Nursing home research in Jinan, China: a focus group approach

Abstract

This qualitative research using the focus group approach has gathered pertinent perceptions from the stakeholders in Chinese elderly care environment, including community-based and institutionalised elderly, medical providers, administrators and governmental officials. The study found that the elderly are willing to live in nursing homes when they are not in good physical condition and are dependent on others for their activities of daily living. The utilisation of nursing home care has gained acceptance in the community as more elders recognise its advantages. The elderly study subjects expressed interest in the service environment, as well as the cultural and recreational activities in nursing homes. Most participants were satisfied with the quality of nursing care. Administrators and providers in the nursing homes agreed that skilled nursing facilities appear to be more competitive because they require more licensed providers and other professional staff members. A majority of nursing homes face serious financial difficulties.

1 Introduction

Long-term care (LTC) has emerged as an important public health and policy issue in both developed and developing countries. China has the largest and one of the most rapidly growing elderly populations in the world (Zhang et al., 2006). According to the National Bureau of Statistics of China (2009), China's elderly population, defined as aged 60 and above, reached 167 million in 2009, accounting for more than 12% of the population. The growth of LTC needs in China, presents a challenging and pressing problem (Xu and Tang, 2007).

A community needs assessment conducted in Shanghai found that 77.4% of the elderly had various chronic diseases and approximately 10.4% were dependent in activities of daily living (ADL) (Lv et al., 2001). Another study conducted in Beijing showed that 34.4% of elderly people aged 80 years and above need LTC (Huang, 2005). Meanwhile, the existing LTC system in China is not prepared to meet this challenge, because the elderly traditionally have been cared for at home by their spouses or adult children, who usually live in the same household. However, the Reform and Open Door, and One Child policies have brought economic and demographic changes leading to smaller average family sizes and fewer adult children residing with their parents (Liu, 1997). With the rapid economic development after the Reform and Open Door policy in the early 1980s, the tradition of three generations ‘living under one roof’ has steadily declined. Increasingly, young adults seek education and job opportunities away from their homes, making it difficult for them to take care of their ill or disabled elderly family members at home as they traditionally did (Chang, 2007; Cui et al., 2000; Sun et al., 2006). The traditional model of family support of the elderly is thus declining. As a result, nursing home care is now considered an important option for the elderly who need care for chronic illnesses and disabilities, but lack family support (Shang, 2008; World Health Organisation, 2003; Zhou and Liu, 2007).

In China, nursing home care is a relatively new phenomenon of the last 20 years and is still evolving. The needs of the elderly for nursing home care and its supply have not been fully investigated and understood. Only a few city- or district-level surveys have demonstrated some aspects of the needs for and supply of institutional LTC. A study conducted in Shanghai found that 12.1% of elderly people, and especially 17.3% of the elderly who are dependent in ADL, are willing to reside in nursing homes (Lv et al., 2001); the percentage in Dalian is 11.2% (Chu et al., 2007). Surveys in Fuzhou and Hangzhou showed that the average occupancy rates of nursing homes are 71.4% and 75.7%, respectively (Chen et al., 2008; Wang et al., 2003). There are also long waiting lists for nursing homes in big cities like Tianjin, Beijing and Shanghai (Yang et al., 2006).

Despite the fact that nursing home care is a relatively new development in China and largely market driven, little is known about the overall demand for and supply of nursing home care, in particular about the service environment, nurse staffing, financing, and quality of care. More complete and specific knowledge about the needs for and the supply of nursing home care is essential to better design the delivery of nursing home care and to allocate limited resources efficiently. More than ever, China needs efficacious strategies and skills to design and manage the LTC system, especially nursing homes (Yang et al., 2006). In this study, we conducted focus group interviews in Jinan, China with stakeholders of nursing homes: the community-residing and the institutionalised elderly, nursing home providers and administrators, as well as government officials, to obtain their views about the demand for and supply of nursing home care, utilisation, quality improvement, facility service environments, financing, and staffing. Results of the analysis could improve the understanding of the nursing home industry in a large city in China.

2 Method

2.1 Participants

Five focus groups were organised, and a total of 49 participants were interviewed (Table 1). In the respective focus groups we interviewed government officials in charge of LTC policy, nursing home administrators including medical directors and directors of nursing, providers including physicians and nurses, nursing home residents, and community-residing elderly. Government officials and nursing home administrators are familiar with nursing home policy on staffing and quality, finance, and community needs. In contrast, providers and nursing home residents offer perceptions about staffing and the quality of care. To solicit a broad range of opinions, we chose participants from different communities and nursing homes in Jinan. For the government officials’ focus group; we chose participants from the Office of Community Health (Municipal Department of Health) and the Office of Welfare (Municipal Department of Labor and Social Security).

Table 1.

Participants in five focus groups

Group	Participants	Number
1	Government officials	9
2	Nursing home administrators	10
3	Nursing home care providers	10
4	Nursing home residents	10
5	Community-residing elderly	10
	Total	49

2.2 Data collecting and analysis

An interview guide was designed with open-ended questions such as, ‘What are your perceptions about community needs of LTC and nursing home care?’, ‘What are your perceptions about the current nursing home supply? Is it adequate?’, ‘Do you believe nursing homes have enough nurses for resident care? How about their skills? Are you satisfied with their services?’ The guide also included questions about the strengths and challenges of demand and supply with regard to nursing home care in Jinan. These open-ended questions were proposed in sequence: opening, introductory, transition, key, and ending questions. The interviews were moderated by the trained researchers of the project. The focus group interviews were video and audio taped to accurately capture the discussions and participants’ emotions, and then transcribed. Members of the research team read the transcripts repeatedly to identify themes, and then developed a coding structure. Content analysis of the data was performed using QSR NVivo8.0. We classified material into themes by creating a coding structure. Coding can gather together all the material related to a topic. For example, when participants described nurse staffing as ‘not well-trained’, we coded the references at the node ‘Training’. When we open the node, we can see all the references gathered there and all the information on a theme summarised.

3 Results

3.1 Need for nursing home care

The majority of the participants in focus groups, both those for the community-residing and those for the institutionalised elderly, showed positive attitude toward nursing home care. When their physical conditions needed care from others, particularly when they were dependent in their ADL, the elderly were willing to live in a nursing home because they did not want to be a burden for their adult children. The elderly who had no pensions and were supported by their children tended to follow the decisions made by their children, including whether they would reside in a nursing home or other place. The elderly with pensions could decide their questions independently. However, the focus groups comprising government officials, administrators and providers reported that only a special elderly population was willing to live in nursing homes, in particular among those who had severe physical conditions or could not be cared for by their families. The utilisation of nursing home care has grown because increasing numbers of the elderly have recognised the advantages of nursing homes. However, two participants in the focus groups refused to accept nursing home care as an option. They firmly believe in the traditional Chinese idea: ‘bring up sons to support parents in their old age’, which is the traditional family support model. Others noted:

“I want to live in a nursing home when I am dependent on others in daily living activities. But now I have not thought about it, as my physical condition is good and I can take care of myself.” (A participant in the group for community elders)

“Three kinds of elderly people are willing to live in nursing homes. One is the elderly who are totally dependent in daily living activities or require assistance, one is the elderly whose adult children don't have enough time to take care of them, the other is the elderly who cannot get along well with their family.” (A participant in the group for governmental officials)

3.2 General introduction of nursing homes in Jinan

The participant from the Office of Welfare in the Municipal Department of Labor and Social Security, who is in charge of nursing home policy, described the general status of elderly care facilities in Jinan. At the end of 2009, there were a total of 63 nursing homes with 6,556 beds in Jinan city. The majority focused on help with daily living activities. Of the total nursing homes, four were owned by the government, 12 were owned by Street or Residents’ Committees, and the others were privately owned. There were a total of 19 adult day care centres, with 650 beds; the average occupancy rate was below 60%. The charges by the nursing homes could be divided into three categories: from 800 to 1,000 yuan per month; from 1,000 to 1,500 yuan per month; and from 1,500 to 2,000 yuan per month.

3.3 The service environment of nursing homes

The participants in the focus group for administrators explained that the construction quality of the nursing homes varies noticeably. Large and newly built facilities usually have good service environment. Both residents in nursing facilities and the elderly in the community expressed interest in the service environments both interior and exterior, of a nursing home, such as places to exercise and to relax, as well as in the cultural, sport and recreational activities in nursing homes. However, since the charges for a nursing home are related to the construction quality and the average income of the elderly is low, some administrators believed that the construction of nursing homes should be based on their affordability and the consumption capacity of the elderly to afford LTC. Two contrasting views were as follows:

“The nursing home located in my community doesn’t have a yard. The residents in that facility only can stay in the building. I don’t like that. I hope that the nursing home has an outdoor playground with fresh air.” (A participant in the group of community elders)

“I like this nursing home because there are many relaxing activities here and its environment is good.” (A participant in the group for institutionalized elderly people)

3.4 Nursing home care supply and quality

Administrators and providers agreed that a medical-care-focused nursing home is more competitive because of having more licensed of the needed providers and other professional staff including nurse aides in comparison to their counterparts. Most nursing home care focuses on daily living care and is usually provided by nurse assistants. According to the participants in the focus group for providers, a nurse assistant in nursing homes usually takes care of six to eight residents.

Most participants in focus groups were satisfied with the quality of nursing care, but some participants in focus groups of nursing home residents were not satisfied with the quality of the food. The participants in the focus groups for administrators and providers believed that because of the market competition, nursing homes should improve the quality of nursing care to attract residents. Most of the participants in the focus group for residents were generally satisfied with the services, particularly with the working attitude of the providers. Some said that residents should lower their expectations and get used to the life in nursing homes. The following remarks portray a general picture of the quality of nursing home care:

“Nurse Assistants in nursing homes play an important role as the daily living care provider. They take responsibility for assisting residents with eating, toileting, bathing, and so on.” (A participant in the group for providers)

“The residents can select nursing homes freely. .... Residents’ family members usually come to the nursing home. So, the nursing home must pay more attention to the care quality to attract residents and satisfy their family members’ requirements.” (A participant in the group for administrators)

“I want to express my thanks for the doctors and nurses in this nursing home. ...They work hard to take care of us.” (A participant in the group for residents)

“What impressed me is their working attitude. They are warm-hearted and friendly.” (A participant in the group for residents)

“I think the quality of food should be improved. It does not taste good.” (A participant in the group for residents)

3.5 Nurse staffing

Daily living care is an important part of the care in most nursing home facilities. Nursing homes need more nurse assistants than physicians and registered nurses. The number of nurse assistants could not meet all the residents’ needs. The participants in the focus group for residents emphasised that considering how busy the providers in nursing homes are, it is important for residents to stay independent in daily living and be conscious of self-improvement and self-efficacy. Participants in the group for administrators mentioned that it is difficult to recruit qualified nurse assistants because professional education and training for elderly care lags behind the current demand. A majority of nurse assistants in nursing homes did not have a professional education for elder care, instead, the recruited personnel are trained by skilled nurse assistants. The training plan is not standardised or knowledge-based, but focused simply on operational skills and experience with elderly care. The participants illustrate:

“Residents in nursing homes should keep independent. The providers work hard but they are too busy. I try to take care of myself in the activities of daily life.” (A participant in the group for residents)

“Concerning the education and training of nurse assistants, a training system and regulation hasn’t been established. ... .there are no regulations about the qualification of assistant. ... we are worried about the recruitment of nurse assistants. It's difficult.” (A participant in the group for administrators)

3.6 Financing

Most of the nursing facilities had been facing financial difficulties. The participants in the groups for administrators and providers mentioned that most nursing homes are for-profit, and charges to residents are the major revenue source. Most aged people pay for their nursing home stays out of their own pockets. Only a small proportion of residents, who have no family members and limited incomes, receive free nursing home care subsidised by local governments. However, the average capacity to pay of the residents in nursing homes is low, so it is difficult for nursing home administrators to increase the charges. Lack of financial support is a serious problem that has slowed the expansion of nursing home care. However, the problem has attracted attention from community advocates and policymakers. The participants in the focus group for government officials emphasised that policies on how to finance nursing homes, the support model and standards would soon be unveiled.

“The building in this nursing home is provided by government, but we did not get financial support from the government...Residents in this nursing home are from middle-income and low-income households. The charges for residents cannot meet the requirements of the nursing home.” (A participant in the administrators group)

“Now the Department of Social Welfare is working on policies of providing support to nursing facilities. We will make a series of policies about the support subject, support model and standards.” (A participant in the administrators group)

4 Discussion

We chose the City of Jinan, China for the qualitative study on nursing home care for two reasons: first, Jinan is a typical, medium-size city in China in terms of its size and population, results from this city can be relatively easy to apply to other cities. Second, it is the capital of Shandong Province, so it was easier to invite government officers to participate in focus groups.

Through this qualitative study on the need and demand for nursing home care, using focus groups of stakeholders, we uncovered that three important factors – including physical condition, financial status and the traditional idea of elderly care – may influence the demand for nursing home care. Advanced age and declining physical health are the most critical conditions that precipitate the need for care in the ADL, and nursing home care. The average age of residents in nursing homes is older than that of community-residing elders (Du et al., 2006). Financial status, particularly an independent income is an important factor in the choice by elderly people to seek nursing home care, given that most of them pay for their nursing home stays (Peng et al., 2006). Many, however, of elderly people or their adult children prefer the traditional idea of family support for the elderly and refuse to be institutionalised. This cultural barrier has had a far-reaching impact on the development for nursing home care. However, since the implementation of the One Child policy in 1979, the family size has become smaller while the percentage of elderly has increased. Nowadays, the 4-2-1 family structure – one child, two parents and four grandparents – is common (Hesketh et al., 2005). An increasing number of young adults seeking education and job opportunities away from their homes make it difficult or impossible for them to take care of their elderly family members at homes as traditionally was done.

As traditional family support declines, more elderly people who are dependent and need constant medical attention have to depend on institutionalised nursing home care. As of 2001, China's elderly had reached 132 million, comprising over 10% of the population (National Bureau of Statistics of China, 2002). The need for nursing home care has been growing. Most nursing homes in Jinan focus on ADL, but those with a focus on medical care are more competitive. The elder-care-centred nursing homes are mostly financed by communities or individuals (Wang et al., 2003) and have fewer physicians and nurses than medical-care-centric nursing homes have. Although the medical care-focused nursing homes are largely government-owned, nursing home care has not been regulated in terms of labour or quality requirements, so no specific regulation mandates the staffing qualifications and levels in nursing homes. A series of studies has demonstrated that a positive association exists between nurse staffing levels and the quality of nursing home care. Nurse staffing is the most important element in providing a good quality of care (Castle and Engberg, 2007; Schmidt et al., 1998; Schnelle et al., 2004). The basic requirement for a nursing facility is to provide services that meet the needs of residents through sufficient nursing staffing. But in most nursing homes the number of well-trained nurse assistants or allied health professionals is grossly inadequate for handling the demand for residents’ care.

Shortage of funds is a problem restraining the further development of nursing homes in Jinan, China. Since 2000, the Chinese Government has provided financial incentives to private organisations to establish social security services for the needy (Yang et al., 2006). However, there are no specific regulations or policies regarding the financial support from central or local government for nursing homes. The social security system gives financial support to senior housing where free elder care is offered to those who have no family member and are poor. For average nursing homes, charges for residents have been the major source of income, and that single financing channel results in financial difficulties for nursing homes. Nursing homes have opted to provide more medical care services (Zhang et al., 2005), probably because of residents’ increasing needs for medical care and the effort to increase revenue. Because of the Chinese Government's limited economic support capacity, it is critical for the nursing home industry in China to explore multi-level financing channels and attract non-governmental investments.

China's nursing home industry is emerging as an alternative for LTC. The market demand for nursing home care in Jinan has been growing. This qualitative study on nursing home care in a large city in China has exemplified the need for validating the actual demand for and supply of nursing home care through a comprehensive needs assessment. The nursing home industry has encountered many challenges in terms of the need for well-trained nurse staff, quality regulation, viable finance mechanisms, and effective management. The knowledge gained here from the interviews with nursing home stakeholders provides useful information to policymakers and identifies the pressing need for evidence-based management and planning for nursing home care in China. This study should have positive impacts on elder care and the elder care system in China, and also provide valuable information on nursing home care for other developing countries in Asia, Africa, and South America, which face the same challenges.

Biography

Min Wu received her PhD in Social Medicine and Health Services Administration at Shandong University in 2011. She has taken part in a research project supported by an NIH grant entitled ‘Nursing home care research and capacity-building in China’. Her research interests are long-term care, analytical modelling, and social medicine.

Shi Xue Li is a Professor in Social Medicine and Health Services Administration at Shandong University. He is the Director of the Department of Health and Hospital Management in Shandong University. His current research interests include national essential drug policies, new rural cooperative medical systems, and long-term care systems in China.

Ning Jackie Zhang is an Associate Professor of Public Affairs at the College of Health and Public Affairs, University of Central Florida. His expertise includes long-term care research, quality and outcomes evaluation, and health informatics.

Ai Ai Zhu is a Master degree candidate in Social Medicine and Health Services Administration at Shandong University. Her research interests include long-term care research and social medicine.

Bo Ning is a Doctoral degree candidate in Social Medicine and Health Services Administration at Shandong University. His research interests are health administration policies and national essential drug policies.

Thomas T.H. Wan is a Professor of Public Affairs and an Associate Dean for Research at the College of Health and Public Affairs, University of Central Florida. His research interests include long-term care research, health services evaluation, and health informatics.

Lynn Unruh is a Professor of Health Management and Informatics at the College of Health and Public Affairs, University of Central Florida. Her research interests are cover nurse staffing, health economics, and quality of care.