Day care for the elderly is not a new idea. It began in England years ago and has been steadily making its way into the larger metropolitan areas of the United States for the last two decades. As institutional costs continue to rise, and as waiting lists for in-home health aid grow longer, it is necessary for even smaller communities to seriously examine the possible advantages of the establishment of a facility to provide day care for its elderly members.
One can assume that in a community with an unusually high proportion of its population over age 65, and with its nursing homes filled to capacity, a need for a day care facility for the elderly does exist. However, many programs sincere in their intent to be of service, have been little utilized or have been forced to close due to lack of community support. Often this is a result of a lack of assessment to determine the community's desire or need of such a service.
In order to carry out an assessment of a specific nature in a sequential and nurse-oriented manner, three conceptual frameworks were chosen: a community model, the Systems Approach; a nursing concept, Roy's adaptation model; and a nursing process of mutual interaction.1·2
Roy's adaptation model views man as a biopsychosocial being in constant interaction with his changing environment. Because community is, simply stated, an aggregate of man, it too is espoused with biopsychosocial characteristics, and is in constant interaction with its own components and with the environment.
The biological aspects of community are: the physical resources, food, water, shelter; necessities for the community's survival. The psychological characteristics are: stressful stimuli, synchrony of components, security and belonging. The social characteristics are: education, employment, mental support and interrelations.
The role of nursing, according to Roy, is to promote adaptation while stimuli to biological, psychological and social aspects of man require change. This is accomplished by the nurse as assessment, planning, intervention, and evaluation are implemented.
As stimuli to the biopsychosocial aspects of community cause an uneven distribution of energy and a need for adaptation, the community nurse, using Roy's model can be instrumental in aiding the community to redistribute energy and move toward adaptation.
As previously stated, the community has, as does each individual, the right to determine those things which affects its function, and therefore must be afforded opportunity to interact as the adaptation process is being implemented. To assist the nurse in assuring this interaction, while working through the adaptation model, it is suggested that the process include the principles of mutual interaction.2
The model of mutual interaction has as its basic precept that man (community) has a right to participate in the process and to determine the events that affect him (it). The function of the nurse when using this process is to assist the client (community) in delineating, implementing, and evaluating alternative strategies for attaining the specific health goals.2
Therefore, the promotion of adaptation, assessing the need for it, planning goals and interventions and evaluating the results, will be a mutual endeavor. The feedback and interaction are the actual determinants of the need in the community and the desire of the community for the specified adaptation.
The community under consideration consisted of two small towns in close proximity with an estimated combined population of 24,000. The 1980 Census5 update showed the number of elderly over 65 comprised 13.4% ofthat area's population. This was an increase of 14.7% in a five-year period.
This assessment was initiated on the assumption that a need for day care for the elderly did exist. This assumption was formulated due to demographic proof of a dramatic increase in the elderly population and overcrowded nursing homes. Also, extended hospital stays for the elderly due to the shortage or inavailability of home supervision, and the intuition that there were families finding full-time home supervision of an elderly family member difficult were contributing factors.
This assumption, then, viewed the psychological and social aspects of the community, the family and the elderly themselves, as being stressed by the lack of day care services. It also showed the community in need of a redistribution of energy or adaptation to reduce this stress.
Roy's model suggests that there are four adaptive modes to be assessed: physiological needs, self-concept, role function, and interdependence. These four modes will be considered by the community nurse as the assessment seeks to test out the assumption made above.
Physiologic Modes Assessed. - The physiologic modes which appeared most relevant to the day care endeavor were the population statistics and the number of existent health structures of the involved communities. These facts were obtained in the communities' demographic files. The files indicated the population of persons 60 and over had made a marginable increase in the last ten years, and two hospitals and six nursing home facilities were presently in operation.
As investigation began, a mutual interaction also began. At first the statistics simply represented the community. However, later they aided the investigator's purpose in searching out the information, and in gaining input and feedback from those in the offices and facilities on their reactions to elderly day care.
This gathering of feedback, as the idea of the day care progressed, continued throughout the assessment.
Self-Concept Modes Assessed. - The assessment of self-concept was directed toward the community's concept of its elderly members. The question of the assessor was, "Can concern for the elderly be detected in this community?" The investigator began seeking out evidences or disproofs of this concern by looking at the action being initiated by the community to meet the needs of its elderly members. The agency involvement was not considered in this phase, as that was more appropriately placed on the role-function mode.
It was found by process of interview, questioning of health service personnel and street interviews, that the community seemed interested and concerned about its elderly members. Many volunteer programs exist which render a variety of services for the elderly, and community members are enthusiastically giving of their time and energy to these programs. Special considerations for seating, parking, transportation and discounts for the elderly have been afforded. In street interviews, respondents often made the statement "I think we should do all we can for the elderly."
Role Functioning Mode. - This selfconcept assessment gave an indication of the general feeling of the community for its elderly, but the role functioning assessment sought to find what was being accomplished in meeting the urgent needs of the elderly. This phase also attempted to determine if the community considered deficits to exist in its role functioning.
In the figure, the subsystems the assessor saw as most directly related to day care are given, and their affiliations to each other are demonstrated by solid lines. Day care is depicted with broken lines as it does not yet exist, and the broken lines running to it are possible sponsors or funding sources.
Contact was made with each of the subsystems to:
1. Determine their present role functioning in terms of the elderly;
2. Present the idea of elderly day care and ascertain their:
c. Consideration of need for the facility;
d. Desire to participate in the initiation of it; and
3. Determine each component's relationship to the other components.
Before proceeding further with the assessment, some sensitizing of the public was carried out by means of newspaper articles, and pamphlets briefly explaining day care.
The interaction with the agencies and government offices was carried out by means of personal visits and interviews. Day care was discussed with the elderly by visiting the senior citizens' centers. Questionnaires were sent to local physicians and social workers, and a sampling of the general population was contacted by sidewalk interviewing. AU of the responses from these contacts were compiled for analysis.
Crucial to the assessment, were those families presently caring for elderly in their homes. They would see day care as most relevant to their immediate situation. Some difficulty was encountered in locating such families. Survey sheets were sent to all of the local churches asking families to sign their name and address if they were caring for a dependent elderly person.
Of the 40 churches contacted, only two names were received. Other families were located through the home health agency and questionnaires were sent to them, along with a pamphlet explaining day care. They were questioned as to their perceived need for day care in their situation and asked if they would utilize a facility if it existed.
The results showed that all agencies, health facilities, and the governmental officials spoken to perceived a need for day care did exist in the community. The physicians and social workers cited over 200 possible candidates for the facility they had encountered in their practice in the last year, and wholeheartedly supported the idea. The general population interviewed also saw day care as a viable idea and thought that they would utilize it if it existed.
The families presently dealing with the problem were divided in their response. About half of those questioned saw day care as an answer to their situation and stated that they would utilize it, but the other half simply said that they would not take their family member to such a place, or that they felt their loved one would not wish to go.
The conclusions reached at the termination of this phase of assessment were:
1 . That a need for day care had been expressed by the community in general; and
2. A desire for the program was expressed but not fully supported by involved family members.
Other considerations which could possibly have contributed to the hesitation of families to express their desire for a day care center were:
1 . Cultural attitudes and values which would not sanction out-of-the-home care for an elderly member; and
2. Lack of adequate information concerning day care, its functions and advantages.
If after assessment it appears that adaptation can be accomplished and day care accepted, planning for intervention can be returned to the community level. The interdependence modes of the community can now be assessed for their potential capabilities to contribute to the redistribution of energy, and the community can begin its adaptation to more adequately meet the expressed needs of its members.
- 1 . Riehl J, Roy C: Conceptual Models for Nursing Practice. New York, Appleton-CenturyCrofts. 1980.
- 2. Williamson J: Mutual interaction: A model of nursing practice. Nurs Outlook February 1981.
- 3 . Health Profiles for Pennsylvania Counties and Towns. (Pamphlet) Division of Health Statistics, Harrisburg, Pa., 1976.