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) © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the articles Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the articles Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. * 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 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> Created from waldenu on 2021-10-05 04:07:43. C o p yr ig h t © 2 0 1 3 . Jo h n W ile y & S o n s, I n co rp o ra te d . A ll ri g h ts r e se rv e d . 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 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> Created from waldenu on 2021-10-05 04:07:43. C o p yr ig h t © 2 0 1 3 . Jo h n W ile y & S o n s, I n co rp o ra te d . A ll ri g h ts r e se rv e d . 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> Created from waldenu on 2021-10-05 04:07:43. C o p yr ig h t © 2 0 1 3 . Jo h n W ile y & S o n s, I n co rp o ra te d . A ll ri g h ts r e se rv e d . 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> Created from waldenu on 2021-10-05 04:07:43. C o p yr ig h t © 2 0 1 3 . Jo h n W ile y & S o n s, I n co rp o ra te d . A ll ri g h ts r e se rv e d . 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> Created from waldenu on 2021-10-05 04:07:43. C o p yr ig h t © 2 0 1 3 . Jo h n W ile y & S o n s, I n co rp o ra te d . A ll ri g h ts r e se rv e d . 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 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> Created from waldenu on 2021-10-05 04:07:43. C o p yr ig h t © 2 0 1 3 . Jo h n W ile y & S o n s, I n co rp o ra te d . A ll ri g h ts r e se rv e d . 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 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> Created from waldenu on 2021-10-05 04:07:43. C o p yr ig h t © 2 0 1 3 . Jo h n W ile y & S o n s, I n co rp o ra te d . A ll ri g h ts r e se rv e d . 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 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> Created from waldenu on 2021-10-05 04:07:43. C o p yr ig h t © 2 0 1 3 . Jo h n W ile y & S o n s, I n co rp o ra te d . A ll ri g h ts r e se rv e d . 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 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049731515572913 journals.sagepub.com/home/rsw https://us.sagepub.com/en-us/journals-permissions https://doi.org/10.1177/1049731515572913 http://journals.sagepub.com/home/rsw http://crossmark.crossref.org/dialog/?doi=10.1177\%2F1049731515572913&domain=pdf&date_stamp=2017-03-02 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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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 Optics 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. 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