Service Experience of the Elderly in Nursing Homes with Integration of Medical and Nursing in Chongqing: A Qualitative Study ()
1. Introduction
According to Statistical Bulletin of National Economic and Social Development in 2019, the elderly aged 60 and above in China accounted for 18.1%, and the elderly aged 65 and above accounted for 12.6% [1]. Meanwhile, the population aged 60 and above accounted for 20.6% in Chongqing, and the population aged 65 and above accounted for 14.96% in Chongqing [2], indicating that the population aging has become very serious in Chongqing. In order to handle the population aging effectively, Chongqing has actively responded to the call for national reforms and has successively issued policies related to medical-nursing integrated services. There are currently three main pension modes in China, they are family pension, institutional pension and home-based community pension, however, traditional family pension functions are gradually weakening and home-based community pension services are not yet perfect, hence institutional pension has become an important way to solve the pension problem [3] [4]. So far, however, medical-nursing integrated services in nursing homes cannot meet the needs of the elderly, and the quality of service needs to be improved [5]. Given that, this research is based on the perspective of the elderly, adopts qualitative research methods, and deeply explores elder people’s real experience and development expectations of medical-nursing integrated services in nursing homes, in order to discover potential problems in medical-nursing integrated services of nursing homes and provide reference for improving medical-nursing integrated services.
2. Objects and Methods
2.1. Research Objects
We adopted the purpose sampling method, and selected elderly people of two large nursing homes (nursing homes have hospitals and support medical insurance payments) in Chongqing as the research objects to conduct semi-structured in-depth interview from December 2019 to January 2020. Inclusive criteria: 1) Age ≥ 60; 2) The time of admission to nursing homes ≥ 3 months; 3) No severe hearing and vision impairment; 4) Ability to express the information needed for the investigation clearly.
The sample size was determined based on the principle of information saturation, until repeated interview information appeared. In the end, a total of 16 elderly people were enrolled, with an average age of 84.25 ± 6.46 years old, and elderly people mainly suffered from common chronic diseases, such as diabetes, hypertension, cardiovascular and cerebrovascular diseases and osteoarthritis. The basic information of 16 interviewees is shown in Table 1.
2.2. Methods
2.2.1. Data Collection
Based on literature review, expert consultation and pre-interview, we finally determined the semi-structured interview outline of the elderly. The main contents of the interview outline are listed as follows: 1) Basic information of the elderly; 2) The time and reason of living in nursing homes; 3) What is the overall feeling of living in nursing homes? 4) What kind of medical-nursing integrated services are provided by nursing homes? Are you satisfied with these services? 5) What are your opinions and suggestions medical-nursing integrated services in nursing homes? The interviewers informed the interviewees of research purpose
![]()
Table 1. General information of 16 interviewees.
and significance, promised the confidentiality of the interview in advance, then conducts face-to-face in-depth interviews after obtaining informed consent. The interview time for each person is 40 - 60 minutes, and the interview contents are well recorded and saved by recording.
2.2.2. Data Analysis
The Colaizi 7-step analysis method consists of seven steps, namely familiarization, identifying significant statements, formulating meanings, clustering themes, developing an exhaustive description, producing the fundamental structure, and seeking verification of the fundamental structure [6]. We transcribed the interview recordings into text materials within 24 hours after the interview, and strictly followed these seven steps to analyze the interview data so as to ensure the completeness, authenticity and credibility of the research results [6].
3. Results
Four themes were refined after being sorted, they are construction of living environment, daily living care, medical service provision, psychological support.
3.1. Theme 1: The Construction of Living Environment
3.1.1. Natural Environment
For the elderly in nursing homes, environmental conditions of nursing homes will affect the quality of life of the elderly [7], and it is also a necessary consideration for the elderly and their families to choose a nursing home. A6: “I have lived in the nursing home for more than 3 months. I choose this nursing home because of its good environment. My husband and I often take a walk in the nursing home.” A11: “This nursing home is far away from the city, green and fresh air, so the body will be healthier. Most people come to here for its environment.”
3.1.2. Layout and Facilities
As the second place of the elderly, the cleanliness of room layout and the completeness of facilities are the primary considerations before they move into nursing home [8]. A3: “The facilities here are very good both inside and outside. There are fitness equipment, chess room, mahjong table outside the room, and there are air conditioners, water heaters, TVs, call bells in the room”. A5: “The facilities are OK, I’m very satisfied. The room is spacious, with heating in winter. The summer is cool, so do not need to turn on air conditioner, but there are too few mahjong tables, too many people”.
3.2. Theme 2: Daily Living Care
3.2.1. Basic Living Service
Basic living services are the key to service for the elderly. The reason why the elderly go to nursing homes is that most of them have difficulties in home-based care due to limited time and energy for their children, their old age and limited mobility. Previous researches show that the elderly in nursing homes value basic living services [9]. A9: “There are service staff here to help us fetch boiled water, do cleaning, wash the bedclothes and assist to walk. Their service is very attentive. In terms of food, there are not a wide variety of dishes, and the meal is scheduled too early, 7:10 in the morning, 11:10 at noon, 5:10 at night. Dinner is too early, so I’ll be hungry in the evening”. A10: “My wife and I have lived here for more than 3 years. The service staff helps us wash clothes, do cleaning, etc., but the food is getting worse and worse. There are not many varieties of dishes, and we often eat the same vegetables, and they do not wash vegetables carefully, so the food needs to be improved”.
3.2.2. Caregivers of Daily Life
As providers of elderly care services, caregivers’ quantity and quality will directly affect the satisfaction of the elderly. A6: “The caregivers here have a good working attitude and an affinity. They treat the elderly very well, like their own relatives. They will chat with us when they come to do cleaning, and they work very seriously, we are satisfied with them”. A7: “My ability to walk is not convenient, so I live in the intermediate nursing area. There is one nurse on each floor of intermediate nursing area, the caregiver usually care for me. A caregiver has to care for 6 elderly people, they are too busy”. A15: “The caregivers have a good service attitude, but they are not well-educated. Most of them are rural women around nursing homes, they don’t know how to care for the elderly, and they have not received any training on the job, so their professional quality is not good”.
3.3. Theme 3: Medical Service Provision
3.3.1. Quality of Medical Service
Of the 16 elderly people, 14 suffered from diagnosed disease with a prevalence rate of 87.5%, which shows that the elderly have a very high demand for medical and health care.
A8: “The hospital in nursing home provides such services as seeing a doctor and hospitalization, and it also organize health talks, as well as traditional Chinese medicine and physical therapy, but medical technology is worse than that of hospital outside nursing home. I was hospitalized in the institution’s hospital for 18 days due to a cough, but it has not been well. The frequency of blood pressure measurement is low, only once a week. I suffer from high blood pressure, nursing home should pay attention to it and monitor blood pressure at any time”. A9: “The hospital can see a doctor and take medicine, but most elderly people are unwilling to go there, because they think its standard of medical care is not high. At the same time, there are not many doctors, and many doctors have resigned, the hospital can’t retain talents”.
3.3.2. Restrictions on Medical Services
The original intention of establishing hospital in nursing home is to facilitate the elderly to obtain professional medical services, but the reality is not optimistic, and there are still many restrictions on the medical services provision.A1: “I suffer from uremia and need dialysis twice a week, but the hospital in nursing home lacks dialysis equipment, so I have to pay for a ride from nursing home to other hospital for dialysis every time”. A11: “My special disease medical insurance can only be reimbursed in the designated hospital, but it cannot be reimbursed in the hospital of nursing home. I took Chinese medicine in the hospital of nursing home for several times, the doctors are very responsible and enthusiastic. However, there were few kinds of drugs in the hospital and the prices were expensive, so I always went to the outside hospital to see the doctor”.
3.4. Theme 4: Psychological Support
3.4.1. Family Care
As the elderly in nursing homes grow older, their various physiological functions gradually decline, and coupled with long-term separation from their families, they are more likely to experience anxiety, loneliness, and other negative psychology than those living at home [10], so they have a strong demand for family care. A1: “I still don’t get used to this nursing home. I can’t fall asleep every day since dialysis, I feel anxious and lonely all the time. My daughter is busy working in Shenzhen, and she hasn’t come to see me since she sent me to the nursing home”. A14: “As I get old, my personality has changed a bit. I feel depressed about a lot of things, my family is not around, I’m very lonely. When I see most of the elderly around me are sick, I feel very pessimistic about that. My children are usually busy at work, and they seldom came to see me, they just called to say a few words. In fact, I still want to go home and live with my children”. A8: “I am very anxious recently. I have lost my husband, so I feel unhappy and lonely”.
3.4.2. Cultural and Recreational Activity
Abundant cultural and recreational activities are beneficial to physical and mental health of the elderly, and many elderly people expressed the need for cultural and recreational activities to enrich their leisure life. A7: “There are many activities in nursing homes, such as playing ball, singing and dancing, watching movies, playing mahjong, etc. Now I don’t participate in them due to my own health. I used to like to play everywhere. The activities are going well, but my body is not good enough to participate in them”. A10: “No personnel organizes the activities. The singing and dancing are all spontaneously organized by the elderly, but not many people take part in them. I still hope that nursing homes can organize everyone to participate together”. A12: “There are many activities in nursing home, and I feel very fulfilled. Now I’m sick, I can’t take part in the mand I’m not used to it. I hope to get better soon”.
3.4.3. Psychological Consultation
The elderly in nursing home often suffer from negative emotions such as loneliness and anxiety due to the absence of their children and the unfamiliarness of old people around them. However, there is no special psychological consultation service in nursing homes at present, so the psychological problems of the elderly cannot be solved. A8: “I suffer from depression, and I usually take medicine to control my random thoughts. The nursing home does not have psychological counseling services, and I have little contact with other elderly people, so I often don’t know who to talk to”. A9: “The nursing home does not have psychological counseling services, sometimes caregiver chats with us. Most of the elderly are lonely, so we hope to have professional staff to ease our emotions”. A16: “It’s okay for me to live in nursing home with my husband, and I don’t feel lonely. Some elderly people live alone and children do not come to visit them often, so they are very lonely. The nursing home does not have psychological counseling services, we still need a professional psychologist”.
4. Discussion
Medical-nursing integrated services of nursing homes cannot effectively meet the needs of the elderly at present. Therefore, improvements can be made from the following aspects to increase the service level of nursing homes.
4.1. Clarify the Content of Medical Services and Improve the Level of Medical Services
The research found that there were some deficiencies in hospitals of nursing homes at present, such as low medical level, lack of medical equipment and limitation of medical insurance payment. To solve above problems, hospitals in nursing homes should clarify the content of medical services, with a focus on prevention and management of chronic diseases, long-term rehabilitation nursing, emergency medical, health consultation and other medical needs of the elderly [11], highlighting their own characteristics. Then hospitals should allocate personnel and equipment in line with the service content to improve medical service capabilities. Meanwhile, hospitals in nursing homes should also moderately increase salary of medical staff, and focus on training, establish a rotation training system for medical staff, and promote professional skill appraisal in integration of medical and nursing [12] to enhance the professional skills of medical staff. Furthermore, nursing homes can sign a cooperation agreement with designated hospitals for special diseases nearby to establish a green passage for the elderly with special diseases to meet their medical needs.
4.2. Increase Emotional and Social Support and Establish a Psychological Counseling Department
Due to long-term separation from family and friends, the elderly in nursing homes are more likely to experience negative emotions such as loneliness and depression than those living at home [13]. Family’s regular visits and contact with family members can reduce the occurrence of negative emotions of the elderly, hence nursing homes should actively communicate with the children of the elderly and advocate their children to make more phone calls and take more visits so as to understand their mental state and living conditions. Previous studies have shown that rich social activities play an important role in improving the mental health of the elderly in nursing homes [14]. Therefore, nursing homes should organize diversified social activities and mobilize the interest of the elderly to participate, in order to enrich their daily life, to strengthen their communication, and to establish a harmonious living atmosphere. Moreover, nursing homes should also establish psychological counseling departments with professional psychologist, and active control over their psychological problems to improve their mental health.
4.3. Introduce Professional Talent Team in Elderly Nursing and Strengthen Knowledge and Skills Training of Carer
The shortage of professional talents in nursing homes will seriously affect the provision of medical-nursing integrated services. Therefore, nursing homes should make efforts in salary, benefits and career development to encourage nursing professionals to engage in caring for the elderly so as to change the shortage of nursing staff in nursing homes [15]. This research found that in-service caregivers in nursing homes have low levels of education with a lack of professional capabilities. Therefore, in addition to introducing nursing professionals, it is also necessary to attach importance to training and establish the certification system, the professional skill standards and the operating norms [16], so the nursing homes also should strengthen on-the-job training, and regularly provide nursing knowledge and skills training to caregivers in order to improve their work abilities. In addition, it is necessary to increase the training of humanistic care for caregivers to improve the happiness of the elderly.
4.4. Have a Scientific Guidance for Rational Diet and Provide Diversified Diet
This research found that the elderly in nursing homes are dissatisfied with their diets, mainly due to poor taste and unbalanced collocation. Relevant studies have found that the unbalanced diet of the elderly in nursing homes can cause malnutrition, which will seriously affect their health [17]. In view of this, in order to improve their health status, nursing homes should pay attention to the diet of the elderly, have a scientific guidance for rational diet, and highlight the characteristics of “medicine” in integration of medical and nursing, so nursing homes should have professional nutritionists to guide scientific food collocation and seasonings, not only pay attention to color, smell and taste, but also regularly change the dishes to meet the needs of the elderly; should establish health records, classify and manage the elderly with special dietary needs, and scientifically prepare meals according to the dietary requirements of doctors; should appropriately adjust the diet time and implement a combination of catering and ordering food to meet the individual needs of the elderly.
5. Conclusion
There are currently many shortcomings in medical-nursing integrated services of nursing homes, which cannot meet the needs of the elderly. Therefore, we recommended the following four measures to improve services so as to increase the satisfaction of the elderly: Firstly, clarify the content of medical services and improve the level of medical services; secondly, increase emotional and social support and establish a psychological counseling department; thirdly, introduce professional talent team in elderly nursing and strengthen knowledge and skills training of carer; fourthly, have a scientific guidance for rational diet and provide diversified diet.
Acknowledgements
We acknowledged these two nursing homes, and their staff for their support in one way or the other. We also acknowledged all elder people we interviewed for their contribution on the completion of this work.
Funding
The 2020 Education and Teaching Reform Research Project of the Department of Public Administration, School of Public Health and Management, Chongqing Medical University. The project number is GWGLXY202007.
The 13th Five-Year Key Discipline Funding Project of Nursing Science of Chongqing Education Commission, project number is 2019hlxk15.
NOTES
*These authors contributed equally to this work.
#Corresponding author.