Australian Occupational Therapy Journal (2013) 60, 445–453
doi: 10.1111/1440-1630.12038
Research Article
Relocating to retirement living: An occupational perspective on successful transitions Emily Walker and Beverley McNamara School of Occupational Therapy and Social Work, Centre for Research into Disability and Society, Curtin Health Innovation Research Institute, Curtin University, Perth, Western Australia, Australia
Background/aim: Older adults are increasingly relocating to alternative housing options, such as retirement villages. Relocations can be stressful and these environmental transitions can cause significant disruption to the personenvironment and occupational fit, thus influencing health, well-being and quality of life. There is a lack of literature from an occupational therapy perspective in relation to healthy older adults seeking to relocate. This study aimed to identify issues healthy older adults face when relocating to retirement living, what strategies they used during this process, how they maintained a sense of home, and the potential for occupational therapy involvement. Methods: Sixteen semi-structured, in-depth interviews were conducted with participants recruited from retirement living facilities across three stages of relocation; ‘Decision’, ‘Early Days’, and ‘Established’. A grounded theory approach was used to code and analyse the data. Results: Having control over the decisions surrounding relocation, being proactive rather than reactive and preparing sufficiently for the move all contributed to a positive post-location adjustment. Four main themes emerged from the narratives: timing of decision making, new beginnings, continuity, and strategies for change. Conclusions: This study contributes to literature surrounding how older adults occupy and make meaning of the spaces they call home and also enriches literature regarding environmental transitions. Relocation can be a disruptive process and occupational therapists are uniquely placed to facilitate healthy ageing throughout
Emily Walker BSc (OT) (Hons). Beverley McNamara PhD, BA (Hons), DipTeach; Professor. Correspondence: Professor Beverley McNamara, Director of Teaching and Learning, School of Occupational Therapy and Social Work, Centre for Research into Disability and Society, Curtin Health Innovation Research Institute, Curtin University, GPO Box U1987, Perth, WA 6845, Australia. Email: [email protected] Accepted for publication 8 February 2013. © 2013 Occupational Therapy Australia
this transition using preventative and community-based occupational therapy. KEY WORDS healthy ageing, preventative occupational therapy, relocation.
Introduction Australia’s population is ageing. By 2056, one quarter of the population is predicted to be aged 65 years or older (Australian Bureau of Statistics, 2008). This will have serious implications for the way ageing is viewed, as older adults are living longer with different expectations and needs than previous generations (Andrews, 2001). Consequently, there is a need for all levels of government and health care providers in Australia to take a proactive stance to encourage Active Ageing (living well and ageing healthily in later life) through preventative programs (Australian Local Government Association, 2004). These programs will help to mitigate potential growing costs associated with age-related chronic disease (Armstrong, Gillespie, Leeder, Rubin & Russell, 2007). It appears older Australian adults prefer to remain in their homes as they age (Stimson & McCrea, 2004). This is likely because the home is a place of increasing importance as one grows older (Grant, 2003). Transitions into retirement mean that more meaningful occupations – self-directed tasks that are engaged in on a day-to-day basis and over a lifetime – are completed in the home than previously and the distance travelled to engage in occupations and roles also decreases (Law et al., 1996; Oswald & Rowles, 2006, p. 132). Sentimental ties also develop over time to provide a living environment that feels familiar and safe (Aged & Community Services Australia, 2004). Despite this, evidence of a shift in desired housing options is already occurring. Increasing numbers of older Australians are choosing to relocate to retirement villages. Retirement villages are residential complexes designed for those aged 55 years or older that offer a range of health, leisure and supportive services
446 (Gardner, Browning & Kendig, 2005). Retirement villages usually promote an independent lifestyle and residents are responsible for their own needs in contrast to Residential Aged Care Facilities, which provide a far greater range of support. In Australia, the number of older adults moving to retirement villages has increased 37 percent since 1981 (Australian Bureau of Statistics, 2003). It may be argued that the increase is motivated by an increasing ageing population who are seeking alternative housing options. Reasons given include decreasing physical ability, increasing social isolation, home maintenance, and limited incomes (Stimson & McCrea, 2004). It is important to understand the relocation process as it can have a significant impact on identity, health and well-being. The relocation process occurs in three stages: (i) making the decision and separating from one’s previous life; (ii) the disorienting stage; and (iii) the adjustment, where control is developed and new meanings established (Schumacher, Jones & Meleis, 1999, p. 4). Relocation in older adulthood can be a stressful and confusing process (Knight & Buys, 2003). There are many decisions surrounding whether to move or stay and it can often be perplexing as to what the different options mean and whether the most suitable option will also be affordable. The transition can be particularly stressful if predated closely by the death of a spouse or declining physical ability (Armer, 1993). Continuity of an individual’s occupations and social relationships must translate to the new environment in order to support their health and well-being (Blair, 2000; Rossen & Knafl, 2007). It is important that older adults choose their initial relocation options carefully. Moving to a retirement village often includes a noteworthy financial investment. Considerable costs may occur should future relocations or modifications be necessary to optimise the environment to better suit their needs as they age (Seniors’ Housing Centre, 2011). Therefore, it is imperative that current and future housing needs are taken into consideration (Seniors’ Housing Centre, 2011). In order to do this, one must look at how factors such as the person, their environment and their occupations correlate to the new home in order to ensure optimal fit. According to the Person-Environment-Occupation Model (Law et al., 1996) the fit between these factors helps assist occupational performance. If older people maintain or increase the fit between these factors, then well-being is likely to improve (Schwartzman, Atler, Borg & Schwartzman, 2006) thereby facilitating healthy ageing across the transition.
Preventative occupational therapy and healthy life transitions Occupational therapists are theoretically well suited to offer positive health promotion outcomes as much of what defines healthy ageing aligns with occupational therapy philosophy (McIntyre & Atwal, 2005, p. 5). © 2013 Occupational Therapy Australia
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Healthy ageing is directly correlated with continued engagement in meaningful occupations (Pizzi & Smith, 2010, p. 466). The Well-Elderly study conducted in the United States of America demonstrated that by participating in preventative occupational therapy, participants were likely to have better health outcomes than those who engaged in non-therapy oriented social activities or who received no intervention (Clark et al., 1997). Another study investigated the potential for preventative occupational therapy during life transitions and proposed this as a growing area of practice (Schwartzman et al., 2006). As older adults are increasingly moving to retirement villages and since relocations are potentially stressful, occupational therapists are well placed to provide support to ensure optimal fit in the person-environment-occupation nexus. Previous studies have explored reasons behind older adults’ relocation to retirement villages or age-segregated communities (Bekhet, Zauszniewski & Wykle, 2009; Dupuis-Blanchard, 2007; Stimson & McCrea, 2004). However, these studies are typically focused on nursing and medical needs and none have explored this relocation through an occupational lens. Therefore, our study aimed to explore from an occupational therapy perspective, the experiences of older adults as they relocate from their existing residence to a retirement village. Focussing on the transition process, the study sought to identify key factors over different stages of relocation; to determine the range of strategies employed by older adults in relocating and maintaining a sense of home; and to explore the scope for preventative occupational therapy in promoting health and well-being throughout relocation for relatively healthy older adults.
Methods Sixteen adults aged 65 years and over participated in the study (Table 1). Both purposive and snowball sampling was used to recruit participants from six different retirement living facilities in the Perth metropolitan area, representing a mix of sociodemographic profiles and payment options for the facility. The older adults needed to be ‘relatively healthy’ in order to participate. Persons who ‘are older and frail and having difficulty with everyday tasks’ are those who typically receive aged care packages (Government of Western Australia, 2011). Thus, as there is no effective measure for defining ‘relatively healthy’, those in receipt of aged care packages were ineligible. Older adults with medical conditions often associated with ageing were included in the study provided they could still engage in activities of daily living independently. As relocation involved a process from decision making through to post-relocation adjustment (Schumacher et al., 1999, p. 4), three stages of relocation were investigated to include the total experience: (i) decision
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- pre-relocation where participants who had decided to relocate to a retirement living facility had not yet made the move; (ii) early days – participants at approximately 1 year post-relocation; and (iii) established – participants at 2 years and more post-relocation. Semi-structured in-depth interviews were conducted lasting from approximately 30 minutes to 1 hour. An interview schedule tailored to the participant’s stage of relocation was used to ensure that the same information was covered in every interview. Questions covered aspects of the change and the kinds of things they thought important in making a home. All interviews, except one which was conducted in a cafe, were conducted in the homes of the participants. Ethics approval was sought from the Human Research Ethics Committee at Curtin University. Participants provided written consent and were advised that they could withdraw from the study at any time without prejudice and the need for an explanation. All interviews were recorded with the participants’ permission and later transcribed verbatim. All data was de-identified through the use of pseudonyms and coding. Member checking occurred during each interview and afterwards via follow-up phone calls to check that the data collected reflected the participants’ thoughts
and to allow further discussion. Any extra information collected via these phone calls was included in the data and used in the analysis process. Data analysis was conducted using a three stage, grounded theory approach; open coding, theoretical coding and selective coding (Glaser & Strauss, 1967). It began simultaneously during the transcription process, focusing on line-by-line coding of the text. Theoretical coding involved the inductive process of breaking down the categories and examining them until they were fully elaborated and defined (Glaser, 1978, p. 55; Holton, 2007, p. 279). The deductive process of selective coding was used to test higher-order categories against the data and explore the meaning of relocation and creating and maintaining home for the participants.
Results Older adults relocate for a variety of reasons. Pull factors such as new facilities, increased support, closeness of services, and pleasant locations, and push factors such as declining physical ability, home maintenance, and finances were common reasons provided by participants. However, four key overlapping factors emerged from the data, which contribute to a deeper understand-
TABLE 1: Sociodemographics of participants Participants/Psuedonym
Gender
Age (years)
Marital status
Housing‡
Stage of relocation
Time since relocated
Sylvia June Eleanor Faith John Josephine Paul Nadine Leo Grace Loretta Jacqueline
Female Female Female Female Male Female Male Female Male Female Female Female
81 80 75 72 84 84 80 80 88 85 76 75
Married Widowed Widowed Separated Married Widowed Married Married Married Married Widowed Divorced
Original home Original home Original home Unit Unit Apartment Unit Unit Villa Villa Apartment Unit
Decision Decision Decision Early Days Early Days Early Days Early Days Early Days Early Days Early Days Early Days Established
Bruce
Male
81
Widowed
Apartment
Established
Jill
Female
75
Married
Apartment
Established
Barbara Judith
Female Female
83 77
Divorced Widowed
Apartment Apartment
Established Established
N/A N/A N/A 2 months 6 months 6-7 months 8 months 8 months 15 months 15 Months 17 months 2 years 6 months 4 years 9 months 8 years 6 months 9 years 11 years
‡Unit – Two bedroom self-contained units either as part of multi-storey complex or part of smaller, group housing arrangement. Apartment – Mix of one or two bedroom apartments under a “Lease for life” agreement. Villa – Three bedroom house under a ‘Lease for life’ agreement. Original home – Original home of residency. © 2013 Occupational Therapy Australia
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ing of how older people manage the relocation process and create a sense of home.
Timing of decision making Timing was crucial for many participants who relocated to a retirement living facility. Moving before ‘it’s too late’, particularly in order to maintain autonomy and control over the decision was a common theme. This was particularly pertinent for those who were still deciding about the move. … see that’s why I want to do it now, a lot of people wait so long that the decision’s taken out of their hands. And then it’s not a voluntary decision. (June)
Being able to maintain the home to a particular standard was important to participants and this often motivated the downsizing process. This was difficult to achieve for many of the participants as their original homes required greater maintenance. While not necessarily unhealthy, the participants said that as they aged, they were not as energetic as they once were. Relocation provided participants with increased independence and maintenance of dignity by decreasing responsibilities and helping to prepare for their potential future needs. I would hate this place to deteriorate into a mess because I couldn’t manage. I’ve seen people… older than me or my age, who live in a cluttered and… not dirty, but messy environments, just because they can’t cope any more. I don’t want that to happen. I think you’ve got to make the hard decisions when you can. (June)
Relocating before there were changes in health and financial needs that would impact on their day-to-day functioning was important to most participants. Out of the sixteen participants, nine moved proactively to retirement living in order to mitigate the potential for a decline in health and/or to decrease their responsibilities and costs around the home. By planning to move early participants also had a greater choice as to when they would relocate and where they could go. And so then I thought ‘here am I in this big house’ and it’s all getting expensive because you’ve got to pay for a lot of help. It was beginning to need things, like [fixing] rusty gutters. So I looked around, and I found this place advertised…I made enquiries here and they had quite a lot available then. So I had a big choice. (Loretta)
New beginnings Moving brought with it the chance for some participants to engage in new routines and occupations and forge a new identity within the community © 2013 Occupational Therapy Australia
environment. Those who felt they had been more proactive in the relocation process spoke positively, emphasising how they had taken on new interests. …it was nice to come into a nice modern place… I mean it was really a new life, which was good for us. You know, a new routine, which was really good when you’re in your 70s. (Jill)
A number of participants who were not as proactive in the relocation process still embraced the new phase of life. For them, it was important to work at letting go of their previous lifestyle and take on the new opportunities presented to them; for example, social dinners, carpet bowls, and morning teas often available in retirement living facilities. For a small number of participants who had few choices in relocating, beginning new activities and keeping busy helped them accept the new community way of life. [Maintaining hobbies] used to be very important to me…I do other things now. I either read or play the cards on there [the computer] or talk on the phone to my friends. And I visit different people in their apartments for a cup of tea or they come here. (Josephine)
Relocating to a retirement village seemed inevitable for some. Adult children having left home and the loss of a partner meant that some participants felt an increasing sense of isolation within a large family home. This is my bedroom. I mean what else do I need? It’s only me! There’s nothing else I need really. It’s perfect for me. I don’t have children. I think I had just reached that stage in my life where I thought, ‘OK, from now on it’s just going to be me and my comfort’. I suppose really it was sort of a new beginning for me. (Jacqueline)
Continuity While some had relocated to retirement villages seeking a new lifestyle, others wished to continue their previous lifestyles, but within an environment that provided decreased responsibilities, added security and enhanced social networks. By relocating, some participants felt they had/would have additional ability to engage in meaningful occupations. And for me to live alone in this house by myself, I wouldn’t feel secure. So when you live there, although it’s not a nursing home, there are people around you and if you’re on your own, you ring a bell and they get the ambulance for you. And it’s smaller. Our apartment won’t be bigger than this area here, so why do I need a bigger space than this? That’s the main reason. (Sylvia)
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Eight participants relocated within the same area as their original home. Relocating within their ‘comfort zone’, participants knew where to find community services such as shops and could continue to engage in community relationships such as attending the same church community or continuing to see the same doctor. Nevertheless, relocation presented challenges to many who needed to negotiate both threats to security and identity. Familiarity and maintenance of routines helped alleviate this issue. When I first came here and I was on my own it was a little bit sort of, distressing in so far as I was frightened that if something happened, I would be all alone and there’d be no one. With my imagination my body might rot and it would take weeks for them to find me. It took a while to adjust. I had to gain the confidence and carry on as normal. [Continue to] do my meals on wheels and just keep occupied. Get to meet the people. (Jacqueline)
Relocation can be hugely disruptive to social relationships. For some participants the proximity to friends or the ability to be able to see the family on a daily or weekly basis was critical as it provided reassurance and an opportunity for continuity of relationships and roles as a friend, grandparent and/or parent. … the thing that really…made this attractive was the fact that our daughter and her husband lived just up around the corner and they had three young kids, two of which went to school just around the back here, and I used to go get them every afternoon and bring them back here…so it was great from our point of view that we got to know the grandkids very well. (Bruce)
Being able to bring possessions from the original home helped to recreate a sense of home within the new environment. Whether it was furniture, paintings, dried flowers or photographs, each item held particular sentimental value to the participant: ‘… they’re the things that are specific to you. They give you your identity that you’ve chosen over the years that you love’. And when the grandchildren come and they say, you know even the 25 year old grandson said ‘It’s just like being back at Bedford’ because we’ve got our familiar pictures. (Grace)
Several participants mentioned that the process of deciding where to move was not difficult, but choosing what to bring and what to leave behind was ‘traumatic’. When it came time to move, participants suddenly had to ‘pare down’ their lives. For a select few, this process was not difficult. More commonly, the process of sorting through possessions was emotionally and physically challenging for participants. Adapting to loss, sacrificing
items of sentimental value, breaking attachment to the family home and letting go of the past self was particularly difficult, especially for those who had been in their original homes for a long time and/or were relocating on their own. Making the decision was all right but putting it into action was the traumatic part. And having to clean out the living cupboard and clean out the… children’s bedrooms…I had to dispose of the beds that they used to sleep in and their wardrobes. (Barbara)
Strategies for change Exercising agency through making decisions, either about the process itself or around modifying the physical space, was essential in order for the participants to be happy and content in their new homes. Often limitations in being able to choose where to go were as a result of limited finances, for example, being on a pension. Some participants acknowledged the difficulty of leaving the original home and the freedom it provided as some retirement villages imposed restrictions on their ability to modify the environment to suit their needs. So, it was hard leaving that sense of being in your own home and you know, doing what you wanted to, whether it was growing honeysuckle on the shed or just whatever. (Judith)
Other participants felt the opposite. One in particular noted that she and her husband felt they had absolute control over their own lives since moving. I’ve heard people say they wouldn’t go into a village because they’re too controlled. I don’t feel that at all. Nobody’s controlling us. (Grace)
Out of the 16 interviews, twelve participants mentioned gardening or maintaining their garden as being a major factor in deciding to relocate, often reporting that it ‘was getting too much’ to handle. However, once relocated, six participants still continued to partake in gardening of some form as it was now a matter of choice rather than a chore. …I get something out of it by looking at it and I get the love of gardening still and I don’t have to do it, I can do it if I want to. (Faith)
Participants who were active in gathering information prior to the move were better prepared and ultimately better able to adapt to their new environment. Information gathering was done at two crucial points in the relocation process, prior to choosing a location and once a decision had been made. Those who had researched different locations, financial requirements, received advice © 2013 Occupational Therapy Australia
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from others, and looked into the type of social atmosphere provided, often felt better prepared and more reassured it would suit their needs. These participants enquired about public transportation and community activities that may suit their interests. Two participants even joined the social activities of the village before relocating in order to make sure the community resonated with their own values and interests. Well, [my friend] Helen and I, looked around and worked out that it would be great for us because we’d come to some of the socials here…so I did things here before I moved in to get that feel of the place. (Faith)
While some participants felt they were ‘fortunate’ that everything just fell into place, it was usually research and good timing that helped ease the transition. One participant who did not have the time to investigate other alternatives worried that she and her husband had made the wrong decision, not because there was anything wrong with the village, but because it did not suit their needs. …it’s not really wholly the fault of the village. It’s partly ours because we perhaps didn’t look closely enough, and didn’t realise that a big village like this… It may have been the wrong move to come here. (Nadine)
Gathering information once the choice to move had been made was also essential in helping participants embrace the decision to relocate and prepare for the move. Participants referred to measuring their furniture to ensure that they could bring as much from the original home into the new home as possible. This helped reduce the loss participants experienced and resulted in continuity of the family home within the new environment, while aiding them through the process of downsizing. Well, before we came here, of course we drew a plan of the place and measured all our furniture and worked out what would fit in and where it would go. There were certain things that we would keep, definitely. I mean, like that’s a family historic piece and there’s various family history things around the place but the ones that we couldn’t bring, we then spread out around the family. (Judith)
Two main strategies to facilitate successful transitions were found to be used by older adults in this study, researching and gathering information prior to moving and maintaining the ability to exercise agency across the relocation process.
Discussion The study found that the older adults moving from their previous residence to retirement living who had © 2013 Occupational Therapy Australia
positive post-relocation adjustments had the ability to facilitate optimal person-environment and occupational fit throughout the relocation process. For the majority of participants, relocation to a retirement village was strongly shaped by their desires to move to an environment that was more supportive to their future health needs, required less upkeep, and was within the same location or potentially closer to meaningful occupations, friends, and/or family. Evidence suggested timing of the decision was critical to how people adjusted. Those who chose proactively to relocate before it was ‘too late’ often experienced an almost immediate positive adjustment to the new location. For two participants who moved reactively in response to changing needs, the initial relocation resulted in limited choices, increased stress, declines in physical and mental health, and a longer adjustment period. Limited finances and relocating in response to declining health or environmental stressors creates less choice and control over where to relocate (Pope & Kang, 2010). For those who relocated reactively, maintaining familiar routines and occupations or engagement in new occupations helped to facilitate adjustment and minimise anxiety. This finding corresponds to occupational therapy literature that outlines participation in meaningful occupations as a requirement for health and a necessity to the human experience (Wilcock, 2006, pp. 51–53). In order to minimise the length of time spent in the disorienting middle stage of relocation (Schumacher et al., 1999, p. 4), engagement in meaningful occupations needs to translate across environments. As found in previous studies, exercising agency in decision making positively affects a persons’ ability to adjust (Bekhet et al., 2009; Chen, Zimmerman, Sloane & Barrick, 2007), and recreate a sense of home post-relocation. This study found that choosing how to decorate and which items of importance from the previous home to bring, the ability to make modifications to the physical space, and being able to choose to engage in previous hobbies and social activities were common themes to helping shape the new environment into a home. Choice and continuity between environments eased the process of letting go and also gave participants the opportunity to choose a location that best suited their needs. Reinforcing results from earlier studies (Bekhet et al., 2009), those who felt they were restricted in their choices, or felt pushed into relocation, had a harder time adjusting. However, if participants embraced the decision, even if it was not initially their own, their ability to adjust post-relocation was generally better than those who did not. These findings further support the belief that any form of participation in the decision making process appears to have a positive effect on post-relocation adjustment (Bekhet et al., 2009), and the ability to call the new environment home. In order for occupational therapists to help facilitate a positive relocation, the voluntary nature of relocation should be
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stressed, and decision making should principally lie with the older adult. Occupational therapists should encourage people who are approaching this stage in life to plan ahead for their future needs. There is no reason why older adults cannot be encouraged to plan the move from their original homes in a similar way to how one would actively plan for retirement from the workforce. Consistent with literature surrounding push-pull frameworks (Bekhet et al., 2009; Boldy, Grenade & Lewin, 2010; Pope & Kang, 2010; Stimson & McCrea, 2004), this study also found that the increasing incongruence between participants’ physical abilities and escalating home maintenance tasks were common push factors in participants’ desire to relocate. Some participants had been living in homes that they had built many years before. However, the environment had since become isolating and restricting and was impacting negatively on their health. The study also found that there was a need to maintain dignity and pride in the home, as participants often displayed regret or fear about letting their previous homes deteriorate due to an inability to sufficiently manage upkeep. By relocating, participants were able to increase their personal, environmental and occupational fit; allowing for less maintenance around the home, preparation for their future physical energy levels, and consequently, increase in time available to participate in social activities and other desired occupations. As increasing control over the environment helps to minimise stress (Oswald & Rowles, 2006, p. 15) and increases participation in meaningful occupations that promote health and well-being (Clark et al., 1997; Pizzi & Smith, 2010, p. 458), the process of downsizing helped mitigate negative outcomes associated with relocation. Thus, programs aimed at educating older adults who are thinking of relocating about the importance of person-environment-occupation fit could help to facilitate them to independently manage the challenges of this potentially stressful transition. When preparing to relocate, a smooth transition requires thorough planning for a range of factors (Pope & Kang, 2010). Participants’ outlined the importance of information gathering to being able to adapt to the new environment. Those who had done prior research about what to do with belongings, available social activities, the community lifestyle and the financial requirements of moving, had a greater person-environment and occupational fit post-relocation. Information gathering by participants helped decrease the sense of unease associated with the unknown, as identified by prior researchers (Rossen & Knafl, 2003). It included enquiring whether there would be activities of interest, or whether the other residents were friendly, and what important items should be brought from the home. The study found that by contrast those who had difficulty adjusting felt that a lack of information hindered a positive transition. Asking fewer questions, or not looking at
enough alternatives, led to potentially making ‘the wrong decision’ and relocation to a facility that perhaps did not suit the person’s unique living and environmental needs. Future interventions to assist the transition should emphasise the importance of gathering information before relocating to ascertain whether the retirement facility truly matches the person’s needs and wants. As this process is complex and there are a multitude of factors that need to be taken into consideration when deciding where and when to relocate, occupational therapists could help to simplify the process by developing checklists or assessments to ensure older adults had researched the options thoroughly before making a decision. This study was reliant on participants self-selecting involvement. Results are consequently dependent on those who had something to say, whether it be positive or negative. It could have been that those most dissatisfied or unable to articulate their feelings decided not to participate. Alternatively, those most satisfied and occupied may have been too busy to participate. The study design initially proposed a fourth stage of relocation, which would have focussed on the process of moving. However, as relocation can be a stressful and extremely busy experience, participants were unsurprisingly impossible to recruit.
Conclusion The study demonstrated that the people who did not defer the process of relocation were able to make the best decisions regarding their needs. Traditionally, occupational therapy with older adults has focused on promoting health and well-being through home modifications or improving participation in activities of daily living (Jonsson, Josephsson & Kielhofner, 2001). However, there is evidence to suggest that preventative occupational therapy focused on promoting meaningful occupations and wellness can have positive effects on mental and physical health (Clark et al., 1997; Matuska, Giles-Heinz, Flinn, Neighbor & Bass-Haugen, 2003). With the population of older adults increasing, there will be a greater demand for health care professionals to work proactively towards promoting healthy ageing. Despite relocation to retirement villages increasing in popularity, and moving being a potentially stressful event for older people, there are currently gaps in service provision to facilitate healthy ageing during this transition. It is not easy for older people to make relocation decisions as the process is often complex. Based on the results of this study, occupational therapists could promote healthy ageing across this transition by following an approach similar to the WellElderly study (Clark et al., 1997). Occupational therapists may be able to advise older people on the advantages and disadvantages of staying in their original homes or moving to retirement living. They are uniquely placed to facilitate healthy transitions through initiating preventa© 2013 Occupational Therapy Australia
452 tive programs aimed at simplifying the relocation process; providing guidance in relation to information gathering; actively encouraging decision making and forward planning; and providing education about the importance of maintaining engagement in occupations. Future research should include the implementation of a preventative, community-based occupational therapy intervention to determine whether it may facilitate health and well-being throughout home relocations in older age.
Acknowledgements The authors would like to thank the participants who agreed to be interviewed and the Retirement Living Facilities who assisted with recruitment of the participants. We gratefully acknowledge the School of Occupational Therapy and Social Work, Curtin University for the financial support for the project.
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Chen, C. K., Zimmerman, S., Sloane, P. D. & Barrick, A. L. (2007). Assisted living policies promoting autonomy and their relationship to resident depressive symptoms. The American Journal of Geriatric Psychiatry, 15 (2), 122–129. Clark, F., Azen, S. P., Zemke, R., Jackson, J., Carlson, M., Mandel, D. et al. (1997). Occupational therapy for independent-living older adults: A randomized controlled trial. The Journal of the American Medical Association, 278 (16), 1321–1326. Dupuis-Blanchard, S. M. (2007). Building a new nest: The experience of women relocating to a seniors-designated apartment building. Canadian Journal of Nursing Research, 39 (4), 136–153. Gardner, I. L., Browning, C. & Kendig, H. (2005). Accommodation options in later life: Retirement village or community living? Australasian Journal on Ageing, 24 (4), 188–195. Glaser, B. G. (1978). Theoretical sensitivity. Mill Valley, CA: The Sociology Press. Glaser, B. G. & Strauss, A. L. (1967). The discovery of grounded theory: Strategies for qualitative research. Chicago, IL: Aldine Publishing Company. Government of Western Australia. (2011). Home and Community Care (HACC) in Western Australia, Retrieved 22 September, 2011, from http://www.health.wa.gov.au/ hacc/consumers/introduction.cfm Grant, B. C. (2003). Retirement villages: An alternative place to live. Australasian Journal on Ageing, 22 (3), 136–139. Holton, J. A. (2007). The coding process and its challenges. In: A. Bryant & K. Charmaz (Eds.), The SAGE handbook of grounded theory (pp. 265–290). London, UK: SAGE Publications Ltd. Jonsson, H., Josephsson, S. & Kielhofner, G. (2001). Narratives and experiences in an occupational transition: A longitudinal study of the retirement process. American Journal of Occupational Therapy, 55 (4), 424–432. Knight, S. C. & Buys, L. R. (2003). The involvement of adult children in their parent’s decision to move to a retirement village. Australasian Journal on Ageing, 22 (2), 91–93. Law, M., Cooper, B. A., Strong, S., Stewart, D., Rigby, P. & Letts, L. (1996). The Person-Environment-Occupation model: A transactive approach to occupational performance. Canadian Journal of Occupational Therapy, 63 (1), 9–23. Matuska, K., Giles-Heinz, A., Flinn, N., Neighbor, M. & Bass-Haugen, J. (2003). Brief Report - Outcomes of a pilot occupational therapy wellness program for older adults. American Journal of Occupational Therapy, 57 (2), 220–224. McIntyre, A. & Atwal, A. (2005). Occupational therapy and older people. Oxford, UK: Blackwell Publishing Ltd. Oswald, F. & Rowles, G. D. (2006). Beyond relocation trauma in older age: New trends in today’s elders’ residential decisions. In: H. -W. Wahl, C. Tesch-Romer & A. Hoff (Eds.), New dynamics in old age: Environmental and societal perspectives (pp. 127–152). Amityville, NY: Baywood Publishing. Pizzi, M. A. & Smith, T. M. (2010). Promoting successful ageing through occupation. In: M. E. Scaffa, S. M. Reitz & M. A. Pizzi (Eds.), Health promotion and prevention from an occupational therapy perspective (pp. 454–469). Philadelphia, PA: F.A. Davis Company.
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Pope, N. D. & Kang, B. (2010). Residential relocation in later life: A comparison of proactive and reactive moves. Journal of Housing for the Elderly, 24 (2), 193–207. Rossen, E. K. & Knafl, K. A. (2003). Older women’s response to residential relocation: Description of transition styles. Qualitative Health Research, 13 (20), 20–36. Rossen, E. K. & Knafl, K. A. (2007). Women’s well-being after relocation to independent living communities. Western Journal of Nursing Research, 29 (2), 183–199. Schumacher, K. L., Jones, P. S. & Meleis, A. I. (1999). Helping elderly persons in transition: A framework for research and practice. In: E. A. Swanson & T. TrippReimer (Eds.), Life transitions in the older adult: Issues for nurses and other health professionals (pp. 1–26). New York, NY: Springer Publishing Company.
453 Schwartzman, A. J., Atler, K., Borg, B. & Schwartzman, R. C. (2006). Fueling the engines: A role for occupational therapy in promoting healthy life transitions. Occupational Therapy in Health Care, 20 (1), 39–59. Seniors’ Housing Centre. (2011). Your home: A guide to housing options for people over 55. Retrieved 22 September, 2011, from http://www.commerce.wa.gov.au/consumerprotection/PDF/Publications/SeniorsHousingGuide. pdf. Stimson, R. J. & McCrea, R. (2004). A push-pull framework for modelling the relocation of retirees to a retirement village: The Australian experience. Environment and Planning, 36 (8), 1451–1470. Wilcock, A. (2006). An occupational perspective of health (2nd ed.). Thorofare, NJ: SLACK Incorporated.
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doi: 10.1111/1440-1630.12038
Research Article
Relocating to retirement living: An occupational perspective on successful transitions Emily Walker and Beverley McNamara School of Occupational Therapy and Social Work, Centre for Research into Disability and Society, Curtin Health Innovation Research Institute, Curtin University, Perth, Western Australia, Australia
Background/aim: Older adults are increasingly relocating to alternative housing options, such as retirement villages. Relocations can be stressful and these environmental transitions can cause significant disruption to the personenvironment and occupational fit, thus influencing health, well-being and quality of life. There is a lack of literature from an occupational therapy perspective in relation to healthy older adults seeking to relocate. This study aimed to identify issues healthy older adults face when relocating to retirement living, what strategies they used during this process, how they maintained a sense of home, and the potential for occupational therapy involvement. Methods: Sixteen semi-structured, in-depth interviews were conducted with participants recruited from retirement living facilities across three stages of relocation; ‘Decision’, ‘Early Days’, and ‘Established’. A grounded theory approach was used to code and analyse the data. Results: Having control over the decisions surrounding relocation, being proactive rather than reactive and preparing sufficiently for the move all contributed to a positive post-location adjustment. Four main themes emerged from the narratives: timing of decision making, new beginnings, continuity, and strategies for change. Conclusions: This study contributes to literature surrounding how older adults occupy and make meaning of the spaces they call home and also enriches literature regarding environmental transitions. Relocation can be a disruptive process and occupational therapists are uniquely placed to facilitate healthy ageing throughout
Emily Walker BSc (OT) (Hons). Beverley McNamara PhD, BA (Hons), DipTeach; Professor. Correspondence: Professor Beverley McNamara, Director of Teaching and Learning, School of Occupational Therapy and Social Work, Centre for Research into Disability and Society, Curtin Health Innovation Research Institute, Curtin University, GPO Box U1987, Perth, WA 6845, Australia. Email: [email protected] Accepted for publication 8 February 2013. © 2013 Occupational Therapy Australia
this transition using preventative and community-based occupational therapy. KEY WORDS healthy ageing, preventative occupational therapy, relocation.
Introduction Australia’s population is ageing. By 2056, one quarter of the population is predicted to be aged 65 years or older (Australian Bureau of Statistics, 2008). This will have serious implications for the way ageing is viewed, as older adults are living longer with different expectations and needs than previous generations (Andrews, 2001). Consequently, there is a need for all levels of government and health care providers in Australia to take a proactive stance to encourage Active Ageing (living well and ageing healthily in later life) through preventative programs (Australian Local Government Association, 2004). These programs will help to mitigate potential growing costs associated with age-related chronic disease (Armstrong, Gillespie, Leeder, Rubin & Russell, 2007). It appears older Australian adults prefer to remain in their homes as they age (Stimson & McCrea, 2004). This is likely because the home is a place of increasing importance as one grows older (Grant, 2003). Transitions into retirement mean that more meaningful occupations – self-directed tasks that are engaged in on a day-to-day basis and over a lifetime – are completed in the home than previously and the distance travelled to engage in occupations and roles also decreases (Law et al., 1996; Oswald & Rowles, 2006, p. 132). Sentimental ties also develop over time to provide a living environment that feels familiar and safe (Aged & Community Services Australia, 2004). Despite this, evidence of a shift in desired housing options is already occurring. Increasing numbers of older Australians are choosing to relocate to retirement villages. Retirement villages are residential complexes designed for those aged 55 years or older that offer a range of health, leisure and supportive services
446 (Gardner, Browning & Kendig, 2005). Retirement villages usually promote an independent lifestyle and residents are responsible for their own needs in contrast to Residential Aged Care Facilities, which provide a far greater range of support. In Australia, the number of older adults moving to retirement villages has increased 37 percent since 1981 (Australian Bureau of Statistics, 2003). It may be argued that the increase is motivated by an increasing ageing population who are seeking alternative housing options. Reasons given include decreasing physical ability, increasing social isolation, home maintenance, and limited incomes (Stimson & McCrea, 2004). It is important to understand the relocation process as it can have a significant impact on identity, health and well-being. The relocation process occurs in three stages: (i) making the decision and separating from one’s previous life; (ii) the disorienting stage; and (iii) the adjustment, where control is developed and new meanings established (Schumacher, Jones & Meleis, 1999, p. 4). Relocation in older adulthood can be a stressful and confusing process (Knight & Buys, 2003). There are many decisions surrounding whether to move or stay and it can often be perplexing as to what the different options mean and whether the most suitable option will also be affordable. The transition can be particularly stressful if predated closely by the death of a spouse or declining physical ability (Armer, 1993). Continuity of an individual’s occupations and social relationships must translate to the new environment in order to support their health and well-being (Blair, 2000; Rossen & Knafl, 2007). It is important that older adults choose their initial relocation options carefully. Moving to a retirement village often includes a noteworthy financial investment. Considerable costs may occur should future relocations or modifications be necessary to optimise the environment to better suit their needs as they age (Seniors’ Housing Centre, 2011). Therefore, it is imperative that current and future housing needs are taken into consideration (Seniors’ Housing Centre, 2011). In order to do this, one must look at how factors such as the person, their environment and their occupations correlate to the new home in order to ensure optimal fit. According to the Person-Environment-Occupation Model (Law et al., 1996) the fit between these factors helps assist occupational performance. If older people maintain or increase the fit between these factors, then well-being is likely to improve (Schwartzman, Atler, Borg & Schwartzman, 2006) thereby facilitating healthy ageing across the transition.
Preventative occupational therapy and healthy life transitions Occupational therapists are theoretically well suited to offer positive health promotion outcomes as much of what defines healthy ageing aligns with occupational therapy philosophy (McIntyre & Atwal, 2005, p. 5). © 2013 Occupational Therapy Australia
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Healthy ageing is directly correlated with continued engagement in meaningful occupations (Pizzi & Smith, 2010, p. 466). The Well-Elderly study conducted in the United States of America demonstrated that by participating in preventative occupational therapy, participants were likely to have better health outcomes than those who engaged in non-therapy oriented social activities or who received no intervention (Clark et al., 1997). Another study investigated the potential for preventative occupational therapy during life transitions and proposed this as a growing area of practice (Schwartzman et al., 2006). As older adults are increasingly moving to retirement villages and since relocations are potentially stressful, occupational therapists are well placed to provide support to ensure optimal fit in the person-environment-occupation nexus. Previous studies have explored reasons behind older adults’ relocation to retirement villages or age-segregated communities (Bekhet, Zauszniewski & Wykle, 2009; Dupuis-Blanchard, 2007; Stimson & McCrea, 2004). However, these studies are typically focused on nursing and medical needs and none have explored this relocation through an occupational lens. Therefore, our study aimed to explore from an occupational therapy perspective, the experiences of older adults as they relocate from their existing residence to a retirement village. Focussing on the transition process, the study sought to identify key factors over different stages of relocation; to determine the range of strategies employed by older adults in relocating and maintaining a sense of home; and to explore the scope for preventative occupational therapy in promoting health and well-being throughout relocation for relatively healthy older adults.
Methods Sixteen adults aged 65 years and over participated in the study (Table 1). Both purposive and snowball sampling was used to recruit participants from six different retirement living facilities in the Perth metropolitan area, representing a mix of sociodemographic profiles and payment options for the facility. The older adults needed to be ‘relatively healthy’ in order to participate. Persons who ‘are older and frail and having difficulty with everyday tasks’ are those who typically receive aged care packages (Government of Western Australia, 2011). Thus, as there is no effective measure for defining ‘relatively healthy’, those in receipt of aged care packages were ineligible. Older adults with medical conditions often associated with ageing were included in the study provided they could still engage in activities of daily living independently. As relocation involved a process from decision making through to post-relocation adjustment (Schumacher et al., 1999, p. 4), three stages of relocation were investigated to include the total experience: (i) decision
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- pre-relocation where participants who had decided to relocate to a retirement living facility had not yet made the move; (ii) early days – participants at approximately 1 year post-relocation; and (iii) established – participants at 2 years and more post-relocation. Semi-structured in-depth interviews were conducted lasting from approximately 30 minutes to 1 hour. An interview schedule tailored to the participant’s stage of relocation was used to ensure that the same information was covered in every interview. Questions covered aspects of the change and the kinds of things they thought important in making a home. All interviews, except one which was conducted in a cafe, were conducted in the homes of the participants. Ethics approval was sought from the Human Research Ethics Committee at Curtin University. Participants provided written consent and were advised that they could withdraw from the study at any time without prejudice and the need for an explanation. All interviews were recorded with the participants’ permission and later transcribed verbatim. All data was de-identified through the use of pseudonyms and coding. Member checking occurred during each interview and afterwards via follow-up phone calls to check that the data collected reflected the participants’ thoughts
and to allow further discussion. Any extra information collected via these phone calls was included in the data and used in the analysis process. Data analysis was conducted using a three stage, grounded theory approach; open coding, theoretical coding and selective coding (Glaser & Strauss, 1967). It began simultaneously during the transcription process, focusing on line-by-line coding of the text. Theoretical coding involved the inductive process of breaking down the categories and examining them until they were fully elaborated and defined (Glaser, 1978, p. 55; Holton, 2007, p. 279). The deductive process of selective coding was used to test higher-order categories against the data and explore the meaning of relocation and creating and maintaining home for the participants.
Results Older adults relocate for a variety of reasons. Pull factors such as new facilities, increased support, closeness of services, and pleasant locations, and push factors such as declining physical ability, home maintenance, and finances were common reasons provided by participants. However, four key overlapping factors emerged from the data, which contribute to a deeper understand-
TABLE 1: Sociodemographics of participants Participants/Psuedonym
Gender
Age (years)
Marital status
Housing‡
Stage of relocation
Time since relocated
Sylvia June Eleanor Faith John Josephine Paul Nadine Leo Grace Loretta Jacqueline
Female Female Female Female Male Female Male Female Male Female Female Female
81 80 75 72 84 84 80 80 88 85 76 75
Married Widowed Widowed Separated Married Widowed Married Married Married Married Widowed Divorced
Original home Original home Original home Unit Unit Apartment Unit Unit Villa Villa Apartment Unit
Decision Decision Decision Early Days Early Days Early Days Early Days Early Days Early Days Early Days Early Days Established
Bruce
Male
81
Widowed
Apartment
Established
Jill
Female
75
Married
Apartment
Established
Barbara Judith
Female Female
83 77
Divorced Widowed
Apartment Apartment
Established Established
N/A N/A N/A 2 months 6 months 6-7 months 8 months 8 months 15 months 15 Months 17 months 2 years 6 months 4 years 9 months 8 years 6 months 9 years 11 years
‡Unit – Two bedroom self-contained units either as part of multi-storey complex or part of smaller, group housing arrangement. Apartment – Mix of one or two bedroom apartments under a “Lease for life” agreement. Villa – Three bedroom house under a ‘Lease for life’ agreement. Original home – Original home of residency. © 2013 Occupational Therapy Australia
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ing of how older people manage the relocation process and create a sense of home.
Timing of decision making Timing was crucial for many participants who relocated to a retirement living facility. Moving before ‘it’s too late’, particularly in order to maintain autonomy and control over the decision was a common theme. This was particularly pertinent for those who were still deciding about the move. … see that’s why I want to do it now, a lot of people wait so long that the decision’s taken out of their hands. And then it’s not a voluntary decision. (June)
Being able to maintain the home to a particular standard was important to participants and this often motivated the downsizing process. This was difficult to achieve for many of the participants as their original homes required greater maintenance. While not necessarily unhealthy, the participants said that as they aged, they were not as energetic as they once were. Relocation provided participants with increased independence and maintenance of dignity by decreasing responsibilities and helping to prepare for their potential future needs. I would hate this place to deteriorate into a mess because I couldn’t manage. I’ve seen people… older than me or my age, who live in a cluttered and… not dirty, but messy environments, just because they can’t cope any more. I don’t want that to happen. I think you’ve got to make the hard decisions when you can. (June)
Relocating before there were changes in health and financial needs that would impact on their day-to-day functioning was important to most participants. Out of the sixteen participants, nine moved proactively to retirement living in order to mitigate the potential for a decline in health and/or to decrease their responsibilities and costs around the home. By planning to move early participants also had a greater choice as to when they would relocate and where they could go. And so then I thought ‘here am I in this big house’ and it’s all getting expensive because you’ve got to pay for a lot of help. It was beginning to need things, like [fixing] rusty gutters. So I looked around, and I found this place advertised…I made enquiries here and they had quite a lot available then. So I had a big choice. (Loretta)
New beginnings Moving brought with it the chance for some participants to engage in new routines and occupations and forge a new identity within the community © 2013 Occupational Therapy Australia
environment. Those who felt they had been more proactive in the relocation process spoke positively, emphasising how they had taken on new interests. …it was nice to come into a nice modern place… I mean it was really a new life, which was good for us. You know, a new routine, which was really good when you’re in your 70s. (Jill)
A number of participants who were not as proactive in the relocation process still embraced the new phase of life. For them, it was important to work at letting go of their previous lifestyle and take on the new opportunities presented to them; for example, social dinners, carpet bowls, and morning teas often available in retirement living facilities. For a small number of participants who had few choices in relocating, beginning new activities and keeping busy helped them accept the new community way of life. [Maintaining hobbies] used to be very important to me…I do other things now. I either read or play the cards on there [the computer] or talk on the phone to my friends. And I visit different people in their apartments for a cup of tea or they come here. (Josephine)
Relocating to a retirement village seemed inevitable for some. Adult children having left home and the loss of a partner meant that some participants felt an increasing sense of isolation within a large family home. This is my bedroom. I mean what else do I need? It’s only me! There’s nothing else I need really. It’s perfect for me. I don’t have children. I think I had just reached that stage in my life where I thought, ‘OK, from now on it’s just going to be me and my comfort’. I suppose really it was sort of a new beginning for me. (Jacqueline)
Continuity While some had relocated to retirement villages seeking a new lifestyle, others wished to continue their previous lifestyles, but within an environment that provided decreased responsibilities, added security and enhanced social networks. By relocating, some participants felt they had/would have additional ability to engage in meaningful occupations. And for me to live alone in this house by myself, I wouldn’t feel secure. So when you live there, although it’s not a nursing home, there are people around you and if you’re on your own, you ring a bell and they get the ambulance for you. And it’s smaller. Our apartment won’t be bigger than this area here, so why do I need a bigger space than this? That’s the main reason. (Sylvia)
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Eight participants relocated within the same area as their original home. Relocating within their ‘comfort zone’, participants knew where to find community services such as shops and could continue to engage in community relationships such as attending the same church community or continuing to see the same doctor. Nevertheless, relocation presented challenges to many who needed to negotiate both threats to security and identity. Familiarity and maintenance of routines helped alleviate this issue. When I first came here and I was on my own it was a little bit sort of, distressing in so far as I was frightened that if something happened, I would be all alone and there’d be no one. With my imagination my body might rot and it would take weeks for them to find me. It took a while to adjust. I had to gain the confidence and carry on as normal. [Continue to] do my meals on wheels and just keep occupied. Get to meet the people. (Jacqueline)
Relocation can be hugely disruptive to social relationships. For some participants the proximity to friends or the ability to be able to see the family on a daily or weekly basis was critical as it provided reassurance and an opportunity for continuity of relationships and roles as a friend, grandparent and/or parent. … the thing that really…made this attractive was the fact that our daughter and her husband lived just up around the corner and they had three young kids, two of which went to school just around the back here, and I used to go get them every afternoon and bring them back here…so it was great from our point of view that we got to know the grandkids very well. (Bruce)
Being able to bring possessions from the original home helped to recreate a sense of home within the new environment. Whether it was furniture, paintings, dried flowers or photographs, each item held particular sentimental value to the participant: ‘… they’re the things that are specific to you. They give you your identity that you’ve chosen over the years that you love’. And when the grandchildren come and they say, you know even the 25 year old grandson said ‘It’s just like being back at Bedford’ because we’ve got our familiar pictures. (Grace)
Several participants mentioned that the process of deciding where to move was not difficult, but choosing what to bring and what to leave behind was ‘traumatic’. When it came time to move, participants suddenly had to ‘pare down’ their lives. For a select few, this process was not difficult. More commonly, the process of sorting through possessions was emotionally and physically challenging for participants. Adapting to loss, sacrificing
items of sentimental value, breaking attachment to the family home and letting go of the past self was particularly difficult, especially for those who had been in their original homes for a long time and/or were relocating on their own. Making the decision was all right but putting it into action was the traumatic part. And having to clean out the living cupboard and clean out the… children’s bedrooms…I had to dispose of the beds that they used to sleep in and their wardrobes. (Barbara)
Strategies for change Exercising agency through making decisions, either about the process itself or around modifying the physical space, was essential in order for the participants to be happy and content in their new homes. Often limitations in being able to choose where to go were as a result of limited finances, for example, being on a pension. Some participants acknowledged the difficulty of leaving the original home and the freedom it provided as some retirement villages imposed restrictions on their ability to modify the environment to suit their needs. So, it was hard leaving that sense of being in your own home and you know, doing what you wanted to, whether it was growing honeysuckle on the shed or just whatever. (Judith)
Other participants felt the opposite. One in particular noted that she and her husband felt they had absolute control over their own lives since moving. I’ve heard people say they wouldn’t go into a village because they’re too controlled. I don’t feel that at all. Nobody’s controlling us. (Grace)
Out of the 16 interviews, twelve participants mentioned gardening or maintaining their garden as being a major factor in deciding to relocate, often reporting that it ‘was getting too much’ to handle. However, once relocated, six participants still continued to partake in gardening of some form as it was now a matter of choice rather than a chore. …I get something out of it by looking at it and I get the love of gardening still and I don’t have to do it, I can do it if I want to. (Faith)
Participants who were active in gathering information prior to the move were better prepared and ultimately better able to adapt to their new environment. Information gathering was done at two crucial points in the relocation process, prior to choosing a location and once a decision had been made. Those who had researched different locations, financial requirements, received advice © 2013 Occupational Therapy Australia
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from others, and looked into the type of social atmosphere provided, often felt better prepared and more reassured it would suit their needs. These participants enquired about public transportation and community activities that may suit their interests. Two participants even joined the social activities of the village before relocating in order to make sure the community resonated with their own values and interests. Well, [my friend] Helen and I, looked around and worked out that it would be great for us because we’d come to some of the socials here…so I did things here before I moved in to get that feel of the place. (Faith)
While some participants felt they were ‘fortunate’ that everything just fell into place, it was usually research and good timing that helped ease the transition. One participant who did not have the time to investigate other alternatives worried that she and her husband had made the wrong decision, not because there was anything wrong with the village, but because it did not suit their needs. …it’s not really wholly the fault of the village. It’s partly ours because we perhaps didn’t look closely enough, and didn’t realise that a big village like this… It may have been the wrong move to come here. (Nadine)
Gathering information once the choice to move had been made was also essential in helping participants embrace the decision to relocate and prepare for the move. Participants referred to measuring their furniture to ensure that they could bring as much from the original home into the new home as possible. This helped reduce the loss participants experienced and resulted in continuity of the family home within the new environment, while aiding them through the process of downsizing. Well, before we came here, of course we drew a plan of the place and measured all our furniture and worked out what would fit in and where it would go. There were certain things that we would keep, definitely. I mean, like that’s a family historic piece and there’s various family history things around the place but the ones that we couldn’t bring, we then spread out around the family. (Judith)
Two main strategies to facilitate successful transitions were found to be used by older adults in this study, researching and gathering information prior to moving and maintaining the ability to exercise agency across the relocation process.
Discussion The study found that the older adults moving from their previous residence to retirement living who had © 2013 Occupational Therapy Australia
positive post-relocation adjustments had the ability to facilitate optimal person-environment and occupational fit throughout the relocation process. For the majority of participants, relocation to a retirement village was strongly shaped by their desires to move to an environment that was more supportive to their future health needs, required less upkeep, and was within the same location or potentially closer to meaningful occupations, friends, and/or family. Evidence suggested timing of the decision was critical to how people adjusted. Those who chose proactively to relocate before it was ‘too late’ often experienced an almost immediate positive adjustment to the new location. For two participants who moved reactively in response to changing needs, the initial relocation resulted in limited choices, increased stress, declines in physical and mental health, and a longer adjustment period. Limited finances and relocating in response to declining health or environmental stressors creates less choice and control over where to relocate (Pope & Kang, 2010). For those who relocated reactively, maintaining familiar routines and occupations or engagement in new occupations helped to facilitate adjustment and minimise anxiety. This finding corresponds to occupational therapy literature that outlines participation in meaningful occupations as a requirement for health and a necessity to the human experience (Wilcock, 2006, pp. 51–53). In order to minimise the length of time spent in the disorienting middle stage of relocation (Schumacher et al., 1999, p. 4), engagement in meaningful occupations needs to translate across environments. As found in previous studies, exercising agency in decision making positively affects a persons’ ability to adjust (Bekhet et al., 2009; Chen, Zimmerman, Sloane & Barrick, 2007), and recreate a sense of home post-relocation. This study found that choosing how to decorate and which items of importance from the previous home to bring, the ability to make modifications to the physical space, and being able to choose to engage in previous hobbies and social activities were common themes to helping shape the new environment into a home. Choice and continuity between environments eased the process of letting go and also gave participants the opportunity to choose a location that best suited their needs. Reinforcing results from earlier studies (Bekhet et al., 2009), those who felt they were restricted in their choices, or felt pushed into relocation, had a harder time adjusting. However, if participants embraced the decision, even if it was not initially their own, their ability to adjust post-relocation was generally better than those who did not. These findings further support the belief that any form of participation in the decision making process appears to have a positive effect on post-relocation adjustment (Bekhet et al., 2009), and the ability to call the new environment home. In order for occupational therapists to help facilitate a positive relocation, the voluntary nature of relocation should be
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stressed, and decision making should principally lie with the older adult. Occupational therapists should encourage people who are approaching this stage in life to plan ahead for their future needs. There is no reason why older adults cannot be encouraged to plan the move from their original homes in a similar way to how one would actively plan for retirement from the workforce. Consistent with literature surrounding push-pull frameworks (Bekhet et al., 2009; Boldy, Grenade & Lewin, 2010; Pope & Kang, 2010; Stimson & McCrea, 2004), this study also found that the increasing incongruence between participants’ physical abilities and escalating home maintenance tasks were common push factors in participants’ desire to relocate. Some participants had been living in homes that they had built many years before. However, the environment had since become isolating and restricting and was impacting negatively on their health. The study also found that there was a need to maintain dignity and pride in the home, as participants often displayed regret or fear about letting their previous homes deteriorate due to an inability to sufficiently manage upkeep. By relocating, participants were able to increase their personal, environmental and occupational fit; allowing for less maintenance around the home, preparation for their future physical energy levels, and consequently, increase in time available to participate in social activities and other desired occupations. As increasing control over the environment helps to minimise stress (Oswald & Rowles, 2006, p. 15) and increases participation in meaningful occupations that promote health and well-being (Clark et al., 1997; Pizzi & Smith, 2010, p. 458), the process of downsizing helped mitigate negative outcomes associated with relocation. Thus, programs aimed at educating older adults who are thinking of relocating about the importance of person-environment-occupation fit could help to facilitate them to independently manage the challenges of this potentially stressful transition. When preparing to relocate, a smooth transition requires thorough planning for a range of factors (Pope & Kang, 2010). Participants’ outlined the importance of information gathering to being able to adapt to the new environment. Those who had done prior research about what to do with belongings, available social activities, the community lifestyle and the financial requirements of moving, had a greater person-environment and occupational fit post-relocation. Information gathering by participants helped decrease the sense of unease associated with the unknown, as identified by prior researchers (Rossen & Knafl, 2003). It included enquiring whether there would be activities of interest, or whether the other residents were friendly, and what important items should be brought from the home. The study found that by contrast those who had difficulty adjusting felt that a lack of information hindered a positive transition. Asking fewer questions, or not looking at
enough alternatives, led to potentially making ‘the wrong decision’ and relocation to a facility that perhaps did not suit the person’s unique living and environmental needs. Future interventions to assist the transition should emphasise the importance of gathering information before relocating to ascertain whether the retirement facility truly matches the person’s needs and wants. As this process is complex and there are a multitude of factors that need to be taken into consideration when deciding where and when to relocate, occupational therapists could help to simplify the process by developing checklists or assessments to ensure older adults had researched the options thoroughly before making a decision. This study was reliant on participants self-selecting involvement. Results are consequently dependent on those who had something to say, whether it be positive or negative. It could have been that those most dissatisfied or unable to articulate their feelings decided not to participate. Alternatively, those most satisfied and occupied may have been too busy to participate. The study design initially proposed a fourth stage of relocation, which would have focussed on the process of moving. However, as relocation can be a stressful and extremely busy experience, participants were unsurprisingly impossible to recruit.
Conclusion The study demonstrated that the people who did not defer the process of relocation were able to make the best decisions regarding their needs. Traditionally, occupational therapy with older adults has focused on promoting health and well-being through home modifications or improving participation in activities of daily living (Jonsson, Josephsson & Kielhofner, 2001). However, there is evidence to suggest that preventative occupational therapy focused on promoting meaningful occupations and wellness can have positive effects on mental and physical health (Clark et al., 1997; Matuska, Giles-Heinz, Flinn, Neighbor & Bass-Haugen, 2003). With the population of older adults increasing, there will be a greater demand for health care professionals to work proactively towards promoting healthy ageing. Despite relocation to retirement villages increasing in popularity, and moving being a potentially stressful event for older people, there are currently gaps in service provision to facilitate healthy ageing during this transition. It is not easy for older people to make relocation decisions as the process is often complex. Based on the results of this study, occupational therapists could promote healthy ageing across this transition by following an approach similar to the WellElderly study (Clark et al., 1997). Occupational therapists may be able to advise older people on the advantages and disadvantages of staying in their original homes or moving to retirement living. They are uniquely placed to facilitate healthy transitions through initiating preventa© 2013 Occupational Therapy Australia
452 tive programs aimed at simplifying the relocation process; providing guidance in relation to information gathering; actively encouraging decision making and forward planning; and providing education about the importance of maintaining engagement in occupations. Future research should include the implementation of a preventative, community-based occupational therapy intervention to determine whether it may facilitate health and well-being throughout home relocations in older age.
Acknowledgements The authors would like to thank the participants who agreed to be interviewed and the Retirement Living Facilities who assisted with recruitment of the participants. We gratefully acknowledge the School of Occupational Therapy and Social Work, Curtin University for the financial support for the project.
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