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In current healthcare in Japan, hospitalized patients have more serious conditions and hospital stays are becoming shorter. Older adults with health problems who cannot live independently at home usually decide to relocate to a recovery phase rehabilitation ward. For older adults relocation to a recovery phase rehabilitation ward is a life event that requires adaptation to new living circumstances.
The purpose of this study was to develop an assessment sheet for use during relocation to a recovery phase rehabilitation ward in Japan, based on a conceptual model that views relocation from the perspective of older adults (Komatsu, Hamahata, & Magilvy, 2007).
Methods:
A Relocation Assessment Sheet (Assessment Sheet) was developed with reference to this model and included questions on constipation and insomnia, which readily appear after relocation, especially among Japanese older patients. Five of the 43 questions on the Assessment Sheet were on background and personal factors. The other 38 questions were set up as a scale to understand whether or not an older adult had adapted during relocation. This scale consisted of 10 subscales. The subscales and number of questions were Relocation-Related Factors, such as intention to relocate, three questions; Physical Environmental Factors, such as constipation, four questions; Social Environmental Factors, such as conversations with others, five questions; Cognitive Appraisal, such as statements on life in the hospital, three questions; Adaptive Tasks such as worsening of disease state, five questions; Coping Skills, such as asking for help from others, five questions; Tasks for Life Integration, such as anxiety toward the future, three questions; Resolution of Unrecognized Problems, such as loss of appetite or troubles with others, three questions; Support of staff and other persons depended on, four questions; and Outcome of Relocation, such as becoming accustomed to the hospital, three questions. Nurses responded to the questions in about the second week from the date of relocation of the older adult.
The subjects for analysis were 336 people for whom there was no missing data among the 371 Assessment Sheets. In the analysis, Cronbach’s alpha coefficient was calculated for the 38 questions that affect adaptation. In addition, using descriptive statistics, the characteristics of the older adults who had relocated to the recovery phase rehabilitation wards were clarified.
This study was approved by the research ethics committee of the participating university. For the consent of study participants, first approval was obtained from the manager of each hospital and then the study was explained to the nurses, and their consent was obtained. Finally, the study was explained in writing to the older adults, their families, and nurses, and their consent was obtained. No direct burden was placed on the older adults from this study. Personal information was protected in the implementation of the study, and privacy was ensured.
Results:
Thirty-eight questions on the Assessment Sheet used in this study constituted a scale to understand whether or not the older adult had adapted at the time of relocation. This scale consists of 10 subscales corresponding to items in the conceptual model. With regard to the reliability of the scale, the overall Cronbach’s alpha coefficient was 0.87. The coefficients for the 10 subscales were 0.42, 0.58, 0.72, 0.70, 0.62, 0.65, 0.79, 0.80, 0.50 and 0.82, respectively.
The mean age of the older adults who had relocated was 81.2±6.4 years, and many were women (67.3%). About half of the subjects had dementia (46.5%), which was mild (27.4%), moderate (14.6%), or severe (4.5%). Among Relocation-Related Factors, A large number were the first relocation to a recovery phase rehabilitation ward (85.1%). Nurses made referrals and explained the hospital before relocation (64.3%), and guided subjects around the hospital after relocation (92.8%).
Physical Environmental Factors included that some of the older adults were independent at the time of relocation (32.7%), and some of them also had language impairments (23.5%). After relocation, constipation (48.2%) and depression (18.8%) appeared in some patients.
Social Environmental Factors included that a little under half of the older adults brought personal items, placing familiar items in their rooms (36.0%) and bringing treasured items with them when they relocated to the hospital (13.7%). However, the rate of participation in recreation and other events held in the hospital was high (46.2%), and many of the older adults communicated with others, having conversations with nurses (65.2%) and other patients (50.0%).
With regard to the older adults’ Cognitive Appraisal of the recovery phase rehabilitation ward , some had not accepted to be hospitalized, saying “I have nowhere else to go,” (2.7%), and “I don’t like it here” (6.0%). Nurses felt that some of the elderly were just “putting up with life in the hospital” (25.9%).On the Adaptive Tasks subscale, complaints of “I want to go home” (22.6%) and “I don't feel well” (14.3%), and worsening disease state (4.8%) were seen in some of the older adults. Older adults who caused trouble with other patients were also seen (5.1%). Nurses also responded that providing care for some of the older adults was difficult (25.0%). These things show that older adults present different kinds of adaptation issues immediately after relocating to a recovery phase rehabilitation ward .In Coping Skills, the older adults often used problem-focused coping for adaptation issues, such as “seeking help from the nurse” (60.4%), “expressing one’s wishes” (58.0%), and “seeking help from other patients” (14.2%). Emotion-focused coping of “getting angry, crying, becoming agitated” was also used (10.7%).
Under Tasks for Life Integration there were older adults who expressed worries or anxiety (12.5%) and made negative statements about themselves (9.2%). Under Support, the persons providing support for the older adults were nurses (38.1%) and family members (48.8%). Resolution of Unrecognized Problems included nurses resolving physical issues such as constipation and loss of appetite that were not recognized by the older adults themselves (35.4%). Similarly, nurses resolved mental issues such as a gloomy countenance or not smiling (21.5%) and social issues such as trouble with other patients and dissatisfaction with the hospital (14.3%).
Conclusion:
The older adults who were the subjects of this study had a high mean age, and many had dementia. For many it was also their first time to relocate to a recovery phase rehabilitation ward and thus for these older adults relocation was a large environmental change. In addition, the level of independence in daily life was low. Older adults with speech disorders were also seen, and it was probably difficult for them to control their environment themselves after the relocation. For many of these older adults the nurse had made a referral and explained the ward before relocation and guided them around the ward at the time of relocation. This is thought to have had an effect in terms of adaptation to the recovery phase rehabilitation ward by the older adults.
Constipation and depressive symptoms appeared in some subjects after the relocation, and attention should be paid to these symptoms as signs of maladaptation in older adults. In the responses to questions in the Cognitive Appraisal subsection, language and behavior indicating resignation with regard to relocation and non-acceptance of life in the hospital were seen. Focusing on words showing such cognition in older adults and understanding the feelings of the individual is thought to be important. Under Adaptive Tasks in hospital life, worsening of disease or worsening of physical symptoms, such as complaining “I don't feel well,” was seen. Nurses need to focus on these physical symptoms and deal with them through early interventions.
The Coping Skills of the older adults were not limited to emotion-focused coping only. Many of the older adults used problem-focused coping. In cases when coping skills were not seen, resolution of mental issues by the nurse on behalf of the individual was related to the individual’s adaptation. Nurses need to recognize anew that they are persons these older adults rely on, and fulfill the role of resolving issues on behalf of these older adults.
The Assessment Sheet used in this study has reliability as a tool that shows adaptation in older adults. It also showed the characteristics of relocating older adults, suggesting that it can be a useful tool in understanding relocating older adults.
This study was supported by 2012 Grant-in-Aid for Scientific Research(24593542) from the Ministry of Education, Science ,and Culture, Japan.