Category: Nursing Home

The following paper is a critique of an article describing a qualitative study aimed at assessing the satisfaction amongst different stakeholders, including seniors, family members, facility managers, and hospital or community care coordinators, regarding a transitional program whereby seniors are kept in the community while they are awaiting admission into a public long-term care facility. The article is designated Living in the Community While Waiting for an Admission in Long-term Care: Satisfaction with a Transitional Nursing Home Project by Diane Morin et al. and was published in the Journal of Nursing Care Quality (January-March 2007). This paper is aimed at critically evaluating all the sections of the aforementioned article, including the title, abstract, introduction, methodology, results, and discussion, highlighting the strengths, weaknesses, and limitations, and provides suggestions for improvement when required.

Title

This article is entitled Living in the Community While Waiting for an Admission in Long-term Care: Satisfaction with a Transitional Nursing Home Project. This title adequately describes the study and its purpose, although it does not specify the study population sufficiently. This title could have been improved by the mention of the study subjects, i.e., the various stakeholders involved. The keywords of the title include Satisfaction, Nursing home and Transitional, and they are appropriately chosen as they appropriately address all aspects of the study. The title is also precise and to the point and helps in arousing the interest of the readers.

Abstract

The abstract provided is precise and summarizes the studys objectives, methodology, and important findings. The abstract does mention the dependent variable of the study viz. satisfaction with the transitional program; it does not, however, mention and discusses the various dimensions of the dependent variable that were measured in order to assess satisfaction. The abstract also doesnt identify the independent variables of the study, including the characteristics of the study group such as age, gender, comorbid, etc., and their influence on the dependent variable. Moreover, while discussing the results, the abstract only mentions that variation amongst satisfaction between different groups was observed with the greatest satisfaction amongst seniors. It does not point out that the least satisfied group was found to be the hospital and CSSS coordinators. Despite these limitations, the abstract does provide enough information to generate interest amongst readers and to keep them reading the article.

Introduction

The introduction to the study clearly identifies the study question and provides adequate background to it. One limitation, however, was that the magnitude of the problem was not defined clearly. The authors should have included recent statistical and epidemiological figures regarding the number of seniors currently facing the problem of having to wait for bed availability in long-term care facilities i.e., being bed blockers, the demand of the services required, the facilities currently available the gap between these two. This would have helped in not only arousing the readers interest but would have also highlighted the enormity of the problem and thus the significance and rationale of conducting the study. Based on the information provided in the introduction, it is difficult to establish whether the problem is significant enough to warrant the study that was conducted. The introduction provides satisfactory theoretical rationale and conceptual framework, which is backed up by previously conducted studies quoted in the literature.

It clearly mentions the operational definition of the study variable of satisfaction and how it was evaluated based on the five most pertinent dimensions including perceived technical competence and interpersonal skills, continuity and accessibility of care, cost and adequacy of the physical environment (Bond, 1992 cited in Morin, 2007). The confounding factors and the limitations of the previously conducted studies are also addressed. The authors point out that most previously conducted studies have focused on the clients views regarding satisfaction and this is subject to bias. Using this background, the researchers have clearly defined their study objective viz. evaluating the satisfaction perceived by different stakeholders involved in the transitional program serving the purpose of keeping the seniors in the community while they are awaiting admission into a long term care facility. By including all the stakeholders in the study population, the researchers aimed at overcoming the limitations present in studies previously conducted. Overall, the introduction provides sufficient background about the rationale and purpose of the study and leads logically into the methodology. There are albeit certain limitations: the research hypothesis is not clearly mentioned, and also it is not identified that once the satisfaction is assessed, what purpose will it serve and what will be the implications of this research.

Methodology

The methodology section clearly describes the study design, i.e., qualitative study, the sample size (ninety nine), the study subjects and their characteristics and the inclusion criteria for the different study groups. The exclusion criteria and whether the participants were offered any reimbursement for participation in the study is not mentioned. The data collection procedure is not adequately discussed. The Questionnaires/interview questions employed for the assessment of satisfaction, their contents and the time duration required for each interview should have been clearly discussed. The methodology also lacks relevant information on the psychometric properties, including the sensitivity, specificity reliability and validity of the satisfaction assessment tools and whether these tools have been pre-validated and tested in this particular population under study. The methodology section does describe the scientific procedures in chronological order but requires but in addition to the aforementioned shortcomings, requires a better description of the analysis section, including which statistical tests were applied and what outcome variables were calculated for categorical and descriptive variables. Although the study design and procedure is appropriately chosen keeping in view the study question and objectives, the methodology section does not provide sufficient information on various aspects of the study and thus cannot be replicated or used as a guide for future studies of similar sort.

Results

The result section is well structured in that the important results for each subgroup of the study population are summarized in different sections. However, there were certain shortcomings. The means and standard deviations for descriptive statistics such as the demographic features and the dependent variable, i.e., satisfaction and certain variables, such as the response rate, are not stated. Moreover, the results could have been presented in a more organized way by the use of tables. The results are pertinent to the study question and state that that satisfaction varied among different subgroups, with the seniors being most satisfied and the hospital and CSSS coordinators being least satisfied. However, the strength of these findings could have been improved by stating the magnitude of the difference between the various groups and their statistical significance using p-values.

Discussion and Conclusion

The discussion adequately addresses the pertinent findings, their importance and their congruence and consistency with previously conducted studies. The limitations of the study and its utility for future research, since this study is the first of its kind in addressing all the key players involved, are also pointed out, but the practical implications of the findings in clinical practice are not discussed. The authors should have discussed how the issues that were identified and the factors contributing towards dissatisfaction amongst different subgroups of the study population could be modified and what measures would be undertaken in order to improve the existing program of transitional accommodation of seniors in private nursing homes. The conclusion effectively summarizes the pertinent study findings, their usefulness, and the authors recommendations based on these findings.

Reference List

The references were appropriately cited throughout the text. This article was published in 2007 and the most current reference used by the author was 2004 (Morin, 2007 p. 72). Moreover, further literature search on the previously used assessment tools for satisfaction with emphasis on subgroups other than the seniors, i.e., the family, the private facility owners and managers and the hospital and CSSS coordinators, could have been undertaken. Therefore, the reference list had the limitation of not being extensive and sufficiently current.

General Impression

Overall, this article is fairly well written and organized. The study is unique in that its the first one of its kind which assesses satisfaction with the transitional accommodation of seniors in private nursing homes amongst all the key players and stakeholders viz. the seniors, the family, the private facility owners and managers and the hospital and CSSS coordinators. This study is also important because the problem it addresses, i.e., the accommodation of senior citizen in a transitional private facility while they are awaiting admission in a long-term care facility, is significant in todays society and intervention in order to overcome the burden on long term public facilities is imperative. Certain limitations of this study include a lack of appropriate statistics to highlight the significance of the problem, a weak methodology and lack of appropriately used statistical tests to quote the results. Therefore, this study could have been improved by a more extensive discussion of the methodology especially data collection procedure including the questionnaires/interview questions employed for the assessment of satisfaction, their contents and the time duration required for each, use of appropriate statistical analysis and tests and strengthening the results by the use of means, standard deviations, p-values, etc.

References

Bond S, Thomas LH. (1992) Measuring patients satisfaction with nursing care. Journal of Advanced Nursing; 17:52-63.

Morin D., Saint-Laurent L., Dallaire C., Boucher-Dancause G., Lalancette S. & Leblanc N. (2007). Living in the Community While Waiting for an Admission in Long-term Care: Satisfaction with a Transitional Nursing Home Project. Journal of Nursing Care Quality, Vol. 22, No. 1, pp. 66-72.

Introduction

In regard of culture, society and ethics is to respond by analyzing the issues, by seeking ways to solve the issues presented by following the Laws of human right also implying the “FREDA principles” which is a involves of Fairness, Respect, Equality, Dignity, and Autonomy.

The ETHICAL principles (by doing or putting in practice what is morally right) it is suitable in the human constitution & foundation applied.

The general issues which is to be dealt is that the local authority as came in conclusion to occupy Dora permanently into a nursing home that is distanced away from her husband Simon and the children to visit her. This overview will be concluded with conclusion in regard of this matter.

Description

In this there will be a development of the case of the situation of Dora and Simon which are a married couple of a duration of 59 years, through they marital life Dora who is the wife developed a blindness and she became blind also developed an illness called Alzheimer.

Simon the husband was looking after his wife Dora from the moment she became and blind and attained Alzheimer as a career, Simon and Dora had a fall whilst Simon was assisting her with care at their home and Simon became unable to look after Dora.

Therefore, Dora was taken into a local nursing home, in the mean while Simon her husband recovers from the fall which occurred in their home. The local nursing home which Dora was admitted to was funded by the local public, Simon and the children was visiting Dora as the local nursing home was not too far from their home.

As it stands, the local authority who had in charge of the local nursing home where Dora was first admitted decide to transfer and admit Dora permanently into another nursing home which is too far in distance from her house than the previous local nursing home, and Simon and the Children could not visit her. Also, Simon and Dora relationship were threatened, because there will be separation between the married couple and their children for a long period of time.

Discussion

The discussion in this case study will be to study the case, this discover the issues exposes one by one and to expand the discussion. By using the information provided which it will guide it to gain the correct result or the decision which is supposed to be made.

The married couples have been in a long term married relationship of 59years which it clearly describes Simon and Dora hold a strong relationship, whilst Simon and Dora living together in their married house; Dora became blind and attained Alzheimer. Based on the information from (NHS) Alzheimer mostly a type of dementia disease in the uk, Alzheimer is a progressively neurological disease which is typically unknown and affected people form the age of 65 years old and over according to the (brain research uk). There are many things which makes the disease to increase in the body of an individual such as ageing, previously being involved in a serious head injury or it can be family history of someone in the family who suffered from the disease Alzheimer although it can also be genetic.

The disease Alzheimer progress in the body of a individual which means the disease can bring a different symptoms in can be increase regularly or severe throughout the years, according to the (NHS) the symptoms can be such as confusion, getting lost in familiar places; difficulty in remembering people’s faces, difficulty in making decisions and personality changes. According to the (NHS), there is not a cure for Alzheimer disease but treatment or medicines are available to help relieve some symptoms of the disease.

Psychological treatment can be provided such as cognitive stimulation therapy to help support an individual memory also support to help the individual into problem solving skills and language ability.

Among those symptoms which was mentioned, Dora was developing a few of the symptoms hence why Simon had to care for his wife Dora, it can be lack of recognising the environment and it might be the reason why the husband and the wife fall in their home.

The reason of admitted Dora in a local nursing home it is for the duty of the nursing home to take care of Dora as a service user whilst her husband Simon recover from the injury.

The local public were funding the local nursing home, perhaps Simon could not work anymore or retired from work to take care of Dora as the local nursing home were not too far from their house.

In this particular scenario we will be discussing about the decision which was taken by the local authority to move Dora into a nursing home, Dora was admitted into a nursing home not just for a short period time but permanently without the consent of the husband and the children; also this decision was threatening Dora and her husband Simon relationship.

In order to enlarge this issue, we must review the procedure which was taken by the local authority nursing if it was the right procedure according to the law or mental health acts law, the decision from the local authority nursing home was threatening the couple relationship and children.

The importance of the report underneath will be based by explaining the procedure of the agreement made by the local nursing toward the service user, by implicating the agreement tree or decision tree which is a method to detailed the state of health of the service user and in involvement of the government procedures.

According to (thopmson, 2001) Anti-discriminatory Practice book stated certain organizations have been accounted by the government to acts within authorities to bring solution in certain situation by applying the law. Any agreement of the decision must be applied in the following establishment in practice, policy and educational calendar. Nursing homes and certain practice are being handed the autonomy and authority of proceeding in practice their decision-making. The procedure which the local authority nursing did to make decision may be seen as irregular decision and choices, also regarding the procedures the nursing home applied through their service practice it does only applied to Dora but other service users involving int the nursing home. In most of the nursing home especially those who are private or funded by the government, decisions are mostly being made by nurses, doctors and the department of nursing homes coming together by reaching the level of the care their perform toward their service users (Thompson et al,2002).

Also according to (O’Neil et al,2005) lay claim to any clinical decision-making or nursing home decision-making must be a multipart concern which means every decision taken must be involves the nurses, management, and others health professionals who have the knowledge in every healthcare department to be able to attend the reliable resources of data in order to proceed into helpful entourage to obtain the right decision in their services users best interest.

It is quoted by (Adams and Drake,2006) in regard of share decision making the entire service of the nursing home such as nurses and the members of the team are positioned as consultants toward the service user. By involving themselves into providing information, oppose and debate into the options which will be given as they should be in the best interest of the service user. Also, to facilitate requirements, preferences and to encourage the service user’s autonomy. By going through the story of Dora and Simon according the law, the local authority did not process the case of Dora in the right procedures before agreeing in the decision to admit Dora into nursing home which is distanced from Dora’s husband and children. By implicating the Law Equality Human Rights, the Article 14 stated that all the right and freedoms set out in the Act must be protected and applied without discrimination. An individual that is treated unequally or minor than others should be taken as an act of discrimination, as any act of discrimination are not easily reasonably absolve and justified.

Discrimination occurs when an individual is being treated less favourably while their circumstance happens to be different than others.

As an example of: if an service user who suffer from disability or mental health illness being treated less in regard of their circumstance, so it necessary to knowledge and understanding of the Human Right Act in order to protect the service user and to avoid discrimination by applying the Article 14 which is there to protect not just the service user in the nursing home but all of us. No matter an individual range of grounds such as colour, race, religion or sex; political or other opinion, national or social origin, and birth or other status.

Furthermore, the Article in the scenario covers an indirect act of discrimination, which Dora, Simon, and the children faced as the policies is apply to every service users equally without discrimination. But it was applied on the disadvantage of Dora as service user, by implicating FREDA principles in this scenario the local authority and local nursing home did not apply fairness in regard of Dora and Simon case; there is lack of involvement of respect and equality. There was discrimination of dignity not involving the service user into their circumstance and autonomy of the service user was neglected although the service user is enable to recognition of the service and not even applying patient family centered-care.

Introduction

Nutritional issues, especially Malnutrition has been an ongoing challenge for the Long-Term Care industry. During the 20th century, the United States witnessed an 11-fold increase in the elderly population, summing it up to 33 million (Crogan & Evans, 2001). Out of the 33 million, an estimated 5% of the people aged 65 years and above reside in nursing homes across the country. Nursing homes and other long-term care facilities house an assortment of elderly populations suffering from dementia, diabetes, dysphagia, and many others. In most of cases, people come to these facilities only after they have been extremely sick and need assistance with daily activities. As no two people are identical in either their behavior or medical requirements, it becomes extremely important for healthcare professionals to take care of their specific medical and nutritional needs. An intentional or unintentional nutritional negligence toward these patients can put them at a greater risk for infections, pressure sores, ulcers, and even higher mortality rates (Nelson et al., 1993). Malnutrition is a condition of nutrition where either a lack or an excess of nutrients such as energy, protein, vitamins, and minerals can cause adverse effects on the composition and functions of the body, or on clinical outcomes (“Nutritional guidelines and menu checklist,” 2014). To combat such nutritional issues, the U.S. Department of Agriculture (USDA) and the U.S. Department of Health and Human Services (DHHS) has published a set of dietary guidelines for the nursing homes to follow. These guidelines provide specific dietary recommendations for elderly people to promote nutritional suitability (“Dietary Guidelines for Americans, 2010,” 2010). Unfortunately, even after these guidelines, nursing homes are unable to reduce malnutrition rates. According to Rowe & Kahn (1998), the amount of malnutrition in nursing homes range from 35% to 85% and is projected to increase if proper measures are not taken to reduce the rates. Facilities with compromised nutritional availability not only generates greater malnutrition cases but also deteriorates the quality of care and safety for its residents. When healthcare professionals lack in providing basic nutritional care to its residents, it negatively impacts patient outcomes, safety measures, patient and family satisfaction rates, quality of service, quality of life at nursing homes, and many more. This paper discusses some of the root causes of malnutrition in nursing homes and analyzes its effects on the quality of care and on the future of long-term care.

Causes of malnutrition in nursing homes

The dietary branch is the second most important department after nursing services at nursing homes, and yet somehow it is one of the most poorly established one. An investigation was conducted to understand how healthcare professionals perceive nutritional competencies and documentation in nursing homes with the help of 2 focus groups comprising of 14 healthcare professionals each (Hakonsen et al., 2019). The investigation analyzed 5 main causes that lead to such nutritional issues. The first category was a lack of organized communication amongst healthcare professionals. Documentation procedures such as daily monitoring, updating, and communicating about the residents’ nutritional information with other healthcare professionals is not taken seriously by the staff. This not only affects the nutritional care practices, but also breaks the continuity of care, reduces transparency amongst the staff, and decreases staff performance. For instance, if a nurse incorrectly documents or fails to inform the other nurse about a resident’s 5-meal diet plan, the resident may end up receiving less nutrition (3-meal diet plan) because of written and oral discrepancies. The second category explained that healthcare professionals see nutrition as just a ‘form of food service’ and therefore, disregard the dietary guidelines provided by USDA and DHHS. In association to this, the third category states that the quality and service of nutritional care highly depends on the personal interest and attitude of the professionals. If the staff is not interested to begin with, they will not take care of the residents’ nutritional requirements, contributing towards malnutrition. The fourth category states that lack of nutritional care responsibilities amongst healthcare professionals negatively affects quality of care. One of the members of focus group 2 said that the problem is not the availability of officials, rather the problem is “…who you should get a hold of if an issue arises…” (Hakonsen et al., 2019). The last category outlines that additionally, there is also a lack of clinical leadership as there is no training and education provided to the staff about observing proper nutritional care. In a nutshell, it can be narrowed down to three key roots: 1) Lack of documentation and communication amongst healthcare providers, 3) Personal attitude towards nutritional care, and 4) Lack of leadership towards nutritional care management.

Nursing homes also observe challenges with staffing and food service, which are two other noteworthy factors leading to malnutrition. In a survey conducted amongst nurses and nursing assistants, it was found that around 93% nurses and 73% nursing assistants agreed that residents were deprived of appropriate nutrition when the nursing staff was low and when there was no one to assist them (Crogan & Evans, 2001). It is also said that most of the nursing homes fail to adhere to the staffing levels established by the Center for Medicaid and Medicare Services (CMS). As there are less people attending the residents, their meal time and assistance to meal services reduces. Nutrition for the residents who strictly need assistance in feeding can be highly compromised due to a lack of staffing. As a result, residents will end up receiving inadequate nutrition which will increase further malnutrition possibilities.

As an assignment for our Long-Term Care Management class, we visited Parker Health in New Brunswick, NJ on October 6, 2019. We were given a tour of the facility and were also able to interact with a few residents over there. While talking to one of the residents in the dining room, we asked her, “What do you not like about this place?”. She quickly replied, “The food. It doesn’t taste good”. Later when I researched about what she said, I found that this is a very common problem in all nursing homes. Residents often dislike the taste, quality, and appearance of the food served to them. The food is often bland, overcooked or undercooked, and does not seem homely. Being in a nursing home, away from home, food is the one thing that residents look forward to. If they don’t get homelike food, they are more likely to not eat in appropriate quantities suitable for their health. Moreover, nursing homes have a tendency to cut back on prices by reducing the food choices and availabilities (Crogan & Evans, 2001). Due to all these reasons, residents end up taking less nutrition, ultimately contributing towards a higher risk of malnutrition. The following section discusses some of the initiatives that can be taken to prevent malnutrition in nursing homes.

Strategies and recommendations

Healthcare organizations need to work with its staff on several aspects to improve its delivery of nutritional care and its quality of care for nursing home residents. As discussed earlier, documentation and communication amongst healthcare professionals plays a major role in ensuring quality of care. Organizations should implement a standardized documentation and communication approach in order to increase knowledge and understanding of nutritional care practices. This standardized approach will have 2 main features. The first feature will require forming strict protocols for documentation of nutritional information and patient care actions. The second feature will include establishing a “common terminology and language that [is] understood and applied in the same way by all healthcare professionals thus ensuring that patients receive better standard of care in daily clinical practice” (Hakonsen et al., 2019). Consistent terminology and specific documentation protocols will create a more effective and safer environment for the prevention of malnutrition.

In order to improve compliance to the dietary guidelines provided by USDA and DHHS, organizations should start a rewards and incentives program for the employees. For instance, if a healthcare professional successfully obeys to these guidelines for a period of 3 months, he/she gets a reward or incentive, which will mostly be a monetary benefit. Such rewards or incentives can be set at regular intervals throughout the year to ensure continuity of good work by the professionals. This will encourage them to follow the guidelines and make sure that the residents are being fed well, reducing the rates of malnutrition.

A strong leadership and organizational structure have the ability to turnaround bad outcomes of an organization into good outcomes. Along with communication, nursing homes also lack in clinical leadership and management skills that could reduce malnutrition rates. A well-established, hierarchical nutritional care unit should be created with responsibilities assigned specifically for each professional. In this way, people will become more mindful of who to reach out to in case of an issue. Moreover, interactive in-house educational sessions should be conducted for all the employees which should cover topics ranging from malnutrition management, nutritional care practices, time management, effective communication, team building, and many more. Furthermore, ‘nurse-developed rehabilitation’ programs should be implemented by the management. These programs will focus on the importance of staff participation and staff assistance with meals and snacks for the residents (Crogan & Evans, 2001). Nursing assistants are the ones who recognize resident complaints the best because they know the residents the closest. Therefore, efforts should be made to include nursing assistants in conferences and planning committees so they can contribute towards quality improvement and malnutrition management.

Nursing homes can improve the problem of low staffing by implementing 3 variations in their management. The first change will be to hire part-time employees that will only work for meal services. These employees will be hired solely for the purpose of providing assistant to the nurses and nursing assistants so that they can spend more feeding time per resident. The second change will be to incorporate staggered shifts to “… ensure that more personnel are present at mealtime” (Crogan & Evans, 2001). The third change will be to introduce unusual shift times for better staff allocation. For instance, instead of a 3 pm to 11 pm shift, create a 12 pm to 8 pm shift so more staff can be present during mealtime for assistance. Making such small changes to staff scheduling can ensure better assistance during mealtime, thus, reducing the risk of malnutrition.

The primary requirement for nursing home residents is to feel at home, both in terms of environment and food. A satisfying dining experience can increase the nutritional intake of the residents. To improve the food service, dieticians and food service managers should personally observe and talk to the residents about their preferences (Singh, 2016). This will familiarize them about what the residents want, which items on the menu are appreciated and which ones are not, and what improvements are needed in the menu. This will also allow them to find solutions to make the food more attractive and tastier. Several innovative ideas such as changing the dining room lights, using bright colors, making dining mats more colorful, etc. can also increase the food intake. Moreover, aromatherapy and soothing music has proved to be useful in enhancing the dining experience for people with dementia. Sometimes, serving meals in a family style or in the residents’ apartments will provide a sense of independence to the residents, create a homely effect, and reduce agitation. Lastly, instead of buffet style serving, employees should serve the residents on their table to avoid the feeling of restriction. Such small alterations to food services and dining experience can significantly increase the food intake which will prevent further malnutrition cases in nursing homes.

Conclusion: future impacts and implications

In the past century, an increasing amount of the elderly population has opted for nursing homes in the United States. Nursing homes are now required to ensure greater quality of care and safety due to this increase in population. Malnutrition is one the most common issues faced by residents in nursing homes due to reasons such as lack of documentation, lack of communication, poor management and leadership, lack of knowledge and awareness, lack of willingness to serve the elderly, poor food services, low staffing, and many more. These problems not only increase malnutrition rates but also degrade the quality of care in nursing homes. In order to fight malnutrition, several applications and strategies were recommended in the previous section. Some of the changes included improvements in food services, staff participation, documentation and communication methods, and management and clinical leadership. Evidently, a lot of nursing homes have already started changing their approach towards nutritional care to improve the well-being of its residents. In the future, better nutritional care practices will lead to a significant decline in malnutrition rates as the facilities start focusing on the residents’ priorities and necessities. A high-quality nursing home with a focus on nutritional as well as medical care will attract more families and patients, increasing overall admission rates. A happy and supportive staff will keep the residents even happier, increasing their life span. With the application of these processes, the future of nutritional care in nursing homes looks much brighter.

Ethical and Policy factors

Introduction

The elderly in nursing homes are among those who require the highest level of care coordination. However, various ethical and policy issues have been reported to be the primary factor affecting effective care coordination in nursing homes (Townsend et al. 2017). Even though most of the nursing care staff have reported low care coordination, minimal research has been undertaken to determine the extent at which ethical and policy issues affect care coordination in nursing homes (Luther & Hart, 2014). The quality of care in the United States nursing homes has been a recurrent issue in the public domain. It has been an issue for the past thirty years (Townsend et al. 2017). Various regulations such as the federal certification are in place, but still, the problems of poor quality exist. The patients in nursing homes again experience a high level of patient abuse (Luther & Hart, 2014). Therefore, it is clear that ethical and policy factors are among the primary reasons why care coordination in nursing homes in the United States is still a big problem.

Governmental policies related to the health and safety

The quality of patient care for the elderly in nursing homes should not have to be a point of debate, but they require the utmost level of medical care. With the adoption and existence of the federal government controlling activities in the nursing homes and implementing the social security act policy, the level of care coordination provided has drastically reduced (Bower, 2016). The social security act and the old age assistance facilitated the existence of more nursing homes with minimal support from the government. Currently, the Medicare policy has helped in improve the quality of care (American Nurses Association, 2015). The new regulations and policies have meaningfully squeezed on the quality of care in the elderly. Research indicates that nurses who work in nursing homes are poorly paid, offering minimal motivation for attending to elderly persons (American Nurses Association, 2015). Most of the nursing homes are privately owned, stimulating no growth of public nurses who need to work in nursing homes. Nevertheless, currently, the government has adopted the Medicare policy intending to improve the quality of care (Bower, 2016). The Medicare policy provides financial support to nursing homes.

Effect of governmental policies on the coordination of care in nursing homes

The government policies significantly impact the level of care in the nursing homes. The newest Medicare policies consider the practitioners as they are the people who take care of elderly persons (Luther & Hart, 2014). Through this policy, the practitioners’ compensation adopts the bundle payment method that allows the health care practitioners to coordinate care across the nursing homes (Magelssen et al. 2018). Payment of health care practitioners in nursing homes is the main factor that has been considered to reduce or increase the quality of health in nursing homes (Luther & Hart, 2014). The Medicare policy program, which is the current government policy that is in use in the nursing homes, have allowed the adoption of bundled payment method thus motivating the caregivers (Magelssen et al. 2018). Since the adoption and implementation of this policy, the quality of care coordination in nursing homes have greatly improved.

National, state, and local policy provisions that raise ethical questions for care coordination

Ethically, the nurses are expected to execute their job professionally. The affordable care policy is a policy used at the national, state, and local level. Therefore, it is applicable in all health care sectors, including nursing homes (Luther & Hart, 2014). However, several studies have indicated that this policy raises various ethical questions relating to care coordination. Affordable health care increases the amount of persons in older people care homes, reducing the quality of services as this policy does not increase the number of nurses (Luther & Hart, 2014). Increasing the number of older people seeking medical attention in nursing homes and not increasing the number of nurses causes more harm than good (Bower, 2016). The affordable healthcare policy leads to poor diagnosis and long treatment period of significant diseases that if taken, better action would be treated easily. Research indicates that a nursing home in Texas has recorded a 50% increase in the number of older people treated in the nursing home due to this affordable health care policy (Bower, 2016).

Impact of the code of ethics for healthcare providers on the coordination and care

The moral values for healthcare practitioners is one of the paradigms that have facilitated the development and existence of quality healthcare in nursing homes (American Nurses Association, 2015). During the nursing training, the healthcare providers are well trained on the importance of adhering to the code of ethics of nurses. It is not exceptional to nurses working in nursing homes as they are required to exhibit a high level of code ethics. Health services are greatly affected by the disparities in the distribution of money, power, and resources both at a national and local level. In the healthy people 2020, the document has come up with various ways that it will help in eliminating these disparities that significantly affect the healthcare system (American Nurses Association, 2015). The framework will work substantially to reduce the challenges that are currently experienced in the care system. With the positive impact of the code of ethics for nurses, the federal government should come up with more ways of implementing them to advance the attention coordination in the healthcare homes (Magelssen et al. 2018).

Critical ethical and policy issues implicating the coordination of care

Moral values are vital for any healthcare provider in the process of serving the patients. Ethical values and policy issues play a crucial role in coordination care in nursing homes (American Nurses Association, 2015). Some of these ethical issues include involving a high level of professionalism when dealing with patient and enhancing human dignity. The primarily used policy is the affordable care which ensures equal provision of services to all patients, including people in the marginalized areas (Magelssen et al. 2018). As much as the code of ethics for nurses and policies are significantly used, still, some challenges hinder smooth correlation of these two factors (Townsend et al. 2017). The primary factor hinders the smooth implementation is the high level of ignorance among the implementation team, who are supposed to focus on progress (Luther & Hart, 2014). Therefore, future research on the use of ethics and policy in coordination care in nursing homes need to advocate more on creating awareness.

Conclusion

Nursing homes provide areas where older people can attain healthcare services more conveniently. Ethical and policy factors play a vital role in care coordination, especially in nursing homes. Based on their age, they require a high level of careful attention as compared to young people. Therefore, the federal government has come up with various policies and ethical considerations to make this a reality and deliver more quality services.

References

1. American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. Nursesbooks Org. ISBN 1558101764
2. Bower, K. A. (2016). Nursing leadership and care coordination: creating excellence in coordinating care across the continuum. Nursing administration quarterly, 40(2), 98-102. https://journals.lww.com/naqjournal/Abstract/2016/04000/Nursing_Leadership_and_Care_Coordination__Creating.4.aspx
3. Luther, B., & Hart, S. (2014). What does the Affordable Care Act mean for nursing?. Orthopaedic Nursing, 33(6), 305-309. https://journals.lww.com/orthopaedicnursing/Abstract/2014/11000/What_Does_the_Affordable_Care_Act_Mean_for.3.aspx
4. Magelssen, M., Gjerberg, E., Lillemoen, L., Førde, R., & Pedersen, R. (2018). Ethics support in community care makes a difference for practice. Nursing Ethics, 25(2), 165-173. https://journals.sagepub.com/doi/abs/10.1177/0969733016667774
5. Townsend, C. S., McNulty, M., & Grillo-Peck, A. (2017). Implementing huddles improves care coordination in an academic health centre. Professional case management, 22(1), 29-35. https://www.ingentaconnect.com/content/wk/ncm/2017/00000022/00000001/art00008

Executive Summary

This report will focus on the CISSP Domain 5 – Identity and Access Management in Nursing homes. With brief overview of what nursing home is to -how the identity of resident managed in nursing home is covered in the report. The report also contains in root analysis of how authentication and authorization management is carried out in nursing home. This report will also discuss about the different types of information stored in nursing homes and how they are stored in these environments.

Furthermore, this report includes detailed information about access and authorization management like MAC, DAC, RBAC, and procedure taken to maintain the privacy and confidentiality of the residents in nursing home. This report will also analyze and discuss the possible threats to identity and access management in nursing homes and ways to minimize or eradicate all those risk. Some of the related incidents and scenarios will also be discussed in this report.

Introduction

Nursing Homes are special-purpose facility which provides accommodation and other types of support, including assistance with day-to-day living, intensive forms of care, and assistance towards independent living, to frail and aged residents. All these facilities are accredited by the Aged Care Standards and Accreditation Agency Ltd to receive funding from the Australian Government through residential aged care subsidies (AIHW,2010).

In 2017, over 1 in 7 Australians were aged 65 years and over. Today more than 17 % of the Australian population is aged 65 and over 13 % of them are 85 or older. These means there are lot of people who needs places like nursing homes to get better facility and better care. So, it’s important that the nursing home not only take medical care of the aged people (residents) but also of all their data and information. Privacy is very important in aged care homes as they have the most sensitive data collected from their residents and with the increasing threats and vulnerabilities data storage, it vital for nursing homes to have proper identity and access management.

Resident Identity Management

Residential care and supported accommodation for aged persons are also defined in terms of the level of care provided, as assessed through the Aged Care Funding Instrument (ACFI), which assesses care needs as a basis for allocating Australian Government funding. Upon receiving and reviewing these ACFI either through community services or from families of resident, the care facility manager of the aged care home admits the residents based on the services they provide.

Resident Profile

When a resident is admitted, a separate folder is created for them which will include all the information like medical history, hospital records, their general details, emergency contact, their medication and all. An URN number is created which is unique for every resident. Their picture is taken by the admins. A profile is created is for them which helps other staff to recognize and get the basic information about them. Medication and care information are passed to the Registered Nurses (RNs) and Assistant in Nursing (AINs) and their dietary requirements are given to the catering and kitchen staff.

Figure 1 Resident Profile in Nursing home

Types of Resident Information

Usually, the information related to the residents are categorized into two types non-clinical and clinical information. Most of the time, this information can be given by hospital, Aged Care Assessment Team (ACAT). My aged Care provides the aged care home information on residents about their medical status, their condition, their funding source, and other records related to the resident.

Non-clinical Information

Information that are not related to residents’ medical status are considered nonclinical. Usually, this information would also include general details about them like names, dates of birth, gender, and emergency contact information. Apart from that, information related their finance, their funding source, their banking details and their previous personal life history like crime, housing, profession also falls under this category.

The financial information is considered highly confidential.

Clinical Information

Resident clinical information includes all their medical records including medical history, evidence of physical examination, diagnosis, investigations, treatment, procedures, interventions, and progress for each treatment episode. Medical management plan, medication charts, dialysis, allergies, infections, all this information are included in this clinical information.

Since, in aged care home, residents are given care and medication daily, so it’s important to track their progress like dietary, bowel movement, behavior, weights, blood pressure, heart rate, and other hygiene matters. All these are clinical information and managed by nursing staff and qualified medical staff. All the medical records are very confidential.

Figure 2 Resident Clinical information example

Resident Information Storage

Generally, in nursing homes, the resident information both clinical and non-clinical are stored either electronically or physically.

• Electronic/Digital storage:

An electronic health record, or electronic medical record, is the systematized collection of patient and population electronically-stored health information in a digital format. The information and data recorded in cloud-based server or computers folders depending on the size of the aged care. These records can be shared across different health care settings. Records are shared through network-connected, enterprise-wide information systems or other information networks and exchanges. Most of the nursing homes these days have cloud-based data storage servers which offers a complete range of electronic data storage, backup, disaster recovery, business continuity and cloud computing solutions. Electronic storage helps to keep the records up-to date and accurate and reduce the time by eliminating the hassle of tracking the resident old physical record by using electronic records.

Not everyone working in the nursing home can view all the types of information of the residents available, they differ according to the role of the staffs that can only view specific information of resident.

Figure 3 Sample- Electronically stored resident information

• Physical storage:

Many information related to residents are mostly paper based, meaning these hardcopies are stored in physical places like cabinets, folders. Physical records are such as paper, that can be touched, and which take up physical space. These records must be stored in such a way that they are accessible and safeguarded against environmental damage. Usually these physical paper-based documents are stored in filing cabinets or drawers in an office which are locked for security and confidentiality reason and only be accessed by the authorized documentation handling staff.

Staff Identification

It’s very crucial for staff to be easily identified in aged care facility for their job performance, effective care service and security reasons as well.

• Staff ID:

Upon employment staff are given an identity card with their photo and job position. This is for identification purpose not only among the staff but also with the visitors, so that visitors can know who they are talking to and make enquiry only related to their job.

• Staff Uniform:

Each staff are assigned uniform as per their job roles. Registered Nurses (RN), Assistant in Nursing (AIN), Lifestyle Officer (LS0), Admins, General Service Officers (GSO), Food Service Attendants (FSA), Chefs, Maintenance Officer, Clinical Nurse Manager (CM), General Manager(GM), all have different uniform. This is to distinguish among the staff. If their job title doesn’t have uniform for it, proper staff ID is to be carried all the time.

Figure 4 staff uniform according to their duties

Authentication

Authentication is the process or action of verifying the identity of a user or process. In nursing home environment, one of the first steps of access control is the identification and authentication of staffs. There are three common factors used for authentication:

• Something staffs know (such as a login password)
• Something staffs have (such as a smart card, keys)
• Something staffs are (such as a fingerprint or other biometric method)

Figure 5 Need PIN to enter through the restricted door in Nursing home

Staffs are authenticated when they provide both their username and correct password. Permissions, rights, and privileges are then granted to staffs based on their proven identity. The something staffs know factor is the most common factor used and can be a password or a simple personal PIN provided to staffs.

Something staffs have can be a smart car, which is a credit-card sized card that has an embedded certificate used to identify the holder. The staffs can insert the card into a smart card reader to authenticate the individual. Also, sometimes staff can have physical lock keys which can be used to access to lockers and medication cabinets. These are only used once the user has set their authentication using pin code and their Id.

Biometric methods provide the something staffs are factor of authentication. In most nursing home care, fingerprints are used as the biometric authentication factor.

Figure 6 Example of different types of authentication method

Multifactor Authentication

Multifactor authentication uses any two or more authentication factors. A key part of this is that the authentication factors must be in at least two of the categories. For example, staffs using their smartcard and then a physical key to get medicine from a treatment room is multifactor authentication.

Figure 7 Smart card and key is required to access treatment room where medications are stored in a nursing home. (Picture : Opal aged Care – Ashfield)

Access Management

In most nursing homes, access to the network, data base server, and general electronic devices like computers are given to very few staffs only. It’s mostly to maintain privacy and maintain integrity of the information as well.

General Manager (GM) and Regional Manager are the facility managers and have the access to all the information of resident and the aged care home and its staff. Clinical Nursing Manager, Registered Nurse have access to only the medical information. Admin are given access to almost most of the information. LSO are only given electronic access to record the residents exercise and lifestyle activities. Chefs and Kitchen Staffs are only given access to the dietary requirements of the residents.

Authorization Management

Authorization management is concerned with people’s access to different objects, most often to data or physical objects, such as land, buildings, rooms or infrastructure. Access control prevent access to someone who does not have authorization and allow it only to those who should have it. In most nursing homes following authorization management are used:

Mandatory Access Control (MAC)

In this type of access control, operating systems objects or denies the access to some object or information and restrains the ability to change them depending on the authorization rule and attributes of the users. MAC makes decisions based upon labelling and then permissions. MAC supports a security requirement of confidentiality more so than DAC & RBAC. For example, LSO are given access to the resident behavior and social skills charts but restrains them from changing it.

Discretionary Access Control (DAC)

In type of access control governs the ability of subjects to access objects, allows users the ability to make policy decisions and/or assign security attributes. In simple words, the way to go to let people manage the content they own. DAC makes decisions based upon permissions only. DAC supports the availability of the information. For example: Admins can make some change or add some information on resident profile owned by them.

Role Based Access Control (RBAC)

In type of access controls, governs the ability of user to access or restrict their access to objects depending on their role and position. RBAC is made for separation of duties by letting users select the roles they need for a specific task. RBAC makes decisions based upon function/roles. RBAC supports the integrity of the information and data. Its implemented in most aged care along with MAC & DAC.

For instance, Admin in nursing home can add patient/resident but they cannot read and write the prescription for residents. Doctors cannot add new residents themselves in the system. Similarly, RNs can read the prescriptions but cannot change or write other prescriptions. The AINs cannot read or write prescription as they are only care takers. The catering department of nursing home only gets the dietary information of the residents but cannot change the information. The care manager or RNs in approval of care manager can change the dietary requirements of the resident after consulting through a doctor.

Figure 8 Role-Based Access Control in Nursing home

• Authorization revoke:

Under the Health Insurance Portability and Accountability Act (HIPPA) rules, patients have the right to revoke their authorization to share their health information at any time. However, the revocation must be in writing and signed by the patients or patients listed friends or families and it may take a little while to go into effect.

But authorization revoke is not applied when the circumstances is crucial and requires the health information to be shared.

Vulnerabilities and Threats

Recently, there has been lot of incidents in nursing home where data breach, system hacked or malfunction from malware has occurred. In 2017 out of all the reported breaches to Australian Information Commissioner, 33 per cent of breaches involved health information.

These aged cares are established with the main purpose of providing services to aged, ill, people and their focus is on resident care and service, rather than their electronic system and data. So, this leaves them vulnerable to many possible threats. In Aon’s 2017 Global Risk Management Survey, 45 per cent of healthcare industry respondents identified cyber as a Top 10 Risk and Top 5 emerging risk in 2020. It is unlikely to abate any time soon.

Physical Threat

The data and information being lost or stolen is also very likely in nursing home environment. There are many threats like fire, environmental disaster like flood that can damage the physical record stored in the facility. Apart from these events, other likely physical threat to these records can be stealing. Several cases have occurred where the credit cards, photo cards have been stolen from residents and that information has been used to create fake profiles and accounts.

Figure 9 Nurse stealing credit card of patients and demanding her credit card information. More reading at https://www.dailymail.co.uk/news/article-5584587/Sydney-nurse-stole-elderly-cancer-patients-credit-card-1-000-refuses-say-sorry.html

• Solutions:

Physical copies of the data and information should be stored in secure and locked cabinet. Physical security is essential in nursing home to protect those sensitive data. Physical locks with keys can be used to protect the cytotoxic drugs, and files stored in cabinets. These cabinets can be locked using physical keys. Electronic lock for doors is another viable and secure options. Electronic lock works by means of an electric current and is usually connected to an access control system. A key card lock operates with a flat card that needs to successfully match the signature within the key card. Most of the hospital and advanced aged care home are adapting to these systems.

Social Engineering

According to current research, over 2.7 Australians aged 65 or over use the internet each day. And most of them are not tech-savvy person which makes them vulnerable to social engineering attacks like someone pretend to call from bank or insurance to ask credit card information, bank details, etc. over phone or emails.

Figure 10 Resident being scammed pretending to be ATO. More reading at https://www.abc.net.au/news/2018-04-23/scam-call-threatens-arrest-warrant-legal-action-ato/9686796

• Solutions:

Social engineering is a very common attack and elderly people are the most vulnerable to these attacks. The residents residing in nursing home should be made aware about these types of attacks. The residents who have their personal mobile phones and computer should be monitored of their actions. Residents calls, and relative meeting should be registered by the AIN and admins to keep track of their visitors. Staff should be trained in this topic and should be made aware about any suspecting activities performed by the residents and the concerned parties should be made informed. Phones call for residents can be passed through admins which will help to prevent scam.

Malware Attack

Malware or malicious software is any software intentionally designed to cause damage to a computer, server or computer network. Usually most common malwares are ransomware, trojan horse, virus.

The hospital, based in Greenfield, Ind., revealed that a successful ransomware attack on 2018,held the hospital’s IT systems hostage, demanding a ransom payment in Bitcoin (BTC) in return for a decryption key. This malware targets vulnerable servers and after being installed on one machine propagates and spreads to others in the same network. Hancock Health has paid hackers $55,000 to unlock systems following a ransomware infection.

Figure 11 Malware attack on healthcare in Washington D.C. More reading at https://www.npr.org/sections/alltechconsidered/2016/04/01/472693703/malware-attacks-on-hospitals-put-patients-at-risk

• Solutions:

Network security is the basic and most important of all to prevent any sort of malicious attack. Some commons ways are:

Firewalls: Firewall are the basic network security measures which only allows authorized access or data to pass through and blocks any malicious packets. For an aged care home, Best practice is to allow only required network access and block all other connection attempts.

IDS AND IPS: Intrusion detection and prevention system checks all the application within your network to detect any malicious attack or code and prevents it from affecting the network by blocking it. IPS takes in-depth examination of the network to prevent any harmful activities. IDS & IPS should be placed in various parts of the network.

Malware detection and prevention should be adopted by the company to prevent any infected codes or virus from entering the network. Web filtering can be used to authenticate the source of website and its contents.

References

1. Aon. (2018). Aged Care faces significant cyber risk. [online] Available at: http://www.aon.com.au/australia/insights/cyber-risk/2018/aged-care-facessignificant-cyber-risk.jsp [Accessed 16 May 2019].
2. Gadens. (2018). Data Breaches by Aged Care Providers – Complying with The Mandatory Data Breach Scheme | Gadens. [online] Available at: https://www.gadens.com/legal-insights/data-breaches-aged-care-providerscomplying-mandatory-data-breach-scheme/ [Accessed 16 May 2019].
3. Meteor.aihw.gov.au. (2018). Residential aged care facility. [online] Available at: http://meteor.aihw.gov.au/content/index.phtml/itemId/384424 [Accessed 16 May 2019].
4. Marketing, M. (2018). Cyber Security for patient-centric care. [online] Moqdigital.com.au. Available at: https://www.moqdigital.com.au/insights/cybersecurity-for-patient-centric-care [Accessed 16 May 2019].
5. Gibson, D. (2018). Understanding the Three Factors of Authentication | Understanding the Three Factors of Authentication | Pearson IT Certification. [online] Pearsonitcertification.com. Available at: http://www.pearsonitcertification.com/articles/article.aspx?p=1718488 [Accessed 22 May 2019].
6. Roizen, M.(2017). Revoke authorization of health information. Available at https://www.sharecare.com/health/revoke-authorization-to-share-health-information.
7. Security Stack. (2018). Access Control. [online] Information Security Stack Exchange. Available at: https://security.stackexchange.com/questions/63518/macvs-dac-vs-rbac [Accessed 24 May 2019].
8. Wikipedia. (2018). Electronic health record. Available at https://en.wikipedia.org/wiki/Electronic_health_record [Accessed 22 May 2019]
9. Osborne, C. (2018). US hospital pays $55,000 to hackers after ransomware attack | ZDNet. [online] ZDNet. Available at: https://www.zdnet.com/article/us-hospital-pays55000-to-ransomware-operators/ [Accessed 25 May 2019].
10. Wikipedia, (2018). Role-based access control, Available at: https://en.wikipedia.org/wiki/Role-based_access_control [Accessed 5 Nov.2018]
11. Wikipedia; (2018). Security Devices Lock. [online] Available at: https://en.wikipedia.org/wiki/Lock_(security_device) [Accessed at 3 May 2019]
12. Williams, P. (2018). Latest ‘low-life scammer’ claiming to be from the ATO. [online] ABC News. Available at: https://www.abc.net.au/news/2018-04-23/scam-callthreatens-arrest-warrant-legal-action-ato/9686796 [Accessed 5 May 2019].

Imagine forty or seventy years from now, you’re in a beautiful home that you built for you and your family. Then your children and grandchildren try to convince you to go to a nursing home saying it’s better for you and you’d be taken care of better. It’s like a slap to the face, it hurts. Your own children that you’ve taken care of for years don’t want to take care of you back and would rather put you in a place full of strangers that can either help you or treat you badly like you are no longer important to take care of anymore. That’s exactly the feeling of many of the elders now put in nursing homes.

In the health Industry, this is something that happens pretty much every day not because the family doesn’t love the loved one anymore it’s just that it’s hard to juggle life and take care of a person all at once, but I don’t think that the negative perceptions on nursing homes should exist. There are so many people who are affected by this Perception like families (Hardon Wood Legal Blog) “ It can cost families thousands of dollars a year to put a senior member into a nursing home, and it’s not often an expense that the family is ready too handle just yet “ this reading is just stating that yes it’s hard on the senior member but people tend too over look that it’s actually hard on the family also.

Throughout this Research process, I propose that to solve the negative perception society haves on nursing homes should be to create workshops for the families to learn about the nursing home of their choosing, detailed brochures and build more family-friendly nursing homes and also just going and having new guest days where you can look around and kind of get a feeling of the place. (Family matters in-home) “It’s important to bring a few things with your loved one that is recognizable and familiar “This reading is just bouncing off what I said earlier in the text just stating that It wouldn’t be so much of a problem if the senior family member was loved comfortable with their nursing home arrangement.

What brought this problem too my attention was I told my mom that we were going on an internship to a nursing home and she told me about all the bad things she’s heard and everything which make me nervous too know what I was stepping into. I’m in the health science pathway at my school and I went on an internship at a Duncanville nursing home and before I went I already had the negative perception of nursing homes like it’s going to smell they are going to get treated badly and who would I tell. The senior members would look sad just all this stuff but when I walked in those doors I felt so much differently the members were all laughing and having fun and we got assigned to our patient.

I would never forget my Patients Name Betty Tatum, She was a double Amputee and she had a stroke so she had slurred speech but she was kind when I went in my partner and I talked to her and when she spoke it wasn’t clear but she held my hand and kissed it and I just started to cry not only because I felt bad for coming in thinking bad things about the place but she also reminded me of my grandma. And every time after that I enjoyed going to the nursing home every time we would leave see would cry out “NOO” and this wasn’t because she was getting hurt or was in pain she just didn’t get much company and didn’t want us to leave.

I feel like the problem is so much more than just the negative perception of nursing home rather that the family is just scared from all the horror stories that have been told for example (Gray and White Law )“nursing homes often hire nursing home staff with minimal qualifications, having inadequate staff, having insufficient training and having low wages and a very high staff turnover rate. The result of these affects has the effect of serious and life-threatening problems for nursing home residents such as weight loss, bedsores (pressure sores), hospitalization, malnutrition and dehydration, and even death.” This text evidence just ties into the problems of nursing homes and why families are very untrusting to put their families in the nursing homes. Because the senior members can go into the nursing home not doing bad as when the leave or come out. This is because the staff doesn’t get paid enough too fully do their jobs, so they are mistreating their patients despite the pay. The patients don’t come in there too die rather than too be taken care if, so they shouldn’t have repetitive healthcare problems.

(The Pros and Cons of Nursing Homes) “Last March, inspectors found workers there were improperly using side railings on beds. Four months later, records show, a 53-year-old obese resident suffocated when he got stuck between the mattress and side rails. Illinois fined the facility $50,000 for the death, one of the largest nursing home penalties in the state last year. “This is a horrifying statement because who would want their family member going through such pain because they can’t be taken care of at all in their normal house hold.

My problem to this solution is tricky because everyone might not participate in the different activities or still have doubts but in all reality once more and more people sign up there won’t be as much doubt but only hopefulness for the future.” Working with elderly patients who are hearing impaired or unable to process information as quickly as the general populace the elderly may have difficulty retaining information and need to be reminded of things frequently. you may be with many patients when their life ends. You will need to have the emotional fortitude to deal with the sadness and feelings of loss while providing care and services.

These situations are encountered in every setting where the elderly receive health care” This is some of the skills needed for working in a nursing home that staff doesn’t have now but can utilize over time and this will hopefully prevent the negative perceptions of nursing homes.

Works Cited

1. Care, Family Matters In-Home. “5 Disadvantages of Nursing Homes for Seniors.” Family Matters, 28 June 2017, www.familymattershc.com/disadvantages-of-nursing-homes/.
2. DiUlio, Nick. “How Do Race, Age Affect Attitudes Toward Senior Living?” Caring.com, Caring.com, 16 Mar. 2016, www.caring.com/articles/how-does-race-affect-attitudes-toward-assisted-living.
3. Jones, Aprill. “Nursing Home Horror Stories: Are They True?” AgingCare.com, 14 Aug. 2008, www.agingcare.com/articles/nursing-homes-perceptions-and-realities-133358.htm.
4. McCloskey, Rose, et al. “RNs IN NURSING HOMES: Accepting the Challenge and Reaping the Rewards.” Info Nursing, 2018, p. 35. Academic OneFile, link.galegroup.com/apps/doc/A557992656/GPS?u=j057910010&sid=GPS&xid=31501153. Accessed 10 Jan. 2019.
5. “The Pros and Cons of Nursing Homes | Hardison Wood Legal Blog.” The Pros and Cons of Nursing Homes Comments, 5 Nov. 2018, www.hardisonwood.com/blog/the-pros-and-cons-of-nursing-homes/.

The population around the world is growing in the fast pace every year with significant increase in the elder population. As the population ages, there is growing interest in the health care services for seniors. Nursing homes, also known as Long-Term Care facilities (LTC) or personal care homes across Canada, represent a critical component of our health care system, especially as elderly population increases (Canadian Institute of Health Information [CIHI], 2013). LTC provide 24/7 nursing service and supervision, primary medical care, help with daily activities of living and interests, and a safe, caring home environment (Ontario Long Term Care Association [OLTCA], 2019). Gaugler (2016) states that enhancing quality of care in nursing homes has remained paramount for gerontologists with the evolution of nursing homes from 19th century almshouses to more medicalized environments in the 20th century. Quality of care in nursing homes needs improvement for the purposes of conducting scientific research, providing input for policy, and promoting practice improvement (Prins, 2019). Maintaining quality of care in nursing home is a major issue which does not have a simple solution. Inadequate staffing and rising of patient complexity are the contributing factors for poor quality care in nursing homes.

One of the primary factors associated with poor quality care has been nurse staffing (Mueller, Degenholtz, & Kane, 2004). Survey of Ontario’s long-term care homes revealed that 80% of respondents had difficulty filling shifts, and 90% experienced challenges in staff recruiting. 8 homes found themselves working short, working staff into overtime, and sometimes unable to fill the required shifts to provide care that residents need (OLTCA, 2019). (Kayser-Jones et al., 2003) found that inadequate staffing and lack of supervision were among the most significant organizational factors that influenced care. Often, residents did not receive basic care, such as bathing, oral hygiene, adequate food and fluids, and repositioning. A consequence of inadequate staffing was the development of pressure ulcers; 54% of the residents had pressure ulcers; 82% of these residents died with pressure ulcers.

Secondly, residents have entered LTC homes with more complex conditions and health needs, requiring more complex care over time. Most of the people who reside in LTC have some form of cognitive impairment and physical frailty, along with chronic health problems. Elders with middle or advanced stages dementia are the core population in LTC with two out of every three residents (64%) since 2010. Similarly, more than half of LTC residents are 85 years and older, with a significant increase in the number of residents who are over 95 years in the last five years. (OLTCA, 2019). CIHI (2016-2017) found that many residents have some form of cognitive impairment (approximately 90%) and around 85% require extensive or complete support with their activities of daily living. The demand for long‐term care increases with the growing number of seniors with cognitive and physical disabilities challenging in providing quality service.

Although several factors are responsible for influencing nursing home’s quality care, two main of them have been discussed in this paper.

A nursing home is place where people who do not need a hospital but cannot be cared for at home either. Most nursing homes have a nursing aides and skilled nurses on hand 24/7. Some of the issues affecting the nursing home are cost of living, staff to resident ratio, and nutrition. Community Needs Assessment are performed to determine current situations, identify issues to determine a course of action, and establish the foundation for vital planning. The target population for this community needs assessment is 70+ elderly individuals in Tennessee specifically Jefferson City who cannot be cared for at home. The objective of this need’s assessment is to identify barriers and gaps that prevent residents from accessing resources and services, come up with strategies to improve quality of patients care, how to use resources more efficiently, and to assess the coming challenges of caring for large numbers of frail elderly as the Baby Boom generation ages.

The types of data needed for this assessment are statistics comparing Jefferson City to Tennessee and studies on the effects of under staffed healthcare workers. The average median household income for seniors in Jefferson City is “$32,702 with 8% below the poverty level” (ACS) whiles the median household income in Tennessee is “$51,340” with 16.7% below poverty level respectively’ (datausa.io). “There are a little over 10 nursing homes in Jefferson City which comes with an array of preferences suitable for the loved ones needing assistance” (sc.org). The average life expectancy for individuals in is 76.4, 79.3 for females and 73.6 for males individually. There are 3,348,795 in the labor force, 3,243,693 employed and 105,102 unemployed in Tennessee. The utmost waged jobs in Jefferson City are “Health Diagnosing & Treating Practitioners & Other Technical Occupations ($51,875), Healthcare Practitioners & Technical Occupations ($51,146), and Computer, Engineering, & Science Occupations ($49,063)” (ACS).

The Life Care Center Nursing home operates by assigning roles to specific skill criteria such nurses administer medications and record vitals of the residents, etc. The demographics of the nursing home is relatively diverse, there are just about the same number of women to men ratio, different races such Native Americans, Hispanics, African Americans, and Caucasians. There are two residents per room with a curtain divider for some privacy. The facility tries to accommodate every diversity as closely as they can by respecting each their religion, dietary needs, etc. Some of the existing community services and programs that addresses problems and issues are Elder Rights and Long-Term Care Ombudsman program. This advocates for the protection of older Tennesseans from abuse, neglect, exploitation, and discrimination. The Tennessee Vulnerable Adult Coalition (TVAC) was established in 2008, to bring the state’s public and private agencies together to promote the collaboration necessary to prevent abuse, neglect, and exploitation of vulnerable adults.

Long-Term Care Ombudsman program consists of a State long-term care ombudsman, along with 11 district long-term assisted by 200 volunteer ombudsman representatives. The Long-Term Care Ombudsman program is responsible for supporting for the rights of those living in licensed nursing facilities, assisted living facilities and homes for the elderly. The chief concern of this program is to resolve complaints that impact the health, safety and welfare of residents of long-term care facilities, as well as informing residents of their rights. The Ombudsman’s advocacy role takes two forms: 1) to receive and resolve individual complaints and issues by, or on behalf of, these residents; 2) to pursue resident advocacy in the long-term care system, its laws, policies, regulations, and administration through public education, consensus building, and policy or legislative action. The services of the Ombudsman are free, confidential and statewide.

The program accepts complaints and or concerns from anyone including, but not limited to, the residents of any nursing home, assisted living or residential homes for the aged, family members or friends of a nursing home resident, nursing home and administrators, employees of the facility, or any other concerned citizen. This program will also assist individuals and families interested in and considering long-term care placement.

Some of the political, social economic status, and environmental factors that are impacting understaffing in nursing homes are the Advanced Center for Nursing and Rehabilitation and the state Department of Public Health (DPH), the state’s Public Health Code, income and education level, insurance status, access to care, and patients’ health beliefs. The DPH makes sure health facilities such nursing homes have a minimum nurses and staff ratio per shift required to run a successful business and comply with the law. With SES, sometimes individuals who cannot afford, have insurance that does not cover treatments, etc. sometimes hinder them from getting adequate care and treatments. Most individuals that reside in the nursing home have out grown most of their family members, have no children or have family members living far away.

With the facility I gathered information in particular, families have a special day they come and spend with their loved ones, volunteers from neighboring schools and the communities come whenever they can to help out, it they offer equal employment an equal pay for employees, and the Abuse Policy ( this helps to identify and properly report any form of abuse. This in place it helps ease the load on healthcare workers, help protect the elderly, and healthcare workers work better if they get paid better.

Comparing Jefferson City to Tennessee

• 13% of the population of Jefferson City, TN are seniors 13% of the population of Tennessee are seniors.
• 31% of those seniors living in Jefferson City, TN are living alone. 27% of those seniors living in Tennessee are living alone.
• 11% of Jefferson City senior households have an annual income of less than $10k and 41% less than $20k 8% of Tennessee senior households have an annual income of less than $10k and 29% less than $20k.
• 24% of Jefferson City, TN residents 60 and over received food stamps in the last year. 26% of Tennessee residents 60 and over received food stamps in the last year.
• The average Social Security Income in Jefferson City is $14,629/year. The average Social Security Income in Tennessee is $16,841/year.
• The median household income for a Jefferson City senior is $23,180 The median household income for a Tennessee senior is $32,702.
• Compared to other states, Tennessee ranks 45th for Long Term Care and 44th for America’s Health Rankings Compared to other states, Tennessee ranks 45th for Long Term Care and 44th for America’s Health Rankings.
• There are 110 working seniors in Jefferson City. There are 126,939 working seniors in Tennessee
• 26% of the seniors in Jefferson City are veterans. 22% of the seniors in Tennessee are veterans.

Comparing Jefferson City to Tennessee there was not much of a difference in evidence supporting the issue but then the information I could find was generated few years back. Nationally, there is a much recognition to the issue and talks have been engaged in coming up with solutions. The outcomes of nursing home understaffing are many and may vary according to patient needs. Neglect and abuse become more common as the patient to staff ratio increases. The neglect and abuse suffered by patients can cause physical ailments, psychological disorders, and even death. Nursing home understaffing may also contribute to psychological disorders among staff members, as stress increases.

Nursing home understaffing may also result in patients being physically and emotionally abused. Abusive staff members report stress from understaffing issues as a primary factor in becoming abusive. Having a limited amount of time to care for each patient can also cause staff members to become intolerant and use excessive force when caring for patients. Nursing home understaffing is a societal problem that may benefit from increasingly strict laws, policies and penalties, as well as increased public awareness. Many nursing homes have been held accountable for understaffing issues by paying fines and with lawsuits. While this may temporarily halt some nursing homes from practicing unethical hiring and staffing, there is much to be done to rectify the problem.

References

1. (n.d.). Retrieved October 12, 2019, from https://www.truthaboutnursing.org/faq/short-staffed.html.
2. (2016, September 11). Retrieved October 14, 2019, from http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0400-0499/0400/Sections/0400.23.html.
3. (2017, June 24). Retrieved October 13, 2019, from http://www.leg.state.fl.us/statutes/.
4. Jefferson City, TN Senior Guide. (n.d.). Retrieved October 10, 2019, from https://www.seniorcare.com/directory/tn/jefferson-city/#census_footnote.
5. Tennessee Senior Guide. (n.d.). Retrieved from https://www.seniorcare.com/directory/tn/#acs_footnote.
6. A Tennessee Department of Health Fact Sheet Life … (2013, November). Retrieved October 26, 2019, from https://www.tn.gov/content/dam/tn/health/documents/Life_Expectancy_in_Tennessee_2009_to_2011.pdf.
7. Tennessee. (n.d.). Retrieved October 26, 2019, from https://datausa.io/profile/geo/tennessee.
8. Yurtoğlu, N. (2018). http: www.historystudies.net.pdf. History Studies International Journal of History, 10(7), 241–264. doi: 10.9737/hist.2018.658

Understaffing in nursing homes has increasingly become an issue in the United States with over 90% of nursing homes reporting shortages in staff. This is an issue that effects the patients, families, staff, and the nursing homes as a whole. This creates further health concerns for those involved. Labor costs are often attributed to this issue despite research showing it costs more to understaff. Through research and experimentation, it can be seen there are many solutions to this growing problem. This paper will examine the previous research to establish potential reasons and effects of understaffing while also addressing current ways in which facilities have addressed this topic.

Understaffing is a topic of recent focus with the current and projected increase in elderly adults within nursing homes in the future. The increase in cases of understaffing has caused more attention and led to further strides in the research involving understaffing, reasons for it, and potential influences this has on nursing homes and nursing facilities. Recent research revealed that 90% of nursing homes in the United States are understaffed and there is an increase in proposals on what is an acceptable resident to staff ratio within these facilities (Hyer, Temple, & Johnson, 2009). Recent research is also suggesting there could be a correlation between understaffing and wrongful death among residents (Levin, & Rushing, 2008). Wrongful death can occur from any lack of supervision or care of a resident within a facility (Levin, & Rushing, 2008). Finances are often attributed to this short staffing but further examination shows there are more costs than just the assumed labor costs (Burns, Hyde & Killett (2016). There is evidence that proposes the expected marginal benefit of hiring more people will outweigh the expected marginal cost for nursing homes to hire more people. With these factors taken into consideration we must ask, what is the social work profession as well as nursing homes and organizations doing to combat this social issue? These factors included also influence the mental and physical condition of the workers who are working under these conditions (Aleshin, 2014).

This paper will examine the previous research to establish potential reasons and effects of understaffing while also addressing current ways in which facilities have addressed this topic. Further examination will show the effects understaffing has on both the patients and the workers within the nursing home. We will also look at financial factors and misconceptions behind them that has led to this short staffing issue. We will also address what the social work profession is doing in order to address this issue.

Understaffing in Nursing Homes

There has been a variety of studies addressing understaffing within nursing homes and its effect that it has on both the patients and the workers. Understaffing is defined as a shortage in workers leading to patients not receiving proper care (Hefner, 2002). It has been proposed that more than 90% of nursing homes are understaffed in the United States. Studies showed that patients in nursing homes with the least number of workers were more likely to suffer from bed sores, malnutrition, weight loss, dehydration, pneumonia and blood borne- infection (Hefner, 2002). As the life expectancy increases, people require more medical assistance and attention within the nursing home (Preshow, Brazil, McLaughlin, & Frolic, 2016).

A factor of understaffing that affects the patient is inability or lack of communication through staff to provide the care needed for patients. A study proposed that informed decision-making that included both nursing staff, doctors, patients, and family, led to better care within the home. When staff was limited it led to miscommunication and what some residents called questionable care (Preshow, Brazil, McLaughlin, & Frolic, 2016). It was proposed that nurses also get comfort in being able to speak to their fellow nurses and allowed for them to consider ethical dilemmas. With shortness of staff it showed that this time was often not available in order to do so (Preshow, Brazil, McLaughlin, & Frolic, 2016). Due to understaffing, many states such as Ohio and California have adopted minimum staffing standards in an effort to combat this (Chen, Min, Grabowski, & David, 2015). A minimum staffing standard was established by examining the minimum number of hours nursing staff worked in nursing homes on a daily basis.

Patient Issues

The main focus in any nursing home, is the safety and care of the patients that are being housed within. Research is showing that safety and care is often times at jeopardy due to understaffing. An area of recent focus and legislation involves nurse to patient ratio. Nurse to patient ratio shows how many staff there are compared to patients, a ratio of 1:1 shows 1 nurse per 1 patient while a ratio of 50 indicates 1 nurse per 2 patients. Research is showing that when the ratio is lower, indicating more staff per patient, nurses felt they were more safe practitioners (Louch, G., O’Hara, J., Gardner, P., & O’Connor, D. B. (2016). Inversely, when the ratio was higher, they felt they worked safer with the patients and showed higher levels of conscientiousness and emotional stability. When the work load for a nurse is higher we see that prevalence of infections, such as pneumonia and urinary tract infections, failure to rescue, and shock or cardiac arrest (Welton, 2007).

Increased work load directly correlates with wrongful death and its increased rates in nursing homes. Wrongful death is any form of neglect or malpractice by one person led to the death of another. Since the early 1990’s the United States has seen an increase in elderly admitted into nursing homes. Since this happened, the number of claims per nursing home bed has tripled (Konetzka, Park, Ellis, & Abbo, 2013). With the higher number of patients and not enough nurses, staff are required to work significantly more hours which then influences the quality of their care. It was found that patients found their care more favorable if they were involved in the conversation about their care as well as able to put forth their input. When nurses have more hours and higher workload, they are less likely to collaborate with their patients which decreases their comfort and care (Aleshin, 2014). Within nursing homes, we see that understaffing can pose many issues for the patient and influence their safety and overall care.

Staff Issues

Large amounts of research on understaffing in nursing homes focuses on the effects it has on the patients but further research suggests the staff itself is being heavily affected as well. Understaffing creates ethical issues within the nurses themselves. Nurses feel when understaffed they have to prioritize their patients leading to neglect of others and inability to include patients in their own treatment (Aleshin, 2014). Prioritizing patients causing neglect can also lead to malpractice lawsuits against the individual as well as the organization itself which possesses financial implication that will be address later in this paper. With the lack of staff came the issue of not being able to know their patient on a personal level which many said was a meaningful aspect to their job. This lead to feelings of inadequate care which influenced a troubled conscience and increased stress levels within the staff (Preshaw, Brazil, Mclaughlin, & Frolic (2016). We also see that in homes that were understaffed, 90% of staff were willing to break confidentiality if it meant upholding their other responsibilities for their patients (Preshaw, Brazil, Mclaughlin, & Frolic (2016). Lack of confidentiality is alarming because it is vital within the nursing home the for both nurses and their patients yet staff are sharing details of patients with other nurses in order to provide the care that they need. Nursing homes that reported overworked staff also showed indications of ageism, or a type of prejudice due to age. It was seen from both perspectives, the nurses and the patients that were at these nursing homes (Preshaw, Brazil, Mclaughlin, & Frolic (2016). It can be seen that elevated levels of stress within these high workload staff members. Stress is a process in which environmental demands strain an individual’s capacity, this can cause psychological and biological issues leading to illness and other health risks (Salleh, 2008). When illness is contracted in the workers, it can be spread to the easily susceptible patients they are working with on a daily basis. All of this shows the heavy impact it can have on the workers in an understaffed environment.

Cost of Staffing

One of the main reasons for understaffing within nursing homes is the expected cost of labor. Labor costs for registered nurses in the United States are around $65,000 annually per worker which depending on if the nursing home is non-profit, government funded, or for profit, can be a lot of money (Di Giorgio, Filippini, & Masiero 2015). This being said, it has been suggested that the cost associated with understaffing is greater than if the nursing home were to hire more employees. As stated previously, wrongful death and neglect are issues within the nursing home when understaffed. This causes lawsuits, court fees, medical expenses, and lawyer fees to all be placed on the nursing home itself. On average every year there are over 1800 wrongful death and neglect lawsuits in nursing homes. That’s about 1 per home each year. It is estimated that the final total cost in a lost suit can be between $755,00-$943,750. With this being the case, the expected benefit of hiring more staff, less wrongful death, neglect lawsuits and settlements, could outweigh the expected cost of hiring the new staff. Statistics show that nursing homes will potentially save money in the end by having more staff and a higher staff to patient ratio.

Implications for Social Workers

The research suggests that nursing homes need to make changes in order to benefit the patients, staff, families, and the nursing homes as a whole. To do this social worker must work on the macro and micro levels. Social workers must advocate to implement an affective staff to patient ratio in order to legally avoid understaffing. Social workers must also be vocal within the nursing homes themselves in order to influence the hiring of more workers. Social workers must also be more willing to incorporate the patient, staff, and family into the treatment plan. Research suggests that by incorporating all parties involved in the treatment, the level of care and effectiveness is increased. This would also significantly reduce the severity of wrongful injury and frequency of wrongful death.

Within schools and higher education institutions, this problem must be addressed in order to provoke interest for students and aspiring social workers to want to be active in working in nursing homes to reduce understaffing. Nursing homes themselves need to open up networking outlets to increase the number of applicants and potential workers. With research suggesting that the field is growing about 16% over the next 10 years, there should be little issue obtaining enough workers to accommodate an affective staff to patient ratio. Through advocating, raising awareness, and increasing marketing for nursing home jobs, understaffing can be significantly reduced. Also, through the incorporation of all parties within the care of the patient, social workers can increase the quality of care and reduce the likelihood of wrongful death.

Conclusion

Through research and experimentation, we can see the lasting effects of understaffing within nursing homes. Examination of the research also shows the benefits of which can be had by appropriately staffing. Understaffing is a detriment to the quality of care for the patient, the ability for self-care for the staff, and the functioning of the nursing home as a whole. It can be seen that there are misconceptions about the cost of properly staffing despite evidence proposing there is more to gain by hiring more staff. An understaffed nursing home paves the way for neglect, further ailments, and wrongful death. This problem causes ethical dilemmas within the nursing home, creating conflict for many of the staff. Families with patients in the nursing home are also hindered in their pursuit for the best care for their loved ones.

Research proposes relatively simple solutions for this epidemic. With 90% of nursing homes experiencing understaffing and recognizing the issue, citizens and workers must question why more hasn’t been done to combat it. While social workers should be advocating to correct this form of malpractice, it is also up to the people to combat this social issue. Through education, advocating, and implication, understaffing can be significantly reduced throughout the United States. This paper acknowledges that the United States is lacking in this field and can learn more from other nations in order to correct this. Research is addressing this topic in greater detail in an effort to make more strides to solve this issue.

References

1. Aleshin, O. (2014). Understaffing puts strain on all. Lamp, 71(10), 14-15.
2. Burns, D. J., Hyde, P. J., & Killett, A. M. (2016). How Financial Cutbacks Affect the Quality of Jobs and Care for the Elderly. Industrial & Labor Relations Review, 69(4),991-1016. doi:10.1177/0019793916640491.
3. Di Giorgio, L., Filippini, M., & Masiero, G. (2015). Structural and Managerial Cost Differences in Nonprofit Nursing Homes. Economic Modelling, 51289-298. doi:http://dx.doi.org.proxy-millersville.klnpa.org/10.1016/j.econmod.2015.08.015.
4. Hyer, K., Temple, A., & Johnson, C. E. (2009). Florida’s Efforts to Improve Quality of Nursing Home Care Through Nurse Staffing Standards, Regulation, and Medicaid Reimbursement. Journal of Aging & Social Policy, 21(4), 318-337. doi:10.1080/08959420903166910.
5. Konetzka, R. T., Park, J., Ellis, R., & Abbo, E. (2013). Malpractice Litigation and Nursing Home Quality of Care. Health Services Research, 48(6pt1), 1920-1938. doi:10.1111/1475- 6773.12072.
6. Levin, S. M., & Rushing, J. M. (2008). Litigating Nursing Home Malpractice. Gpsolo, 25(5), 42-45.
7. Louch, G., O’Hara, J., Gardner, P., & O’Connor, D. B. (2016). The daily relationships between staffing, safety perceptions and personality in hospital nursing: A longitudinal on-line diary study. International Journal of Nursing Studies, 5927-37. doi: 10.1016/j.ijnurstu.2016.02.010.
8. Preshaw, D. L., Brazil, K., Mclaughlin, D., & Frolic, A. (2016). Ethical issues experienced by healthcare workers in nursing homes. Nursing Ethics, 23(5), 490-506. Doi:10.1177/0969733075576357.
9. Salleh, M. R. (2008). Life Event, Stress and Illness. The Malaysian Journal of Medical Sciences: MJMS, 15http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3341916/ (4), 9–18.
10. Welton, J. (2007) “Mandatory Hospital Nurse to Patient Staffing Ratios: Time to Take a Different Approach ‘OJIN: The Online Journal of Issues in Nursing. Vol. 12 No. 3, Manuscript 1.

Old age is an inevitable and irreversible process. In general, the old age is a period of regression to physical, mental and cognitive function. The most important problem of old age is the loss of communication with the environment and society. Therefore, nursing homes were established to meet the needs of the elderly people. So elderly people are placed to nursing home because need to be care and loneliness, their family’s difficulties for care. But nursing homes are not good enough.

First of all, elderly people are afraid of loneliness. For this reason they want to go nursing home. Because there are lots of friend for elderly people. They are not alone.They have friend for talking every time.For talking, play something or watching tv. After that they do not prefer to be alone because they cannot live on their own. When they are alone they have more psychological trauma. For example they do not have anyone to make their voice heard in an emergency. There is no one to take care of them. Elderly people need care. The care is so important. They should be taken a bath carefully, they should be taken medicine in time and they should eat healthy food. Accordingly, elderly people should not be alone and their care should be done well. If you look at these reasons, nursing homes are a suitable place for the elderly people.

Secondly, old people’s family may also experience difficulty. Because they can go out unnoticed, they can get lost out there; even worse, it could be a bad thing for him outside. Above all, he may lose consciousness. So their family’s , elderly people’s daughter or son, can not find him/her. It is difficult for both sides. Patience is very important for their families. Because elderly people usually act unconsciously, they can get upset. For example an old man who is addicted to bed can’t fulfill his own needs. Their family’s have difficulty in. So elderly people should be put in nursing home.

Last but not least, some nursing homes are not good enough for elderly people. So 62% of the elderly in nursing homes are at risk for depression. For this reason, psychological counseling and guidance services for the elderly in the nursing home should be improved, depression screening should be done. On the other hand, lack of adequate financial support to nursing homes, lack of adequate personnel – those who love their job- and socio-cultural diversity are shows nursing homes disabilities. Taking the elderly people away from the their home, causes diseases like Alzheimer’s. Loneliness and stress can also cause chronic diseases. Especially the place of the healthy elderly is not the nursing homes , but the home of peaceful life. For example, a Turkish film called the ”Beyaz Melek” describes how bad the nursing homes. The film showed that a paralyzed woman was beaten and was taken a wrong medicine. Even the worst care is better than the nursing homes.

In conclusion, according to the study, 20% of the reasons for settling in the elderly were lonely, 17% of them had no one to take care of. They are lonely and they need friends. If they live in nursing homes they have new friends and they are not bored. But in contrast nursing homes are not good. There is a lot of problems there. For the elderly people, social activities should be organised that can stimulate their interest and enable them to participate according to their educational status. Psychological support should be provided to the elderly people, health education and stress management programs should be applied to the elderly accompanied by the health workers. The most important psycho-social problems in old age are lonely at the beginning, interest, love need, sharing and being together. If nursing homes are developed and necessary controls are provided, they may be suitable for the elderly people. Of course, if elderly people’s family wants to look elderly people, there is no need for nursing homes. That way, they are happy and they are together with their families.