WK6 SOCW 6111 Assgnment 2 - Social Science
Each year on or around June 15, communities and municipalities around the world plan activities and programs to recognize World Elder Abuse Awareness Day, a day set aside to spread awareness of the abuse of the elderly (Center of Excellence on Elder Abuse & Neglect, 2013). The abuse of older adults is a growing concern and statistics suggest that the number of elders experiencing abuse is an alarmingly high number. Research suggests that close to half the people diagnosed with dementia experience some form of abuse (Cooper, C., Selwood, A., Blanchard, M., Walker, Z., Blizard, R., & Livingston, G., 2009; Wiglesworth, A., Mosqueda, L., Mulnard, R., Liao, S., Gibbs, L., & Fitzgerald, W., 2010, as cited on http://www.ncea.aoa.gov/Library/Data/index.aspx). Elder abuse takes on many forms and can include physical, emotional, psychological, and economic abuse. The legendary American actor, Mickey Rooney, spoke to the United States Senate, describing his own experiences of pain and neglect at the hands of his stepson, asking legislators to take seriously the abuse of the elderly.
For this Discussion, go to the Walden Library and find a scholarly article that presents some of the most important psychosocial issues related to elder abuse.
By Day 4
Post a summary of the article you found. How does the article reinforce the importance of assessing potential abuse and neglect when working with the elderly? Describe prevention and/or intervention strategies on the micro, mezzo, and macro levels that can be used to address the issue of abuse and neglect of the elderly.
Support your posts with specific references to the Learning Resources. Be sure to provide full APA citations for your references.
RESEARCH ARTICLE Open Access
Elder abuse and neglect: an overlooked
patient safety issue. A focus group study of
nursing home leaders’ perceptions of elder
abuse and neglect
Janne Myhre1* , Susan Saga1, Wenche Malmedal1, Joan Ostaszkiewicz2 and Sigrid Nakrem1
Abstract
Background: The definition and understanding of elder abuse and neglect in nursing homes can vary in different
jurisdictions as well as among health care staff, researchers, family members and residents themselves. Different
understandings of what constitutes abuse and its severity make it difficult to compare findings in the literature on
elder abuse in nursing homes and complicate identification, reporting, and managing the problem. Knowledge
about nursing home leaders’ perceptions of elder abuse and neglect is of particular interest since their
understanding of the phenomenon will affect what they signal to staff as important to report and how they
investigate adverse events to ensure residents’ safety. The aim of the study was to explore nursing home leaders’
perceptions of elder abuse and neglect.
Methods: A qualitative exploratory study with six focus group interviews with 28 nursing home leaders in the role
of care managers was conducted. Nursing home leaders’ perceptions of different types of abuse within different
situations were explored. The constant comparative method was used to analyse the data.
Results: The results of this study indicate that elder abuse and neglect are an overlooked patient safety issue. Three
analytical categories emerged from the analyses: 1) Abuse from co-residents: ‘A normal part of nursing home life’;
resident-to-resident aggression appeared to be so commonplace that care leaders perceived it as normal and had
no strategy for handling it; 2) Abuse from relatives: ‘A private affair’; relatives with abusive behaviour visiting nursing
homes residents was described as difficult and something that should be kept between the resident and the
relatives; 3) Abuse from direct-care staff: ‘An unthinkable event’; staff-to-resident abuse was considered to be
difficult to talk about and viewed as not being in accordance with the leaders’ trust in their employees.
(Continued on next page)
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* Correspondence: [email protected]
1Department of Public Health and Nursing, Faculty of Medicine and Health
Sciences, Norwegian University of Science and Technology NTNU,
Trondheim, Norway
Full list of author information is available at the end of the article
Myhre et al. BMC Health Services Research (2020) 20:199
https://doi.org/10.1186/s12913-020-5047-4
http://crossmark.crossref.org/dialog/?doi=10.1186/s12913-020-5047-4&domain=pdf
http://orcid.org/0000-0001-8983-7998
http://creativecommons.org/licenses/by/4.0/
http://creativecommons.org/publicdomain/zero/1.0/
mailto:[email protected]
(Continued from previous page)
Conclusions: Findings in the present study show that care managers lack awareness of elder abuse and neglect,
and that elder abuse is an overlooked patient safety issue. The consequence is that nursing home residents are at
risk of being harmed and distressed. Care managers lack knowledge and strategies to identify and adequately
manage abuse and neglect in nursing homes.
Keywords: Elder abuse, Neglect, Patient safety, Long-term care, Nursing homes, Care managers, Leadership,
Qualitative, Focus group
Background
Little is known about elder abuse in nursing homes, and
compared to research on other forms of interpersonal
abuse, research about elder abuse in nursing homes is
still in its infancy [1, 2]. Although no national prevalence
data are available in any country internationally, high
rates of elder abuse and neglect have been reported in
nursing homes, including Norway [1, 3]. According to
the World Health Organisation (WHO), elder abuse has
been identified in almost every country where these in-
stitutions exist [4]. In the Toronto Declaration, WHO
defines elder abuse as ‘a single, or repeated act, or lack
of appropriate action, occurring within any relationship
where there is an expectation of trust which cause harm
or distress to an older person’ [5] p:3. Prevention of
harm is a core principle in health care services and a
leadership responsibility [6–8]. Nursing home leaders
are legally and morally responsible for ensuring that re-
quired quality and safety standards are met [6, 9, 10].
The National Patient Safety Foundation (United States)
defines patient safety as ‘freedom from accidental or pre-
ventable injuries or harm produced by medical care’
[10], p,2. This includes preventing elder abuse and
examining the factors that foster an unsafe environment
for both residents and staff [6, 7, 11]. Furthermore, elder
abuse can be categorized according to type of abuse.
The definition from ‘Protecting Our Future: Report from
the Working Group on Elder Abuse’ (Ireland) includes
physical, psychological, financial and sexual abuse, and
neglect (Table 2) [12]. Abuse in nursing homes may also
be categorized according to type of relation [1]; staff-to-
resident abuse [3, 13], family-to-resident abuse [14, 15]
and resident-to-resident abuse, also called resident-to-
resident aggression [16, 17].
A recent meta-analysis of the prevalence of elder abuse
in long-term care settings estimated a pooled prevalence
of 64.2\% of abuse perpetrated by staff in the past year,
where psychological abuse and neglect had the highest
prevalence [1]. A survey of 16 nursing homes in the cen-
tral part of Norway found that 91\% of staff had observed
a colleague engaging in some form of inadequate care,
and 87\% of staff reported that they themselves had
perpetrated some form of inadequate care in the past
[3]. Comparably, in a study from Ireland, Drennan et al.
found that 57.5\% of staff had observed one or more abu-
sive behaviours from a colleague in the previous year
[13]. Neglect and psychological abuse were the most
commonly observed or perpetrated acts [3, 13]. Living in
a nursing home may also mean sharing room and space
with co-residents, and in recent literature, resident-to-
resident aggression has been identified as a common
form of abuse in nursing homes [16–18]. Lachs and col-
leagues revealed that 407 of 2011 residents from ten fa-
cilities had experienced at least one resident-to-resident
event over one month observation, showing a prevalence
of 20.2\%, and the most common form was verbal abuse
[16]. The literature about elder abuse in domestic set-
tings shows that close family and friends can be perpe-
trators of abuse [15], but few studies have investigated
the role of family members as perpetrators of abuse in
nursing homes. A study from the Czech Republic found
that nursing home staff had observed relatives participat-
ing in financial exploitation combined with psychological
pressure on residents in nursing homes [14]. However,
comparing findings in the literature on elder abuse in
nursing homes is challenging because definitions and
understandings of abuse can vary in different cultures,
jurisdictions, and among health care staff, researchers,
family members, and residents themselves [1, 2, 11, 19–
21]. Different understandings of what constitutes abuse
and its severity complicate detecting, reporting and man-
aging the problem.
Nursing homes are complex social systems that consist
of different participants, including staff, leaders, resi-
dents and relatives in constantly shifting interactions
[22, 23]. The aetiology of abuse in nursing home settings
is described as complex, comprising varying associations
between personal, social and organisational factors [2,
24]. Nursing home residents often have complex care
needs, dementia or other forms of cognitive impairment
[25], display challenging behaviour [26], and depend on
assistance in daily activities and care, all factors associ-
ated with a high risk of abuse and neglect [3, 13, 24, 27].
In Norway, 80\% of nursing home residents have demen-
tia, and 75\% have significant neuropsychiatric symptoms
such as agitation, aggression, anxiety, depression, apathy
and psychosis [25]. Residents who display aggressive be-
haviour toward staff are at greater risk of experiencing
Myhre et al. BMC Health Services Research (2020) 20:199 Page 2 of 14
abuse [13, 27, 28]. Findings in Drennan et al.’s Irish
study revealed that 85\% of the nursing home staff had
experienced a physical assault from a resident in the pre-
vious year [13]. Aggressive behaviour has also been
found to trigger resident-to-resident aggression in nurs-
ing homes [16, 17]. Related to organisational factors,
there is an association between inappropriate environ-
mental conditions for residents, low levels of staffing,
and abuse and neglect [13, 14, 29]. As a result of this
complexity, elder abuse in nursing homes is difficult to
define precisely [11]. Within the literature, elder abuse
in nursing homes is conceptualised as a specific form of
institutional abuse [30] and a setting in which abuse and
neglect take place [14], since rules and regulations in in-
stitutions can be abusive themselves, e.g., deciding resi-
dents’ sleeping and meal times, the use of restraint, and
shared living spaces with other residents.
Good leadership plays a key role in developing staff’s
understanding of residents’ needs [31, 32] and creating a
strong safety culture of respect, dignity, and quality [6, 7,
9, 33]. The importance of leadership in developing a pa-
tient safety culture is highlighted in a report from the
National Patient Safety Foundation [10]. In Norway, gov-
ernmental strategies to improve leadership and safety
culture have been launched, such as the Patient Safety
Programme and a system for monitoring health services
using quality indicators [34]. Leadership is defined as a
process whereby a person influences a group of individ-
uals to reach a common goal [35], such as a strong
safety culture. The safety culture of an organisation is
defined as ‘the product of individual and group values,
attitudes, perceptions, competencies, and patterns of be-
haviour that determine the commitment to, and the style
and proficiency of, an organisation’s health and safety
management’ [10, 36] p:23. This includes detecting situ-
ations that can be harmful to residents. However, several
studies have shown that underreporting of abuse and
neglect is a significant problem [1, 37, 38]. Residents’
own inability to communicate about the abuse or their
fear of repercussions and retaliation are important fac-
tors of underreporting [1, 2]. Therefore, staff should be
able to recognise and report situations that can be per-
ceived as harmful or distressful from the perspective of
residents. However, a systematic review of staff’s concep-
tualisation of elder abuse in residential care found that
staff were often uncertain about how to identify abuse,
especially psychological abuse and caregiver abuse and
neglect [39]. Despite the vast knowledge that exists
about the importance of leadership, nursing home re-
search has not yet paid much attention to the role
leaders play regarding identifying elder abuse. Conse-
quently, there is a gap in knowledge about elder abuse
from the perspective of nursing home leaders. Know-
ledge about nursing home leaders’ perceptions of elder
abuse and neglect are essential because their under-
standing of the phenomenon will affect what they signal
to staff as important to report and what they investigate
to create a safe and healthy environment. To our know-
ledge, this is the first study that seeks to understand the
nature of elder abuse from the perspective of nursing
home leaders.
Methods
Aim of the study
The aim of the study was to explore nursing home leaders’
perceptions of elder abuse and neglect.
Design
The present study is part of a larger study funded by the
Research Council of Norway (NFR), project number
262697. A qualitative exploratory design with focus
group interviews was conducted to gain greater insight
into this important but poorly understood topic. Quali-
tative methods provide knowledge about people’s experi-
ence of their situation and how they interpret,
understand and link meaning to events [40, 41]. In focus
group interviews, group dynamics allow the questions to
be discussed from several points of view, and the group’s
dynamics can create new perspectives and opinions dur-
ing the discussion [42]. This study follows The Consoli-
dated Criteria For Reporting Qualitative Research
(COREQ) (Additional file 1).
Settings
In Norway, approximately 39,600 residents live in nurs-
ing homes (12.9\% of the population > 80 years), and their
mean age is 85 years [43]. These nursing homes are
mainly run by the municipalities and financed by taxes
and service user fees. Residents pay an annual fee equal
to 75\% of the resident’s national age pension. In
addition, residents may pay an additional fee if they have
income of their assets, but with an upper limit decided
by the government. However, the payment cannot ex-
ceed the actual expenses of the institutional stay [44]..
Management of care in Norwegian nursing homes is
regulated by ‘the regulation of management and quality
improvement in health care services’ [45]. The regula-
tion focusses on the leader’s responsibility to ensure that
residents’ basic needs are satisfied. This includes the
leader’s responsibility to ensure there is a system in
place to monitor residents’ overall quality and safety and
to create a safety culture that detects situations and fac-
tors that can cause harm to residents and staff [45].
Each nursing home is required to have an administra-
tive manager, called the nursing home director, and
some nursing home directors lead more than one facil-
ity. In addition, each nursing home has ward leaders and
quality leaders, and in some municipalities, a service
Myhre et al. BMC Health Services Research (2020) 20:199 Page 3 of 14
leader. Together, individuals in these leader roles form
the leadership team in each nursing home [46]. The
ward leader is a registered nurse (RN) who supervises
and manages staff. Ward leaders are also responsible for
budgets in their own wards and the quality of care for
residents. There are often several wards and ward
leaders in each nursing home. The quality leader is an
RN who monitors the overall quality of care in the nurs-
ing home in collaboration with the ward leaders. The
service leader supervises and manage service staff mem-
bers who are in contact with nursing home residents
(e.g., activity coordinators, cleaning staff and kitchen
staff) and is also responsible for the budget related to his
or her staff. Individuals employed in one of these leader
positions provide the closest level of leadership to staff
and residents but are not part of the daily direct hands-
on care of residents. There is no national requirement
regarding formal leader education to be employed in
these leader positions, but leader education is a high pri-
ority in many municipalities. These individuals often
have lengthy experience as RNs or have previous leader
experience.
Sample
The study sample was recruited from 12 nursing homes in
six municipalities in Norway. Inclusion criteria were a per-
son who: (a) was employed in a leader position as ward
leader, quality leader, or service leader in a nursing home,
and (b) was employed full time in the leader position. The
inclusion criteria were chosen because these individuals
directly affect quality and safety in the nursing home, as
they are the closest level of leadership to the staff and resi-
dents. Purposive sampling was initially used to ensure that
participants recruited could see the phenomenon from the
perspective of a leader. During the data collection, each
municipality and its nursing home leaders were recruited
using a step-wise approach, as we were seeking to get a
theoretical sampling until saturation of data was achieved
[40, 41]. A total of 28 individuals participated in the study,
23 participants were ward leaders, two participants were
quality leaders, and three participants were service leaders.
However, in this study, all 28 participants are named ‘care
managers’. Characteristics of the participants are pre-
sented in Table 1.
Recruitment and data collection
Participants were recruited over a period of six months,
from August 2018 through the end of January 2019. A
recruitment email was sent to health care managers in
11 municipalities in both urban and rural areas. Health
care managers from five municipalities stated that they
could not find time to participate in the study, while six
health care managers accepted the invitation. Thereafter,
a second recruitment email was sent to all nursing home
directors in these six municipalities. The email included
an invitation letter, which the nursing home director for-
warded to all individuals employed in a leader position
at their nursing homes. Six focus group interviews were
conducted, with three to six participants in each group.
The focus groups were composed as follows: one focus
group with three participants; two focus groups with
four participants; one focus group with five participants;
two focus groups with six participants.
All six focus group interviews took place in a meeting
room in a nursing home in the participating municipal-
ities. Each focus group interview lasted approximately
90 min. All participants gave informed written consent
before the interviews started. Two researchers carried
out the interviews. JM was the moderator in all six inter-
views, SN was co-moderator for two group interviews,
Table 1 Demographics of the sample (n = 28)
Background characteristics Number (\%)
Age (years)
30–39 6 (22)
40–49 11 (39)
≥ 50 11 (39)
Gender
Female 25 (89)
Male 3 (11)
Number of beds managing:
0 5 (17)
10–19 8 (29)
20–29 8 (29)
≥ 30 7 (25)
Number of staffs managing:
0 2 (7)
10–29 9 (33)
30–49 11 (39)
≥ 50 6 (21)
Years in this position
0–4 20 (71)
5–9 7 (25)
≥ 10 1 (4)
Total working experience as a leader in years
0–4 11 (39)
5–9 6 (22)
≥ 10 11 (39)
Formal leader education
0 1 (4)
0,5–1 years course 18 (64)
1–2 years course 3 (11)
Master’s Degree 6 (21)
Myhre et al. BMC Health Services Research (2020) 20:199 Page 4 of 14
and SS was co-moderator in one group interview. In the
other three interviews, two researchers from the larger
research team were co-moderators. During the introduc-
tory information about the focus group interview, we
presented a figure (Fig. 1), and asked participants about
their experience and thoughts on the topic of elder
abuse from health care staff, co-residents or relatives.
Participants were encouraged to speak freely. However,
during the first interview, we experienced that partici-
pants were not familiar with the topic. To explore the
topic in the ensuing interviews, the moderator gave the
participants keywords from the categorization of abuse
(e.g., abuse can be described as physical, psychological,
sexual, financial, or neglect) (Table 2) [12]. We found
that this helped the participants reflect, and they subse-
quently came up with examples of abusive situations
they had heard about or witnessed. During the process
of data collection, we further compared our experiences
in interview one with interview two, which is in line with
the constant comparative method [40]. This led to in-
cluding keywords in the interview guide to ensure that
all topics were covered (Additional fil 2). To ensure the
credibility of an open thematic understanding of partici-
pants’ experiences and diminish bias by presenting the
keywords, we were conscious about letting the partici-
pants speak freely about their experiences and thoughts
on this topic. Moreover, they were not given any defin-
ition of abuse or examples related to these keywords
(Table 2) [12]. The participants freely decided in which
order they wanted to talk about different forms and situ-
ations of elder abuse. All interviews were recorded and
transcribed verbatim, retaining pauses and emotional
expressions.
Data analysis
A constant comparative method with a grounded the-
ory approach was used. This allowed us to generate a
thematic understanding of elder abuse through an
open exploration of the experience described by nurs-
ing home leaders [40, 41]. The constant comparative
method facilitated possible identification of themes
and differences between individuals and cases within
the data [40]. Our analysis started right after each
interview, where the first author listened to the re-
corded interview. Memo writing was then used
through the whole process of data collection and ana-
lysis and served as a record of emerging ideas, ques-
tions and categories [41]. Next, in line with the
constant comparative method, open line-by-line cod-
ing of the transcribed interviews was performed [40,
41], since we wanted to capture the meaning from
the participants’ perspectives as they emerged from
the interviews. The codes were compared for frequen-
cies and commonalities and then clustered to organise
data and develop sub-categories. The sub-categories
were examined to construct the final categories and
main theme. To add credibility and diminish re-
searcher bias, two researchers (JM and SN) coded the
transcribed interviews independently. During the ana-
lysis process, the authors held several meetings where
codes and their connections were discussed until con-
sensus was reached. To ensure that the emerging cat-
egories and themes fit the situations explored, the
researchers went back and forth between
contextualization, data analysis and memo writing
[40]. An example of the analysis process is shown in
Table 3.
Ethical consideration
Ethical approval for this study was given by the Norwe-
gian Centre for Research Data (NSD), Registration No:
60322. Each participant signed a written consent form
after receiving oral and written information about the
study. All identifiable characteristics are excluded from
the presentation of data to ensure the anonymity of all
individuals.
Fig. 1 Model of interactions where abuse can occur as used in the interviews
Myhre et al. BMC Health Services Research (2020) 20:199 Page 5 of 14
Results
The main theme, ‘Elder abuse in nursing homes, an
overlooked patient safety issue’, found in this study indi-
cates an overall lack of awareness of elder abuse and its
harm among care managers. Three analytical categories
emerged from the analyses: 1) Abuse from co-residents –
‘A normal part of nursing-home life’, 2) Abuse from rela-
tives – ‘A private affair’, and 3) Abuse from direct-care
staff – ‘An unthinkable event’. Since there were no re-
markable differences in care managers’ experiences, we
present results without differentiating the participants.
Below, we describe each category, together with exam-
ples of forms of abuse and neglect. These examples are
used to describe the care managers’ perceptions of elder
abuse and neglect (Table 4).
Abuse from co-residents – ‘A normal part of nursing-
home life’
Resident-to-resident aggression was described as the big-
gest issue related to abuse in nursing homes and a daily
challenge for the participants: ‘That is what I also see,
that co-residents are the biggest challenge regarding this
topic’ (Group 2). The main cause of resident-to-resident
aggression reported by care managers was symptoms of
dementia, especially in the initiator, but also in the vic-
tim. The care managers expressed that they did not
know how to address this problem. As one said, ‘It hap-
pens because of the cognitive failure, so yes. But, at the
same time, it is also difficult to do something about it’
(Group 2). Some care managers also stated that the risk
of harm caused by resident-to-resident aggression was
something residents must accept when living in a
Table 2 Operational definitions of abuse and neglect in residential settings [12]
Five areas of abuse and
neglect
Abusive actions
Physical Abuse Hitting, slapping, pushing, kicking, misuse of medication or restraint.
Psychological abuse Emotional abuse, threats of harm or abandonment, deprivation of contact, humiliation, blaming, controlling, intimidation,
coercion, harassment, verbal abuse, isolation or withdrawal from services or supportive networks.
Sexual Abuse Rape and sexual assault or sexual acts to which the older adult has not consented, or could not consent, or into which
he or she was compelled to consent into which he or she was compelled to consent.
Financial Abuse Theft or the misuse or misappropriation of property or possessions.
Neglect Ignoring medical or physical care needs, failure to provide access to appropriate health care, social care or educational
services, withholding of necessities of life, such as medication, adequate nutrition and heating.
Table 3 Example of data analysis in the category “abuse from co-residents”
Sub- Categories Code Meaning unit
Common Resident-to resident aggression are common We have very often residents that are both physically and psychological
aggressive towards other residents.
Resident - to resident
aggression as
normalized
Difficult to do something with resident- to
resident aggression
I think it is due to the cognitive failure, so then it is not an abuse, because it
doesn’t help to just talk to the resident.
Resident-to-resident aggression a big part of
everyday life in nursing homes
We may have a little thick skin in relation to where the limit goes for what
we accept. Because it is such a big part of our everyday life that it became
normal in a way.
Normal behaviour from people with dementia When we have focus on dementia, it becomes normal for us to see such
behaviour.
Hitting Physical abuse – hitting when trespassing a
resident rom
We had a patient who was hit and beaten by the same resident several
times. The resident walks into his room and simply knocked him down, and
that is a despair.
Verbal abuse Psychological abuse – verbal abuse normal
behaviour for people with dementia
Then we have residents with frontotemporal dementia who just acts in that
way, they just verbally offending others, but it is their way of behaving.
Violation of resident’s
privacy
Psychological abuse – violation of resident’s
privacy when trespassing into another resident’s
room
Trespassing into another residents’ room that happens a lot, but it’s a
violation of their privacy, and if the resident can’t speak or is cognitive
impaired, they may be unable to tell if something is happening.
Stealing things Financial abuse – stealing things They steal things from each other’s room, yeas that happened.
Sexual assault Sexual abuse – sexual assault and an ethical
dilemma
We see sexual approaches or that they forgot that they are married and find
each other instead. But that is more a dilemma than an assault …. or
maybe it can be an assault… well I don’t know.
Myhre et al. BMC Health Services Research (2020) 20:199 Page 6 of 14
nursing home: ‘There is a predictable risk, when living in
nursing homes, [of] such incidents; there is a foreseeable
risk that this will happen’ (Group 5). This demonstrates
that resident-to-resident abuse is normalized.
Care managers considered physical abuse to be the
most serious form of resident-to-resident aggression,
often leading to visible harm and despair. At the same
time, all care managers had examples of residents who
had been beaten, knocked down, or kicked by co-
residents.
‘We have one resident now that is beaten a lot by the
other residents. It’s a little extreme, but I think that such
things can happen quite often in dementia care because, as
in this case, the resident being beaten is not silent for a mi-
nute. She speaks and yells all day, and the other residents
become annoyed since she disturbs them’ (Group 4).
Care managers described psychological abuse as acts
of ‘everyday bullying’ and threats made among residents.
They interpreted these situations as a normal conse-
quence of the dementia disease in the individual resi-
dent. One care manager noted, ‘What I think is …
Chapter 7
Assessment of the Elderly
Gregory J. Paveza
Purpose: The purpose of this chapter is to provide the reader with an under-
standing of comprehensive geriatric assessment and its various aspects.
Rationale: As more social workers are confronted with older adult clients, it is
critical that they understand how to initially assess older adults who come in to
receive care.
How evidence-informed practice is presented: Information is presented on
Mental Status exams and the usefulness of those instruments in assessing for
initial signs of dementia; data are presented on various instruments for assessing
functional status and their importance in determining need for services.
Overarching question: When working with older adults, how could I best
include elements of an assessment into my interview, and which elements
should I include?
Comprehensive geriatric assessment (CGA) has emerged as an important
method for helping social workers address the needs of older adults,
particularly as the number of older adults and their need for services
continues to grow within the United States.
CGA is a process of engaging in a total evaluation of older adults.
It requires that the practitioner gather information in multiple areas of
client functioning, including medical history, cognitive status, emotional
well-being, the ability to perform activities of daily living (ADLs) and
instrumental activities of daily living (IADLs), the person’s social-support
system, the physical environment in which the person lives, and many
other areas of the older person’s life. Such a process requires that the social
work practitioner have a broad command of all areas of aging practice.
One must understand how to effectively gather medical information; assess
current cognitive status, the emotional well-being of the client, ADLs and
IADLs, and the person’s social-support system; and conduct an effec-
tive and thorough assessment of the older adult’s physical environment
(Gallo & Bogner, 2006). Finally, the social work practitioner must be able to
comprehensively link the findings from the assessment to an intervention
plan for the individual client (Gallo, Fulmer, Paveza, & Reichel, 2000).
Because the process of CGA is not a single subject but rather an
amalgamation of several areas, this chapter of necessity addresses both
the broad subject as well as the specific elements that comprise a CGA.
177
Holosko, M. J., Dulmus, C. N., Sowers, K. M., & Sowers, K. M. (2013). Social work practice with individuals and families : Evidence-informed assessments and
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178 Social Work Practice With Individuals and Families
This chapter details a process for gathering and organizing information
rather than a specific intervention or method of engaging in practice.
As such, this chapter is organized differently than other chapters in this
book. This chapter reviews each of the elements that comprise a CGA,
discusses some of the instruments that may be of assistance for obtaining
information in that area of the assessment, summarizes some of the unique
issues encompassed in that area of the assessment process, and looks at the
import of the area for arriving at a care plan. The chapter concludes with
a discussion concerning the integration of the elements of the assessment
into a whole that informs a recommended care plan for the client and a
review of the literature on effectiveness of the process.
The elements that are recommended for inclusion in a CGA have
broadened over the past several years. This is evident when one reviews
any text on geriatric assessment with multiple editions. A perfect example
is the Handbook of Geriatric Assessment. The first edition, published in
1988, consists of 10 chapters totaling 231 pages of text and index, with
a single contributed chapter (Gallo, Reichel, & Andersen, 1988). By the
second edition, published in 1995, the book still has 10 chapters, but it has
expanded to 257 pages of text and index, with 2 contributed chapters (Gallo,
Reichel, & Andersen, 1995). The third edition of the Handbook consists of
13 chapters with 361 pages of text and index, with 5 contributed chapters
(Gallo et al., 2000). The latest edition of the Handbook, the fourth edition,
has expanded to 20 chapters with 473 pages of text and index, and 18
of the chapters include authors other than the editors of the book (Gallo,
Bogner, Fulmer, & Paveza, 2006). These changes in the Handbook suggest
that both the amount and complexity of information has so expanded that
no single group of authors can adequately address the topic.
As stated at the beginning of this chapter, CGA is not an intervention
technique but rather a process for gathering comprehensive information
on older adults within the context of the older person’s environment.
Given the breadth and depth of this biopsychosocial environmentally
cognizant approach to gathering information on older adults, one might
suspect that the approach was developed by social workers to address their
work with older adults. Unfortunately, there is no substantive evidence
to support this contention. Rather, this approach seems to be built on
the experiences of early geriatric physicians. They discovered that, when
working with older adults in in-patient settings, information beyond that
of the medical history and presenting medical problems was required in
order to effectively create a treatment plan for their older patients (Gallo
et al., 1988).
Historical Background
CGA is a direct outgrowth of the earlier movement within geriatric
medicine to develop comprehensive geriatric assessment units (GAUs).
Holosko, M. J., Dulmus, C. N., Sowers, K. M., & Sowers, K. M. (2013). Social work practice with individuals and families : Evidence-informed assessments and
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Assessment of the Elderly 179
GAUs identified the need for a comprehensive assessment process, usually
beginning with a physical exam and medical history and then adding
information on functional status—that is, the ability to perform basic activ-
ities of daily living, mental health, size of the social-support network, and
interactions that support network, economic needs, and environmental
considerations (L. A. Rubenstein, 1995). These domains with some mod-
ifications continue to remain the focus of CGA (Mouton & Esparza, 2006;
Chang & Mamun, 2008). A comprehensive assessment should consist of
assessment in at least six areas: mental status, functional assessment, social
and environmental assessment, nutritional- and health-practices review,
medical history and treatments, and assessment of emotional well-being
(Paveza, 1993). The consistency across authors and across disciplines in
identifying the areas essential to the assessment process suggests that there
is a generally accepted concept of the information that needs to be gathered
to adequately address the care needs of the older adult patient, whether
that person is in the hospital or residing in the community.
Moving from this historical perspective, let us begin a more in-depth
discussion of the elements comprising the assessment process. Each of
these elements is discussed from the perspective of how the element
helps us understand the current biopsychosocial status of the older adult,
techniques and instruments the practitioner can use to assess an element
of the comprehensive assessment, potential problems with using some
of the discussed instruments, and the relationship of that element of the
assessment to care planning for the older adult.
Elements of the Comprehensive Assessment
I have already suggested that the comprehensive-assessment process
should address some common areas, including current medical problems
and medical history, assessment of the person’s ability to perform the basic
activities of daily living, assessment of emotional problems, and social and
economic issues (Gallo et al., 1995; Mouton & Esparza, 2006; Paveza,
1993; L. A. Rubenstein, 1995). Beyond these basic elements, authors differ
on the other elements to be included in the assessment. When discussing
the assessment of functional status, several authors also suggest that, in
addition to basic activities of daily living, the assessment of functional
status must include the instrumental or independent activities of daily liv-
ing (Older Americans Resources and Services [OARS] Methodology, 1978).
The addition of assessment for elder mistreatment has also recently been
suggested as important to a thorough and complete assessment (Fulmer &
O’Malley, 1987; Gallo et al., 2000; VanderWeerd, Firpo, Fulmer, & Paveza,
2006). The need to assess values and the impact of those values on do-not-
resuscitate directives and durable power of attorney for health care have
also been added to the growing list of items to be covered in the assessment
process (Doukas, McCullough, & Crane, 2006). Additional areas suggested
Holosko, M. J., Dulmus, C. N., Sowers, K. M., & Sowers, K. M. (2013). Social work practice with individuals and families : Evidence-informed assessments and
interventions. ProQuest Ebook Central <a onclick=window.open(http://ebookcentral.proquest.com,_blank) href=http://ebookcentral.proquest.com target=_blank style=cursor: pointer;>http://ebookcentral.proquest.com</a>
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180 Social Work Practice With Individuals and Families
for incorporation into the process include older adults’ ability to continue
to drive, their use of alcohol and drugs, and pain assessment (Carr &
Rebok, 2006; Richardson, 2006; Zanjani & Oslin, 2006). Some of these
special areas of concern were originally considered to be part of one of
the broader categories, such as medical history, social history, or environ-
mental assessment, the assessment for elder mistreatment being a perfect
example. In an earlier edition of the Handbook of Geriatric Assessment,
the discussion of elder mistreatment is included in the chapter on social
assessment, but in the latest edition, it merits a chapter of its own (Gallo
et al., 2000; VanderWeerd et al., 2006). Although these special areas are
addressed in this chapter, most are included under broader headings to
more appropriately place them in the context of the assessment process.
This chapter also discusses the elements of CGA using a modification of
my previously mentioned framework. The elements of the assessment are
discussed under six broad areas: mental status, functional assessment,
medical history, and treatments including nutrition- and health-practices
review, emotional/psychological well-being, and social and environmental
assessment (Paveza, 1993).
Mental Status
The assessment of mental status should be one of the initial components,
if not the initial component, of the comprehensive assessment. Although
the social work practitioner needs to be cognizant that clients may be
somewhat taken aback by the introduction of this item as the first element
of the interview, I have argued consistently that, after establishing initial
rapport, starting the remainder of the assessment process with the mental-
status review is essential to avoid engaging in an information-gathering
process that could yield little or no useful information while taking up a
significant amount of both the client’s and practitioner’s time and money
(Paveza, Cohen, Blaser, & Hagopian, 1990a; Paveza, Prohaska, Hagopian, &
Cohen, 1989).
Gathering information on a client’s mental status has generally been
described as requiring the practitioner to assess at a minimum the client’s
level of consciousness, her or his orientation to time and place, and his
or her attention and memory (Gallo & Wittink, 2006a). Additional areas
that may be covered include information concerning language, the ability
to engage in abstract thinking, and constructional ability (Chodosh, 2001;
Gallo & Wittink, 2006a; Scalmati & Smyth, 2001). Each of the domains
covered in a mental-status exam can provide important information con-
cerning the client’s ability to provide historically accurate information,
engage in conversations that require abstract thinking, and consent to or
reject care plans or elements of care plans (Paveza, 1993; Paveza et al.,
1990b; Paveza et al., 1989).
Gathering mental-status information has become relatively standard-
ized. This means that a social work practitioner can quickly ask the
Holosko, M. J., Dulmus, C. N., Sowers, K. M., & Sowers, K. M. (2013). Social work practice with individuals and families : Evidence-informed assessments and
interventions. ProQuest Ebook Central <a onclick=window.open(http://ebookcentral.proquest.com,_blank) href=http://ebookcentral.proquest.com target=_blank style=cursor: pointer;>http://ebookcentral.proquest.com</a>
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Assessment of the Elderly 181
questions needed to obtain information in this area. Included among the
instruments commonly used are the Folstein Mini-Mental Status Exam
(MMSE; Folstein, Folstein, & McHugh, 1975), Pheiffer’s Short Portable
Mental Status Questionnaire (SPMSQ; Pheiffer, 1975), and the six-item
Orientation-Memory-Concentration Test (Katzman et al., 1983). Other tests
that can provide additional information are category-fluency sets and the
clock-drawing test. These two instruments provide some additional bene-
fits over those more typically used for screening, with the set test generally
being seen as less offensive to older adults than the more traditional screens
(Gallo & Wittink, 2006a). Moreover, the clock-drawing test can provide
useful information about the ability of the older adult to transition between
abstract and concrete thinking and his or her use of judgment as he or
she draws the clock and puts in the required elements (Gallo & Wittink,
2006a). Mental-status screening has been well researched, and a general
description of some of the problematic issues with these screens can be
found in the Handbook of Geriatric Assessment, fourth edition (Gallo &
Wittink, 2006a); the Geropsychology Assessment Resource Guide (National
Center for Cost Containment, 1993); and Measuring Health: A Guide to
Rating Scales and Questionnaires (McDowell & Newell, 1996).
In general, issues of importance when interpreting a mental-status
screen focus on the level of formal education of the older adult, with
those having less formal education often scoring lower than their actual
level of cognitive functioning and those with higher levels of education
often appearing to do better than their actual level of cognitive functioning
(Gallo & Wittink, 2006a). For this reason, as well as others discussed
in the literature, the clinician should never use the results of any single
mental-status assessment to arrive at a diagnosis of dementia, nor should
a client accept this diagnosis based solely on a mental-status screen. The
diagnosis of dementia must be arrived at in a manner that addresses all
criteria established either in the Diagnostic and Statistical Manual of Mental
Disorders, fourth edition (American Psychiatric Association, 1994), or in the
NINCDS-ADRDA Consensus Criteria (McKhann et al., 1984). The purpose
of the mental-status exam is to assist the clinician in determining whether
the client can provide useful information for consenting to treatment and
for planning care, and whether the client needs referral for a complete
neuropsychological exam.
Functional Assessment
Probably the most critical element of the assessment is determining the
client’s functional ability. Functional ability is the capacity of the individual
to perform certain personal-care behaviors that are seen as essential to
being able to care for him- or herself independently in a community-living
environment. The original seven behaviors seen as essential to being able
to function in the community, and usually referred to as activities of daily
living, are feeding, bathing, grooming, dressing, continence, toileting, and
Holosko, M. J., Dulmus, C. N., Sowers, K. M., & Sowers, K. M. (2013). Social work practice with individuals and families : Evidence-informed assessments and
interventions. ProQuest Ebook Central <a onclick=window.open(http://ebookcentral.proquest.com,_blank) href=http://ebookcentral.proquest.com target=_blank style=cursor: pointer;>http://ebookcentral.proquest.com</a>
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182 Social Work Practice With Individuals and Families
transfer (Gallo & Paveza, 2006; Katz, Ford, Moskowitz, Jackson, & Jaffe,
1963). Eventually, to these six behaviors was added an additional set of
behaviors usually referred to as the instrumental activities of daily living.
These behaviors were seen as more complex and demanding than the ADLs
but still important for a person who wanted to reside independently in the
community (OARS Methodology, 1978). The behaviors initially included
in the IADLs were telephone usage and the ability to travel around town,
go shopping, prepare his or her own meals, do housework, take needed
medications, and manage his or her own money. Although, over time, this
initial set of IADLs has been modified for various reasons (Fillenbaum,
1995; Paveza et al., 1990a; Paveza et al., 1989), in general the behaviors
included in the IADLs have remained relatively stable.
As with the other areas of the comprehensive-assessment process,
a number of different standardized instruments have been developed to
measure either separately or in combination ADLs and IADLs. These
assessment instruments use different metrics to arrive at the determination
of functional ability, but all offer a quick and easy method to obtain this
information (Fillenbaum, 1995; Katz et al., 1963; Paveza et al., 1989).
Some, such as the direct assessment of functioning (DAF), which was
developed for use with dementia patients (Lowenstein et al., 1989), were
designed for use with specific types of clients.
The importance of a well-conducted functional assessment cannot be
overstated. The measure of functional ability has been shown to be the
best single predictor of cost of community-based services (Paveza, Mensah,
Cohen, Williams, & Jankowski, 1998) and is the essential component for
developing a care plan that identifies those client behaviors most likely
requiring intervention (Gallo & Paveza, 2006; Paveza et al., 1989).
The assessment of mental status and functional status sets the
first two elements of the assessment process. With these two elements
completed, the next most logical step is to gather medical history and
information on nutritional and health practices.
Medical History and Nutritional and
Health-Behaviors Assessment
The next elements of the comprehensive assessment focus on obtaining
an accurate medical history and gathering information about the per-
son’s nutritional well-being and other health practices that may impact
the client’s well-being or quality of life. The medical history needs to
gather information about both current and past medical conditions. One
of the easiest ways to obtain information on medical conditions is to use
a body-systems approach. Information concerning both past and current
medical conditions for each of the body’s systems serves as a reference
point for a set of questions about various medical conditions that might
occur in that bodily system. One seeks information on the circulatory
system, for example, by asking questions that address likely medical
Holosko, M. J., Dulmus, C. N., Sowers, K. M., & Sowers, K. M. (2013). Social work practice with individuals and families : Evidence-informed assessments and
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Assessment of the Elderly 183
conditions a client may have or have had, such as hypertension, angina,
heart attack, and other diseases of the circulatory system. By taking this
structured approach to obtaining medical history, it is less likely that
the clinician will forget to ask questions about likely medical conditions
or that a client will forget to provide information on a specific illness
(Paveza et al., 1989). Included as part of gathering information about
medical conditions is obtaining information about the medications that
are being taken. This includes both physician-prescribed medications as
well as all over-the-counter medications and includes vitamin and mineral
supplements, herbal and other homeopathic remedies, aspirin and other
nonsteroidal anti-inflammatory agents (NSAIDS), cold and flu medica-
tions, and anything else that the client may use on a regular basis. It is
important to recognize, however, that many clients may be unsure about
which medication is for which medical condition. To assist the client in
providing and the social work practitioner in obtaining accurate informa-
tion in this area, it is often helpful to work with the client to complete a
drug inventory.
The drug inventory is conducted by asking the client to bring all
prescribed medications, over-the-counter medications, herbal medicines,
and vitamin and mineral supplements to a common area. When assembled,
the clinician first reviews all the prescribed medications and writes down
the name of the medication, the date that it was prescribed, and the
doctor who prescribed it. Then, all other medications and supplements are
recorded. After the completion of the interview, the clinician should work
with a knowledgeable pharmacist to ensure that there are no potential
interactions either between the prescribed medications or between any of
the prescribed medications and the other medications and supplements
taken. Should potential interactions be discovered, the clinician should
contact the client or caregiver and raise the concern with him or her as
well as include this information in the care plan.
Having completed the medical history and drug inventory, it is also
important that the clinician gather information concerning nutritional sta-
tus and health practices. A simple procedure for obtaining information
on nutritional status is to use the Nutritional Screening Initiative Check-
list. This simple 14-item questionnaire gathers information about issues
that impact older adults’ ability to stay nutritionally healthy, including
financial, emotional, and logistic ability to identify, purchase, and prepare
appropriate foods as well as identifying the potential impact of medications
and psychological illness on food intake (Wallace, Shea, & Guttman, 2006).
In addition to the nutrition screening, it is important for the clinician to
seek information from the client concerning the use of alcohol, smoking
behavior, the amount of exercise engaged in, whether he or she is expe-
riencing any problems with sleep, and whether the older adult has been
able to obtain various recommended immunizations. Each of these areas
has the potential to impact both the older adult’s risk of mortality as well
as his or her quality of life. An area that is often overlooked but needs to
be included in this portion of the assessment is the current sexual activity
Holosko, M. J., Dulmus, C. N., Sowers, K. M., & Sowers, K. M. (2013). Social work practice with individuals and families : Evidence-informed assessments and
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184 Social Work Practice With Individuals and Families
and practices of the older adult. This area is often overlooked because
of the clinician’s discomfort in seeking this type of information from the
older adult. Yet unless some time is spent talking about this important
area of functioning, an area of potential emotional distress and risk-taking
behavior in some older adults will be missed (Nicklin, 2006).
The clinician should also include in this section an assessment of
pain. Many older adults experience pain from the same causes as younger
adults, to which can be added the pain impact of many chronic illnesses.
Although it was once believed that older adults did not experience pain
with the same intensity as younger adults, recent literature suggests this is
not true. Moreover, older adults are often given the impression that they
should be able to tolerate the pain they are experiencing based on this
mistaken notion that their qualitative perception of pain is diminished.
Simple assessments of pain include the Numeric Rating Scale, in which a
client is asked to rate his or her pain on a scale from 0 to 10, with 0 equaling
‘‘no pain’’ and 10 equaling ‘‘the worst pain the person can imagine.’’ A
Visual Analog Scale—in which a 10-cm line is shown to the client, with
one end being labeled ‘‘no pain’’ and the other end labeled as ‘‘worst
imaginable pain’’ on which the client then indicates where his or her pain
falls—is another alternative for quickly assessing the current level of pain
experienced by the client. Although both of these measures are useful for
monitoring pain, because they can be used to detect small changes in the
client’s experience of pain, it is important to remember that these scales do
not provide information on changes in psychological distress or physical
function that may be caused by pain (Richardson, 2006).
To assess pain in areas other than intensity, one must consider the
use of a multidimensional pain scale, such as the McGill Pain Questionnaire
(MPQ). This instrument assesses pain in sensory, affective, and evaluative
areas. Although the MPQ has been used in a variety of settings, it can
take up to 20 minutes to complete and may not be appropriate for use
during the initial assessment of the client. Rather, the clinician may wish
to indicate that, as part of the care plan, a more comprehensive assessment
of the client’s pain be conducted with a referral to a pain clinic.
Having completed this portion of the medical history and assessment
of health behaviors and practices, it is important for the clinician to include
recommendations in the care plan that will help mitigate or remove the
impact of any deficiencies (Wallace et al., 2006).
The final area to cover as part of the medical history and assessment
of health behaviors and practices is an assessment of emotional well-being.
Assessment of Emotional Well-Being
The assessment of emotional well-being as part of the comprehensive
assessment should focus at a minimum on the presence of depression
and/or anxiety. However, if at all possible, the clinician should explore
Holosko, M. J., Dulmus, C. N., Sowers, K. M., & Sowers, K. M. (2013). Social work practice with individuals and families : Evidence-informed assessments and
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Assessment of the Elderly 185
a range of psychiatric symptoms and the psychiatric illnesses …
Research Article
Development of an Instrument
for Assessing Elder Care Needs
Elizabeth Åhsberg1,2, Gunilla Fahlström1, Eva Rönnbäck3,
Ann-Kristin Granberg1, and Ann-Helene Almborg1
Abstract
Objective: To construct a needs assessment instrument for older people using a standardized terminology (International
classification of functioning, disability, and health [ICF]) and assess its psychometrical properties. Method: An instrument was
developed comprising questions to older people regarding their perceived care needs. The instrument’s reliability, validity, and
utility were tested. Forty-one social workers and 251 older people participated. Results: The questions were sufficiently
unambiguous (inter-rater reliability, intraclass correlation ¼ .60–.80); measured a person’s care and service needs to a satisfactory
extent (criteria validity, agreement between social workers’ and older people’s assessments ¼ 72–94\%); both social workers and
older people considered the questions useful; and the needs of older people were documented in social records to a greater
extent when the instrument was used. Conclusion: The psychometric properties of the instrument support its use by social
workers to gain relevant information on elder care needs.
Keywords
instrument, old, needs assessment, ICF
Introduction
The Swedish society’s care for older people is regulated by the
Socials Services Act. The Act’s principal goal is that the social
services should promote economic and social security, equal
living conditions, and an active participation in society. The
law also states that the 290 municipalities in Sweden each have
a responsibility to ensure that help and support are offered to
those who need it. The municipalities have the authority to
decide if public care is necessary in order to ensure a reason-
able standard of living for the individual.
A basic value in Swedish welfare is that care and services
should be offered to those in need. When considering elder care
and service needs, social workers must try to answer two basic
questions: Do a person’s problems create a nonreasonable stan-
dard of living? How can care needs best be met while adhering
to relevant regulations and best known practice? The responsi-
bility to decide on these matters places high demands on social
workers. It is, therefore, important that social workers get both
correct and sufficient information in order to be able to make
the best possible decision. In the case of older people, the deci-
sion typically relates to whether they are in need of some kind
of care or services at home or should instead be offered a place
in a nursing home (or another form of residential care).
The concept of need is complex and definitions may vary
depending on the context. One definition that may be of rele-
vance for elder care concerns health and disability: the present
condition should be established, a goal for health should be
formulated, and a need of care exists if there is a difference
between the present condition and the goal (Liss, 1990). But the
significance of disabilities, physical or cognitive, may differ
depending on the individual situation (Kaufman, 1994). For
example, the need for help or care is often dependent on
whether or not the older person has relatives who are able to
provide support.
It has been argued that the needs of older people are not
always given sufficient weight in decisions regarding public
elder care. In particular, social, psychological, and existential
needs have been shown to be considered to a lesser extent (Jan-
löv, 2006; Lindelöf & Rönnbäck, 2004; Olaison, 2009, 2010).
Even health problems are not given sufficient emphasis in
some cases (Karlsson, 2008). One explanation for these
observed results may be that social service decisions must be
made within set cost limitations. These restrictions may pose
a dilemma for social workers since it is not always obvious
1 National Board of Health and Welfare, Stockholm, Sweden
2
Department of Public Health and Caring Sciences, Uppsala University,
Uppsala, Sweden
3 Sundsvall municipality, Sundsvall, Sweden
Corresponding Author:
Elizabeth Åhsberg, National Board of Health and Welfare, Stockholm 10630,
Sweden.
Email: [email protected]
Research on Social Work Practice
2017, Vol. 27(3) 291-306
ª The Author(s) 2015
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which needs entitle a person to public care (Dunér & Nord-
ström, 2006; Thorslund & Larsson, 2002).
Instruments used within the Swedish municipal elder care
(Socialstyrelsen, 2002) measure, for example, cognitive ability
(Folstein, Folstein, & McHugh, 1975), ability to handle every-
day life (Katz, Ford, Moskowitz, Jackson, & Jaffe, 1963), well-
being (e.g., depression, Yesavage & Brink, 1983), and quality
of life (Hillerås, Jorm, Herliz, & Winblad, 2001). Other instru-
ments are more comprehensive and aim to capture all informa-
tion necessary for health and social care (e.g., Hawes et al.,
1997). There are also simple questionnaires for self-rated
health (e.g., Jylhä, 2002) and instruments for drug-related
symptoms (Hedström, Lidström, & Hulter Åsberg, 2009). The
majority of these instruments have been developed internation-
ally and later translated to Swedish. To our knowledge, no
instrument aiming to assess one or several elder care needs is
based on a standardized terminology.
The International Classification of Functioning, Disability,
and Health (ICF) is developed by the World Health Organiza-
tion (WHO) as a means for international communication
(WHO, 2001). ICF offers a standardized framework for terms
related to health and disabilities and is based on a biopsychoso-
cial model which includes components such as activities and
participation, body functions, and body structures. It also con-
siders contextual components such as environmental and per-
sonal factors. The structure of ICF is hierarchical and a
generic scale (0 ¼ no problem to 4 ¼ total problem) can be
used when assessing functioning and the influence of contex-
tual factors. This classification system makes comparisons over
time possible, as well as comparisons between both caregivers
and countries. The ICF has been translated to Swedish and
included in the national interdisciplinary terminology resources
(Socialstyrelsen, 2010).
Aim
The aim of this study was to develop a relevant, reliable, and valid
instrument that can be used by social workers to assess older peo-
ple’s needs of care and services. Although based on ICF terminol-
ogy, the instrument must be adapted to the Swedish context.
Method
An instrument was first constructed and then tested for reliabil-
ity, validity, and utility in three successive phases of data col-
lection. See Table 1 for methodological overview.
Seven municipalities were selected to represent major cities
of >200,000 inhabitants (one city), medium-sized cities of
50,000–200,000 inhabitants (two cities), and rural areas of <8
inhabitants per km
2
(four areas; Sveriges Kommuner och Land-
sting [SKL], 2010). This was made in order to ensure variation
in the nature of the cases, in so far as cases in elder care vary by
region and type of community. Ethical approval of this study
was granted by the regional ethical board in Stockholm in April
2011 (reg. No. 2011/396-31/5).
Construction of an Instrument
Thirty-five terms describing everyday activities and two terms
describing safety and security were initially identified in a pilot
study as particularly relevant for elder care. The first version of
the instrument therefore consisted of 37 terms, formulated as
questions about difficulties (ICF response scale from 0 to 4)
and help or support needs (response scale ¼ yes/no). The terms
were subcategories belonging to nine different ICF domains of
activities:
1. Learning and applying knowledge—for example, to
mend something that is broken or to throw away bad
food.
2. General tasks and demand—for example, to eat regu-
larly, follow a medical ordination, or keep an
appointment.
3. Communication—for example, to hear and understand
speech, see and understand text, be able to speak Swed-
ish and to use a phone, and an alarm or a computer.
4. Mobility—for example, to be able to get up from a chair
or a bed, pick up a pen, move between different floors,
go out on a balcony, or take a walk in the neighborhood.
5. Self-care—for example, to wash oneself, cut one’s
nails, comb one’s hair, brush one’s teeth, eat healthy,
or follow health advices.
6. Domestic life—for example, to cook and serve food,
gather and throw garbage, repair clothes, maintain
means of aid, and take care of plants or animals.
7. Interpersonal interactions and relationship—for exam-
ple, to have contacts with family/relatives, friends/
neighbors, or organizations such as public authorities,
health centers, or the hairdresser.
8. Major life areas—for example, to pay bills or handle
money when shopping.
Table 1. Methodological Overview.
Test Data Collection Analysis Older People Social Workers ICF
Inter-rater reliability 1 Intraclass correlation 151 41 37 terms
Construct validity 1 Factor analysis 151 41 37 terms
Criteria validity 2 Agreement \% 100 23 42 terms
Utility reports 3 Number of reports 80 (40 þ 40) 9 domains
Utility opinions 1, 2 Categorization 201 41
Note. ICF ¼ International classification of functioning, disability, and health.
292 Research on Social Work Practice 27(3)
9. Community, social and civic life—for example, to par-
ticipate in a club or association, practice a hobby, visit
church (synagogue, mosque) or a graveyard, or vote in
general elections.
The instrument should be used by social workers (also
called needs assessors) in a semi-structured interview. Prefer-
ably, the older person would answer the questions for each ICF
domain and report if he or she has any difficulties and is there-
fore in need of help or support. A preliminary manual was for-
mulated according to the explanations of each term given in the
ICF. Some of the terms were later explained by presenting
explicit and illustrative examples in a plain language.
Reliability Test—First Data Collection Phase
Social workers’ inter-rater reliability was tested during assess-
ments of elder care needs using the first version of the instru-
ment. The purpose was to measure the agreement among
social workers when interpreting an older person’s answers
to each question. Forty-one female social workers participated,
with an average of 7.60 years (standard deviation (SD) ¼ 6.39,
range ¼ 1 month–30 years) of work experience in the field.
The older people were recruited prospectively during Sep-
tember to December 2011. Those who only applied for security
alarms or meal distribution as well as those who were only par-
took in discharge care planning at a hospital were excluded.
The older people were first informed verbally about the study
and then asked if they wanted to participate. Those who agreed
to participate were given information on a consent form that
they had to sign before participating.
One hundred and fifty one older people participated (99
women and 52 men), with an average age of 83.57 years (SD
¼ 7.51, range ¼ 58–97). All applied for some kind of elder care
or were subject to a follow-up. The objective was to collect data
from about 150 cases for double assessments in order to
achieve sufficient data for statistical calculations (Donner &
Eliasziw, 1987). Four older people declined to participate due
to fatigue, illness, or poor hearing during the initial phone con-
tacts. Two persons declined as they were afraid to let two social
workers enter their home due to recent media coverage report-
ing people who had entered homes with false social worker
identification.
The social workers worked in pairs. Both social workers in
each pair conducted independent assessments of each older
person using the instrument. Although one social worker inter-
viewed the older person, the other strictly observed the dialogue.
Validity Test—Second Data Collection Phase
Criteria validity was tested with help from social workers,
using a revised, second version of the instrument (see Results
section). The social workers now worked individually as they
usually do. The social workers also rated if they themselves
found that the older person needed help based on each of the
ICF activity domains. The agreement between older people’s
and social workers’ ratings of elder care needs was calculated.
The social worker’s assessment was regarded as a criterion.
This is because it was made with reference to all available
information such as information from relatives, medical staff,
and documents, in addition to the social worker’s own observa-
tions during the meeting with the older person. The social
worker’s assessment is of particular relevance as it is the social
worker who makes the formal decision about public elder care,
a decision which may be appealed in court. Twenty-three social
workers participated, with an average of 8.61 years (SD ¼ 6.11,
range ¼ 1 month–22 years) of work experience in the field.
The older people were recruited prospectively among those
who applied for elder care or were subject to a follow-up during
January to April 2012. Individuals subject to discharge care
planning in hospitals and those who had a dementia diagnosis
were excluded. As in the first data collection, the older people
were informed verbally and asked if they wanted to participate.
Those who agreed to participate were given information on a
consent form that they had to sign before participating.
One hundred older people participated (70 men and 30
women), with an average age of 82.47 years (SD ¼ 7.12, range
¼ 56–99). About 100 cases were estimated to be sufficient for
this particular test (Gardner & Altman, 1989).
In addition, ratings from the first data collection were ana-
lyzed using factor analysis in order to obtain a measure of con-
struct validity (i.e., the extent to which the ICF domains are
confirmed empirically by the present data).
Test of Utility—Third Data Collection Phase
The test of utility consisted of two parts. First, information was
collected during the first two data collection phases described
previously. All social workers answered a questionnaire (eight
questions, Appendix C) about the usefulness of the instrument.
Furthermore, the social workers also asked if the older person
had any comments on the instrument. A total of 201 older peo-
ple gave such comments.
Second, social records from assessments of 40 cases where
the instrument was used were examined and compared to 40
cases where the instrument was not used. These comparisons
were made in order to determine whether or not use of the
instrument contributed to an increased identification of older
people’s needs. Each record chosen for comparison was
matched according to the complexity of a case where the instru-
ment was used in order to ensure that the matched case pairs
represented as similar cases as possible. These 80 case records
were selected by the social workers, copied, and edited in order
to ensure anonymity.
Data Analysis
Measures of inter-rater reliability were obtained by calculating
the agreement between social workers on the 5-degree ICF
scale (estimates based on pairwise comparisons for each ques-
tion and each older person), using intraclass correlations (ICC).
Åhsberg et al. 293
Measures of criteria validity were obtained by calculating the
agreement between the older person’s answer (Do you need
help? Yes/No) and the social worker’s assessment (Public care?
Yes/No). The calculations were based on individual pairwise
comparisons and reported as percentages. In addition, construct
validity (if overall domains of activity could be identified) was
explored using exploratory factor analysis on the data used for
the reliability test. The factor analysis method applied was obli-
que with maximum likelihood extraction and varimax rotation.
Both older people’s and social workers’ reported opinions
about usability were analyzed descriptively. Two people indepen-
dently categorized the responses as negative, neutral, or positive.
The social records were reviewed and the number of ICF activity
domains mentioned in each was recorded. The review was con-
ducted independently by three reviewers using an audit form. One
of the reviewers was blinded to the coding (with or without instru-
ment). The initial agreement between reviewers was in total 86\%
(113 of 800 variables [10 variables � 80 records] were rated dif-
ferently). The variables that were coded differently by the
reviewers were discussed until consensus was reached.
Results
In total, 41 social workers and 251 older people participated in
the 3 data-collection phases. Twenty-three of the social work-
ers participated in both the reliability and the validity studies.
Reliability
The degree of pairwise agreement between social workers
regarding their interpretation of the older people’s answers to
the 37 questions in the first version of the instrument varied
between .60 and .88 per question (Table 2). Although the
degree of agreement differed between questions, the results can
be considered to be generally good (Fleiss, 1986).
However, the two terms with the lowest correlation coeffi-
cients were perceived as difficult to distinguish from other
terms by the majority of social workers. These two terms were
therefore excluded in the second version of the instrument (the
terms are Sense of security and To maintain basic body posi-
tion). The social workers also suggested some additional areas
of importance for older people. As a result, seven questions
were added in the second version: (i) solving problems; (ii)
complex economic transactions; (iii) voting and change the rest
of the sentence to (iv) feeling sad; (v) feeling loss of appetite;
(vi) housing; and (vii) personal support.
Validity
The agreement between the older person’s opinion of whether
she or he felt a need for help or support and the social worker’s
opinion of the older person’s need for public care was tested
using the 42 questions in the second version of the instrument.
The degree of agreement varied between 72\% and 94\% per ICF
domain (Table 2). It can, therefore, be concluded that the older
people and the social workers were in agreement as regard the
need for help in the majority of cases.
The cases where the social workers and older people did not
agree were examined more closely. The most common point of
disagreement (4–18\%, depending on the ICF domain) was
when a social worker assessed that there was a need for help
despite the fact that the older person did not want any help.
Table 2. Summary of Results From the Three Data Collection Phases.
ICF domain
Degree of Agreement Between Social
Worker and Social Worker
Degree of Agreement Between Older
People and Social Workers
Number of Records
Containing Each
ICF-Domain
No
instrument
With
instrument
n ¼ 151 (ICC) n ¼ 100 (\%) n ¼ 40 n ¼ 40
Learning and applying knowledge 0.88 93 0 7
General tasks and demand 0.75 91 11 15
Communication .63–.88 89 17 21
Mobility .60–.84 72 32 39
Self-care .74–.85 91 33 37
Domestic life .79–.88 83 37 40
Interpersonal interactions and
relationship
.76–.86 94 38 40
Major life areas 0.85 85 7 18
Community, social, and civic life .75–.83 82 17 33
Additional questions, feelings about:
Safety 0.72 84
Sadness 86
Lack of appetite 90
Note. ICC ¼ intraclass correlation; ICF ¼ International classification of functioning, disability, and health. Type of test, analysis, type and number of participants, and
number of ICF variables.
294 Research on Social Work Practice 27(3)
A further measure of validity was obtained using a factor
analysis with data from the reliability study. Eight factors with
eigenvalues above 1.0 were initially extracted. Most of the 37
variables loaded positively onto several factors (Appendix A).
Only three ICF domains were identified as coherent factors: (i)
Domestic life; (ii) Interactions and relationships; and (iii)
Community, social, and civic life. All eight factors correlated
to varying degrees. These results suggest that, when applied
in the context of elder care, the different activity domains in the
ICF are not distinct but overlapping as a specific activity may
belong to several domains. For example, if a person has mobi-
lity problems, he or she is also likely to have difficulties man-
aging domestic life.
Overall, the results suggest that the questions based on ICF
terms sufficiently captured the older person’s perception of his or
her need for help or support. Furthermore, the ICF activity domains
were not independent but instead correlated to one another.
Utility—Perceived Usefulness
The majority (81\%, 163 of 201 people) of the older people who
gave their opinion of the questions were generally neutral or
positive. They described the questions as good, easy to respond
to, and/or relevant. Of these 163 responses, 76 were neutral, 4
people saw both advantages and disadvantages, and 83 gave
explicitly positive comments. They reported, for example, that
standardized questions can make it easier for them to describe
and to reflect about their life situation in general. The remain-
ing 38 of the 201 people’s responses reflected more negative
views, for example, that there were too many questions, that
some questions felt intrusive, and that it was hard to grade the
difficulties they had.
The majority (88\%, 36 of 41) of the social workers reported
that the instrument was both useful and contained relevant ques-
tions, but that some of the questions were difficult to ask an older
person. Six social workers also pointed out that it took longer at
first to complete the interview based on the instrument as they
were unaccustomed to it. Overall, the social workers expressed
that the instrument provided both advantages and disadvantages
when compared to assessing the need of older people without
any instrument. Examples of disadvantages included difficulties
using a response scale to assess the degree of difficulty; that cer-
tain questions were not included (mainly about health); that
some questions were difficult to ask (mostly on religion, rela-
tionships, and decision making); that the conversation became
rigid when using the instrument; and that the terms were not
adapted to plain language. Advantages of using the instrument
included the experience that reticent people can be induced to
express themselves; that the questions can help the older person
to reconsider his or her situation; that the ICF domains cover an
older person’s daily life to a large extent; that the instrument
gives a structure to the assessment process; and that it may clar-
ify an older person’s difficulties in ambiguous cases.
The time to work through the instrument for an individual
older person varied between 10 minutes and 2 hours, depending
on the complexity of the case.
Utility—Documented Aspects of Everyday Life
A greater number of ICF activity domains were mentioned in
social records when the instrument was used than when no
instrument was used. In particular, activities such as Major life
areas (here only financial transactions) and Social community,
social, and civic life were documented to a greater extent when
the instrument was used (Table 2).
Final Version
A final version of the instrument was developed after the three
data collection phases were completed. The instrument can be
described as a questionnaire for a semi-structured interview,
where questions with fixed response alternatives are comple-
mented with the possibility to give more details in free text.
The instrument consists of nine general questions regarding
difficulties in everyday life. If the older person reports difficul-
ties on any of these general domains, more detailed questions
can then be asked based on the 42 ICF codes (see Table 3). The
social worker is supposed to ask if the older person wants help
or support every time he or she reports a difficulty on a general
domain. Additional questions address home and personal sup-
port respectively (two questions) and how the person has been
feeling lately (four questions).
The instrument should be used by social workers when
interviewing people applying for elder care or when current
elder care is followed-up. Both the instrument and the man-
ual are available in Swedish at the website of the National
Board of Health and Welfare, www.socialstyrelsen.se (in
Swedish BAS ¼ Behov Av Stöd, corresponds to Need Of
Care). For an English version of the instrument, please see
Appendix B.
Table 3. ICF Domains With Codes for Detailed Questions in the
Final Version of BAS.
Domain Codes
Learning and applying
knowledge
d175, d177
General tasks and demand d230
Communication d330, d310, d325, d345, d3600
Mobility d410, d430, d440, d450, d4551,
d4600, d4602
Self-care d510, d520, d530, d540,
d550þd560, d570
Domestic life d6200, d630, d6401, d6405, d6400,
d6402, d650
Interpersonal interactions and
relationship
d740, d750, d760
Major life areas d860, d865
Community, social, and civic life d910, d920, d930, d9508
Additional questions
Home, support e155, e399
Safety, appetite, and sadness b1528, b1302, b1528
Note. BAS ¼ Behov Av Stöd; ICF ¼ International classification of functioning,
disability, and health.
Åhsberg et al. 295
Discussion
The psychometric testing showed that the questions in the
instrument were sufficiently unambiguous to be useful in the
context they were developed for; that the questions measure
different aspects of an older person’s perceived need of social
care to a satisfactory extent; that the majority of both older peo-
ple and social workers considered the questions to be useful;
and that the needs of older people were documented to a greater
extent in social records when the instrument was used com-
pared to when no instrument was used.
Although the instrument mainly comprises questions about
everyday activities, an interview can touch on many different
aspects of a person’s situation. Physical, psychological, social, and
existential aspects may be discussed if the older person so wishes.
The various ICF domains are overlapping. This is not surprising
as, for example, physical ability may affect responses on the ICF
domains Mobility, Self-care, Domestic life, and Communication.
Mental functions in terms of cognitive functions could affect
responses on the domains Learning and applying knowledge, Gen-
eral tasks and demand, and Major life areas. Mental functions in
terms of emotional aspects can also be expected to affect responses
to the questions exploring safety, sadness, and loss of appetite.
Furthermore, social circumstances can reflect not only responses
on the domain Interpersonal interactions and relationships but
also existential issues (e.g., to participate in ceremonies).
The responses to a single instrument cannot provide all pos-
sible relevant information when making elder care decisions
(Chernesky & Gutheil, 2008). An instrument can, however,
contribute to more systematic assessments, which can promote
social justice and older people’s rights to individualized care
and services. Unlike other instruments used in elder care
(e.g., Activities of Daily Living [ADL] or Resident Assessment
Instrument [RAI] [Hawes et al., 1997; Katz et al., 1963]), the
instrument developed and presented in this study (called BAS)
is designed to enable a comprehensive assessment of how older
people perceive their need of care. Furthermore, to our knowl-
edge, BAS is the first instrument that aims to capture the need
of elder care based on a standardized international terminology.
Still, BAS has several limitations. For example: (a) it is often
necessary to collect additional information about, for example,
medical diagnoses, housing, and/or family relationships; (b) as
elder care in Sweden should be adapted to each individual’s
unique situation, no cutoff level was established; (c) the instru-
ment is yet to be tested on people with dementia or when cog-
nitive impairment is suspected, since needs assessment in
these cases often requires specific information from relatives;
and (d) reliability testing was restricted to inter-rater reliability.
A test–retest was judged problematic due to systematic error as a
result of the potential change in older people’s needs over time;
(e) there was variation in the social workers’ level of work expe-
rience and the most inexperienced social …
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After viewing the you tube videos on prayer
Your paper must be at least two pages in length (not counting the title and reference pages)
The word assimilate is negative to me. I believe everyone should learn about a country that they are going to live in. It doesnt mean that they have to believe that everything in America is better than where they came from. It means that they care enough
Data collection
Single Subject Chris is a social worker in a geriatric case management program located in a midsize Northeastern town. She has an MSW and is part of a team of case managers that likes to continuously improve on its practice. The team is currently using an
I would start off with Linda on repeating her options for the child and going over what she is feeling with each option. I would want to find out what she is afraid of. I would avoid asking her any “why” questions because I want her to be in the here an
Summarize the advantages and disadvantages of using an Internet site as means of collecting data for psychological research (Comp 2.1) 25.0\% Summarization of the advantages and disadvantages of using an Internet site as means of collecting data for psych
Identify the type of research used in a chosen study
Compose a 1
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effect relationship becomes more difficult—as the researcher cannot enact total control of another person even in an experimental environment. Social workers serve clients in highly complex real-world environments. Clients often implement recommended inte
I think knowing more about you will allow you to be able to choose the right resources
Be 4 pages in length
soft MB-920 dumps review and documentation and high-quality listing pdf MB-920 braindumps also recommended and approved by Microsoft experts. The practical test
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One thing you will need to do in college is learn how to find and use references. References support your ideas. College-level work must be supported by research. You are expected to do that for this paper. You will research
Elaborate on any potential confounds or ethical concerns while participating in the psychological study 20.0\% Elaboration on any potential confounds or ethical concerns while participating in the psychological study is missing. Elaboration on any potenti
3 The first thing I would do in the family’s first session is develop a genogram of the family to get an idea of all the individuals who play a major role in Linda’s life. After establishing where each member is in relation to the family
A Health in All Policies approach
Note: The requirements outlined below correspond to the grading criteria in the scoring guide. At a minimum
Chen
Read Connecting Communities and Complexity: A Case Study in Creating the Conditions for Transformational Change
Read Reflections on Cultural Humility
Read A Basic Guide to ABCD Community Organizing
Use the bolded black section and sub-section titles below to organize your paper. For each section
Losinski forwarded the article on a priority basis to Mary Scott
Losinksi wanted details on use of the ED at CGH. He asked the administrative resident