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DISCUSSION PAPER
Psychological transition into a residential care facility: older people’s experiences Julie M. Ellis Accepted for publication 16 January 2010
Correspondence to J.M. Ellis: email:
[email protected] Julie M. Ellis PhD Director of Research Aged Care Services Australia Group Pty Ltd, Central Park Residential Aged Care Facility, Melbourne, Victoria, Australia
E L L I S J . M . ( 2 0 1 0 ) Psychological transition into a residential care facility: older people’s experiences. Journal of Advanced Nursing 66(5), 1159–1168. doi: 10.1111/j.1365-2648.2010.05280.x
Abstract Title. Psychological transition into a residential care facility: older people’s experiences. Aim. The aim of this paper is to discuss the complexity of admission into a residential care facility from a psychological perspective for residents and their relatives and the resulting implications for nursing care. Background. Admission into a residential care facility can be a stressful time for older people, as well as for their relatives. Many relatives have requested continued, meaningful involvement in care in the home, and researchers have identified reasons why it is important to implement strategies for including relatives in care. Data sources. The background for the paper is published research from the year 2000 on relocation into nursing homes and psychological transitions. Discussion. The concepts of transition from the theory of Personal Constructs are used to make sense of challenges faced by residents and their relatives. The psychological transition is experienced in very different ways by both residents and their relatives, and nurses can make a difference to how this major transition is experienced. However, nurses require improved communication strategies (based on the concepts of transition) that will support residents and their relatives during the admission phase. Implications for nursing. Nurses in residential care facilities need to develop communication strategies that will have a positive impact on the psychological transition that occurs when an older person is admitted into care. Conclusion. Improving the psychological health of older people moving into care should be an important goal for all nurses in residential care facilities. Using the theory of personal constructs as a guide, nurses can intervene to make this psychological transition a more positive experience. Keywords: experiences, nursing, older people, psychological, residential care, transition
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Introduction The aim of this paper is to discuss the complexity of the transition into a residential care facility from a psychological perspective for the resident and their relatives, and implications and issues for nursing care. The concepts of transition, developed by Fisher (1999, 2000) from the theory of Personal Constructs by Kelly (1955, 1991), are used to make sense of the issues and challenges faced by both residents and their relatives when an older person is admitted to a residential care facility. Suggestions are made for how nurses can use this theoretical perspective to understand the psychological transitions experienced by both residents and their relatives, and for implementing strategies that will help residents and their relatives with alternative ways of interpreting the transition process.
Background Admission to a residential care facility is one of the most stressful events in the life of an older person and their family (Melrose 2004). This process, usually referred to as relocation, has been well-researched, and several themes describing relocation have been identified. Cheek and Ballantyne (2001) examined the issues faced by people searching for an aged care home for a relative and identified five major themes: ‘good fortune, wear and tear on the sponsor, dealing with the system, urgency, and adjusting’ (p. 221). Themes identified in the study by Davies (2005) were ‘making the best of it, making the move and making it better’ (p. 663). Similarly, the themes identified by Lundh et al. (2000) were: ‘making the decision, making the move, adjusting to the move and reorientation’ (p. 1180). Hodgson et al. (2004) found that the most stressful time for a resident is the first 4 weeks after admission to a home, and during this time the older person is most likely to feel abandoned and helpless (Kao et al. 2004). Deterioration of psychological status in the form of confusion and depression are strong indicators of stress in this situation (Hodgson et al. 2004). The focus of other recent literature in this field has been on need for a meaningful role for and involvement of relatives in the care of an older person who has been admitted into a residential care facility (Bauer & Nay 2003, Kao et al. 2004, Marquis et al. 2004, Pearson et al. 2004, Davies 2005, Cheek et al. 2006, Davies & Nolan 2006, Voutilainen et al. 2006, Grenade & Horner 2007). There are suggestions (Marquis et al. 2004, Voutilainen et al. 2006) that nurses are responsible for difficulties in interpersonal relationships that develop or fail to develop 1160
between themselves and residents, and more particularly with relatives. According to Voutilainen et al. (2006) and Marquis et al. (2004) this may even be manifest as poor nursing practice; however, this is refuted by Meyer et al. (2006, p. 28), who argue that ‘researchers often blame staff for poor practice, when what is needed is a better understanding of the nature of their work’. In this paper, I offer a theoretical understanding of the psychological transition and resulting issues and challenges that occur for older people and their relatives, and describe the implications for nursing staff when an admission into a residential care facility occurs.
Data sources The literature search for this paper was conducted through LibXplore using the Category search, then Health Sciences and Gerontology sections. This resulted in a search of 13 different databases: Amed (Ovid), CINAHL (EBSCO), Cochrane Library, EMBASE (Ovid), Expanded Academic ASAP (Gale), Family (Informit), Health & Society (Informit), Medline 1966 – (Ovid), Proquest Health, Proquest Social Science Journals, PsycINFO 1985 – (Ovid), Social Sciences Abstracts (CSA) and Sociological Abstracts (CSA). Keywords used were: relocation and admission with nursing homes and residential aged care facilities; relocation and admission with older people and residents, and psychological transition, personal construct theory and older people, personal construct theory and nursing were also used. I have an extensive personal collection of books, articles and conference papers on Personal Construct Theory, and this information was also searched for relevant information for the paper. The inclusion criteria for a source were its relevance to the main concepts of the paper: the relocation and admission of an older person into a residential care facility; psychological transitions relevant to older people; Personal Construct Theory and older people and Personal Construct Theory and nursing.
Discussion Psychological transition Transition is defined as ‘the action or process of passing or passage from one condition, action or place to another’ (Dictionary 2002, p. 3328). It has also been described as a person’s psychological reactions to demands placed upon them suddenly, such as during a natural disaster (Viney 1980). The term ‘transition psychology’ has evolved from
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work on bereavement, family crisis and depression and is used by psychologists working in the field of organization change management (Williams 1999a,b). Viney (1980) argues that it is normal for individuals to be in transition; it is not a pathological experience, but one that has potential for psychological growth. Models of transition describe how people respond to changes in their lives, either in their personal worlds or within their environment. For a change to be referred to as a transition, it must be of a large magnitude and refer to a major life event. These major changes require a person to develop alternative ways of seeing their world or an experience. As defined by Kelly (1955, 1991),this concept is referred to as reconstruing, and during a psychological transition extensive reconstruing of the person’s view of themselves and their world is required. A transition process takes much longer than most people realize (from 6 to 12 months or longer) and often takes place at a subconscious level, especially as it takes so long to move through. It involves at least two levels of adaptation – behavioural and cognitive reconstruing – and this reconstruing ‘enables us to make fundamental changes to how we see the world and respond creatively to our new reality, good or bad’ (Williams 1999b, p. 1). The least understood part of transitions is how the mind reconstructs itself and adapts to a new reality. Personal Construct Theory offers some useful key ideas with which to explain this aspect of the transition (Fisher 1999, 2000).
The theory of personal constructs and transition Personal Construct Theory (Kelly 1955, 1991) is an approach that identifies individuality of experiences, proposing that all individuals develop their own personal views of the world and what goes on in it. Consequently, there is an infinite number of ways of making sense of the same reality, event or experience. As each individual ‘places an interpretation on’ (Kelly 1991, p. 35) or ‘attaches meaning to’ (Landfield & Leitner 1980, p. 4) an event, experience or person, a set of relevant, personal constructs is produced. Therefore, a construct encompasses the meaning, definition or discrimination a person places on events, experiences or persons. It is important to note that constructs are not only names, concepts, attitudes or opinions; constructs have a function for the individual. They serve as tools to replicate events in a person’s imagination, and constitute their view of their world by continuous validation or invalidation (Kelly 1955, 1991). One aspect of the theory is the 5-phase experience cycle (see Figure 1) that describes the psychological processes a person goes through when making meaning in their world. The first phase is anticipation, which means that each person is constantly looking to the future for what is going to happen. This could be short-term or long-term anticipation and may be at the unconscious level, as emotion or affect. These anticipations could also be at the ‘gut’ level of fear and excitement (Kelly 1955, 1991).
Commitment or involvement in event, experience or person Anticipation of event, experience or person Encounter with the event, experience or person
Constructive revision of anticipations of event experience or person
Confirmation or validation of anticipations of event experience or person
Disconfirmation or invalidation of anticipations of event experience or person
Figure 1 The experience cycle. 2010 The Author. Journal compilation 2010 Blackwell Publishing Ltd
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The next phase is one of commitment or involvement, where a person makes a decision or choice to be involved in a new event or experience. Sometimes a person cannot make a decision, and sometimes decisions are imposed on them by circumstances (Kelly 1955, 1991). In this case, the event or experience happens and the person will be making every effort to make sense of it. At this time, if there is discrepancy between what the person anticipated would happen and what actually happens, then anticipations are invalidated. Ideally, this should lead to a search for more information and a change or revision in the person’s anticipations. If events occur as the person expected, then the anticipations are validated. Whatever is the outcome, the person will have changed in some way because of that experience (Kelly 1955, 1991). For short-term anticipations, the cycle happens very quickly. For other anticipations, the cycle can take longer. The role of anticipation in human life can be tentatively split into two questions: ‘What will be next?’ and ‘What will be later on?’. ‘What will be next?’ relates to the day-to-day questions faced by people, such as: ‘What is today going to be like? What will happen today? How will I feel today? Will everything go to plan today?’. ‘What will be later on?’ questions relate to the bigger questions of the future, such as ‘Have I made the right personal choice? and ‘How is this change going to affect my family and me?’.
Can I cope?
The process of transition Fisher (1999, 2000) has developed a personal transition process (see Figure 2) based on the Theory of Personal Constructs (Kelly 1955, 1991). His process is composed of nine stages (see Table 1) and four possible pathways, each leading to a different outcome. Several of his stages are elaborated from Kelly’s descriptions of constructs of transition (Kelly 1991, p. 359) and he has added several new stages. A person going through a transition will almost certainly go through the first stage of anxiety when they are aware than an event or experience lies outside their range of understanding or control, and they are unable to ‘adequately picture the future that lies ahead of them’ (Fisher 2000, p. 430). As explained by Kelly (1991, p. 366), ‘A person is confronted with a changing scene, but has no guide to carry him/her through the transition’. Many people experiencing a transition will also experience some happiness after the initial anxiety phase. This happiness occurs because the person becomes aware of a feeling of anticipation and relief that something is going to change and not continue as before. As explained by Fisher (1999, p. 2), ‘in this phase, people generally expect the best and anticipate a bright future’. After people move through these two phases, as can be seen in Figure 2, there are then four different pathways that can be
What impact will this have? How will it affect me?
At last something’s going to change!
Change? What change?
This is bigger than I thought!
Did I really do that
Anxiety
This can work and be good
Denial
Disillusionment I’m off!! ... this isn’t for me!
I can see myself in the future
Moving forward
Who am I?
Happiness
Gradual acceptance Fear
Threat
Guilt
Depression Hostility
I’ll make this work if it kills me!!
© 2000/3 J M Fisher. Free use for personal and organizational development, provided this notice is retained. Not to be sold or copied for general publication. A free resource from www.businessballs.com Permission has been granted from John M. Fisher to reproduce this figure.
Figure 2 The process of transition. 1162
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Table 1 The nine stages of transition by Fisher (1999, 2000) Anxiety The awareness that events lie outside the person’s range of understanding or control. Individuals are unable to adequately picture the future that lies ahead of them, because of this transition. They do not have adequate information to allow them to consider behaving in a different way in this new environment. They are unsure how to adequately construe acting in these new situations (Fisher 1999, 2000). From a PCT perspective, anxiety is neither good nor bad Happiness The awareness that a person’s viewpoint is recognized and shared by others. The impact of this is two-fold. At the basic level there is a feeling of relief that something is going to change and not continue as before. Whether the past is perceived positively or negatively, there is still a feeling of anticipation, and possibly excitement, at the prospect of improvement. On another level, there is the satisfaction of knowing that some of the person’s thoughts about the old system (how it used to be) were correct and that something is going to be done about it. In this phase, people generally expect the best and anticipate a bright future (Fisher 1999, 2000) Fear The awareness of an imminent incidental change in a person’s core behavioural system. People will need to act in a different manner and this will have an impact on both their self-perception and how others externally see them. However, in the main, they see little change in their normal interactions and believe they will be operating in much the same way, merely choosing a more appropriate, but new action Fisher 1999, 2000). We are fearful of things that we construe simply Threat The awareness of an imminent comprehensive change in one’s core behavioural structures. Here, people perceive that a major lifestyle change is about to happen, one that will radically alter their future choices and other peoples’ perception of them. They are unsure as to how they will be able to act/react in what is, potentially, a totally new and alien environment – one where the ‘old rules’ no longer apply and there are no ‘new rules’ established yet (Fisher 1999, 2000). The prospective change must be substantial Guilt Awareness of dislodgement of self from one’s core self-perception. Once the person begins exploring their self-perception, how they acted/ reacted in the past and looking at alternative interpretations they begin to re-define their sense of self. This, generally, involves identifying what are their core beliefs and how closely they have been to meeting them. Recognition of the inappropriateness of their previous actions and the implications for them as people can cause guilt as they realize the impact of their behaviour (Fisher 1999, 2000) Depression This phase is characterized by a general lack of motivation and confusion. Individuals are uncertain as to what the future holds and how they can fit into the future ‘world’. Their representations are inappropriate and the resultant undermining of their core sense of self leaves them adrift with no sense of identity and no clear vision of how to operate (Fisher 1999, 2000) Disillusionment The awareness that a person’s values, beliefs and goals are incompatible with those of the people around them. The pitfalls of this phase are that the person becomes unmotivated, unfocussed and increasingly dissatisfied and gradually withdraws – mentally and or physically (Fisher 1999, 2000) Hostility Continued effort to validate social predictions that have already proved to be a failure. The problem here is that the person continues to use processes that have repeatedly failed to achieve a successful outcome and are no longer part of the new processes or are surplus to the new way of working. The new processes are ignored at best and actively undermined at worst (Fisher 1999, 2000). Hostility involves the manipulation of events or people – who may become aware of what is going on and resent the behaviours’, even though they may not be able to do anything about it (Dalton & Dunnett 1990, p. 34) Denial This stage is defined by a lack of acceptance of any change and denies that there will be any impact on the individual. People keep acting as if the change has not happened, using old practices and processes and ignoring evidence or information contrary to their belief systems (Fisher 1999, 2000)
taken as they progress through the psychological transition. The first stage of the first of these pathways (see Figure 3) is fear. This can lead the person into denial, where they act as though the change has not happened, and where they are likely to remain (Fisher 1999, 2000). If the person moves through the fear stage, it will be followed by threat – the person is aware that a major change is about to happen, which they want to avoid – and guilt, the guilt of doing something that the person would
normally not consider doing (Dalton & Dunnett 1990). This can be followed by permanent disillusionment, or feelings of not fitting into the new world around them (Fisher 1999, 2000). This is the second pathway that can be selected (see Figure 4). If the person moves through the fear, threat and guilt stages, and avoids the two previous pathways, they are likely to become depressed, experiencing feelings of uncertainty about their future (Fisher 1999, 2000). From here there are
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two more pathways available. The person can either move into the pathway of permanent hostility (see Figure 5), where they will try to manipulate the situation for their own ends (Fisher 1999, 2000), or they can work through the depression into a gradual acceptance of the new situation and take a positive move forward to make the new situation or experience work for them (see Figure 6) (Fisher 1999, 2000). This last pathway is, of course, the best outcome. Kelly (1991) identified that the process of psychological transition is more difficult for some people than others. He stated that ‘some people seem to have much more difficulty than others in setting up adaptive solutions to their problems. Any person is likely to be able to make his transitions more easily in some areas and at some times than at others’ (Kelly 1991, p. 359). Happiness
Fear
When a person is admitted to residential care, they and their relatives need to go through what Neimeyer (2000, p. 6) calls ‘the meaning reconstruction in response to a loss’. He argues that some events ‘can profoundly invalidate the tacit, and taken for granted constructions that provide a foundation for the narrative of our lives, resulting in a shattering of our assumptive world’ (Neimeyer 2000, p. 6). This move to a residential care home may profoundly alter the older person’s anticipated world. How individuals cope with periods of transition depends on certain conditions: their level of anxiety and positive aspects of their lives, such as support from relevant others. Personal control over the experience will also influence how well a person copes with the transition (Viney 1980). People can only change if they themselves perceive that they have options that make sense to them. For example, ‘some people prefer to cope by reducing rather than increasing their awareness of what is going on’ (Viney 1980, p. 159).
Denial
Psychological transition for residents and their relatives Anxiety
Figure 3 The process of transition – pathway 1. Happiness
Fear Threat
Anxiety
Guilt
Disillusionment
Figure 4 The process of transition – pathway 2.
Happiness Fear Threat Guilt
Anxiety
Depression
Hostility
Figure 5 The process of transition – pathway 3. Moving forward
Happiness Fear
Gradual acceptance
Threat Anxiety
Guilt Depression
Figure 6 The process of transition – pathway 4. 1164
The Theory of Personal Constructs (Kelly 1955, 1991) and the process of transition (Fisher 1999, 2000) can be used to make sense of the complex relationships that occur for those involved when an older person is admitted into a residential care facility. In this situation, they and their relatives are required to adapt to a new social context, one with which they may not have any previous experience except possibly from the negative views of residential care facilities portrayed by the media. In attempting to make sense of the new situation, residents will be asking themselves ‘What will be next?’, and ‘What will be later on?’ questions such as ‘Will my daughter come and visit me today?’, ‘Will the nice nurse be working today?’ and ‘What is going to happen to me next? Why am I living at this place?’. At the same time the relatives will also be asking themselves the ‘What will be next?’ and ‘What will be later on questions?’, such as ‘How will my mother be today? Which nurses will be working today? (I hope it is the nice one)’ and ‘Will this home ever understand my mother? or ‘How is this going to end for my mother?’. As residents and their relatives start on this psychological transition journey, they will be filled with anxiety about a future that they may not be able to comprehend. For some relatives, there may be a brief moment of happiness as they are aware that something is going to change, and previous concerns are going to be resolved. For residents who are pleased about relocation into residential care, there could also be a feeling of happiness associated with receiving care and with opportunities to develop new social supports.
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The next stage for both resident and relative is the feeling of fear – awareness that the relocation may have a bigger impact than they had previously considered. They fear that they may have to behave differently in their new environment. For many older people, living in a communal environment is a new experience and they do not know how it will affect them. This may result in unrealistic expectations of relatives and in wanting to do things as they did when they were living in their own homes. Fear may also lead to anger and acting out in a hostile manner to those around them. This can occur because they are aware that their constructions of self are being invalidated by nurses who are caring for them. This fear can also lead to feelings of threat that there are major life changes happening, and they begin to act in a way that is anathema to them. This is particularly relevant for relatives and can be followed by guilt about the things they may have done or not done concerning their relative now in care. They may have thought of themselves as people who would always care for their relatives at home and not abandon them to care. Disillusionment occurs for relatives who cannot accommodate an older, sick person into their values and belief system and so admit the relative in care. For residents, if disillusionment occurs it may stem from feeling that their personal goals are incompatible with living in the residential care home. These residents (and their relatives) are likely to be those who cannot see the benefits of the new environment, and complain endlessly about the care and the environment. However, for others the threat and guilt are followed by depression as they are unsure how they can fit into this new world and they have no answer to the question ‘What does my future now mean?’. Residents may also feel that they have lost themselves and have no clear way of operating, and so they lose motivation to live. As they move through this transition process, residents and relatives will be able to accept changing circumstances and develop ways of making it work for them. Others will continue to remain negative about circumstances to which they cannot adapt, and will remain hostile to those around them. This can then be particularly difficult for the nurses who are providing care, as these residents and their relatives will show open hostility to those around them.
Implications for nurses and nursing care From a Personal Construct Theory perspective, each nurse has their own construction of older people and caring for them, as well as of their self as a carer, which involves an elaborate network of personal constructs that have evolved
Psychological transition into aged care
from their unique experiences (Kelly 1955, 1991). Nurses’ caring identities, like all other constructs of themselves, continue to change as they live, work and develop psychologically. Nurses will be construing or making sense of a new resident and their relatives in ways they have learnt from previous experiences with residents and relatives, and from ways learnt about dealing with older people from their childhood, such as from their own grandparents (Ellis 1996). Nurses should have discussions about the new living environment with residents and relatives and identify the advantages as well as disadvantages. This can give residents and their relatives opportunities to talk through the transition stages and pathways available to them and to offer opportunities for both residents and relatives to look forward to each week. Nurses have an important role in validating or invalidating the views of an older person is admitted into a residential care home. These people may be ill or unwell to some degree, and are in a new environment; therefore, an important nursing role is to invalidate a resident’s negative anticipations of what is happening and going to happen to them. Many older people and their relatives will have negative anticipations or views of the new environment, developed through the media and from previous experiences. Nurses need to invalidate these negative anticipations and help residents and relatives to reconstrue the new environment by developing more positive anticipations of the new situation. Residents and relatives are consequently very vulnerable to the nurses’ attitudes, expectations and influences. If their negative anticipations are validated, residents and relatives are likely to experience a wide range of stressful emotions. However, nurses are in a position to invalidate these negative anticipations and influence the person a change in their anticipations into more appropriate perceptions. The following fictionalized account is an example of how a nurse’s invalidation of negative anticipations can make a difference. Mrs D. was very anxious about her admission and was fearful of how she was going to be able to survive in an environment where so many older people were living. She still denied the serious disability that forced her to be admitted to a home and became quite hostile towards staff. She was confined to a wheelchair and was a smoker. The nurses decided that she was only to be taken outside once each day to have her cigarette, which increased her hostility. A new charge nurse took over the unit and took on the challenge of decreasing this woman’s hostility towards the nurses. This nurse spent time with Mrs D. every day, encouraged her to do as much for herself as possible, and discussed the history of her disability and how she had managed at home. She also took her into the garden several times a day for a cigarette. Slowly,
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Mrs D. admitted that she had not been managing well at home and required the level of care provided by the nurses. At the same time, her hostility decreased and she made friends with several other residents who smoked, and together they would go into the garden twice a day for a smoke. Consequently, she developed more appropriate anticipations of herself, her disability and the care she needed. If residents’ and relatives’ anticipations or views of the new environment are positive, then validation of these anticipations is achieved by the way in which nurses perform their role, communicate with residents and relatives, and perform nursing functions. Another fictionalized account highlights how positive anticipations and validation can work. Mrs J. decided herself that it was time to move into care as she was physically frail and lived alone. Her sister had lived in the nursing home into which she moved, and so she already knew many of the staff and the routine in the nursing home. As she was known to the nurses, they welcomed her with ‘open arms’ and treated her as a ‘special resident’. They visited her frequently to say ‘hello’, and gave her extra food and flowers from the garden. Her positive anticipations were validated by the special attention.
Table 2 Strategies for promoting a healthy transition using Kelly’s (1955, 1991) Experience cycle from personal construct psychology and Fisher’s (1999, 2000) concepts of transition 1. Educate staff on the experience cycle and the concepts of transition 2. Educate staff on how each step and stage can be identified 3. Provide opportunities for staff to identify examples from their own lives of the experience cycle and the process of transition 4. Undertake role playing exercises using the triads of resident or relative, nurse and observer 5. Through the role playing exercises, the nurses identify ways in which the resident or relative is anticipating or construing their new situation (nine stages and four pathways) 6. Through the role playing exercises, the nurses develop supportive communication to help the resident or relative to disconfirm their current anticipations and to help them to re-construe their new situation 7. Encourage staff to implement strategies to support the relatives and staff during the most difficult first 4 weeks (validation of positive constructions) 8. Implement daily discussions of new residents at the handover, encouraging staff to discuss how they think the new relative is feeling (what stage they are at) and to give examples of why they have drawn this conclusion 9. Support staff in having confidence to discuss the new living environment with the resident and relatives 10. Ensure that all communication and behaviour towards residents, relatives and other staff is positive, so that a positive environment is reinforced to both residents and relatives
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This psychological theory and the process of transition is a useful framework for developing and implementing supportive communication by nurses caring for new residents and their relatives during the relocation into residential care and in on-going care. This could be achieved through use of an experiential learning programme using role playing activities founded on: • Basic understanding of the theory, particularly the experience cycle and the process of transition. • Identification of which pathways the older person and relatives might be taking, as discernible through verbal and non-verbal communication. • Use of appropriate language to give opportunities for residents or relatives to progress through the stages of the transition towards a gradual acceptance and moving forward position (Table 2). The experiential learning programme, based on role playing with nurses working in groups of three, would consist of the roles of resident or relative, nurse and consultant observer. The aim of the exercise would be for each triad to develop and formalize identification of each of the nine stages, exchange of dialogue and development of supportive communication strategies. A role would be written for the resident and relative that reflects each of the nine transition stages and resulting pathways. The nurse’s role would also be written to reflect what they have observed about the resident. The consultant’s role is to take notes, observe and make suggestions for supportive communication that the nurse will use when communicating with the resident or relative. A role for a resident (Mrs F.) could be as follows: You were admitted to the home yesterday and you are feeling very anxious and frightened about everything that is happening around you. You are walking up and down the unit. You see the nurse coming towards you and ask her several questions.
On the card provided, you have been given asked to say: What should I be doing now? Is there somewhere I should be at this time?
The role for the nurse would be: You are working an evening shift and you know you will have a busy evening. You notice that the new resident, Mrs F. is walking up and down the corridor, r and you decide that she may be anxious about her new environment. You are aware that she does not have dementia.
On the card provided, you have been given the following information to say:
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What is already known about this topic • Admission into a residential care facility can be a stressful time for older people, as well as for their relatives. • Many relatives have requested continued, meaningful involvement in care in the home, and researchers have identified reasons why it is important to implement strategies for including relatives in care. • There have been suggestions in the literature that the nurses are responsible for difficulties in the interpersonal relationships that develop or fail to develop between themselves, new residents and their relatives.
What this paper adds • A strategy based on Personal Construct Theory and psychological transition that would benefit both new residents and their families. • A theoretical explanation of the psychological challenges faced by older people and their relatives when a person is admitted into care. • An outline of an educational programme that can be used by nurses to develop communication strategies to support residents and their relatives during the admission phase.
Implications for practice and/or policy • Nurses can learn to identify the psychological transition pathways experienced by new residents of a residential care facility and their relatives. • Nurses can assist both new residents and their relatives to adjust to the psychological transition by understanding and supporting them through the psychological transition by using supportive communication. • Further research is required to identify what difference nurses could make to the relocation process of residents by using this process and theory as a basis for assessment and care provision.
When did you come into this home? So, it’s only your second day – are you feeling a little lost? Are you feeling anxious (first stage of transition) about coming here
Psychological transition into aged care Are you sure she is in the first stage of transition? What are the manifestations of anxiety?
Through the experiential learning programme and role playing activities, nurses are able to compile a collection of strategies that they can use to identify the psychological stages being experienced by new residents and their relatives, and learn supportive communication messages they can use to help psychological transition.
Conclusion It is important for a person to understand the impact that a change will have on their own personal construct systems and for them to be able to work through implications for their self-perception. Any change no matter how small, has potential to have an impact on an individual and may generate conflict between existing values and beliefs and anticipated altered ones. One danger for the person occurs when they persist in operating a set of practices that have been constantly shown to fail (or result in an undesirable consequence) in the past and that do not help extend and elaborate their worldview. Another danger area is that of denial, when people maintain operating as they always have, denying that there is any change at all (Fisher 1999, 2000). Personal Construct Theory produces a psychological map of how people construe their social reality. Therefore, each resident, relative and nurse is free to construct their own uniquely different version of the reality of the caring environment, and each construction is real for that individual. The recurrent nature of events or situations – their replications and routineization – enables people to construe or give meaning to those events. Previous research conducted by the author produced images from nurses about older people, and demonstrated how nurses construe residents on the basis of previous and recurrent experiences with older people. If residents and relatives are given opportunity to understand the magnitude of the psychological transition that they are experiencing, then this can open up for them the opportunity to reconstruct new meanings about the new phase in their lives. When nurses, relatives and residents are able to mutually construct understandings of what it means for all of them when an older person is admitted into care, than the care will be enhanced and will be beneficial to all.
to live? Tell me a little about yourself?
Funding
The role for the observer is to make suggestions about supportive communication as follows:
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
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J.M. Ellis
Conflict of interest No conflict of interest has been declared by the author.
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