Similar to other developing countries, the long-term care facilities in Taiwan were rare in the 1980s. The care of adults older than age 65 was primarily provided by family caregivers, usually in the homes of elderly individuals or their family members. However, with expanding industrialization and an improving economy, a decreasing number of elderly individuals are living with their children, indicating a change from traditional family structures to those emphasizing nuclear or stem families.
More chronically ill older adults discharged from acute care hospitals in Taiwan are being admitted to nursing homes (Hu, Wang, & Kuo, 1995), as are increasing numbers of community older adults requiring long-term care (Liou, 1998). Although only approximately 32,000 of the 1.75 million older adults in Taiwan were estimated to need institutional long-term care in 1997, there are currently only 5,367 formally registered nursing home beds. There will undoubtedly be many more nursing homes in Taiwan, with thousands of new beds in the coming years.
With this rapid increase in the number of nursing homes in Taiwan, it is timely to assess the quality of care provided in these facilities. The quality of nursing home care is a major concern for the elderly residents, family members and caregivers, and health care providers (Yeh, 1995). Previous studies of long-term care in Taiwan, specifically nursing homes, have focused on the characteristics of elderly residents (Shyu, Hsiung, Dai, Chen, & Huang, 1993), number of staff and their educational preparation (Leu, Wu, & Hu, 1993), equipment (Lee, Wang, fie Chou, 1990), and environmental conditions (Dai, Shyu, Hsiung, Chen, & Huang, 1992). Yet, the quality of nursing home care in Taiwan is not known. The primary purpose of this article is to describe the quality of care and how elderly residents perceive the quality of their care in nursing homes in Taiwan.
The assessment of quality of care often includes the elements of structure, process, and outcome (Donabedian, 1988). Structure describes physical, organizational, and other durable characteristics of the system (e.g., the equipment of the facility). Process is what is done when caring for patients (e.g., nurses' activities). Outcomes refer to the benefits and harms that result from care, health status, satisfaction with care, and quality of life (Donabedian, 1980). Nursing home quality of care depends on how structure and process characteristics produce health outcomes. Peters (1995) asserted that outcomes are the mainstay of a framework for quality care. Indeed, resident outcomes have become markers of care effectiveness and quality in long-term care facilities (Braun, 1991; Harris & Warren, 1995).
According to Kane (1995), the components of outcomes in longterm care usually encompass physiological functioning, activities of daily living, pain and discomfort, cognition, affect, social activity, social relationships, and satisfaction. Yang, Simms, and Yin (1998) studied many of the same outcome components identified by Kane and found positive changes occurred in Taiwanese nursing home residents' health conditions regardless of the nursing staff's practice patterns (structure and process). However, nursing practice patterns indirectly influenced residents' satisfaction with care. Yang et al. (1998) also found residents' physical and psychological functioning was positively and significantly related to social functioning. In addition, perceived quality of care and resident satisfaction directly affected overall functioning. Schnelle, Ouslander, Osterweil, and Blumenthal (1993) also support including both objective health status outcome measures and consumer satisfaction data to evaluate quality of care.
Resident satisfaction has been considered to be one of the desired outcomes of nursing home care in the United States (Bliesmer & Earle, 1993; Eriksen, 1995; Ryan, Collins, Dowd, ei Pierce, 1995). It is an indispensable source of data in assessing the quality of care (Kruzich, Clinton, Oc Kelber, 1992). Grau, Chandler, and Saunders (1995) found that residents who were disengaged from others, and those who had few expectations for the future, were most likely to focus critically on the details of daily life.
Dai et al. (1992) found that degree of privacy determined by number of individuals sharing a room and the facility's interior decoration was associated with residents' reports of satisfaction with the long-term care facility. Similarly, Rodgers (1989) and Tai val and Raatikainen (1993) found home-like environments and small care groups of residents with more personal human interaction resulted in less loneliness and more satisfaction of residents' needs. Research also suggests resident satisfaction is a potentially important medical outcome indicator of quality of care (Cleary & McNeil, 1988; LavizzoMourey, Zinn, &C Taylor, 1992; Tarlov et al., 1989).
The following research questions were proposed for this study:
* What is the prevalence of selected resident clinical care outcomes among Taiwanese elderly residents in nursing homes?
* How do Taiwanese elderly residents rate their level of satisfaction with nursing home care?
* What demographic factors correlate with clinical care outcomes and level of satisfaction with nursing home care in Taiwan?
Fourteen, of 18 nursing homes registered with the Department of Health in Taiwan in the beginning of 1998 were selected for this study by use of a random table. One of the nursing homes refused to participate. The selected nursing homes had to meet the inclusion criteria of being identified as a long-term care facility and providing nursing care supervised by professional health care providers.
Participants were randomly selected from 13 nursing homes by tossing a coin for each nursing home to indicate whether residents in even or odd numbered beds would be asked to participate. Only four of the selected residents refused to participate. The total participant sample was 308 residents. Elderly residents with mental problems or inability to respond to orai interview questions were also included in this study, but consent to participate and responses were given by family caregivers.
A number of instruments were used to collect data for this project. A demographic questionnaire was used to collect information on the elderly residents' characteristics, such as age, gender, diagnoses, educational level, religious preference, length of stay, and place of residence prior to nursing home admission. In addition, basic health status information was collected from medical records. The demographic questionnaire for the nursing homes included the nursing home location; ownership; year of opening for business; number of beds; number of residents; and number of nursing staff, physicians, physical therapists, and social workers.
The patients' cognitive function was assessed with the Short Portable Mental Status Questionnaire (SPMSQ) (Pfeiffer, 1975). The SPMSQ consists of 10 questions testing remote memory, awareness of current events, and mathematical ability. The SPMSQ is part of the multidimensional Older Adult Resources and Services (OARS) instrument and has been used extensively with elderly individuals (Duke University Center for the Study of Aging and Human Development, 1978). The Chinese version of the SPMSQ was developed and modified by Lm, Dai, Lin, Chen, and Lai (1996) who reported the norms for the Chinese version with the Taiwanese population. Interrater reliability of the SPMSQ was .90 across five raters in this study.
The Functional Independence Measure (FIM) instrument is part of the Uniform Data System for Medical Rehabilitation (State University of New York at Buffalo, 1997). The FIM has 18 functional area items scored on a Likert scale from 1 (dependent) to 7 (independent). The categories in the instrument include mobility, self-care, communication, and cognitive function. The scores obtained by elderly residents are commonly used to reflect the burden of care and costs of disability (Pollack, Rheault, & Stoecker, 1996). The Chinese version of the FIM instrument was developed and modified by Chen, Chen, Liu, and Kou (1996). Five clinical experts in Chen's study established face validity of the Chinese version of the FIM. The Cronbach's alpha reliability coefficient was .97 and interrater reliability was .89 in this study.
A clinical outcomes checklist was developed to record whether or not a resident had experienced pressure ulcers, urinary tract infections, stool impactions, physical restraints, falls, injuries, re-hospitalizations, and short-stay return home. These data were obtained by reviewing the residents' medical records.
The Satisfaction with Nursing Home Scale (SNHS) (McCaffree & Harkins, 1976; Kane, Riegler, Bell, Potter, & Koshland, 1982) was used to measure the satisfaction of nursing home care from the residents' perspective. The SNHS has 17 items designed to measure the residents' satisfaction with issues directly related to the nursing home environment and staff. Each item is scored as 1 (disagree), 2 (neutral), and 3 (agree). The SNHS has reliability coefficients of .88 and .80 (Kane et al., 1982).
Two independent translators accomplished translation of the SNHS scales from English to Chinese and back translation from Chinese to English prior to initiating the study. Two bilingual researchers were asked to verify the Chinese version of the SNHS for expert validity. Only minimal wording changes were made to be compatible with Taiwanese culture.
Two items were added to the Chinese version of the SNHS including satisfaction with rehabilitation and language as a barrier when talking to staff. Five research experts assessed content validity of the SNHS (Chinese version). The SNHS had a Cronbach's alpha reliability coefficient of .79 and interrater reliability of .90 across five research assistants in this study. Only elderly residents with intact or mild impairment of mental function were interviewed using the scale.
A pilot study was conducted with five residents in a nursing home. Data collection instruments and procedures were then refined. The purpose of the research was discussed with nursing home administrators of the 13 selected nursing homes, selected patients, and the selected patients* family caregiver.
RESIDENTS' SHORT PORTABLE MENTAL STATUS QUESTIONNAIRE (SPMSQ) SCORES (N= 308)
To preserve anonymity and confidentiality, only code numbers were used to identify respondents. Patients and their family caregivers were interviewed and were informed of their rights in participating in the study. The interviews were conducted in Mandarin or Taiwanese by one of five research assistants in each of the nursing homes. The research assistants received 8 hours of training in interviewing procedures including administration of study instruments to secure consistency of data collection. Interrater reliability of the instruments was determined prior to conducting the formal interviews. The duration of each face-to-face interview was approximately 45 minutes. All data were collected during a 3-month period. Statistical analysis of the survey data was computed using the Statistical Package for Social Sciences for Windows version 8.0 (SPSS Inc., Chicago, IL, 1998).
Demographic Characteristics of Residents
The average age of the residents was 75.8 years (SD = 11.2). More than half of the residents were women (56.3%). The educational level in the older generation in Taiwan is relatively low. Almost 45% (44.8%) of the patients were illiterate. Approximately 19% (18.5%) had an elementary school education, with 9.7% junior high school, 12.3% high school, and 8.8% college or graduate school education. The residents were predominantly Taoist and Buddhist (67.2%). Almost 62% (61.9%) of the general population of elderly Taiwanese were presently married, compared to 43.2% of the patients in the study. Approximately 48% (47.7%) of the respondents were widowed. Percent of women, educational level, and religious preference of study respondents were similar to these characteristics in the general Taiwanese population (Department of Health, 1999).
Stroke was the most common primary diagnosis of nursing home patients (44.5%), followed by dementia (28.5%), hypertension and diabetes (5.2%), fracture (3.9%), head injury (3.6%) and other (14.2%). In the general Taiwanese population, the prevalence of stroke is only 0.2%, but 75% of those affected are elderly. Only 2.5% of the general elderly population have a diagnosis of dementia. The average length of stay in the nursing home at the time of the study was 330.8 days (SD = 388.2). Eighty-one percent (81.2%) of the respondents had previously lived at home, whereas another 9.4% had been placed in other nursing homes before this admission.
Demographic Characteristics of the Nursing Homes
Two nursing homes were located in northern Taiwan, two in central Taiwan, and nine in southern Taiwan. The government owned one nursing home, two nursing homes were owned by a private consortium, two nursing homes were funded by churches, and eight other nursing homes were private, independently owned. The average number of years the nursing homes had been established was 2.23 years (SD = 1 .28, range from 1 to 4.5 years) with an average of approximately 45 beds (M = 44.7, SD = 13.4). The average number of residents in the nursing homes was 37.9 residents (SD = 12.08, range from 19 to 56). There was an average of five residents per room (M= 4.9, SD= 1.9).
An average of 5.5 RNs were employed in each nursing home with a range of 4 to 10 RNs. The average number of nursing assistants (NAs) employed in the nursing homes was 12.7 (SD = 4.4). One or 2 RNs with 2 to 5 NAs per shift took care of the residents. This indicates some RNs carried a large caseload of residents each shift. Overall, the ratio of nursing staff (RNs and NAs) to patients was approximately 1 to 2, although the ratio of RNs to elderly residents was lower at 1 to 7. Four nursing homes employed a full-time physician and nine nursing homes employed a part-time physician. Only five nursing homes had a full-time physical therapist and eight nursing homes did not employ licensed physical therapists at all. Two nursing homes employed a fulltime social worker and one nursing home had a part-time social worker.
Functional Status of the Residents
The SPMSQ results indicated 75% of the patients in the nursing homes had some degree of cognitive impairment (SPMSQ scores with fewer than five correct answers). The average number of correct answers on the SPMSQ was 2.47 (SD = 3.20, range from O tolO) (Table 1).
The average score on the FIM was 49.69 (SD = 30.70), indicating most of the patients were dependent and required assistance in at least two areas of function (Table 2). The overall mean score for each item of the FIM was 2.83 (SD = 1.74), which means most of the patients needed moderate to maximum assistance, especially with stairs and bathing.
Other Clinical Care Outcomes
Medical chart review of the 308 study patients indicated the following prevalence for the remaining selected clinical care outcomes: pressure ulcers (13.1%), urinary tract infections (27.9%), stool impactions (13.1%), physical restraints (25.1%), falls (11.7%), injuries (13.0%), re-hospitalizations (14.9%), and returning home for short stay (18.8%) (Table 3). Approximately 65% of the residents had not been weighed during their stay in the nursing homes. Therefore, weight loss was unavailable as a clinical care outcome.
RESIDENTS' MEASURE OF FUNCTIONAL INDEPENDENCE* (FIM) (N = 308)
PREVALENCE OF CLINICAL CARE OUTCOMES (N = 308)
RESIDENTS' SATISFACTION WITH NURSING HOME SCALE (SNHS) SCORES (AT = 67)
The number of RNs was not significantly correlated with the prevalence of pressure ulcers (r = . 1 1 , p = .06), urinary tract infections (r=~ .02, p = .71), stool impactions (r = .04, p = .49), physical restraints (r = .05, p = .37), falls (r = - .00,/» = .97), injuries (r = .05, p = .42), re-hospitalizations (r = .01, p = .93), or returning home for short stay (r = .01, p - .94). However, the prevalence of physical restraints and injuries were positively correlated with the number of RNs (t = 16, p = .005).
! Residents' Satisfaction
Sixty-seven residents who were mentally intact or had mild cognitive impairment reported moderate satisfaction with the nursing home care. The two items receiving the highest satisfaction scores were that the staff welcomed visits of the residents* family members and friends (92.4%), and the cleanliness of the room and surroundings in the nursing home (92.4%) (Table 4). One half (51.5%) of the residents reported their personal belongings had disappeared. Thirty-nine percent (39.4%) of the residents responded that life was boring in the nursing home.
The level of satisfaction with nursing home care of 67 residents who could respond to the SNHS was positively correlated with the number of RNs (r = .30, ? < .01), and number of NAs (r = .31,/) < .01), but negatively correlated with the number of physicians (r = -.48, p < .01). Satisfaction with nursing home care was not correlated with the length of stay (r = -.10, p > .05), age of the resident (r = .12, p > .05), or how long the nursing home had been operating (r = -.20, p > .05).
The average age of the Taiwanese nursing home residents in this study was 75.8 years (SD = 11.2), younger than nursing home residents studied by Williams and Engle (1995) (M = 78, SD = 10), and Mattiasson and Anderson (1997) (M = 80, range from 57 to 98) in the United States. This age difference may be because of the relatively short nursing home history in Taiwan.
Nursing home residents in Taiwan had relatively poor mental and physical functioning as measured by the SPMSQ and the FIM. Taiwanese nursing home residents may represent the sickest and least functional population of older adults in the country as noted in the high percentage with diagnoses of stroke and dementia. Indeed, Yeh (1990) found that Taiwanese older adults were placed in a nursing home because they were very dependent or ill, family members were incapable of caring for them at home, or the family exhausted all caregiving resources.
Residents' poor functional status may also reflect the low nursing staff-to-resident ratio, and the low numbers of physicians, physical therapists, occupational therapists, and social workers providing care in the nursing homes. If functional status of nursing home residents can be shown to be positively correlated with the amount and type of care provided by a multidisciplinary staff, then low numbers of professional clinical care providers may negatively impact residents1 physical, mental, and social functioning.
The clinical care outcomes in nursing homes in this study provide baseline quality indicators that may be compared to outcomes in other Taiwanese nursing homes and markers to measure changes in the status of Taiwanese nursing home residents. A specific outcome in this study, the use of physical restraints (25%), was similar to that reported by the National Nursing Home Survey in the United States in 1977 (Hing, 1981). However, the restraint rate in the United States decreased to approximately 15% in the 1990s because of new restrictions on their use (Guttman, Altman, OC Karlan, 1999). Sixty-five percent of study residents had not been weighed during their stay in the nursing homes, indicating the nutritional status of residents in these homes may not be adequately assessed or monitored.
Clinical care outcomes as a measure of quality of nursing home care may not be viewed as simple cause and effect, but are influenced by structural and process variables and other outcome measures. Although many uncontrollable resident characteristics (e.g., diagnosis and age) are associated with functional decline, morbidity, and mortality, quality indicators or outcomes (e.g., prevalence of falls, incontinence, urinary tract infections, pressure ulcers, weight loss, physical restraints) are markers of potentially good or poor care practices and indirect measures of quality of care (Popejoy, Rantz, Conn, Wipke-Tevis, Grando, & Porter, 2000). These markers may be valid indicators of quality of care of older adults worldwide, not only in the United States and Taiwan (Schroll, Jonsson, Mor, Berg, & Sherwood, 1997).
The lack of correlation between the number of nursing home staff per resident and the prevalence of the clinical care outcome indicators as reported in the clinical outcomes checklist was unexpected. In an early study, Linn, Gurel, and Linn (1977) found patients in nursing homes with more RN hours per resident were more likely to survive, show improvement, and be discharged from nursing homes. Similarly, Braun (1991) found a predictive inverse relationship between resident mortality and nursing home quality indicators of RN hours per parient, nursing care process, security (e.g., prosthetic aids, orientation aids, safety features), and a mean quality measure. Yet, in a study of 224 nursing home patients in Taiwan, Yang et al. (1998) found that individual resident factors, rather than organizational factors, significantly predicted patients" biopsychosocial functioning. Yang et al. (1998) did find that nursing practice patterns indirectly affected residents' functioning through residents* perceived satisfaction with care, but assessment and measurement of additional environmental factors affecting quality in nursing homes are required.
Greater precision in measurement of health outcomes related to various structure, process, and outcome variables may be needed to explain the lack of correlation between the number of nursing home staff and residents' clinical care outcomes in this study. For example, the nursing home atmosphere that contributes to a "boring environment1* may also decrease residents' motivation to participate in activities that could improve functional abilities. Another possibility is that the nursing staff's preparation in gerontological nursing may be a better predictor of residents' clinical care outcomes than the number of actual nursing staff providing care.
Although residents were moderately satisfied with their life in the nursing home, approximately 40% thought nursing home life was boring and the majority were dissatisfied with rehabilitation therapy. The lack of staff who initiate and supervise recreational and therapeutic activities such as activity therapists, occupational therapists, and physical therapists may partially account for this finding. Because nursing homes are relatively new in Taiwan, the lack of family life that includes younger family members, diverse family activities, and performing of traditional roles may be a cultural factor that accounts for the dissatisfaction with planned activities in the nursing home.
The positive correlation of resident satisfaction with the number of RNs and NAs in this study suggests relationships between residents and nursing staff influence a resident's satisfaction with overall nursing home care. Grau et al. (1995) found the majority of residents' perceptions of both the best and worst experiences were directly related to the attitudes and interpersonal behaviors of the nursing home staff. In addition, developing positive relationships with nursing home staff is more likely when there is an adequate staff-to-resident ratio and staff are skilled in the care of older adults.
In contrast, the number of physicians was negatively correlated with the residents* satisfaction with nursing home care. This may be because of the part-time status of physicians, a lack of medical preparation in geriatrics, or physicians' attitudes toward the added responsibilities of caring for nursing home patients.
There are a number of practice, education, and research implications indicated by this study. The functional status of nursing home residents participating in this study in Taiwan, indicates the need to improve clinical care outcomes that represent quality care (Henkel, 2000). Continuing efforts to recruit and retain a diverse professional and technical nursing home staff are required to provide the emotional and social environments, physical exercise and therapy, and recreational activities to improve the overall functioning of elderly residents. Making environmental changes and creating alternatives to physical restraints is one way to improve care that may require increased staffing.
Participation in nursing home activities and resident care by family members and others from the community may increase residents' participation in physical, recreational, and social activities and improve their overall functional status. Family members may be invited to particípate with their elderly relative in nursing home celebrations of holidays such as the Lantern Festival, Dragon boat Festival, Double Ninth Festival, and Lunar New Year 's Eve.
Individual family meetings may be scheduled so the resident, famÜy members, and staff can identify ways to provide support and meet the specific needs of the elderly resident. Some nursing homes may have community meetings where all residents, their family members, and staff have a forum to discuss issues of life in the nursing home. One important goal of these meetings is to provide information on how to communicate with and support the resident who is adjusting to life in the nursing home.
The general Taiwanese population may be better able to anticipate their future needs if offered informational programs about the aging process, the likelihood of being widowed, and options for living arrangements for older individuals. Encouraging volunteerism, continued participation in various social activities and physical recreation, and use of all sources of information including the Internet, may help older individuals stay healthy and active and delay deterioration in their functioning.
A review of residents' medical charts for the 13 nursing homes participating in this study revealed diverse requirements for documentation and limited the scope of data collection. Taiwanese nursing homes may benefit from a standardized assessment and documentation record such as the Resident Assessment Instrument (RAI) and Minimum Data Set (MDS), mandated for use in certified nursing homes in the United States (Greene & Nennstiel, 1997). The RAI and MDS have been used to develop quality care indicators, assess residents, and improve clinical care outcomes (Karon OC Zimmerman, 1998; Rantz, Popejoy, ZwygartStauffacher, Wipke-Tevis, & Grando, 1999). Standardized assessment, care planning, and clinical outcomes evaluation instruments may especially be of value for the relatively new nursing homes in Taiwan that are developing quality assurance and improvement programs.
Formal geriatric nursing education and continuing in-service education for RNs and NAs is necessary to keep pace with new treatments and ways to manage care of older adults. Nurses with advanced education and experience in care of older adults are needed in long-term care settings. These educational needs also apply to physicians, physical therapists, and other professional and assistive personnel who work in long-term care. Nursing research may most productively focus on identifying variables that affect clinical care outcomes and satisfaction with nursing home care. Variables found to be most predictive of improved clinical care outcomes and resident satisfaction may then be addressed in practice, education, and further research to improve the overall quality of nursing home care in Taiwan.
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RESIDENTS' SHORT PORTABLE MENTAL STATUS QUESTIONNAIRE (SPMSQ) SCORES (N= 308)
RESIDENTS' MEASURE OF FUNCTIONAL INDEPENDENCE* (FIM) (N = 308)
PREVALENCE OF CLINICAL CARE OUTCOMES (N = 308)
RESIDENTS' SATISFACTION WITH NURSING HOME SCALE (SNHS) SCORES (AT = 67)