Health care needs of older people living permanently in a residential home setting in Gauteng

Abstrak This article reviews some of the prevailing health needs of elderly people living permanently in a residential old age home. A qualitative, exploratory and descriptive design was employed. Twenty-one black elderly peo­ ple were purposively selected to participate in a focus group interview session for the purpose of describing their perception of their health care needs. From de­ scriptive content analysis, three main data sets emerged, namely physical health needs, unmet psychological needs and the need for a healthy social relationship. Recommendations to deal with these health needs were made based on the empirical data supported by litera­ ture. Measures of trustworthiness were ensured as de­ scribed by Lincoln and Guba (1985:316-327). Hierdie artikel kyk na die algemene gesondheidsbehoeftes van bejaardes wat permanent in ‘n ouetehuis bly. ‘n Kwalitatiewe, verkennende en beskrywende ontwerp is gebruik. Een en twintig swart bejaarde persone is met ‘n bepaalde doel geselekteer om aan ‘n fokusgroeponderhoudsessie deel te neem, naamlik om hul persepsie met betrekking tot hulle gesondheidsorgbehoeftes te beskryf. Uit die beskrywende inhoudontleding het drie stelle hoofdata na vore gekom, naamlik: die fisiese gesondheidsbehoeftes, onbevredigde sielkundige behoeftes en die behoefte aan’n gesonde sosiale verhouding. Aanbevelings om die behoeftes te hanteer is gedoen gegrond op die empiriese data ondersteun deur die literatuur. Betroubaarheidsmaatreëls is verseker soos wat Guba en Lincoln (1985) dit beskryf.


Introduction
The old age home in question was established in 1988 in response to the concern of the community for meeting the comprehensive health care needs of the aged.The purpose of the institution is to meet the health care needs of the aged and to offer refuge to the destitute and extremely in firm elderly.Therefore, they admit and accommodate eld erly people with no accommodation, who are destitute, abused and handicapped with no care giver and those who are extremely infirm.
It is traditionally an honour to have an elderly person in the family who is looked upon as a rich source of knowledge, skills and values among the black community.The pres ence of an elderly person enhances the dignity and respect of a family.With the current political, economic and social changes, the black community is inclined to adopt the Western culture where children take their elderly people to the nursing homes to live there permanently.They are re lieved when an institution takes over the responsibility of the family, not realizing that their cooperation with the nurs ing staff is still very important.Some children pay them a visit, but some never do (Recitikainen in ICN, 1999:63).This situation raises some concerns especially among the black people, who regard elderly people as the roots re sponsible for the transmission of culturally-based knowl edge, beliefs, customs and values.Older people in nursing homes generally lack family support.According to the Pa tients Rights Charter as guaranteed in the Constitution of the Republic of South Africa Act (Act No 108 of 1996), everyone has the right to a healthy and safe environment that will ensure their physical, mental and social well-be ing.They have rights of access to health care services that include a positive disposition displayed by health care workers who demonstrate courtesy, human dignity, pa tience, empathy and tolerance.
The health-related problems that exist in old age homes are of concern to the community and the health care services as a whole.It has been projected by ICN (1996:60) that by 2020, the population of older people in developing coun tries will rise by nearly 240% from the 1980 level due to a rapid decline in fertility, and there will be a longer life ex pectancy due to the use of advanced technology and medi cation.An estimation based on the 2001 census statistics in South Africa, shows that a total of 6,6% of the total population in Gauteng province to be older than 65 years.Of this total, older people who are white constitute 43,1%, blacks 51 %, Indians 2,5% and Coloreds 3,1%.Life expect ancy in Africa is 52 years compared to 63 years for South African population and 74 years for the developed coun tries.It must be noted that the health of the entire S A popu lation has improved significantly, but the black population have not yet reached their optimum life expectancy (Hattingh;Van DerMerwe;Van Rensburg & Dreyer 1996:57-58).This is evidenced by the overcrowded old age homes, so much so that most of the elderly people cannot be ac commodated in the institutions and they are therefore left with no choice but to live with their families.According to the researcher's observation family members sometimes lock the elderly people in the house when they go to work since they have no one to care for them.
The health needs of elderly people living permanently in a specific old age home became a concern of a nursing de partment at a university in Gauteng.A project was initiated in 1998 where post-basic nursing students doing commu nity nursing science undertook a project to provide 'serv ice learning' to the elderly people by performing physical examinations, giving health education and physical exer cises.The identified problems were referred to the doctor at a nearby clinic.This prompted the need for research to explore the health needs as perceived by the elderly people themselves and to make recommendations to deal with the problems outlined.
Elderly people are prone to develop age-related physical, psychological and emotional conditions.They have poor functional disabilities, dementia and the lack of family sup port (Reconstruction and Development Programme, 1994).There is a real need for students placement opportunities to carry out constant physical examinations and provide psychological and emotional support to meet these healthrelated problems and to elevate their morale (Lockey, 1999:21).
The purpose of the study was to conduct qualitative, ex ploratory and descriptive research that would establish the perceived health needs of the older people living perma nently in an old age home with the aim of making recom mendations for dealing with these health problems.The following research question was used to guide the study: "What are the health care needs of the aged living perma nently in an old age home and how could nurses meet these health care needs?".
To meet the purpose of the study, the following research objectives were realised: • To explore and describe the health needs of the aged living permanently in an old age home in Gauteng.

•
To make recommendations to meet the perceived health care needs of the aged living in an old age home.

Terminology
Some confusion arises from terms used outside the context within which they are defined.The terms health, health care needs, older people and old age home are relevant to the study.Health The good health of an older person is defined in terms of Curationis the ability to function autonomously within a given social setting.If socially and intellectually active, the older per son may be considered healthy even in the presence of chronic disease.The health of an older person is best measured in terms of function rather than pathology (ICN, 1999:60).

Health care needs
A need has been defined as an individual ability to benefit from a specific health care intervention (Steven and Roberts in Vernon, Ross & Gould, 2000:284).Health care needs are potentially limitless, especially when competing for stretched resources and evidence-based care within a pri mary health care approach.

Older people
People who cross the 60-year threshold are regarded as older people, with the proposal that 65 years and older is the norm for old age.The age composition in our society is changing at the same rate or at an even faster rate in the future (ICN 1999:60;Hattingh et al 1996:56).

Old age home
This is an institution where older people are cared for.The goal of this care is to assist older people in achieving opti mal health, well-being and quality of life, as determined by those receiving care or consistent with the values and known wishes of the individual (ICN, 1999: 61).It is an institution established and registered to provide accom modation to, and care of, aged or debilitated people (Aged Persons Act, Act No 81 of 1967 -as amended).

Research method
An exploratory, descriptive, qualitative design was used to explore the health care needs of elderly people living per manently in an old age home in Gauteng (Mouton & Marais, 1990:32).The old age home consists of 97 elderly people 75 of whom are women and 22 are men.Their ages range from 60 years to 100 years with a mean of 74.Some have lived in the old age home for 14 years.
A student facilitator, who is an elderly person herself, purposively selected a sample of 21 elderly women and 6 men.The selection was made from those classified in group one, that is, those who are healthy and independent.This made the collection of data far more enjoyable as someone of their age group who understood their health care needs better conducted the focus group interview.The partici pants were requested permission to participate in the study a day before the interview and verbal consent was obtained.
Written permission was also obtained from the manage ment committee of the institution.A tape recorder was used with their permission.Three people were involved in the data collection.Two facilitators who were of the partici pants' age group, one of them led the focus group inter view.Another facilitator helped with the clarification of questions and the exploration of responses in order to ob tain in-depth information while using humour to ease the climate.The researcher's role was to gather as many field notes as possible to enrich the data.The following criteria were used to determine eligibility for participation in the study: • 60 years and older; • healthy; • able to communicate freely in own language; • orientated with regard to person, time and place; and • complete voluntary participation.
The participants were informed that they could refuse or refrain from answering the questions at any time.They were assured of confidentiality and anonymity.The central re search question asked was: "What are your health care needs as residents of this home and how could nurses who come on Thursdays meet these needs?"The interviews lasted for 2 hours and 30 minutes due to the relaxed atmos phere which included humor.Data was collected until satu ration was reached.The data was analysed by using the open coding method of qualitative data analysis as de scribed by (Tech's in Creswell 1994:154-155).The two tapes were transcribed verbatim and translated into English by the two facilitators.An external coder, who was also purposively selected, was requested to analyse the data using the same protocol.Lincoln and Guba's (1985:316-327) method of ensuring trustworthiness was used in ac cordance with the four principles, namely credibility, trans ferability, dependability and conformability.
referrals to the doctor at a nearby clinic under the supervi sion of the facilitator.Surprisingly, most of the participants indicated that they had varied physical problems that are not identified and treated, such as constipation, insomnia, lack of appetite and chronic diseases.The following cita tions indicated the participants' perceptions: "At present my major problem is my tummy.I am always constipated.
Nurses will always say that I must drink lots of water and exercise so that my tummy can be loose, but they will not show me how to do it.I am tired of people just talking".
"The constipation has given me piles in that my whole body is affected." "Yes, I need help because I eat well but I am unable to pass a stool.What helps me is the muti from the veld that I got".
"I have no appetite, and this is how I live." "I have been suffering for a long time now.I was told that I have asthma, rheumatism, high blood pressure.. .eh!... there is no illness that I have not suffered from, even cramps." "I have headaches, dizziness and backache.This is the work of a devil.""I have no strength, I feel weak.I have poor eyesight and that is why I use a walking-stick as a pathfinder.I also cannot sleep well at night.Hawu!I become restless through the night and if I am awake I think all along."

Results
Three main categories and sub-categories emerged as fol lows: physical health needs, psychological needs and healthy social relationships, as indicated in table 1.

Physical health care needs
Community health nursing students are placed in old age homes for their experiential learning.They provide health care services, such as physical assessment, and they make Nurses should not lose sight of their role in geriatric nurs ing care.They should provide a wide range of health serv ices, including health promotion, illness prevention, reha bilitation, acute/chronic care and palliative care.Achiev ing the older people's optimal health, well-being and qual ity of life is the ultimate goal of geriatric nursing (ICN, 1999:61).Geriatric nursing is increasingly acknowledged as a nursing specialty included in the basic nursing courses that equip nurses with the specific professional knowledge, skills, attitudes and values to be able to provide quality nursing care to the older generation (ICN, 1999:61) The community nursing curriculum empowers students to provide holistic quality health care, but when it comes to the actual delivery of that care, the opposite occurs.Do nurses and staff undermine the quality of care to be given to older people?Is it that the said curriculum does not challenge students in the case of the elderly?Does the problem lie in the implementation of the said curriculum?Is it in the effective way of clinical accompaniment?Is it a question of low paid salaries, poor conditions of service and poor staffing in the old age homes?Where do we go wrong?These questions are serious and need to be ad dressed by management and nurses themselves.
As stated by Lockey (1999:17), low pay devalues the role of the nurse and other key workers and may have a marked effect on standards of care because it is often linked to a lack of investment in education and training, and a high staff turnover.Some institutions employ low level training personnel to provide care.Lockey states that diluting the skills mix by using cheaper and more flexible workers as a substitute for nurses has an adverse effect on the quality of care and it is not an efficient or cost-effective solution to the problem.Lockey's argument (1999:18) is that relevant authorities should offer an attractive and realistic work pack age, review the conditions of service, reconsider staffing levels, offer better training facilities, and support students and nursing staff in their professional development to im prove the quality of care in nursing homes.
With reference to staffing, the participants indicated that most of the time it was the matron who spoke to them.When she was off duty, they were left with less experi enced staff who were not supportive.Quality of care may also be affected by lack of resources: " ... as you can see, our beds are falling down.They are old.Quality of food is poor".Lockey (1999: 18) states that 61% of nurses in nurs ing homes carry out a wide range of non-nursing duties and 48% of homes do not have adequate equipment such as transport to take the older people to clinics or any other referral, such as eye testing.Because of the problems expe rienced by the nurses, it is not surprising that many elderly people are not likely to receive the health care services they require.
Nurses are in a good position to improve the health of the elderly and should challenge and enjoy working with this group so as to anticipate their health care problems and needs, employ disease prevention strategies and promote health.The task of the nurse to care for the aged involves not only certain nursing skills, but also the distinctive needs of the aged.Elderly people have very specific needs be cause of their vulnerability (Bridges 2001:34).Their physi cal, psychological and social needs of elderly people make extreme demands on the community nurse (Nursing Act, No 50 of 1978 as amended; Hattingh, 1996:266).To meet the complex health needs of the aged, a multi-disciplinary team approach to the health care of the elderly is manda tory.Such a team approach would, among others, provide the opportunity to develop health-oriented programme, such as exercise for the elderly, to maintain their functional ability to care for themselves and remain independent.These abilities are essential to relieve ailments such as constipa tion and other debilitating diseases (Gonzalez & Jirovec, 2001:46).
Exercise is taboo among black elderly people, especially the women.It is linked to the activities of young adults.The elderly are not viewed as capable of exercising.Older women often have to take care of grandchildren (Modungwa;Poggenpeol & Gmeiner 2000:65), and attend to church commitments (Gonzalez & Jirovec, 2001:47).Johnson (2000:45) states, however, that exercise could im prove the physiological, psychological and cognitive func tioning of the aged.Young generations urge the aged to slow down and "act according to their age" while others strongly believe that the biological changes associated with aging naturally limit the ability to be physically active and to exercise (Johnson, 2000:45).However, recent research indicates that moderate exercise can retard and even re verse the aging process and improve the daily functioning of the aged (Nazarko, 1999).Whatever theories, myths and believes that exist, the value of exercise for the aged should not be underestimated (Hattingh et al, 1996:245).
A collaborative partnership between a coordinating uni versity, other stakeholders and the old age home should not only lead to an improvement in the care of older people, but also promote a better understanding of the education and training needs of nurses working with older people.A well-established and integrated teaching team, including the 'matron' of the home, will benefit from expertise in evi dence-based nursing for older people, nation and interna tional research, teaching networks, and high level links with national policy-makers.Evidence-based training should contribute to a better understanding and foster a change in the culture of nursing older people (Johnson, 2000:45;Davies & Jheeta, 2001:24).
Elderly people and their families should be made aware of their rights and the procedures to follow when they are dissatisfied (Davies & Jheeta 2001: 24).The attitude of health care workers and students should be challenged.Student nurses should be provided with effective educa tion and training to ensure that they are equipped to deal with the specific health needs and demands of older people wherever they might be.

Psychological needs
The main themes that emerged to demonstrate the unmet psychological needs of the older people are depression, loss of trust, forgetfulness, fear, anger and irritability.Peo ple often assume that depression, like cognitive impairment, is a normal aspect of aging.According to Hattingh et al, (1996:144,145), depression is not a normal phenomenon in elderly people.It is characterised by, over and above, a feeling of guilt, boredom, loneliness, difficulty to concen trate, forgetfulness, retarded thinking or speech, overwhelm ing worthlessness and helplessness, exaggerated low self esteem or self-reproach, loss of trust, expressing a death wish and statements about the futility of life.A depressed person will communicate distress and provide answers such as "I don't know" when asked a question.
Indeed, it was sometimes difficult to get answers from the old people, as they would say "I don't know, those who want to talk can talk".Therefore, the interviewer had to probe gently through careful questioning to obtain infor mation about their perceived health needs.Expressing their state of forgetfulness, the participants would say, "I know I look like a fool because I forget easily.You can tell me something now, but within a minute I shall have forgotten, and at night I suddenly remember".Expressing loss of trust, the participants indicated: "We can no longer trust nurses or the clinic.They give us medicines, which are not effec tive.We do not get help so we go and get traditional medi cines from the veld and we get better.All what nurses can do is take blood pressure, temperatures and test urine.Thereafter, they will tell us not to take food with salt and we must drink lots of water.I am stopping here.I do not want to talk anymore".At this stage, the participant expressed anger and irritability.When asked how nurses could help in this regard, he stated: "I don't know.You should know how to help me.I have finished talking to you".Another participant stated: "I cannot stand noise.I feel like being alone, but oh! Sister, I am scared here".
It is stated that aggressive feelings, attitudes and behav iour lead to isolation, deprivation, abuse, distrust and dis respect of the aged.Hattingh et al (1996:97,99) advocate full psychological assessment to determine the fear of the elderly towards the institution; aggressive behaviour; sud den change in moods; talks of suicide; depression; loss of interest, respect and trust; and loss of appetite (Colin-Shaw, 1998).One should make sure that privacy is respected.
Nurses should play their advocacy role and build a respect ing and trusting relationship with the aged.They should be supportive and explore different situations, communica tions and counselling skills.However, nurses must always keep in mind that each older person has the right to make his/her own decision (Hattingh et al, 1996:222).

Social relationship
All the participants expressed their dissatisfaction and dis may at their social relationship.They indicated that they lacked "UBUNTU" and therefore did not live in harmony as evidenced by the following citations: "There is no life in this home.Life here is unbearable.Oh! What can 1 say?".
"Hey!It is difficult to live here.I don't know what to say.I am asking God to help me shut my mouth.People here have no morals and respect for another person.They don't speak to each other unless there are visitors".
"My life is at risk here.This person has insulted me.He is poking his finger in my eyes.I do not like it because once I can become angry, I fight.I have asked that people who are troublesome should not worry me.People do whatever they like in this place.They bang doors and we cannot have a peaceful night.Life is made out of love and respect".
When asked what could be done about this situation, they responded: "Talk to us about 'UBUNTU'.We pray every day for God to help us, but the same thing happens again.
The root cause must be addressed".Another participant indicated: "Maybe if we can be fully occupied with hand work and we do some exercises so that we are preoccupied.
As it is, we sit on chairs, go for meals and come back to the chairs until we go to sleep.So we have ample time to swear and to hate each other".
According to the Parliamentary Bulletin, White Paper for Social Welfare (1997), 'ubuntu' people are people through other people, so the principle of caring for the well-being of others, and the spirit of mutual support will be fostered.Ubuntu refers to the values of "human dignity" (Asmal, 2001;James, Auerbach, Desai, Giliomee, Jordaan, Krog, Kulati, Lehoko, Leibowitz & Tlakula 2001).The group is of the opinion that from the values of ubuntu and human dig nity flow the practice of compassion, kindness, altruism and respect, which are at the very core of making schools places where the culture of teaching and the culture of learning thrive; of making them dynamic hubs of industry and achievement rather than places of conflict and pain.Ubuntu goes beyond quality, because it embodies the con cept of mutual understanding and the active appreciation of the value of human difference.It requires one to know others if one has to know oneself within a multicultural environment.Ultimately, ubuntu requires one to respect others if one is to respect oneself.The need for exercise, respect, trust, physical health needs and the value of ubuntu was evident..

Discussion
The purpose of the study was to explore and describe the perceptions of elderly people living permanently in an old age home in Gauteng with regard to their health care needs.The physical, psychological and social relationship (health care needs) strongly suggested that the nurses should be in possession of specialised, professional knowledge, skills values and an attitude of humanity to provide quality geri atric care.Nurses have to act as advocates, care givers, counselors and educators, and make the difference in the health care of the aged over and above being able to pro vide clinical skills (ICN: 1999:61).
Nurses have the responsibility to maintain their level of competency, raise awareness and be culturally sensitive to create an environment that is safe, warm, friendly, caring and supportive in a creative and enjoyable manner.It must be remembered that the aged themselves, especially black women, generally have no authority to complain about their dissatisfaction with reference to their health care, probably because it is culturally embedded in them not to question authority.They will be content with the little care they re ceive.They rely entirely on the nurse who should act as an advocate to ensure delivery of quality health to the aged.
The following recommendations are made based on the perceptions of the aged living in an old age home, sup ported by literature.The old age home should be inspected several times a year by health authorities to ensure compliance with the old age act, thereby guaranteeing that the home provides adequate service (Lockey, 1999:21).

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A strong partnership model is advocated for a ho listic approach to health care for older people, as indicated in figure 1 (effective partnership model by Gravett 1987:72).
The nurse is responsible for supervising and coordinating all the services, including the human resources manage ment team, the ophthalmologist, the dental therapist, pre ventive forums, mobile clinics, local authorities and non governmental organizations, to provide resources, trans port, funding and recreational facilities.The entire team is responsible for teaching the family members and aides, and for providing physical, psychological and emotional sup port to older people (Hattingh, 1996:216).

Conclusion
With the fast-changing society and the demands for qual ity assurance in clinical nursing education and health care practices, the quality of health care of the aged is highly challenged.The curricula should equip nurses with expert, comprehensive knowledge, skills and values to provide quality health care to older people.Nurses should also be able to establish a good working relationship with the other health care team members, including the family of the older people.
The International Council of Nurses claims that nurses have the potential to be change agents.They have the potential to influence broad debates on global ageing.Nurses have an impact on the political and social environments and can advocate for better health and health services.They should increasingly be involved in meeting the needs of the eld erly and act as advocates and facilitators in policy making, including the allocation of resources within the health and social sciences (ICN, 1999:61).Old age homes need nurses who care and not nurses who abuse and neglect older people physically, psychologically and emotionally.Abuse is utterly unacceptable and we have to root out contributing factors such as -not enough fund ing, overworked staff, victim-blaming management and chance-takers (Anderson, 1999:10).

Table 1 .
Hypertension and diabetes prevalence is rapidly increasing in the developing world and is exacerbated by the presence of persistent poverty.Ophthalmic diseases Health care needs of older people living perm anently in an old age home "Please send me to a doctor who will treat my eyes and give me glasses to see.It is difficult not to be able to see.You can't do anything and you fall easily."such as cataracts, glaucoma, trachoma and xerophthalmia underlie visual disabilities in the developing world.