Nursing Diagnosis: Application to Clinical Practice
11th Edition

Relocation Stress [Syndrome]
DEFINITION
Relocation Stress [Syndrome]: State in which a person experiences physiologic and/or psychological disturbances as a result of transfer from one environment to another.
Other terms found in the literature that describe relocation stress include admission stress, postrelocation crisis, relocation crisis, relocation shock, relocation trauma, transfer stress, transfer trauma, translocation syndrome, and transplantation shock.
DEFINING CHARACTERISTICS*
Major (80% to 100%)
Responds to transfer or relocation with
  • Loneliness
  • Apprehension
  • Depression
  • Anxiety
  • Anger
Increased confusion (older adult population)
Minor (50% to 79%)
  • Change in former eating habits
  • Change in former sleep patterns
  • Demonstration of dependency
  • Demonstration of insecurity
  • Demonstration of lack of trust
  • Vigilance
  • Weight change
  • Sad affect
  • Decrease in self-care activities
  • Decrease in leisure activities
  • Gastrointestinal disturbances
  • Increased verbalization of needs
  • Need for excessive reassurance
  • Restlessness
  • Withdrawal
  • Allergic symptoms
Unfavorable comparison of post-transfer to pretransfer staff
Verbalization of being concerned/upset about transfer
Verbalization of insecurity in new living situation
RELATED FACTORS
Pathophysiologic
Related to compromised ability to adapt to changes secondary to:
Decreased physical health status
  • Physical difficulties
Decreased psychosocial health status
  • Increased/perceived stress before relocation
  • Depression
  • Decreased self-esteem
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Situational (Personal, Environmental)
Related to moderate to high degree of environmental change in new environment secondary to:
Loss of privacy
Decreased control of individual care
Decrease and/or change in available caregivers
Decrease/increase in client-monitoring equipment
Increased noise/activities in post-transfer environment
Decreased privacy as a result of changes in lifestyle
Related to concurrent, recent, and past interpersonal losses secondary to:
Negative experiences dealing with earlier separation(s) (for adults as well as children)
Loss of social and familial ties
Abandonment
Perceived/actual rejection by caregivers
Anticipation of lengthy and/or permanent stay in new environment
Threat to financial security
Change in relationship with family members
Related to little or no preparation for the impending move
Lack of predictability in new environment
Little or no time between when the person is notified of an impending move and the actual move
Unrealistic expectations of individual/family members regarding facility and staff
Lack of decision making and control on behalf of the person who is moving
Maturational
School-Aged Children and Adolescents
Related to losses associated with moving secondary to:
Fear of rejection, loss of peer group or school-related problems
Decreased security in new adolescent peer group and school
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Focus Assessment Criteria
Subjective Data
Assess for Defining Characteristics
The relocated person complains of
  • Dissatisfaction with new environment
  • Problems adjusting
  • Feelings of insecurity
  • Anger toward people responsible for placement
  • Increased family conflicts
  • Loneliness
  • Loss of control
  • Anger at loss of control over own life
Changes in
  • Sleep patterns
  • Socialization
  • Orientation
  • Nutritional intake
  • Cognition
Assess for Related Factors
History of
One or more changes in environment in last 3 months
Multiple moves in last 5 years
Traumatic experiences after previous moves
Being in the same environment for more than 40 years
Risk factors
Moderate to severe confusion/disorientation
Perceived poor health
Lack of support/family/friends/staff
Low self-esteem
Functional deterioration
Involuntary move
Communication difficulties
Lack of continuity of care
Expression of dissatisfaction with life
Lack of preparation for move(s)
Lack of choices or input on the part of the relocating person
Multiple chronic illnesses
Lack of familiarity with nursing home before relocation
Nursing home location far from previous residence
Objective Data
Assess for Defining Characteristics
  • Change in weight
  • Increased medical visits
  • Sleep problems
  • Change in cognition
  • Change in eating patterns
  • Decline in self-care activities
For more information on Focus Assessment Criteria, visit http://connection.lww.com.
Goals
The person/family will:
  • Report adjustment to the new environment without physiologic and/or psychological disturbances.
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Indicators
  • Share in decision-making activities regarding the new environment.
  • Express concerns regarding the move to a new environment.
  • Verbalize one positive aspect of the relocation.
  • Establish new bonds in the new environment.
  • Become involved in activities in the new environment.
General Interventions
Encourage Each Family Member to Share Feelings About the Move
Provide privacy for each individual.
Encourage family members to share feelings with one another.
Discuss the possible and different effects of the move on each family member.
Inform parents regarding potential changes in children’s conduct with relocation, such as regression, withdrawal, acting-out, and changes with eating (breast/bottle-feeding).
Instruct parents to obtain all pertinent documents regarding children’s medical/dental history (eg, immunizations, communicable diseases, dental work).
Allow for some ritual(s) when leaving the old environment. Encourage reminiscing, which will bring closure for many family members.
Teach Parents Techniques to Assist Their Children with the Move
Remain positive about the move before, during, and after, accepting that the child may not be optimistic.
Explore various options with children on how to communicate with friends/families in previous environment. Children’s relationships with friends in the previous community are very important, especially for “peer reassurance” after relocation.
Keep regular routines in the new environment; establish them as soon as possible.
Acknowledge the difficulty of peer losses with the adolescent.
Join the organizations to which the child previously belonged (eg, Girl Scouts, sports).
Assist children to focus on similarities between old and new environments (eg, clubs, Scouts, church groups).
Plan a trip to school during a class and lunch period to reduce fear of unknown.
Allow children some choices regarding room arrangements, decorating, and the like.
Ask teacher or counselor at new school to introduce adolescent to a student who recently relocated to that school.
Allow children to mourn their losses as a result of the move.
Assess the Following Areas When Counseling a Relocated Adolescent: Perceptions About the Move; Concurrent Stressors; Usual and Present Coping Skills; and Family, Peers, and Community Support Groups.
Initiate Health Teaching and Referrals, as Indicated
Alert family to the possible need for counseling before, during, or after the move.
Furnish a written directory of relevant community organizations such as area churches, children’s groups, Parents Without Partners, senior citizens’ groups, and Welcome Wagon or other local new-neighbor groups.
Instruct the family about appropriate community services.
Consult school nurse regarding school programs for new students.
Rationales
  • Many researchers report that relocation stress is preventable (Lander et al., 1997). Therefore, eliminating and/or minimizing the causative, contributing, and risk factors can decrease the occurrence of relocation stress.
  • Assessing individuals before relocation is important to identify those most at risk.
  • Early relocation planning is paramount in ensuring a smooth transfer for all involved individuals.
  • Children need early notification, predictability, and decision-making opportunities when an upcoming relocation is planned.
  • Peer networks are important during adolescence because the relocated adolescent needs additional parental and peer reassurance.
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Footnote
*Harkulich, J., & Brugler, C. (1988). Nursing diagnosis—translocation syndrome: Expert validation study. Partial funding granted by the Peg Schlitz Fund, Delta Xi Chapter, Sigma Theta Tau International; Barnhouse, A. (1987). Development of the nursing diagnosis of translocation syndrome with critical care patients. Unpublished master’s thesis, Kent State University, Kent, OH.
RELATED TO CHANGES ASSOCIATED WITH HEALTH CARE FACILITY TRANSFERS OR ADMISSION TO LONG-TERM CARE FACILITY
Goals
The person will:
  • Make positive statements about acceptance of the new environment and reasons for leaving the previous environment.
  • Adjust to the new environment without physiologic and/or psychological disturbance.
  • Establish new bonds in the new environment.
  • Become involved in activities in the new environment.
Indicators
  • Participate in decision-making activities regarding the new environment.
  • Voice concerns regarding the move to a new environment.
  • Describe realistic expectations of the new environment.
General Interventions
Prevention is Key. Strategize How Best to Prevent Stress for Each Person Before Relocation
All staff members must be aware of and alert to the complex process of relocation for both the person and family before proactively decreasing stress factors (Maun, 1996; Morgan, 1996).
Assess for Factors that May Contribute to Relocation Stress (See Related Factors and Focus Assessment Criteria)
Reduce or Eliminate Causative and Contributing Factors
Environmental Differences Between Old and New Settings/Minimal Continuity of Care in New Environment
Design a program to prepare relocated residents and staff for the move, orienting them to the physical layout many times until they feel familiar with the new environment.
Provide visual presentations (through bulletin boards, posters, letters, and so forth) and first-hand accounts of new environment for those who cannot view the area before relocation.
Seek input from former staff regarding client and plan of care.
Initially maintain client on same activity level and diet through pretransfer and post-transfer units.
Transfer person to similar, proximal area when possible.
Wean any monitoring equipment gradually before transfer.
Transfer all personal items with the person, such as mobility aids, eyeglasses, hearing aids, dentures, prostheses, and belongings.
Transfer person during daytime hours.
Maintain similar heights of furnishings/beds.
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Clearly mark steps and other potential environmental hazards.
Maintain people in familiar groups at mealtimes and in living arrangements.
Promote a welcoming, warm, and clean receiving environment.
Allow time for discussions regarding living spaces in old and new environments.
Gradually decrease nursing attention before ICU transfer, when possible.
Involuntary Relocation/Lack of Control in Decision Making
Offer decision-making opportunities throughout relocation experience.
Promote person’s input regarding new environment when possible, such as use of decorations and arrangement of furniture.
Present transfer from a critical care unit as an indicator of improvement.
Inform hospitalized person of signs of daily progress.
Transfer client in an unhurried manner.
Establish mutual goals before relocation to nursing home.
Provide opportunities for questions/answers with relocation preparation.
Hold regular staff/resident meetings after relocation, encouraging new members to be involved with the facility’s rules and regulations (Wilson, 1997).
Include parents in the care of their hospitalized premature infant as much as possible.
Promote use of support systems both inside and outside the hospital for parents of hospitalized infants.
Recent or Concurrent Interpersonal Loss
Discuss adaptation to the relocation with family members.
Assess responses of all family members to the relocation.
Identify family members who may need additional help with adjustment.
Encourage family members to share their perceptions of relocation with one another.
Offer the person help in maintaining contact with significant others by telephone calls, letters, and visits with previous roommates when applicable.
Introduce person to nurse from post-transfer unit before transfer.
Accompany client to post-transfer unit.
Provide follow-up visit of nurse from pretransfer unit to person on post-transfer unit.
Encourage family members to visit person during and after relocation.
Minimize number of transfers in the health care facility.
Visit resident daily.
Promote formation of friendships in new environment.
Encourage family involvement in resident’s care.
Visit person in own home before nursing home placement.
Support the client’s efforts to adjust to the new environment.
Assist client to remember past relocations that were positive (Johnson & Hlava, 1994).
Provide gatherings for clients and staff experiencing closure of their facility (Craig, 1997).
Decreased Physical and/or Psychosocial State
Promote discussion of feelings regarding relocation.
Encourage use of problem-solving skills.
Offer potential solutions to problems when person cannot do so.
Promote sleep with use of previous bedtime routines, back rubs, white noise, music, warm milk, and minimization of noise in surrounding areas.
Encourage positive eating habits with use of favorite foods, a pleasant eating environment, and any appropriate supplements.
Orient the client fully to the new environment.
When possible, retain highly anxious person in pretransfer unit until anxiety decreases.
Provide for spiritual needs (eg, visit from clergy, hanging religious symbols in new location, transporting client to a religious ceremony).
Use cues such as signs and arrows for the relocated.
Assist person in learning to view the relocation more positively.
Teach/mobilize coping strategies.
Reassess relocation perceptions periodically.
Residents diagnosed with pneumonia have more effective outcomes when treated at the nursing home compared with those who were hospitalized (Fried et al., 1997).
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Reduce the Physiologic Effects of Relocation (Refer to Key Concepts)
Assess Before Relocation
  • Blood pressure, temperature
  • Signs of infection
  • Respiratory function
  • Level of discomfort
  • Orientation
Identify Person at High Risk for Selected Physiologic Responses
Musculoskeletal/neurologic deficits
Advanced age
Cardiovascular disorders
Changes in orientation
Cardiovascular complications (eg, ischemia, dysrhythmias)
Prevent or Reduce Confusion and Activity Intolerance
Promote Integration After Transfer into a Long-Term Care Nursing Facility
Allow as many choices as possible regarding physical surroundings and daily routines.
Encourage person or family to bring familiar objects from person’s home.
Orient to physical layout of environment.
Introduce relocated individuals to new staff and fellow residents.
Encourage interaction with other people in new facility.
Assist client to maintain previous interpersonal relationships.
Clearly state smoking rules and orient client to areas where smoking is permitted.
Promote the development or maintenance of a relationship with a confidante.
Reestablish normal routines, while initially increasing staffing and lighting, when a large number of long-term care residents are involved in a secondary relocation.
Assist nursing home residents to meet people from their previous geographic area.
Arrange frequent contacts by a volunteer or staff member with each newly admitted resident. Also, match a successfully relocated resident with the new resident to begin the networking process.
Initiate Health Teaching and Referrals, as Indicated
Prepare person for relocation.
  • Notify him or her as early as possible to increase predictability regarding eventual relocation.
  • Provide ongoing and structured teaching regarding:
    • Characteristics of new environment
    • Staff capabilities
    • Mechanisms for continuity of care
    • Rationale for relocation and less constant professional attention when applicable
    • Expectations of person in new environment
    • Any increasing stages of activity/independence
Include family in teaching.
Offer information about positive health habits and resources during illness.
Make appropriate professional referrals as needed, as well as suggesting a phone monitoring system such as “Lifeline.”
Refer relocated families to community agencies related to newcomers and to mental health agencies when at risk for relocation stress syndrome.
Assess the perceptions of parents of hospitalized infants regarding an upcoming transfer and their interest in related information.
Maintain at least daily communication with parents about their hospitalized infant (eg, condition, timing of transfer, mechanisms for continuity of care between the pre- and post-transfer nurseries) and their concerns.
Suggest that parents of hospitalized infants visit the nursery where their child will be transferred before the event.
Develop and use a mechanism for a thorough exchange of information between pre- and post-transfer nurseries.
Rationales
  • Open communication with older adults both before and after a move is necessary, assessing their experiences with change and adjustment, coping history and style, and decisional control.
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  • With the influx of people who have chronic mental illness into the community, it is important that their needs and problems be assessed accurately so interventions and services that ensure successful relocation and adjustment can be planned and implemented.
  • Before nursing home placement of a loved one, family members should be assessed regarding their perceptions of this decision. Areas of conflict and vulnerability can serve as the foci for family-centered nursing interventions.
  • Minor changes between intrainstitutional settings may be challenging for relocating people within the context of decreased behavioral competence and few remaining opportunities to exercise autonomy—the loss of any opportunity could be critical.
  • Wilson (1997) and Meacham and Brandriet (1997) found older adults made an effort to protect their significant others by hiding their feelings about relocation and attempting to maintain a sense of normalcy. Therefore, it is critical for new residents to develop trusting relationships with others to discuss the stressors of relocation.
  • Case management by way of telephone calls to residents or family members and prompt attention to resident problems after nursing home admission can help to prevent adjustment problems.
  • Parents of hospitalized infants frequently reported lack of information and communication with staff as sources of overall and relocation stress.
  • The stress of a negative transfer from an NICU to a community hospital can affect parent–infant bonding adversely or increase stress regarding parental roles (Flanagan et al., 1996).
  • Parents of preterm infants want to protect their child during hospitalization in addition to wanting to receive information about each new environment where their child will be transferred (McDonald Gibbins & Chapman, 1996).
  • Gatherings for reminiscence and closure between clients and staff can assist them to move forward emotionally during a psychiatric hospital closure and relocation (Craig, 1997).
  • Residents who were allowed choices regarding room location and favorite objects had an increased sense of control and less stress (Mitchell, 1999).
  • Parents of children facing transfer from the ICU to a general unit who were given a verbal explanation 1 to 2 h before the transfer had significantly less anxiety than parents who were informed immediately before the transfer (Miles, 1999).