Relocation to a new environment: decisional control and the move to a nursing home.

Recent federal legislation has attempted to protect the autonomy and decision-making rights of long-term-care residents. The Omnibus Budget Reconciliation Act of 1987 mandated clearly written admissions documents, reductions in the use of both physical and chemical constraints, resident participation in the development of care plans, and evaluative data on how facilities enhance resident independence. The Omnibus Budget Reconciliation Act of 1990 legislated that Medicare- or Medicaid-eligible facilities address residents' rights regarding life-sustaining decisions and advance directives. There is no legislation, on the other hand, that promotes participation and autonomy in the decision to move to a nursing home - an event that may influence much of the following long-term-care experience. In fact, policies limiting the number of nursing home beds or prospective payment systems encouraging shorter hospital stays may work against decision making, limit the number of options, or curtail the period in which a decision can be made (Abramson, 1990; Coulton, 1990). Given these considerations, social workers involved in long-term-care planning need to be aware of the effect of nursing home decision making on acceptance of the home and its services once the admission has taken place. This awareness may be especially important, because some findings suggest that patients have less influence over discharge planning than family members do (Abramson, 1988; Townsend & Poulshock, 1986) and that approximately 50 percent of those admitted to nursing homes may not have taken part in the decision (Kane, Illiston, Kane, & Nyman, 1990; Reinardy, 1992). This article examines assessment data on newly admitted nursing home residents to determine associations between their participation in the decision to move and initial reactions to the home. Reactions are measured in the areas of satisfaction with services, participation in activities, and social interaction. Control over the decision and its influence on initial reactions to the new environment may set the tone for experiences of autonomy and well-being beyond the first weeks of admission. Studies in the relocation literature have found, for example, that preparation programs have had a favorable effect on measures such as health status and mortality (Hunt & Hunt, 1983; Pastalan & Bourestom, 1975). The move and initial adjustment to a nursing home involve a broad constellation of experiences some have called the "first month syndrome" (Tobin & Lieberman, 1976). Owning the experience by perceiving oneself in control of the decision and by focusing on desirable aspects of the move may provide strength in coping with the loss of the old home and the stress and challenges of the new environment. DECISION MAKING AND REACTION TO NURSING HOME ENVIRONMENT Studies of perceived control over the decision to relocate to a nursing home suggest that it has a positive effect on variables such as mortality, health, morale, life satisfaction, early discharge to the community, and overall adjustment (Chenitz, 1983; Coulton, Dunkle, Goode, & MacKintosh, 1982; Coulton, Dunkle, Haug, Chow, & Vielhaber, 1989; Farrari, 1963; Lieberman & Tobin, 1983; Pohl & Fuller, 1980; Reinardy, 1992; Rodin, 1986). Few studies have investigated the effect on the specific variables of satisfaction with services, social interaction, or participation in activities. In a prospective study of elderly patients discharged from a hospital, Coulton et al. (1989) found that patients who perceived more control over their discharge plans reported higher satisfaction with their posthospital setting 30 days after discharge. Perceived decisional control was measured by the degree to which patients felt they were actively able to make a choice about posthospital care. Harel and Noelker (1982) studied 125 nursing home residents over a two-year period. Their multivariate analysis suggests that perceived choice on entry has some effect on satisfaction with treatment as well as life satisfaction. …