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Relocation stress effects and the elderly : implications for social work practice and long-term care… McLachlan, Lynne 1981

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c *K2> fa >u fcMiii-iilCo, RELOCATION STRESS EFFECTS AND THE ELDERLYi IMPLICATIONS FOR SOCIAL WORK PRACTICE AND LONG-TERM CARE POLICY by LYNNE McLACHLAN BSW, THE UNIVERSITY OF BRITISH COLUMBIA, 1978 A Major Paper Submitted in Partial Fulfillment of the Requirements for the Degree of Master of Social Work in The Faculty of Graduate Studies School of Social Work Accepted as conforming to the standard required for the Degree?, of Master _of S/icial w 0rk THE UNIVERSITY OF BRITISH COLUMBIA AUGUST 1981 * TABLE OF CONTENTS PAGE INTRODUCTION 1 LITERATURE REVIEW . 4 A. Definition of Terms 4 B. The Rate of Institutionalization 7 C. A Summary of Relocation Stress Studies 8 D. Conditioning Variables 15 E. The Study of Institutions 21 1. Positive Institutional Factors . . . . . . 28 IMPLICATIONS FOR SOCIAL WORK PRACTICE 32 A. Characteristics and Precipitating Factors . . . 34 B. Practice Issues in Decision-Making 39 1. The Importance of Seeing the Family Together . . . . . 41 2. Family and Community Supports . . . . . . 47 C. Research as a Basis for Practice . . . . . . . . 50 D. Assessment and Preparation . . . . . . 52 E. Separation . . . . . 56 F. The Transition 57 1. Hospital . . . . . 60 2. Intra/lnter Institutional Transfers . . . 63 G. The Stage of Impact and Incorporation 63 POLICY ISSUES 71 A. Factors Influencing Placement 72 B. Future Policy Directions . . . . . 78 C. Psycho-Social Assessment 80 1. Selection as a Basis for Policy . . . . . 83 D. The Quality of the Institutional Milieu . . . . 86 E. Social Supports and the Social Worker 92 IMPLICATIONS AND RECOMMENDATIONS 99 A. Policy . . . . . . . . . . . . . 99 B_. Practice 102 BIBLIOGRAPHY 106 * * * * * * * 1 INTRODUCTION Considering the enormous cost and the high degree of institutionalization among Canada and British Columbia's older population indicates that delineations among the elderly and the conditions that surround relocation and institutionalization must be made to alleviate the dele-terious effects of relocation stress. The realization of these objectives are crucial in view of the fact that an extensive body of relocation stress studies and their findings clearly demonstrate the negative effects that relocation can pose for the elderly. The re-location experience has been found to be related not only to decreased health and psycho-social functioning, but also to increased rates of mortality and morbidity. In addition, the experience of relocation is potentially stress inducing not only for the elderly, but for their families who may have an aging parent(s) or relative requiring institutional place-ment. These are problems which affect the well-being, life satisfaction and adequate functioning of an increasing number of people. Such concerns demand an obligation from society, as well as a concomitant of the health system, to direct and guide the development of further research, practice and policies aimed at minimizing the risk of'relocation. After examining the effects of relocation stress found in the literature, I propose to consider the implications for 2 social work practice as well as implications for long-term care policies. Thus, the purpose of this paper is three-fold. The first section will briefly outline the research studies, findings or conditions that have been identified and related to either promoting or hindering effective re-location. Many of the research studies and their implica-tions have a direct bearing and relevance for determining current and future policy and practice development for helping the elderly successfully adjust to institutional settings. Drawn from personal experience of work with the elderly in an acute care hospital, a home for the aged, and from my understanding of the literature concerned with relocation stress, the second section will focus on strategies and interventions that have been found useful and which merit consideration by health workers and professionals for miti-gating the observed adverse effects. The predominant focus will concern the relocation of the elderly from the community to institution, as well as those elderly who are rerouted or admitted to old age institutions via the acute care or general hospital. Where appropriate, other moves between and within institutions will also be included. The rationale for focusing primarily on the population who move from the community or from acute general or allied hospitals rests on the assumption that these moves incur the 3 greatest degree of change or disruption. Accordingly, these transitions elicit and reflect an increasing con-cern for facilitating and devising more effective and innovative policies and procedures for relocating the the elderly at risk. Thus, the latter section of this paper will suggest implications for long-term care policies, often paralle-ling the objective for actualizing effective relocation practice and outcome. * * * * * * * LITERATURE REVIEW A. Definition of Terms In the relocation stress literature, relocation has generally been defined as the change in environment that occurs when an individual moves from one location to another (Hasselkus, 1978). Numerous researchers have viewed the relocation process as a sequence of stages be-ginning with situational or life change events that preci-pitated the move and ending several months after relocation or following a period of adjustment (Pope, 1978? Tobin and Lieberman, 1976). Recently, there has been considerable concern about the stress effects that may be produced by relocation and life changes in the stress literature. Un-fortunately, the term, "stress," has been difficult to define. Therefore, it is important to know what is meant by the term, "stress," and how it is conceived in the literature. The pioneering work of Holmes and Rahe (196?) reflecting a life change approach to stress identified that discrete changes in life patterns could create stress. Their research with United States navy personnel suggested that the signi-ficance of stressful events demands adaptation which in itself is costly to the organism as demands increase. These researchers found that persons who had been exposed to occurrences of life-change events were more susceptible to 5 an onset of physical or mental disorders. Essentially, "stress" has been used to refer to the adjustive demands made upon the individual (Coleman, 1973*169). As well, "stress" has been used to refer to a situation that causes an individual to react as though he/she has been threatened. The stressful situation may be a physical, social or cul-tural condition which induces discomfort in the individual (Mechanic, 1973*91). On a psychological level, research describing an indi-vidual's reaction to environmental events and life stress has also been advanced by the work of Engel, Schmale et al., (1970)5 Seligman (1975); Langer (1979); and Langer and Bene-vento (1978). Their respective concepts of "the giving up syndrome," "learned helplessness," and "self-induced indepen-dency" have been suggested to partially account for the ad-verse psychological traits and adjustment difficulties of the institutionalized elderly. The way in which stress has been linked to somatic ill-ness has also been widely recognized in recent years. The foundation for systemic research originated with the work of Cannon (1929) who showed that stimuli associated with emo-tional arousal caused changes in basic physiological pro-cesses. Further impetus for systemic study also arose from Hans Selye's classic work demonstrating how physical and psychological stressors may lead to "diseases of adaptation" or the syndrome he described as "just being, sick" (Selye, 6 1956). Selye defined stress as "the non-specific response of the body to any demand made upon it" (p. 27). In summary, the concept of stress has usually been examined or studied on three levels of analysis, namely» social stress concerned with the disruption of social units or systems; psychological stress, with cognitive variables leading to the evaluation of threat; and systemic or physio-logical stress concerned with tissue disturbances. It has generally been recognized that stressful life events, such as relocation, "plays a role in the etiology of various somatic and psychiatric disorders and may pose a threat to health" (Dohrenwend and Dohrenwend, 1973*1)- In this sense, stress is conceived as an event in the environment and not as a state of the total organism. While looking at stress in this way is valuable, there has been a lack of consensus or clarity in developing a concise, but comprehensive, definition of stress. For purposes of this paper, Lazarus" definition of stress will be adopted and defined "as a generic term for the whole area of problems that includes the stimuli producing stress re-actions, the reaction themselves, and the various inter-vening processes"(Lazarus, 1966:27). As a result, the field of stress will encompass the physiological, psychological and sociological phenomena and their respective concepts. To elaborate further, the arena to which stress refers "consists of any event in which environmental demands, internal demands 7 or both, tax or exceed the adaptive resources of an indi-vidual social system, or tissue system" (Lazarus, 196613)' The Rate of Institutionalization The effects of relocation stress on the aged has been a recent concern, with over two hundred studies devoted to the examination of this phenomenon. Among the reasons for this rising interest in the well-being of the elderly is their rapid increase in absolute numbers, their increasing propor-tion to the total population, and in the high rates of insti- / tutionalization. Unfortunately, Canada has the major distinction of insti-tutionalizing more than 8.4 percent of those over sixty-five in some type of quasi-institutional setting in comparison to the United States where only 5 or 6 percent and the United Kingdom where only 5.1 percent of the elderly are institu-tionalized (Schwenger and Gross, 198O). Within the Province of British Columbia as of May 1, 198O, 7.8 percent of the elderly over sixty-five were housed in some form of care facilities. Of these, 16,312 were in intermediate care facilities, while 5,500 were in extended care facilities (Long-Term Care Statistics, Victoria, September 1980). In addition, a further 2,811 beds will be available before 1982 (Ministry of Health Annual Report, 1979) to provide a continuum of institutional care. Besides a growing realization of the high personal, social and human waste of resources in institutionalizing our elderly, 8 interest has also been stimulated in part by the high ex-penditures of public and private dollars involved. For example, projections from Canada's hospitals over the next five years include a tripling in demand for health care facilities by a rapidly expanding elderly population (Statistics Canada, Population Projection, 1980). The above figures provide ample testimony to the high rate and demand for institutional care among Canada's elderly population. For the elderly, relocation - particularly from the community to an institutional setting - is a stress-provoking experience (Lieberrnan, 1961; Costello and Tanaka, 19615 Tobin and Lieberrnan, 1976). A considerable body of research (Aldrich and Mendkoff, 1963; Markus et al.. 1971; Bourestom and Tars, 1974; Killian, 1970) suggests that re-location entails considerable risk in terms of increased mortality and morbidity rates. As well, studies have shown that ensuing stress from relocation can pose considerable problems for those who survive relocation in terms of psycho-logical, physiological and social functioning (Dohrenwend, Dohrenwend, 1973; Bourestom and Tars, 1974; Brand and Smith, 1974; Tobin and Liberman, 1976). C. A Summary of Relocation Stress Studies Historically, relocation studies have overwhelmingly been preoccupied with mortality rates in assessing the impact of relocation stress (Borup, et al.. 1980i468). At least 9 half a dozen studies have found that relocation resulted in an increase in mortality rates (Aldrich and Mendkoff, 19635 Markus, Blenkner, Bloom and Downs, 1972; Bourestom and Pastalan, 1975? Jasnau, 1967; Killian, 1970; Markus et al.« 1971; Marlow, 1972). On the other hand, more than a dozen studies have found no significant effects on mortality rates (Borup, et al., 1979? Bourestom and Pastalan, 1975; Lawton and Yaffe, 1970; Markson and Cummings, 1975? Markus et al.. 1971? Miller and Lieberman, 1965; Pino et al.. 1978; Wittels and Botwinick, 1975? Zweig and Csank, 1975). To further confuse issues, several studies found a lower death rate in a relocated group. For example, Carp (1966), Lawton and Yaffe (1970), and Markus et al. (1971) found generally favorable results. Needless to say, the study results are often conflicting and somewhat confusing. To begin to make sense of inconsistent research findings that use mortality as a criterion for determining the effects of relocation, one must question and examine the research design used, including the population sampled, the type of move studied, the conditions under which the move took place, and other variables that might affect the results. Types of Moves Studied In the relocation stress literature, studies have pri-marily fpcused on four types of moves or transitions, namely» moves from the community to institution, inter and intra-institutional moves, and moves from one building to another. 10 Given that relocation is thought to be a generally stressful experience, one must examine the quality of moves studied in terms of assessing the effects of relocation stress. An increasing concern regarding the elderly relocating / from the community to institution has arisen because these moves appear to entail the greatest risk. It is believed — that the elderly experience a more radical environmental change which, in turn, has been related to destructive physical and adverse psychological effects (Aldrich and Mendkoff, 19635 Blenkner, 1967; Ferrari, 1963; Tobin and Liberman, 19?6). Furthermore, those elderly facing pending institutionalization often anticipate placement with fear and dread, as well as an accompanying loss of social and personal status and/or a general disruption of their previous life-style. < In the stress literature, three notable studies have demonstrated that relocation from community to institution has proved lethal for relocated elderly (Blenkner, 1967; Ferrari, 19635 Costello and Tanaka, 1961). Blenkner (1967) introduced one of the few controlled studies by randomly allocating non-institutionalized aged to one of three commu-nity service programs ranging from "minimal" service to a "medium" intensive service to an "intensive" direct service provide'd by social workers and public health personnel. Unfortunately, the sample size negated a significant study of the effects noted. At a six-month follow-up, the mortality 11 rate was considerably higher for those elderly involved in the "maximum" service program (24 percent), while those on the "midway" and "minimal" service program experienced a death rate of 12 percent and 6 percent, respectively. Costello and Tanaka (1961) also reported a higher mortality rate of 38 percent in the first six months of institutional placement in contrast to a reported death rate of 11 percent for those elderly who were on an institutional wait list during a one-month period. Ferrari (1963) also reported a dramatically high mortality rate for elderly who moved from community living to an institutional environment. Although these study findings lead one to conclude that community to institutional moves may result in increased mortality rates, the study designs and research methodology are open to a variety of interpretations. For example, the study by Blenkner, although using a random sample, was not large enough to justify any firm conclusions about the differential mortality rates. In the last studies cited by Costello and Tanaka (1961) and Ferrari (1963), both compared wait listed and post admission mortality rates which ruled out self-selection or random sampling. As well, the study design posed related problems since a comparison of the elderly who had been admitted to an institution with a wait listed group was not necessarily valid. It is likely that those who required facility care were more unhealthy; thus, it is predictable or expected that they should reflect a higher death rate (Rowland, 1977*357). 12 In the study by Costello and Tanaka (1961) when the rates were adjusted to compare equal time periods between those on the wait list and those subjected to institutional placement, the results showed that the death rate was more likely to occur during the waiting period than it did after admission (Kasl, 1977)• The waiting period has, in fact, been shown to be one of stressful anticipation which may partially account for the observed effects (Tobin and Lieber-rnan, 1976). Still,an association between death and general health deterioration has been linked with entrance to an institution. Research studies concerning the effects of other moves, such as inter-institutional, or en-masse moves, or moves from building to building, often pose fewer problems in research. First of all the problem of initial differences in health status between controls and experimental groups is reduced. Possible institutional effects on the individual and affecting mortality rates are also diminished. Generally, two types of research methods have been uti-lized to establish a relationship between inter-institutional relocation and mortality rates 1 an experimental control design in which mortality rates of movers are compared to mortality rates of elderly who do not move; a baseline design in which mortality rates prior to relocation are compared with mor-tality rates after relocation. One of the better studies was done by Killian (1970). He used an experimental control design 13 where controls were matched with relocated patients on six variables (i.e.. age, sex, race, diagnosis, length of hos-pitalization and ambulation abilities). His stronger re-search design, unlike many others, provides convincing evidence regarding the association between death and re-location. Other researchers have used a baseline design to compare mortality rates before and after transfer (Aldrich and Mend-koff, 1963; Markus et al.. 1971; Zweig and Csank, 1975; Gutman and Herbert, 1976). In the majority of these studies, mortality rates increased following relocation from one insti-tution to another. However, Borup et al. (1979) have criti-cized the use of a baseline approach because of the difficulty of establishing a valid matching or comparable baseline of groups being relocated. As well, the study findings are open to interpretation since the receiving environments may not have been comparable to the former and/or admission and health care factors may have tended to bias the results. In the Zweig and Csank study (1975), the researchers found a decrease in mortality rates which may have been attri-buted to extensive use of a preparation program. However, convincing data concerning the effects of environmental change of the elderly comes from studies of institution to institution moves (ftasl, 1977«95). Not only community to instiution or inter-institution moves create distress and trauma for the elderly. Other 14 studies support the fact that relocating the elderly from one ward to another or within the same institution can also promote adverse effects (Aleksandrowicz, 1961; Jasnau, 196?j Pablo, 1977). Although methodological concerns are also relevant in interpreting these studies' results, there is an increasing acceptance that " intra-institutional transfers can result in perceptible changes in the patients' living patterns that can influence survival and overall physical and mental levels of functioning" (Pablo, 1977:4-34). Health and Social Adjustment There are fewer studies which are directly concerned with the psychological and health consequences of relocation since those effects pose considerable methodological and interpretational problems for researchers. As well, few studies are available which use either an experimental de-sign control and/or a longitudinal design (George, 1980sll6). However, two longitudinal Canadian studies done by Kraus, Spasoff et al. (1978a) demonstrated changes in health sub-sequent to relocation from community to institution. Al-though Kraus et al (1978) reported improvements in health among institutional residents one month after moving, a long-term observation showed that relocated subjects experienced a significant deterioration in their general health status. In a similar study, conducted by Tobin and Lieberman (1976), these researchers found comparable results. Other studies examining the effects of relocation and health in inter-15 institutional moves (Bourestom and Tars, 197^; Pino, Rosica and Carter, 1978) report that these moves also are accom-panied by declines in health. In terms of the effects on psychological and social aspects of individuals, study findings are suggestive but inconclusive. Possibly, the most convincing data or evidence for supporting the contention that relocation has a negative impact on self-concept and self-esteem have been provided by Tobin and Lieberrnan (1976). In their well-known studies of community residents who moved to an institutional setting, their findings strongly suggested that relocated elderly were characterized by lower levels of self-esteem prior to and after institutionalization (in contrast to individuals who remained in the community). However, it is still not clear whether the adverse effects reported are due to the process of relocation itself, or to the loss of health status and general assaults of aging (George, 1980ill8). Because of contradictory findings in these studies, there is reason to suspect that other variables are involved that may be influencing how relocation affects older persons. D. Conditioning Variables Recent studies of the effect of relocation stress have utilized more sophisticated empirical research designs and methodology. In a review of the literature, Bourestom and Pastalan (1981) suggest that the nature of current studies no 16 longer question "whether relocation has negative (or positive) effects, but under what conditions and with what kinds of populations are those negative or positive effects most likely to be observed" (p. 45). Information is accumulating which indicates that the way the move is organized or handled may affect how an individual copes with the move (Bourestom and Pastalan, 1981; Jasnau, 1967; Novick, 1967). Unfortunately, most preparation programs have focused exclusively on inter-institutional moves (Gutman and Herbert, 1976; Markus, Blenkner, Bloom and Downs, 1971; Novick, 1967; Pino, Rosica and Carter, 1978; Zweig and Csank, 1975). These programs have tended to ensure that the resident was as in-volved as possible in decisions about the move, selection of room, and roommates, etc. Before the actual move, all resi-dents were encouraged to become familiar with the new institu-tion beforehand. As well, counselling family and supportive friends were resources used to alleviate fears and anxieties about the move. Lastly, the program culminated in the un-packing of their possessions by residents to help them feel at home. These studies, reporting low mortality rates, have been criticized on the basis that the move of residents from one facility to another is not so different or radical. As Morton.Lieberman (1974) states: "Relocation is a risk to the individual not because of the symbolic meaning that such transitions imply, but because it entails radical changes 17 of the life space of an individual that require new learning for adaptive purposes" (p. 497). The findings of Bourestom and Tars (1974) are also relevant. These researchers conceptualize that relocation is more harmful in moves where there is a radical environ-mental change that may overload the old person's adapative capacities. As well, there are divergent views on whether the stress of relocation is partially due to the loss of familiar stimuli or from the trauma of new stimuli (Markus et al.. 1971). Most importantly, Bourestom and Tars (1974) contend that "preparation programs should become mandatory policy in all situations which contemplate radical and involuntary relocation of elderly individuals" (Bourestom and Tars, 1974i509). Although most of the preparation programs have been developed for en masse transfers where the previous environ-ment was similar to, or an improvement upon, the receiving environment, few post preparation programs have been devised to help the elderly adjust after admission. Grant and Gutman (1980) are the only researchers, I am aware of, who have de-vised a post preparation program. Prom my experiences in helping the elderly relocate to an intermediate care facility, I am strongly convinced of a need for such programs. As Grant, and Gutman suggest, post preparation is needed parti-cularly in those moves which incur the greatest degree of change (i.e., community to institution transitions). Most 18 preparation programs focus on the pre-move period, but intervention is needed to help individuals cope once they are in the institution. In view of the fact that the first three months pose the greatest threat to successful adjustment, (Bourestom and Tars, 197^5 Miller and Lieberman, 1965), it seems logical that preparation should encompass the major stages of relocation. The implementation of preparation programs is based not only on common sense, but also on theoretical assumptions that individuals wish to have control over their personal environment. Institutionalization of the aged represents an abrupt loss of personal control that results in feelings of hopelessness, helplessness, and depression (Seligman, 1975' 185). More serious consequences may ensue as a result of perceived loss of control. Seligman (1975) statess "We should expect that when we remove the vestiges of control over the environment of an already physically weakened human being, we may well kill him" (p. 186). A component of the "grey" institutionalized portrait has been an observation that residents tend to lose interest-in the outside world, and learn to become passive and depen-dent. This is not entirely disadvantageous to the institu-tion, since it is much easier for the staff to deal with a passive individual than one who is encouraged to be as inde-pendent as possible. Research supports the position that dependent behaviour is likely to be reinforced while 19 independence may be ignored (Barton, Baltes and Orzick, 1980). The proposal by Grant and Gutman (1980) to assess the functional and coping skills of new residents to be used as an evaluative tool for goal setting for the relo-catee and institutional staff holds'interesting and hopeful promise. Variables Identified Which Mitigate the Relocation Effect Factors found that help reduce, negative effects and have been integrated into most preparation programs. The provision of opportunity for choice, (Ferrari, 1962), posi-tive attitudes toward the move (Pino, Rosica, and Carter, 1978), and careful individualized preparation for moving through counseling and orientation to the new facility have proven to be important factors. Other factors which appear to mitigate the potentially lethal risk include reducing the degree of social and phy-sical discontinuity between the old and new environments (Bourestom and Tars, 197^), the degree to which the older person participates in the decision-making process, leading to institutionalization (Carp, 1967; Lawton and Yaffe, 1970; Ferrari, 1967; Beaver, 1970) and the voluntary/involuntary nature of the transition (Ferrari, 196?; Schulz and Brenner, 1977)- As well, factors, such as the characteristics of the relocatees, are also associated with both positive and negative relocation effects. Researchers have identified 20 age, poor physical health and a psychological pattern of coping characterized by passivity, hopelessness, help-lessness and depression as factors positively associated with risk (Aldrich and Mendkoff, 1963; Blenkner, 1967). In contrast, those with angry, aggressive assertive or ; narcissistic personalities are more likely to successfully survive relocation (Tobin and Lieberrnan, 1976; George, 19801120). /,, Figure 1 is a diagrammatic presentation of some of the major variables which need to be considered in understanding the effects of relocating the elderly to institutional settings. The diagram is for illustrative purposes only and is not intended to suggest that these are all of the vari-ables which influence the process of relocation and the sub-sequent outcome. The basic notion of the diagram is that there is a direction of influence from left to right, and that at any one intersection the "conditioning variables" may modify or mediate the process and outcome. Similarly, if there is a relationship from the physical environment or antecedent conditions conducive to stress, to physical and mental health and social functioning (outcome), then the process can best be understood if one takes into considera-tion the objective environment, the individual's interpre-tation of his environment, and the mediating processes which include the physiological, affective and behavioural reactions (Kasl, 1977*106). TT 1 ^  2 * D Tl H S > •n •n 2 Ti 0 % 1 < f a •a o TV 70 f* 5 uJ rv x * c r o •b i-m U £ IK =F r t-<i\ ft r* ft • 1 C m lo a 3 r> m c D Pi r o IA £ K \n s o D i> 0 1 ta * Wt o a i>\ t, £ i/> o 2. S> r ? 0 1 o 2 •n * m ^ r> * b It ft I h S? TV 2 * I C •0 0 v> 1 m 3 £ o VI > p •c o u ! 5 5 2 -I 2 m 2. -1 " > ~ r 3 o X ^ •c u r o r» R th C D n t v I r» n I D * r A i> » z to o £ r> 0 I fp > r -1 1 » I m o < to r» e> D ^ % m r-m rft e> TV * S> "t £ 5 2. 4 2 5> o •n •n irt r> < t> r m p o J D s <T\ o D c Pu 0 z. I * itj ICS & o a o c\ nt 2 a: ni ® t? ^  •o I 70 Iri D H s z »-> m 2 m r^  x > m c c o > 4 o Z -i > 7) I 8 D r V > D r> 0 T) ^ 1 r rn n W c in 5 r -c E o J 0 1 r> o n » & r * D r -£. -& > s m tf> 0 Tl •b r* 1 O g >« E r r» \ P o f> pv u >c >5 IP m m * 4. 0 ?p 3> r s r & is F Z. 70 rt> r o th o u -c I 2 Ss 0 01 2. R H X n> 2 o r w •o X r> c r ^ c a i. r ( to C n C r •i C a> r e-o -v c c. C 7> -H Pi > 0 Tl -+ f9 S» > 2 v> c o a ^ c t Z H * 18 to H c 4 0 Z 1 r h 2 Cb t-•D tn F5 C. 3 D > - D c? c S i 5 0 r 5 2. o In i s - D> o r z m tn r o < 0 •n m -n •n m 5 In O TV -j -v rr\ ?> rn v> D m 2 > r m 2 < ?D o Z 3T m 2 -1 o 2 1 IT* i. > Z a m fh X > < & aJ C m 2 3 S> •i rO m fr> IM £ > o z o 2 v K o K) lA m o TV $ 70 % R r m m I 21 Similarly, a variety of characteristics of the person and his situation must be understood to determine how the process can be altered or modified. For instance, the way individuals cope and adjust would be dependent on whether they altered some aspect of the precipitating stressful conditions, whether they improved their skills, or whether they changed their subjective perceptions, and so forth. The diagram has been adapted from a theoretical frame-work presented by Kasl (1977). Although the diagram is a very limited and somewhat arbitrary statement of the overall relocation stress process, it serves the purpose of providing a more systematic guide for understanding the complexity of the variables involved which may affect the health and be-haviour and the subsequent adjustment of the institutionalized elderly. E. The Study of Institutions In addition to preparation programs and conditioning variables, the institutional environment has also been iden-tified and related to adjustment and stress of the elderly newly admitted to care facilities. In British Columbia, there are approximately 700 existing facilities to provide a range or continuum of institutional care from minimal supervision and assistance with activities of daily living to extensive medical and skilled nursing care (Ministry of Healths Annual Report, 1980). 22 In the relocation stress literature, it is generally assumed that the experience of relocation of the elderly is associated with deleterious somatic and psychiatric disorders. The typical institutionalized personality and other adverse traits are well documented in the litera-ture. As well, the move or transition can result in the death of the elderly. However, what part does the institu-tional environment contribute to these negative effects? After thirty years of research in the field of gerontology, Lieberrnan (1969) reports the following depressing portrait of the aged in institutions-, (p. 330) They share the following characteristics! poor adjustment, depression, and unhappiness, intellectual ineffectiveness because of increased rigidity and low energy (but not necessarily intellectual incom-petence), negative self-image, feelings of personal insignificance and impotency, and a view of self as old. Residents tend to be docile, submissive, show a low range of interests and activities, and to live in the past rather than the future. They are with-drawn, and unresponsive in relationship to others. There is some suggestion that they have increased anxiety which at times focuses on feelings of death. (There are) marked increases in mortality rates for aged persons entering mental hospitals and homes for the aged. | Although these characteristics cannot be wholly attributed ! to the institutional environment since some of the effects may be due to selection biases of the population or to the institutionalization process, still there is evidence to strongly suggest that in many institutions the environment ] is conducive to deleterious effects for the institutionalized i j elderly (Brody, 1974:42; Tobin and Lieberrnan, 1976:23). 23 In answer to the question regarding what aspects or characteristics of the institution affect the elderly individual, Goffman's classic work, Asylums, offers a powerful analysis in an attempt to identify the effects of institutionalization in organizations such as prisons, hospitals, and homes for the aged and disabled. He suggests that institutions have an encompassing "total" feature which is dictated by the organizational staff and which is symbolized by barriers of interaction with ex-ternal society (Goffman, 196li4). The handling of many human needs by the bureaucratic organizations of whole blocks of people is central to his theory. Since Goffman was dealing with the diversity among organizations, indi-vidual institutions must be viewed with more flexibility. However, his general theory of total institutions has been applied to homes for the aged. Similarly, a study by Kahana and Coe (1969) of 33 residents in a Jewish home for the ageid found that the elderly were able to adapt where there were minimal forma-lized, clear and unambiguous rules. Although the sample used was small, it seems logical that an institutional environment providing a less structured or rigid setting would be conducive to enhancing adjustment and autonomy. Many of these ideas can be applied to long-term care facilities for the aged in Canada. Degrees of ritualism and standardization, rifts between staff and resident 24 populations, role deprivation, are prevalent charac-teristics of our homes for the aged and our health care institutions in general. Research studies concerned with the effects of institutionalization on various inmate populations -psychiatric, hospital, and handicapped patients — have revealed similar deleterious effects (Townsend, 1962:329). The effects of loss, deprivation and distortion of rela-tionships on young children have also been generalized to long-term care of the elderly in understanding identifiable "symptoms" of institutionalization (Brearley, 1977*52; Townsend, 1962:335). A contrasting perspective has been argued by John F. Myles, a sociologist at Carlton University. Myles argues that institutionalization provides the elderly with relief from poverty, illness and social isolation. He supports this argument with research studies demonstrating that the most significant correlates of life satisfaction and morale is the provision of relief from the preceding assaults of aging mentioned (i.e., poverty, illness and so forth). Thus, institutionalization is beneficial rather than detri-mental (Myles, 1980:264). Like Goffman, his theory has been criticized on the basis that a number of other dimensions are also of paramount importance and that variations or diffe-rences among institutions must also be considered. 25 What variables of characteristics of the institution should we be focusing on in order to mitigate the effects of relocation stress and subsequent adjustment of resi-dents? The study of changes in the recently institutiona-lized elderly becomes the selection of effects of institu-tional life from other factors of the environment and the process of institutionalization. A brief look at past research will reflect some of the different dimensions that researchers have found useful when studying institutional effects and adaptation. One of the earlier attempts, using a few dimensions to assess the extent to which a setting was institution-like, was done by Kleemier (1963). He isolated three dimensions which, he believed, were related to the lifestyle of elderly institutional residents: (l) segregate dimension: a conti-nuum at one end of which older people live exclusively among their age group, and at the other end they are with people of all ages; (2) non-institutional dimensions the imposition of rules, regulations, etc., and (3) the congregate dimen-sions: group size, closeness of individuals and a degree of privacy. In an attempt to refine Kleemier*s multi-dimensional approach, Pincus (1968) developed a framework for studying institutional environments in homes for the aged. He identified four dimensions of the institutional environment i as: (1) public versus private; (2) the structured-26 unstructured dimension; (3) resource sparse versus resource richj the degree to which the environment permits the re-sident to engage in meaningful activities and roles other than that of patient, and (4) the isolated versus inte-grated! the degree to which the resident is able to interact with the outside community. Pincus stressed the need to study the relationship of these environmental dimensions to each other as well as the self-report or perceptions of the re-sidents' satisfaction or dissatisfaction with his environ-ment . A secondary analysis by two researchers, Penning and Chappel (1980), based on a study conducted by the Manitoba Department of Health and Social Development in 1971, was initiated to test the adequacy of using an approach which considers only a few dimensions. These researchers con-cluded that "perceptions of well being among the institu-tionalized do not appear conditioned by single defining characteristics of the institutional environment" (p. 278). As well, they concluded that neither bureaucratic organiza-tion or the degree of totality or the provision of relief were adequate in explaining the experience of institutiona-lization of the elderly. They further concluded that only autonomy in choice of residence was significant in supporting those factors identified by Kleemier (19*61) and Pincus (1968). Of particular interest is their finding that not only autonomy but perceptions of health, economic security and social 27 support and interaction are also related to perceptions of well-being (p. 278). Therefore, their study results have implications for future policy and planning. In view of present economic restraint, and the buregoning increase of health care costs in Canada (Lalonde, 197*0» possibly the elderly can be maintained by less costly means (other than in institu-tions) through provisions such as day care and day hos-pitals, etc. As well, institutions may do well to foster independence and social interaction in the facility en-vironment. Related studies, such as O'Donnell et al. (1978*267), have recently presented a methodological approach for assessing the subjective perceptions of nursing-home living by the nursing-home residents themselves. O'Donnell and his associates feel that psychosocial perception assess-ment can tap into important aspects of "quality of care" often missed by staff-resident ratios, cost per patient data, and patient chart review approaches to nursing-home evalua-tion surveys (p. 270). The above researchers and many others have attempted to rationally examine the psychosocial environment and its effect on the elderly resident since the time Goffman first initiated his concept of the total institution. 28 In summary, research thus far underscores the com-plexities of the relationship among a host of variables in a variety of long-term care facilities (the quality and components of care, physical environment, size, resident and staff attitudes, source of reinbursement, administra-tive policies, relationship to community, and so forth). However, there are a number of general factors which have been identified that affect a positive outcome for those experiencing institutional transitions. Most importantly, the positive factors identified from research may provide the basis for future practice and policy directions to assist us in providing a more optimal environment for our elderly population. 1. Positive Institutional Factors In a study conducted by Lieberrnan (1969), the negative effects the elderly experience when entering institutions were attributed to the degree of change between the receiving and original environment. Of particular importance was the strong association of outcome status of the patient with the psycho-social "milieu" or quality of the receiving environ-ment. The study also indicated "that patients placed in cold, dehumanized, dependency-fostering environments show declines" and emphasized the importance of the institution permitting continuity of previous lifestyle (Lieberrnan, 1969*33°)• It is possible that current trends aimed at "deinstitutionalizing" institutions, for example, making them more open and accessible 29 to the outside community, less congregate, and so forth, are effective because they prevent the use of prior and less adaptive responses (Tobin and Lieberman, 1976j22). A study by Marlowe (1972) found that two comparable groups, who moved, experienced opposite outcomes: one group adjusted successfully, the other did not. The results of the study suggested that the improved group went to environ-ments that encouraged resident control and independence in their lives, offered privacy and respect, fostered community access and integration, promoted social interaction and self-disclosure, and treated residents with warmth and positive attitudes. Under opposite conditions, the other group deteriorated. Other evidence also supports the contention that the institutional environment has an impact on the adjustment and life satisfaction of the elderly. Factors of importance suggested by researchers include: improved visiting patterns and reassessment by attending physicians, a positive per-ception of the facility and staff, self-rated health, a more favourable disposition toward entry, and a view of the resi-dence as permanent (Gutman and Herbert, 1976; Noelker and Harel, 1978). Practitioners and researchers have £lso provided prac-tical and constructive measures that have beneficial results: "preparation of the mover via individual and group counselling, 30 orientation to the new facility such as pre-move visits, participation of the potential mover in the decision-making process, opportunities for choice and continuity of the staff" (Liebowitz, 1974.-294). In fact, Liebowitz (1974), a well-known researcher, goes so far as to state "that a review of the literature suggests that lack of attention to the psycho-social, human needs of the elderly can be lethal" (p. 294). The relocation period lends itself to the implementa-tion of innovative and imaginative techniques to lessen the 1 / stress of relocation and generally improve the quality of care. For example, assessment, diagnostic and treatment techniques may help to assist in the appropriate placement, orientation, and treatment plan for individuals (particularly the psycho-geriatric resident and the brain-damaged). As well, positive attitudes of the administrator and institu-tional staff, the encouragement of social responsibility, interaction with other residents, and significant others, can also contribute to one's feeling of belonging and self-worth. It has also been shown that the elderly benefit from a highly individualized treatment plan, tailored to their unique life experiences, personalities, and needs (Brody, 19771274). At the same time, however, adequate integration of the individual and -institution is still in the nascent stages of our knowledge, thus proffering potential challenges for those working in the community and institutional settings. 31 The preceding discussion has attempted to cover a wide range of current research and some theoretical concepts relevant to understanding the effect relocation has on the elderly. Relocation stress literature has demonstrated that relocation affects psychological, biological, and even physiological processes. Although a great deal of past research findings has often been questioned and criticized on the basis of the study design and methods used, more recent and sophisticated research methodology strongly indicates an association or linkage between the experience of relocation and the noted deleterious effects. Current research no longer disputes the fact that relocation is a hazard for those elderly re-locating to institutional settings. As Bourestom and Pastalan (1981) suggest, current research is now attempting to determine what characteristics of the population and under what conditions are the negative or positive effects observed. Of major importance is the search for more effective strategies for alleviating the negative consequences of relocation (Bourestom and Pastalan, 1981). At the present time, some important clues have been found that may be beneficial in influencing and improving better strategies and interventions of helping the elderly adapt to reloca-tion. 32 Given that relocation is a major stress that radically affects many elderly and can be a predictor of death, the fact remains that although we have some ideas about how to minimize the risk, we still have little knowledge of how to facilitate the well-being of the elderly. Despite the wide variations of the samples studied and the conditions under which individuals were relocated, the empirical findings suggest that the percentage of elderly, showing decline after relocation, is still significant. As well as helping the individual through the transi-tion process of pre- and post-relocation, a broader outlook is demanded. That is, we must concern ourselves with helping each individual to express those aspects of self that yielded satisfaction in independent living. IMPLICATIONS FOR SOCIAL WORK PRACTICE During the past several years, social workers are assuming an increasing role in the delivery of health, social and mental health services to the aged. In the future, it can be predicted that their function will increase and become more diversified. Although difficult, it is imperative that health professionals understand not only the significance and complexity of the relocation process, but also utilize and develop further innovative strategies to help minimize the risk <5f relocation. The process of relocation is important for a number of reasons. First of all, relocation frequently signifies a 33 relinquishment of independent living. As well, social relationships and a former pattern of living are dis-rupted. The disruption and stress involved often requires considerable adaptation and adjustment on the part of the individual. Furthermore, a decision to enter a home and actual entry has usually been preceded by a series of pre-cipitating events which may overwhelm or overtax the indi-vidual and his/her family. Most importantly, the conditions and procedures regarding how the move transpires can have lasting or residual effects for the individual in the re-ceiving institutional setting. Consequently, it is crucial that the process of relocation is sensitively and carefully managed. In the following section, the stages of relocation will be outlined with implications for social work practice. Hopefully, the material presented may be helpful to social workers and other health workers who are interested in pro-moting the well-being of the elderly relocating. To help clarify the variety and complex sequence of emotional responses and experiences characteristic of the relocation process .and the demands that face the older person, the process will be arbitrarily divided into a framework of four stages: (l) the decision and preparation: encompassing the period of time that relocation is being considered to the time that the prospective resident is notified that a facility bed is available; (2) separation* 34 refers to the time that the actual notification is given until the point of admission or impact, (3) transition, refers to the first day in the facility; (4) incorporation and settling-in; refers to the days after actual admission and continues until the resident views the facility as a permanent home (Pope, 1978; Tobin and Liberman, 1976). A. C h a r a c t e r i s t i c s and P r e c i p i t a t i n g F a c t o r s Before turning to practice issues that may help mitigate relocation stress, it is important to have some knowledge of the research studies which have examined the reasons or pre-cipitating factors that have been associated with the elderly seeking and entering institutional care. Researchers have found that the period prior to moving ) is particularly stressful as the older person anticipates < relocation to an unfamiliar environment (Zweig and Csank, 1976; Tobin and Lieberrnan, 1976). During this period, the individual must make the crucial decision as to whether a move is required, find a suitable institutional setting, deal with entry procedures, and contemplate disposing of his possessions. Considering that institutional moves are invariably a n t i c i p a t e d with considerable anxiety and fear along with a sense of separation, loss and rejection (Lieberrnan, 1976), why do older people move at all? Furthermore, who enters long-term care facilities? 35 Although precise data is difficult to obtain about the institutionalized elderly for a number of statistical rea-sons, generally those who apply are the very old, impaired mentally and physically, are predominantly white, with few representatives from racial or ethnic minorities (Brody, 1977:90). In his United Kingdom survey of institutions, Townsend (1962) found that far more women than men, the single, those who never had children, or those who lacked social supports, were characteristic of the elderly who entered institutional care. The proportionately high rate of the institutionalized old is also characteristic of Canada's population. In Ontario, for example, over one-third of the population over 85 years of age were in some kind of institutional setting on any given day in 1976 (Schwenger and Gross, 1980:252). For those over age 75 in Canada, 15 percent are estimated to be living in institutions (Special Committee, 1966:107). The chances of applying and becoming a resident in-creases progressively with advancing age (Brody, 1977? Brotman, 1968). Accordingly, the very old are vulnerable to multiple assaults of aging, i.e., mental, physical and environmental. It is interesting to note that many people with similar characteristics are not necessarily in insti-tutions but remain in the community. Shanas and associates (1968) have identified that between 9 to 14 percent of old 36 people living at home are bedfast while approximately 15 to 25 percent of elderly community residents appear to suffer from some degree of mental impairment or illness. Thus, there is reasonable evidence that the degree of mental or physical impairment are not the predominant reasons for the admission of a large number of old people ' to institutions. Certainly, reasons for moving vary with the type of move or transition being considered. In the cases of inter-institutional and intra-institutional moves, elderly indi-viduals may be subjected to a transfer, often beyond their control. For those elderly already in institutions, they often have no one to care for them after discharge, or their medical/emotional condition warrants the kind of skilled nursing and supervisory care that can more easily be dealt with in another institution. These elderly may also share similar reasons for moving as those elderly moving from the community to an instituion. Studies focusing on identifying reasons for community elderly applying to institutional settings have identified a multi-/ 'Z) plicity of reasons or precipitating factors, besides a need for medical or nursing care (Brody, 1969; Tobin and Lieberman, 19?6). Briefly, additional reasons identified are as followst social isolation engendered by a lack of, or adverse change in close and supportive relationships with significant others (Barney, 1977; Beaver, 1979; Tobin and Lieberman, 1976)1 37 inadequate housing or neighbourhood deterioration (Beaver, 1979)5 economic difficulties (Harris, 1968; Townsend, 1962); anticipated inability for self-care (Gutman, 1978; Kraus et al., 1976 b); and a lack of community based re-sources to provide assistance at home (Brody, 1966; Kraus et al.. 1976 b). Additional support for these findings was also reported in a recent Vancouver survey conducted by two Master of Social Work students. Based on a small sample of residents recently admitted to a local Vancouver intermediate care facility, "we found that the primary reasons given by resi-dents for entering care were: declining health, lack of social supports, and dissatisfaction with neighbourhood and/ or location. Of the sample population studied, 50 percent also gave additional reasons including most of the above" (Hanvey and McLachlan, 1981). In general, poor health and/or emotional problems, often in combination with a deficiency of economic, social, per-sonal and community resources, may culminate in a decision to apply for facility care or a transfer to a more appropriate medical setting. Literature Regarding Decision-Making In view of the fact that the decision—making process, including reasons for the move, anticipation, planning, pre-paration and emotional reactions to the move, is crucial to 38 relocation outcome (Beaver, 1979), there is a paucity of literature or studies, particularly Canadian, which have focused on the relocation process per se. Canadian re-search of the relocation process is necessary to deter-mine possible fragmentation or gaps in the existing ser-vices which may impede the transition of relocation on a provincial and local level. With this in mind, a Vancouver survey (previously cited) was undertaken to determine not only the most influential factors that led the local residents to seek institutional care, but also to determine if older persons consulted with others prior to deciding to move or arrived at the decision independently. Since the voluntary/involun-tary nature of the move has also shown to be an important predictor of the outcome, the study also examined whether the institutional residents felt "pressured" to move by others. In the study, only 3° percent made the decision on their own, while 70 percent consulted with others. Physi-cians and medical social workers were more likely to play an important role in the decision to apply for institutional care than either family members or other relatives. Considering the number (20 percent) who were hospita-lized immediately prior to institutionalization, these findings are not surprising. No doubt, hospitalization and the change in medical, social and psychological status, 39 as well as contact with medical personnel, led to their subsequent placement in a long-term care facility. Of concern was the finding that 40 percent reported they felt "pressed" to move by either physicians, hospital social workers and, to a lesser extent, family members. Several subjects mentioned a lack of alternatives preci-pitated a move to a care facility. This finding led us to conclude that perhaps professionals (and families) need further education regarding the availability of community services and greater expertise regarding preparation of the frail elderly. B. Practice Issues in Decision-Making What practical aspects or interventions can assist the elderly during the decision-making and preparation phase of relocation? First of all, it is important for the assessor or social worker to explore with the elderly their motivations for considering institutional care. Is institutional care the only available alternative? In view of the fact that some-times pressure is placed on the individual to seek institu-tional care, underlying incentives and an understanding of individual and family dynamics should be thoroughly and sensitively explored. If, for example, the family is not included at an early stage, members may sabotage or interfere with the carrying out of future planning. Often, a decision 40 for application is considered during times of emotional crisis, when the individual and/or family feel cornered or trapped into viewing facility care as the only defi-nitive solution. At these times, people may not be in a position to adequately explore or evaluate more appro-priate alternatives. In my opinion and from experience of working with the elderly, it is often useful and beneficial to counsel or interview individuals in their natural surroundings, not only because of physical and mental incapacity, but also to ensure that they feel comfortable and more at ease. While the elderly play the role of host, they often provide in-sight into who they are, their values, norms, history and filial bondings by referring to family photographs, sharing colorful anecdotes and reminiscing about their lives. Since the individual is often under a considerable degree of stress, or feeling vulnerable, it is also more productive to initially interview the elderly alone, thereby freeing self-expression without the fear of sanctions or defensive stances from concerned and interested family members. As well, individual visits help to convey and confirm that the prospective resident's opinions and concerns are important, valued, and that their participation is essential. After all, crucial and final life decisions are essentially theirs. 41 Sensitive issues regarding whether they had antici-pated spending their final years in an institution? whether they feel abandoned, rejected or angry toward significant others; the quality and frequency of help received in the present and past; whether they had pre-viously anticipated eventual institution; and whether they believe placement to be the ultimate separation, ending in death or another beginning, help to clarify or identify areas that may merit further exploration and testing within the family group or on an individual basis. 1. The Importance of Seeing the Family Together Family members should be encouraged to attend family sessions, thus providing the social worker or the health worker with the opportunity of viewing each family member within the context of the family network. Seeing the family conjointly may assist the social worker in identi-fying faulty communication patterns or dysfunctional inter-actions. As well, family systems work supports the con-tention that at times of emotional crisis or disruption, family members are more open to intervention, and with pro-fessional assistance may be able to mobilize their resources and energies to effect positive changes (Haley, 1977:126). A premise of family therapy for bringing the family together also rests with the assumption that change in one part of the system affects the rest of the system (Freeman, 1981:21). kz In instances where a decision is being made to separate a member of one generation by placement in an institution, this process can have repercussions or effects within and among other generations. As well, it has been demonstrated that a disruptive family member can become part of the scapegoat process or, as Brody states, "the older person can become the focus and storm center of irrational feelings" (Brody and Spark, 1966s78). With increasing age and accompanying dependency, the aged person's family may not be able to deal with the de-mands and escalation of stress incurred by the elder member's situation. The role of the social worker is to help identify internal and external resources within the family and commu-nity, as well as assist the family to devise its own stra-tegies and solutions to restore the family's equilibrium (Freeman, 1981:24). A Case Illustration The following illustration of a three-generation family demonstrates the disruption, stress and ensuing guilt that may accompany anticipation of an elder member separating from the family. Most importantly, it will serve to illus-trate and emphasize the emotional and behavioural processes that occur throughout the generations. -On behalf of her elderly mother, Mrs. N. made applica-tion for admission to a local multi-level care facility. After a period of several months, a facility bed became available. Two interviews were arranged in the home of Mrs. N. which produced the following impressions. For the past eight years, Mrs. L., an 86-year old woman, had lived in her daughter's (Mrs. N.'s) home along with her son-rin-law and their two teenage children, a boy and a girl. Of concern to the social worker was the know-ledge that the daughter had avoided discussion with her mother regarding the pending move, giving such reasons as "she would not be able to understand and, even if she did, she would resist placement." Mrs. N. was obviously con-cerned and fearful about her mother's reactions to placement and needed help in this area. As a result of the social worker's suggestion, Mrs. N. was encouraged to rehearse beforehand how she would inform her mother about the possi-bility of placement and how she would introduce and explain the arrival and function of the social worker. Mrs. N. had placed her mother on the facility waiting list at the time her mother had become incontinent. However, now that placement was imminent, she was having difficulties following through with the plan and was reconsidering her decision. She admitted that she felt enormous guilt and had difficulty accepting the idea that her mother would likely be placed with other confused, debilitated and sick people in an old-age institution. While Mrs. N. had several sisters and a brother, she had borne the burden as a primary care giver. For a recent one-week period, the mother was sent to another relative's home to give the family some relief. This was the only time the elderly woman had been absent from the home in many years. Mrs. N-'s mother had limited sight and walking abili-ties, compounded by periodic incontinence. Although often delightful, she experienced periods of confusion, forgetful-ness and eccentric behaviour. Having strong likes and dis-likes, she threw food on the floor or cagily crumpled it into a ball and slipped it on to the floor. In addition to meal times, tasks of bathing and changing her clothes often erupted into a family battlefield. Suspicious and mistrust-ful of others, she believed the family was trying to steal from her. Usually, she clutched a large "security blanket" which she would not easily part with, and only if accompanied by her daughter would she venture out-of-doors. In this illustration, the daughter assumed the role of "burden bearer" (Brody, 1966), while the only son, who remained on the periphery of the family, was seen by the elder as one of her favourites. The favoured position of the son or specific family members is not uncharacteristic of inter-generational families. Frequently, relatives who live some distance away, or who have minimal involvement in the actual care demands, may not understand the full 45 implications of what it means to care for a dependent parent on a daily basis. Often, visits are conducted during the most optimal, favourable and pleasant conditions which may not reflect the more unpleasant aspects of the situation. Relatives who have minimal responsibility may be more tolerant, shower attention and affection on their elderly parent(s). Similarly, relatives may experience pangs of guilt due to their inaccessibility and may question or challenge the caretaker's actions or decisions. Certainly, complex factors may lead to friction, misunderstanding, hostility, and blame among the family. In order to identify areas for intervention, the worker must be alert and sensitive to the underlying currents and interactions within and among the network of multi-genera-tional families. In my opinion, the health worker must take a holistic view of the family rather than primarily focusing on the identified problem. In the illustration, the granddaughter resented her grandmother's increasing dependence and limited functioning since she had to assume responsibility in the form of "baby-sitting" services. The son-in-law and grandson were re-lieved from responsibility for care or modification of the grandmother's behaviour in the family. In this instance, the grandmother's condition and behaviour seemed to fragment and polarize family relationships. The social worker helped the daughter to openly and honestly discuss with her mother 46 the issues around placement. Although it was a painful and emotional experience for the daughter and the mother, the discussiom helped clarify and provide a basis for eventual separation. In contrast, a lack of open communi-cation may later have proved disastrous, or have led to serious adjustment problems throughout the relocation process. As a preventative measure, the worker facilitated the expression of feelings, helped the family obtain appropriate information about community services and facility life. The worker also helped them (particularly the daughter) to iden-tify their part in the process of maintaining the status quo. Most importantly, the worker focused on maintaining their self-esteem, relieving their guilt and anxiety, as well as exploring the meaning and change in family structure that would result from the grandmother's removal from the home. How would they spend their time, devote their extra energies and relate to each other once the centre of their attention and routine was missing? As well as feeling enormous guilt, devotion and responsibility, Mrs. N. had to consider her own aging and future. With her teenage daughter's hostile, angry and resentful attitude in caring for an aging member, how would the daughter respond to Mrs. N. in later years? All of these issues and a vast array of others are themes that are often interwoven into the earlier stages of the relocation process. 47 Although Mrs. N. decided to deter placement for the time being, the family was encouraged to visit the facility with the elder and participate in social events, and to continue contact with the worker if they wished. In this way, all would, hopefully, be able to adjust to the idea of placement and become more familiar with institutional life. 2. Family and Community Supports The case illustration is also indicative of the con-siderable caretaking role that family members assume and how the provision of such support can delay or prevent institu-tionalization for an elderly member manifesting significant infirmities. Research studies have also shown that persons living with their children or significant others are more infirm on admission than those elderly living alone in the community (Townsend, 19&5)• The enormous and extensive help that relatives supply to people at risk in the community is well-documented (Town-send, 1965). For example, a Canadian survey of an institu-tionalized population (Kraus et al., 1976 a) reported that more than half of their sample were receiving assistance from the family prior to admission; had been moved to the family home, or were receiving total or extensive help. As in the example cited, the offspring often devote equiva-lent or additional time as that required in full-time and paid employment. 48 A survey, conducted in Vancouver (Hanvey and McLachlan, 1981) of a small sample of intermediate care residents, re-ported that 55 percent of the sample who had close relatives received help either on a daily basis (45 percent) or re-ceived this help on a weekly basis (10 percent) prior to coming into care. Of these subjects, 45 percent had actually lived with a spouse, or son or daughter, who assumed the res-ponsibility of providing the daily assistance. Accordingly, the burden and stress incurred from looking after an aging parent is one of the more significant reasons found for relatives making or considering application to an institu-tional facility on behalf of their parents (Kraus, 1976 b). It appears that if the elderly require instrumental assistance they first approach their families, then their friends or neighbours, and lastly, bureaucratic substitutes for families (Shanas, 1979). Furthermore, there is a reci-procal or mutual expectation from both aging parents and offspring that the elderly have a "right" to filial services (Sussman, 1976). In the Vancouver study of intermediate care residents (Hanvey and McLachlan, 1981), it was found that although 80 percent of the residents had friends, only 35 percent had received help from these friends. The assistance re-ceived from friends in contrast to that received from relatives was of a lesser degree and/or quantity and of a i different nature (i^e., transportation, shopping/banking, 49 yard maintenance and surveillance). The survey concluded that the reasons for some not receiving assistance from friends may have been partially attributable to the possible declining health and frailty of the friends, or may reflect a tendency to view emotional support given by friends to be more important than help with tasks, thus accounting for the low reporting of services provided. Kowever, this hypothesis would have to be validated by further research and study. As represented by 45 percent of the sample, the absence of an informal family support system would indi-cate that while these subjects lived in the community prior to institutionalization they would have required compre-hensive care from community agencies. For those subjects having family support, further community support might have helped to supplement their current care needs as well as provided some relief to family members. In the same sample, it was found that 60 percent had regularly utilized home-maker services while 35 percent had utilized meals-on-wheels. Although it was gratifying to note that the utilization of homemaker services and meals-on-wheels was high in com-parison to other Canadian samples of community elderly, it was of some concern to learn that other existing services were either under-utilized or not used at all. For example, services such as home nursing, transportation, friendly visitors, phone-service, day-care servicesand so forth, 50 were barely represented — possibly reflecting the con-siderable degree of support that family and, to a lesser extent, friends had provided. It is unfortunate that services such as day-care were not used since these services can often help to provide an effective interim or alternative service to placement in an institution. If we are genuinely concerned about pre-venting undue stress and disruption in relocating the elderly, the availability, accessibility and suitability of existing services must be thoroughly explored and examined. As well, these services must be made known to those in most need of such resources. C. Research as a Basis for Practice The above discussion indicates the pattern of support and care that is utilized by community elderly. It seems that family ties and bonding remain strong, that family care and support, if available, are preferred in comparison to alternative support services. Only when the demands exceed or overtax the family's ability to cope, or when all re-sources have been exhausted, do families consider applica-tion to an institution as exemplified by the preceding illustration. Considering the importance that the family holds for the elderly, and in view of the onerous responsibility often assumed by family members, it is crucial that not only the 51 individual at risk, but also family members should be in-volved at an early stage in the decision and preparation stage. In my opinion and as the studies indicate, other transi-tions should also include and involve family members, if possible. Although other moves, such as a transfer of resi-dents from one institution to another, to another ward or even a room change, may prove less traumatic, still these transitions should be thoroughly discussed and include parti-cipation by the individual and available family. Studies indicate that the family may play an important role in alleviating relocation stress. Since many Canadian citizens have immigrated to Canada from other countries, often reflecting different cultures, customs, religions and languages, it is important for the social worker to be aware of the heterogeneity and unique-ness of the elderly population. In 1976, for example, 8 .7 percent of all immigrants to Canada were over the age of 65 (Immigration Statistics, 1961-1977). The decision to enter an institution for multicultural aging populations may hold different meanings, connotations, and anticipations for these elderly. In the Jewish culture, for example, being placed into an old-age institution, or moshave zakenim, is equated with being sent to the unpleasant European poorhouses for the aged and indigent. Differences may preclude the attainment of entitled services because of language barriers and social 52 and cultural isolation, to name but a few. In view of these differences, the social worker should ensure that elderly cultural groups are aware of the avail-able services and realistically understand the implications of services offered. In the previous case illustration, the elder woman spoke faulty English as a second language. It was imperative that the important information regarding placement plans were relayed to her by the daughter using her native language. Particularly for confused, forgetful elderly who may not have a good command of the English language, one cannot assume that receipt of information will be accurately assimilated or interpreted. D. Assessment and Preparation Once the decision has been made, the aged individual must make application. In British Columbia, a professional consultant or assessor receives the referral from a multitude of possible sources (the individual, family, friends, physi-cians, community agency personnel, and so forth). An appoint ment is usually scheduled to meet with a local long-term care assessor to determine whether the person would benefit from institutional care, considering his/her care level and the individual's personal situation. In most cases, a long-term care assessment form with the individual's demographic information, medical diagnosis, prescribed medication, psycho logical and functional ability, the name of a sponsor, if available, and two facility selections, must be gathered by 53 the assessor. In my opinion, care should he taken to pre-serve the individual's rights, dignity and self-respect when the elderly person is initially being assessed. Empathy, sensitivity and active listening are a few of the skills required. For many elderly, the symbolic significance of signing their name on the assessment form, thereby mobilizing the bureaucratic system and process for institutional place-ment, is in itself stressful and anxiety producing. Preferably, when application is made, the individual's family or concerned others should have visited a number of care facilities to ensure that a suitable or appropriate / . -placement is eventually realized. Moreover, the applicant will, hopefully,have accurate and realistic knowledge con-L cerning specific facilities upon which he/she can base his/ her choice. Ideally, it should be feasible for the elderly^ to spend a weekend or an overnight visit (or an appropriate period of time) in a facility of their choice to gradually prepare for institutional life if they so desire. Well in advance of actual placement it'is hoped that the assessor would be able to determine which of the applicant's selec-tions will have the earliest vacancy. This information could then be relayed to the individual and family. Obviously, some individuals may require a greater degree of preparation than others. Flexibility within the system should preferably accommodate individualized planning. Pre-placement visits and tailor-made planning for relocating 5 4 children and adolescents is an integral component of good child welfare practice. Personally, I believe such prac-tices should be included in our methods for relocating the elderly. If possible, cost factors, the physical and social milieu, the size and choice of rooms, whether they can bring their own furniture, an understanding of their rights and other specifics regarding individual facility selections should be considered and discussed. As indicated in the literature, an honest appraisal of the person's situation, the reasons or basis for recommending institutional placement, the encouragement and voluntary participation of the individual, are important and crucial aspects of the preparatory stages of relocation. In general, the assessor should ensure that during the application phase, the individual's rights and vulnerabilities are protected. Waiting and Preparing for a Move Once the decision and application has been made, the individual must now wait and anticipate institutional place-ment. As well, personal and legal affairs must be put in order, arrangements made for the dispostion of many of life's possessions including family pets and property, and a shift in mental set or attitude is required to prepare for relinquishing the former lifestyle. At the same time, how-ever, a few community elderly may experience a series of precipitating events which may demand immediate entrance to 55 a facility on an emergency basis. Thus, neither the indi-vidual, family or health care workers are able to adequately prepare for relocation during a serious crisis. The progression of events leading to institutional care is invariably not easy or effortless, particularly when one considers that often the resources of the elderly r at this stage may be at their lowest ebb. Moreover, Tobin and Lieberrnan (19?6), in their studies of community elderly awaiting placement, have noted that feelings of separation, rejection, abandonment, and thoughts of death are often evidenced in the waiting list population (p. 99). The sense of abandonment or separation may be understandable when we note that often the loss or lack of supportive re-latives, or the incapacity of the relatives to provide care, distinguishes those people who live in the community from those who must seek institutional care (Tobin and Lieberrnan, 1976*109). For those on the waiting list, what effect does waiting'' have on the ill and debilitated older people who require institutional care immediately but must endure severe stress in precarious situations and/or possibly dangerous environ-ments? What are the effects on the families? The waiting period lends itself to providing interim) services and supports as well as indicating a need for / social work interventions to help the individual (and family) cope with the emotional and stress-provoking 56 experience. During the interim period, there may be a crucial need for the assistance of a social worker to mobilize community services and family supports. E. Separation Once Long-Term Care notifies the prospective resident of a vacancy, sufficient time should be allocated to pack personal belongings, say good-bye to friends, and make suitable arrangements for admission. As it exists now in British Columbia, Long-Term Care can give little notice of a facility vacancy (usually only one to a few days prior notice) and can provide minimal or, in some cases, no assistance to help individuals deal with the actual physical tasks of moving. A lack of instrumental assistance is particularly evident when the elderly lack available social support. For example, an elderly gentleman in a local hospital was noti-fied of an available bed and rushed to the facility the same/ / day. His only relative, a niece, lived on the east coast and was unavailable to help perform and organize the instru-mental task of moving his furniture and belongings from his previous hotel residence. For over a week, this mentally alert and pleasant fellow was without a change of clothing and other personal effects. Needless to say, this caused y him considerable distress, anger and hostility. He reacted by refusing to budge and held a "sit-in" in the facility's lobby. It was beyond his and the facility staff's 57 comprehension that there was a lack of professionals, para-professionals, and/or volunteers available to meet his vociferous demands. This example illustrates how not to relocate an individual. One can speculate about how this horrendous experience affected his subsequent adjustment and the residents' and institutional staffs' initial impression' and attitudes towards him. F. The Transition In order to avoid the development of unfortunate situa-tions like the one previously cited, Long-Term Care should, if possible, forewarn individuals at least one week in advance. Adequate notice could assist the liaison worker in arranging for a smooth and organized transfer from the community to institution, between facilities, or within an institution. For the elderly, it is particularly important that the move is handled in an unhurried, uncomplicated and patient manner since they may not be as resilient to dis-ruption and change as younger individuals, A reasonable length of notice given before the move transpires can also ensure that adequate and suitable arrangements are being made in the receiving environment. Community and institu-tional staff must coordinate their efforts to provide a welcoming and comforting atmosphere at the point of entry or impact of admission. Crossing the facility threshold is a deeply emotional and stirring experience not only for the individual, but 58 for the family and concerned others. With few exceptions, tears accompany admission. At the point of entry, an inner hope or faith seems to persist in the mind of the older person that somehow he/she will miraculously be saved from the fate of institutionalization. When family members or friends do not offer or Invite the relocatee to live with them, or when alternate solutions do not materialize, the reality of their situation is often "accepted" with a variety of attitudes and emotions. These emotions may set the tone for adjustment in the new life. The family also may be experiencing mixed emotions at this time. The series of events leading to actual admission may have caused considerable stress and anxiety while waiting for placement. As well as a sense of relief or a freedom from responsibility, family members may also experience mixed feelings of guilt, resentment and anger, love and affection. Thoughts and concerns about whether they made the correct decision, whether the newcomer will "fit in" with other resi-dents, make friends, find their way around, and receive some satisfaction and happiness in the new environment are very real issues in the minds of family members and the new arrival. Throughout the stages of relocation, emotional support and encouragement should be given by the social worker and residential staff to assure both families and the newcomer that they have made the best decision possible under the 59 circumstances. Of importance also is the social worker's role of instilling in the relocatee the sense of connection or continuity between his past and present life. The idea must be conveyed that satisfying aspects, interests, per-sonal and social relationships of independent living may continue and may possibly be enriched in the new environ-ment. A sense of hope, optimism, confidence and reaffirma-tion of purpose for the future (and tempered with realism) should be encouraged or promoted. Respectful attitudes, reminders of past accomplishments and assets will help to realize these objectives. An appropriate or typical "first day" might include the following considerations. During the first day pre-ferably, the social worker should meet and greet the new arrival (and family) at the door. Introductions should be made to key staff, and particularly, to reacquaint them with residents they may have known in the past. The trauma of admission may be as much as the frail newcomer can deal with for one day, so it is important not to overexpose or overtax the individual. If possible, family or a staff member should be en-couraged to stay for most of the day to help unpack belongings, decorate the room and generally help the new-comer get settled. It is preferable to have a family member join the relocatee for meals or tea to assure the individual that family ties will be maintained or continued. 60 In addition, the presence of a "concerned other" contributes to feelings of comfort, security and a sense that he/she is still loved and cherished. Since the frail elderly are vulnerable to abuses of their rights and dignity and do not, as a rule, fight for these rights, it is crucial that a resident handbook or specific information outlining the rules, procedures and appeal mechanisms of the home is given to the residents and family. Constraints of the institution, formal policies, written rules and procedures, tradition, professional and sub-professional roles and investments, patterned ways of looking and dealing with the elderly, administrative and business operations — all may affect and hamper intentions to safeguard the rights and dignity of the elderly and their subsequent adjustment to facility life. Often, families can act as advocates to ensure that their elderly relatives' rights are not abrogated. If relatives have some knowledge of the facility's and Long-Term Care's regulations, admini-strative structure and mandates, they can also help inter-pret existing rules in an acceptable manner. 1. Hospital -Although transitions described often involve a move from the community, transitions from other institutional environments and situations frequently occur. For example, studies demonstrate that placement from hospitals is not an uncommon occurrence. In a study of institutionalized 61 populations, York and Calsyn (1977) reported that 59 percent and 55 percent of two samples had come directly from hos-pital. In a Vancouver survey of intermediate care residents (Hanvey and McLachlan, 1981) , 20 percent of the sample were in hospital immediately prior to institutionalization. In acute care hospital settings, management committees have concerned themselves with accounts of in-patient costs in order to free up beds and send the elderly out at the first opportunity. Attitudes of hospital staff and physi-cians, lack of knowledge of each facility, and transfers of patients with insufficient information also contribute to slow transfers, disruption, and stress. As a result, there is a need to improve and coordinate transfers between long-term care facilities and acute care hospitals. A Multi-Discipline Approach In instances where the prospective resident is awaiting placement in an acute care bed, the facility social worker or the long-term care assessor and the patient should (if pos-sible) be given several several days notice by "central registry" that a facility bed is vacant or will soon be avail-able. Prior to discharge, either the facility worker or local assessor should arrange to meet with the hospital social worker and resident to first determine if the individual is, in fact, ready for discharge, and that the chosen facility is able to meet the patient's care needs. Coordination of transfers could include a team meeting of hospital, medical 62 and nursing staff, local assessor (and the patient). A team approach would be useful in identifying possible medical, physical or social difficulties that are per-tinent and crucial to the effective transfer arrangements and the subsequent adjustment of the individual after dis-charge . A multi-discipline and unified approach to after care might help alleviate possible confusion and misconceptions that the patient or the various disciplines and their res-pective agencies may have regarding the transfer and dis-charge plans. Similarly, arrangements for physiotherapy, outpatient care, prescriptions, medical care plans, the mode of transfer for the individual and his/her personal effects, and contact with the patient's family or friends are some of the major issues that require attention well in advance of actual placement. Within the constraints of the current health care system, the facility social worker or the long-term care consultant could act as a liaison and ensure that he/she is informed of a change in plans or in the condition of the patient. The hospital social worker, on the other hand, could accept the responsibility of closely monitoring the patient's condition and plans in order to accurately relay relevant information to the liaison worker. Not to be forgott en, facility providers have a need to know of plans for discharge so they, too, can help facilitate a smooth and organized move. 63 2. Intra/lnter Institutional Transfers Within the present Long-Term Care system, a change in an individual's care level can also result in a transfer to another floor or, more likely, to another facillity. An individual settled in a facility may find himself forced to move to a facility where his needs can be met. Again, moving to either another facility or withinxthe facility can be disrupting and stressful for not only the individual, but also concerned family members. Again, a coordinated team approach between facilities or wards might prove bene-ficial. The facility staff or assessor (if a social worker is not available) should adequately prepare the individual and family for the pending move. Packing, moving and re-adjusting may not be easier the second time in view of the likelihood that the individual has experienced an increasing loss of health and functioning. Casework services and pro-fessional counseling may be needed to help the individual and relatives get through this difficult time. G. The Stage of Impact and Incorporation The final phase, the stage of impact or Incorporation, refers to the period of time after the first day of ad-mission and until the new resident views the new facility as "home" (Pope, 1978). Several studies indicate increased mortality both imme-diately before and after relocation (Costello and Tanaka, ek 19615 Epstein et al., 1971). Furthermore, during this period, the most adverse psychological effects of reloca-tion are evidenced (Tobin and Lieberrnan, 1976). Coleman (1973). f o r example, has shown that stress may be charac-terized by such forms as hyperirritability, sleep distur-bances, disrupted relationships, and ego-defense oriented reactions including emotional insulation and detachment. The work of Bowlby (1969) and his study of children's reactions to separation experiences as a result of hospita-lization also revealed similar effects. Brearley (1977) reports the distress and distortion of relationships that accompany admissions to hospital and homes for the aged, as well as increased susceptibility to infections and hospital related illness. Further evidence by Pope (1978), in a review of residents newly admitted to old people's homes as emergency admissions, found that a quarter were depressed or confused on admission, 6.1 percent resigned to their fate, and a further 12.2 percent died within the first three months. Tobin and Lieberrnan (1976) also found that mortality rates particularly increased during the first three months after relocation. Townsend ( 1962 ) suggests more specifically that the chief changes in an individual's psychology and behaviour occur during the first days or weeks after admission to an institution. He comments: "The individual seems to receive a lethal shock which causes him to adapt quickly to a new level of behavior and to adopt certain new attributes toward 65 his environment and himself" (p. 367)» Of particular interest is also a study by Zweig and Csank (1975) of a mass transfer of geriatric war veterans of St. Anne's Hospital near Montreal to a new medical building. These researchers found that the months that immediately follow relocation is not necessarily the cru-cial period. Although patients were involved in a stress-prevention program, "there was a latency period of some months' duration after which the major post-relocation impact of the move was felt" near the end of five months of residence (p. 275). It may be that not only immediately prior and after relocation, but several months following the move is also a critical period resulting in an increase in mortality rates. Practice Implications With respect to the above research, actual entry to the institution and several months following is a particularly vulnerable and climacteric period for the new resident and existing relatives. What kinds of interventions and stra-tegies can be utilized by the professional social worker, consultant or residential staff to help prevent or alleviate adverse relocation effects? More importantly, how can we help the individual (and significant others) adjust or adapt to relocation and institutional life? 66 Experience in working with elderly indicates that some practical considerations and direction are necessary to help the individual "settle in" and prepare for his/her new life. Obviously, time should be taken to gradually familiarize the individual with the schedule, routines, key staff, residents, residential services, physical environment, and so forth. Since the first days in the facility may seem overwhelming, confusing and hectic for the individual, it is important that staff and other contacts have a great deal of patience, em-pathy, consideration and positive regard for the newcomer. The individual's situation could be compared to what most of us have experienced at one time: being the new kid in school or a foreigner in a strange country. Although these analogies are oversimplified, they serve the purpose of alerting care staff to some of the feelings and diffi-culties the individual may be experiencing on a more personal level. It is important that everyday procedures or routines, often taken for granted by residential staff, are discussed and clarified for the resident's benefit. For example, fore-warning the new resident that a nurse may enter their room to perform a customary bed check at night, or that their room-mate is a fretful and noisy sleeper, or that a staff member will knock on their door to awaken him/her at a certain hour are courtesies that should be extended to the resident. In this way, possible concerns, fears and anxie-ties that may escalate in a strange and unfamiliar environ-ment could be alleviated. 67 Washing, bathing, and toileting are everyday events which we also take for granted, and yet, facility staff may as a matter of course perform or regulate these functions. Residential staff may inadvertently infringe on the resi-dent's personal dignity or privacy within the constraints or regime of the institutional setting. Although not to belabour a point, considerations of basics such as these can influence a person's sense of self-worth and his/her desire to belong. Coping and Adaptation In working with relocated elderly, feelings of loss, hostility, separation, helplessness and hopelessness are often noted. These characteristics are often accompanied by reminiscencesj a longing for a former environment and lifestyle; regrets or mourning regarding decreased mental and/or physical health. Increased regression and/or the use of defenses such as denial are often observed. However, these factors should not constitute the sole attention of the social or health worker to the neglect of recognition of patterns of adaptation and/or reconstruction of a new life for the resident and family (Mailick, 1978*118). Residual functioning and the assets of the individual and family should be encouraged and supported. It is hoped that the resident, as well as offspring, will view the ex-perience of institutionalization, adaptation and change as 68 another of life's challenges rather than as a defeat. Initially, this may be difficult since new residents, for example, may test or explore their relationship with family. Guilt induced tactics may be utilized by a new resident to bond children or relatives to them, to reaffirm that he/she is still loved and not abandoned, or as a method of blame or punishment for placement in a facility. On the other hand, relatives may feel guilt and pain in spite of knowing that placement is the only viable alternative. At the same time, they may initially have difficulty visiting or facing their aged relative due to the uncertainty of the reception they may receive, or because they find it difficult to see their parent living / among debilitated or confused elderly. Casework services and preparation of the individual and family can help to mediate between conflicting parties to facilitate reconciliation and the expression of feelings. It is also important for relatives and staff to understand that erratic or disruptive behaviour may be a reaction to admission or as a reflection of underlying family dynamics rather than interpreting the behaviour or attitude exhibited as a personal affront or as an inherent pattern of the individual. Other coping behaviour may be evidenced in the indi-vidual's lack of identification with the communal group. For instance, he/she may tend to view his/her psycho-social 69 functioning, health, or situation as special or unique from others. The resident may over-compensate or justify his/ her position by making derogatory, generalized, or over-exaggerated statements regarding the mental and physical deficiences of the residential population. As a result, the individual may withdraw or make little effort to "fit in." Instead, the relocatee may rely heavily on favoured family members as primary sources of emotional and social support. The family, driven by guilt and distress, may reciprocate by increasing the frequency of visiting and over-responding to the dependency and demands being made by the aging resident. In most instances, family interaction should be encouraged. At the same time, however, health or social workers should attempt to ensure that visits are kept short in order to preserve individual and family re-sources. Since research suggests that institutional care staff may promote dependency (Barton, Baiter and Arzeck, 1980), it is important that care staff are aware of these findings in order to encourage independent behaviour. The reactions and attitudes thus far described under-score the complexity and range of possible adaptive mecha-nisms and coping styles that may emerge during the first months of institutionalization. Although also limited in scope, perspectives of aging and social and personal adjust-ment, such as the classic "activity" or "disengagement" 70 theories, have been advanced to partially explain the com-plexity and variations of individual patterns of aging (Cavan, 1962; Cummings and Henry, 1961). However, the individual must be considered as unique within the context of a-socio-environmental framework. A broader view is needed to begin to understand and determine problem areas -(if such exist) that may require or yield to intervention. The social worker's attention must encompass the family and other social networks as well as the physical environ-ment and the individual. The focus of work during the "settling in" stage should be aimed at helping the new resident (presuming that he/she has family) to understand the impact of change and to begin to rebuild a new life while maintaining linkages with the past. In my opinion, it is advantageous to ensure that the interests and needs of the resident and family are being met in the instution and community. Studies indicate that factors such as the degree of choice and participation have an effect on relocation out-come. As a result, the individual will need appropriate information to guide his action, a degree of autonomy to allow for the flexibility of options, and a maintenance of internal balance in order to allow the elder person to engage in purposeful activity and interaction if he so desires (White, 1974; Schulz and Brenner, 1977). The strengths and resources of the family, the health and psycho-71 logical status of the individual, and a host of other factors will also have an effect on whether the individual adequately adapts to the new environment. The health worker's difficult task will be to select priorities, where the greatest potential for change may occur within an economy of action. The provision of a variety of group work and treatment approaches have proved beneficial for even the most debili-tated elderly (Brody, 1977). Establishing a resident's welcoming committee or a "newcomers club" may also help new residents establish contacts and/or provide vehicles for the expression and sharing of feelings. A variety of innovative and imaginative approaches are particularly needed during the post relocation period. POLICY ISSUES The. process and stages of relocation as outlined have essentially been viewed from a personal and family pers-pective with implications for micro practice and intervention. However, under the current constraints and organization of the Long-Term Care program and health system in general, there are a number of policies and issues which parallel these stages, often posing obstacles or barriers to the successful outcome of relocating the elderly. Since the process of relocation cannot realistically be viewed in isolation from the bureau-cratic and organizational structure, the balance of this paper will examine and recommend policy and changes that could facilitate effective relocation and outcome. 72 From a perusal of the literature concerned with the relocation stress and the negative effect of recent ad-missions, it has been demonstrated that the actual place-ment procedure (including application, assessment, selection and admission policies), the quality of the institutional environment, and the importance of the social worker and family — all have an effect and influence in the relocation process (Brody, 1977; Tobin and Lieberman, 1976; Townsend, 1962). Accordingly, these areas will be generally examined from a policy perspective. A. Factors Influencing Placement As mentioned previously, admission to a care facility is frequently arranged from an acute care, general or allied hospital. Usually, the physician in consultation with medical social workers and other personnel act as the "gatekeepers" to the institution (Brody, 1979*5°)• On the surface, this hier-archical system may appear reasonable. However, the initia-tion for placement often obscures underlying or more expedient motives such as political and organizational struggles, or more simply, reflects the shortage of acute care beds and/or a lack of other alternatives. Often application is made to institutions most likely to have an early vacancy rather than to facilities which may best provide the care and quality of environment the older individual required if, indeed, institu-tional placement is the most suitable arrangement. This is especially true when an emergency or crisis situation exists. 73 The practice of choosing the most available facility also occurs in community placements. Although a medical social worker, or long-term care assessor is likely to be involved in the decision to apply for institutional care, usually their focus or attention rests with functional or practical planning rather than arrangements for after care ' needs. Given these factors, it is not surprising that there are a number of misplaced people who may negatively experience the impact of the move (Williams, et al., 1973)' Add to this experience the generally assumed view seniors hold toward placement: All old people - without exception - believe that the move to an institution is the prelude to death. . .(the old person) sees the move to an institution as a decisive change in living arrangements, the last change he will experience before he dies. . . .Finally, no matter what the extenuating circumstances, the older person who has children interprets the move. . .as rejection by his family. (Townsend, 1962:103) Certainly, moving to an unsuitable or inappropriate facility would confirm and actualize an individual's worst fears and suspicions. The impetus to develop interventive placement mechanisms is gaining credence not entirely based on humanitarian motives. Problems associated with human costs do not pre-cede the rising financial costs of maintaining the acute care hospital and the growing proportion of the number of the very old who often take up acute care beds. The budget for health care services is the largest single item of 74 provincial expenditures. Over 7.2 percent of the Gross National Product of Canada was paid to health services in 1978 to 1979 (Arkinstall, March 19, 1981). This year, health expenditures will fall 25 million short of $2 billion, with hospital programs reaching $1,043 million (Bell, March 11, 1981). In comparison to the total population, the elderly have more than twice as many hospital stays, which are twice as lengthy as young people (Schwenger and Gross, 1980). As a result of rising costs, society cannot respond to all of the perceived needs and demands people may make. Assessments must be made concerning the amount of a society's resources devoted to the elderly and other disadvantaged groups relative to other endeavours and the way these re-sources should be allocated. Unfortunately, health care has often favoured those populations who are well-provided for already. The frail elderly who are characterized by a lack of social, economic, and personal resources, often find that health care and other crucial services are unavailable or inaccessible. Many physicians, for example, prefer to deal with conditions that pose a diagnostic challenge and about which, they feel, they can do something. In contrast, the elderly do not as a rule respond well to medical treatment and may present psycho-logical and psycho-social problems. Such problems, unlike technical procedures, are time-consuming and have uncertain outcomes. With the proliferation of technical and medical 75 knowledge, physicians often feel uncomfortable dealing with the individual in a social context. Similarly, few doctors consent to make night calls or home visits even in emer-gencies. These factors are particularly important when we consider the chronic health problems and limited mobility of the elderly. A similar failing on the part of physicians is evidenced in the care of the institutionalized elderly. Generally, the elderly may be short-changed in receiving entitled services. The neglect of psycho-social aspects of the elderly are also evident at the time of application to an institution. Often, referral and placement involves a physician at some point. Eligibility for placement is often based on his/her recommendations or referral. As well, eligibility is made either by home evaluation, out-patient or in-patient assess-ment by a long-term care assessor. Often placement can be indiscriminately arranged or, according to the assessor's personal judgment, done without adequate information or pre-paration given to either the patient or family and, in a few instances, without the patient's informed consent. Situations have arisen where a new resident suddenly arrives by taxi, or some other means, at the facility door with no family, no clothing, or personal effects, and no social history. In most cases, Long-Term Care assessment forms have been completed prior to admission, but they are often out of date and/or arrive days after the individual 76 has moved to the facility. (More than one Long-Term Care form has been lost or misplaced in the system.) In order to remedy this situation, several facilities have developed their own individual application form, thereby duplicating and increasing paper-work demands for health care staff and increasing frustrations for applicants and their families. The process of application to homes for the aged is an example of a fragmented approach to placement, not only in British Columbia. According to Walter Lyons, director of the Baycrest Home in Toronto, the application process is superficial and fragmented "if it is primarily oriented to the individual while generally neglecting the social, cultural, and psychological components of the individual" (Lyons, 1966:5). Although psycho-social aspects may be acknowledged in written form, in actual practice, a medical model approach dominates: an approach modelled after short-term care, emphasizing illness, diagnosis and cure. Deci-sion-making and eligibility has usually been determined by government supports which also control bed availability (Brody, 1975? Lefroy and Page, 1972). Similarly, reinburse-ment to facilities is usually paid for by physical illness and disability rather than for social and psychological services (Shore, 1976:2). The practice of inaccurate assess-ment of social, medical, and functional needs, as well as inadequate preparation and delivery of services, can nega-tively influence adjustment and life satisfaction for those entering institutional care. 77 Accordingly, a new formula which includes all aspects of systems supports, with a particular emphasis on the anticipated resources of the aged at risk, must be devised. Again* a systematic approach to assessment is also indicated before more facilities or services are planned. As well as measuring functional ability, assessment mechanisms should logically encompass the environmental supports of those seeking placement (family, friends, etc.), thus facilitating a better match of need to services (Brody, 1977). Of course, assessments will only be as good as the staff who complete them. At the present time, assessments and placement are usually arranged by assessors who are not primarily trained in dealing in personal relationships. Long-Term Care's original scheme or proposal of having a multi-disciplinary team (including social workers) to assess, screen, and counsel individuals for entry to Long-Term Care facilities was never realized (possibly as a result of the unanticipated numbers who are applying for some type of ser-vice). However, it is imperative that a critical considera-tion of a team approach to assessment and placement should be revitalized and implemented by Long-Term Care policy makers. The institutions themselves also have an increasing responsibility and investment in promoting social and commu-nity supports for the institutionalized felderly. 78 B. Future Policy Directions It should be kept in mind that often the elderly at risk in the community or in hospitals may manifest limited mobility and/or psycho-social functioning. Consequently, these individuals may not be able to actively seek or participate in locating institutional care. How can we ensure that the bedfast, housebound or confused and their families are involved in the relocation process? Most importantly, who can assist or help if family members are unavailable? For example, the frail elderly in the community are difficult to detect since they do not necessarily come to the attention of an agency until a crisis arises. As well, the old person in need of protective services does not and often cannot seek the help he/she needs. Someone must go to them since their motivation for seeking help and using it is minimal (Hemmy, 1961:151). As it exists now in British Columbia, there are few individuals providing services who remain constant in the lives of the elderly at risk in the community. The know-ledge of whom to contact, where to send "mother", how to arrange moving, or how to handle crisis are areas that reflect insufficient staff and resources. On a local level, the dissemination of information through the provision of printed material, news media, pictures, and so forth, might aid the elderly and their 79 families in the receipt of more accurate information and appropriate resources. A detailed local "shoppers" guide of facilities (such as those that are prepared now in many neighbourhoods) will ensure that people make more informed and appropriate facility selections. Not only the general public, but medical, nursing para-professionals and others, who are in contact with the elderly, could also benefit from an informative guide. Frequently, professionals and others have limited knowledge of local facilities and re-sources. At the same time, their role often requires a referral for services, an involvement in the decision-making and/or arrangements for placement. In my opinion, it seems imperative that health professionals and the community at large have easy access to accurate information in order to make more informed care and placement plans. In British Columbia and elsewhere, new ideas and suggestions are presently being discussed to facilitate communication and linkages within the myriad of government agencies now in existence. Suggestions, such as a "facili-CXa tator" program or intermediary service to act as a referral system and provide actual integration and follow-up for the individual, are presently being considered. A component of such a program would include a single continuous contact (preferably a social worker) whom the "elderly and their families could turn to for advice and support services. Possibly, facilitator services could operate from the local 80 long-term care offices or could be operated under voluntary or non-profit auspices or under an appointed board. Often, the complexity of the health system, the frag-mentation of service and the lack of adequate numbers of available long-term care staff may prevent the frail elderly from attaining entitled services. An intermediary service is needed to coordinate existing services on behalf of the elderly. Similarly, there is a further need to implement additional referral centres, counseling agencies and home rehabilitation services (occupational and physiotherapy) for seniors and their families. C. Psycho-Social Assessment At the present time, there are few hospital resources which focus on the continuity of care during treatment, on preparation for discharge, or in the provision of suitable after care. In the hospital setting, for example, the elderly who have greater residual capacities and potential for improved psychological and physical functioning are often transferred to rehabilitation wards or hospitals. Eligiblity criteria for more intensive treatment and therapy are often limited to those who may benefit the most in the least amount of time. However, for those elderly who have the greatest degree of disability, require more intensive care, and/or treatment, and who are likely awaiting placement for a nursing home bed, programs, treatment, and therapy are 81 either negligible or non-existent. Within the acute care hospital, more chronic care beds could be designated with the express purpose of improving or, at least, maintaining current functioning levels. The psycho-social components of care and rehabilitation could be administered primarily by para-professionals and, to a lesser extent, professionals. As a result, the elderly would have a greater and less pressured period of time to adjust and improve limited functioning, and/or to arrange an alternative plan for after care in their own homes or other housing. In the present situation, elderly indivi-duals are left to vegetate in hospital wards, lacking social stimulation, personal caring, and other essential basics for living. Certainly, blame cannot be placed with either medi-cal or nursing staff since, in reality, they simply are not allowed the time to adequately attend to the psycho-social needs of those elderly awaiting placement. Although the preceding proposal is a rather short-term solution to a long-term and complex problem, it was pre-sented as an example of a variety of proposals that are currently being considered and discussed by service pro-viders and planners in Canada and elsewhere. . In British Columbia, there are some recent developments of hospital programs which are geared to a concern of con-tinuity of care during treatment and discharge. The geria-tric in-patient assessment units at Mount St. Josephs and 82 the Jubilee Hospital in Victoria are recent examples of hospitals which contain a diagnostic, treatment, and discharge planning unit within an in-patient hospital framework. These serve not only individuals within the institutions, but also provide needed services for the community elderly as well. This type of approach, of comprehensive assessment and appropriate referral, has proven effective in matching the needs of the individual with the type of care and environment required. At the same time, however, admission criteria is stringent since the centres accept only those elderly who exhibit "unexplained" confusion, sudden irrational or emotional behaviour, or a recent onset of a multiplicity of problems. Similarly, the elderly are admitted for a short or limited period of time lasting four to six weeks approximately. Since the criteria for admission is strictly monitored, it excludes a number of people who may benefit from the service. If possible, admission require-ments should be more lax to encompass a wider range of the elderly population who may be prematurely admitted to insti-tutions. Another alternative is the day hospital, where patients who do not require twenty-four-hour care come to the faci-lity in the morning and return to their primary residence in the evening after receiving medical care, rehabilitation and social services as needed. An increase in programs such as 83 these would have major benefits. First of all, "day care" is less disruptive and stressful than being admitted as a hospital in-patient. As well as receiving medical care and so forth, the individual's social needs and capabilities can be more accurately assessed to again facilitate a more appro-priate and suitable environment to meet the individual's needs. These benefits could also be increased or expanded to facilities, families and other care providers of the elderly who have meager medical and professional resources. If we are interested in reducing relocation stress, then programs must be more accessible and available to a wider variety of elderly people. Development of outreach programs to bring these services to the elderly could also be con-sidered by service providers. Selection as a Basis for Policy Certainly, not all elderly people suffer ill effects in relocating to institutions. Physical status, cognitive ability, and personality traits play a crucial role in out-come. Those who have an aggressive, narcissistic per-sonality often fare better than the mentally impaired. The functionally disturbed and those with chronic brain syndrome, the physically ill, the depressed, hopeless, and those who use denial as a defense mechanism, have a greater risk of adverse effects (Aldrich, 1964; Aldrich and Mendkoff, 1963; Miller and Lieberrnan, 1965; Turner, Tobin and Lieberrnan, 1972). 84 Certain factors appear to relate to those who are most at risk and who may benefit from service intervention. Specific programs and services should be linked and provided to those most in need rather than attempting to service an entire elderly population who do not require services. Many people would say that the health system is oriented to pro-viding expensive and highly technical care that appears inappropriate to health needs of the majority of the people. As well, it is often argued that possibly a third of the persons in nursing homes and long-term care facilities are not in need of expensive institutional care (Anderson, 1974« 522 ). As a result of increasing costs and bed shortages, admissions to Vancouver and British Columbia care facilities are more strictly screened and bureaucratically regulated. Essentially, problems arising in Long-Term Care are clouded by the lack of clarity as to the target population and the kind of service to be afforded. If more stringent eligibi-lity requirements include those elderly who are the most at risk in the community (i.e.. the seriously confused, incon-tinent, or more physically impaired), the residential care facilities are likely to thwart these efforts by refusing or rejecting applicants on the basis of inadequate facility staffing, fiscal reinbursement and/or the convenience of the provider. 85 It should be mentioned that the facilities' refusal to accept certain applicants may, in fact, be realistic and valid. Staffing requirements, as determined by the Community Care Facilities Licensing Act (1979), are often inadequate to meet the needs of those individuals who require a greater de-gree of care or supervision. Variations within facilities, such as the range of care and services provided, the physical setting and other conditions, affect those who are accepted or rejected for admission. The increasing number of ad-missions of the psycho-geriatric patient often pose problems for service providers. Under the present system, if complex nursing procedures are not required, the patient is often not deemed as needing skilled care, and may be assessed at a re-latively low level of care. Thus, the ambulatory but con-fused and impaired residents are not linked to the appropriate fee level in spite of the fact they require additional thera-peutic and supervised care. For these people particularly, custodial approaches must be replaced by innovative, experi-mental, and optimistic treatment interventions. Risk can be minimized by selecting an environment that agrees with the personal characteristics and functional abilities of the individual. The Philadelphia Geriatric Centre in Philadelphia, which fosters and rewards aggressive-ness, found that aggressive personalities were conducive to the successful use of therapeutic programs (Kleban, Brody and Lawton, 1971). Additional studies support the importance 86 of matching a person and environment fit to help reduce the excess morbidity and mortality among the mentally and phy-sically debilitated. Part of the rationale for supporting this notion is the belief that reducing environmental dis-continuity will help to facilitate adjustment without re-linquishing his/her personal coping style (Tobin and Lieber-rnan, 1976j230). There is some question, however, as to whether differences in the pre- and post-environments make a difference for the most frail elderly and for whom relocation may have already exhausted and depleted personal resources (p. 2 3 0 ) . If certain personality traits such as agression or asser-tiveness help to diminish relocation stress and mortality, possibly programs, medical and health care staff attitudes reflect these traits. This position has been advocated by others. Goldfarb (1974), for example, has implemented therapy designed to heighten the elderly's sense of mastery, a charac-teristic opposed to passivity. Seligman*s classic work re-garding "learned helplessness" also indicates or supports the need for interventions which mobilize psychological resources. Grant and Gutman's proposal (1980), cited earlier, also concur with the preceding objectives. D. The Quality of the Institutional Milieu Studies concerned with relocation stress and the elderly have indicated that not only the process of relocation, but the "quality" of the receiving environment affect the outcome 8 7 of those placed in institutions. Findings suggest a sig-nificant relationship between a positive outcome and such factors asi the degree of change incurred because of moving; the continuity of the previous lifestyle; the degree of preparation; opportunity for choice and independence; parti-cipation; medical status; the quality of the psycho-social milieu, including attitudes of residential staff and signi-ficant others; access for social interaction; community involvement, and so forth, (Marlow, 1973; Tobin and Lieber-man, 1976; Noelker and Harel, 1976; Penning and Chappell, 1980). While it is recognized that institutional residents require and deserve the most sophisticated medical, nursing, and para-medical services, it is also beyond question that attention to psycho-social needs are also critical to well-being. However, there is a great deal of current criticism that institutions are patterned after short-term acute care or the medical model. Although economics is one of the chief reasons for Long-Term Care, paradoxically, the use of the medical model has resulted in a series of inappropriate and costly consequences (Shore, 1976«73). Examples supporting this idea include the use of endless documentation of the patient's medical chart, and the use of employing medical and nursing staff to the exclusion of para-professionals or practitioners and others who have a psycho-social orienta-tion. Often, evaluations of Long-Term Care have determined -88 that facilities have increasingly adopted a medical model of professionalization to a non-medical problem -(Ministry of Health Task Force, 1980). Other evaluations advocate a blending and balance between social and health services, a psycho-social health model, which seems to be a more logical and appropriate position (Shore, 1976:70). Part of the reasons for the conflicting opinions re-garding the function and purpose of institutions arises from a lack of clarity, confusion and ambivalence regarding goals and philosophy. There is a lack of consensus, for example, about such basics as whether facilities should be primarily concerned with treatment, or just provide maintenance or custodial service to their clients (Ministry of Health Task Force, 1 9 8 O ) . An opinion survey of British Columbia Health Association members varied greatly in their understanding of what the provincial philosophy for long-term care services were. Some said they were unaware there was any philosophy, while others believed that custodial care and placement were the primary objectives (Ministry of Health Task Force, 1980). Additional factors contributing to the confusion about nursing homes are the various types of ownership, and the various types of nomenclature (i^e., nursing homes, geriatric centres, levels of care; the variety and types of facility of design, etc.). As well, confusion has increased because of a lack of policy, cost factors, and inappropriate payment mechanisms, to name a few (Shore, 1976.71). Obviously, a clear and unified 89 but uncomplicated approach to care is urgently needed to provide the basis or groundwork for a continuum of quality care, including rehabilitation and other psycho-social components. Ironically, although the social service aspects of care are often acknowledged in planning, the hierarchical nature of the health system often prevents successful im-plementation. For example, within the Long-Term Care system, a change in an individual's care level can result in a transfer to another ward or more often to another facility. An individual settled in a facility may find himself forced to move to a facility where his/her care needs can be met. The situation can become more dis-tressing when a married couple is separated due to their differing care levels. Each may have to live in different facilities, sometimes miles from each other and their families. These difficulties could be partially remedied if facilities were built on a multi-level concept, offering a range or continuum of care. Of the few multi-level facilities, one or two maintain two licenses: an Extended Care, and a Community Care Faci-lity license (e.g., Louis Brier Home and Hospital in Vancouver, and the Priory in Victoria). Both licenses are provided under the Ministry of Health but within the juris-diction of two different divisions of the Health Ministry. Each division has the responsibility for admitting residents 90 to their particular facilities through different channels. The local central registry in Vancouver admits residents to the Vancouver long-term facilities while a registry in Victoria specifically controls admissions to extended care hospitals. (It should be mentioned that the North Shore local Long-Term Care offices and other district offices arrange and list their own admissions to facilities within the limits of their jurisdiction or catchment area.) Con-sequently, extended care beds, for example, are not ne-cessarily coordinated with the existing regional system, thereby creating unnecessary duplication, inefficiency, and a hindrance in the continuum of care. Important as well is the fact that those elderly on waiting lists for long-term care or living in long-term care facilities, and who are now requiring extended care as a re-sult of declining health, will receive no preferential treat-ment in terms of placement in an extended care facility. In spite of the fact that individuals have been in the Long-Term Care system for several months, they will receive no prio-rities by the extended care division to facilitate an earlier placement in an extended care bed. Therefore, they must wait up to a year or more for an extended care bed in addition to the length of time since they first applied for long-term care. In the interim, the elder persons may be forced to transfer and await placement in an acute care bed or, at the worst, may remain for an undetermined period of time in a facility not licensed for their individual care level. 91 Again, if the focus of Long-Term Care is to foster the well-being and adjustment of the elderly, Extended Care could logically be placed under the mandate of the Long-Term Care program. (At the least, Long-Term Care could control Extended Care admissions or a cooperative arrangement be-tween the two divisions could be devised.) At this point in time, there appears to be a political or territorial struggle between the two divisions which is resistive to change. However, efforts should be made at integrating services in spite of the fact it may not seem popular or even possible. The above discussion suggests first the importance of providing psycho-social services as well as medical needs, but not at the expense of one or the other. Secondly, since services are determined by fiscal policy and reflect atti-tudes and priorities of those in leadership positions, there is an urgency to review the health care system and ensure that meagre resources are distributed to those areas of care that produce the greatest benefit at the least cost. Thirdly, it is important that transitions between Extended-Gare facilities and other institutions are coordinated to facilitate an efficient, organized and expedient transfer. An ideal fourth goal would be the construction of multi-level facilities in the future to prevent relocation of the elderly between institutions, and to accommodate couples who require differing levels of care. Generally, a realignment of the / 92 health care system and a more progressive philosophy of goals and attitudes in combination with competence and commitment are needed. As well, greater awareness by the public might also help influence and improve the current health care system. E. Social Supports and the Social Worker The prospect of placement and admission of an older person in a long-term care facility is a painful, over-whelming psychological experience for the individual and family members of each generation. Although family involvement should be encouraged from the time the elder person applies and continue for as long as the individual lives in the institution, the time of ad-mission and the adjustment period are particularly crucial. Dr. Butler, director of the National Institute on Aging in the United States, suggests that homes for the aged could very shrewdly develop more effective relationships with the family at the time of admission so that a great deal of grief, guilt, and discomfort could be dealt with and, hope-fully, dissipated (Butler, 1978«22). Ironically, the strength of family ties has usually been overlooked in spite of the fact that family involve-ment from the beginning of application and throughout relocation can help to mitigate adjustment difficulties for the staff of the facility as well as the residents 93 (Brody, 1977ill6). A recurring view among practitioners is the idea that residential facilities should regard the family, as well as the resident, as clients. All need to be helped and supported through the trauma of the reloca-tion process. Several suggestions have been proposed and adopted by some facilities to work with the elderly and their families! (1) facility staff should involve themselves with families before and after admission and provide opportunities for them to join orientation and discussion groups with others who placed their parents in the facility; (2) qualified pro-fessionals, including social workers, should conduct the admission process, giving equal attention to family and new residents; (3) as a result of the guilt and anxiety evident at admission, families must be reassured regularly that they have reached the correct decision in choosing facility care; (4) facility staff should provide opportunities for families to play an active role in caring for the patient if they wish (Butler, 1978). Basically, what is being suggested is a more integrated and encompassing approach to application and institutional services. For example, the application should be viewed as a plea for help. Time should be taken to understand the individual's problem while encouraging family involvement and discussion regarding possible alternatives to placement. 94 However, there is some question as to the degree or extent of responsibility that facilities should accept in terms of helpful involvement. If local Long-Term Care offices do not include counselling as a component of their mandate and hire few social work professionals, the faci-lities themselves should be held accountable for providing casework services. In addition, facilities are most likely to derive the greatest benefit from satisfactorily inte-grating the,individual into the communal group (in terms of staff time and efficiency, resident satisfaction and adjust-ment ). In spite of professional consensus which states that the ratio should be one social worker for every fifty to sixty beds (Brody, 1979J55), and that social workers are an integral part of quality care, the Long-Term Care Program in British Columbia has not reflected these views. Although it was not the intent of the program that every facility would be able to provide all necessary professional services within its staff complement, in larger facilities it has been possible to either hire social workers or purchase services. In- British Columbia, however, smaller facilities can hardly afford this luxury, while only a few large facilities under non-profit or government auspices have a full-time paid professional social worker on staff. One facility with which I am familiar is the Jewish home and hospital for the aged, Louis Brier. In this facility, the social worker is involved 95 with the resident and family from the point of application and throughout the relocation process. Prior to admission, the social worker organizes family orientation meetings for residents, families and other relatives. At these sessions, relatives are able to vent frustrations, guilt, anger, and the whole complex of emotions between parents and children, and between siblings and relatives. An additional focus of the monthly sessions familiarizes relatives to institutional life and better prepares them for a range of affective be-haviour or responses that may accompany the newly-admitted resident. The day the resident arrives at the facility, relatives are encouraged to help the relocatee unpack and generally get settled. In addition, staff invest time and energy to welcome newcomers, and generally encourage the participation and continued involvement of family members. Part of the rationale for this approach rests on the assumption that the importance of contact cannot be equated with the quality and significance of strong emotional rela-tionships. As Lowenthal and Havens(1968130) have aptly expressed 1 "The maintenance of closeness with another is the centre of existence up to the very end of life." Accordingly, no bureaucracy and no array of interventive services can totally substitute for someone who cares and on whom one; can depend. In spite of the fact that many institutionalized elderly do have close supportive relatives, a large I 96 percentage of elderly do not. The childless, single, divorced, and widowed are often over-represented in the institutional population. Of those who do have relatives, often these emotional ties are disrupted or weakened as a result of admission. For example, in his study of the institutionalized elderly, Townsend ( 1 9 6 2 * 3 6 9 ) noted a marked decrease of social contacts attributed to geographic distances or location of facilities from the original home or relatives* home; to their infirmities; to the shortage of facilities; and to the inflexibility and characteristics of the facility. This author also noted that a large number of people were never visited and others did not have as much as one visit per week. Of interest also was the finding that only one resident in five made friends with other resi-dents. Although physical geography and so forth may tend to weaken filial ties, a recent study by Smith and Bengston (1979) questions the view that elderly persons in institu-tions are isolated from their families. Briefly, they found the opposite. Over half of the resident-family relationships examined experienced "renewed and strengthened closeness and a continuation of family closeness" (p. 444). The most common reasons given for these results were "the alleviation of pre-admission strains on the family- caused by the multiple and acute needs of the parent" (p. 444). The authors felt the positive family consequence may have implications for 97 policy and practice. In view of the findings, they re-commended that counselling of families following institu-tionalization and the general incorporation of family members with the services provided for residents. Although it would take relatively little additional money or staff to attend to the needs of residents' fami-lies, the apparent lack of social workers in facility staffing exists in the method of f u n d i n g , particularly for proprietary facilities. Present facility payment practices do not provide a financial incentive to hire social workers or other treatment oriented professionals since to do so would reduce their income or profit. Furthermore, the Adult Care Regulations permit the absence of such personnel. Also of major importance is the present scheme of fee for levels of care. Under the present system, it has become financially more profitable to the proprietary facility owner to have residents deteriorate to higher levels rather than to promote adjustment and optimal functioning. Obviously, it is-imperative that the financial arrangements and payment procedures to proprietary facilities should be changed. Facilities should receive fiscal reimbursement for those elderly who experience an increase in their level of func-tioning. As well, staffing guidelines should be changed to promote the hiring of psycho-social professionals and para-professionals as integral components for providing a better quality of life for elders spending their last years in an institution. 98 Paradoxically, these vital services: activity and recreational directors, chaplaincy personnel, social workers, and so forth, who are most important to the well-being of residents, are the ones least recognized by the government and the medical model. At the same time, institutions are recognizing the value of providing more opportunity for interaction and contacts with families and the community at large. Louis Brier, for example, has arranged regular visits from school . children, rabbis, ladies auxiliaries, volunteers, enter-tainers, and other interest groups. Other facilities are also leading the way in providing a stimulating and en-riching social environment. For example, an Italian old age home in Toronto, Villa Colombo,has rented space to a nursery school in order to benefit both the old and the young. As well, the children and the elderly share meals and other events together. Other facilities, like the Priory in Victoria, Penticton and District's Retirement Complex, Baycrest and Maimonides in the east, also promote community interaction and involvement for their residents. As well, all of these homes ensure that residents participate in activities outside the institution. In the last several years, there is a growing interest in facilities to provide a mix of services that include not only the maintenance of functioning, but also restorative, rehabilitative, and social services to promote the well-being 99 and life satisfaction of the institutionalized. Paralle-ling this trend, the community is in need of services that some institutions are in a position to provide. The role and function of the facility is subtly expanding, changing, and reaching out to the community. Most professionals have approved of this blending between community and institution". A hopeful consequence of the inclusion of family and interest groups in institutional life would be the regula-tion of services offered and the general improvement in the quality of life. As one authority optimistically writes (Shanas and Sussman, 1973)» In some circumstances, by acting collectively for non-compliance or in proposing alternative methods of behavior, using techniques similar to those employed by bureaucracies, families can actively influence organizations and institutions to change their policies and practices. IMPLICATIONS AND RECOMMENDATIONS A. Policy Some specific policy recommendations flow naturally from the preceding discussion. First of all, a more com-prehensive assessment must be completed to include the psycho-social aspects of the individual. Instead of focusing on the medical and problem areas of the individual, the assessment should also encompass strengths, areas and concerns that are important to the individual. A more indi-vidualized and tailor-made assessment may prove useful for 100 the care providers and elder person once admitted to the institution. Secondly, a multi-discipline approach to assessment and evaluation as originally conceived by Long-Term Care planners would also result in a more accurate and realistic care plan to match the individual with an appropriate environment as well as prevent premature institutionaliza-tion. Thirdly, social casework services are necessary in assisting individuals and their extended families to cope with ensuing stress and disruption related to institutional placement. Larger facilities should include social workers and other therapeutic or rehabilitation disciplines as an integral part of their regular staff complement. Smaller facilities could share professional casework and rehabili-tation services between them. Fourthly, adequate and reasonable notice of a bed vacancy should be relayed to the prospective resident and their sponsors in order to ensure that they have the opportunity for a pre-placement facility visit and that arrangements for transfer can be efficiently organized in an unhurried manner. Unfortunately, even if these recommendations were im-plemented, many of the difficulties inherent in the health care system concerning relocation and placement would remain 101 A revamping or restructuring of Long-Term Care and the health system is essential if a more coordinated, continuous and effective approach to relocation is to be realized. The present practice for placing patients and applicants in care facilities would be more effective and humane if planners would implement the development of a network of multi-level care facilities. Changes in residents' physical or emotional needs would then prevent a transfer from one facility to another more or less skilled nursing unit or facility. The development and expansion of multi-level care facilities would result in an improved continuum of care. Although some trauma invariably results in intra-institu-tional moves, it would not be as great as the disruption and stress resulting from transfers between institutions. Furthermore, there is a striking and obvious need for acute hospitals to provide additional beds and long-stay units for those elderly awaiting placement for institutional care. As well, long-stay units should be equipped and staffed with recreational and rehabilitative personnel to facilitate residual functioning, "capitalize on existing strength and replace psycho-social supplies" (Brody, 1975*474). A similar suggestion for increasing the existing care levels of residential facilities and nursing homes would also help counteract the experience of relocation and living in an institution. 102 Most importantly, a coordinated, multi-discipline approach to create more humane transfer procedures be-tween the long-term care facility and other institutions would also facilitate the preceding objectives. Innovative and cost effective forms for providing long-term care services must be a primary focus of concern. Day-care, day hospitals and in-patient assessment units are a few of the more recent arrangements that could also be included as part of the multi-level facility concept to help provide easy access or linkages between the community and institutionalized elderly. In this way, more appropriate planning and the prevention of premature or unnecessary placement can be actualized and achieved. Multi-service geriatric centres and/or facilitator programs are needed to provide ongoing and stable contacts to help coordinate and organize geriatric services, to provide a wide range of outreach services, and to reduce the dichotomy and fragmented approaches between institu-tional care and community home care services. B, Practice Experience in relocating the elderly throughout the process or stages of relocation, as previously outlined in this paper, indicates the excessive stress and demands that this stage of life holds for not only the elder person, but also for their families and other supports including 103 care providers in residential facilities and the community. While it is recognized that relocation stress can escalate and often prove detrimental for older persons, it is also important to recognize that this population is not homogeneous and that many elders successfully survive and may benefit from facility care. However, for those who are seriously ill, debilitated mentally and physically, and have few personal resources, often institutionalization is the appropriate and only available alternative. Of importance for social workers and health pro-fessionals is the acceptance of the elder person as a unique person with individual characteristics, assets, values, histories and expectations. Similarly, misconceptions, stereotypes and negative attitudes toward the aged, which conceive that work with the elderly is not challenging, interesting and worthwhile, is not founded on reality and does not reflect our current knowledge and experience. Assumptions of the Long-Term Care program and health pro-fessionals must include the acceptance that the elderly, like younger people, have the right to live the balance of their lives with dignity and maximum well-being. Moreover, the elderly have the potential for growth and change, and our institutional settings and health care system in general must provide not only the medical aspects of care, but also the provision of psycho-social components of care. 104 In view of the fact that relocation and increasing institutionalization is a growing concern, those involved with the care and planning for this population must have an understanding of'not'only aging and the relocation process, but must also be in touch with their own aging and how these attitudes may influence proposed priorities, program development and practice. A "whole" person concept within the context of the family, community and society must be considered and empha-sized from the point of initial application for service and, particularly, throughout the crucial first months after institutional admission. Careful consideration of the appli-cant, his social networks and supports may help identify issues and concerns necessary for adequate assessment, evalua-tion and adjustment to institutional living. As illustrated in the early case study cited of a multi-generation family, it is important for the health worker to be alert or aware of the complexity of emotions, interactions and processes that are interwoven and may occur at each stage of the move. An awareness and sensitivity of intergenera-tional family dynamics, and an ability to identify resources, strengths and liabilities of both clients (the individual and family) will enable social workers and other professionals to contend with the ensuing stress that accompanies relocation. While a personal bias towards a systems approach for working with the elderly has been advocated and found useful, 105 selective use of other interventions, such as pre- and post-orientation programs, individual and group therapy, and other innovative approaches can provide a viable alternative or supplement throughout the initial, middle and final phases of relocation. As well, opportunities for participation and choice, the continuation of family and community involvement, adequate preparation, the preservation and respect for the individual's uniqueness, dignity and rights, are some of the factors found which help mitigate relocation stress. Most people fight for their rights, but the elderly usually do not do so. Too often, they are excluded from decision-making regarding their lives. Instead of saying to the elderly, "Trust us, we know what is good for you," we should be asking their assistance and direction in planning for their future. 106 BIBLIOGRAPHY Aldrich, O.K. 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Last Home for the Aged. Washington, Joseey-Bass, 1976. Townsend, P. The Last Refuge* A Survey of Residential Institutions and Homes for the Aged m England and Wales. London* Routledge and Kegan Paul, 1962. Townsend, P. "The Effects of Family Structure on the Likeli-hood of Admission to an Institution in Old Age* The Application of a General Theory." In Social Structure and the Family, Ethel Shanas and Gordon, F. ftreeb . (eds.).—Englewood Cliffs, N.J. * Prentice Hall, 1965. Turner, B., Tobin, S. and Lieberman, M.A. "Personality Traits as Predictors of Institutional Adaptation Among the Aged." Journal of Gerontology. 1972, 22» 61-68. White, R. "Strategies of Adaptations An Attempt at Syste-matic Disruption." In Coping and Adaptation, C. Coelho, D. Hamburg and J. Adams (eds.).New York* Basic Books, 1974, 47-68. Vfiiiiams T.F.. Hill. J.G., Fairbank, M.E. and Knox, K.G. "Xpro^riate Placement of the Chronically 111 and Aged* A Successful Approach to Evaluation." Journal of the American Medical Association, 1973, 226. 133^-133^• Wittels, I. and Botwenick, J. "Survival in Relocation.'" jnnrnai of Gerontology, 1974, 2£, 440-443. 114 York, J.L. and Calsyn, R.J. "Family Environment in Nursing Homes." Gerontologist. 1977, 11, 500-505. Zweig, J. and Csank, J. "Effects of Relocation on Chroni-cally 111 Geriatric Patients of a Medical Unit: Mortality Rates." Journal of Geriatrics Society. 1975• Zweig, J.P. and Csank, M.A. "Mortality Fluctuations Among Chronically 111 Medical Geriatric Patients as an Indicator of Stress Before and After Relocation." Journal of the American Geriatrics Society, 1976, 24(6), 264-277. * * * * * * * Fig. 2 City and Suburbs , 1 9 8 1 A g e Composi t ion (By Five Y e a r A g e Groups) CITY 5 o f e o f $ $ | l n April 1982, a Quarterly Review article reported 31 that the number of residents in the city increased | about one percent between 1976 and 1981, while the j lumber of households increased by over eight percent. | n the October issue, another article described changes ,n the density and spatial distribution of the city's oopulation. This article examines recently obtained lata from the 1981 Census to describe and discuss ignificant changes in the age composition of the city's rapulation. The Population Grows Older While individuals grow older each year, a popula'-l ion can become younger i f the number of younger people increases relative to the number of older people. Io many countries of the world however, and particu-arly in their larger cities, populations are growing older is a result of declining fertility rates and longer life pans. This is the case in Vancouver and the surround-ng metropolitan area, as well as throughout Canada. A convenient way of comparing the age of two jopulations, or a population's age at two points in time, s to examine median age. I f all the people in any large gathering were lined up from the youngest to the eldest, ig. 1 C h a n g e s in M e d i a n A g e A G E -20 4 3 2 1 0 1 2 3 4 5 M A L E S FEMALES PERCENT OF TOTAL P O P U L A T I O N the age of the person in the middle of the line-up would be the median age of the group. Vancouver has an older population than the other cities and municipalities of the metropolitan area, as shown in Figure 1. However, this age difference has declined in the last decade as median age. has increased throughout the metropolitan area. T h e median age of the city's population increased from 33.6 in 1971 to 34.3 in 1981. T h e median age of the suburban population increased more rapidly with the result that a six-year difference in median age has shrunk to a three-year difference. 35 -4 30 < 25 4 CITY C M A S U B U R B S 1961 — 1971 • 1981 A g e Composi t ion Differences T h e age composition of a population refers to the distribution of people among various age groups. Figure 2 shows the age composition of the city and surrounding suburban area. There are significant dif-ferences. T h e suburbs have a much greater proportion of children than the city does. About 30 percent of the suburban population is under 20 years of age as com-pared to 21 percent of the city population. T h e baby-boom generation, or those people in the 20 to 34 age group, is about 25 percent of the suburban population and about 30 percent of the city population. Both the city and suburbs have about 34 percent of their popula-tion between 35 and 64 years of age. The city has ' significantly more-people aged 65 years and over, about 15 percent of its total population compared to 10 per-cent in the suburbs. Q U A R T E R L Y R E V I E W J A N U A R Y / 8 3 


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