The Stress of Nursing Home Admission

In 1967, psychiatrists Holmes and Rahe created a scale that measures the stress levels of various life events, and found that people with stress levels over 300 are at high risk of illness. I’ve always considered a nursing home stay to be a very stressful experience, but applying the scale was illuminating.

I took the Holmes and Rahe Stress Scale and modified it based on working with nursing home residents. For example, the Social Readjustment Rating Scale (SRRS)  allots 65 points for a marital separation, but since moving away from one’s spouse to enter a facility isn’t a typical marital separation, I gave it 50 points. Nursing home residents aren’t technically imprisoned (63 points), but it is extremely confining, so I reduced that item to 50 points.

In my view, residents are not retired, but have started their jobs of working with the staff 24/7 in order to attend to the business of taking care of themselves, so I included many work-related items not usually considered the province of residents.

This left me with the following items on the 43-item scale:

Marital Separation  (50)
Imprisonment  (50)
Personal Injury or Illness  (53)
Business Readjustment  (39)
Change in Financial State  (38)
Change to a Different Line of Work  (36)
Change in Responsibilities at Work  (29)
Change in Living Conditions  (25)
Revision of Personal Habits  (24)
Change in Working Hours or Conditions  (20)
Change in Residence  (20)
Change in Recreation  (19)
Change in Church Activities  (19)
Change in Social Activities  (18)
Change in Sleeping Habits  (16)
Change in Eating Habits  (15)


Grand Total: 471 points

471 points, on a scale that finds a high risk of illness at stress levels over 300 points.  On the updated SRRS, the total comes out much higher, with the person considered in a life crisis.

Upon admission to the nursing home, residents are required to see the dietician, dentist, social worker, and recreation therapist. A life crisis, and we have yet to require a psychological evaluation of the residents.  Referrals are currently haphazard, and based on the psychological-mindedness of the nursing home staff.

Readers who feel they, their residents, or their loved ones might benefit from the assistance of a psychologist in coping with the magnitude of these life changes can suggest a referral for evaluation for a particular individual (until regulations catch up with the need).

12 thoughts on “The Stress of Nursing Home Admission”

  1. Dr. El,

    Just the loss of independence would be enough to put me over the edge.

    It is shocking that psychological evaluation upon admission is not a regulation. It does not take a rocket scientist to know that most people entering a nursing home would benefit from psychological support. You would think "they" might have figured it out already.

  2. Amazing……..I, too have often used the anology in talking with Residents that what they are embarking on is a new career. "this is your new profession", I tell them. Getting through the day is huge, demanding so much energy, newfound skills and patience. I tell them that they are heros/explorers in unchartered territory. The Nursing home environment, lets face it, can be like Antartica, and they are all like Admiral Bird, trying to find their own way on many levels. When you see this environment as a microcosm in terms of everyday life, you can compare every movement/action as something similar to real life. For example, manuvering the wheel chair out of your room is ike trying to get out of the garage. Being transported/pushed occassionally in your wheelchair is like getting a taxi after hours of weary walking in the City. I could go on and on with these. Yes, SO TRUE, they are not retired! And yes, it absolutely should be a standard practice that upon admission a "guidance counselor" help them find their way in an unhurried, meaningful and supportive way!!!!

  3. Sue, there are a lot of aspects of nursing home admission that would bother me, but I think I'd be put over the edge by the patronizing tone many people adopt when talking to seniors.

    Providing psychological support during this time of crisis would make the nursing home experience better for residents, families, and staff members. I hope regulations change, and/or that more nursing homes recognize the need in their facilities. This should happen to some extent with the increased focus on depression in the MDS (minimum data set).

  4. Hello, I loved the Admiral Bird reference and wouldn't it be nice if everyone had this attitude. I am in a four month placement at a long term care and am desperately looking for ideas to make transition to long term care a friendlier experience. I am looking for examples of "life history/personality" face sheets…that could be put together for each "house" in the facility..accessible to staff with hopes that they would look for info on new residents to avoid unneeded conflict. With the constant rotation of overworked staff, the residents are the ones that suffer when staff do not know who they are caring for…
    If anyone has any examples of face sheets dealing with life history/personality/likes and dislikes, I would greatly appreciate it. There is not enough time in the day to make a change in this facility. Thanks so much.

  5. Anonymous, I haven't seen a "person-centered face sheet," but I've seen memory boxes outside people's rooms that have reflected the lives and interests of the residents. They're used mostly for residents with dementia. Encouraging family members to bring photos and mementos from home can fill the same function.

  6. Thank you so much for your prompt reply! I have started memory boxes on residents and we had to stop for a while after encountering a family member that wanted to press charges….Our memory boxes were done years ago, but for some reason were all removed by one administrator.
    Sad when people don't understand the importance of these life stories for the staff and everyone else that must care for someone unable to express themselves. I want to make an "at a glance" face sheet for personality/likes/dislikes that Personal Support Workers could take a quick look at to avoid upsetting residents. I will probably have to put something together myself, but I was hoping someone out there had a great idea that was already in practice. So difficult to sit down and create documents when so many residents need one on one personal attention. (I am the only person that has the time to talk to lonely residents as we are understaffed and overworked like most long term care facilities. If anyone has any ideas, please share them. In the meantime, thank you for this blog. I have found some wonderful information that I will be taking back to the staff of our "Life Enrichment" Department. Thanks again.

  7. Hello,
    i have the good fortune of consulting in a great facility that has a terrific motto, “Life and all the living that goes with it”. While adjusting is always hard, i see lots of people who have a life that is of higher quality than they’ve ever had living on their own. I think it’s important to remember that these places are not prisons, and the comparison to prison is not useful! It insults the people who work in care centers providing loving care every day of their lives.
    So yes, all change is stressful! And a good life can come of it, even in long term care. I think our attitude about placement impacts the outcome. If we believe in the facilities we serve, we will do a better job helping people adjust..
    thanks for listening
    Dr. Carol

    • Thanks for your thoughtful comment, Dr. Carol. I agree that many people living in nursing homes can have a higher quality of life than they could on their own. I meant no insult to the people who work in long-term care (as I do) by using the “prison” item on the stress scale. There was no other item to reflect the confinement of the nursing home situation and I lowered the value of the item accordingly. Most nursing homes don’t allow residents to go out on their own and require them to be signed out of the facility by a “responsible party.” Most residents I talk to find that requirement confining even if they’re pleased with other aspects of life within long-term care.


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