who experienced only a moderate change i n ph y s i c a l environment. Their findings l e d Pablo (1977) to suggest that i n t r a - i n s t i t u t i o n a l relocations should be le a s t s t r e s s f u l because of the low degree of environmental change involved. Conversely, one would expect r e l o c a t i o n from the community to an i n s t i t u t i o n to be the most s t r e s s f u l type of move. Unfortunately, however, systematic investigations of the r e l a t i v e impact of re l o c a -t i o n from the community to an i n s t i t u t i o n , from one i n s t i t u t i o n to another, and within an i n s t i t u t i o n are lacking. There i s evidence to suggest that the impact of r e l o c a t i o n i s not only influenced by the degree of d i s s i m i l a r i t y between the environ-ments, but also by the nature of the environmental change. For instance, i t has been suggested that r e l o c a t i o n to an improved f a c i l i t y may r e s u l t i n improved functioning (Kraus et a l . , 1976; Novick, 1967). Researchers have also suggested that the s o c i a l and phys i c a l charac-t e r i s t i c s of the new environment are associated with r e l o c a t i o n out-come ( I t t e l s o n et a l . , 1974; Lawton, 1974; Leibowitz, 1974). For instance, those c h a r a c t e r i s t i c s which appear to be associated with a d i f f i c u l t p o s t - r e l o c a t i o n adjustment are: a lack of privacy; l i t t l e opportunity to personalize one's immediate environment, to claim t e r r i t o r y i n a public area, to engage i n s o c i a l i n t e r a c t i o n and meaning-f u l a c t i v i t i e s ; no access to the community; and a cu s t o d i a l o r i e n t a -t i o n (Brody, 1971; I t t e l s o n et a l . , 1974; Lawton, 1974; Leibowitz, 1974; Lieberman, Tobin, & Slower, 1971; Pastalan, 1976). A d d i t i o n a l l y , Turner, Tobin, and Lieberman (1972) have suggested that r e l o c a t i o n 13 outcome i s not influenced by the s o c i a l and p h y s i c a l c h a r a c t e r i s t i c s of the new environment per se, nor the degree of environmental change be-tween the old and new environments, but rather by the match between the patients' sociopsychological c h a r a c t e r i s t i c s and the s p e c i f i c demands of the new environment. They suggested that the greater the congruency be-tween the c h a r a c t e r i s t i c s of the i n d i v i d u a l and the s p e c i f i c demands of the new environment, the greater the reduction of r e l o c a t i o n s t r e s s . Preparation for Relocation Several studies have dealt with the problem of preparing the e l d e r l y person for r e l o c a t i o n . However, conclusions about the e f f e c t i v e -ness of the various preparation programmes and comparisons among these studies are complicated by the f a c t that the relocations investigated were very d i s s i m i l a r with respect to the aforementioned factors ( i . e . , degree of choice, degree of environmental change, and c h a r a c t e r i s t i c s of the r e c e i v i n g f a c i l i t y ) . Preparation programmes for patients moving from one part of an i n s t i t u t i o n to another, from an old b u i l d i n g to a newly constructed b u i l d i n g , from a mental h o s p i t a l to nursing homes, and from one i n s t i t u t i o n to another i n s t i t u t i o n have been conducted. Two studies reported the e f f e c t s of preparation on i n t r a - i n s t i t u -t i o n a l r e l o c a t i o n . Leibowitz (1974) reported the preparation of 48 moderately impaired e l d e r l y patients who were i n v o l u n t a r i l y relocated from one f l o o r of an i n s t i t u t i o n to another because of changes i n s t a f f p o l i c y which required the creation of a 24-bed intermediate care area. The planning and implementation of the preparation programme, including the transfer of the patients, took place i n one week and a l l patients were moved on the same.day. .Staff, patients, and f a m i l i e s were involved 14 i n the preparation for r e l o c a t i o n . Patients p a r t i c i p a t e d i n small d i s -cussion groups, i n d i v i d u a l counselling sessions, v i s i t s to the new rooms, and introductions to new roommates. During group sessions, patients were provided with information and given the opportunity to discuss s p e c i f i c concerns and state roommate preferences. Letters explaining the move and the problems of r e l o c a t i o n were sent to fam i l i e s to e l i c i t t h e i r support. A meeting between interested r e l a t i v e s and s o c i a l workers responsible for the programme was held to discuss concerns about the move. At the s o c i a l worker's d i s c r e t i o n , a meeting including the patient and his/her family was held for some patients. While the move did not involve the degree of change that would be experienced when moving from one i n s t i t u t i o n to another, i t did involve changes from double to multiple bedrooms and, i n some cases, a change i n roommates. Leibowitz (1974) reported that the h o s p i t a l mortality rate during the four months following r e l o c a t i o n was no greater than that during the year preceding r e l o c a t i o n . The author concluded, however, on the basis of ratings of the patients' o v e r a l l adjustment and changes i n personality variables conducted one week before the move and at two weeks, four months, and eight months follow-ups that even i n t r a - i n s t i t u t i o n a l moves cause short-term stress reactions and emphasized the need for the preparation of patients before such a move. Unfortunately, the v a l i d i t y of th i s study i s l i m i t e d by the lack of a con t r o l group and measures of health and f u n c t i o n a l competence. Another study involving the preparation of e l d e r l y patients f o r an i n t r a - i n s t i t u t i o n a l move was reported by Pablo (1977). One important factor d i f f e r e n t i a t i n g t h i s study from Leibowitz's (1974) 15 study i s that Pablo appears to have enhanced the patients' perceived degree of d e c i s i o n a l c o n t r o l by asking those who have been selected for r e l o c a t i o n to give t h e i r consent. Patients were only relocated i f formal consent was given. S t a f f , patients, and f a m i l i e s were involved i n the preparation programme. Letters containing information about the nature and purpose (which was to desegregate an all-male ward) of the move were sent to a l l patients (movers and nonmovers) three weeks before r e l o c a t i o n . S o c i a l workers met with the movers i n -d i v i d u a l l y to discuss any problems involved i n the move. They also attempted to meet with r e l a t i v e s . A l l patients were encouraged to discuss the r e l o c a t i o n during patient c o u n c i l meetings. In order to minimize any d i s r u p t i o n of h o s p i t a l a c t i v i t i e s , the transfers were implemented during a three day period. Relocation involved a minimal amount of environmental change. Not only were patients assigned s i m i l a r accommodations, but also patients from a four-bed room were moved together whenever possible so that interpersonal r e l a t i o n s h i p s could remain i n t a c t . Also, there were no major changes i n s t a f f i n g patterns. In evaluating the effectiveness of the preparation programme, Pablo compared the mortality rates of movers and nonmovers at 3, 6, 12, and 24 months following r e l o c a t i o n . At each assessment during the f i r s t year, Pablo reported s i g n i f i c a n t l y more observed than ex-pected deaths among the movers, and s i g n i f i c a n t l y fewer than expected deaths among the nonmovers. By contrast, no s i g n i f i c a n t differences between movers and nonmovers were found i n assessments of p h y s i c a l , cognitive, and behavioural functioning. Although Pablo 16 (1977) concluded that mortality and morbidity was minimized by the preparation for the move, the absence of a con t r o l group of unprepared movers precludes any d e f i n i t i v e statement about the effectiveness of the programme. Two studies of the e f f e c t of preparation programmes involved re-l o c a t i o n of the e n t i r e s t a f f and patient population to a newly con-structed f a c i l i t y . In the f i r s t , Novick (1967) developed a prepara-t i o n programme for 125 c h r o n i c a l l y disabled e l d e r l y patients who were moved i n v o l u n t a r i l y to a new f a c i l i t y . S t a f f , patients, and family were involved i n the r e l o c a t i o n programme. Patients received i n f o r -mation about the move and were encouraged to discuss t h e i r reactions to the move i n group meetings, to provide input into administrative decisions, and to p a r t i c i p a t e i n the packing of t h e i r belongings. Patients were also asked to state t h e i r room and roommate preferences. A l l patients were encouraged to v i s i t a l i f e - s i z e d model of a new bedroom on exhibit at the old h o s p i t a l , and those patients able to leave the h o s p i t a l were taken on tours of the new f a c i l i t y . Families were s e n s i t i z e d to the problems of r e l o c a t i o n and encouraged to make frequent v i s i t s following the move. The post - r e l o c a t i o n h o s p i t a l mortality rate of 16% was apparently less than the mortality rate i n the old h o s p i t a l i n the preceeding year. More recently, Zweig and Csank (1975) investigated the impact of a modified version of Novick's (1967) programme on 350 c h r o n i c a l l y disabled war veterans who were i n v o l u n t a r i l y transferred en mass from a g e r i a t r i c medical unit to a new, modern f a c i l i t y . On the basis 17 of a comparison between mortality rates f o r the three years pre-ceeding r e l o c a t i o n and the f i r s t year following r e l o c a t i o n , the authors concluded that mortality did not increase as a r e s u l t of r e l o c a t i o n . Unfortunately, the i n t e r p r e t a t i o n of both Novick's (1967) and Zweig and Csank's (1975) r e s u l t s i s complicated by several factors — the lack of an unprepared, transferred c o n t r o l group; the lack of systematic p r o v i s i o n of. a l l treatment components to every patient; and the confound of moving to a new, better-equipped f a c i l i t y . Furthermore, these studies were a t y p i c a l of most relocations because the s t a f f were relocated with the patients and the patients were allowed to provide input into the design of the new f a c i l i t y . Bourestom and Pastalan (1971) evaluated two preparation approaches designed to help minimize the stress on e l d e r l y patients moving i n v o l u n t a r i l y from one i n s t i t u t i o n to another as a r e s u l t of ammendments i n f i n a n c i a l p o l i c y and i n f i r e and safety regulations which forced several nursing homes to close. The programmes attempted to reduce the anxiety associated with moving to a new place, to f a m i l i a r i z e the patients with the new s e t t i n g , and to provide support services to ease the impact of the t r a n s i t i o n . Staff from both old and new f a c i l i t i e s , family members, and patients were involved. 18 Patients were relocated during the l a s t two weeks of the ten week programme. Subjects were matched on age, sex, length of hospita-l i z a t i o n , and p h y s i c a l condition and were assigned to one of two preparation programmes. Group 1 v i s i t e d the new f a c i l i t y four times f or introductory and information-providing tours, which were followed by group discussions. Group 2 received one tour of the new f a c i l i t y and several group sessions i n which s l i d e -presentations of the new f a c i l i t y were shown. Staff of the old h o s p i t a l were f a m i l i a r i z e d with the new i n s t i t u t i o n so that they would be better able to deal with the questions and con-cerns of the patients. A l l patients p a r t i c i p a t e d i n group meetings i n which p a r t i c u l a r concerns were i d e n t i f i e d and d i s -cussed. Individual counselling was also a v a i l a b l e on request. A l l patients were asked to. state preferences for roommates and phy s i c a l arrangements of t h e i r room and were given calendars with the moving date c i r c l e d . Family members were introduced to old and new s t a f f , given information concerning r e l o c a t i o n , taken on s i t e v i s i t s , and asked to make frequent v i s i t s f o l -lowing the move. One year a f t e r r e l o c a t i o n , 52% of Group 2 had dies, compared to 27% of Group 1. The authors a t t r i b u t e d t h i s f i n d i n g to the differ e n c e between the groups i n terms of the number of s i t e v i s i t s and concluded that s i t e v i s i t s were more e f f e c t i v e than slide-presentations i n preparing the e l d e r l y f o r r e l o c a t i o n . However i t i t also possible that the s p e c i f i c content of the 19 s l i d e presentation was not equivalent to the information provided on the s i t e v i s i t s . Moreover, patients indicated that the s l i d e s were quite small and d i f f i c u l t to s e e — a feature which un-doubtedly reduced the effectiveness of t h i s mode of presentation. Pastalan and h i s colleagues (Haberkorn, Davis, Pastalan, & Walker, 1977) have continued to develop t h e i r comprehensive patient prepara-t i o n programme. Now i n i t s fourth year of operation, the Pennsylvania Relocation Programme t r i e s to reduce r e l o c a t i o n stress by maximizing the patient's c o n t r o l of his/her environment. Four four-member.Nursing Home Relocation Teams, each consisting of s o c i a l workers, RNs, LPNs, and a coordinator, implement the r e l o c a t i o n programme i n the four state regions. The team i s responsible for dealing with a l l aspects of the move (e.g., l e g a l , f i n a n c i a l , sociopsyetiological, and health), for providing continuity through each phase of r e l o c a t i o n , and for making the best possible placement of the patient. The patient preparation programme consists of three phases: preparation before the move, support on moving day, and extensive follow-up to f a c i l i t a t e the patient's adjustment to the new f a c i l i t y . Patients receive an in-depth o r i e n t a t i o n to the r e l o c a t i o n process i n i n d i v i d u a l counselling sessions with a team member. They are taken on s i t e v i s i t s to the receiving f a c i l i t i e s , and then they are given the opportunity to discuss concerns and ask questions during i n d i v i d u a l or group sessions. A d d i t i o n a l l y , patients are given the opportunity to p a r t i c i p a t e i n r e l o c a t i o n decisions and help the team develop an i n d i v i d u a l transfer plan. The s t a f f of,:both f a c i l i t i e s are provided with i n s e r v i c e education designed to s e n s i t i z e them to the problems 20 of r e l o c a t i o n , the need for preparation of persons involved i n the re l o c a t i o n , and the need for a smooth r e l o c a t i o n . They are also pro-vided with t r a i n i n g i n supportive techniques. The team provides the rece i v i n g f a c i l i t y with information about the patient, a suggested patient care plan, and follow-up a i d . Family and friends receive o r i e n t a t i o n and counselling. They also p a r t i c i p a t e with the patient and team members i n the development of the transfer plan. During the period from July 1975 to July 1976, 236 patients were relocated. The authors reported that the mortality rate for the re-located population was 11% per year as compared to 26.6% for the state's e l d e r l y population. As the authors themselves concluded, i n the absence of an appropriate control group, the lower mortality rates could be at t r i b u t e d to the effectiveness of the r e l o c a t i o n programme, better care provided by the new f a c i l i t y , the Hawthorne e f f e c t due to increased attention to the patient, or to s e l e c t i o n bias. There has been only one study of a preparation programme for r e l o -cation reported i n the l i t e r a t u r e which included an unprepared compari-son group. Pino, Rosica, and Carter (1978) studied the ef f e c t s of re-lo c a t i o n on four groups of e l d e r l y patients: (1) a group of unprepared patients who were relocated from a pri v a t e home or h o s p i t a l to a nursing home complex, (2) a group of prepared patients who were transferred to a new bu i l d i n g i n the same nursing home complex due to expansion of the f a c i l i t y , (3) a s i m i l a r group of unprepared patients who were transferred to the new bu i l d i n g , and (4) a cont r o l group of nonmovers at a neigh-bouring i n s t i t u t i o n . Each group consisted of 25 patients matched for age, sex, medical diagnosis, and o v e r a l l l e v e l of functioning. The preparation 21 programme provided patients with information regarding changes i n the new p h y s i c a l environment, s t a f f and patient i n t e r a c t i o n pattern, and d a i l y routines. S o c i a l workers met with patients during f i v e i n d i v i d u a l counselling sessions to discuss the r e l o c a t i o n , i d e n t i f y concerns, answer questions, and o u t l i n e choices a v a i l a b l e to the patient, such as the s e l e c t i o n of room and roommates. The move was also discussed during group a c t i v i t i e s i n the h o s p i t a l such as r e a l i t y o r i e n t a t i o n and remotivation therapy. Staff received i n s e r v i c e edu-cation designed to s e n s i t i z e them to the problems of r e l o c a t i o n . Letters explaining the move were sent to patients' f a m i l i e s to encourage . t h e i r support and p a r t i c i p a t i o n i n the r e l o c a t i o n programme. A d d i t i o n a l l y , patients and t h e i r f a m i l i e s were also able to tour the new f a c i l i t y . The authors predicted higher mortality rates for the group of pa-t i e n t s relocated from outside the nursing home complex than for the other three groups. Although there were no s i g n i f i c a n t differences i n mor-t a l i t y rates among the four groups, the authors concluded on the basis of a nonsignificant trend toward higher mortality for the relocated group ( i . e . , group 1) that the preparation programme was e f f e c t i v e . This con-c l u s i o n i s not warranted, however, because there were no differences i n mortality rates between the prepared and unprepared transfer groups ( i . e . , groups 2 &.3). A d d i t i o n a l l y , one could a t t r i b u t e a higher mortality rate for the relocated group to a greater degree of environmental change. A l -though both prepared and unprepared transfer groups did s i g n i f i c a n t l y better than the other two groups on measures of independence i n a c t i v i t i e s of d a i l y l i v i n g (ADUO, mental status, and l i f e s a t i s f a c t i o n , the lack 22 of differences between these two groups on these measures further indicates that one cannot conclude that the preparation programme was e f f e c t i v e . In summary, while the use of multifaceted preparation programmes to reduce r e l o c a t i o n stress i s appealing, the r e s u l t s of the research on the effectiveness of such programmes are inconclusive. Furthermore, studies which c l e a r l y define the treatment programme, systematically provide the e n t i r e treatment package to a l l patients i n the preparation group, and employ adequate co n t r o l groups, are obviously needed. The findings of research on the impact of r e l o c a t i o n previously discussed leave l i t t l e doubt that r e l o c a t i o n i s a s t r e s s f u l experience. Moreover, i t would seem reasonable to assume that the e f f e c t s of t h i s type of stress are mediated by the same factors that operate i n laboratory research on s t r e s s . Extensive research with both animals and humans has i d e n t i f i e d two r e l a t e d factors as mediators of an organism's response to s t r e s s : p r e d i c t a b i l i t y and c o n t r o l l a b i l i t y . P r e d i c t a b i l i t y The simplest case of p r e d i c t a b i l i t y which does not allow the organism any behavioural c o n t r o l over the s t r e s s f u l event i s a warning s i g n a l . Several laboratory studies have investigated the e f f e c t s of warning signals on human subjects ( A v e r i l l & Resenn, 1972; D'Amato & Gumenik, 1960; Glass & Singer, 1973; Lovibond, 1968; Pervin, 1963; Staub, Tursky, & Schwartz, 1971). They suggest that reduction of uncertainty regarding the occurrence of a threatening event i s often stress-reducing. Results from a number of studies (D'Amato & Gumenick, 1960; Glass, Singer, & Friedman, 1969) support Pervin 's 23 (1963) conclusion that, i n general, then p r e d i c t a b i l i t y of a threatening stimulus i s preferrable to, and less anxiety-arousing than unpredic-t a b i l i t y , even when p r e d i c t a b i l i t y does not provide the opportunity for escape, avoidance, or termination of the s i t u a t i o n . Lefcourt (1973) suggested that when an aversive event i s predictable i t s e f f e c t s are minimized, possibly because the organism i s afforded the opportunity to prepare i t s e l f so as to beJ.less s e n s i t i v e to the d i s -turbing event. With p r e d i c t a b i l i t y , psychological and p h y s i c a l pre-paration are at an optimum and surprise i s avoided. A few studies (Monat, A v e r i l l , & Lazarus, 1972) suggested that although p r e d i c t a b i l i t y i s preferable, i t sometimes 'increases the i n d i v i d u a l ' s response to a s t r e s s f u l event. For instance, Epstein (1973) reviewed a number of studies which dealt with the e f f e c t s of d i f f e r e n t kinds of information on reactions to noxious s t i m u l i (loud noises and e l e c t r i c shocks). He noted that information regarding the nature of the stimulus could either reduce or enhance r e a c t i v i t y to the impact of the s t i m u l i s . He concluded, however, that "the f i n d i n g of greatest generality was that an accurate expectancy tended to f a c i l i t a t e habituation ... i t i s at times necessary to pay the p r i c e of a momentary unpleasurable increase i n arousal i f one i s l a t e r to be able to respond at a reduced l e v e l of arousal" (Epstein, 1973, p. 105). S i m i l a r l y , A v e r i l l (1973) suggested that although predic-t a b i l i t y may occasionally lead to i n i t i a l increased r e a c t i v i t y , there i s some i n d i c a t i o n that i t f a c i l i t a t e s long-term adaptation. Staub and K e l l e t (1972) found that the more complete and accurate the information provided, the greater the reduction of s t r e s s . They 24 found that subjects who received information about both the objective c h a r a c t e r i s t i c s of an e l e c t r i c shock and the sensations of being shocked, had a higher tolerance for pain and were less anxious than subjects who received only one type of information or no information. In a s e r i e s of experimental studies, Lazarus, A v e r i l l , and Opton (1970) demonstrated that subjects who received accurate information about an anthropological f i l m which showed boys being mutilated as part of a puberty r i t e experienced less p h s y i o l o g i c a l arousal during the f i l m than uninformed subjects. C o r r e l a t i o n a l data from a number of c l i n i c a l studies on s u r g i c a l patients lend further support to the notion that accurate preparatory information reduces stress reactions (Janis, 1958). C o n t r o l l a b i l i t y A v e r i l l (1973) defines behavioural c o n t r o l as "the a v a i l a b i l i t y of a response which may d i r e c t l y influence or modify the objective c h a r a c t e r i s t i c s of a threatening event'! (p. 287). Most analogue studies of behavioural c o n t r o l have allowed the subject to modify the objective nature of the threatening event. For example, subjects have been allowed to prevent e n t i r e l y or at least avoid some instances of a noxious stimulus ( A v e r i l l & Rosenn, 1972; Bowers, 1968; Glass & Singer, 1973; Houston, 1972); interpose r e s t periods, or take time out from a s e r i e s of noxious s t i m u l i (Hokanson, Degood, Forrest, & B r i t t a i n , 1971); terminate prematurely (escape) a noxious stimulus (Bandler, Madaras, & Bern, 1968; Champion, 1950; E l l i o t , 1969; Geer, Davison, & Gatchel, 1970; Geer & Maisel, 1972); or l i m i t the i n t e n s i t y of a noxious stimulus (Staub et a l . , 1971). In a review of the behavioural c o n t r o l l i t e r a t u r e , A v e r i l l (1973) 25 concluded that "when subjects are given the opportunity to modify the nature of an aversive stimulus, decreased stress reactions generally have been observed i n comparison with conditions i n which no c o n t r o l i s p o s s i b l e " (p. 291). Furthermore, there i s evidence which indicates that the perception, or b e l i e f of c o n t r o l i s equally as important as actual c o n t r o l i n stress reduction (Bowers, 1968; Geer et a l . , 1970; Glass et a l . , 1969). Lefcourt (1973) reviewed a number of studies which i n d i c a t e that either c o n t r o l or the perception of co n t r o l over an aversive stimulus helps reduce stress reactions. He concluded that "the perception of c o n t r o l would seem to be a common predictor of the response to aversive events regardless of species ... the sense of c o n t r o l , the i l l u s i o n that one can exercise personal choice has a d e f i n i t e and p o s i t i v e r o l e i n sustaining l i f e " (p. 424). Researchers have attempted to determine the nature of the r e l a -tionship between p r e d i c t a b i l i t y and c o n t r o l l a b i l i t y . In a w e l l -c o n t r o l l e d i n v e s t i g a t i o n , Geer and Maisel (1972) attempted to deter-mine whether the e f f e c t s of the a b i l i t y to c o n t r o l aversive s t i m u l i were mostly due to the a b i l i t y to predict the occurrence of those s t i m u l i , since subjects who can control the termination of a stimulus can also predict i t s duration. Comparisons among a group which had c o n t r o l , a prediction-only group, and a no-control-no-prediction group, indicated that being able to terminate aversive s t i m u l i reduces the impact of those s t i m u l i more than j u s t being able to predict the occurrence of those s t i m u l i . The r e s u l t s of the previously discussed studies suggest that the greater the perceived p r e d i c t a b i l i t y and c o n t r o l l a b i l i t y of a s t r e s s f u l event, the less aversive are i t s e f f e c t s on the person. 26 A d d i t i o n a l support for the importance of c o n t r o l l a b i l i t y i n stress reduction i s provided by Seligman's (1975) "learned helplessness" model which provides a useful framework for conceptualizing the r e l o c a t i o n process. Seligman suggested that the c r u c i a l factor i n the e f f e c t s of a s t r e s s f u l event i s the loss of co n t r o l over environmental events. He posited that when i n d i v i d u a l s experience aversive events that they can-not c o n t r o l , they stop making coping responses. They learn to be help-l e s s , become passive, and may undergo some p h y s i o l o g i c a l changes. Re-lo c a t i o n to an i n s t i t u t i o n i s t y p i c a l l y an aversive event i n v o l v i n g many losses over which the e l d e r l y person has l i t t l e c o n t r o l (e.g., loss of privacy, friends and loved ones, pr i z e d possessions, and f a m i l i a r sur-roundings) . According to Seligman (1975) i f the e l d e r l y person i s i n poor health, removing control.over the environment may contribute to phy s i c a l and psychological d e t e r i o r a t i o n and possibly even death. Em-p i r i c a l support for the r e l a t i o n s h i p between helplessness and the onset of p h y s i c a l and psychological d e t e r i o r a t i o n was provided by Schmale and Engel's (1967) research on the "giving-up given-up" phenomenon. Accor-ding to Schmale and Engel, f a i l u r e to cope with a s i g n i f i c a n t l o s s , or threat of l o s s , r e s u l t s i n feeli n g s of helplessness and hopelessness and increases v u l n e r a b i l i t y to a wide v a r i e t y of diseases. Schmale (1958), for instance, reported that 30 out of 42 patients h o s p i t a l i z e d f o r various diseases reported a negative l i f e s tress event occurring within one week of the onset of t h e i r i l l n e s s . Coping S k i l l s and Stress-Inoculation Training Approaches In an attempt to enhance treatment generalization, behaviour therapy has s h i f t e d i t s focus from d i s c r e t e , s i t u a t i o n - s p e c i f i c res-ponses and problem-specific procedures to the development of coping 27 s k i l l s t r a i n i n g approaches that can be applied across a v a r i e t y of response modalities, s i t u a t i o n s , and problems (Meichenbaum, 1977). A number of complex, multifaceted coping s k i l l s t r a i n i n g approaches have been developed and applied i n a number of different.problem areas. These approaches, i t has been noted (Poser, 1975), have p o t e n t i a l f or a p p l i c a t i o n to prevention. The following review w i l l focus on the approaches which have the most to o f f e r to the development of t r e a t -ment strategies f or r e l o c a t i o n s t r e s s . G o l d f r i e d , Decenteceo, and Weinberg (1974) developed a.coping s k i l l s t r a i n i n g procedure c a l l e d "systematic r a t i o n a l r e s t r u c t u r i n g . " Based on the notion that emotional reactions are determined by an i n d i v i d u a l ' s l a b e l l i n g or evaluation of a s i t u a t i o n , they developed a technique which involved anxiety induction through imagery and/or ro l e p l a y i n g ; and t r a i n i n g c l i e n t s i n evaluation of t h e i r anxiety l e v e l , recognition of anxiety-provoking conditions, r a t i o n a l reeva-l u a t i o n of these conditions, and observation of the decreased l e v e l of anxiety following the r a t i o n a l reevaluations. "Systematic r a t i o n a l r e s t r u c t u r i n g " has been used to t r a i n c l i e n t s to cope with various forms of anxiety, depression and anger. Anxiety management t r a i n i n g (AMT), developed by Suinn and Richardson.(1971), i s another coping s k i l l s t r a i n i n g approach with p o t e n t i a l for preventive a p p l i c a t i o n . AMT i s a conditioning pro-cedure designed to reduce anxiety reactions, which i s t h e o r e t i c a l l y s i m i l a r to systematic d e s e n s i t i z a t i o n . I t i s based on the theory that anxiety responses can be d i s c r i m i n a t i v e s t i m u l i , and that c l i e n t s can be trained to respond to these cues with competing responses 28 which remove anxiety through r e c i p r o c a l i n h i b i t i o n . AMT involves the arousal of anxiety, through imaginal scenes of a v a r i e t y of events which aroused anxiety i n the past (these scenes are not presented i n a hierarchy and may be unrelated to the c l i e n t ' s p a r t i c u l a r problem), and t r a i n i n g of the c l i e n t to use the onset of increasing l e v e l s of autonomic and/or skeletomuscular anxiety responses as d i s c r i m i n a t i v e cues for producing competing responses such as r e l a x a t i o n . AMT i s a r e l a t i v e l y n o n - s i t u a t i o n - s p e c i f i c procedure. Relaxation i s emphasized as an a c t i v e coping s k i l l which may be used by the c l i e n t to cope with anxiety i n the future. Also n o n - s i t u a t i o n - s p e c i f i c i s Meichenbaum's (1975) s t r e s s -i n o c u l a t i o n t r a i n i n g . This procedure i s a behavioural analogue to medical i n o c u l a t i o n against b i o l o g i c a l disease. Designed to provide the c l i e n t with a set of behavioural and cognitive s k i l l s to deal with future s t r e s s f u l s i t u a t i o n s , s t r e s s - i n o c u l a t i o n t r a i n i n g i s based on the p r i n c i p l e that the c l i e n t ' s resistance to stress i s enhanced by graded exposure to s t i m u l i strong enough to arouse defenses, but not so strong that they overcome them. The s t r e s s - i n o c u l a t i o n programme consists of three phases. In the f i r s t phase, which i s intended to provide a conceptual framework for understanding the nature of emotions and s t r e s s f u l reactions, the c l i e n t i s taught to view stress reactions as a series of four stages: (1) preparing for a stressor, (2) con-front i n g or handling a stressor, (3) possibly being overwhelmed by a str e s s o r , and (4) r e i n f o r c i n g oneself for having coped with the stressor. In the second phase of t r a i n i n g , the c l i e n t i s taught, and asked to rehearse, several behavioural and cognitive coping s k i l l s such 29 as: c o l l e c t i n g information about the threatening event, a n t i c i p a t o r y problem-solving, r e l a x a t i o n , coping self-statements, and cognitive c o n t r o l through s e l e c t i v e attention. Once c l i e n t s become p r o f i c i e n t i n the use of these coping s k i l l s , they are given the opportunity to p r a c t i c e these s k i l l s i n the t h i r d phase during graded exposure to a v a r i e t y of laboratory stress s i t u a t i o n s , including imaginary stress s i t u a t i o n s and stress-inducing f i l m s . Altogether, t h i s multifaceted treatment package u t i l i z e s a wide v a r i e t y of therapeutic techniques such as d i d a c t i c teaching, discussion, r e l a x a t i o n t r a i n i n g , modeling, reinforcement, s e l f - i n s t r u c t i o n , and behavioural rehearsal, a l l of which are intended to t r a n s l a t e the c l i e n t ' s sense of "learned help-lessness" into "learned resourcefulness." According to Poser (1975) researchers have recently turned t h e i r attention to the development of prevention programmes which focus t h e i r e f f o r t s on those persons at r i s k because of some ant i c i p a t e d s t r e s s f u l event (e.g., r e l o c a t i o n , surgery). While cautioning that the effectiveness of s t r e s s - i n o c u l a t i o n t r a i n i n g and the other coping s k i l l s t r a i n i n g approaches have yet to be conclusively demonstrated, Meichenbaum (1977) suggested t h e i r possible a p p l i c a t i o n i n j u s t t h i s type of programme. To date, however, few investigations of t h e i r prophylactic value have been conducted. Preparation Programmes for Surgery A few c l i n i c a l studies i n v e s t i g a t i n g the e f f e c t s of preparation programmes on s u r g i c a l stress have been reported i n the treatment l i t e r a t u r e (Egbert, B a t t i t , Welch, & B a r t l e t t , 1964; Langer, Janis, & Wolper, 1975, c i t e d i n Meichenbaum, 1977; V i s i n t a i n e r & Wolfer, 1975). 30 Langer , J a n i s , and Wolper (1975, c i t e d i n Meichenbaum, 1977) p rov ided a coping s k i l l s t r a i n i n g programme s i m i l a r to tha t o u t l i n e d by G o l d f r i e d et a l . (1974) to surgery p a t i e n t s . T h e i r programme con-s i s t e d of p repara to ry i n f o r m a t i o n concerning p o s t - s u r g i c a l d i scomfor t s and pre—and p o s t - o p e r a t i v e ca re , and a v a r i e t y of c o g n i t i v e s t r a t e g i e s such as c o g n i t i v e r e a p p r a i s a l of a n x i e t y - p r o v o k i n g even ts , ca lming s e l f - t a l k , and c o g n i t i v e c o n t r o l through s e l e c t i v e a t t e n t i o n . In r e a p p r a i s a l t r a i n i n g , p a t i e n t s were t o l d that they could l e a r n to c o n t r o l t h e i r apprehension and anx i e ty about the impending o p e r a t i o n . P a t i e n t s were t o l d tha t i t was t h e i r pe rcep t ions about su rge ry , r a t h e r than the event i t s e l f , which c o n t r i b u t e d to the degree of s t r e s s they exper ienced . P a t i e n t s were taught s e v e r a l a l t e r n a t e ways of v i e w i n g surgery and were i n s t r u c t e d to t h i n k p o s i t i v e l y whenever they s t a r t e d to f e e l anxious about the a n t i c i p a t e d su rge ry . The p r e p a r a t i o n p r o -gramme appeared to reduce p re - and p o s t - s u r g i c a l d i s t r e s s as i n d i c a -ted by nu r ses ' o b s e r v a t i o n s , reques ts fo r s e d a t i v e s , and l e n g t h of h o s p i t a l s t a y . Whi le i t i s not c l e a r from Meichenbaum's (1977) d e s c r i p t i o n of the study whether a c o n t r o l group was employed, the content of t h i s p r e p a r a t i o n programme may p rov ide u s e f u l ideas fo r the development of a p r e p a r a t i o n programme f o r r e l o c a t i o n s t r e s s . Egbert et a l . (1964) s t u d i e d the e f f e c t s of a p r e p a r a t i o n p r o -gramme on the s t r e s s of abdominal su rge ry . Subjects i n the c o n t r o l group r e c e i v e d r o u t i n e i n f o r m a t i o n about the o p e r a t i o n ( e . g . , t ime and d u r a t i o n , nature of the anes the s i a , l o c a t i o n of r e g a i n i n g con-sc ioueness) from the a n e s t h e s t i s t the n i g h t before the o p e r a t i o n . I n a d d i t i o n to the r o u t i n e i n f o r m a t i o n g i v e n to the c o n t r o l group, subjec ts 31 i n the experimental group received information, t r a i n i n g i n coping s k i l l s , and reassurance from the anesthetist, both before and a f t e r the operation. More s p e c i f i c a l l y , they were given a d e s c r i p t i o n of post-operative pain and e x p l i c i t reassurance that post-operative pain i s a normal consequence of an abdominal operation, i n s t r u c t i o n s to re-lax abdominal muscles to reduce pain, and assurance the p a i n - k i l l e r s would be a v a i l a b l e . Both surgeons and ward nurses were uninformed about t h i s experiment. Results indicated that subjects i n the experi-mental group required about h a l f as much sedation as did c o n t r o l sub-j e c t s during the f i r s t f i v e days a f t e r surgery. A d d i t i o n a l l y , experi-mental subjects were discharged from the h o s p i t a l an average of 2.7 days e a r l i e r than c o n t r o l subjects. While i t i s possible that d i f -ferences i n time spent with the patient could have contributed to the e f f e c t s of the programme, the treatment appeared to be e f f e c t i v e i n reducing s u r g i c a l s t r e s s . Two studies on the e f f e c t s of psychological preparation of c h i l d r e n for tonsillectomy were reported by V i s i n t a i n e r and Wolfer (1975). The intervention i n both studies, c a l l e d "stress-point pre-; paration", was designed to reduce the stress experienced by the c h i l d r e n and t h e i r parents. The intervention consisted of information, t r a i n i n g i n coping behaviours, and an opportunity to rehearse coping behaviours, and was conducted by a nurse before s i x p o t e n t i a l l y -stressful periods (e.g., admission, blood t e s t , the afternoon of the day before surgery, preoperative medication, before and during transport to the operating room, and return from recovery, room). The nurse provided each c h i l d and parent (usually the mother) with a d e s c r i p t i o n of h o s p i t a l routines 32 an explanation of procedures (e.g., when and how the procedure would be conducted, who would do i t , what would be done, and what could be expected a f t e r i t would be completed), and a d e s c r i p t i o n of s t a f f , parent, and patient r o l e s . The nurse also described the sensations the c h i l d might experience during d i f f e r e n t procedures. The chi l d r e n were then encouraged to express t h e i r f e e l i n g s about each event, helped to i d e n t i f y attainable goals f o r coping (e.g., holding one's arm s t i l l for an i n j e c t i o n ) , and in s t r u c t e d to p r a c t i s e the coping behaviour. In the f i r s t study, the prepared group was compared to an un-prepared control group. The r e s u l t s demonstrated that prepared c h i l d -ren and parents showed s i g n i f i c a n t l y less emotional d i s t r e s s and better adjustment than the con t r o l c h i l d r e n and t h e i r parents on a v a r i e t y of measures including nurses' observations of the c h i l d ' s d i s t r e s s and cooperation, ratings of the parents' anxiety and s a t i s f a c t i o n with the information provided, and pulse rates. In the second study, which was a r e p l i c a t i o n and extension of the f i r s t , the "stress-point pre-paration" group was compared with a sing l e - s e s s i o n preparation group, a supportive-care-only group, and a con t r o l group. The "stress-point preparation" was i d e n t i c a l to that i n the f i r s t study. The s i n g l e -session preparation provided the same information and opportunity f o r rehearsal as the "stress-point preparation" during a s i n g l e 45 minute session conducted by a nurse shortly a f t e r admission. Subjects i n the supportive care condition were given the opportunity to express f e e l i n g s , emotional support, and reassurance before each of the s i x s t r e s s f u l periods. The r e s u l t s indicated that the "stress-point 33 preparation" was s i g n i f i c a n t l y more e f f e c t i v e i n reducing anxiety i n both c h i l d r e n and parents than a l l the other conditions, including the sin g l e - s e s s i o n preparation. The authors suggested that t h i s i n t e r -vention was more e f f e c t i v e because i t enhanced a s s i m i l a t i o n of i n -formation over several sessions; prepared the c h i l d f o r one event at a time, shortly before the event's occurrence; and permitted the nurse to r e i n f o r c e the c h i l d for coping behaviours. Another study which involved the psychological preparation of chi l d r e n for h o s p i t a l i z a t i o n and surgery was reported by Melamed and Siegel (1975) . They investigated the e f f i c a c y of filmed relevant-peer-modeling i n reducing anxiety i n c h i l d r e n undergoing surgery. One hour before the scheduled admission time, the relevant-peer-modeling group observed a 16 minute f i l m which depicted a 7 year old boy, admitted to the h o s p i t a l for surgery, from the time of admission to discharge. The f i l m included information about h o s p i t a l s t a f f , rou-t i n e s , equipment, and procedures, narrated by h o s p i t a l s t a f f , and narration by the boy of his thoughts and fee l i n g s at each stage of the h o s p i t a l experience. The boy presented a coping model rather than a mastery model (Meichenbaum, 1971). He was i n i t i a l l y f e a r f u l and anxious before each procedure but managed to cope s u c c e s s f u l l y with each s t r e s s f u l s i t u a t i o n . The c o n t r o l group of c h i l d r e n , matched for age, sex, race, and type of operation with the relevant-peer-modeling group, observed a 12 minute unrelated co n t r o l f i l m , matched for i n -terest with the preparation f i l m . At a l a t e r time during admission day, both groups received routine preoperative i n s t r u c t i o n from a nurse who used pictures and demonstrations to explain what would 34 happen to the c h i l d on the day of surgery. In addition, the c h i l d r e n and t h e i r parents were v i s i t e d by the surgeon and/or anesthesiologist who t o l d them what the operation would involve, what the c h i l d would see i n the operating room, and how the c h i l d would be anesthetized. The r e s u l t s indicated that ;.the c h i l d r e n who watched the modeling f i l m were s i g n i f i c a n t l y less anxious than the c o n t r o l c h i l d r e n the night before the operation and three to four weeks a f t e r the operation as measured by state measures of anxiety, including s e l f - r e p o r t , behavi-oural observation, and a p h y s i o l o g i c a l measure, but not on measures of t r a i t anxiety. The authors plan to i n v e s t i g a t e the s p e c i f i c compo-nents that made the f i l m e f f e c t i v e by comparing a peer model, adult model, and demonstration-no-model condition. They are also r e p l i c a -t i n g t h e i r research i n a h o s p i t a l im.which the s t a f f - p a t i e n t r a t i o does not allow for preoperative i n s t r u c t i o n , to i n v e s t i g a t e the effectiveness and g e n e r a l i z a b i l i t y of the f i l m i t s e l f . The r e s u l t s of these studies would appear to suggest that m u l t i -modal preparation programmes designed to minimize the negative e f f e c t s of s u r g i c a l stress are e f f e c t i v e . To the extent that s u r g i c a l stress and r e l o c a t i o n stress are comparable, i t i s reasonable to assume that a s i m i l a r approach would be e f f e c t i v e i n reducing r e l o c a t i o n stress i n the .elderly. Although several r e -searchers have i d e n t i f i e d necessary components•for a successful pre-paration programme' to minimize the. impact of,.,a s t r e s s f u l event, Janis' (1965) suggestions seem p a r t i c u l a r l y u s e f u l . In h i s view, an e f f e c -t i v e preparation programme should include information about the nature 35 and possible consequences of the s i t u a t i o n , reassurance that the p o t e n t i a l l y aversive consequences can be kept under con t r o l or m i t i -gated, and i n s t r u c t i o n i n coping s k i l l s to reduce the damaging impact of the p o t e n t i a l changes. The preparation programme evaluated i n the present study in c o r -porated these suggestions, and u t i l i z e d the research findings on pre-d i c t a b i l i t y and c o n t r o l l a b i l i t y , coping s k i l l s t r a i n i n g , stress i n o c u l a t i o n , and preparation programmes for s u r g i c a l s t r e s s . S p e c i f i -c a l l y , the programme was designed to test the hypothesis that the stress of i n s t i t u t i o n a l r e l o c a t i o n on the e l d e r l y would be reduced by (a) increasing the p r e d i c t a b i l i t y of moving into the Extended Care Unit (ECU) at the Univ e r s i t y of B r i t i s h Columbia (UBC), (b) increasing patients' c o n t r o l over environmental events through t r a i n i n g i n a va r i e t y of stress management techniques, and (c) encouraging family support. 36 METHOD Subj ects P a r t i c i p a n t s i n the present study were 74 patients admitted to the Un i v e r s i t y of B r i t i s h Columbia's (UBC) newly opened, 300-bed Extended Care Unit (ECU) during i t s i n i t i a l six-month period of opera-t i o n from July 1977 to January 1978. Subject s e l e c t i o n was based on ratings of the patient's hearing, comprehension, and communication s k i l l s made by the patient's physician and the h o s p i t a l assessment team (see Appendix A for Extended and Intermediate Care A p p l i c a t i o n Form and B r i t i s h Columbia Hospital Insurance Service c r i t e r i a for Ex-tended Care). Patients with severe impairments i n any of these areas were excluded from the study sample. A d d i t i o n a l l y , p r i o r to a person's p a r t i c i p a t i o n i n the study i t was necessary to obtain the consent of the i n s t i t u t i o n where the patient previously resided and personal con-sent from the patients themselves (see Appendix B). Subjects were assigned to one of three experimental conditions: (1) assessment-only c o n t r o l , (2) attention placebo, and (3) preparation programme (PREP). A l l subjects from any one p a r t i c u l a r f a c i l i t y were assigned to the same condition to prevent possible contamination e f f e c t s from h o s p i t a l s t a f f f a m i l i a r with the PREP programme. F a c i l i t i e s were s t r a t e f i e d on the basis of population s i z e (small, medium, and l a r g e ) . Then f a c i l i t i e s within each s i z e category were randomly assigned to one of three experimental conditions. Subjects were admitted to the ECU from pr i v a t e homes and from 41 f a c i l i t i e s i n the Greater Vancouver area representing four l e v e l s of care — personal, intermediate, 37 extended, and acute (see Table l..for the percentage of subjects i n each group coming from each l e v e l of care). The percentages of subj.ects coming from these f i v e l e v e l s of care were 15.6%, 10.9%, 6.3%, 32.8%, and 34.4%, re s p e c t i v e l y . Inspection of Table 1 reveals that a dispor-portionately large number of subjects i n the attention placebo group came from acute care f a c i l i t i e s . Because f a c i l i t i e s were randomly assigned a f t e r being s t r a t i f i e d according to s i z e , there was no c o n t r o l over the type of care provided by the previous f a c i l i t y . The subjects ranged i n age from 44 to 101 years with a mean age of 80.2 years and a median age of 89 years (S.D. = 11.09). Seventy-eight percent of the study sample were female (F = 52, M = 22), and 79.73% were non-ambulatory ( i . e . , used a wheelchair). The most f r e -quent primary diagnosis, cerebral i n s u l t (e.g., tumour, stroke, Parkinsons's disease) accounted for 38.4% of the study sample (see Table 2). Of the 74 subjects selected for the study, 58 remained i n the h o s p i t a l at the three month follow-up, and 43 remained at the s i x months follow-up. A t t r i t i o n was due to death, transfer to other h o s p i t a l s , r e f u s a l to be re-interviewed, and d e t e r i o r a t i o n (e.g., loss of hearing).-As shown i n Tables 3 and 4, there was no evidence of d i f f e r e n t i a l a t t r i -t i o n among the three groups, nor were there s i g n i f i c a n t differences among them i n number of deaths, t r a n s f e r s , r e f u s a l s , or deteriorations between preadmission and the s i x months follow-up ,^ as .'indicated by analyses of proportion (Marascuilo, 1966). Assessment Instruments Information relevant to the subject's s o c i a l , psychological, arid 38 Table 1 Percentage of Subjects i n Each Group Coming from Privat e Homes, Personal, Intermediate, Extended, and Acute Care F a c i l i t i e s Levels of Care Groups Private Personal Intermediate Extended Acute Assessment (5) (3) (1) (13) (8) Only Control 16.7% 10.0% 3.3% 43.9% 26.7% Attention (2) (1) (0) (2) (13) Placebo 11.1% 5.6% 0.0% 11.1% 72.2% Preparation (3) (3) (3) (6) X i ) Programme 18.8% 18.8% 18.8% 37.5% 6.3% T o t a l (10) (7) (4) (21) (22) 15.6% 10.9% 6.3% 32.8% 34.4% H O t - 1 T J > o > i-i r t 0 CO ro fa r t l-> cn o ro v; ro {0 ro 3 cn I f cr r t n cn I" o H - o S r t O 3 ro H - 3 r t 3 O i f r t 3 Ol i — • r—' ho /—\ ho ^—> .ho • vO • -P- • r—' • C o ^ O ^ 0 0 On 1—< r—' hO ho / - N O oo O N • VD • K ) • On • hO U J ^ O ^ 0 0 *— <•*> —' i — • r—» 0 0 / - N O o ho ,—s • CT* • ho • O • 0 0 ho ' O ^ o "— On O J / - N •P- 0 0 U> , N 0 0 ho On 0 0 —s -P- 1—• • 0 0 • v o • 0 0 • r—* J S w O ^ v • -P- * r—• 0 0 / - N O o ^— v 0 0 \ • CT> • O • o • O N ho w O ^ o *—^ 0 0 ^—' -P- ^ On VD o • 0 0 r-* • ho • o H-i ' o On *—s o 1—' <—\ o • - s ' o • r - - • o • r—' • o J>- v—- o ^ CO p —' I—' O ^ - N o • o • t—' • o -P- ~ - - / o Co o o 0 0 ^—\ • c o • o ho • r—1 i — w o ^ On —^' t—' ^—^ i — ^ O / ~ N o / s CO • o • O 1—' •P- ^ O ' o ' t—' r—1 0 0 ^ O —s ^—^ • O • 0 0 • r - 1 • 0 0 ho w o ^ 0 0 ^ - —^' ^—* / ~ \ —v ho ho 0 0 0 0 o r—' ho s — ' ^—' Q H O C x> cn P s y c h i a t r i c Problems Heart Disease C i r c u l a t o r y Problems Cerebral Insult Musculo/ Sk e l e t a l Problems Metabolic Disorders Gastro I n t e s t i n a l Disorders Organ F a i l u r e Integument Sensory Impairments Miscellaneous ro rf n ro 3 rt [u 00 ro cn o t-ti c/i & ro o 0 E (B O rr o i f o c •a s: H -r t 3* H -3 K fa O D* >n rf H -S fu I f VI a H -Co 0Q 3 o cn r t H -O n w rt ro O P o n T o t a l 40 Table 3 Number of Subjects i n Each Group at the Preadmission, Three Months, and Six Months Follow-ups Assessment Periods Groups Preadmission Three Months Six Months Assessment-Only Control 32 23 18 Attention Placebo 22 19 15 Preparation Programme 20 ' 16 10 T o t a l 74 58 43 41 Table 4 Summary of Subject A t t r i t i o n between Preadmission and Six Months Follow-up Deterio- _N @ 6 mo. Groups N Transfers Deaths Refusals rations follow-up Assessment Only Control 32 Attention Placebo 22 18 15 Preparation Programme 20 6 2 1 1 10 T o t a l 74 19 6 4 2 43 Transfers X 2.( 2) = 1-07, £ = 0.58 Deaths x 2(2) = 0.27, £ = 0.87 Refusals x 2(2) = 0.09, £ = 0.96 Deteriorations x 2(2) = 1.04, £ = 0.60 T o t a l drop-outs x 2(2) = 1.60, £ = 0.45 42 health functioning was provided by (1) the subjects themselves, (2) an interviewer, and (3) the s t a f f caring f o r the subject. These data were obtained at three assessment periods — preadmission, three month follow-up, and s i x month follow-up. In addition, data from behavioural observations were c o l l e c t e d at the two follow-up periods. The preadmission battery c o l l e c t e d information concerning (1) demo-graphic c h a r a c t e r i s t i c s , (2) mental status, (3) l i f e s tress envets, (4) health status, (5) l i f e s a t i s f a c t i o n , and (6) attitudes towards the forthcoming r e l o c a t i o n . Information regarding age, b i r t h p l a c e , m a r i t a l status, education, previous occupation, and h i s t o r y of recent h o s p i t a l i z a t i o n was provided by the subject (see Appendix C), while primary diagnosis was obtained from the a p p l i c a t i o n for extended care (see Appendix A). The Mental Status Questionnaire . (Kahn, Galdfarb, Pollack, & Peck, 1960, see Appendix D), a ten-item instrument designed for an e l d e r l y population, was used to assess the subject's o r i e n t a -t i o n to time, place, and person, while the L i f e Stress Events Schedule, adapted from Amster and Kraus' (1974) Checklist of L i f e Events, was used to determine the number and dates of l i f e stress events which occurred during the previous s i x months (see Appendix E). A measure of the subjects' s e l f - r a t e d health was provided by the Health Status Questionnaire (adapted from Gutman, 1978, see Appendix F ) , c o n s i s t i n g of a c h e c k l i s t of 16 health problems that occur frequently i n an e l d e r l y population. The nature, number, and severity of the subject's health problems were recorded and a weighted health status score was derived from the t o t a l number of health problems weighted by t h e i r s e v e r i t y . The subject's degree of l i f e s a t i s f a c t i o n was measured by the L i f e S a t i s f a c t i o n Index, an instrument developed f o r an e l d e r l y population 43 by Neugarten, Havighurst, and Tobin (1961, see Appendix G). A d d i t i o n a l l y , the battery included several items which determined the subject's per-ceived choice i n the decision to relocate and attitudes towards the forthcoming r e l o c a t i o n (see Appendix H). A l l of the above information was c o l l e c t e d during a one-hour assessment interview at the three assessment periods, with the exception of the demographic characterise t i c s , schedule of l i f e s tress events, and a t t i t u d e s towards the f o r t h -coming r e l o c a t i o n which were assessed ar preadmission only, and the Post-Relocation Adjustment Scale (Lawton & Cohen, 1974, see Appendix I) which was administered only at the two follow-ups. The Post-Relocation Adjustment Scale consisted of. 14 items which measured the subjects' perceptions of t h e i r health status, s o c i a l i n t e r a c t i o n s , and l e i s u r e a c t i v i t i e s a f t e r admission to the ECU. Interviewer data. The Interviewer's Observation Form was com-pleted immediately a f t e r each assessment of the subject (see Appendix J ) . This form included the VIRO Scale (Kastenbaum & Sherwood, 1972), which consisted of 13 items designed to assess the subject's behaviour during the interview on four dimensions: (1) energy l e v e l (Vigour), (2) a b i l i t y to use s o c i a l l y appropriate behaviour (Intactness), (3) l e v e l and s t y l e of i n t e r a c t i o n s (Relationship), and (4) cognitive functioning (Orientation). Items were scored on a 4 point scale with a score of 4 representing normal adult functioning. The i n t e r - r a t e r r e l i a b i l i t y of t h i s instrument has been shown by i t s developers to be s a t i s f a c t o r y . The form also included a r a t i n g scale of the perceived r e l i a b i l i t y of the information provided by the subject and space for a d d i t i o n a l comments. 44 Data from h o s p i t a l s t a f f . ; Hospital s t a f f were requested to com-ple t e two assessment instruments. The f i r s t of these, the Nurses's Observation Scale (NOS) (Buchan, 1978), was designed to provide a global assessment of the subject's l e v e l of functioning, based on behavioural indices r e a d i l y observable by nurses through t h e i r d a i l y contact with the subject (see Appendix K). The scale assessed f i v e major areas: (1) cognitive functioning, (2) s o c i a l functioning, (3) adaptive behaviour, (4) global p h y s i c a l well-being, and (5) a c t i v i t i e s of d a i l y l i v i n g . Each section consisted of a number of items which were rated on a 4-point scale. A score of 4 indicated the highest l e v e l of functioning, while a score of 1 represented the most severe l e v e l of impairment. Nurses were instruc t e d to c i r c l e the number which most accurately r e f l e c t e d how the subject was a c t u a l l y functioning. The second instrument, the Functional Assessment of A c t i v i t i e s of Daily L i v i n g (ADL) (Campbell, 1978) was designed to measure the sub-j e c t ' s degree of independence i n dressing, hygiene, eating, and ambula-t i o n (see Appendix L ) . The subject's a b i l i t y to peform components of these a c t i v i t i e s was measured on a 3-point scale. A score of 1 repre-sented t o t a l independence or the a b i l i t y to perform the a c t i v i t y with-out supervision, d i r e c t i o n , or a c t i v e personal assistance, while a score of 3 indicated t o t a l dependence i n the a c t i v i t y . Nurses who were f a m i l i a r with the subjects and b l i n d to the experimental conditions to which they were assigned, completed the NOS and ADL at preadmission, and at the two follow-up assessment periods. Data from behavioural observations. .The Planned A c t i v i t y Check-l i s t (PLA Check), adapted from Doke and Risl e y ' s (1972) instrument, was 45 used to determine the subject's pattern of p a r t i c i p a t i o n i n s o c i a l , r e c r e a t i o n a l , and therapeutic a c t i v i t i e s at four d i f f e r e n t time periods during the day, one mealtime, two scheduled a c t i v i t y periods, and one free-time period (see Appendix M for sample c h e c k l i s t ) . Raters (student volunteers for the study) observed a subject for 10 seconds, then recorded the subject's (1) l o c a t i o n , (2) state of consciousness, (3) type of a c t i v i t y engaged i n , and (4) degree of s o c i a l p a r t i c i p a -t i o n . Observations were made on two nonconsecutive days weekly f o r two weeks at each of the two follow-up periods . While i t i s possible that a small minority of raters may not have been b l i n d to the experi-mental conditions to which the subjects they were observing had been assigned, r e l i a b i l i t y checks were made on hal f of the observations to reduce the l i k e l i h o o d of observer bias. Therapists Six t h e r a p i s t s , including the in v e s t i g a t o r , p a r t i c i p a t e d i n the study. Five of the therapists had either a BA or MA i n psychology, and the s i x t h was a graduate student i n g e r i a t r i c nursing. Three of the therapists conducted the preparation programme condition and the assessment-only condition. They received a d e t a i l e d d e s c r i p t i o n of the preparation programme and t r a i n i n g i n interviewing the e l d e r l y and the a p p l i c a t i o n of modelling, behavioural rehearsal, and reinforcement. The other three therapists conducted assessments on subjects i n the attention placebo and assessment-only conditions. They received t r a i n i n g i n interviewing the e l d e r l y , but were unfamiliar with the preparation programme. They were instructed to answer subjects' questions to the best of t h e i r a b i l i t y and provide emotional support. 46 The Preparation Programme Condition: PREP Two to three weeks before the move, a therapist conducted a preparation programme designed to minimize r e l o c a t i o n stress f o r sub-j e c t s i n the preparation condition. The intervention consisted of three components: (1) an information slide-tape programme, (2) a stress-management t r a i n i n g s l i d e - t a p e programme, and (3) sponsor t r a i n i n g and involvement. The PREP programme was conducted during three 45-minute sessions subsequent to the preadmission assessment interview. Therapy, session 1. During the f i r s t therapy session, the subject was shown a 15-minute sli d e - t a p e programme, e n t i t l e d "A Time for Change" (Campbell & Hutton, 1977) which was designed to provide accurate information and create r e a l i s t i c expectancies about the UBC ECU (see Appendix N for a t r a n s c r i p t ) . In the programme, an e l d e r l y woman described the f a c i l i t y ' s a r c h i t e c t u r e , i n t e r i o r design, routines and regulations, s t a f f duties, medical s e r v i c e s , and s o c i a l and r e c r e a t i o n a l programmes. The therapist answered the subject's questions about the ECU and r e l o c a t i o n process, and helped the subject to i d e n t i f y and solve s p e c i f i c problems such as lo s i n g one's privacy and f r i e n d s . Therapy sessions 2 and 3. A second slide-tape programme de-signed to teach the subject coping s k i l l s was shown i n two parts during the second and t h i r d sessions. In th i s 35-minute programme, e n t i t l e d , "Getting Ready for Moving Day", an .elderly woman described problems commonly experienced i n a move to an ECU (e.g., how to decide what to bring, how to get enough privacy, and how to get information about regulations) and described methods of solving these problems (see 47 Appendix 0 for a t r a n s c r i p t ) . These methods consisted of several stress-management techniques. Part I provided i n s t r u c t i o n i n problem-solving, t a l k i n g to others, and assertiveness, while Part II focussed on deep breathing, coping self-statements, and p o s i t i v e thinking. The a p p l i c a t i o n of these techniques to the subject's problems was demon-strated by the therapist at designated points during each session (see Appendix P for therapist g u i d e l i n e s ) . The therapist used modelling, behavioural rehearsal, and reinforcement to f a c i l i t a t e learning of the techniques. A b r i e f d e s c r i p t i o n of each stress-management technique i s given below. Problem s o l v i n g . D ' Z u r i l i a , and Goldfried's (1971) problem-solving method was presented as an active coping strategy. Subjects were given a general o r i e n t a t i o n to problem-solving. They were then taught how to define the problem, generate several s o l u t i o n s , and decide upon an appropriate s o l u t i o n . Talking to others. Subjects were to l d that expressing t h e i r con-cerns to others (e.g., patients, s t a f f , or r e l a t i v e s ) could help them to gain s o c i a l support, gather information, and i d e n t i f y , .and possibly solve, problems. Assertiveness. Not only were subjects encouraged to accept the r i g h t to be as s e r t i v e , but also they were t o l d that behaving asser-t i v e l y (e.g., by asking questions when information was needed) would f a c i l i t a t e adjustment to the new environment. I n s t r u c t i o n i n behaviour rehearsal of a s s e r t i v e behaviour was also provided. Deep breathing. The deep breathing method as described by Meichenbaum (1975) was presented as a technique f o r handling subjective 48 and p h y s i o l o g i c a l anxiety responses. Subjects were t o l d to take short deep breaths u n t i l t h e i r lungs f e l t f u l l , hold the breath f o r about f i v e seconds, and exhale slowly through s l i g h t l y parted l i p s . They were also encouraged to p r a c t i c e deep breathing d a i l y f o r about 10 minutes and breathe deeply whenever they became anxious. Coping self-statements. Cognitive s t r a t e g i e s f o r coping with s t r e s s f u l events such as those described by Meichenbaum and Cameron (1973) were outlined. The contribution of negative self-statements to stress and anxiety was discussed. Subjects were instructed i n the observation of negative or s e l f - d e f e a t i n g statements, and the use of those statements and accompanying p h y s i o l o g i c a l stress responses as di s c r i m i n a t i v e cues f or coping statements. The use of coping statements was also modelled. P o s i t i v e thinking. Subjects were t o l d that imagining themselves r e l o c a t i n g and l i v i n g at the ECU could help t h e i r preparation for the move. They were encouraged to think about t h e i r current personal assets and past accomplishments, and to imagine themselves p a r t i c i p a -t i n g s u c c e s s f u l l y i n h o s p i t a l a c t i v i t i e s which they might f i n d enjoyable. Sponsor t r a i n i n g and involvement. Sponsor support (e.g., family, f r i e n d , or s o c i a l worker) and p a r t i c i p a t i o n i n a l l phases of the r e -l o c a t i o n was encouraged. Sponsors attended two group meetings de-signed to provide them with information about r e l o c a t i o n s t r e s s and the preparation programme, and i n s t r u c t i o n i n methods of helping t h e i r r e l a t i v e s prepare for the move. During these meetings, the sponsors were shown the two slide-tape programmes, taken on a tour of the f a c i l i t y , given the opportunity to ask questions, and given a sponsor's 49 manual (see Appendix Q). This manual outlined the stress-management techniques discussed previously and offered suggestions for making the patients' move as easy as possible. These suggestions included t a l k i n g openly about the move, discussing the mechanics of the move, and pro-v i d i n g information about the ECU. Attention Placebo Condition The attention placebo condition was intended to con t r o l f o r therapeutic e f f e c t s r e s u l t i n g from nonspecific factors such as i n d i -v i d u a l i z e d a t t e ntion, expectation of b e n e f i t , and emotional support during a s t r e s s f u l period. A therapist, unfamiliar with the prepara-t i o n programme, conducted the preadmission assessment interview on the subjects i n t h i s condition and v i s i t e d each subject on three a d d i t i o n a l occasions before the move. Subjects were t o l d that during these v i s i t s the therapist would be a v a i l a b l e to answer questions and discuss con-cerns about moving. Assessment-Only Control Condition Subjects i n th i s group were assessed only at preadmission and the two follow-ups. The r a t i o n a l e given to a l l subjects i n the three experimental conditions f o r the assessment interviews was that the information obtained during the interviews would enable the s t a f f at the ECU to develop and update an i n d i v i d u a l i z e d care plan. 50 RESULTS Pre-Existing Differences Among Groups An attempt was made to determine whether there were any pr e - e x i s t i n g differences among the groups at preadmission i n demographic charac-t e r i s t i c s , number of l i f e stress events occurring during the s i x months period before r e l o c a t i o n , attitudes towards the forthcoming r e l o c a t i o n , and on any of the dependent v a r i a b l e s . Table 5 shows the demographic c h a r a c t e r i s t i c s of subjects i n the three groups. A one-way analysis of variance (ANOVA) revealed s i g n i f i -cant differences among the three groups i n age , F_(2,70) = 5.49, _p_ = .006 (see Appendix R) . A Scheffe post-hoc analysis indicated that the subjects i n the preparation group were s i g n i f i c a n t l y younger (_p_ < .05) than those i n the assessment-only c o n t r o l group. Chi-square analyses on sex and ambulatory status did not y i e l d s i g n i f i c a n t d i f -ferences . Table 6 shows mean scores and standard deviations of measures of l i f e stress events and atti t u d e s towards the forthcoming r e l o c a t i o n . One-way ANOVAs on each of these measures did not reveal any s i g n i f i c a n t differences (see Tables 1 and 2 i n Appendix S). A seri e s of one-way ANOVAs were also conducted on preadmission scores on each of the following dependent v a r i a b l e s : (1) mental status, (2) weighted health status, (3) l i f e s a t i s f a c t i o n , (4) VIRO, (5) NOS, and (6) ADL (see Tables 1 to 6 i n Appendix T). Mean scores and standard deviations on these variables are presented i n Table 7. S i g n i f i c a n t group differences were revealed for (1) l i f e s a t i s f a c t i o n , F_(2,69) = 3.09, 51 Table 5 Demographic C h a r a c t e r i s t i c s of Subjects i n Each Group Age (in years) Group N Sex Ambulatory Status Mean S.D. % Females % Ambulatory Assessment Only Group 32 84.72 7.97 78.1 78.1 Attention Placebo Group 22 77.86 9.76 59.1 86.4 Preparation Programme 20 75.55 14.10 70.0 75.0 T o t a l 74 80.20 11.09 70.3" 79.7 52 Table 6 Means and Standard Deviations on Measures of the Number of L i f e Stress Events Occurring During the Six Months Period Before Relocation and Number of P o s i t i v e Attitudes Towards the Forthcoming Relocation L i f e Stress Events Attitudes Group N Mean S.D. Mean S.D. Assessment Only Control 29 1.00 1.28 5.39 2.30 Attention Placebo 19 0.63 0.83 6.33 2.26 Preparation Programme 20 0.40 0.50 4.75 2.21 To t a l 68 53 Table 7 Summary of Means on Mental Status, Weighted Health Status, L i f e S a t i s f a c t i o n , VIRO, NOS, and ADL Measures at Preadmission Measure Assessment Only Control (n = 32) Groups Attention Placebo (n = 22) Preparation Programme (n = 20) Mental Status 9.00 Weighted Health Status 11.47 L i f e S a t i s f a c t i o n 5.72 VIRO 40.56 NOS 2.94 ADL 8.98 8.86 11.57 6.76 40.90 3.11 7.99 8.76 10.6 4.95 34.89 2.98 6.88 54 p_ = .051 (see Table 3 i n Appendix T), (2) VIRO, F(2,69) = 4.10, £ = .02 (see Table 4 i n Appendix T), and (3) ADL. F(2,63) = 7.05, p_ = .002 (see Table 6 i n Appendix T). I t i s evident from these data that sub-j e c t s i n the preparation programme group scored lower than the other : two groups on a l l of these variables i n d i c a t i n g that they were l e a s t s a t i s f i e d with l i f e , functioned more poorly i n the areas of behaviour assessed by the VIRO, and functioned at a higher l e v e l on ADL. A l -though a Scheffe post-hoc comparison did not reveal s i g n i f i c a n t d i f -ferences among group means on l i f e s a t i s f a c t i o n , a separate post-hoc comparison on VIRO scores indicated that the subjects i n the prepara-t i o n programme group.scored s i g n i f i c a n t l y lower (p_ < .05) than subjects i n the other two groups. A d d i t i o n a l l y , a Scheffe post-hoc comparison on ADL scores indicated that subjects i n the preparation programme group were s i g n i f i c a n t l y better (p_ < .05) i n ADL than subjects i n the assessment-only co n t r o l group. Pre-Post Comparisons Since s i g n i f i c a n t preadmission differences were found among the three groups on l i f e s a t i s f a c t i o n , VIRO, and ADL, these v a r i a b l e s were subjected to a repeated measures analysis of covariance on scores at the three and s i x months follow-ups. The r e s u l t s of these analyses appear i n Tables 1, 2,.and 3 i n Appendix U. No s i g n i f i c a n t main ef f e c t s or i n t e r a c t i o n s were found on any of these v a r i a b l e s . In order to determine whether there were any s i g n i f i c a n t d i f -ferences among the three groups over time i n terms of dependent variables on which there were no s i g n i f i c a n t preexisting d i f f e r e n c e s , a ser i e s of repeated measures ANOVAs was used to compare the three 55 experimental conditions over the preadmission, three months, and s i x months follow-up periods on (1) mental status, (2) weighed health status, and (3) NOS. A d d i t i o n a l l y , a repeated measures ANOVA was used to compare the three groups on Post-Relocation Adjustment Scale scores over the two follow-up periods. The r e s u l t s of these analyses appear i n Tables 1 to 4 i n Appendix V. The only s i g n i f i c a n t r e s u l t s were found i n mental status. This analysis revealed a s i g n i f i c a n t time e f f e c t , F ( 2 , 4 ) = 1 9 . 0 4 , JJ < .01 (see Table 1 i n Appendix V). A Tukey's range test comparing mental status score at the three time points indicated that scores f o r a l l groups at the s i x months follow-up were s i g n i f i c a n t l y improved (_p < . 05 ) from those at preadmission and the three months follow-up (see Table 8 for group means at each of the time p o i n t s ) . Since there was considerable subject a t t r i t i o n from preadmission to the s i x months follow-up period (see Table 3 ), a d d i t i o n a l repeated measures ANOVAs were conducted on (1) mental status, (2) weighted health status, and (3) NOS over the preadmission and three month follow-up assessment periods, i n order to determine whether there were any a d d i t i o n a l differences for th i s somewhat larger sample. Analyses of these data did not reveal any s i g n i f i c a n t main e f f e c t s or i n t e r -actions (See Tables 1 to 3 i n Appendix W). Data from Behavioural Observations An attempt was made to determine whether data c o l l e c t e d from behavioural observations at the two follow-up periods of the subject's (1) l o c a t i o n , (2) state of consciousness ( i . e . , awake vs. asleep), (3) type of a c t i v i t y engaged i n , and (4) degree of s o c i a l p a r t i c i p a t i o n 56 Table 8 Mean Scores on Mental Status at Preadmission, Three Months, and Six Months Follow-ups Means Groups N Pre- Three Six Admission Months Months Assessment Only Control 19 12.74 12.84 11.37 Attention Placebo 13 12.31 12.77 10.77 Preparation Programme 10 11.80 12.30 10.40 57 r e f l e c t e d any s i g n i f i c a n t differences among the groups. Seclusiveness. An attempt was made to. determine the extent to which subjects secluded themselves. Accordingly, the subject's loca-t i o n was recorded at each of the four d a i l y observation periods for each of the four days that the behavioural observations were conducted. A repeated measures ANOVA was conducted on the percentages of obser-vations over the three and s i x months follow-ups when subjects i n each of the groups were located i n t h e i r bedrooms and/or bathrooms (see Table 1 i n Appendix X). No s i g n i f i c a n t main e f f e c t s or in t e r a c t i o n s were found. Sleep. A repeated measures ANOVA was used to compare the percen-tages of behavioural observations over the three and s i x months follow-ups when the subjects i n each group were found to be sleeping. The analysis did not reveal any s i g n i f i c a n t main e f f e c t s or in t e r a c t i o n s (see Table 2 i n Appendix X). Engagement i n a c t i v i t i e s . The a c t i v i t y section of the PLA check form included 16 a c t i v i t i e s comprising.the most frequently observed behaviours i n an extended care population (see Appendix M). Data from t h i s section were coded to in d i c a t e whether the subject was engaged i n any of. these a c t i v i t i e s . Two 3x5 contingency tables were constructed which present the percentage of subjects active during 0%, 25%, 50%, 75%, or 100% of the observation periods at the two follow-ups (see Tables 4 and 5 i n Appendix X). Since greater than 80% of the expected c e l l frequencies of the tables were less than f i v e , i t was not possible to proceed with a chi-square analysis (Ferguson, 1959). Accordingly, a repeated measures ANOVA was conducted on the percentage of subjects 58 ±n:;each group engaged i n any a c t i v i t y during 100% of the behavioural observation periods over the three and s i x months follow-ups. There were no s i g n i f i c a n t main e f f e c t s or int e r a c t i o n s (see Table 3 i n Appendix X), Interpersonal i n t e r a c t i o n . The percentage of subjects from each group who were not engaged i n any interpersonal in t e r a c t i o n s during 0%, 25%, 50%, 75%, or 100% of the behavioural observations at the three and s i x months follow-up are presented i n two contingency tables i n Tables 6 and 7 i n Appendix X. Although the expected c e l l frequencies were too low to proceed with a chi-square analysis (Ferguson, 1959), from v i s u a l inspection of the data, i t may be seen that there are no apparent differences among the groups at either of the follow-ups. What i s noteworthy i s that a l l three groups spent almost a l l of t h e i r time alone. For example, the mean percentage of subjects i n the assessment-only c o n t r o l , attention placebo, and preparation programme groups alone during a l l of the observation periods at the three months follow-up were 87%, 88.9%, and 85.7%, r e s p e c t i v e l y . Similar r e s u l t s were obtained at the s i x months follow-up. 59 DISCUSSION The r e s u l t s of the present study do not support the o r i g i n a l hypothesis. The group which received the preparation programme de-signed to increase p r e d i c t a b i l i t y of the consequences of moving to the UBC ECU, to enhance con t r o l over environmental events, and to encourage family support did not score s i g n i f i c a n t l y higher than the assessment-only control and attention placebo groups on any of the dependent variables at e i t h e r the three or s i x months follow-up. The preparation programme was c l e a r l y not as e f f e c t i v e as expected. Although no s i g n i f i c a n t main e f f e c t s or i n t e r a c t i o n s were found on any of the dependent v a r i a b l e s , s i g n i f i c a n t time e f f e c t s over the preadmission, three months, and s i x months follow-up were indicated for mental status. A post-hoc analysis of mental status scores at each of the three assessment periods indicated that a l l three groups deteriorated s l i g h t l y at the three months follow-up and improved s i g -n i f i c a n t l y at the s i x months follow-up. These r e s u l t s are consistent with researchers' suggestion that the f i r s t three months a f t e r r e l o c a -t i o n to an i n s t i t u t i o n are the most s t r e s s f u l for the patient (Tobin & Lieberman, 1976). The f a c t that subjects improved i n mental status over time, however, i s quite i n t e r e s t i n g since the few studies which measure changes i n cognitive functioning following r e l o c a t i o n (e.g., Lieberman, 1974; Pablo, 1977) report declines i n me"ntal status over time. A reconsideration of the o r i g i n a l hypothesis and the assumptions underlying the conceptualization, experimental design, and methodology 60 of the present study may be useful i n explaining why subjects i n the preparation programme group d i d not function on a higher l e v e l a f t e r r e l o c a t i o n than the other two groups. It was conceptualized that the e f f e c t of r e l o c a t i o n on the e l d e r l y depends upon (1) c h a r a c t e r i s t i c s of the relocatees; (2) circumstances of r e l o c a t i o n (e.g., voluntariness, degree of environmental change, s o c i a l support, preparation, and f o l -low-up support); (3) c h a r a c t e r i s t i c s of the new l o c a t i o n ; and (4) the match between (1) and (3). Furthermore, i t was hypothesized that other factors being equal, a group which received a multimodal preparation programme would experi-ence less stress than a group which received attention and/or assess-ment interviews only. With respect to the subject c h a r a c t e r i s t i c s , i t was assumed that the subjects were i n i t i a l l y comparable i n terms of d e f i c i e n c i e s i n coping s k i l l s (e.g., problem-solving, assertiveness, r e l a x a t i o n , coping self-statements, and p o s i t i v e thinking). I t was also assumed that subjects i n the preparation programme group would learn these s k i l l s and apply them i n the new environment. Assessments of these s p e c i f i c s k i l l s , however, were not conducted at any of the assessment periods. As a r e s u l t , i t i s not known whether subjects i n the three groups were i n i t i a l l y comparable i n t h e i r a b i l i t y to cope with s t r e s s . In addition, i t i s not known whether subjects i n the preparation programme group did, i n f a c t , learn these s k i l l s . Assessments of sub-^ j e c t s ' s p e c i f i c coping s k i l l s would obviously have been valuable at 61 a number of points (e.g., preadmission, immediately a f t e r the prepa-r a t i o n programme, shor t l y a f t e r admission to the UBC ECU, three months, and s i x months a f t e r admission). Future investigations could make use of recently developed tech-niques for the behavioural assessment of coping s k i l l s . Behaviourally oriented researchers, dealing with c l i e n t s who lack assertiveness, problem-solving s k i l l s , and cognitive coping s t r a t e g i e s , have conducted fun c t i o n a l analyses of both cognitive and behavioural coping s k i l l s .(Kanfer & Saslow, 1969; Meichenbaum, 1977) through a combination of s e l f - r e p o r t measures (Gambrill & Richey, 1975), observation of r o l e -playing behaviours (Goldfried & D ' Z u r i l l a , 1969; Meichenbaum, 1977), and n a t u r a l i s t i c time-sampling observations (Jones, Reid, & Patterson, 1975). Research conducted by Toseland and Rose (1978) provides a good i l l u s t r a t i o n of the p o t e n t i a l u t i l i t y of behavioural assessment i n gerontological research. They used a r o l e - p l a y i n g test based on a model by Goldfried and D ' Z u r i l l a (1969) and an adaptation of the Gambrill-Richey Assertiveness Inventory (1975) to assess the e l d e r l y i n d i v i d u a l ' s s o c i a l s k i l l s , p r i o r to and following a s o c i a l s k i l l s t r a i n i n g programme. Anecdotal evidence c o l l e c t e d from p i l o t subjects during the de-velopment of the slide-tape programme, indicated that the programme was of appropriate length, comprehensibility, and relevance to a g e r i a t r i c population. However, since a systematic and objective as^ sessment of the slide-tape programme was not conducted with the sub-j e c t s i n t h i s research, one cannot conclusively r u l e out the p o s s i b i l i t y that the programme was either too long or too d i f f i c u l t to comprehend. 62 It i s also possible that a preparation programme alone i s insuf-f i c i e n t to minimize r e l o c a t i o n stress i n the e l d e r l y to a s i g n i f i c a n t degree. Since research suggests that the period immediately following r e l o c a t i o n i s very s t r e s s f u l , several authors have recommended that a comprehensive r e l o c a t i o n programme should include a p o s t - r e l o c a t i o n component (Haberkorn et a l . , 1977; Lawton, 1974; Leibowitz, 1974; Tobin & Lieberman, 1976). Although.sponsors were encouraged to make f r e -quent v i s i t s during the patient's f i r s t month i n the ECU, a sys-tematic .post-relocation programme was not included i n the present study. In order to i n v e s t i g a t e whether preparation i s e f f e c t i v e only i n combination with follow-up, i t would be worthwhile for future research to investigate the e f f e c t s of preparation with and without a follow-up programme. According to Lawton (1974) a follow-up programme should provide the patient with o r i e n t a t i o n to the i n s t i t u t i o n . S p e c i f i c a l l y i t could include systematic introduction to s i g n i f i c a n t persons and t h e i r functions (e.g., s t a f f and roommates), to a c t i v i t y programmes, and to mechanical aids (e.g., century bath tubs, c a l l buttons). A d d i t i o n a l l y , i t could include v i s i t s to the patient by the therapist to determine whether the patient i s having any d i f f i -c u l t i e s i n coping and review s k i l l s i f necessary. It was assumed that the procedure for assignment of subjects to groups would c o n t r o l for differences i n the degree of environmental change i n the r e l o c a t i o n . The actual degree of environmental change, however, was not d i r e c t l y assessed. Although i t i s tempting to examine the percentage of subjects i n each group coming from p r i v a t e homes, personal, intermediate, extended, and acute care f a c i l i t i e s , there may 63 w e l l be greater v a r i a t i o n i n environmental c h a r a c t e r i s t i c s of f a c i l i t i e s w i thin each l e v e l of care category, than between f a c i l i t i e s from two d i f f e r e n t l e v e l s of care. It i s i n t e r e s t i n g to note, however, that the major differences among the three groups i n terms of the l e v e l of care provided i n the subjects' previous f a c i l i t i e s was i n the percen-tages coming from acute care f a c i l i t i e s . The percentage of subjects i n the assessment-only, a t t e n t i o n placebo, and preparation programme groups were 27%, 72.2%, and 6.2%, r e s p e c t i v e l y . An analysis of proportions (Marascuilo, 1966) on t h i s data revealed s i g n i f i c a n t differences among the groups (X 2(2) = 29.44, p_ < .001). Scheffe post-hoc comparisons indicated that the percentage of subjects i n the a t t e n t i o n placebo group from an acute care f a c i l i t y was s i g n i f i c a n t l y d i f f e r e n t from per-centages of subjects i n both the assessment-only and preparation pro-gramme groups. Many patients e l i g i b l e for extended care i n B r i t i s h Columbia are i n i t i a l l y admitted to acute care h o s p i t a l s for an acute problem (e.g., broken leg, stroke, i l l n e s s ) and remain i n these f a c i l i t i e s u n t i l an ECU bed becomes a v a i l a b l e . The mean number of months that subjects spent i n an acute care f a c i l i t y immediately before r e l o c a t i o n to the UBC ECU, for example, was 8.2 months (S.D. = 6.12). Since acute care hospit a l s lack s o c i a l and r e c r e a t i o n a l programmes and opportunities to eat meals i n a communal dining area, a move from an acute care h o s p i t a l to the UBC ECU would l i k e l y have represented a change for the better. Since i t has been suggested that r e l o c a t i o n to an improved f a c i l i t y appears to r e s u l t i n improved functioning (Kraus et a l . , 1976) i t i s possible that the disproportionately large number of subjects from 64 acute care f a c i l i t i e s i n the assessment-only and attention, placebo groups may have masked the e f f e c t s of the preparation programme. To c o n t r o l for v a r i a t i o n i n the degree and d i r e c t i o n of environ-mental change i n the move, future investigations could (a) s e l e c t subjects from one f a c i l i t y only, or (b) match subjects on t h i s v a r i -able. In order to do the l a t t e r , an assessment of the p h y s i c a l and s o c i a l c h a r a c t e r i s t i c s of the p r e - r e l o c a t i o n f a c i l i t y and the UBC ECU would be necessary. Recent work i n the conceptualization of human environments and development of s o c i a l climate scales (Moos, 1974) and attention to the f u n c t i o n a l context of e l d e r l y behaviours (Rebok & Hoyer, 1977) could be useful i n the development of assessment to o l s . The preceeding discussion of environmental change i s equally relevant to a consideration of the c h a r a c t e r i s t i c s of the UBC ECU alone. Subjects i n the present study were admitted to the h o s p i t a l during the f i r s t s i x months of i t s operation from July 1977 to January 1978. At that time, the h o s p i t a l s t a f f responsible for patient care were undoubtedly unfamiliar not only with the large number of newly-admitted patients, but also with each other and with the h o s p i t a l ' s p o l i c i e s and routines. Moreover, subjects may have been more d i r e c t l y a ffected by dramatic changes which occurred i n the h o s p i t a l s t a f f , patient population, p o l i c i e s , and routines during the f i r s t year. I t i s i n t e r e s t i n g to note i n t h i s regard that the r e s u l t s of the present study indicated that 87% of the subjects were not engaged i n i n t e r -personal i n t e r a c t i o n during any of the observation periods at the two follow-up periods. A d d i t i o n a l l y , subjects spent an average of 58% of t h i s time i n t h e i r bedrooms. To the extent that s o c i a l withdrawal can 65 be viewed as a means of conserving resources during a s t r e s s f u l s i t u -ation, (Lawton, 1974), these data suggest that r e l o c a t i o n to the UBC ECU during the f i r s t s i x months of i t s operation may have been p a r t i c u l a r l y stressful.„ In the absence of data c o l l e c t e d from residents of a hos-p i t a l with well-established s o c i a l networks and routines, one can only speculate that the e f f e c t s of the preparation programme might have been mitigated by the conditions present i n the newly-opened i n s t i t u -t i o n . I t would be i n t e r e s t i n g f o r future research to compare r e s u l t s obtained for subjects admitted during the f i r s t s i x months of the hos-p i t a l s ' operation with those for subjects admitted a f t e r t h i s time. In addition a behavioural analysis of the environmental contingencies for patients' engagement i n a s s e r t i v e behaviour, a c t i v i t y , and s o c i a l i n t e r a c t i o n might o f f e r some explanation for the patients' apparently seclusive and s o l i t a r y patterns of behaviour. Summary Since a s i g n i f i c a n t proportion of the e l d e r l y w i l l experience r e l o c a t i o n i n the next 20 years, i t i s important to develop treatment str a t e g i e s to reduce the apparently deleterious e f f e c t of t h i s process. The present study attempted to answer the need for research which would employ adequate co n t r o l groups and systematically provide an e n t i r e treatment package to subjects i n a preparation group. The preparation programme, i t s e l f , incorporated findings from research on psychological s t r e s s , coping s k i l l s t r a i n i n g programmes, and preparation programmes for s u r g i c a l s t r e s s . The r e s u l t s did not support the hy-pothesis that a programme which would provide p r e d i c t a b i l i t y and c o n t r o l -l a b i l i t y , and encourage family support would s i g n i f i c a n t l y minimize. 66 r e l o c a t i o n s t r e s s . I t i s suggested that future studies include.! assessments of subjects' s p e c i f i c coping s k i l l s before and a f t e r the completion of the preparation programme, of the s u i t a b i l i t y of the content and format of the preparation programme, and of the socio-psychological and ph y s i c a l c h a r a c t e r i s t i c s of the pre and post r e l o c a -t i o n environments. Future research should also be directed toward determining whether i t i s necessary to include a post-relocation com-ponent i n a programme designed to minimize r e l o c a t i o n s t r e s s . 67 REFERENCES A l d r i c h , C.K. & Mendkoff, E. Relocation of the aged and disabled: A mortality study. 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Toe r o l e of t r a n s i t i o n states — including d i s a s t e r s — i n mental i l l n e s s . Symposium on Preventive and S o c i a l Psychiatry. Washington, Walter Reed Army I n s t i t u t e of Research, 1957. V i s i n t a i n e r , M. & Wolfer, J.A. Psychological preparation for s u r g i c a l p e d i a t r i c patients: The e f f e c t of children's and parents' stress responses and admustment. P e d i a t r i c s , 1975, 56, 187-202. Weaver, H., McPhee, M., & Lambert, P. G e r i a t r i c s report. Vancouver Regional Hospital D i s t r i c t , 1975. Whittier, J.R. & Williams, D. The coincidence and constancy of mortality figures f o r aged psychotic patients admitted to state h o s p i t a l s . Journal of Nervous and Mental Disorders, 1956, 124, 618. W i t t e l s , I. & Botwinick, J . Surv i v a l i n r e l o c a t i o n . Journal of Gerontology, 1974, 29, 440-443. Zweig, J.P. & Csank, J.Z. E f f e c t s of r e l o c a t i o n on c h r o n i c a l l y i l l g e r i a t r i c patients on a medical g e r i a t r i c u n i t : M o r t a l i t y rates. Journal of the American G e r i a t r i c s Society, 1975, 23, 132-136. APPENDIX A 79 Ap p l i c a t i o n Form for Extended and Intermediate Care i n B.C. 1 PATIENT'S FAMILY NftMt BIRTH DATE 2 PATIENTS FULL AODRESSES (LAST 12 MONTI'S Wil l ) DATES! SOCIAL INSURANCE NUMBER J _ l I L _ l i 1 L 3 MEDICAL PLAN NUMBER 4 SPONSOR'S NAME CONTACT PATIENT Q DIRECTLY Q THROUGH SPONSOR OLD AGE PENSION NUMBER A SPONSOR IS A PERSON WILLING TO MAINTAIN CONTACT Wl I H THE REGISTRY OR FACILITY ON BEHALF OF THE PAIIENT 5 SPONSOR'S ADDRESS RELATIONSHIP HOME PHONE BUSINESS -JONE 6 PATIENTS LOCATION ADMISSION NUMBER DATE RECEIVED REGISTRY NUMBER R E N R E M E N M E PREFERRED FACILITY ALTERNATE FACILITIES 7 PHYSICIAN'S NAME W I L L V O U C O N S I D E R A L T E R N A T E F A C I L I T I E S W I T H L A T E R T R A N S F E R T O P R E F E R R E D F A C I L I T Y ? • N O • Y E S , A S K P H Y S I C I A N T O L I S T A C C E P T A B L E S E L E C T I O N S IN S E C T I O N 24 B E L O W APPLICATION POSTAL ADDRESS POSTAL CODE I H E R E B Y A P P L Y F O R T H O S E B E N E F I T S F O R W H I C H T H E P A T I E N T M A Y B E E L I G I B L E W H I L E L O D G E D IN A C A R E F A C I L I T Y SIGNATURE OF PATIENT OR SPONSOR PHYSICIAN TO C O M P L E T E DIAGNOSES. R E M A R K S A N D SIGN. PHYSICIAN OR NURSE TO C O M P L E T E SECTIONS 10 22 BY P L A C I N G X" IN THE BOX OR B O X E S WHICH MOST C L O S E L Y FIT T H E PATIENT'S SITUATION ON MOST DAYS. C O M P L E T E A L L S E C T I O N S P L E A S E D I A G N O S E S ( L I S T W I T H D U R A T I O N ) 10 W A L K I N G • INDEPENE WITHOUT • • • 1 1 T R A N S F E R S OENT WITH OR M E C H A N I C A L AIOS REQUIRES SUPERVISION BUT NOT ASSISTANCE REOUIRES P H Y S I C A L ASSISTANCE T O WALK I U N A B L E 12 W H E E L C H A I R U S E |~~] T R A N S F E R S I N D E P E N D E N T L Y j^ j NOT USED • REQUIRES SUPERVISION B E T W E E N I J B E D . W H E E L C H A I R A N D T O I L E T | \ INDEPENDENT USE • R E O U I R E S ASSISTANCE B E T W E E N J | Q BED, W H E E L C H A I R A N D T O I L E T | | H l ( | U N A B L E Ri 13 V I S I O N • A B L E TO M O V E A B O U T S A F E L Y EQUIRES SUPERVISION EQUIRES ASSISTANCE • REOUIRES D I R E C T I O N A L ASSISTANCE TO M O V E A B O U T S A F E L Y F U L L C O N T R O L REOUIRES ROUTINE T O I L E T I N G T O M A I N T A I N C O N T R O L • REOUIRES ASSISTANCE T O MAINT, 15 E A T I N G A B I L I T Y ^DEPENDENT REOUIRES SUPERVISION I AIN C L E A N L I N E S S [ j O C C A S I O N A L L Y INCONTINENT | ~ ] R E G U L A R L Y INCONTINENT • j j R E Q U I R E S ASSISTANCE | | U N A B L E D R E S S I N G , G R O O M I N G , W A S H I N G  [ ) INDEPENDENT • • I • ! | | U N A B L E i7 N U T R I T I O N  | 1 S E L F SUFFICIENT • • REQUIRES ASSISTED M E A L S E R V I C E R E Q U I R E S T H E R A P E U T I C D I E T A R Y SUPPORT S U P E R V I S I O N R E Q U I R E D  [ | LIMITED LAY SUPERVISION VISITING R N , LPN OR PSYCHIATRIC NURSE • • DAILY BY RN Ol PSYCHIATRIC N • • N U R S E 24 HOUR LAY SUPERVISION '9 B E H A V I O U R | [ NO P R O B L E M j | WANDERS AWAY ( | DISTURBS O T H E R S [ | D E P R E S S E D OR A G I T A T E D [~~| D E S T R U C T I V E OR A G G R E S S I V E 2 0 C O M P R E H E N S I O N  [~) UNIMPAIRED | | M I L D L Y IMPAIRED M O D E R A T E L Y IMPAIRED | 1 S E V E R E L Y IMPAIRED 21 C O M M U N I C A T I O N S  j | NO P R O B L E M | [ MINOR P R O B L E M • C O M M U N I C A T E S WITH D I F F I C U L T Y | 1 C A N N O T C O M M U N I C A T E 32 S P E C I A L R E Q U I R E M E N T S F R E Q U E N C Y Q • O R A L M E D I C A T I O N S UJ • INJECTIBLE MEOICATIONS 2 • O X Y G E N • T R A C H E O S T O M Y • S U R G I C A L DRESSINGS • PRESSURE SORES • T U B E F E E O I N G • O T H E R 23 P H Y S I C I A N S OPINION OF R E Q U I R E D C A R E T Y P E - SEE REVERSE FOR DEFINITIONS 1 2 3 (31 P E R S O N A L C A R E [^J INTERMEDIATE C A R E ( J E X T E N D E D C A R E 25 PHYSICIAN'S A D D I T I O N A L R E M A R K S (SPECIAL C I R C U M S T A N C E S . ETC.) 2« S T A T E O N E O R M O R E , A C C E P T A B L E A N D A P P R O P R I A T E C A R E F A C I L I T I E S IN C O N S U L T A T I O N W I T H P A T I E N T O R S P O N S O R D A T E OF E X A M I N A T I O N ON WHICH THIS APPLICATION IS B A S E D PHYSICIANS SIGNATURE HOSPITAL P R O G R A M S HIA 15 R E V I S E D J U L Y 75 EXTENDED AND INTERMEDIATE CARE APPLICATION HOSPITAL PROGRAMS 80 CARE TYPE DEFINITIONS IN BRITISH COLUMBIA Type 1 - Personal Care Features - Independently mobile ( with or without mechanical a i d s ) . May have a mild mental d e f i c i t . Needs - Room and board ( any s p e c i a l d i e t s w i l l be of a simple nature, such as d i a b e t i c , pureed, low s a l t , low f a t , or bland). Limited l ay supervision. Assistance with a c t i v i t i e s of d a i l y l i v i n g ( s e l f - c a r e ) , finances, etc. Planned pro-gramme of s o c i a l and r e c r e a t i o n a l a c t i v i t i e s . Occasionally required s k i l l e d nursing procedures of the s o r t which could be performed by a v i s i t i n g nurse or or d e r l y . Usual Sit e s - Home, Personal Care Home, Boarding Home. Type 2 - Intermediate Care Features - Independently mobile ( with or without mechanical a i d s ) . May have a more serious mental d e f i c i t . US'?<te - .Room and bop.rd ( with more complex di e t s a v a i l a b l e ) . D a i l y p r o f e s s i o n a l supervision and p r o v i s i o u of some, nursing proced-ures such as g i v i n g medications by mouth and by i n j e c t i o n , changing s u r g i c a l dressings, the management of colostomy and urinary appliances, postural drainage, oxygen therapy, i n t e r -mittent positive-pressure breathing exercies, and so on. (Not every Intermediate Care f a c i l i t y i s able to provide a l l of these services.) Assistance with a c t i v i t i e s of d a i l y l i v -i ng ( s e l f - c a r e ) , finances, etc. Planned programme of s o c i a l and r e c r e a t i o n a l a c t i v i t i e s . Usual S i t e s - Home, Intermediate Care Home, P r i v a t e H o s p i t a l . Type 3 - Extended Care Features - Usually unable to move about without the p h y s i c a l a s s i s t -ance of another person, or i f more mobile, presenting a comp-lex problem of medical management. May have a mild to moder-ate mental d e f i c i t . Needs - Twenty-hour-a-day s k i l l e d p r o f e s s i o n a l care with graduate nurse supervision. Organized a c t i v i t y and s o c i a l programme to pro-mote as much independence as p o s s i b l e . Usual S i t e s - Home, Extended Care Unit or H o s p i t a l , P r i v a t e H o s p i t a l 81 APPENDIX B Letter of Informed Consent I understand that p a r t i c i p a t i o n i n the "PREP" project involves several v i s i t s to my home or the center where I am staying before I enter the Extended Care Unit. I am also aware of the f a c t that these v i s i t s w i l l be spent discussing my move and I agree to permit the PREP s t a f f to evaluate my adjustment. I agree to provide the PREP s t a f f with information about my stay at the Extended Care Unit a f t e r I am admitted and to provide them with any suggestions for changing or improving the programme once admitted. Signed 82 APPENDIXC Demographic Information 1. Name 2. F a c i l i t y Name . Level of Care: P, I, E, A, H 3. Date of Interview 4. Interviewer's Name 5. Sponsor's Name 6. Relationship to patient 7. Primary Diagnosis 8. Date of Admission 9. M a r i t a l Status: M S D W never married 10. When were you born? _ 11. How old are you? i 12. Where were you born? ^ 13. Have you made many moves i n your l i f e t i m e ? Yes No How many moves? 0-2 2-5 5+ 14. How many years of schooling did you have? none 1-6 7-8 9-10 11-12 Technical 1-^ 2, 3-4 Academic 1-2, 3-4 15. What kind of occupation did you have most of your l i f e ? 16. Do you have any children? Yes No 17. How many ch i l d r e n do you have? 18. How long have you l i v e d here? 83 APPENDIX D Mental Status Questionnaire 1. Where are we now? 2. Where i s t h i s place? 3. What i s today's date? 4. What month i s i t ? 5. What year i s i t ? 6. How old are you? 7. What i s your birthday? 8. What year were you born? 9. Who i s the Prime Minister of Canada? 10. Who was the Prime Minister before him? 84 APPENDIX E L i f e Stress Events Schedule I am going to ask you about events that can be important i n people's l i v e s . Could you t e l l me i f any of the following have occurred i n the l a s t two years and approximately when i t occurred? (IF EVENT OCCURRED, CHECK AND ALSO CIRCLE DATE) EVENT DATE B i r t h of grandchild 0-3, 4-6, 7-12, 13- 18, 19- 24 Major personal i l l n e s s / i n j u r y 0-3, 4-6, 7-12, 13- 18, 19- 24 Change i n residence 0-•3, 4-6, 7-12, 13- 18, 19- 24 Change i n job/retirement 0-•3, 4-6, 7-12, 13- 18, 19- 24 Family wedding 0-•3, 4-6, 7-12, 13- 18, 19- 24 F a i l i n g eyesight 0-•3, 4-6, 7-12, 13- 18, 19- 24 F a i l i n g hearing 0--3, 4-6, 7-12, 13- 18, 19- 24 Death of spouse 0-3, 4-•6, 7-12, 13- 18, 19- 24 Death of close f r i e n d 0-•3, 4-6, 7-12, 13- 18, 19- 24 Death of close family member 0-•3, 4-6, 7-12, 13- 18, 19- 24 Family reunion 0-•3, 4-•6, 7-12, 13- 18, 19- 24 M a r i t a l d i f f i c u l t i e s 0-•3, 4-6', 7-12, 13- 18, 19- 24 Change i n group of friends 0-•3, 4-6, 7-12, 13- 18, 19- 24 Other (SPECIFY) 0-3, 4-6, 7-12, 13- 18, 19- 24 0-3, 4-6. 7-12, 13- 18, 19- 24 0-3, 4-6, 7-12, 13- 18, 19- 24 TOTAL LIFE EVENTS TOTAL POSITIVE TOTAL NEGATIVE TOTAL LIFE EVENTS IN LAST 6 MONTHS 85 APPENDIX F Health Status Questionnaire I am going to read o f f a l i s t of health problems that people sometimes have. Could you please t e l l me i f you have any of them nowadays? CO cu o CO 3 o u u > CO CO 3 o •H u cu CO 1. Seeing (even when wearing eye-glasses?) 2. Hearing (even when wearing a hearing aid?) 3. Nervousness? 4. A r t h r i t i s . o r Rheumatism? 5. Kidneys or Bladder? 6. Varicose Veins? 7. Heart? 8. Diabetes? 9. Dizziness? 10. Stroke? 11. Headaches? 12. High Blood Pressure? 13. Sleeping? 14. Cramps? 15. Tiredness or fatigue? 16. Are there any other health problems or accidents that are of concern to you? SPECIFY: 86 APPENDIX G L i f e S a t i s f a c t i o n Index Z Could you please t e l l uie i f you agree or disagree with the following statements? There are no r i g h t or wrong answers, we merely want your opinion. (TICK THE APPROPRIATE ANSWER.) (ASK: DO YOU THINK THAT ...) AGREE DISAGREE 1. As you grow older, things seem better than you thought they would be 2. You have gotten more breaks i n l i f e than most of the people you know 3. This i s the dreariest time of your l i f e 4. You are j u s t as happy as when you were younger 5. These are the best years of your l i f e 6. Most of the things you do are boring or monotonous 7. The things you do are as i n t e r e s t i n g to you as they ever were 8. As you look Back on your l i f e you are f a i r l y w e ll . s a t i s f i e d . 9. I have made plans for things I ' l l be doing a month or a year from now 10. When I think back over my l i f e , I didn't get most of the important things I wanted 11. Compared to other people, you get down i n the dumps too often T o t a l 87 APPENDIX H Attitudes Toward the Move I would l i k e to know a l i t t l e about how you f e e l about moving to the new Extended Care Hospital at UBC. 1. Whose decision was i t to apply for extended care? family doctor s o c i a l service agency s e l f other family & doctor family & s e l f family & s o c i a l service agency family & other doctor & s o c i a l service agency doctor & s e l f s o c i a l s e rvice agency & s e l f s o c i a l s e rvice agency & other (ASK IF RESPONSE TO 1 IS OTHER THAN 'SELF') 2 . Did you agree to t h i s decision? Yes No 3. Why do you think you are moving to extended care? Health Family Pressure Finances Other (SPECIFY) Health & Family Pressure Health & Finances Family Pressure & Finances 4. How do you f e e l towards the move? (ASK THE PERSON HOW THEY FEEL ABOUT THE MOVE. PUT A STAR BESIDE THE FEELINGS THE PERSON FIRST SAYS TO THE GENERAL QUESTION. THEN INQUIRE AS TO WHETHER THEY HAVE THE.OTHER FEELINGS AND CIRCLE ANSWER. IF THE PERSON FEELS WORRIED, PLEASED, UNEASY, ANGRY, SAD, ASK WHY AND PLEASE NOTE.) Do you f e e l angry? How angry? 1 ._2 3 _ 4 5_ very angry somewhat neutral not angry angry angry 88 APPENDIX H continued SPECIFY REASONS IF ANGRY: Do you f e e l s a t i s f i e d ? How s a t i s f i e d ? 1 2 3 4 5 very s a t i s f i e d somewhat neutral not s a t i s f i e d s a t i s f i e d s a t i s f i e d Do you f e e l sad? How sad? 1 2 3 4 5 very sad somewhat neutral not sad sad sad SPECIFY REASONS IF SAD: Do you f e e l happy? How happy? 1 2 3 4 5 very happy somewhat neutral not happy happy happy Do you f e e l worried? How worried? 1 ' 2 . ' 3 4 5 very worried somewhat neutral not worried worried' worried SPECIFY REASONS IF WORRIED: 89 APPENDIX H continued Do you f e e l excited? How excited? 1 2 3 4 5 very excited somewhat neutral not excited excited excited Do you f e e l pleased? How pleased? 1 2 3 4 5 very pleased somewhat neutral not pleased pleased pleased SPECIFY REASONS IF NOT PLEASED: Do you f e e l uneasy? How uneasy? 1 2 .3 very uneasy somewhat neutral not uneasy uneasy uneasy SPECIFY REASONS IF UNEASY: OTHER (SPECIFY) 90 Post Would you say you have have moved.to t h i s hos] 1. Do you f e e l 2. Do you worry 3. Do you have 4. Is your health 5. Are you 6. Do you have 7. Do you eat 8. Do you see your chi l d r e n 9. Do you see your r e l a t i v e s 10. Do you sleep 11. Do you get out 12. Are you 13. Do you dress up 14. Is there anything you would now . consider doing that you would not have considered before you moved If yes, please specify a c t i v i t y below APPENDIX I Relocation Adjustment changed i n any of the l i t a l ? ( ) More Safe ( ( ) Less ( ( ) More Energy ( ( ) Better ( ( ) More Active ( ( ) More Friends ( Better ( More Often ( More Often ( Better ( More Often ( Happier ( More Often ( ( ) Yes ( Scale following ways since you Less Safe ( ) Same More ( ) Same Less Energy ( ) Same Wors,e ( ) Same Less Active ( ) Same Less Friends ( ) Same Worse ( ) Same Less Often ( ) Same Less Often ( ) Same Worse ( ) Same Less Often ( ) Same Less Happy ( ) Same Less Often ( ) Same ) No 91 APPENDIX J Interviewer's Observation Scale INTERVIEWER'S OBSERVATIONS Resident's Name: Date of Interview: Interviewer's Name:_ Admission Date: (THE FOLLOWING QUESTIONS ARE TO BE DETERMINED THROUGH OBSERVATION; CIRCLE APPROPRIATE WORD). CARD l| ij | IDENTITY # 3! y y 1 COMPREHENSION Abil i ty to attend or understand verbal cues (questions, comments, instructions). 1 2 3 4 5 I I I I I slight mild moderate marked ORIENTATION DISTURBANCE TIME: Does not know the year, season, month, day, or time of day. PLACE: Does not know where he is or in what kind of place he is l iv ing . PERSON: (Self or others) Does not know who he is or misidentifies others. TIME: none PLACE: slight mild _1_ moderate J marked 1 none PERSON: slight mild moderate J marked a slight mild moderate J marked MEMORY DISTURBANCE REMOTE: Events of several years ago. RECENT: Events of the last few hours or days. REMOTE: RECENT: slight mild moderate I marked slight mild moderate marked CUMULATIVE INTERVIEWER'S RATING SCALE (VIRO SCALE) (CIRCLE ONE NUMBER FOR EACH ITEM)  Rl - Vigorous A 3 2 1 Feeble Erect posture, impression of capacity for effective, decisive movement vs. slumped, collapsed posture, impression of weak, ineffective movement R2 - Receptive 4 3 2 1 Closed Welcoming gestures, facial expression that lights up at E's approach, implicit movements toward interviewer, impression of extending self and shortening distance between self and interviewer vs no gestures or expressions that acknowledge presence of interviewer, or implicit aversive, shrinking-away movements, impressions of withdrawing self and lengthening distance between self and interviewer R3 - Comfortable 4 3 2 1 Distress Pained expression, awkward position or posture suggesting bodily discomfort vs absence of these behaviours and general impression of person being at ease, not preoccupied with body condition R4 - Quite Trustful 4 3 2 1 Quite Suspicious Repeated questioning such as, "Why are you asking me these questions?" "What is this a l l about?" Repeated failure to answer questions adequately when there is no indication of mental incapacity or knowledge. "Eyeing" E as though E were on a mission of mischief vs none of these behaviours R5 - High Energy Level 4 3 2 1 Low Energy Level Both verbal and nonverbal behaviour have a convincing intensity or power, amount of "output" is normal or supernormal vs. mumbling, weakly-uttered speech, minimal intensity and output of behaviour R6 - Fluent Speech 4 3 2 1 Minimal Speech "Yes", or "No", "Don't know" responses, sentence fragments, lack of elaboration or stumbling bits of speech vs normal flow in which words are integrated into statements and statements into larger contextual units. (Distinquish this item from energy level) R7 - Keen Attention 4 3 2 1 Poor Attention Loses track of conversation, responds as though previous conversation had not taken place, seems to take no notice of changes in E's topic, intensity, personal behaviour vs seems to anticipate the next question, responses indicate that previous conversation has registered, notices changes in E's speech or behaviour R8 - Controlled Thought 4 3 2 1 Poor Attention Maintains a frame of reference with fa ir ly clear boundaries, context of statements is clear or becomes clear readily, thoughts follow in logical or reasonable sequence vs conversation peppered with irrelevant statements and expressions, context of remarks not clear, takes off from mutual topic in idiosyncratic ways, "train of thought derailed". R9 - Eager 4 3 2 1 Reluctant Participation Participation Responsive to a l l questions and comments, spontaneous vs_ choreful reaction to E's questions, volunteers nothing, complains about effort of responding. E must expend considerable energy of his own to extract responses from subject. (Distinquish from trustful - suspicious dimension and energy level). RIO - Keen Perspective 4 3 2 1 No Self-perspective Comments about his own role in the interviewer situation, expresses awareness of how he might look to others, wonders "How am I doing?" or expresses an opinion on that, divides his own experience into favourable and unfavourable, strong and weak, and other categories vs no awareness that he is being interviewed, absence of a l l the other characteristics mentionned above, labels his experiences or functioning as all-good or all-bad 94 Rll - Engrossed in own No Self-Ideas/Feelings 4 3 2 1 engrossment Animated, "alive" when talking about his l i f e or opinions, as shown in sparkling or intense eyes, appropriate gestures, body posture, speech patterning may also be shown by deeply reflective, inward-turning behaviour, "lost in own thoughts and feelings" to such an extent that E's presence seems momentarily ignored. These are two different patterns of self-engrossment v £ f la t , neutral, transient "Uncommitted" behavioural and expressive "commentary" when talking about his l i f e or opinions, not "caught up" in his internal l i f e . Talks about himself in same, rather uninvolved way he talks about most everything else 2 Q R12 - Engrossed in No shared Relationship 4 3 2 1 Engrossment Direct eye contact, S & E meet on common ground, or in some universe of discourse, interested in E as a person, may affectionately touch E vs absence of these characteristics, perhaps related to a type of self-engrossment that shuts off the relationship, gross disorientation, or impression of deciding to keep E at a distance R13 - Eager to see 4 3 2 1 Discontinue interviewer again session Verbal expression of wishing interview to continue, or another contact to be made (with appropriate nonverbal commentary) vs inquiring how much longer this is going to last , is this the f inal question, I hope I don't have to go through something like this again CUMULATIVE 27 a D O RELIABILITY OF INFORMATION 1 2 3 I I L VERY GOOD NEUTRAL POOR VERY- , 1 GOOD POOR 29| | REFERENCES FOR DETERMINING RELIABILITY OF INFORMATION: (FROM: SPITZER MSER) (PLEASE CIRCLE MOST IMPORTANT REFERENCE AND PLACE A CHECK MARK BESIDE SECONDARY REFERENCES) 1) Refuses information 2) Physical i l lness ft 95 RELIABILITY OF INFORMATION 3) Sensorial or cognitive disorder 4) Massive denial 5) Preoccupation 6) Conscious fals i f icat ion i 1 j 1 7) Quality of speech 34| [3^  | 8) Dialect o r foreign language 9) Lack of response 10) Deafness 96 APPENDIX R NURSES' OBSERVATION SCALE Resident's name Date Aide, L . P . N . , R.N. INSTRUCTIONS FOR COMPLETION OF SCALE: 1. For each item a score of 4 indicates the highest level of functioning or adaptation. A score of 1 represents the most severe level of impairment. 2. Please c irc le the number you think most accurately estimates the patient's functioning. Behaviours that indicate a score of 4 and 1 (the highest and lowest) have been outlined below each item. 3. To obtain a score of 4, a patient should be consistent in his behaviour. For example, in scoring 'orientation', i f some confusion occurs at night or infrequently at other times, a score of 3 should be given. That i s , the frequency of behaviour must be taken into account along with the degree of impairment. 4. Try not to answer in the way you 'hope' the patient wi l l be able to function, or what you think he/she is actually capable of doing. Rather i t is important to obtain an accurate assessment of how the person functioning based on the evidence you have gathered in your day-to-day contact. That is the only way an accurate plan of care and subsequent evaluation of progress can be made. 97 A. COGNITIVE FUNCTIONING: 1. Orientation: Indicates a r e a l i s t i c awareness of s e l f and surroundings. (a) Time 4 3 2 1 1 1 | I 4= Knows t h e month, year, 1= Seems t o t a l l y unaware of whether season, time of day i t i s daytime or nighttime. Or-accurately and consistently. i s l i v i n g i n another time period, (eg. thinks he/she i s a c h i l d again.) N.B. Being unaware of the exact date or day of the week does not necessarily indicate d i s o r i e n t a t i o n . (b) Place 4 3 2 1 1 1 1 1 4= Knows where he/she i s and 1= Seems t o t a l l y unaware of i n what type of place, (eg. surroundings and i s unable to acute care hospital) Is able locate own room, bedroom, or to f i n d his/her way around dining-room, without getting l o s t . (c) Person 4 3 2 1 l i l t 4= Knows exact age 1= F a i l s to recognize own name, and recognizes family or the faces of s i g n i f i c a n t members, friends, s t a f f , others i n the environment, (eg. and other patients. the nurse who has been i n close contact for some time). 2. Memory: Indicates the a b i l i t y to r e c a l l information and experiences i n the past, whether an hour before or ten years before. (a) Short Term (Recent)- events of the past few minutes, hours, or days. 4 3 2 1 t i l l 4= Remembers where he/she 1= Unable to remember what meal was placed personal belongings served l a s t or forgets what has and the d e t a i l s of a c t i v i - happened a f t e r a few minutes, t i e s of the recent past. 98 (b) Long Term (Remote)- events of several years ago. 4= Is able to relate the slgni- 1= Cannot remember own name, or those ficant events of his/her l i f e . (eg. the death of a spouse, number of children, main occupation, birthplace, etc.) of immediate family. Unable to generate the names of body parts on request, (eg. leg, arm.) Cannot recognize a familiar tune, as indicated by humming or singing along. 3 Comprehension: Indicates the abi l i ty to understand or to obtain a rea l i s t ic , intelligent grasp of the situation. 4 3 2 1 J I I L 4= Is able to follow instructions and understand explanations. New situations and infor-mation are readily grasped. 1= Unable to understand or follow the simplest of instructions. Indicates no abi l i ty to grasp new situations or deal with simple information. 4. Attention Span: Indicates the abi l i ty to attend or concentrate on a single situation or event. 4 3 2 1 J i I I 4= Becomes engrossed in activity, reading, etc. Is able to follow conversation, or maintain interest in a task unti l completion. 1= Is very easily distracted by irrelevant stimuli or preoccupa-tion with other matters. Not able to attend to even short conver-sations or tasks without continual 'calling back'. N.B. If the patient is disoriented, abi l i ty to attend w i l l be indicated by listening intently and maintaining attention without distraction, whether or not the person can take part in the conversation. 5. Judgment: Indicates the abi l i ty to evaluate alternative courses of action and to draw proper conlusions from experience. This includes a real ist ic self perspective and insight. 4= Able to make sound judg-ments on important matters. Recognizes own strengths and limitations and acts accordingly. Has quite good insight into own behaviour. 1= Unaware of abi l i t ies and attempts dangerous acts. Has totally unrealis-t i c plans for the future. Unable to make day-to-day decisions, such as what clothes to wear. 99 6. Speech: Communicates in a fluent manner that is readily understood by others. ( a ) 4 3 2 1 1 1 1 1 4= Speaks clearly, fluently, 1= Unable to communicate in any manner and coherently. Maintains (speech, gesture, writing). Or-a frame of reference with speech is such that i t is impossible clear boundaries. Context to decipher, for whatever reason, of statements is relevant Or- speech is totally irrelevant and follows a logical and meaningless, sequence. Aphasic- Has disturbances of language due to a specific brain injury such as cerebrovascular accident (stroke), tumour, or accident. 4 3 2 1 1 1 1 1 4= No disturbance in language of this type has been identified. 3= Expressive aphasia (difficulty in executing speech or expressing oneself.) 2= Receptive aphasia (difficulty in understanding speech, or unable to read. 1= Global aphasia ( diff iculty in both speaking and understanding communications. B. SOCIAL FUNCTIONING: 1. Emotional Involvement: Has a close emotional relationship with another person. 4 3 2 1 J 1 1 I 4= Has a close relationship 1= No vis i tors . Lacks relationship with family member, friend, with any one. Lonely, or staff on a regular basis. ' \ 2. Participation: Participates in group activit ies with staff, other patients, or uti l izes materials in a stimulating manner. 4 3 2 1 l i l t 4= Takes part in group activit ies . 1= Withdrawn from group activit ies Finds stimulation either or programs. Does not take through organized, staff- part in any form of individual directed programs, or through activity or stimulation, self-directed endeavours such as knitting, craft wark, hobbies, reading, etc. 100 3. Interaction: Responds to another person on a one-to-one basis with interest and enthusiasm. 4 3 2 1 -1 1 I L 4= Shows interest, responsiveness 1= Indicates a suspicious, with-spontaneity, trust, and drawn, closed tendency when approach-eagerness when approached ed. Gives the impression of by another person. shrinking away from personal interaction. 4. Co-operation: Acts in a considerate, helpful, and sensitive manner to others. 4 3 2 1 J 1 1 I i 4= Considerate, co-operative, 1= Disruptive of hospital routine, helpful, and sensitive to Belligerent, unco-operative, other patients. Behaves objectionably or in a manner which is annoying to staff and/or other patients. C. ADAPTIVE BEHAVIOUR: 1. Trusting/ Suspicious: 4 3 2 1 1 1 1 1 4= Indicates openness, trustful- 1= Indicates severe suspicion or ness of others. paranoia, (eg. Thinks that others are stealing or hiding things from him/her.) Refuses to give information and eyes staff suspiciously. 2. Relaxed/ Anxious: 4 3 2 1 1 1 1 1 4= At ease, relaxed, calm. Takes 1= Severely agitated, nervous, things in stride. worried, restless, or fidgety. (pacing, rocking, nai l -bi t ing, etc.) . Generally indicates unsettled behaviour. .101 3. Passive/ Aggressive: Aggressive Well-balanced 1 2 3 4 1 I 1 • 3 2 1 1 Passive 1 I 1= Extremely assertive and overly aggressive to the point of being h o s t i l e or threatening. Tries to control the environment t o t a l l y . 4= Well-balanced. Not too aggressive or passive. 1= Extremely passive and dependent. W i l l not attempt anything on his own. Makes no attempt to control what happens or events around him/ her. 4. Animated/ Depressed: 4 3 2 I 1 1 1 1 4= Has enthusiatic, o p t i m i s t i c , happy outlook on l i f e . Shows active i n t e r e s t i n surroundings. 1= Very depressed, despondent. Ex-presses extremely self-derogatory hopeless f e e l i n g s . 5. Recognition/ Denial: 4 3 2 1 1 I 1 4= Recognition and acceptance of his/her state of health ( i e . s o c i a l , p h y s ical, and functional s i t u a t i o n ) . Able to discuss openly. 1= Denial of loss i n health and functioning a b i l i t y . Responses which are obviously incongruent with actual f e e l i n g s . (eg. States that he/she i s not depressed when a l l other observations indicate otherwise.) D. GLOBAL PHYSICAL WELL-BEING: 1. Energy Level: Indicates the capacity to sustain e f f o r t or exert oneself. 4 3 2 1 1 1 1 1 1 1 1 1 4= Gives the impression of 1= Gives the impression of being maintaining good strength extremely weak and feeble (eg. and power for his/her age. slumped, collapsed posture). (erect posture, decisive Spends most of the day on or i n movements). Able to bed. maintain a c t i v i t i e s most of the day without rest or sleep. 102 2. Comfort Level: Experiences no pain or discomfort as a result of disease or disabi l i ty . 4= Free from pain/discomfort. Suffers from severe pain or discomfort frequently. Pain is such that i t interferes with his/her day-to-day act ivi t ies . 3. Body Intactness: The body systems have maintained their wholeness in structure and function. Intact body. No major deterioration, paralysis, amputation, areas of anaesthesis, or loss of body part (eg. mastectomy) or function (eg. colostomy). Skin is in good condition. Gives impression of having severe overall deterioration in physical health. Has loss of body part or function, paralysis, amputation, or areas of anaesthesia, etc. Or-skin is in very poor condition with severe breakdown. 4. Vision: The abi l i ty to see (with the aid of glasses, i f necessary). 4= No problem or very slight diff iculty seeing. 1= Severe problem. Unable to see anything but vague outlines, shadows. Functionally blind. 5 . Hearing: The abi l i ty to hear (with the. aid of a hearing device, i f necessary). 4= No problem, or very slight diff iculty hearing. 1= Severe problem. Cannot hear even when spoken to very loudly. Functionally deaf. 103 E. ACTIVITIES OF DAILY LIVING: 1. Chewing Abi l i ty: Indicates the abi l i ty to eat a diet of normal consistency. 4 3 2 1 1 1 I I 4= Normal diet 3= Minced diet 2= Soft diet 1= Fluid diet 2. Continence: Indicates the abi l i ty to control bladder function appropriately. 4 3 2 1 1 1 1 1 4= Has fu l l control. 3= Rarely incontinent. Occasional accident. 2= Usually or frequently incontinent. 1= No control. Always incontinent. Cathe ter , 3. Bowel Function: Indicates the abi l i ty to pass formed stools independently on a regular basis. 4 3 2 1 1 1 1 1 4= Has normally formed stool on regular basis without the aid of medication, enema, or manual assistance. 3= Occasionally requires the use of laxative for regular elimination. 2= Takes laxatives routinely. Rarely needs enemas or manual removal. 1= Incontinent of stool or_ totally dependent on mechanical/chem-ica l means of stool elimination. 104 APPENDIX L A c t i v i t i e s of Dai l y L i v i n g (ADL) Chart INSTRUCTIONS FOR THE USE OF THE VISUAL CHART: Please write a score of 1, 2, 3 beside each area of the visual chart that represents particular act ivi t ies . 1= Total Independency: Independence means the abi l i ty to perform an activity without supervision, direction or personal assistance. The patient who refuses to perform an activity is scored 3, dependent, even though he may be considered able to do i t . He/she may use any method or aid to perform the activity. The score of 1 in the activity of walking represents the abi l i ty to walk approximately 1 block independently. 2= Partial Dependence: The patient can perform the greater part of the activity himself but needs supervision to complete the activity. In walking abi l i ty this refers to the abi l i ty to walk short distances (to bathroom) without personal assistance. May use cane or walker, etc. 3= Total Dependence: The activity is carried out for the patient. In walking this refers to walking short distances with personal assistance. •105 107 APPENDIX M Planned A c t i v i t y (PLA) Name Date Room No. Check o o S-l C N cu i - t > 1 S-i o cu cn CD • ' . O r - l Observer 1:30-2:00 Observer 2:30-3:00 Observer 4:00-4:30 LOCATION: Dining Room/Activity Physio Room Kitchen (Occupational Area) Bedroom Offices/Nursing Station Corridor Bathroom Classrooms Other: Specify STATE: Walking Standing S i t t i n g : (1) Appar. awake (2) Appar. asleep Wheelchair: (1) Independent (2) Dependent TYPE: Drinking Eating: (1) Meals (2) Other than meals Grooming: (1) Oneself (2) By someone (3) Both Dressing: (1) Oneself (2) By someone (3) Both Writing Reading/Leafing thru magazine 108 Appendix M continued U CM CD I—I > I M O CD CO CO • • O O O CNl u cu > f-i CO CO ^ •• O - i CO c O O CM O ro <r i o o Recreation: (-1) Observer  (2) P a r t i c i p a n t  Conversation: (1) Talking (2) L i s t e n i n g  Therapy: (1) OT-PT  (2) Med. Proc.  (3) Counsel.  Group Meeting  SOCIAL LEVEL:  S o l i t a r y  Dyad: (1) Staff  (2) Another Patient (3) Volunteer  (4) Family  Group: (1) I n c l . Staff/Volun. (2) Patients only  (3) Family  COMMENTS: 109 APPENDIX N Transcript of Information Slide-Tape Programme A Time for Change Hello J I'm Mrs. Bradbury and I understand that y o u ' l l be moving to the Extended Care Unit i n the University of B r i t i s h Columbia campus. I would l i k e to recount for you my experiences when I f i r s t a r r i v e d . This i s moving day and I'm on my way to my new residence, the Extended Care Unit on the b e a u t i f u l UBC campus. UBC i s quite large with nearly 25,000 students enrolled. Any many of them also l i v e i n residence on the campus. The Extended Care Unit i s part of the larger Health Sciences Centre which includes a regular h o s p i t a l , a mental..health centre, a dental c l i n i c , and student health services. The new residence i s a bright, f i v e - s t o r y b u i l d i n g designed to meet the s p e c i a l needs of some of our older population, l i k e me for instance. Approximately three hundred people l i v e here. The f i r s t person I met on a r r i v a l was the admitting c l e r k . Also, at t h i s time, a s t a f f member appeared from the elevator to show me to my room and to take me on a tour of the u n i t . A l l resident rooms are located on the f i r s t , second, third,., and fourth f l o o r s , so w e ' l l take the elevator up. And here we are, at my f l o o r . If we take a turn we come upon the Patient Care Centre. This i s an important area as i t ' s the communication centre for my f l o o r . I t ' s also important as medical information and other ' c o n f i d e n t i a l ' matters are dealt with here. Don't be surprised to see many d i f f e r e n t s t a f f 110 buzzing around. I t ' s sort of the hub of a c t i v i t i e s f o r them. Con-tinuing past the Centre, and down the h a l l , we come to my room. Some of the rooms are p r i v a t e , some semi-private, but most of them have four people. They are assigned according to your requests as much as poss i b l e . And here's what my area looked l i k e . There's a dresser, shelves, a notice board, and desk. With the help of a l i t t l e i n t e r i o r decorating, l i k e my neighbour has done, i t ' s amazing what you can create ... So think about the things you'd l i k e to bring with you to make you area more 'homey.' I suggest pi c t u r e s , momentos, and a bright coloured cover for your bed. Each room has a washroom with handrails and other aids to make i t a l i t t l e b i t easier to move about. The bathroom i s also equipped with a c a l l b e l l i f one needs assistance. Oh! And i f we go back to me bed for a moment, y o u ' l l also notice the emergency c a l l and intercom above the bed. That's j u s t i n case I need someone and the s t a f f can get there as f a s t as possible. Well, l e t ' s J:go on a l i t t l e tour. If you look down the h a l l outside the room, y o u ' l l see the Patient Care Centre. I t ' s never far away and always within sight. And notice the hand r a i l s . They're one of the many safety features y o u ' l l see. The f l o o r even has non-skid surface. A b i t d i f f i c u l t for dancing, however! Just along the h a l l we f i n d the bathing area. I t ' s a b i g room with l o t s of conveniences including a shower and tub. The big machine over there i s a century tub. I t ' s a great way to take a bath, complete with whirlpool. And notice again that there are hand-r a i l s for assistance. Here's that Patient Care Centre again. I t seems that every time you look around i t ' s always there. Right i n I l l front i s the d i n i n g / a c t i v i t y area. They're having lunch now. The residence serves three meals a day. In addition, snacks i n the morning are served i n bed and a f t e r dinner there are evening refreshments around 7:30. We have our own d i e t i c i a n here so that the meals are well-balanced and s p e c i a l diets can be arranged when necessary. And, or course, there's table service. No t i p s accepted, however.' A l l residents share a table with others. I t ' s nice to see the same face across the breakfast table each morning. Turning around and continuing down the h a l l , we pass the Patient Care Center again. Anyway, to the l e f t i s the Physio department. They have a l o t of exercise equipment and are experienced i n helping the residents learn new ways of doing things. Here, for example, i s someone learning how to walk between p a r a l l e l bars. There i s the nurse with the medication c a r t . The s t a f f make sure I get my p i l l s on time. Let's go back to the dining room now that lunch i s over. A l l the places are cleared and i t has become the a c t i v i t y area. There's always something going on here. Y o u ' l l f i n d that s t a f f and volunteers are eager to help you with almost any a c t i v i t y you're interested i n . Some of the scheduled a c t i v i t i e s include bingo, bowling, exercise, cooking, woodworking, and often people w i l l j u s t decide to get together for a card game, arts and c r a f t s , or j u s t a b i t of k n i t t i n g and t a l k i n g . Quite often enter-tainment i s provided by bands, actors, musicians, dancers, and singers. There are also pub nights. Y o u ' l l have the opportunity to go on some of the planned bus t r i p s to Stanley Park, the Planitarium, Queen Eliza b e t h gardens, restaurants, musicals, and so f o r t h . And, of 1.12 there are a l l the d i f f e r e n t things to do on campus with theatre, bowling a l l e y , swimming pool, l e c t u r e s , l i b r a r y , and many other things. Let's go back to my room now and get my suitcase which w i l l be stored i n a locker i n the basement. There's the Patient Care Centre again. A l l the s t a f f are there. There's my doctor, nurse, occupa-t i o n a l t h e r a p i s t , and s o c i a l workers. Well, we had better get that suitcase stored away so past the Patient Care Centre and down the h a l l to my room. Oh, here's a chance to put things i n focus. This i s a plan of the t h i r d f l o o r . I t shows a l l the places that we've been. Now w e ' l l explore the r e s t of the b u i l d i n g . We'll j u s t grab my suitcase and take the elevator down to the basement. Here's the locker room where I can store my suitcase and other belongings, as you w i l l too. As we walk on down the h a l l we come across the c j a p e l where interdemonimational services w i l l be held. Of course, the clergy of various r e l i g i o n s w i l l be dropping i n from time to time. Continuing along, we f i n d the beauty parlour. Get the nurse to make an appointment i f you want your hair done. Next to the beauty parlour i s the laundry for your personal clothes. There i s laundry service a v a i l a b l e . This i s a combination reading room, l i b r a r y , and lounge. It's a nice quiet place to bring your friends and family, or j u s t get away from i t a l l . Snuggle up i n one of the comfortable chairs and read a book. Lot's of them have extra-large p r i n t . Let's go back to the elevator now, and up to the roof. I t ' s a 113' b e a u t i f u l day today and you get a wonderful view from up here. There's English Bay and the mountains behind. And i f you're at a l l interested i n gardening, w e ' l l be making good use of these planters i n the spring and summer. And you can e a s i l y reach them from a wheel-chair . Back to the elevator and down to the main f l o o r where I f i r s t came i n . There's the reception and information desk and the admitting cle r k . Remember, she's the f i r s t one y o u ' l l meet. Also, on the main f l o o r i s a g i f t shop where you can purchase magazines, candies, and g i f t s , of course, a dining room where one can have dinner with family and friends when they come to v i s i t . " V i s i t i n g hours are very f l e x i b l e as i t would be i n your own home i f you are entertaining. My family v i s i t s often and they l i k e p a r t i c i p a t i n g i n the evening a c t i v i t y pro-grammes . I can't believe a l l the attention a person gets here. Soon af t e r I came, a s t a f f meeting was set up with me and the professional, s t a f f including the s o c i a l worker, the doctor, the nurse, and occupa-t i o n a l therapist.to discuss my health concerns and to set up a t r e a t -ment programme for me. They also asked about my hobbies, i n t e r e s t s , and a c t i v i t i e s . Although most of the friends I have made here have some of the same problems you would see anywhere, some have s p e c i a l problems. Some are unsteady on t h e i r f e e t . Many are i n wheelchairs, but i t ' s easy for them to get around here. Some residents are confused and a few are bedridden. But most j u s t have a b i t more d i f f i c u l t y doing things for themselves. 114 Because the Extended Care Unit i s part of the Health Sciences Centre at UBC, i t also serves as a teaching f a c i l i t y . There w i l l be many students working around the b u i l d i n g — some from medicine, r e h a b i l i t a t i o n medicine, d e n t i s t r y , nursing, and s o c i a l work, and at some point you may become involved with them. But i t ' s always nice to meet new faces and have the opportunity to teach the younger generation a thing or two. S c i e n t i f i c research w i l l also be conducted here. I t i s important to l e a r n more about aging and about some of the problems we older people have. I t i s hoped that you and I may be able to contribute to t h i s knowledge and the q u a l i t y of care given. There's a l o t of things going on here at the Extended Care Unit TT-H there's teaching, research, an i n t e r e s t i n g a c t i v i t y programme, and l o t s of opportunities to grow and learn. I'm enjoying myself. I hope you do, tool 115 APPENDIX 0 Transcript of Coping S k i l l s Training Slide-Tape Programme Getting Ready for Moving Day Part I "Hello, My name i s Mrs. Mary Adams. I understand that you're going to be moving to a new h o s p i t a l . Whether y o u ' l l be coming from your own home or another h o s p i t a l , the move w i l l probably be a big change for you. Y o u ' l l probably have to get used to a new way of doing things. At the same time y o u ' l l be fi n d i n g your way about a new place, : y o u ' l l be meeting a low of new people. I t ' s a l o t to think about, I know, and may even seem overwhelming. I t ' s h e l p f u l to think about the move, e s p e c i a l l y i f you can imagine ways to enjoy your new home to the f u l l e s t . I moved into a h o s p i t a l two years ago myself and I thought'it might be h e l p f u l to share some of my experiences with you. In that way, I ' l l be able to t e l l you some of the things that helped me to prepare myself for the move and to get used to my new home. By the way, f e e l f r ee to ask my ass i s t a n t f i t t i n g beside you to stop the s l i d e s i f you have any questions or want to t a l k about something as we go along. Now, as I've said , I've l i v e d i n a h o s p i t a l for the l a s t two years. I used to l i v e with my children, but as I began to need some s p e c i a l help that my family couldn't provide, my doctor and I discussed several a l t e r n a t i v e s . We decided that t h i s h o s p i t a l would be best f o r me. Thinking about the move, a l o t of things bothered me. I didn't know how I was going to get used to a new place. A f t e r a time, I d i s -covered a good way of working things out. I'd l i k e to share my experience 116 with you. One of the things that upset me was having to leave behind my lov e l y room at my children's. I knew that my new bedroom j u s t wouldn't be the same. When my daughter asked me to explain exactly what bothered me about the new room, I r e a l i z e d that i n general I was quite s a t i s f i e d with i t . A f t e r a l l , i t was brand new, plenty b i g , and I'd have my own cupboard and table. But i t bothered me that a l l the rooms would look exactly the same — l i k e peas i n a pod. I wanted my room to have some character to i t . Then my daughter sai d , "Look Mom, I'm sure you can think of ways to make your room unique. Remember, you can take some of your belongings with you to decorate and add i n t e r e s t to your room." Well, I started to think. "Mary," I said to myself,"why not deco-rate the walls of your rooms with some of your favourite landscape paintings? And you can take a few plants l i k e your favourite A f r i c a n v i o l e t s to put on the window s i l l and nighttable and photos of the family to look at and show to the other f o l k s , and some needlepoint p i l -lows to decorate your bed!" In the end, I though of several things to bring that made me proud to say, "Welcome to Mary's room." My daughter suggested that I could take some of my f i g u r i n e s . Then we made a l i s t of things I had decided to take and packed up everything i n boxes ready to go. You know, I a c t u a l l y enjoyed thinking about the favourite treasures I wanted to put i n my new room. Each one had so many memories for me. I imagined how I would arrange them, and when I a c t u a l l y got to the h o s p i t a l I enjoyed moving pictures and plants around. I was r e a l l y glad that I brought them, since i t ' s nice to be surrounded by f a m i l i a r things. People would often remark about a 117 picture or momento and I'd have the chance to t a l k about something I l i k e d . I'm sure that you have a l o t of favou r i t e belongings that are im-portant to you. Which one would you l i k e to bring? Can you imagine where you'd l i k e to put them? What you'd l i k e to t e l l others about them? You know, ju s t stopping for a moment and thinking about a problem i s very h e l p f u l to me. Whenever I'm worried about something, I ask myself, "Now, Mary, what exactly i s bothering you about the situation? What_are three - or f o u r ways to make things better f o r yo u r s e l f ? " I even found t h i s method of dealing with problems helps my f r i e n d s . One day my f r i e n d Sarah came into my room. She looked quite upset. Let's look at what happened between me and Sarah. Sarah: Mary, you've got to help me. I've got to t a l k to you. I j u s t can't take her any more. Mary: Can't take who any more? Sarah, I don't know what you're t a l k i n g about. Why don't you s i t down and t e l l me what's the matter? Sarah: I'm j u s t so upset, Mary. I've had about as much of my roommate, Mrs. B e l l , as I can take. Mary: What do you mean Sarah? Please t e l l me what happened j u s t now to make you so upset. Sarah: Remember I t o l d you that a f t e r lunch I was going back to my room to read that Agatha C h r i s t i e book, the one my f r i e n d lent me? Mary: Oh yes, I remember. You said i t looked very i n t e r e s t i n g . What about i t ? 118 Sarah: A f t e r lunch I went back to my room and s e t t l e d down i n my chair. Well, j u s t as the story was getting i n t e r e s t i n g , i n walked Mrs. B e l l , singing in. that awful voice of hers. Mary: Go on. Sarah: You know how she sings. I can't concentrate on anything when she's singing with that whining voice of hers. Mary: So, Mrs. B e l l ' s singing made i t hard for you to read your book? Sarah: She made i t impossible. Mary: Now calm down, Sarah. I t doesn't do you any good to get so worked up about t h i s . You're beginning to look flushed. Your blood pressure i s probably up. Sarah: I know Mary, but r i g h t now I f e e l l i k e I could strangle that woman. Mary: Well, that wouldn't do much good. Has Mrs. B e l l interrupted you before? Sarah: Yes, a few times. Often when I'm .reading, or w r i t i n g a l e t t e r . Mary: What have you done about i t ? Sarah: Well, usually. I j u s t get up and walk out of the room i n a huff. I,.don't get my reading done or my l e t t e r written. Mary: Do you stay angry? Sarah: Yes, I'm often cross with the other fo l k s for no reason at a l l , but I can't help i t , and afterwards I f e e l t e r r i b l e , but what can I do about i t ? Mary: Sarah, you're awfully upset. Is i t because you d i s l i k e Mrs. B e l l so much? Sarah: Well, Mary, I wouldn't say I d i s l i k e Mrs. B e l l so much. She's 119 got her good points. Sometimes we have i n t e r e s t i n g t a l k s . But I do f i n d that t h i s singing when I'm reading i s awfully annoying and that recently i t ' s harder for me to be c i v i l with Mrs. B e l l . Mary: So there are some things you l i k e about Mrs. B e l l . Sarah: Yes, and when I r e a l l y think about i t , i t ' s not j u s t Mrs. B e l l that bothers me. I get upset when anyone interrupts me when I want to be alone. Mary: So you get upset when anyone interrupts your privacy — not j u s t Mrs. Bell? Sarah: Yes, Mary. I gues what i s r e a l l y bothering me i s that i t ' s hard to be alone when I want to be. Mary: That c e r t a i n l y can be bothersome, Sarah. I know that i t s harder to have privacy i f you're sharing a room withtother people and have others around much of the time. Being alone when you want i s important. There must be some solutions to your problems. See i f you can think of some ways to have more privacy. Sarah: Well, I guess stra n g l i n g Mrs. B e l l i s n ' t t e r r i b l y appropriate. And i f I l o s t my temper with her i t would j u s t be harder for us to l i v e i n the same room. Mary: Well, those are two solutions that you've decided might not be h e l p f u l i n the long run. Can you think of some that would be helpful? Sarah: I could ask Mrs. B e l l i f she would not sing while I'm reading or wri t i n g a l e t t e r . Or, even better, I could try to do my reading and l e t t e r w r i t i n g when I know that s h e ' l l be busy i n the lounge playing bingo. Or, I've got another idea — I could read or s i t 120 q u i e t l y i n the l i t t l e l i b r a r y down i n the basement. I t ' s usually quiet. And when the weather gets a b i t warmer, I'd r e a l l y enjoy s i t t i n g outside on the balcony. You know, Mary, I j u s t love to s i t and think and watch the people walking by. And for,the time being I could also read for a l i t t l e while i n the lounge when most of the others s t a r t to go to bed. Mary: I t sounds l i k e there are l o t s of ways for you to have some privacy without you being i r r i t a b l e with others. Sarah: There c e r t a i n l y are. You know, I f e e l much better now, Mary. I think I ' l l go to the l i b r a r y r i g h t now and read my book. Well, As you saw, Sarah was quite upset at f i r s t . She was ex-periencing a problem almost everybody has to deal with when they move to a place where people have to share things. Each person knows how much privacy they need and r e a l i z e when they are not getting enough. Sarah was able to fi g u r e out several ways to have privacy. I've j u s t given two examples of problems and described a general method for dealing with them. The f i r s t involved my atti t u d e s to-wards my new room, the second dealt with Sarah f e e l i n g that she wasn't getting enough privacy. Let's review the things to do i f you're t r y i n g to solve a problem. F i r s t , i f something i s bothering, you, try to de-cide what the main problem i s . Once you've put your finger on the problem think of a l l the ways you can solve i t . If the problem i s complex you may have to look at each of the solutions and decide which i s better. In general, before you decide on any one s o l u t i o n you should ask yourself, "What are the consequences going to be?" When your problem 121 involves another person you can ask yourself: 1. How w i l l I f e e l i f I do that, and how w i l l the other person feel? 2. What w i l l hapen r i g h t a f t e r I do that and what w i l l happen l a t e r on? Remember my assistant that I introduced to you at the beginning of our talk? If there are things that you have been worrying about, you might l i k e to t a l k to my assistant and try to follow the steps l!ve ju s t discussed. Most people f i n d that t h i s method of solv i n g problems works pretty w e l l . They f e e l better and t h e i r worries seem more manage-able. Try to use t h i s method to think about problems between now and your move. As you saw, t a l k i n g to my daughter was very h e l p f u l to me when I was wondering how I could make my room look i n t e r e s t i n g , and t a l k i n g to me helped Sarah to r e a l i z e she was so upset because she found i t d i f f i -c u l t to be alone when she wanted to be. Sometimes t r y i n g to t e l l a person how you f e e l helps you to r e a l i z e exactly what's bothering you. For me, t a l k i n g to another person — l i k e my daughter or my f r i e n d Sarah or my favou r i t e nurse — often helps me to c l a r i f y my thoughts and work through problems. When my f r i e n d agrees with me I f e e l great and t e l l myself, "See Mary you're not alone i n your opinion. Sarah f e e l s the same way that you do." Now i f my f r i e n d disagrees with me, I may be a b i t upset f o r a l i t t l e while — depending on how strongly I believe i n my view, but I try to say, "Now, Mary, Sarah i s your f r i e n d . She cares about you and you respect her so why don't you give some thought to what she says. Maybe her point of view has some value to i t . " 122 The f i r s t time I had my hai r done at the h o s p i t a l , I complained to Sarah. Mary: Sarah, she's j u s t not a good hairdresser. Not a good h a i r -dresser at a l l . Look at how she did my h a i r . She ruined i t . Why do I need so many curl s r i g h t here? She made me look l i k e a poodle with a l l these cur l s up top. And to think I paid good money for t h i s . (Well, I went on and on). I'm never going back to that woman. The way they t r a i n those haxrdlressers nowadays. They think they can get away with anything. (Sarah brought me to my senses though. Sarah: How do you know she's.not a good hairdresser? Mary: Well, look. I look r i d i c u l o u s — i s n ' t that proof enough? Sarah: Now Mary. You don't look r i d i c u l o u s . Your ha i r i s j u s t done d i f f e r e n t than you're used to. Did you t e l l her how you wanted i t done? Mary.: Why, I — She shouldn't known how I l i k e my ha i r or she shouldn't be a hairdresser. Why ... Sarah: Come on Mary. I didn't think they trained hairdressers to be mindreaders nowadays. Well, that ..really got to me. Sarah was r i g h t . Here I was vowing never to go to that hairdresser again. I should never have expected her to know how I l i k e d to wear my hair without having t o l d her. Boy, Sarah r e a l l y helped bring me back to my senses. If I hadn't talked to her I'd probably s t i l l be angry. Instead, the next time I went to that 123 hairdresser I t o l d her exactly how I l i k e d my h a i r and you know she did a nice job. That was j u s t one small example of how t a l k i n g with someone helped me. I have a few favourite friends i n the h o s p i t a l that I t a l k to about what i s on my mind. If there i s a r u l e that I don't understand I ask a f r i e n d i f she knows the reason f or i t . I f she doesn't and wants to f i n d out too, we go together to ask one of the s t a f f to explain i t . Often we f i n d we have more ri g h t s than we thought. For instance, when I f i r s t moved i n I assumed that everyone had to go to bed at the same time. For several days I'd get angry at the thought of going to bed before I wanted to. I talked to Sarah and she agreed that i t seemed l i k e there was a set time f or going to bed, something l i k e a curfew for college g i r l s but she wasn't sure. She didn't think we'd a c t u a l l y been t o l d that we had to go to bed at a c e r t a i n hour. We decided to ask someone. F i n a l l y we got up enough nerve to ask an a i d that we l i k e how l a t e we were allowed to stay up and you know i t turned out that we could stay up i n the lounge u n t i l we f e l t ready to go to bed. Once we r e a l i z e d that we could save ourselves a l o t of f r u s t r a t i o n by asking the s t a f f questions, we made i t a p o l i c y that i f you don't know some-thing, ask someone. You know usually the s t a f f were happy to answer our questions. I t i s n ' t always easy to ask questions or to express f e e l i n g s honestly and d i r e c t l y when I want to e s p e c i a l l y to a s t a f f person. Some-times because of nervousness or anger I f i n d i t d i f f i c u l t to say or do what I want. A f t e r wards I could kick myself for not standing up for my r i g h t s or being more honest. But you know when the idea of t a l k i n g 124 to someone l i k e a s t a f f person scares me, I p r a c t i c e what I want to say with a f r i e n d . My f r i e n d pretends she i s the nurse and I p r a c t i s e asking my question. That r e a l l y helps calm me down. Part II Getting Ready for Moving Day There's something else I learned to help myself calm down. You've probably heard of t h i s technique since i t ' s as old as the h i l l s . And that's a technique c a l l e d "deep breathing." My grandmother taught i t to me when I was a young giftl about to go to my f i r s t dance. I f i n d that deep breathing s t i l l helps me when my heart s t a r t s to pound before I meet someone new, or when I j u s t f e e l nervous without knowing why. What I do i s take several short deep breaths, holding each one u n t i l my lungs f e e l f u l l . Then I part my l i p s s l i g h t l y and slowly exhale. Soon I being to f e e l relaxed. You know, as I continued deep breathing, I f e e l l i k e I can a c t u a l l y c o n t r o l my nervousness. Why don't you give i t a t r y . Now, f i r s t of a l l make sure your hands and arms f e e l relaxed and comfortable. Now, s t a r t to take short deep breaths, holding each one. Good. Now ., once you f e e l that you've breathed i n as much as you can, try to hold the breath for about f i v e seconds. Part your l i p s s l i g h t l y and slowly exhale. Slowly. That's good. Wasn't that easy? Try i t again. Breathe i n deeply several times. Hold your breath. Now, slowly exhale and f e e l yourself relax as you l e t the a i r out. You know, I've found that I can relax even more deeply i f I think the word "relax" to myself as I exhale. You can try the deep breathing again and think "rel a x " as you 125 exhale. There, now don't you f e e l better? 1 l i k e to p r a c t i c e the breathing exercise while I'm s i t t i n g i n my favourite chair with my eyes closed to shut out d i s t r a c t i o n s . I make sure my body's i n a com-fo r t a b l e p o s i t i o n . Sometimes I put on some soothing music or think pleasant thoughts. Prac t i . ing my deep breathing for ten minutes every day r e a l l y helped me to relax when I f e l t j i t t e r y both before and a f t e r the move. Now that you know how simple i t i s , when you have nervous moments, deep breathing may be j u s t the thing to help you to f e e l more relaxed. Before I moved into the h o s p i t a l there were l o t s of times when I f e l t r e a l l y nervous. I get a headache occasionally and there were several nights when I had a l o t of trouble getting to sleep, Ijiguess because I'd been thinking about the move to the h o s p i t a l . I found that doing my deep breathing exercises helped me to calm down and f e e l more relaxed. I r e a l i z e d that when I started f e e l i n g nervous and un-comfortable, I had usually been thinking c r i t i c a l l y about myself, some-times saying things l i k e I ' l l never l e a r n a l l the new routines. No-body w i l l l i k e me and I won't be able to f i n d my way to my room. I said negative things about myself so often that I didn't even notice the e f f e c t they had on how I was f e e l i n g . Sometimes I f e l t jumpy with-out knowing why. But one day I r e a l i z e d that the c r i t i c a l things I was t e l l i n g myself made me f e e l nervous. After, that, when I would f e e l nervous and uncomfortable, instead of l e t t i n g myself get a l l worked up I would say, "Now, stop Mary and look at what you're saying to yourself. Saying negative things about yourself won't help a b i t . They only make you f e e l nervous and anxious." Instead I'd try to t e l l 126 myself h l e p f u l things l i k e "OK, I'm f e e l i n g uncomfortable and nervous but I'm l e t t i n g myself get c a r r i e d away. I have to calm down and look at things more reasonably. Of course i t ' s going to be hard to get used, to a new place,- but i t w i l l be hard for everybody and i f I take things slowly, I ' l l be able to manage." By t e l l i n g myself h e l p f u l things I f e l t more relaxed and was able to think about the things I could do rather than things I couldn't do. The f i r s t few days i n the h o s p i t a l were hard for me and I f e l t r e a l l y nervous. Everything was new and when the nurse was showing me around I thought that I'd never be able to remember people's names or where things were. I f e l t so nervous I couldn't even l i s t e n to what the nurse was t e l l i n g me. I used my anxious f e e l i n g s as a sign to t e l l myself, "Now Mary, calm down, you can be i n c o n t r o l . " And I took a few deep breaths and sai d , "Take i t slow, relax, and j u s t l i s t e n to what the nurse i s saying. Nobody expects you to remember everything r i g h t away. Sure i t ' s going to take some time to l e a r n how they do things around here, but i t won't be long before you get things s t r a i g h t . " A f t e r saying these things to myself, I was able to relax, l i s t e n , and understand what the nurse was saying. T e l l i n g myself h e l p f u l things when I f e e l nervous helps a l o t . Sarah t o l d me that what made her nervous the f i r s t few days i n the h o s p i t a l was meeting the other patients f o r the f i r s t time. She t o l d me, "Mary, I wanted to make a good impression, but sometimes I'd f e e l so j i t t e r y that I could hardly say, How d'you do. So I'd t e l l myself Sarah, calm down. This person i s probably j u s t as nervous as you are. You know, Mary, somehow, by. t e l l i n g myself that, I'd s t a r t to f e e l a 127 b i t better." Before I moved to the h o s p i t a l I handled my nervousness about meeting the patients by t r y i n g to imagine myself meeting my roommates for the f i r s t time. I thought of things I..wanted to t e l l about!myself anH a l o t of things I'd l i k e to ask them. I a c t u a l l y t r i e d to imagine myself doing a good job of meeting my roommates. I was r e a l l y lucky, too. When Minnie, one of my f r i e n d s , came to v i s i t me at my children's, I said to her, "Minnie, you know I'm a b i t nervous about meeting the folk s at the h o s p i t a l . I've been trying to think of what I could say to them but I s t i l l f e e l a b i t unsure of myself. "Mary", ;she sai d , " Y o u ' l l probably do f i n e . You're a nice person and I'm sure that f o l k s w i l l l i k e you. Y o u ' l l probably have a l o t of good friends before you know i t . But I have an idea — you say that you've been thinking about what you'd l i k e to say when you meet the people i n the h o s p i t a l . Why don't we pretend that I'm going to be your new roommate and you're meeting me for the f i r s t time. You can p r a c t i c e what you'd say on me. How does that sound?" Mary: Well, I guess i t couldn't hurt. Minnie: OK, l e t ' s give i t a t r y . I ' l l s t a r t . Hello, my name i s Minnie Barnes. I think that we're going to be roommates. Mary: Hello, Mrs. Barnes. Pleased to meet you. My name i s Mary Adams. Minnie: Please c a l l me Minnie. Mary: A l l r i g h t , Minnie, and you be sure to c a l l me Mary. Minnie: Well, Mary have they given you a tour of our room? 128 Mary: Yes, j u s t t h i s morning. I t looks quite bare r i g h t now, but I think i t has p o s s i b i l i t i e s . I l i k e the bright orange cup-boards . Minnie: I think they're quite a l l r i g h t myself, although i t ' s sure d i f f e r e n t from the kind of f u r n i t u r e I'm used to. I used to have some b e a u t i f u l oak pieces i n the old house i n K i t s i l a n o . Mary: Minnie, I don't know what to say next! Minnie: Well, I j u s t t o l d you that I came from K i t s i l a n o , Ask me about i t . Mary: You l i v e d i n K i t s i l a n o ? Minnie: Yes, f o r 50 years/ Mary: Minnie, t h i s i s fun. Minnie: I t i s . Do you remember when we met for the f i r s t time, Mary? Mary: Yes, l e t ' s see. I t was ... Well, Minnie's suggestion to p r a c t i c e what I'd say when I'd meet my new roommates r e a l l y helped me to f e e l more confident i n myself. Imagining what I'd do i n d i f f e r e n t s i t u a t i o n s helped me to get ready for the move. I'd imagine a normal day and t r y to p i c t u r e what I'd be doing at d i f f e r e n t times of the day. I imagined myself doing the things I enjoyed l i k e k n i t t i n g and reading and I looked forward to playing bingo and learning how to do new c r a f t s . I'm sure that you have many talents you'd l i k e to explore and develop. Have you thought about that? You may even have some s k i l l s that you canjshare with the other fo l k s or some i n t e r e s t i n g s t o r i e s to t e l l . Each one of us i s d i f f e r e n t and we've a l l had a l i f e of varied and e x c i t i n g experiences. 129 Thinking about what you'd l i k e to do and what you'd l i k e to p a r t i c i p a t e i n may help you to look forward to t h i s move. Well, I'm glad that we've had th i s opportunity to chat. I hope that y o u ' l l f i n d some of my experiences i n the h o s p i t a l h e l p f u l i n preparing yourself got your move and i n getting used to the h o s p i t a l . F e e l free to try to work your concerns and solve problems the way we discussed. Talk to others when you're concerned about something and breathe deeply when you're f e e l i n g nervous. Be good to yourself and try to say h e l p f u l things. You're going to be experiencing a big change but I think that you can manage. I hope that things go w e l l for you. I'd l i k e to say good-bye now. If you have any questions about what we've j u s t talked about, f e e l free to ask my a s s i s t a n t . 130-- . - APPENDIX i P ^ .^ r> ...v. - -Therapist Guidelines for Coping S k i i l s T raining S 1 ' J q - Tape Programme There are three stops during each of the two parts of the s l i d e tape presentation. The therapist should stop the tape at each of these designated spots and follow the steps outlined i n these guidelines. The therapist should also f e e l f r e e to stop the presentation whenever the patient has a question or concern he/she would l i k e to discuss. The presentation i s meant to be a takeoff point for discussion of problems r e l a t e d to moving to the h o s p i t a l as w e l l as an introduction to several stress management techniques that may be of use to the p a t i e n t . No>t a l l of the problems discussed during the presentation w i l l be of concern to any p a r t i -cular patient, i n that case t r y to focus the discussion on issues of concern to the patient." INTRODUCTION: -Explain to the patient that they w i l l be seeing a presentation that w i l l feature comments made by a patient who has moved to an extended care unit and some simple methods f o r making getting ready f o r moving day easier f o r them. SjT0P_£l£ -Stop the tape a f t e r the discussion about Mary's a t t i t u d e s towards her new room -the l a s t l i n e of dialogue i s "What you'd l i k e to t e l l others about them?" - t a l k about what the patient's new room w i l l be l i k e -ask the patient i f he/she has any f a v o u r i t e belongings that he/she would like, to take -you may want to make some suggestions of things that they could bring -you can even make a l i s t up for them STOP #2: -Stop the tape at the end of the discussion of the problem so l v i n g method - l a s t l i n e of dialogue i s "Try to use t h i s method to think about problems between now and your move." -go over Sarah's problem emphasizing the steps involved i n s o l v i n g her problem --discuss the issue of sharing a room with others - i - i s i t a problem for them -do they get enough p r i v a c y 7 PART TWO: .131 STOP #1: -Stop the tape a f t e r the discussion of deep breathing - l a s t l i n e of dialogue i s "Now that you know how simple i t i s , when you have nervous moments deep breathing may be j u s t the thing to help you f e e l more relaxed." -model the deep breathing exercise -have the patient do i t a few times - p r a i s e the patient f o r following i n s t r u c t i o n s - s t r e s s the usefulness of the deep breathing exercise f o r get t i n g r i d of pounding heart, b u t t e r f l i e s i n the stomach, etc., during nervous moments both before and a f t e r the move » STOP #2: -Topic of dis c u s s i o n : the r o l e of things we t e l l ourselves -stop the tape a f t e r the se c t i o n discussing s e l f - i n s t r u c t i o n - l a s t l i n e of dialogue i s "You-know Mary, somehow, by t e l l i n g myself that, I'd s t a r t to f e e l a b i t b e t t e r . " -review the se c t i o n on the tape -explain how Mary r e a l i z e d that t e l l i n g h e r s e l f negative things made her f e e l anxious -how she made h e r s e l f aware of the negative things she was saying and how she t r i e d to t e l l h e r s e l f more reasonable things -ask the patient i f he/she i s aware of negative things he/she t e l l s him/herself -what kinds of negative things do they say ? -are there any s i t u a t i o n s i n which they t y p i c a l l y t e l l themselves negative things ^--ask what p o s i t i v e or more reasonable things they could t e l l themselves instead -you may have to give suggestions here - t e l l the patient to t r y to no t i c e when he/she says c r i t i c a l things about themselves and to t r y and say p o s i t i v e things instead STOP #3: -Stop at the end of Part 2 7 •-can they think of ways to have more privacy < -ask the patient how he/she has solved problems i n the past 132 -ask i f he/she discusses problems with any p a r t i c u l a r people - s t r e s s the bene f i t s of t a l k i n g over problems with others - s t r e s s the importance of thinking about the move to the h o s p i t a l and t r y i n g to work through problems -ask the patient i f there are things he/she has been worrying about concerning the move - make a note of these -use one of t h e i r concerns as an exercise f o r teaching them the problem s o l v i n g method -use prompts to guide them through each of the steps (e.g. ask them i f they can pinpoint the problem exactly, then can they think of any solutions -make sure to pr a i s e the patient for responding - i f they are having d i f f i c u l t y you may have to help by giving suggestions f o r a s o l u t i o n , then ask them to come up with another -you may have to give an example of a problem of your own or a hypot h e t i c a l problem and model the technique f o r them -once the patient has gone through the steps with you see i f they can do i t on t h e i r own without prompting - r e f e r to problem so l v i n g s e c t i o n i n the sponsor's manual STOP #3: -Stop at the end of Part 1 - t o p i c of disc u s s i o n : t a l k i n g to someone, patient r i g h t s , assertiveness, r o l e p l a y i n g - s t r e s s the be n e f i t s of t a l k i n g to another person -ask the patient i f he/she has someone they can confide i n -does i t help them -how does i t help ? -encourage the patient to t a l k about t h e i r f e e l i n g s about the move to the h o s p i t a l with t h e i r sponsor and to make fri e n d s i n the h o s p i t a l -review the importance of asking the s t a f f questions i f they don't understand something, need information about r u l e s , when the doctor i s coming etc. - s t r e s s the f a c t that they have the r i g h t to information regarding t h e i r welfare -that every person i s e n t i t l e d to express themselves while remaining considerate of the other person - t a l k about r o l e p l a y i n g to p r a c t i c e asking questions -do a very general review of the techniques i n part one - s t r e s s how imagining what t h e y ' l l be doing i n the h o s p i t a l can help -ask what they'd l i k e to do and learn i n the-'hospital -review the techniques discussed i n both parts of the presentation -encourage them to t r y them PROBLEMS SOMETIMES ENCOUNTERED BY PATIENTS MOVING TO A LONG TERM CARE, FACILITY 1. Lack of privacy - having to share a room, dining f a c i l i t i e s 2. Set routines - set times f o r eating meals, reduction i n # of choices of what to eat, set bath times, bath days, medications administered by others, rules regarding smoking, how they w i l l l e a r n the hew routines 3. W i l l they l i k e roommates 4. What w i l l the other residents be l i k e - w i l l there be a l o t of confused people there 5. W i l l family come to v i s i t - what are the v i s i t i n g hours Feelings of abandonment 6. Leaving behind f r i e n d s - how can they maintain contact 7. Leaving behind f u r n i t u r e , belongings 6. Feelings of going to a place to die - -9. Finances - who's going to take care of things, what's the cost APPENDIX „ Q • .. . ^ 134 Sponsor's Manual - H o s p i t a l i z a t i o n of a family member i s often a d i f f i c u l t d e c i s i o n to make. The e l d e r l y parent or grandparent often occupies an important p o s i t i o n i n the family. The choice of moving to an extended care u n i t , however, i s often necessary to ensure that the patient receives proper medical care. At the same time, a son, daughter or grandchild may f e e l g u i l t y because ' they are not able to provide that care at home. P o t e n t i a l p a t i e n t s may be hesita n t to move in t o an extended care u n i t (ECU) because they fear the lo s s of contact with t h e i r f r i e n d s or loved ones. Leaving f a m i l i a r sur-roundings, o l d f r i e n d s and the habits of l i v i n g that have been established over a l i f e t i m e i s d i f f i c u l t for the e l d e r l y . It would be d i f f i c u l t for ' anyone! Yet, the problems of moving must be balanced against the need f o r regular, expert medical care. This manual has been w r i t t e n f o r the f a m i l i e s and sponsors of e l d e r l y patients who require long term care. There i s often very l i t t l e that the family or sponsor can do d i r e c t l y to help the patient deal with h i s or her medical problems. However, there i s a great deal 'that can be done to help patients deal with t h e i r stay i n an ECU. The work of the family or sponsor can begin well before the patient moves and continues throughout h i s or her stay. This manual w i l l o u t l i n e some h e l p f u l ways of making the move to the ECU as easy and su c c e s s f u l as p o s s i b l e . A group of concerned and i n t e r e s t e d people from the U n i v e r s i t y of B r i t i s h Columbia would also l i k e to take t h i s opportunity to help the sponsors i n the move of th e i r f r i e n d or r e l a t i v e . 'Sponsors' (family, f r i e n d or s o c i a l worker) w i l l be asked to p a r t i c i p a i n 2 group meetings. These meetings w i l l focus on the r o l e the sponsor may play i n easing the move to the ECU. Methods of helping and teaching the future patients i n ways of preparing and dealing with the move w i l l be 135 discussed. Slide-tape presentations of the new ECU and problems and s o l u t i o n s surrounding a move w i l l be shown during these meetings. Group d i s c u s s i o n w i l l also form a large part of these meetings and sponsors w i l l be encouraged to express t h e i r f e e l i n g s and a t t i t u d e s about the move of t h e i r r e l a t i v e or f r i e n d . We w i l l also be making four v i s i t s to the person who w i l l be moving to the ECU. During these v i s i t s the e l d e r l y person w i l l have the opportunity to see a s l i d e presentation that describes the ECU at the U n i v e r s i t y of B r i t i s h Columbia. In a d d i t i o n , we have taped the comments of another e l d e r l y person who o f f e r s some advice on how to get ready for the move, what to b r i n g , how to pack and how to handle f e e l i n g s about the move. Our v i s i t s w i l l also give the patient a chance to bring up any s p e c i a l concerns he or she has about the move and to t a l k them over with someone who i s f a m i l i a r with the ECU. In essence, we want the person to know that people from the h o s p i t a l are concerned about h i s or her welfare and are there to help should they be needed. PREPARATION FOR RELOCATION OF THE ELDERLY PROGRAM (PREP) Our preparation program i s based on some f a c t s that we know about making the move a better experience for the e l d e r l y . PATIENT EXPECTATIONS Patient expectations of the new f a c i l i t y are p a r t i c u l a r l y important to s u c c e s s f u l adjustment. Negative expectations such as: " i t ' s the end of 136 the road", " a l l the people w i l l be confused", "there w i l l be nothing to do except s i t and wait for the end" and "nobody w i l l come to v i s i t " w i l l hinder the e l d e r l y p a t i e n t ' s adjustment. Patients with overly p o s i t i v e expectations such as: " I ' l l have my own room", " t h e y ' l l make me walk again" and " I t w i l l be j u s t l i k e i t was at home" w i l l only be d i s i l l u s i o n e d and unhappy upon a r r i v a l at the ECU. Those with more moderate expectations seem to adjust more adequately because they have a much more r e a l i s t i c p i c t u r e . INSTRUCTIONS  AND ACCURATE INFORMATION ABOUT THE ECU HELP TO CREATE A MORE REALISTIC  VIEWPOINT and t h i s has a p o s i t i v e e f f e c t upon adjustment. With information on the ECU made a v a i l a b l e to them, pat i e n t s are better able to accurately p r e d i c t the s i t u a t i o n they w i l l soon f i n d themselves i n . In t h i s way, they are better able to prepare for the move. A member of the PREP program w i l l show each e l d e r l y person a s l i d e - t a p e presentation d e s c r i b i n g the a r c h i t e c t u r e , i n t e r i o r design and s e r v i c e s of the new f a c i l i t y . This f i l m w i l l o u t l i n e the a c t i v i t i e s a v a i l a b l e , the routines and r e g u l a t i o n s , the s t a f f and t h e i r d u t i e s , as well as the available.resources (volunteers, b u s t r i p s , s e r v i c e s on campus) with i n the community. This presen-t a t i o n w i l l also allow us to discuss concerns and to i d e n t i f y s p e c i f i c prob-lems that are troublesome for the p a t i e n t . S p e c i f i c problems may include lack of privacy, l o s s of valued possessions, l e s s contact with family and f r i e n d s , etc. The PREP th e r a p i s t w i l l help with these problems and hopefully reduce the worry and uneasiness that the patient f e e l s about the move. The sponsor should also COUNSEL THE PATIENT ON WHAT TO EXPECT from ex-tended care h o s p i t a l i z a t i o n , thereby in c r e a s i n g the opportunity for the patient to develop a more r e a l i s t i c p i c t u r e . The sponsor w i l l be given a booklet of information on the ECU and w i l l also be shown the s l i d e - t a p e presentation 137 of the new f a c i l i t y . Any questions that the sponsor may have w i l l be answered by the PREP s t a f f during the course of the group meetings. In t h i s way, the sponsor can r e l a t e t h i s information to the patient on a more continuous b a s i s than could be achieved by the PREP s t a f f . Also, REASSURE THE PATIENT that others with s i m i l a r d i f f i c u l t i e s have s u c c e s s f u l l y adjusted. This w i l l some-times create a p o s i t i v e and h e l p f u l expectation about extended care h o s p i t a l i -z ation . PATIENT INSTRUCTION AND TRAINING The second and t h i r d session with the patient w i l l focus on i n s t r u c t i o n and t r a i n i n g i n methods of dealing with problems surrounding the move. The PREP s t a f f assigned to the patient w i l l show a presentation e n t i t l e d "Getting Redy for Moving Day". This f i l m describes the problems and s o l u t i o n s i n moving to an ECU by another e l d e r l y person who o f f e r s some advice based upon her own experiences. Sponsors w i l l also be shown t h i s f i l m i n order to acquaint them with some of the techniques of dealing with problems. These techniques are l i s t e d below. Problem Solving Most of us f i n d ourselves i n d a i l y s i t u a t i o n s where we must solve prob-lems by making choices and a r r i v i n g at a d e c i s i o n . Those of us who push problems aside i n the hopes that they w i l l 'just go away' or allow others to make decisions f o r us are often faced with more problems than we s t a r t e d with. We may also begin to f e e l somewhat he l p l e s s and powerless i n what hap-pens to us from day to day. 138 Your r e l a t i v e or f r i e n d moving to a long term care h o s p i t a l i s con-fronted with a l o t of changes. Some changes, such as sharing a room with others for the f i r s t time, l o s i n g contact with f r i e n d s or having a new doctor care fo r them can lead to worry, anxiety, nervousness and•a sense of helplessness. The sooner these worries are de a l t with, the sooner the patient w i l l get used to h i s or her new home. However, the e l d e r l y person can get rusty at handling t h e i r own problems without the help of others. A general method f o r dealing with problems and t h e i r s o l u t i o n i s o u t l i n e d i n the s l i d e presentation "Getting Ready for Moving Day". The sponsor can be a r e a l help by taking time to TEACH THE PATIENT THE PROBLEM SOLVING METHOD and ENCOURAGE THE PATIENT TO THINK ABOUT WORRIES AND ATTEMPT TO WORK THROUGH  PROBLEMS. The f i r s t task i s to SPECIFY THE PROBLEM. When something i s bothering you, t r y to specify,the problem exactly by asking yourself:"What i s bothering me about that s i t u a t i o n ? " Very often problems seem to become overwhelming and unmanageable. By f o r c i n g yourself to define exactly what's bothering you, the problem becomes more concrete and manageable. Once the problem has been de-f i n e d , i t i s then necessary to THINK OF SEVERAL SOLUTIONS to the problem. Try to think of as many sol u t i o n s as you p o s s i b l y can. Next, EVALUATE EACH SOLUTION and decide which one i s best. To do t h i s , consider what the consequences would be for each p o s s i b l e s o l u t i o n . Ask your s e l f what the immediate consequences of your s o l u t i o n w i l l be and what the long term consequences w i l l be. I f your problem involves another person ask your s e l f how you w i l l f e e l i f you did that and how the other person w i l l f e e l . The f i r s t problem discussed i n the f i l m involves Mary's a t t i t u d e s towards her new room. At f i r s t Mary knows only that she i s n ' t looking forward to her new room at the h o s p i t a l but she doesn't know why. I t i s not u n t i l Mary's 139 daughter asks her to try to say exactly what's bothering her that Mary r e a l i z e s what the problem i s . Mary i s upset because a l l the rooms w i l l be i d e n t i c a l and she wants hers to have some character to i t . The problem has now been defined but Mary has not thought of any s o l u t i o n s . Mary's daughter prompts her by asking her to think of things to take with her to put i n her room. Mary i s now able to think of s e v e r a l important possessions that she would l i k e to b r i n g . She has been able to think of many so l u t i o n s to her problem of making her new room more unique - p i c t u r e s , plants, photos and f i g u r i n e s . The.next problem discussed i n the f i l m involves Mary's f r i e n d 'Sarah' who i s upset because Mrs. B e l l has i n t e r r u p t e d her reading. When Mary began asking questions to understand why Sarah was so upset, Sarah was able to define the main problem. I t wasn't Mrs. B e l l ' s i n t e r r u p t i o n as Sarah had f i r s t stated, but rather, Sarah was having trouble g e t t i n g the privacy she needed i n the hospital.•Even with t h i s r e a l i z a t i o n though, Sarah did not think of any s o l u t i o n s . With Mary's encouraging (prompting), Sarah i s able to think of s e v e r a l , not a l l of which were equally appropriate,.however. Sarah's s o l u t i o n s were to strangle Mrs. B e l l , ask Mrs. B e l l not to sing while she's reading, read i n the lounge when the other residents are g e t t i n g ready to go to bed and read i n the l i b r a r y . Sarah r e a l i z e s that s t r a n g l i n g Mrs. B e l l i s u n r e a l i s t i c and that confronting her might create f r i c t i o n . She eliminates two s o l u t i o n s because of t h e i r immediate and long term consequences but i s s t i l l l e f t with several s u i t a b l e ways to have more privacy. With the use of these examples, the PREP s t a f f w i l l teach problem-solving to the p a t i e n t . The sponsor can also help i n t h i s teaching process. Use the following steps as a guide i n helping the patient l e a r n t h i s technique. 140 1) To begin, i t i s e f f e c t i v e to GIVE THE PATIENT AN EXAMPLE OF HOW YOU WOULD  SOLVE A PROBLEM that i s bothering you. Be sure to: a) DEFINE THE PROBLEM; b) THINK OF A NUMBER OF SOLUTIONS TO THE PROBLEM; c) EVALUATE EACH SOLUTION AND DECIDE WHICH IS BEST. Go through each step slowly, making sure that the patient i s l i s t e n i n g and can understand. Showing the patient how you would solve a problem i s an e f f e c t i v e way of teaching a s k i l l of t h i s s o r t . 2) Once you"have demonstrated problem-solving, LET THE PATIENT TRY IT. In the same way that the daughter helped Mary solve a problem, you can help along the way. Ask the patient i f he or she has any problems or worries. You may not even have to ask i f you already know of one. Try to GET THE  PATIENT TO IDENTIFY THE PROBLEM AS SPECIFICALLY AS POSSIBLE. If the patient i d e n t i f i e s the s p e c i f i c problem COMMEND THE PATIENT FOR DOING SO. 3) HELP THE PATIENT TO THINK OF SOLUTIONS TO THE PROBLEM. It i s sometimes necessary to prompt the patient by g i v i n g a s o l u t i o n so that he or she gets the idea. Try to get the patient to think of more s o l u t i o n s by prompting with clues or ideas i f necessary. When he or she thinks of a so l u t i o n , even though i t may not be the most appropriate, PRAISE THE  PATIENT IMMEDIATELY. The patient w i l l then be more l i k e l y to think of others. 4) Once a number of so l u t i o n s have been created, i t ' s now time to EVALUATE  EACH ONE AND DETERMINE WHICH IS BEST. To do t h i s , the patient has to CONSIDER WHAT THE CONSEQUENCES WOULD BE FOR EACH POSSIBLE SOLUTION. The patient should ask himself what the immediate consequences of each po s s i b l e s o l u t i o n w i l l be and what the long term consequences w i l l be. I f the pati e n t ' s . "141 problem involves another person not only should he ask how i t w i l l e f f e c t him, but how i t w i l l e f f e c t the other person. Again, prompting the patient and a c t u a l l y evaluating a s o l u t i o n y o u r s e l f w i l l help him i f d i f f i c u l t y a r i s e s . Be sure to p r a i s e the patient i f he evaluates a s o l u t i o n i n terms of i t s consequences. Make sure each s o l u t i o n i s evaluated and a f i n a l r e -sponse i s reached. Commend the patient for t h i s . 5) Steps 2, 3 and 4 are important steps i n problem-solving. U n t i l now you have prompted and praised the patient for each step along the way. I t i s now time to PUT THESE STEPS TOGETHER i n order for the patient to use t h i s technique. One way of doing t h i s i s to SLOWLY WITHDRAW THE PROMPTS that you have used u n t i l now. You may s t i l l have need for them but not as many w i l l be necessary. Another method i s to COMBINE THE STEPS. Before g i v i n g p r a i s e , allow the patient to think of a number of s o l u t i o n s . Then thinking of a number of s o l u t i o n s and evaluating them before commending him. In t h i s way, the patient w i l l soon be able to do step 2, 3 and 4 before i t i s necessary for you to give p r a i s e . By continuing t h i s method of teaching with guiding, prompting and p r a i s i n g when necessary, the patient w i l l soon be able to use t h i s method for s o l v i n g problems. Remember that, i n p r a i s i n g the patient, you are encouraging him to l e a r n a s k i l l that w i l l be u s e f u l both before and a f t e r the move. Discussing With Others Just t a l k i n g s o l v i n g problems. to someone i s often one of the best and T e l l i n g a f r i e n d why you're upset about easiest methods something often of helps 142 you r e a l i z e what the problem r e a l l y i s . People who have close f r i e n d s h i p s , therefore, have many more resources a v a i l a b l e to them i n handling l i f e events. Family and f r i e n d s can play an important r o l e i n t h i s regard. A patient faced with a move to a new home w i l l be experiencing a l o t of d i f -ferent f e e l i n g s . ENCOURAGE THE PATIENT TO TALK ABOUT FEELINGS AND WORRIES. In t h i s way, you can help to so r t out t h e i r f e e l i n g s about the move. Also, ENCOURAGE THE PATIENT TO DEVELOP NEW FRIENDSHIPS IN THE ECU and to share f e e l i n g s with someone e l s e . You can help i n developing resources f o r the patient's future. In the f i l m "Getting Ready for Moving Day" Jti^ry, i n t a l k i n g to her daughter, was able to c l a r i f y her f e e l i n g s about her new bedroom and came up with several s o l u t i o n s to her problem. Mary and her daughter were also given an opportunity to do something together. We also saw i n the f i l m how Sarah was able to calm down, r e a l i z e that her problem was r e l a t e d to lack of privacy and think of some sol u t i o n s by expressing her f e e l i n g s to Mary. Another example was the in c i d e n t with Mary and the h a i r d r e s s e r . Sarah was able to calm Mary down and o f f e r a more r e a l i s t i c i n t e r p r e t a t i o n of Mary's problem. Mary should not have expected the hai r d r e s s e r to have known how to do her h a i r without Mary t e l l i n g her. If Mary hadn't expressed her f e e l i n g s to a f r i e n d she probably would have remained angry and f r u s t r a t e d . Often an e l d e r l y person's WORRIES MAY BE CAUSED BY A LACK OF INFORMATION  OR INCORRECT INFORMATION. In the f i l m Sarah and Mary r e a l i z e d that they could save themselves a l o t of f r u s t r a t i o n by making i t a p o l i c y that IF YOU DON'T  KNOW SOMETHING, YOU SHOULD ASK SOMEONE. Friends and r e l a t i v e s should t e l l the patients that they have the r i g h t to information concerning t h e i r welfare and should ENCOURAGE THE PATIENT TO ASK FOR INFORMATION when he or she i s not 143 aware of something. For instance, i f the patient i s h e s i t a n t about asking s t a f f members what h i s r i g h t s are, the sponsor could take on the r o l e of a ' s t a f f member' for a moment and p r a c t i c e with the patient on how he could go about asking. Prompting the patient on things to say may encourage him or her to be more a s s e r t i v e . This kind of p r a c t i c e w i l l also make the patient more comfortable about asking when a c t u a l l y i n a s i t u a t i o n of needing to ask. What We Say To Ourselves What we say to ourselves e f f e c t s the things we do and the way we think about the world around us. When we are f e e l i n g nervous or discouraged, i t i s often because we have been thinking negatively, saying things to ourselves l i k e " I ' l l never be able to do that" or " there are. a l o t of people that don't l i k e me". If we have convinced ourselves that we can't do something such as play a sport or k n i t a sweater, we probably won't even t r y or give ourselves the chance to be proven wrong. In t h i s way we can severely l i m i t our actions and p o t e n t i a l s a t i s f a c t i o n and enjoyment by being u n r e a l i s t i c a l l y harsh on ourselves. We begin to think that "my l i f e i s t e r r i b l e " and before too long, we have thought ourselves into a state of depression. I t i s p o s s i b l e to MAKE YOURSELF AWARE OF NEGATIVE UNREALISTIC BELIEFS that you have about yourself and to change your thinking i n such a way as to t e l l y ourself more reasonable things. For example, i f you are thinking of k n i t t i n g a sweater for a new grandchild and you haven't attempted a task of t h i s sort before, you're apt to t e l l y ourself that y o u ' l l j u s t make a t e r r i b l e mess. You may p o s s i b l y not make the attempt and f e e l badly afterwards. However, i f you t e l l y o u r s e l f that t h i s i s your f i r s t e f f o r t and you're bound to make 144 some mistakes, "but with p r a c t i c e I ' l l get the hang of i t " , then you're much more l i k e l y to begin k n i t t i n g the sweater. And you may have a new ac-complishment to f e e l good about. You can lea r n to TELL YOURSELF MORE CONST- RUCTIVE AND POSITIVE THINGS ABOUT YOURSELF and t h i s w i l l have a b e n e f i c i a l e f f e c t on your f e e l i n g s and what you do. The e l d e r l y patient about to move to the ECU may f e e l overwhelmed by the changes that w i l l soon take place. He or she may f e e l unsure of whether t h e y ' l l get used to things, or not. In the sl i d e - t a p e presentation Mary kept t e l l i n g h e r s e l f things l i k e " I ' l l never be able to f i n d my way to my room", "nobody w i l l l i k e me" and " I ' l l never be able to l e a r n the way they do things around here". F i n a l l y she r e a l i z e s that THE NEGATIVE THINGS YOU TELL YOURSELF  MAKE YOU FEEL NERVOUS. Mary became aware of the negative things she said and would t e l l h e r s e l f to LOOK AT THINGS MORE REASONABLY and TRY TO SAY THINGS  THAT ARE MORE REALISTIC. The sponsor can take an a c t i v e part i n t e l l i n g the patient that saying things l i k e "I'm too old to change" won't help a b i t , but w i l l only keep the patient from focusing on ways to make things better for himself. POINT OUT  TO THE PATIENT THE NEGATIVE THINGS HE OR SHE IS SAYING and make him or her aware that these thoughts w i l l not help i n adjusting to the new h o s p i t a l . As one gets older i t i s more d i f f i c u l t to change and i t may take more e f f o r t , but i t can be done. Attempt to have the patient see things more reasonably and r e a l i s t i c a l l y . DISCUSS THE PATIENT'S POSITIVE PERSONAL ASSETS, STRENGTHS AND  ACCOMPLISHMENTS through t h e i r l i f e as well as i n the present. When the patient does express p o s i t i v e personal f e e l i n g s , praise him for doing so as t h i s w i l l increase the l i k e l i h o o d of the patient continuing to express and think of p o s i t i v e h e l p f u l statements. P o s i t i v e Thinking 145 Thinking about a future event can r e a l l y be h e l p f u l i n preparing oneself for an event, e s p e c i a l l y i f you can think p o s i t i v e l y about your future actions The sponsors can help i n the preparation for the move by encouraging patients to imagine what they w i l l be doing at d i f f e r e n t times of the day and what they would l i k e to become involved i n while at the h o s p i t a l ( i e . what r e c r e a t i o n a l a c t i v i t i e s they'd l i k e to take part i n , which c r a f t s they'd l i k e to do). ENCOURAGE THE PATIENT TO IMAGINE DOING POTENTIAL ACTIVITIES SUCCESSFULLY AND  ENJOYING THEMSELVES. Praise the patient f or thinking about what he w i l l be doin when l i v i n g at the h o s p i t a l and commend him for thinking about doing these a c t i v i t i e s s u c c e s s f u l l y and enjoying himself. Deep Breathing Sometimes we f i n d ourselves i n s i t u a t i o n s where, we can't solve a problem or j u s t r e a l l y f e e l nervous. At d i f f e r e n t times our hearts may s t a r t to pound, our palms sweat, our stomach develops ' b u t t e r f l i e s ' and our knees quiver. During times l i k e these, SIMPLY BREATHING DEEPLY MAY HELP US TO CALM DOWN  AND RELAX. The e l d e r l y patient w i l l probably have several nervous moments before and a f t e r the move. Deep breathing i s an easy method to master and provides another way of handling worry and nervousness. The sponsor can go over each step of the deep breathing exercise with the patient and encourage him or her to p r a c t i c e i t . The procedure, as ou t l i n e d i n the s l i d e presentation i s as follows: a) TAKE SEVERAL SHORT, DEEP BREATHS HOLDING EACH ONE UNTIL YOUR LUNGS FEEL FULL; b) HOLD YOUR BREATH FOR ABOUT 5 SECONDS; c) PART YOUR LIPS SLIGHTLY AND SLOWLY EXHALE; d) THINK THE WORD 'RELAX' AS YOU GO THROUGH THE STEPS; e) REPEAT FOR ABOUT 10 MINUTES AT A TIME. The sponsor can help i n teaching t h i s technique by using the following steps as a guide: 1) DEMONSTRATE THE DEEP BREATHING PROCEDURE TO THE PATIENT. Go through each step slowly and c a r e f u l l y , making sure the patient i s l i s t e n i n g and can understand. By showing the patient how you would use t h i s method, he or she can watch, l i s t e n and imitate what you do. 2) Once you have demonstrated t h i s deep breathing procedure, LET THE PATIENT  TRY IT. D i r e c t the patient through each step i n the procedure. INSTRUCT  THE PATIENT ALONG THE WAY.. Praise the p a t i e n t as he or she follows your i n s t r u c t i o n s . 3) Repeat the procedure but, instead of using i n s t r u c t i o n s , use only prompts when necessary. If the patient does not know what to do next, then.let him or her know. Again PRAISE THE PATIENT FOR COMPLETING THE STEPS ALONG  THE WAY, without the need of i n s t r u c t i o n s . 4) Repeat the procedure u n t i l prompts are no longer necessary. P r a i s e the patient at the completion of the procedure. 5) Whenever you see that the patient i s nervous or anxious, remind him to use the deep breathing procedure. Praise the patient for doing so and commend him when you f i n d the patient using t h i s method without the need of your prompting. SPECIFIC AIDS TO PREPARATION AND ADJUSTMENT 147 The following suggestions are designed to ease the task of moving f o r the e l d e r l y person. These suggestions attempt to decrease the number of unknowns and minimize los s e s . Moving can be l e s s arduous for both you and the patient i f a conscious e f f o r t i s made to prepare for the move. 1) TALK ABOUT THE MOVE OPENLY. Simply by acknowledging the fact that the patient w i l l be moving and by allowing him or her to t a l k openly about the prospect, w i l l reduce anxiety and fear. Encourage the patient to express his fears and the problems he forsees i n moving. Attempt to deal with these problems and fears , as out l i n e d i n t h i s manual. 2) DISCUSS THE MECHANICS OF THE MOVE, when i t w i l l take place, who w i l l help, what things can be brought, etc. 3) TELL THE PATIENT WHAT THE NEW ECU WILL BE LIKE, what r i g h t s he or she w i l l ' hive, what d i f f i c u l t i e s may a r i s e because of the move. Emphasize that the move w i l l not mean lower l e v e l s of care and concern but w i l l provide continuing care. This w i l l help the patient to regard the move as an impending r e a l i t y . 4) Suggest that the patient think about and CHOOSE SOME OF THEIR FAVOURITE MOMENTOS TO TAKE WITH THEM, along with p i c t u r e s and ornaments to decorate the room. Encoura Encourage the patient to think about arranging and decorating the new room and what things would best s u i t that arrangement. This w i l l allow the patient to i n d i v i d u a l i z e the new room and thus, make i t more f a m i l i a r . A f t e r the move has taken place, encourage the patient to follow through on the decorating plans 1.48 5) LET FRIENDS AND RELATIVES OF THE PATIENT KNOW OF THE MOVE. Send out Postal Change of Address Forms and allow the patient to help you. 6) ENCOURAGE THE PATIENT TO WRITE A SELF-DESCRIPTION o u t l i n i n g important events, and c h a r a c t e r i s t i c s that the patient would l i k e h o s p i t a l s t a f f to know about. 7) PLAN TO VISIT THE PATIENT REGULARLY and perhaps more often during the d i f f i c u l t period immediately before and a f t e r the move. V i s i t s are better to be made frequent and short rather than infrequent and long. To increase the frequency of v i s i t s a suggestion would be to have d i f f e r e n t family members v i s i t on d i f f e r e n t days. 8) Set up a schedule for v i s i t i n g i f p o s s i b l e , and LET THE PATIENT KNOW BEFOREHAND WHEN YOU WILL BE VISITING. An i d e a l way i n which to do this i s to obtain a large calendar and mark the v i s i t s you w i l l make on i t . The unknown w i l l not loom so large i f the patient knows i t does not mean l o s s of caring, concern and support. 9) On the same calendar, CIRCLE MOVING DAY. This w i l l help to prepare the p a t i e n t . 10) If po s s i b l e , ACCOMPANY THE PATIENT TO THE NEW HOSPITAL on the day of the move and a c t i v e l y take part i n the process of packing and getting ready. 11) Soon a f t e r admission the PREP s t a f f w i l l help arrange a schedule of v i s i t s between the family or sponsor and the pat i e n t . We w i l l also o u t l i n e the ho s p i t a l ' s r e s p o n s i b i l i t y for care. The PREP s t a f f s i n c e r e l y hope that the information contained i n th i s manual w i l l help both you and the resident prepare for the move to the Extended Care Hospital at the U n i v e r s i t y of B r i t i s h Columbia . 149 APPENDIX R Table 1 Analysis of Variance on Age Source SS MS df F Between Groups 1201.05 600.53 2 5.49* Within Groups 7651.93 109.31 70 Tot a l 8852.98 122.96 72 p_ = .006 APPENDIX S Table 1 Analysis of Variance on Number of L i f e Stress Events Occurring within Six Months Before Relocation Source SS MS df F. Between Groups 4.47 Within Groups 63.22 To t a l 67.69 2.24 2 2.30 0.97 65 67 15,1 APPENDIX S Table 2 Analysis of Variance on the Number of P o s i t i v e Attitudes Towards the Forthcoming Relocation Stated at Preadmission Source SS MS df F Between Groups 23.92 11.96 2 2.32 Within Groups 335.02 5.15 65 To t a l 358.94 67 152 APPENDIX T Table 1 Analysis of Variance on Mental Status at Preadmission Source SS MS df F Between Groups 14.65 7.33 2 .92 Within Groups 558.66 7.98 70 To t a l 573.31 72 153 APPENDIX T Table 2 Analysis of Variance on Weighted Health Status at Preadmission Source SS MS df F; Between Groups 12.14 6.07 2 .15 Within Groups 2907.91 41.54 70 Tot a l 2920.05 72 154 APPENDIX T Table 3 Analysis of Variance on L i f e S a t i s f a c t i o n at Preadmission Source SS MS df F Between Groups .33.43 16.71 2 3.09* Within Groups 373.23 5.41 69 To t a l 406.65 71 p_ = .05 155 APPENDIX T Table 4 Analysis of Variance on VIRO Scores at Preadmission Source SS MS df F Between Groups 472.54 236.27 2 4.10* Within Groups 3969.47 57.53 69 To t a l 4442.01 71 p_ = .02 APPENDIX T Table 5 Analysis of Variance on NOS Scores at Preadmission Source SS MS df F Between Groups 0.06 0.03 2 .38 Within Groups 1.23 0.08 16 T o t a l 1.29 18 157 APPENDIX T Table 6 Analysis of Variance on ADL Scores at Preadmission Source SS MS df F Between Groups 49.15 24.58 2 7.05* Within Groups 219.49 3.48 63 To t a l 268.64 65 p_ = .0017 158 APPENDIX U Table 1 Repeated Measures Analysis of Covariance on L i f e S a t i s f a c t i o n Scores at Three Months and Six Months with Preadmission L i f e S a t i s f a c t i o n Scores as Covariates Source MS df F Between Groups (G) 8.39 2 1.97* Subjects Within 4.25 31 Periods (P) 0.60 1 0.33 G x P 1.61 2 0.89 P x Subjects Within 1.80 32 p_ = .156 159 APPENDIX U Table 2 Repeated Measures Analysis of Covariance on VIRO at Three Months and Six Months Follow-ups with Preadmission VIRO Scores as Covariate Source MS df F Between Groups (G) 15.38 2 .27 Subjects Within 56.45 37 Periods (P) 11.43 1 .29 G x P 36.35 2 .94 P x Subjects Within 38.53 38 160 APPENDIX U Table 3 Repeated Measures Analysis of Covariance on ADL at the Three Months and Six Months Follow-ups with Preadmission ADL Scores as Covariate Source MS df F ; Between Groups (G) Subjects Within Periods (P) G X P P x Subjects Within 1.44 2 0.29 4.98 29 0.15 1 0.15 0.49 2 0.47 1.04 30 161 APPENDIX V Table 1 Repeated Measures Analysis of Variance on Mental Status Over Preadmission, Three Months, and Six Months Follow-ups Source MS df F Between Groups (G) 6.55 2 0.38 Subjects Within 17.33 39 Periods (P) 35.25 2 19.04* G x P 0.29 4 0.16 P x Subjects Within 1.85 78 _p_ = .001 162 APPENDIX V Table 2 Repeated Measures Analysis of Variance on Weighted Health Status Over Preadmission, Three Months, and Six Months Eollowups Source MS df F Between Groups (G) 30.02 2 0.36 Subjects Within 84.64 38 Periods (P) 4.24 2 0.24 G x P 27.92 4 1.56 P x Subjects Within 17.89 76 163 APPENDIX V Table 3 Repeated Measures Analysis of Variance on NOS Scores Over Preadmission, Three Months, and Six Months Follow-ups Source MS df F Between Groups (G) 0.09 2 0.18 Subjects Within 0.51 8 Periods (P) 0.12 2 0.31 G x P 0.01 4 0.03 P x Subjects Within 0.39 16 164 APPENDIX V Table 4 Repeated Measures Analysis of Variance on P o s t - r e l o c a t i o n Adjustment over Three Months and Six Months Follow-ups Source MS df F Between Groups (G) 0. ,89 2 0. 09 Subj ects Within 10. ,45. 34 Periods (P) 0. .75 1 0. 23 G x P 0. ,27 2 0. 08 P x Subjects Within 3. .30 34 165 APPENDIX W Table 1 Repeated Measures Analysis of Variance on Mental Status Over Preadmission and Three Months Follow-up Source MS df F Between Groups (G) 7.12 2 0.70 Subjects Within 10.16 54 Periods (P) 1.12 1 0.35 G x P 1.06 . 2 0.31 P x Subjects Within 3.47 54 16.6 APPENDIX W Table 2 Repeated Measures Analysis of Variance on Weighted Health Status Over Preadmission and Three Months Follow-up Source MS df . F Between Groups (G) 1.93 2 .03 Subjects Within 68.38 52 Periods (P) 11.51 1 .53 G x P 32.72 2 1.52 P x Subjects Within 21.55 52 167 APPENDIX W Table 3 Repeated Measures Analysis of Variance on NOS Scores Over Preadmission and Three Months.Follow-up Source MS df F Between Groups (G) 0.08 2 .15 Subjects Within 0.52 11 Periods (P) 0.02 1 .78 G x P 0.40 2 .05 P x Subjects Within 11 168 APPENDIX X Table 1 Repeated Measures Analysis of Variance on Seculsiveness Over the Three Months and Six Months Follow-ups Source MS df F 0.07 2 0.55 0.12 44 0.01 1 1.00 0.001 2 0.08 0.01 44 Between Groups (G) Subjects Within Periods (P) G x P P x Subjects Within 169 APPENDIX X Table 2 Repeated Measures Analysis of Variance on Sleeping Behaviour Over Three Months and Six Months Follow-ups Source MS df F Between Groups (G) 0.06 2 1.67* Subjects Within 0.03 44 Periods (P) 0.01 1 0.63 G x P 0.01 2 0.80 P x Subjects Within 0.01 44 £. = .2 170 APPENDIX X Table 3 Repeated Measures Analysis of Variance on Time Spent Engaged i n A c t i v i t y over the Three Months and Six Months Follow-ups Source MS df F Between Groups (G) 2.79 2 2.41* Subjects Within 1. 16 37 Periods (P) 0.19 1 0.;30 G x P 0.53 2 0.79 P x Subjects Within 0.67 37 £ = .104 171 APPENDIX X Table 4 Percentage of Subjects i n Each Group Engaged i n A c t i v i t y During 0%, 25%, 50%, 75%, and 100% of the Observation Periods of the Three Months Follow-up Percentage of Time Groups N 0% 25% 50% 75% 100% .. Assessment (0) (3) (4) (7) (6) Only Control 20 0.0% 15.0% 20.0% 35.0% 30.0% Attention CO) (0) (1) (4) (8) Placebo 13 0.0% 0.0% 7.7% 30.8% 61.52% Preparation (0) (0) (1) (3) (6) Programme 10 0.0% 0.0% =10.0% 30.0% 60.0% T o t a l 43 (0) (3) (6) (14) (20) 0.0% ,.6.9% 13.9% 32.6% 46.5% 172 APPENDIX X Table 5 Percentage of Subjects i n Each Group Engaged i n A c t i v i t y During 0%, 25%, 50%, 75%, and 100% of the Observation Periods of the Six Months Follow-Up Percentage of Time Groups N 0% 25% 50% 75% 100% Assessment (1) (1) (2) (7). (7) Only Control 18 5.6% 5.6% 11.1% 38.9% 38.9% Attention (0) (0) (2) (4) (9) Placebo 15 0.0% 0.0% 13.3% 26.7% 60.0% Preparation (0) (2) (1) (1) X 6 ) Programme 10 0.0% 20.0% 10.0% 10.0% 60.0% T o t a l 43 (1) (3) (5) (12) (22) 2.3% 6.9% 11.6% 27.9% 51.2% 173 APPENDIX X Table 6 Percentage of Subjects i n Each Group Alone During 0%, 25%, 50, 75%, and 100% of the Observation Periods at the Three Months Follow-Up Percentage of Time Groups N 0% 25% 50% 75% 100% Assessment (0) (0) (0) (3) (20) Only Control 23 0.0% 0.0% 0.0% 13.0% 87.0% Attention (0) (0) (1) (1) (16) Placebo 18 0.0% 0.0% 5.6% 5.6% 88.9% Preparation (1) (0) (0) (1) (12) Programme 14 7.1% 0.0% 0.0% 7.1% 85.7% T o t a l 55 (1) (0) (1) (5) (48) 1.8% 0.0% 1.8% 9.1% 87.3% 174 APPENDIX X Table 7 Percentage of Subjects In Each Group Alone During 0%, 25%, 50%,.75%, and 100% of the Observation Periods at the Six Months Follow-Up Percentage of Time Groups N 0% 25% 50% 75% 100% Assessment (0) (0) (0) (3) (17) Only Control 20 0.0% 0.0% 0.0% 15.0% 85.0% Attention (0) (0) (0) (1) (14) Placebo 15 0.0% 0.0% 0.0% 6.7% 93.3% Preparation (0) (0) (0) (2) (9) Programme 11 0.0% 0.0% 0.0% 18.2% 81.8% T o t a l 46 (0) (0) (0) (6) (40) 0.0% 0.0% 0.0% 13.0% 87.0% 

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