The Composition Of Old Age Homes in South Africa in Relation to the Residents and Nursing Personnel

This research project is the first phase of a larger study aimed at describing and exploring the cost-effective utilisation of nursing personnel in old age homes in South Africa. The aim in the first phase was to describe the composition of the residents and nursing personnel of old age homes in South Africa. An explora­ tory and descriptive survey was con­ ducted and the data was collected by means of a questionnaire. The ques­ tionnaire also included data on the finan­ cial implications of utilising professional nursing personnel to manage the care of the frail residents/older persons in old age homes in South Africa. The ques­ tionnaires were mailed to 612 old age homes published in the Hospital and Nursing Yearbook of 1997 (100% sam­ ple). A total of 145 (23.69%) question­ naires were returned and included in the descriptive data analysis. The residents are mainly female (77%), older than 85 years of age, belong to the white race group (83,74%) and are highly depend­ ent on nursing care and supervision (69,7%). Old age homes are mainly man­ aged/controlled by welfare organisa­ tions and lay health care workers are utilised to a large extent (42,22% of the nursing workforce) to render nursing care to the frail residents. The cost-ef­ fective utilisation of nursing personnel (registered and enrolled), as well as the utilisation of lay health workers in old age homes, needs to be critically examined.


Introduction
Ageing is a world wide phenomenon, which makes heavy demands on a vari ety of service delivering action to persons who are not anymore economically vi able.The 1991 census indicated that 4,7% of the total South African popula tion (approximately 1,8 million people) in South Africa are 65 years and older.It is a generally accepted policy that all older people / elderly should remain in the community as long as possible with the aid of home care services and other support to the family.Unfortunately these support services are still grossly under developed and not available in most ar eas of South Africa.This situation puts a strain on the care of the elderly in the community.It is estimated that 2,5% of the South African older population will be in need of institutional (old age home) care, even if all the mentioned support systems are in place, because they are frail and / or destitute (Van den Heever, 1998;Erasmus 1995:176).
Old age homes came into existence in South Africa within the social work do main because of various social problems in c lu d in g loneliness, e c o n o m ic and housing problems, deteriorating mobil ity of the older persons and lack of fam ily and other support systems for them in the community.Welfare and church organisations, m ainly from the white population groups, developed institu tional care within their own cultural back ground to take care of their older peo ple.The population of older people in old age homes changed over the years as the residents became older, more frail and in need of nursing care.
The W hite Paper fo r S ocial W elfare (South Africa, 1997) and the Aged Per sons Amendment Act (South Africa, Act No. 100 of 1998) Stipulates that only frail older persons may be admitted to sub sidised beds in old age homes.The nursing care of older persons in old age homes differs from the hospital-based, curative model of health care where the emphasis is placed on short term care and early discharge.Gerontology and geriatrics are considered part of com munity nursing because of the long term involvement of nurse and patient and the holistic nature of the relationship.The old age home becomes the "home" of the frail older person as his/her stay is extended.The nursing care of the frail in old age homes became increasingly a health service m anagem ent problem within a social work milieu.A pilot study was conducted on five old age homes to test and refine the ques tionnaire as well as to confirm the face validity of the instrument.No problems were indicated during the pilot study and the questionnaire was also discussed with experts in the field for additional comments.The questionnaire was trans lated in both Afrikaans and English and then prepared to be mailed to the man agers of the old age homes.Due to the basic nature of the data required, statis tical reliability and validity of the ques tionnaire was not determined.
The target population for the study fo cuses on registered old age homes in all nine provinces of South Africa.The published list of names of old age homes in the Hospital and Nursing Yearbook 1997, which was compiled by the Na tional C ouncil fo r the Aged, was re garded as the population for this study.Address lists were also asked from vari ous provincial offices of the Department of Welfare as well as from welfare organi sations.It was clear during this phase that there is a lack of reliable address lists due to the closure of many old age homes.It also became apparent that many existing old age homes were not listed on the national database.The re searcher therefore decided to utilise the total available population as the sample (100%).The number and distribution of old age hom es in South Africa is shown in table one, including the sam ple realisation.
A total of 612 questionnaires were mailed to the managers of old age homes dur ing the first week in February 1998, with the request of com pletion and return within six weeks.Questionnaires were coded to indicate the province and reg istered old age home without any refer ence to the name of the old age home.A total of 145 (23,69%) completed ques tionnaires were received up to the end of May 1998.These questionnaires were representative of the nine provinces and type of m anagement/control, and was therefore accepted as the sample used in this study.A relative smaller sample was also acceptable as no correlational statistical analysis were planned.An accompanying letter, addressed to the management board, was included to ask permission for completing the question naire and to give information regarding the research project.The original popu lation list did not give any indication of the controlling organisation, therefore the managers were requested to gain permission from the relevant controlling body before com pleting the question naire.Where this information came to the knowledge of the researcher, the spe cific organisations were addressed to ask permission for the old age home's manager to participate.Only one wel fare organisation reacted negatively to wards this request.Participating old age homes generally reacted positively re garding the research.A few managers (N=32) returned the questionnaires w ithout com pleting the section on fi nances as they regarded this as confi dential and some (N=6) returned the questionnaires back without completing them because they were of the opinion that the inform ation requested on fi nances was confidential.

Results
Completed questionnaires were coded and processed by two independent stat isticians on the STATS and the SPSS computer software programmes for sta tistical analysis.Descriptive analysis was conducted without any complex infer ences or manipulation of the data.The relevant results relate to the organisa tions in control of old age homes, the nature and scope of management, the size (number of beds) of the old age home, the dependency levels of resi dents, age distribution and cultural back ground of the residents.The nature and scope of the nursing personnel in terms of their registration or enrolment level, was also determined.

Organisations in control of old age homes
It seem s th a t W elfare o rg a n isa tio n s (NGO's) are mainly (44,06%) involved in the welfare and care of frail older peo ple in old age homes (N=63).Church organisations control a quarter (25,17%) of the old age homes (N =36), while societies for the aged (N= 1 9; 13,29%) and private enterprises (N = 18; 12,59%) have almost equal interests in old age homes.Only nine (5%) of the respond ents indicated that the old age home is run by other organisations, like family enterprises or utility companies.Welfare and church organisations are involved in a variety of services, whereas the so cieties for the aged are solely focused on the older people.The societies for the older persons aim at keeping them in dependent in the com m unity and are perhaps for this reason not the most pertinent controlling bodies of old age homes.The small percentage of private enterprises involved with old age homes (frail care) confirms the view that frail care is a very costly service which limits profit making.The lack of compensation from medical schemes for long term care out of hospital, may possibly also influence the limited interest of private enterprises in frail care.Some private old age homes indicated that the residents of retirement villages associated with the old age home (frail care unit) are responsible for cross subsidising the old age home because of the assurance that they will receive first priority to be admitted to the old age home should they become in firm.
Welfare and church organisations, jointly in control of 69,23% of old age homes (N=99) in this study, are receiving funds from government subsidies, fundraising in the community and limited payments by the residents.It seems as if these organisations were the hardest hit by the cut in government subsidies to old age homes.It became clear from feedback received from old age homes who re turned uncom pleted questionnaires, that the restricted funds is the reason why ten of the old age homes opted to close down, while 11 others converted the old age homes to assisted living ar rangements without nursing care or su pervision.

Managers of old age homes
Professional nurses were the managers at most (N = 62) of the old age homes (43%).This trend was noticed by differ ent organisations in control of old age homes.Although no statistical significant d iffe re n c e s w ere n o tic e d (p-valu e =0,0474), it seems as if ministers of re ligion and social workers were manag ers in old age homes where most of the residents were more self-caring.
Evi dence was found that professional reg istered nurses were appointed as man agers in larger old age homes where the residents were frail and in need of nurs ing care.

Size of the old age homes
Just more than half (N=74) of the old age homes (51%) had less than 70 registered beds.The smallest old age home had 17 beds and the largest had 500 registered beds.The largest per centage (30%) of old age homes (N= 44) had between 45-70 registered beds and only 10% had more than 150 beds (N = 14).Eighteen respondents indi cated that they had no beds registered for sub-econom ical residents and did therefore not receive any funds in the form of subsidies from the government.On the other hand 39 (26,9%) respond ents indicated that all their registered beds were used for poor older people and that they received a governm ent subsidy for these residents.The number of vacant beds was small (0,06% of the total of 12208 registered sub-economi cal and private beds).Eighty six old age homes had no vacant beds.From en quiries at old age homes it seems as if most of them had long waiting lists and Curationis March 2000 89 that vacant beds were filled very quickly.

Dependency levels of residents/older persons
The resident's physical, mental and so cial situation is assessed to determine the level of care needed.The support systems available to the older persons in the community who are in need of help to fulfill the activities of daily living (eat ing, dressing, personal hygiene, bathing, toileting and mobility), as well as the need for medical and nursing care, are taken into consideration to determine the level of dependency and the necessity for admission to an old age home (De partment of Health and Welfare, 1987:30; Van den Heever 1998).The levels of dependency are grouped into the follow ing three groups: group one refers to the group on self care, group two needs a minimum of nine hours of nursing care per week and the third group requires full time nursing care for 24 hours of the day.Since April 1997 only group three older people are adm itted to old age homes and the remaining two groups who were residents in old age homes are to be phased out in a matter of tim e (South Africa, White Paper, 1997).Fig ure one displays the graphic presenta tion of the dependency levels of resi dents of old age homes.
A small percentage (8,4%) of the resi dents (N=959) are self-caring (group one).The m a jo rity of o ld e r people (N=7929) in old age homes (69,7%) are frail and categorised as group three residents.Increasing frailty of the resi dents of old age homes leads to more com p lica te d care delivery w hich be comes more labour intensive as far as nursing care is concerned.Nursing care plans are adapted to aid the older per son with impaired functions to fulfill the activities of daily living.Wicht, Prinsloo, Skibbe, Lombard and Lombard (1989:1) found that the frail older person on aver age suffers from three different chronic diseases, but up to nine pathological conditions can be found in one ind i vidual.This implies that large quantities of medication are administered to the older people in old age homes and that more specialised nursing responsibilities are placed on the caregivers.

Gender of residents in old age homes
The residents are mainly (77%) female (N=8273).Although the male residents are in the minority (N=1948), they rep resent never the less almost a quarter (23%) of the residents and may need special consideration as far as gender sensitive care is concerned.From this study it was evident that old age homes with residents mainly from the traditional d is a d v a n ta g e d p o p u la tio n g ro u p s (mainly Black) had a larger percentage of male residents.This finding correlates with the fin d in g s o f Ferreira, Moller, Prinsloo and Gillis (1992:33) that Indian, Coloured and Black population groups consist of slightly fewer females in the age group older than 80 years compared to the White population.From conversa tions with social workers of the Depart ment of Welfare, it appears that the older women in traditional black families are easier integrated within the family life and that they are sharing responsibilities within the family.The black older men are not as easily accommodated by the fam ily when they become frail and in need of more care than the family is able to provide.Adm ission to an old age home becomes a reality to these older men if they become incontinent and very frail.

Age distribution of residents in old age homes
A high age does not necessarily imply frailty.The physiological changes asso ciated with ageing, however, may cause an increase in chronic diseases and the a ccom pa nie d need fo r m edical and nursing assessm ent and m on itoring (Wicht et al 1989:1).The age distribu tion of the residents in old age homes is displayed in figure two.
From figure two it is obvious that the resi dents of old age homes are very old.Advanced frailty and the presence of chronic diseases already necessitated the admission to old age homes and cat e g o ris in g m ost (N = 7929) o f th e residents (69,7%) as group three resi dents.

Cultural background of residents and nursing personnel
The care of the older p eo ple in old age homes takes place in a particular cu l ture which had been the collective result of the cultural back ground of residents, m a n a g e m e n t and p e rs o n n e l.
The n ursing personnel moves in and out of this " acquired c u l ture" within the spe cific old age home, b u t th e re s id e n ts who are already frail, are in m ost cases According to Brubaker (1996:28) com munication between nursing personnel and residents are of great importance to assess the individual's needs.The older person wants to be informed about the daily development and routines related to his/her care (Brubacher 1996:26).W ithout sufficient com m unication be tween the caregiver and the resident it may be possible that the resident's in put and contribution towards individual ised care will be limited or ignored.The resident then becom es a passive re ceiver of institutionalised care without the right and privilege of personal care aimed at meeting real individual needs as communicated by the resident to the caregiver.Inability to communicate leads to sem antic confusion and m isunder standing.The caregiver then tends to come to her/his own conclusion about the needs of the frail resident and more often only focus on the obvious physical needs.The older person as a whole person with bio-physical-mental-social needs lack the necessary holistic care.
A ttention is then paid to care needs which had been formulated unilaterally by the personnel without taking the resi dent's wishes and preferences into con sideration.
It was found in this study that the home language of the nursing personnel and the residents differed considerably.The same trend was noticed regarding the population groups of (see  It was also evident that 43,3% of the old age homes (N=63) admitted older people from all population groups, al th o u g h th e m a jo rity of re sid e n ts (N = 8545) were from one particular population group and corresponding language orientation.In the Western Cape province more than half (58,97%) of the old age homes (N= 23) admit ted older people from all population groups in South Africa.At the 14 old age homes where only Coloured, Indian and Black residents are accommodated, the population groups and language orien tation of the nursing personnel and resi dents corresponded.

The composition of the nursing personnel establishment in old age homes
Nursing personnel are appointed in old age homes to take care of all the needs of the frail residents.The correct skills mix is necessary to ensure that quality care and a cost-effective service is deliv ered.Five categories of nursing care personnel can be differentiated in the old age homes if the levels of training and the legal scope of practice of nurses in South Africa are taken into considera tion.All the categories, except the lay workers, received training according to regulations of the South African Nursing Council (SANC).These categories are as follows: a) Registered It is quite clear that registered nurses are crucial in the quality of the care of frail residents of old age homes.The circu lar no 7 of 1994 (Department of Welfare, A d m in is tra tio n : H ouse of A sse m bly 1994:3) recommended that registered nurses should compose 33% of the nurs ing personnel in old age homes where 75% of the residents were group three (frail) and that 50% of the rest of the nursing personnel could be lay workers.
It appears that the overall serious short age of registered nurses in old age homes is critical at some old age homes.Five (0,03%) old age homes indicated that they had no professional registered nurse on the staff estab lish m en t al though they took care of frail older per sons.Sixteen old age homes (11,03%) had only one registered nurse and 30 (20,69% ) had two registered nurses on the personnel establishment to take care of a 24-hour based frail care service.The average ratio registered nurse to regis tered beds in this study was 1:23,71.The median was 1:20 and 3,6% of the re spondents indicated this ratio.A CHIsquare analysis on the p-value of 0,05 in d ica te d no s ig n ific a n t d ifferen ce s amongst the nine provinces on this item.Small differences were dem onstrated amongst the five service organisations where private organisations had the low est ratio (1:11,8) and church organisa tions the highest (1:18,2) in old age homes where both group two and three residents were cared for.The accepted norm is a ratio of 1:15 (registered Nurses to frail residents) which was the case before 1994 (Du Rand, 1993:13).

Conclusions
The following concluding statements are made: • The realisation sample of 145 (24%) resp on de nts (m anagers of old age homes) could be seen as representa tive of the 612 old age homes in South Africa as published in the Hospital and Nursing Yearbook 1997.
• The existing database of the Depart ment of Welfare regarding registered old age homes in South Africa is outdated.
• The majority of old age homes are located in Gauteng, Western Province, Free state and Kwazulu Natal.
• Welfare organisations are in control of most (44,06%) of the old age homes in South Africa.
• Most (42,66%) of the managers of old age homes are registered profes sional nurses.
• Residents of old age homes are highly dependent on nursing supervision and care as 69,7% are classified as group three frail residents/older persons.
• Most (77%) of the residents are fe male.The males are, however, a sig nificant group (24%) who need special gender-sensitive care.
• The residents of old age homes are very old as 41,9% are older than 85 years.
• Communication problems between the residents and nursing personnel could develop due to different home lan guage orientations.
• Most of the residents in old age homes in South Africa at the time of the study were white (83,74%) whilst more than half (51,11%) of the nursing personnel were black.
• A serious shortage of registered pro fessional nurses prevails in old age homes resulting in an unacceptable low ratio of registered nurse in relation to the residents and registered nurse in rela tion to the other nursing personnel (en rolled category/lay health worker).
• Lay workers (unregulated geriatric caregivers) with no formal nursing train ing, constitutes 42,22% of the total nurs ing workforce in old age homes in South Africa which is unacceptably high for frail care.

Recommendations
The fo llo w in g reco m m en d atio ns are made: • The relationship between cost-effec tiveness and quality of frail care in old age homes should be determined.

Concluding Remarks
A complete and reliable database is nec essary for the development and formu lation of policy.The database provided in this study could contribute signifi cantly to the development of national policy regarding the care of the frail older people, not only in South Africa, but also in the whole of Africa.The process of transformation in relation to the com po sition of old age homes in South Africa, needs to be carefully monitored.Due to the high costs of frail institutionalised care, the empowerment of the comm u nity in taking care of their elderly, in a cultural sensitive manner, should also receive attention.The rights of the eldery must, however, also be respected.

Figure
Figure 1 : D ependency levels of resid en ts in Old A ge Hom es (N = 145)

Figure
Figure 3 : Com position of th e Nursing Personnel in Old Age Hom es (N =145)

ab le 2: T h e hom e language and population groups o f resid en ts and nursing personnel in old ag e hom es (N = 140 Old Age Hom es)
table two). T • The utilisation of lay workers in the care of frail older people should be criti cally evaluated.* The affordability of registered profes sional nurses in old age homes should be investigated.* The responsibilities of registered pro fe ssio n a l nurses in old age hom es should be appraised to justify the cost implications.* Guidelines for the cost-effective utili sation of registered professional nurses in old age homes should be formulated.* Communication skills and cultural sen sitivity should be included in the training courses of nursing personnel in old age homes.