Improving care in nursing homes using community advocacy

Community organizations have often focused their campaigns for social change on the health care system. While the techniques of Saul Alinsky and to a lesser extent Paulo Friere have provided the theoretical backbone for most community organizing efforts, these campaigns frequently are characterized by a rather eclectic synthesis of different methodologies. The nursing home industry has been one of the most severely publicly criticized components of the American health care system, and during the last decade consumer groups have sought to achieve fundamental improvements in the quality of life and care available to nursing home residents. However, the standard Alinsky and Friere techniques have limitations in organizing efforts directed toward nursing home reform. One case study is presented which describes a relatively successful community organizing project for better care in a San Francisco Bay Area nursing home. The organizing method used in this project was one of community advocacy. This method is described in detail, and the limitations and potentials of community advocacy are analyzed.     

Demographic change in Germany and implications for the health system

Demographic change will create additional stress for the German health system and require substantial adjustments in the coming decades. The article discusses the nature and dimensions of demographic change and shows the range of insecurity in todays population projections. The most important impact for the health system can be expected from aging as many patterns of morbidity and costs are age-specific. The article discusses the impact of changes in age structure on health-care expenditure in Germany. If age-specific costs would remain constant the impact of aging would increase total disease-related costs by more than 30% within the next 50 years. Considering arguments about the impact of proximity to death on costs rather than age, the real cost increase should be expected to be lower. Substantial cost increases should be expected particularly in long-term nursing care. Immigration and the increasing number of inhabitants with a migration background is another element of demographic change with influence on the German health system. To a small degree immigration could help to fill the growing need for manpower in the health system. The impact of demographic change on the health system is diverse and in no way deterministic.     

Student Nurses' Attitudes toward a Career in Community Health

Changes in the practice of health care delivery to include a greater focus on community-based care is becoming an issue of increasing importance throughout the Western World. In Australia, factors such as a reduction in the average patient stay within acute care hospitals and the allocation of additional funds to community resources presents evidence of this change in focus. Nurses, who form the largest professional group involved with health care delivery, must by necessity become an important part of such change. A significantly larger number of nurses will be required to work in the community in the future. Despite this trend, there is a paucity of research examining the attitudes of student nurses towards a possible career in the area of community health. In order to address this deficit, a longitudinal study examining the career preferences of undergraduate nursing students is being conducted. The study sample comprises undergraduate nursing students from 9 universities in the State of Victoria. The results of stage 1 of this research are presented in this paper. The findings indicate that at the commencement of their educational program, undergraduate student nurses do not have a strong understanding of or interest in the area of community health nursing. A preference for employment within a hospital environment, particularly in the highly technical areas, and in the care of mothers and babies, is evident. The implication of these findings for the future of community health nursing is briefly discussed.     

The nursing shortage: a worldwide problem

A worldwide shortage of nurses has been acknowledged by the multidisciplinary Global Advisory Group of the World Health Organization. The shortage is caused by an increased demand for nurses, while fewer people are choosing nursing as a profession and the current nurses worldwide are aging. The shortage applies to nurses in practice as well as the nurse faculty who teach students. The inter-country recruitment and migration of nurses from developing countries to developed countries exacerbates the problem. Although public opinion polls identifies the nurse as the person who makes the health care system work for them, the conditions of the work environment in which the nurse functions is unsatisfactory and must change. Numerous studies have shown the positive effects on the nurse of a healthy work environment and the positive relationships between nursing care and patient outcomes. It is important that government officials, insurance companies, and administrators and leaders of health care systems acknowledge and operationalize the value of nurses to the health care system in order to establish and maintain the integrity and viability of that system.     

日本预防保健体系对我国构建家庭保健体系的启示

日本的医疗卫生保健体系从广义上讲以预防保健、医疗和照护为三大支柱,并针对儿童、残疾人、老年人等弱势群体通过社会福利政策给予支持,从而打造了全方位的预防保健、医疗、照护、福利网络。随着医疗费用在国民收入中所占比例的不断增加和人口老龄化的不断加剧,日本逐步深化预防保健的重要性,积极促进以治疗为重点的医疗体制向重视疾病预防、健康促进的预防保健医疗体制转变。同时,加强保健、医疗、照护、福利在社区层面的联合。本文重点分析日本预防保健体系的构成及特点,总结其经验,以期为中国强化预防保健意识,促进人口计生系统转型,构建全面深入的家庭预防保健体系提供借鉴和参考。     

When the manager encounters "We can't do it!"

This article has described the importance of increasing staff feelings of self-worth, of promoting feelings of personal power, involving staff actively in practice issues, of increasing staff knowledge of the health care and agency system, and of setting limits on negative discussion in a group. When nurses feel power in the health care system, it not only has the benefit of increasing job satisfaction but increases positive responses on the job. On the other hand, nursing staff who are unable to conquer the feeling of powerlessness may respond to assignments with statements signifying the subjective state experienced: "We can't do it!" Such staff are unlikely to experience personal and professional rewards and may ultimately leave the health care field. This negative process may be blocked by the manager who assists staff to develop feelings of worth, professional autonomy, and control and who can appropriately handle negative feelings expressed in a group.     

Japan's experience in long-term home health care of the elderly

Due to increasing national health expenditure and an aging society, Japan in the 1980s started to reinforce home health care, going beyond her long-time investment in institutional care. Since 1983, a sequence of policies was issued focused mainly on frail elderly care. In support of this governmental approach, a variety of enterprises and charity activities have flourished. Now, however, in the midst of a worldwide recession, rationing as health policy is under reconsideration and has an influence on health care for minorities, including the elderly. In Japan, home health care is under review and a new service system was initiated in April 1992. In this article, the newly inaugurated community-based home visiting nursing scheme is introduced together with a short history of elderly care and related business activities in Japan. Feasibility of the new scheme is discussed and compared with the previous version of home visiting nursing, which had its base in hospitals.     

Rural Hospital Nursing as an Elective*

A rural hospital elective in a diploma nursing program is described. A need and opportunity for this unique practicum was identified in a Canadian province where one-third of the acute care beds are in hospitals of under 100 beds, located primarily in towns outside of metropolitan areas. The six week course offers students 35 hours of classroom content focusing on rural health care concepts plus a 150 hour practicum in one of three participating hospitals. The course is seen as unique in that it focuses on rural health care and is offered within the context of a diploma nursing program. Vive student outcomes are identified: awareness of the differences between rural and urban health care; integration of knowledge and experience from previous nursing courses as it relates to the rural context; increasing understanding of how rural population groups affect health care delivery; awareness of rural employment opportunities; and, preparation for the graduate role. A shared vision and collaborative effort on the part of the School of Nursing, the rural hospitals and the host communities has been necessary to establish and maintain such a course.     

Moral hazard in nursing home use

Nursing home expenditures are a rapidly growing share of national health care spending with the government functioning as the dominant payer of services. Public insurance for nursing home care is tightly targeted on income and assets, which imposes a major tax on savings; moreover, low state reimbursement for Medicaid patients has been shown to lower treatment quality, and bed supply constraints may deny access to needy individuals. However, expanding eligibility, increasing Medicaid reimbursement, or allowing more nursing home bed slots has the potential to induce more nursing home use, increasing the social costs of long-term care. A problem in evaluating this tradeoff is that we know remarkably little about the effects of government policy on nursing home utilization. We attempt to address this shortcoming using multiple waves of the National Long-Term Care Survey, matched to changing state Medicaid rules for nursing home care. We find consistent evidence of no effect of Medicaid policies on nursing home utilization, suggesting that demand for nursing home care is relatively inelastic with respect to public program generosity. From a policy perspective, this finding indicates that changes in overall Medicaid generosity will not have large effects on utilization.     

Problems of organizing home nursing

Nursing has been practiced for centuries. Public health reformation suggests further development of nursing care, particularly at the level of primary health care, and improvement of the status of a nurse in the society and her role in the public health system. Outpatient forms of nursing care are regarded as the most effective nurse's services. Nurses' functions within the framework of primary health care are extended to include therapy and diagnosis, rehabilitation, medicosocial care, and disease prevention. The main tasks in the development of nursing are improvement of the quality of nurses' services, renaissance of the charity traditions, increase of the profession prestige and improvement of training.     

Health care and secondary access to care inequalities

The role of health care inequalities in social inequalities in health should be reconsidered since the quality of health care varies according to the social status. Some of the health care inequalities are constructed by not taking account of health inequalities in the development of programs or recommendations of medical practice and thus ending up with management procedures that do not reduce inequalities to a minimum but even contribute to increasing them. Other health care inequalities are due to omission, linked to the operating inertia of a health care system that does not recognize these inequalities and has no plan to catch them up. To reverse this situation it seems necessary to act at the three levels of the health care system: to change the clinical paradigm at the micro level, tackle the organizations issues at the meso level, and pursue the reform of the entire health care system at the macro level.     

A nursing home rotation in a family practice residency

A nursing home rotation can be a complementary component of geriatrics education in a family practice residency curriculum. Using nursing homes in teaching geriatrics has been done for some time but has of late received more emphasis. This increasing emphasis has been brought about by the growing health care needs of an aging population and a concomitant focus on education in geriatrics. If implementation of a nursing home rotation is contemplated, both the positive and negative aspects of such action as it relates to the residents, the nursing home, and the nursing home patients should be explored. The rotation as incorporated into the geriatrics curriculum of the Family Practice Residency, Knoxville Unit, University of Tennessee College of Medicine, involves all second-year and third-year residents in the medical care for patients of a 222-bed long-term care facility. From an educational standpoint, overall evaluation of the rotation reflects satisfaction. The experience exemplifies personal and comprehensive continuity of patient care. Other educational benefits include desensitization to the nursing home environment, understanding the kinds of medical care that can be delivered in this setting, and appreciation for the cost not only to the patient and the family but also to the medical care system as well.     

Caring for the infirm: a task for the individual or for a social insurance programme?

In West Germany, seventy per cent of all nursing home patients receive only a pocket-money, for social health insurances are responsible only for the care of "sick" people, but not of those needing only "care". The infirm individual, however, rarely can pay for the costs of nursing homes out of his own revenue. Despite general agreement that guarding against the financial risks of becoming dependent on nursing is insufficient there is little consensus on what a new concept should look like. Some proposals are more concerned with avoiding cost-expansion than with effective health care. On the one hand, the implementation of a new branch in the social insurance system, called "nursing insurance", is demanded, which would pay for the stay in nursing homes. On the other hand, it is emphasized that the capacity for voluntary individual provision should be strengthened as well as the families' means to care for their bedridden members. This paper presents the discussion and outlines implications for health care of the various proposals.     

Older women and health: an overview

Older women's health issues are unique. There are more older women than ever before. They are living increasingly longer than men, yet they report more acute and chronic illness and disability than men. They are disproportionally represented in nursing homes, since many women are alone: twenty-five percent aged 70 or over have no living children and over 60 percent of older women are widowed, divorced, or single. Older women have fewer personal financial resources for health care than men. Health care reimbursement does not meet their needs for financial coverage of chronic outpatient and nursing home care. They face age and sex discrimination on the part of many health care providers and are subject to a growing tendency to be seen as "burdens" and "problems" in the American health care system.     

Bed-blocking. Discharge of the late brigade

Delayed discharges are seen as a litmus test for how the whole health and social care system is working. The problem has been exacerbated by delays in developing intermediate care schemes. There has been less use of the private nursing homes for intermediate care than envisaged a year ago, possibly because of NHS concerns about standards. More support should be given to people with chronic conditions to keep them out of hospital.     

An alternate level of care, the prospective payment system and the challenge of extended care

Due to demographic, morbidity and public policy shifts, the health care system is undergoing a profound change. In this unsettled context the problem of the alternate level of care (ALC), or sub-acute care, patient has acquired a new meaning and importance. An ALC patient falls between the traditional levels of acute and skilled care. This study tries to identify the nature and scope of the ALC problem in Illinois, because it is symptomatic of changing morbidity patterns; because it exemplifies the consequent dilemmas for the health care industry; and because it typifies the ambivalent response of the health care institutions. The data reveals that the ALC patients are backed up in 78% of the hospitals in the state, and they pose a heavy burden and future risk both to hospitals and nursing homes. The hospital industry has sensed the challenge of extended care, but it is not responding with a reasoned and concerted strategy. Rather, in a worsening competitive situation, a unique opportunity to bridge the hiatus between acute and long-term care, and to build towards a humane and equitable system of care, may pass us by.     

Comprehensive health care for the aged and initiatives for an insurance for care in Germany

The traditional German health insurance system covers a broad variety of needs for health care provision. However, parts of the German population are at a disadvantage. No adequate coverage is accessible to those individuals, who need more than medical care: to long-term patients, to people with handicaps and functional impairments, to those, whose condition requires rehabilitation, nursing, and promotion due to a functional disability. One of the groups mostly affected by the shortcomings of the health insurance system is the growing aged population, especially the very old and among them the chronically disabled. This contribution is a review of the attempts to introduce a new insurance for care (Pflegeversicherung). The range of these insurance plans is analysed in consideration of the increasing need for comprehensive health care.     

Demografischer Wandel als Chance für die Gesundheitswirtschaft

Further demographic change in Germany is “preprogrammed”. With the increasing number of older people, the range of illnesses within the population will shift, thus, resulting in an increased number of multimorbid persons. From these two developments, a further increase in the demand for medical supplies and health services is expected. Thereby, diverse opportunities for healthcare management are associated with the creation of a health-related supply of goods and services taking into account the effects of demographic change. As measured by the number of employees, health care is already the largest economic branch in Germany. For health care workers, a number of opportunities are associated with qualification and professionalization as well as increased cooperation of occupational groups and multidisciplinary work by the changing demands in health care and nursing care of the aging population. Particularly personal or household-related services in the care of old and sick people harbor the potential for more employment.     

个性化护嘱制度在保健工作中应用价值探讨

目的评估个性化护嘱制度在保健工作中的护理价值。方法采用自身前后对照的方法,比较个性化护嘱制度在干部病房实施前后对护理质量的影响。结果个性化护嘱制度在干部病房实施前后比较,护理质量有明显差异(P<0.05)。结论个性化护嘱制度有利于提高护理质量,有利于高质量地完成保健工作。     

人文关怀在肿瘤专科带教中的应用

随着护理模式的转变,如何将人文素质教育渗透于肿瘤专科护理带教中,是一个值得探讨的问题.＂以病人为中心＂的整体护理理念已逐步完善,人文关怀更是肿瘤专科护理必不可少的因素,人文关怀的能力只有在进入临床之初就开始实践,才能帮助护理实习生更好地适应未来健康服务系统改变的趋势,充分发挥临床带教的价值.