needs assessment of elderly people living in polish nursing homes-上海市老年护理院服务质量评价体系研究

NeedsassessmentofelderlypeoplelivinginPolishnursinghomesJustynaMazureka,DorotaSzczeniakb,n,DorotaTalarskac,KatarzynaWieczorowska-Tobisd,SylwiaKropiskae,HannaKachaniukf,JoannaRymaszewskabaTarnowskieGory,UpperSilesianRehabilitationCentre“REPTY”,PolandbWroclawMedicalUniversity,DepartmentofPsychiatry,PolandcPoznanUniversityofMedicalSciences,FacultyofHealthSciences,PolanddPoznanUniversityofMedicalSciences,DepartmentofPalliativeMedicine,PolandePoznanUniversityofMedicalSciences,DepartmentsofGeriatricMedicineandGerontology,PolandfMedicalUniversityofLublin,FacultyofNursingandHealthSciences,PolandarticleinfoArticlehistory:Received19August2014Receivedinrevisedform1October2014Accepted17December2014Availableonline29December2014Keywords:NeedsassessmentFrailelderlyNursinghomesabstractIntroduction:DemographicagingofthePolishpopulationisbecomingachallengeforhealthandsocialpolicy,similarlytootherEuropeancountries.Itisalsoseenasoneofthemostimportantcausesfordevelopingformallong-termcare.Objective:Theaimofthisstudywastoanalysethecomplexneedsofresidentsofnursinghomesover75yearsoldindifferentPolishcitiesfromdifferentperspectivesandtoexploretheunmetneedassociationsofhealth-relatedfactors.Materialandmethods:Thesampleconsistedof300randomlyselectedpeopleover75yearsoldfromdifferentnursinghomesinthreemetropolises:Wroclaw,PoznanandLublin.ThedetailedneedswereassessedusingtheCANEquestionnaireandpsychophysicalconditionwasbasedonMMSE,GDSandBI.Results:Comparisonofneedsexaminedfromthreedifferentperspectivesshowedthatnursinghomeresidentsreportedsignicantlyfewerproblemsthannursinghomestaffandraterandsignicantlymoreunmetneedsthanstaff.Themostcommonareaswhereunmetneedswerereportedwerecompany/friendsandpsychologicaldistress.Moreover,themoreseverethedepressionandtheworsethecognitivefunctionswere,themoreunmetneedswerereportedbynursinghomeresidents.Conclusions:Inordertoimprovethecareprovidedforelderlypeople,itseemsnecessarytopromoteknowledgeconcerningwiderneedsofelderlypatientsamongtheemployeesofdifferentgeriatriccarefacilites.Interventionstoreduceseniorsunmetneedsshouldbetargetedatorganisationalandmedicalassessmentissues.Futurestudieswithlongitudinalfollow-upsarerequired.&2014ElsevierGmbH.Allrightsreserved.1.Introduction1.1.Demographicdataandsocio-economicchangesTheagingprocessasademographicproblemisseenasoneofthemostfrequentlydiscussedtopicsinscienticdiscourse.Popu-lationprojectionsshowthatinEuropeancountries,thenumberofpeopleaged65yearsandolderisprojectedtorisefrom84.6millionto151.5million(Eurostat,2008).DemographicforecastsforPolandin2030areunfavourable.ThecountryisseenasthefastestagingcountryinEurope.In2007,6%ofthetotalpopulationinPolandwasaged75andover.However,inthenextthreedecades,thispercentagewillrapidlyincrease,withthegreatestincreasetakingplacein2025(Szweda-Lewandowska,2009).Apartfromtheagingofthepopulationthatdirectlyaffectsthegrowthofthenumberofpeopleseenascare-dependent,thereareanumberofotherfactorsthatshouldbetakenintoconsideration.Poland,duetoitssocio-economicchanges,facesachallengetoprovidedecentlivingconditionsforpeopleunabletoliveinde-pendently(BledowskiandMaciejasz,2013).1.2.ElderlypeopleinnursinghomesTheresearchersagreethateffectivecommunity-basedcareforelderlypeoplerequiresaholistic,biopsychosocialperspectiveandamorepatient-centeredapproachtothispopulationgroupsneeds(Wildetal.,2000;Muszaliketal.,2012;Dijkstraetal.,2012;Hoogendijketal.,2013).Theaimofpatient-centredcareistoacknowledgethepersonhoodofelderlypeopleinallaspectsofContentslistsavailableatScienceDirectjournalhomepage:/locate/gmhcGeriatricMentalHealthCare/10.1016/j.gmhc.2014.12.0012212-9693/&2014ElsevierGmbH.Allrightsreserved.nCorrespondenceto:WroclawMedicalUniversity,Pasteura10,50-367Wroclaw,Poland.Tel.:48717841628;fax:48717841602.E-mailaddress:(D.Szczeniak).GeriatricMentalHealthCare2(2015)915theirfunctioning.Suchcareinvolvespatient/residentinpartner-shipwhilecreatingatherapeuticplan.IntroducingtheComprehensiveGeriatricAssessmenttakingintoaccountnotonlyphysicalbutalsopsychologicalandsocialdimen-sionsintomedicalpracticeisseenasastandard(Derejczyketal.,2005).Anaccurateidenticationofneedsshouldconstitutethebasisofplanningandcreatingacareframeworkinnursinghomes,wherethedependenceofelderlypeopleonothersappearstobehigheramongresidentsofnursinghomesthanthoselivingoutsidecarefacilities(Harrisonetal.,1990;Briggsetal.,2013).Moreover,goodpractice(amethodthathasconsistentlyshownresultssuperiortothoseachievedwithothermeanstomaintainquality)requiresthattheassessmentalsoincludetheperspectiveofelderlypeopleandtheircaregivers(Miranda-Castilloetal.,2013).TheCamberwellAssessmentofNeedfortheElderly(CANE)isanuseful,comprehensive,psychometrictooldesignedtoassesstheneedsofelderlypeopleseeninadifferentperspectives:theelderly,rater,caregiverandmedical/nursinghomestaff.TheCANEisalsousedinotherstudiesinvolvingcaringrelativesoftheresident(Fink,2011).AccordingtoCANE,aneedisasituationinwhichthereisasignicantproblem,forwhichthereisanappropriateinterventionthatcouldpotentiallyhelporalleviatetheproblem.Furthermore,authorsdenedmetandunmetneeds.Aneedismetwhenthereisamoderateorseriousproblemthatisreceivinganintervention,whichisappropriate.Anunmetneedisseenasaproblemrequiringintervention,whichiscurrentlyreceivingnoassistanceoraproblemregardedtobeseriousdespiteanyhelpreceived(OrrellandHancock,2004).Innursinghomes,itisfoundthatthemostfrequentunmetneedsidentiedbytheauthorsareintheareaofdaytimeactivities,psychosocialdistressandcompany(Martinetal.,2002;Hancocketal.,2006;Orrelletal.,2008).Thesystematicreviewofthestudiesonneedsofpeoplewithdementiainlong-termcare,publishedbetween2000and2010,showsthatpsychosocialneedssuchastheneedtoengageindailyindividualizedactivitiesandcaremustnotbeignoredincommunitydwellingsettings(Cadieuxetal.,2013).Theaimofthisstudywastoidentifytheperceivedneedsinnursinghomesaccordingtothenursinghomeresidents,raterandnursinghomestaffinvolvedintheirrunninginthreedifferentcitiesinPolandandtoidentifydemographicandclinicalfactorsassociatedwithunmetneedsandthehelpadequacydenedassatisfactionreportedonlybyresidents.Indicationofspecicneeds,inwhichtherearediscrepanciesbetweendifferentper-spectives,willenabletohighlightthoseaspectsofcare,andindicationsofdifferencesintheperceptionofdemandandtheresultingsupport.Indicationoftheparameterscorrelatedwiththenumberofunmetneedswillenabletoindicateagroupofelderlypeople,inwhomitisappropriatetodeterminetheirfunctionalstatus,deneneedsandplansupportanditsmonitoring.1.3.EthicalissueTheresearchwasconductedasapartofthenationalNN404520738projectfoundedbyMinistryofScienceandHigherEducation.EthicalapprovalwasobtainedfromtheLocalEthicsCommitteeandallsubjectslledoutaninformedconsentformpriortoinclusioninthestudy.Therateraddressedanydoubtsaboutthestudyandrestatedthesubjectsrighttowithdrawatanytimeduringitscourse.Moreover,allsubjectswereensuredthatalltheinformationwouldbekeptcondential.2.Method2.1.ProcedureThesamplepopulationwasmadeupofpublicnursinghomesresidentsfromthreelarge,voivodshipcitiesfromEast,WestandSouthPoland(Wroclaw,PoznanandLublin).Atotalof300residents,100ineachcity,aged75andolderunderwentacross-sectionalstudy(Table1).Interviewswereconductedbyratersfromthreeresearchinstitutesinthreecities,whowerecliniciansorpsychologistsandwhoweretrainedtousetheCamberwellAssessmentofNeedfortheElderly(CANE).Theassessmentwascarriedoutwithrespecttothreeperspectives:thenursinghomeresident,theraterandthenursinghomestaff.Incaseswhereresidentsdidnotunderstandcertainquestions,onlytheraterandstaffperspectivewastakenintoaccount.Theraterobtainedinformationabouttheresidentsthroughpersonalinterviewandobservation.InordertokeeprobustmethodologythereauthorschoseapriorithattheMini-MentalStateExaminationscorebelow15wouldbetheexclusioncriteriaforusingCANEfromthenursinghomeresidentsperspectiveineachcity.2.2.MeasuresResidentswereaskedforinformationregardingsocio-demographicvariablessuchastheirageandyearsofeducation.TheCamberwellAssessmentofNeedfortheElderly(CANE)wasusedasacomprehensiveinstrumentdesignedtoevaluatetheneedsofelderlypeopleseenfromthreeperspectives:thenursinghomeresident,theraterandnursinghomestaff(OrrellandHancock,2004).CANEwaschosenasitoffersastructuredassessmentofhealthandpsychosocialneedsfromstaffandserviceaswellasfromelderlypeople.Itcovers24areasofneedsandcanbeansweredin30min,whichisseenascrucialduringelderlypeopleassessment.Eachitemisratedbasedoninformationgatheredabouttheresidentduringthe2monthspriortotheinterview.Moreover,CANEhassoundpsychometricproperties(reliability0.99)(Reynoldsetal.,2000).ThepreviousstudyofthePolishversionofthetoolshoweditshighvalidity,reliabilityandfeasibilitywhichappearstobecometheattractiveaswellaseffectivetoolfortheassessmentofneedsofelderlypersonsinthePolishculturalcontext(Rymaszewskaetal.,2008).Itisnotaself-administratedinstrumentandcanbeusedbyawiderangeofprofessionals.Whatisimportant,itisbasedontheholisticapproachtoneedsandissuitableforclinicalandresearchpurposes.AllsubjectsunderwenttheMini-MentalStateExamination(MMSE)includedasabrieftestofcognitivefunction(Folsteinetal.,1975)Table1Samplingdesign.ThewholepopulationofresidentsThepopulationofresidents75Expectednumberofresidentswhoagreetoparticipateinthestudy(80%)Firstdrawnnursinghome(I)1429072Seconddrawnnursinghome(II)382419III91Thirddrawnnursinghome(III)694032III:9peoplewerechosentocompleetethesample(n100)J.Mazureketal./GeriatricMentalHealthCare2(2015)91510conductedbyraters.Consideringdepressivesymptomsasthemostfrequentmentalhealthproblemamongelderlypeople,theGeriatricDepressionScale(GDS)wasusedtoassessthelevelofdepressioninresidents(Yesavageetal.,1983).However,dataofonlytwohundredandtwentyninesubjectswereavailableduringanalysis.Seventy-onesubjectswerenotabletounderstandquestionsfromGDS.Further-more,theresidentsfunctionalcapacitytoperformdailyactivitieswasevaluatedusingtheBarthelIndex(BI)(WadeandCollin,1988).2.3.StatisticalanalysisTheWilcoxonSigned-RankTestwasusedtomeasurethedifferencesinthenumberofneedsidentiedbyvariousinter-viewees,sincetheneedswerenotnormallydistributed.Meansarepresentedinsteadofrankstodisplaytheresultsmoreclearly.Thebetween-groupcomparisonofage,lengthofresidencyandpsy-chologicaltestscoreswereassessedusingaone-wayanalysisofvariance(ANOVA)withtheposthocTukeytestforanequalsamplesize.AccordingtoHoeetal.,theanalysisofvariance(ANOVA)wasalsousedtoinvestigatefactorsassociatedwithhavingoneormore(1)unmetneeds(Hoeetal.,2003).TheSpearmanrankcorrelationtestwasusedtoinvestigatetherelationshipbetweenunmetneeds,helpadequacyandotherfactors.Thesignicancelevelwaspreviouslysetatpo0.05.AnalyseswereperformedusingSTATISTICA,StatSoftInc.,Polska,version10.2.4.DescriptivedataAtotalof300randomlyselectedresidentslivinginnursinghomesfromthreeurbanareasinPolandwereincludedinthestudy(Table2).Theassessmentwasconductedwithrespecttothreeperspectives,elderlypeople,theraterandthepermanentmedicalstaffinvolved.Therewere63(21%)malesand237(79%)femalesinthegroupofresidents.Subjectsrangedinagefrom74to102withameanageof83.475.88.Thelengthofresidencyrangedwidelyfrom1to303monthswithamean64.4765.11.ThetotalsampleofsubjectshadameanMMSEscoreof14.779.32indicatingamoderatecognitiveimpair-ment.ThemeanGDSscoreinthesamplewas7.273.77signifyingmoderatedepressionamongtheresidents.TheBarthelIndexwhichmeasuredtheperformanceindailyactivitieswas50.3735.59.Almosthalfofthetotalsubjectpopulation(49.33%)weresecondaryschooleducated.3.Results3.1.NeedscomparisonbythreeperspectivesAlthoughwetriedtointerviewatotalsampleofresidentsusingCANE,onehundredandtwenty(40%)ofthemwereunabletounderstandthequestions(thosewithaMMSEscorebelow15).Thus,insuchcases,onlytheraterandnursinghomestaffanswerswereobtained.Tables3and4showtheneedsratedfromthreeperspectives:thenursinghomeresidents,theraterandthestaffinvolved(Tables3and4).Accordingtoacomparisonofthetotalnumberofneedsidentiedbydifferentinterviewees,nursinghomeresidentsreportedsigni-cantlyfewermetneedscomparedwiththenursinghomestaff(Z8.25;po0.0001)andrater(Z8.29;po0.0001).Therewasastatisticallysignicantdifferencebetweenthereportsoftheresidents,raterandstaffastotheneeds,whichweremet.Intotal,nursinghomeresidentsidentiedsignicantlymoreunmetneedsthanstaff(Z6.36;po0.0001).However,therewasnosignicantdifferenceinthenumberofunmetneedsreportedbyelderlypeopleandrater(Z0.95;pn.s).Overall,comparedwithstaff,therateridentiedsignicantlyfewermetneeds(Z3.62;po0.001)andsignicantlymoreunmetneeds(Z7.55;po0.0001).3.2.Areasofneedsratedbytheperspectiveofnursinghomeresidents,raterandnursinghomestaffOnehundredandeightyresidentswithaMMSEscoreof15andmorecompletedtheCANE.Themeantotalnumberofneedswas9.16,ofwhich7.84weremetneedsand1.32wereunmetneeds.Themostcommonlymetneedswereaccommodation(n148,82%),householdskills(n169,94%),food(n171,95%)andphysicalhealth(n170,94%).Themostfrequentlyunmetneedswerepsychologicaldistress(n45,25%),company(n51,29%),intimaterelationships(n25,14%),information(n24,13%),eyesight/hearing/communication(n29,16%)anddaytimeactiv-ities(n24,13%).Allresidentsneveridentiedtheareasofaccommodation,food,continence,drugs,accidentalself-harm,behaviourandalcoholasunmetneeds.Itmeansthataccordingtonursinghomeresidentsfromthisstudytheareasabovemaybeseenasproblemsrequiringintervention,howeverthereceivedassistanceisappropriate.Themostcommonarearatedbynursinghomeresidentsasunsatisfactoryconcerneddaytimeactivities(29,16%),company(28,15%),eyesight/hearing/communication(26,14%)andpsycho-logicaldistress(24,13%).TheCANEstaffratingswerecompletedbyallthreehundredsubjects.ThemeantotalnumberofneedsreportedbynursingTable2Demographicdataforstudygroup(means7sd).FactorTotal(n300)Age83.475.88GenderM/F63/237Lengthofresidency(inmonths)64.4765.11MMSE14.779.32BI50.3735.59GDS7.273.77Table3Needsratedbynursinghomeresidents,raterandnursinghomestaff(means7sd).Residentsn180Ratern300Staffn300Metneeds7.8473.209.4972.209.7173.01Unmetneeds1.3271.470.8871.200.5170.92Totalneeds9.1673.4610.3773.2110.2273.23Table4Acomparisonofthetotalnumberofneedsidentiedbydifferentinterviewees.VariableTworelatedsamplesaWilcoxonsigned-ranktestZpMetneedsResidentsvsrater8.29o0.0001Residentsvsstaff8.25o0.0001Ratervsstaff3.63o0.001UnmentneedsResidentsvsrater0.95n.sResidentsvsstaff6.36o0.0001Ratervsstaff7.55o0.0001TotalneedsResidentsvsrater7.97o0.0001Residentsvsstaff4.87o0.0001Ratervsstaff2.23o0.05an180foreachsample(residenst,raterandstaff).J.Mazureketal./GeriatricMentalHealthCare2(2015)91511homestaffwas10.22.Ofthese,9.71weremetneedsand0.51unmetneeds.Themostfrequentlymetneedswereaccommoda-tion(n253,84%),householdskills(n295,98%),food(n288,96%)andphysicalhealth(n290,96%).Themostcommonunmetneedswerepsychologicaldistress(n30,10%)andcompany(n35,12%).TheraterCANEresultswereavailableforallthreehundredsubjects.Themeantotalnumberofneedsidentiedbyraterwas10.37,where9.49weremetneedsand0.88wereunmetneeds.Themostcommonlymetneedswereaccommodation(n262,87%),householdskills(n297,99%),food(n290,96%)andcontinence(n286,96%).Themostfrequentlyunmetneedswerecompany(n50,17%),intimaterelationships(n36,12%),psy-chologicaldistress(n44,15%),eyesight/hearing/communication(n37,12%)anddaytimeactivities(n38,13%).DetailsoftheareasofneedsareshowninTable5.3.3.AssociatedfactorsofunmetneedsInordertoinvestigatethepredictorsofunmetneeds,theCANEnursinghomeresidentsperspectiveandclinicalfactorswereanalysedamongallresidentsfromthethreedifferentcities.Datafrom180residentswereavailable.114(63.3%)subjectsrespondedashavingoneormoreunmetneeds.Theresidentsageandlengthofresidencywerenotassociatedfactors,astherewasnosig-nicantdifferencebetweenparticipantsaccordingtothosevari-ables(Table6).SubjectswithoneormoreunmetneedshadsignicantlylowerBarthelIndex(po0.0001)score,hadgreaterdepressivesymptoms(po0.05)andalowerlevelofcognitivefunctions(po0.05).Overall,thelevelofhelpadequacy(satisfaction)wasnotcorrelatedwiththenumberofunmetneeds(r0.7,pn.s)reportedbyresidents.Moreover,therewasasignicantmoderatenegativecorrela-tionbetweenthehelpadequacyidentiedbysubjectsandtheBarthelIndex(rC00.5,po0.0001),aswellasaweakpositiverelationshipbetweenthehelpadequacyandGDSscore(r0.2,po0.01).Generally,nursinghomeresidentswhoscoredhigheronMMSEshowedalowerlevelofhelpadequacy(rC00.2,po0.05).4.DiscussionTheclientsperspectiveisconsideredoneofthemostimpor-tantpointsofviewduringtheneedsassessmentprocess,particu-larlywhenassessingelderlypeople.However,authorsemphasizethediscrepancybetweenthesubjectiveneedsassessmentandtheperspectiveofcarersandrater(McCroneetal.,2005).Therefore,thegreatestadvantageoftheCANEquestionnaireisitsmulti-dimensionalperspectiveresultingfromseveralpointsofview:elderlypeople,raterandmedical/nursinghomestaffinvolved(interdisciplinaryapproach).Comparingtheresultsfromvariousperspectivesenablestoobtainthedifferenceintheperceptionofthedemandforhelp.Itpointsatanadditionalpossibilityofusingthequestionnaireforthepurposesofverifyingthelevelofprovidedcare.Italsofacilitatescommunicationbetweenprofes-sionalsandrulesoutprospectiveduplicationofsupportinsomeareasand/oritslackinothers.Inthepresentstudy,thediscrepancybetweenthenursinghomeresidentsperspectiveandtheremainingintervieweeswasalsorelevant.Theresidentsreportedsignicantlyfewermetneeds,andtogetherwithratertheyperceivedsignicantlymoreTable5Levelofneedsindifferentareasidentiedbynursinghomeresidents(NHR),rater(R)andnursinghomestaff(S)andthelevelofhelpadequacyidentiedbyusers.NHR180,R300,S300Metneedn(%)Unmetneedn(%)Notadequaten(%)NHRRSNHRRSNHRAccommodation148(82)262(87)253(84)0(0)0(0)0(0)5(2.8)Householdskills169(94)297(99)295(98)1(1)0(0)0(0)0(0.0)Food171(95)290(96)288(96)0(0)1(1)1(1)2(1.1)Self-care106(59)248(82)250(83)3(2)1(1)0(0)4(2,2)Caringforsomeoneelse1(1)3(1)3(1)2(1)2(1)3(1)0(0.0)Daytimeactivities64(36)101(34)98(33)24(13)38(13)25(8)29(16.1)Memory48(27)146(49)151(50)5(3)3(1)2(1)7(3.9)Eyesight/hearing/communication68(38)120(40)195(65)29(16)37(12)9(3)26(14.4)Mobility/falls108(60)177(59)176(59)9(5)8(3)7(2)19(10.6)Continence96(53)220(73)218(73)0(0)1(0,5)0(0)1(0.6)Physicalhealth170(94)286(96