Public Health Nursing Vol. 32 No. 4, pp. 298–306 0737-1209/© 2014 Wiley Periodicals, Inc. doi: 10.1111/phn.12163
POPULATIONS
AT
RISK ACROSS
THE
LIFESPAN: POPULATION STUDIES
Continuity of Care for Older Adults with Chronic Illness in China: An Exploratory Study Shu-Ling Cheng, RN, MSN,1,† Jin-Zhi Zhao, MS Student,2,† Jinbing Bai, RN, MSN,3 and Xiao-Ying Zang, RN, PhD4 1
Tianjin Stomatological Hospital of Nankai University, Tianjin, China; 2Seven-Year System of Basic Medical College, Tianjin Medical University, Tianjin, China; 3School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and 4School of Nursing, Tianjin Medical University, Tianjin, China Correspondence to: Xiaoying Zang, School of Nursing, Tianjin Medical University, 22 Qi Xiang Tai Road, He Ping District, Tianjin 300070, China. E-mail: snxiaoying@ tijmu.edu.cn
ABSTRACT Objective: To explore nurses understanding of continuity of care and existing problems in implementation of continuity of care for Chinese elders with chronic illnesses. Design and Sample: Cross-sectional survey and semi-structured interview were performed on 15 nurses and older patients and 1,902 older patients between July 2010 and February 2011. Measures: Semistructured interview guideline and four-section scale were used. Results: The interviews showed nurses lacked knowledge of continuity of care, and nurses from small towns or rural areas had less understanding of continuity of care and discharge planning than nurses from central cities. Significant differences were found among patients located in referred areas in selection of medical institutions for treatment, suggesting older adults were more likely to choose general hospitals for treatment. Selfreported surveys demonstrated more than 70% of hospitalized elders chose community hospitals for further recovery after discharge from general hospitals. Conclusions: Chinese nurses lack knowledge of continuity of care, and significant discontinuity exists between health care provided by general hospitals, community hospitals and other institutions for elders. A further model for the development of continuity of care should be established that addresses older patients demands and current barriers in China. Key words: chronic illness, continuity of care, older adults.
Background Consistent with the global dramatic increase in the older population, China has a large aging population (Wong & Leung, 2012). The elders are the demographic group of people most likely to experience chronic illnesses and physical and psychological disorders, such as retirement syndromes (i.e., a kind of complex psychological abnormal reaction after retirement at the age of 60 for men and 55 for women in China, like anxiety, depression, sadness †
These authors contributed equally to this work.
298
or fear in emotion or repeat, distraction or misdoing in action), empty nest syndromes, and mental disorders (National Bureau of Statistics, 2009). All these diseases or disorders among the elders increase the burden to the current health care system, including extra health care costs, difficulties of hospital bed turnover and waste of medical resources (National Bureau of Statistics, 2009). Many well-developed countries (e.g., Britain, the United States) seek to improve discharge planning processes to improve care transitions for patients and the efficient use of health care system resources (Brian et al., 2009). Meanwhile, health care-related laws and regulations
Cheng et al.: Continuity of Care for Older Adults with Chronic Illness were introduced, such as the Omnibus Reconciliation Act (Mao, 2007). For older adults with chronic illnesses, western countries have set good examples for the appropriate use of patient discharge planning, and have demonstrated that continuity of care can significantly and effectively relieve the health care system burden and improve patient care outcomes (Mao, 2007). Continuity of care refers to the nursing process for transitioning patients from one environment (e.g., acute care settings) to another one (e.g., community care settings and nursing homes). This requires a collaborative team (patients, medical staff, social workers, and others) to develop and implement a corresponding care plan by evaluating patients’ continuing care needs, so as to ensure patients’ optimal prognosis (McClelland, Kelly, & Buckwalter, 1985). As an important component of the nursing care process, discharge planning is the foundation of implementing continuity of care, especially for older people with chronic illnesses. Recently, discharge planning has been widely developed and studied. For example, Damiani et al. (2009) conducted a random control trial that demonstrated appropriate discharge planning could significantly reduce the mortality rate of long-term care patients and ensure continuous care as well. Moreover, discharge planning is effective in managing hypertension, cancer, hemodialysis, and other chronic illnesses for older people (Arendts et al., 2013; Karolich & Ford, 2010; Konrad, Howard, Edwards, Ivanova, & Carey, 2005). Caregivers, community nurses, patients, and clinicians all agreed that discharge planning played a crucial role in the continuity of nursing care process (Hovlid, von Plessen, Haug, Aslaksen, & Bukve, 2013; Jeffs, Lyons, Merkley, & Bell, 2013; Rose, Bowman, & Kresevic, 2000). However, these results depended on close collaborations between acute care hospitals, community hospitals, and nursing homes. Researchers from mainland China have explored the use of continuity of care in patients with chronic illnesses. Previous studies showed that telephone follow-up and home visits could improve patients’ cognitive level and compliance to self-behavior management, thereby decreasing hospital readmission rates and medical costs (Cai, Chen, & Chen, 2010; Luo, Peng, Shen, & Wang, 2009). Interventions based on continuity of care were also examined in patients with coronary heart disease, hypertension, or chronic
299
obstructive pulmonary disease. All the findings of these studies supported the conclusion that these interventions could promote patients’ disease recovery and increase their quality of life (Cheng et al., in press; Wang et al., 2014; Zhao & Wong, 2009). Although the effectiveness of continuity of care has been supported by previous researches in Chinese populations, it is less well explored in nursing practice. Specifically, nurses’ knowledge and understanding of the concept of continuity of care are still unknown; the issues around the implementation of continuity of care have not been addressed by previous studies. A comprehensive study of the continuity of care from nurses’ and patients’ perspectives can guide our next steps to improve continuity of care for Chinese older people. Thus, the purpose of this study was to explore nurses’ understanding of continuity of care and the demands of nursing care by older people with chronic illnesses in China. Findings of this study will provide further insight into establishing a continuity of care system for public health nurses and older people.
Methods Design and sample Using a purposive sampling method, a total of 15 participants (eight nurses and seven older patients with chronic illnesses) were recruited from the city of Tianjin and interviewed to explore nurses’ understanding of continuity of care and existing problems during the implementation of continuity of care in China. Located in northeast China, Tianjin is one of China’s four municipalities and about 120 km away from Beijing. Nurses with different professional titles (e.g., staff nurse and head nurse) and older patients were selected so that more indepth data could be obtained. All the participants were selected from two general hospitals (3 nurses and 2 elders), two nursing homes (2 nurses and 2 elders), one community hospital (2 nurses and 1 elder) and one clinic (1 nurse and 2 elders). These participants were recruited from different regions of Tianjin: city center (5 nurses and 3 elders), small towns (2 nurses and 2 elders), and rural areas (2 nurses and 1 elder). Differences between city center, small towns, and rural areas lie in the density of the population and its gross national product per year based on data from the Chinese government.
300
Public Health Nursing
Volume 32
Number 4
In addition, a total of 1,902 older adults were recruited using the convenience and stratified sampling method to investigate the situation and demands of nursing care for elders with chronic illnesses. Inclusion criteria for these participants: (1) were age ≥60 years; (2) have a diagnosis of at least one kind of WHO-standardized chronic illness; and (3) agree to participate in this study. The older people were excluded if they had severe physical or mental illnesses or refused to participate. Sample size was calculated by the sample size formula of stratified sampling based on the morbidity rate of chronic illness for older people (Tang et al., 2004). Taking the attrition rate into consideration, the sample size was eventually confirmed as 1,900 (Tang et al., 2004). According to the National Bureau of Statistics (2009), the distribution ratio of the older people in central cities, small towns and rural areas was 5:2:3; therefore, the sample size for the survey investigation was decided based on this ratio, leading to 879 participants from central cities, 431 participants from small towns, and 592 participants from rural areas. This research was approved by the Medical Ethics Committee of Tianjin Medical University. The purpose of this study was introduced to the participants in detail. Written informed consent was also obtained from all the participants. Participants were also informed about the voluntary nature of their participation, and their rights of privacy, anonymity and confidentiality, and withdrawal from the study at any time.
Measures Before data collection, a semi-structured interview guideline was developed based on the following steps: (1) systematic literature review was conducted to form the original guideline; (2) a pilot interview of 3 nurses and 3 elders was conducted to examine the completeness of this interview outline. Taken all together, the final interview guideline consisted of 12 questions which were categorized into two sections. Detail information on the interview guideline can be obtained from the principal investigator. Finally, 15 participants were interviewed based on our interview guideline. The interviewer (a trained graduate student) along with participants determined the time and place for the interviews. All the interviews were recorded and data collection stopped when data saturation was obtained (Holloway, 2005).
July/August 2015
A four-section scale was designed to investigate the general data, health status and relevant behaviors, utilization of and demands for current nursing services. A pilot study was conducted to ascertain the usefulness of this scale in 100 elders; the final questionnaire was confirmed based on the suggestions from this pilot study, with 24 items left in the last two sections of this scale (i.e., utilization of and demands for current nursing services). Three professionals with expertise in chronic illnesses evaluated the content validity of the questionnaire and indicated that the items and content of this scale were relevant and complete. Cronbach’s alpha and Guttman Split-half values were 0.89 and 0.88, supporting its satisfactory internal consistency. Between July 2010 and February 2011, we distributed this scale to 2020 older adults from 29 provinces in China (940 participants from Tianjin and 1,080 participants from other 28 provinces all over the China). In total, 933 participants from Tianjin (response rate = 99.26%) and 969 participants from the other provinces completed the study (response rate = 89.72%). Figure 1 describes the flowchart of data collection.
Analytic strategy NVivo 7 was used to analyze the interview data and SPSS 13.0 (SPSS Inc., Chicago, IL, USA) was used to analyze the survey data. For the interview data, all the audio-recorded data were transcribed first by repeated playing. Then, all the transcribed data were condensed and coded using the content analysis technique. All the identified codes were finally grouped into categories based on the similarities of their meanings. Relevant themes were identified based on these categories. For the survey results, descriptive statistics, that is, means (standard deviation) or frequencies (percentage) were used to describe sample characteristics. Among these three groups (i.e., central cities, small towns, and rural areas), differences in patients’ choice of medical institutions, utilization of domestic hospital beds, level of demands of each aspect of nursing services and other items were analyzed using the Chi-square test (for categorical variables). One-way Analysis of Variance (ANOVA) was used to test the differences in times to see the doctors, acceptance of home care services, rate of hospitalization, days and cost of hospitalization,
Cheng et al.: Continuity of Care for Older Adults with Chronic Illness
301
Research purpose: Explore nurses’ and patients’ understanding of continuity of care and demands of nursing care for the elderly people with chronic illness in China
Aim 1: Explore nurses’ and patients’ understanding of continuity of care in China;
Aim 2: Analyze the demands of nursing care for the elderly people with chronic illness in China;
Pilot study 1: 3 nurses and 3 elders were interviewed to examine the completeness of the interview outline;
Pilot study 2: 100 elders were recruited to ascertain the questionnaire designed for this study;
Field study 1: 15 interviewees (8 nurses and 7 elders with chronic illnesses) were recruited from Tianjin and interviewed;
Field study 2: Using the convenience and stratified sampling method, a total of 1902 elderly adults completed the study (933 from Tianjin and 969 from the other provinces);
Data analysis 1: NVivo 7 and the content analysis technique were used for data analysis;
Data analysis 2: Chi-square and ANOVA were used for data analysis by SPSS 13.0;
Figure 1. Flowchart of the Study Processes with the Bonferroni correction for the pairwise test. Significance level was set at 0.05.
Results Lack of knowledge of continuity of care by nurses The interviews showed that nurses lacked knowledge of continuity of care and nurses from small towns or rural areas had less understanding of this concept and discharge planning than those nurses from central cities. Specifically, 50% (4 of 8) of nurses interviewed reported that they had heard of this concept and were aware of related concepts; the other 4 nurses (3 of whom were not from central cities) indicated that they had never heard of this concept. In contrast, nurses from central cities indicated that they obtained knowledge of continuity of care through different avenues, such as academic journals, lectures, and websites. Nevertheless, all the interviewed nurses said that they rarely had time to further their understanding of these concepts due to their labor intensive clinical
work. Not surprisingly, head nurses had a better understanding of these concepts than staff nurses. For instance, one head nurse from a general hospital in a city center said that the primary aim of continuity of care was to achieve the integrity and consecutiveness of care, and that the appropriate use of continuity of care and discharge planning can not only save medical resources but can also be consistent with the future development of nursing care. Another three nurses perceived continuity of care as tracking management after discharge.
Existing problems in the implementation of continuity of care All the nurses interviewed said that the current health care provided by general hospitals, community hospitals and other institutions for older care were all disconnected from each other. During the interview, one nurse even said: “After discharge to our hospital (a community hospital), we are unable to know the detailed treatments and nursing care for older patients during hospitalization; we have to reassess the health condition of patients carefully and
302
Public Health Nursing
Volume 32
Number 4
then design our nursing care plans. This process will cause unnecessary waste of healthcare resources.” The interviewees also revealed other barriers of implementing continuity of care, including lack of human resources, unbalanced medical resource distributions between urban and rural areas, and incomplete policy and regulations. One nurse from a general hospital in a central city said: “I work almost 7 days every week because 3 nurses in our department were pregnant or gave birth to a baby; I am so exhausted every day after work. You know I also have to take care of my child when I get home, then I have no time to study.” One head nurse also said: “Nurses are in extreme shortage in our department and we have no extra nurses to implement discharge planning.” Similarly, one nurse from a rural clinic addressed the severely unbalanced resources distribution between urban and rural areas: “Unlike the hospitals of central cities, our facilities and techniques are quite out-of-date. Further steps are needed to change this situation for us.”
Use of current nursing services Significant differences were found among the three groups in the choice of medical institutions for treatment and utilization of the domestic hospital beds (v2 = 150.16, p < .01; v2 = 19.47, p < .01, Table 1). Our analysis also showed that older people were more likely to choose general hospitals for
July/August 2015
treatment. There were significant differences in times to see a doctor and accept home care services in the past year among these three groups (F = 3.723, p < .05; F = 11.405, p < .01, Table 1). Further post hoc analysis showed that patients from central cities went to see a doctor and had home care more often than patients from small towns or rural areas in the past year. However, no significant differences were found in the frequency of hospitalization in the past year and medical expense of hospital stay among the three groups (Table 1). Moreover, we found that more than 70% of hospitalized older patients chose community hospitals for further recovery after discharge from general hospitals; 14.4% of older people had been hospitalized in the past year with an average of 1.5 hospitalizations and an average of 16.24 days of stay in hospital. The average medical expense of hospitalization was $1,859.22, with a reimbursement (60%) of $1,109.49 in the past year. An average of 1.56 necessary hospitalizations was missed due to economic difficulties, especially for the elders from rural areas.
Demand for current nursing services Based on the Chi-square test, significant differences were found among the three groups in the demands for essential nursing care, psychological counseling, hospice care, institutional care, and pain manage-
TABLE 1. Comparison of Utilization of Current Nursing Services, n (%)/(x SD) (N = 1,902) Items
Central cities (n = 879)
Small towns (n = 431)
Rural areas (n = 592)
CMIT GH CH PC UDS PHPY CCFR TSD TH HD MEHS (US $) ER (US $) MTNH THS
559 (63.6) 284 (32.3) 36 (4.1) 87 (9.9) 132 (15.0) 96 (72.7) 3.41 3.92 1.47 0.71 16.65 13.18 1,857.69 2,619.57 1,212.90 2,358.80 1.62 0.91 1.46 4.71
269 (62.4) 133 (30.9) 29 (6.7) 28 (6.5) 66 (15.3) 49 (74.2) 3.05 3.03 1.61 0.84 16.65 15.95 2,480.55 9,725.37 1,689.65 8,145.51 1.49 0.90 0.95 4.01
253 (42.7) 262 (44.3) 77 (13.0) 23 (3.9) 68 (11.5) 50 (73.5) 2.95 2.55 1.38 0.62 15.00 12.34 1,451.61 1,823.33 484.11 639.20 1.55 0.78 0.46 2.48
v2/F
p-value
150.15
POPULATIONS
AT
RISK ACROSS
THE
LIFESPAN: POPULATION STUDIES
Continuity of Care for Older Adults with Chronic Illness in China: An Exploratory Study Shu-Ling Cheng, RN, MSN,1,† Jin-Zhi Zhao, MS Student,2,† Jinbing Bai, RN, MSN,3 and Xiao-Ying Zang, RN, PhD4 1
Tianjin Stomatological Hospital of Nankai University, Tianjin, China; 2Seven-Year System of Basic Medical College, Tianjin Medical University, Tianjin, China; 3School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and 4School of Nursing, Tianjin Medical University, Tianjin, China Correspondence to: Xiaoying Zang, School of Nursing, Tianjin Medical University, 22 Qi Xiang Tai Road, He Ping District, Tianjin 300070, China. E-mail: snxiaoying@ tijmu.edu.cn
ABSTRACT Objective: To explore nurses understanding of continuity of care and existing problems in implementation of continuity of care for Chinese elders with chronic illnesses. Design and Sample: Cross-sectional survey and semi-structured interview were performed on 15 nurses and older patients and 1,902 older patients between July 2010 and February 2011. Measures: Semistructured interview guideline and four-section scale were used. Results: The interviews showed nurses lacked knowledge of continuity of care, and nurses from small towns or rural areas had less understanding of continuity of care and discharge planning than nurses from central cities. Significant differences were found among patients located in referred areas in selection of medical institutions for treatment, suggesting older adults were more likely to choose general hospitals for treatment. Selfreported surveys demonstrated more than 70% of hospitalized elders chose community hospitals for further recovery after discharge from general hospitals. Conclusions: Chinese nurses lack knowledge of continuity of care, and significant discontinuity exists between health care provided by general hospitals, community hospitals and other institutions for elders. A further model for the development of continuity of care should be established that addresses older patients demands and current barriers in China. Key words: chronic illness, continuity of care, older adults.
Background Consistent with the global dramatic increase in the older population, China has a large aging population (Wong & Leung, 2012). The elders are the demographic group of people most likely to experience chronic illnesses and physical and psychological disorders, such as retirement syndromes (i.e., a kind of complex psychological abnormal reaction after retirement at the age of 60 for men and 55 for women in China, like anxiety, depression, sadness †
These authors contributed equally to this work.
298
or fear in emotion or repeat, distraction or misdoing in action), empty nest syndromes, and mental disorders (National Bureau of Statistics, 2009). All these diseases or disorders among the elders increase the burden to the current health care system, including extra health care costs, difficulties of hospital bed turnover and waste of medical resources (National Bureau of Statistics, 2009). Many well-developed countries (e.g., Britain, the United States) seek to improve discharge planning processes to improve care transitions for patients and the efficient use of health care system resources (Brian et al., 2009). Meanwhile, health care-related laws and regulations
Cheng et al.: Continuity of Care for Older Adults with Chronic Illness were introduced, such as the Omnibus Reconciliation Act (Mao, 2007). For older adults with chronic illnesses, western countries have set good examples for the appropriate use of patient discharge planning, and have demonstrated that continuity of care can significantly and effectively relieve the health care system burden and improve patient care outcomes (Mao, 2007). Continuity of care refers to the nursing process for transitioning patients from one environment (e.g., acute care settings) to another one (e.g., community care settings and nursing homes). This requires a collaborative team (patients, medical staff, social workers, and others) to develop and implement a corresponding care plan by evaluating patients’ continuing care needs, so as to ensure patients’ optimal prognosis (McClelland, Kelly, & Buckwalter, 1985). As an important component of the nursing care process, discharge planning is the foundation of implementing continuity of care, especially for older people with chronic illnesses. Recently, discharge planning has been widely developed and studied. For example, Damiani et al. (2009) conducted a random control trial that demonstrated appropriate discharge planning could significantly reduce the mortality rate of long-term care patients and ensure continuous care as well. Moreover, discharge planning is effective in managing hypertension, cancer, hemodialysis, and other chronic illnesses for older people (Arendts et al., 2013; Karolich & Ford, 2010; Konrad, Howard, Edwards, Ivanova, & Carey, 2005). Caregivers, community nurses, patients, and clinicians all agreed that discharge planning played a crucial role in the continuity of nursing care process (Hovlid, von Plessen, Haug, Aslaksen, & Bukve, 2013; Jeffs, Lyons, Merkley, & Bell, 2013; Rose, Bowman, & Kresevic, 2000). However, these results depended on close collaborations between acute care hospitals, community hospitals, and nursing homes. Researchers from mainland China have explored the use of continuity of care in patients with chronic illnesses. Previous studies showed that telephone follow-up and home visits could improve patients’ cognitive level and compliance to self-behavior management, thereby decreasing hospital readmission rates and medical costs (Cai, Chen, & Chen, 2010; Luo, Peng, Shen, & Wang, 2009). Interventions based on continuity of care were also examined in patients with coronary heart disease, hypertension, or chronic
299
obstructive pulmonary disease. All the findings of these studies supported the conclusion that these interventions could promote patients’ disease recovery and increase their quality of life (Cheng et al., in press; Wang et al., 2014; Zhao & Wong, 2009). Although the effectiveness of continuity of care has been supported by previous researches in Chinese populations, it is less well explored in nursing practice. Specifically, nurses’ knowledge and understanding of the concept of continuity of care are still unknown; the issues around the implementation of continuity of care have not been addressed by previous studies. A comprehensive study of the continuity of care from nurses’ and patients’ perspectives can guide our next steps to improve continuity of care for Chinese older people. Thus, the purpose of this study was to explore nurses’ understanding of continuity of care and the demands of nursing care by older people with chronic illnesses in China. Findings of this study will provide further insight into establishing a continuity of care system for public health nurses and older people.
Methods Design and sample Using a purposive sampling method, a total of 15 participants (eight nurses and seven older patients with chronic illnesses) were recruited from the city of Tianjin and interviewed to explore nurses’ understanding of continuity of care and existing problems during the implementation of continuity of care in China. Located in northeast China, Tianjin is one of China’s four municipalities and about 120 km away from Beijing. Nurses with different professional titles (e.g., staff nurse and head nurse) and older patients were selected so that more indepth data could be obtained. All the participants were selected from two general hospitals (3 nurses and 2 elders), two nursing homes (2 nurses and 2 elders), one community hospital (2 nurses and 1 elder) and one clinic (1 nurse and 2 elders). These participants were recruited from different regions of Tianjin: city center (5 nurses and 3 elders), small towns (2 nurses and 2 elders), and rural areas (2 nurses and 1 elder). Differences between city center, small towns, and rural areas lie in the density of the population and its gross national product per year based on data from the Chinese government.
300
Public Health Nursing
Volume 32
Number 4
In addition, a total of 1,902 older adults were recruited using the convenience and stratified sampling method to investigate the situation and demands of nursing care for elders with chronic illnesses. Inclusion criteria for these participants: (1) were age ≥60 years; (2) have a diagnosis of at least one kind of WHO-standardized chronic illness; and (3) agree to participate in this study. The older people were excluded if they had severe physical or mental illnesses or refused to participate. Sample size was calculated by the sample size formula of stratified sampling based on the morbidity rate of chronic illness for older people (Tang et al., 2004). Taking the attrition rate into consideration, the sample size was eventually confirmed as 1,900 (Tang et al., 2004). According to the National Bureau of Statistics (2009), the distribution ratio of the older people in central cities, small towns and rural areas was 5:2:3; therefore, the sample size for the survey investigation was decided based on this ratio, leading to 879 participants from central cities, 431 participants from small towns, and 592 participants from rural areas. This research was approved by the Medical Ethics Committee of Tianjin Medical University. The purpose of this study was introduced to the participants in detail. Written informed consent was also obtained from all the participants. Participants were also informed about the voluntary nature of their participation, and their rights of privacy, anonymity and confidentiality, and withdrawal from the study at any time.
Measures Before data collection, a semi-structured interview guideline was developed based on the following steps: (1) systematic literature review was conducted to form the original guideline; (2) a pilot interview of 3 nurses and 3 elders was conducted to examine the completeness of this interview outline. Taken all together, the final interview guideline consisted of 12 questions which were categorized into two sections. Detail information on the interview guideline can be obtained from the principal investigator. Finally, 15 participants were interviewed based on our interview guideline. The interviewer (a trained graduate student) along with participants determined the time and place for the interviews. All the interviews were recorded and data collection stopped when data saturation was obtained (Holloway, 2005).
July/August 2015
A four-section scale was designed to investigate the general data, health status and relevant behaviors, utilization of and demands for current nursing services. A pilot study was conducted to ascertain the usefulness of this scale in 100 elders; the final questionnaire was confirmed based on the suggestions from this pilot study, with 24 items left in the last two sections of this scale (i.e., utilization of and demands for current nursing services). Three professionals with expertise in chronic illnesses evaluated the content validity of the questionnaire and indicated that the items and content of this scale were relevant and complete. Cronbach’s alpha and Guttman Split-half values were 0.89 and 0.88, supporting its satisfactory internal consistency. Between July 2010 and February 2011, we distributed this scale to 2020 older adults from 29 provinces in China (940 participants from Tianjin and 1,080 participants from other 28 provinces all over the China). In total, 933 participants from Tianjin (response rate = 99.26%) and 969 participants from the other provinces completed the study (response rate = 89.72%). Figure 1 describes the flowchart of data collection.
Analytic strategy NVivo 7 was used to analyze the interview data and SPSS 13.0 (SPSS Inc., Chicago, IL, USA) was used to analyze the survey data. For the interview data, all the audio-recorded data were transcribed first by repeated playing. Then, all the transcribed data were condensed and coded using the content analysis technique. All the identified codes were finally grouped into categories based on the similarities of their meanings. Relevant themes were identified based on these categories. For the survey results, descriptive statistics, that is, means (standard deviation) or frequencies (percentage) were used to describe sample characteristics. Among these three groups (i.e., central cities, small towns, and rural areas), differences in patients’ choice of medical institutions, utilization of domestic hospital beds, level of demands of each aspect of nursing services and other items were analyzed using the Chi-square test (for categorical variables). One-way Analysis of Variance (ANOVA) was used to test the differences in times to see the doctors, acceptance of home care services, rate of hospitalization, days and cost of hospitalization,
Cheng et al.: Continuity of Care for Older Adults with Chronic Illness
301
Research purpose: Explore nurses’ and patients’ understanding of continuity of care and demands of nursing care for the elderly people with chronic illness in China
Aim 1: Explore nurses’ and patients’ understanding of continuity of care in China;
Aim 2: Analyze the demands of nursing care for the elderly people with chronic illness in China;
Pilot study 1: 3 nurses and 3 elders were interviewed to examine the completeness of the interview outline;
Pilot study 2: 100 elders were recruited to ascertain the questionnaire designed for this study;
Field study 1: 15 interviewees (8 nurses and 7 elders with chronic illnesses) were recruited from Tianjin and interviewed;
Field study 2: Using the convenience and stratified sampling method, a total of 1902 elderly adults completed the study (933 from Tianjin and 969 from the other provinces);
Data analysis 1: NVivo 7 and the content analysis technique were used for data analysis;
Data analysis 2: Chi-square and ANOVA were used for data analysis by SPSS 13.0;
Figure 1. Flowchart of the Study Processes with the Bonferroni correction for the pairwise test. Significance level was set at 0.05.
Results Lack of knowledge of continuity of care by nurses The interviews showed that nurses lacked knowledge of continuity of care and nurses from small towns or rural areas had less understanding of this concept and discharge planning than those nurses from central cities. Specifically, 50% (4 of 8) of nurses interviewed reported that they had heard of this concept and were aware of related concepts; the other 4 nurses (3 of whom were not from central cities) indicated that they had never heard of this concept. In contrast, nurses from central cities indicated that they obtained knowledge of continuity of care through different avenues, such as academic journals, lectures, and websites. Nevertheless, all the interviewed nurses said that they rarely had time to further their understanding of these concepts due to their labor intensive clinical
work. Not surprisingly, head nurses had a better understanding of these concepts than staff nurses. For instance, one head nurse from a general hospital in a city center said that the primary aim of continuity of care was to achieve the integrity and consecutiveness of care, and that the appropriate use of continuity of care and discharge planning can not only save medical resources but can also be consistent with the future development of nursing care. Another three nurses perceived continuity of care as tracking management after discharge.
Existing problems in the implementation of continuity of care All the nurses interviewed said that the current health care provided by general hospitals, community hospitals and other institutions for older care were all disconnected from each other. During the interview, one nurse even said: “After discharge to our hospital (a community hospital), we are unable to know the detailed treatments and nursing care for older patients during hospitalization; we have to reassess the health condition of patients carefully and
302
Public Health Nursing
Volume 32
Number 4
then design our nursing care plans. This process will cause unnecessary waste of healthcare resources.” The interviewees also revealed other barriers of implementing continuity of care, including lack of human resources, unbalanced medical resource distributions between urban and rural areas, and incomplete policy and regulations. One nurse from a general hospital in a central city said: “I work almost 7 days every week because 3 nurses in our department were pregnant or gave birth to a baby; I am so exhausted every day after work. You know I also have to take care of my child when I get home, then I have no time to study.” One head nurse also said: “Nurses are in extreme shortage in our department and we have no extra nurses to implement discharge planning.” Similarly, one nurse from a rural clinic addressed the severely unbalanced resources distribution between urban and rural areas: “Unlike the hospitals of central cities, our facilities and techniques are quite out-of-date. Further steps are needed to change this situation for us.”
Use of current nursing services Significant differences were found among the three groups in the choice of medical institutions for treatment and utilization of the domestic hospital beds (v2 = 150.16, p < .01; v2 = 19.47, p < .01, Table 1). Our analysis also showed that older people were more likely to choose general hospitals for
July/August 2015
treatment. There were significant differences in times to see a doctor and accept home care services in the past year among these three groups (F = 3.723, p < .05; F = 11.405, p < .01, Table 1). Further post hoc analysis showed that patients from central cities went to see a doctor and had home care more often than patients from small towns or rural areas in the past year. However, no significant differences were found in the frequency of hospitalization in the past year and medical expense of hospital stay among the three groups (Table 1). Moreover, we found that more than 70% of hospitalized older patients chose community hospitals for further recovery after discharge from general hospitals; 14.4% of older people had been hospitalized in the past year with an average of 1.5 hospitalizations and an average of 16.24 days of stay in hospital. The average medical expense of hospitalization was $1,859.22, with a reimbursement (60%) of $1,109.49 in the past year. An average of 1.56 necessary hospitalizations was missed due to economic difficulties, especially for the elders from rural areas.
Demand for current nursing services Based on the Chi-square test, significant differences were found among the three groups in the demands for essential nursing care, psychological counseling, hospice care, institutional care, and pain manage-
TABLE 1. Comparison of Utilization of Current Nursing Services, n (%)/(x SD) (N = 1,902) Items
Central cities (n = 879)
Small towns (n = 431)
Rural areas (n = 592)
CMIT GH CH PC UDS PHPY CCFR TSD TH HD MEHS (US $) ER (US $) MTNH THS
559 (63.6) 284 (32.3) 36 (4.1) 87 (9.9) 132 (15.0) 96 (72.7) 3.41 3.92 1.47 0.71 16.65 13.18 1,857.69 2,619.57 1,212.90 2,358.80 1.62 0.91 1.46 4.71
269 (62.4) 133 (30.9) 29 (6.7) 28 (6.5) 66 (15.3) 49 (74.2) 3.05 3.03 1.61 0.84 16.65 15.95 2,480.55 9,725.37 1,689.65 8,145.51 1.49 0.90 0.95 4.01
253 (42.7) 262 (44.3) 77 (13.0) 23 (3.9) 68 (11.5) 50 (73.5) 2.95 2.55 1.38 0.62 15.00 12.34 1,451.61 1,823.33 484.11 639.20 1.55 0.78 0.46 2.48
v2/F
p-value
150.15
