4.1. The main nursing risks and factors in long-term care facilities
(1) Nursing risks
Falls are the most common accidents among older people in long-term care facilities. (Reference point 1). In our study, 10 long-term care facilities mentioned falls as being an important nursing risk for the elderly. The managers of long-term care facilities should formulate targeted comprehensive health education programs, specifically focussed on the elderly with low educational levels and cognitive impairment. Training includes knowledge of fall prevention, self-rescue after a fall, knowledge of medications, choice of food and posture while eating, skincare methods, early intervention of cognitive impairment, proper use of wheelchairs, etc. A study12 that included a total of 1832 residents in Japan also showed that falls were significantly associated with an inability to walk or stand up or go to the toilet without assistance, visual impairment, insomnia, and dementia. Furthermore, there are many medications associated with falls among nursing homes residents, such as antiparkinsonian drugs, muscle relaxants, antiepileptics, antipsychotics, antidepressants, opioids, etc. To prevent falls, caregivers should provide adequate care, and healthcare professionals should consider monitoring or management of these medications.
A woman once had difficulty with swallowing and inhalation, which resulted in vegetables being stuck while swallowing (Reference point 5). Therefore, caregivers should pay more attention by accompanying and observing the elderly while they are eating, to avoid choking. The risk of pressure ulcers among the bedridden elderly is higher, which is also a common nursing risk (Reference point 3 & 4).Frail, older people admitted to nursing homes are at risk of a range of adverse outcomes, including pressure ulcers13. Individuals who are most at risk of developing pressure ulcers are those with serious illness, elderly, have impaired mobility, and/or poor nutrition14. Effective prevention consists of a set of strategies aimed at reducing the intensity and/or duration of pressure and shear on the tissue and underlying body structures15.
(2) Factors affecting nursing risk
The elderly become frail with age, and their energy and motivation decrease (Reference point 16). Physiological factors, such as lower extremity muscle weakness and functional limitations in gait and balance, have been associated with a risk of falling16. Additionally, economic status, social role, and habits of the elderly change with age resulting in psychological diseases. The mental health status of the elderly in institutional care is worse than those in family care, among whom the incidence of depression is 65.52%7. Besides, more than two-thirds of nursing home residents have dementia in high-income countries, and fewer than half of these residents report good quality of life17. A study18suggested that these geriatric syndromes (multiple morbidities, cognitive impairment, frailty, disability, sarcopenia, malnutrition, impaired homeostasis, and chronic inflammation) are associated with a risk of hospitalization or nursing home admission, after controlling for the presence of specific diseases. Efforts to prevent nursing risks in long-term care facilities should target strategies to prevent and manage these syndromes.
Managers, nursing assistants, and the elderly and their family members have poor awareness of safety and show negligence in safety risk assessment and management, which may lead to adverse events such as scalds and falls (Reference point 1). Besides, some participantssaid that the main environmental factors for falls are unreasonable infrastructural designs, for example, many long-term care facilities do not install floor lights, provide anti-skid measures, install toilet handrails, etc. (Reference point 3 & 6).Accordingly, long-term care facilities should be designed to provide a living environment that would help prevent slips and falls to ensure the safety of the elderly.
4.2. Risk early warning intervention measures
(1) Risk assessment
Multiple scales are often used to comprehensively evaluate the living habits and care of the elderly, and their daily living ability, physical functioning, geriatric syndromes, geriatric health status, long-term care facilities, etc. (Reference point 5). The residents of long-term care facilities typically have a passive lifestyle, as most of the elderly spend their daily lives in a seated or lying position, that results in a lower physical capacity related to balance, walking speed, and aerobic endurance, which, in turn, affects their quality of life19. Consequently, performing an exercise regimen that is adapted to the ability and aspirations of the residents of long-term care facilities to increase their physical functioning and self-care ability is necessary.
An assessment of falls from beds mainly includes an elderly’s situation, the environment, and equipment, such as whether or not bed bars press on an elderly individual’s hands (Reference point 3). The fear of falling leads people to adopt a passive, sedentary lifestyle, that almost doubles the risk of falls. Positive outcomes have been reported, even among the very old and frail, with a 7-week exercise program or a home-based physical training program16. There are indications that simple activity or exercise can result in increased balance and physical function among the elderly in long-term care facilities.
(2) Training or education
New employees should be trained. The training methods are mainly on-site teaching and self-study, and the head nurse supervises and evaluates trainees at regular intervals. Training content includes feeding position, skills, life care, falls, pressure ulcer prevention, etc. (Reference point 3). Most elderly people who live in long-term care facilities suffer from chronic diseases, and a decline in physiological functioning and other factors, leading to a decline in self-care ability, a lack of ability in keeping themselves safe, and a decreased ability to handle emergencies after accidents occur. Chunmei Zha et al. 20 investigated and analyzed the status quo of nursing safety risk cognition of 221 elderly people in long-term care facilities, and found that the score of nursing safety risk knowledge of elderly people was at a relatively low level, with the score for fall safety cognition being the lowest. Nurses should therefore pay attention to the education of nursing safety risk knowledge of the elderly, and targeted comprehensive health education programs should be formulated to improve nursing safety and risk awareness of elderly people in long-term care facilities, to reduce risks and improve quality of life.
After the occurrence of adverse events, there is great psychological stress on our nurses. Therefore, managers should include care providers while addressing the caregiver-elderly relationship and comforting their families, to avoid the occurrence of new errors after care providers experience excessive stress (Reference point 6). After the occurrence of adverse events, some patients and their families do not understand the situation, which results in medical disputes that require the long-term care facilities to compensate, and affects the performance appraisal of the nursing staff (Reference point 4). It is necessary to facilitate and support caregivers continually, to care for the elderly in long-term care facilities.
(4) Comprehensive preventive measures
Communicating regularly with family members to discuss the current situation and the risk points of the elderly, enhance mutual trust, and obtain family support and care (Reference point 4). Quality control seminars are held every month, case analyses are conducted, and risk responses are planned and processed (Reference point 11). A comprehensive nursing risk management system is an important guarantee in reducing the incidence of choking and asphyxia among the elderly in long-term care facilities21 and should help improve and standardize risk management. Therefore, multifactorial interventions should include exercise, balance, strength and gait training, nutritional supplementation, management of medications (especially psychoactive medications), home environment modifications, and management of postural hypotension, vision, foot, and footwear problems. These interventions could effectively decrease falls in the community, hospital, and nursing home settings22.
Timely risk assessments of the elderly and the environment are necessary. Risk assessments of the elderly include mental state, physical condition, history of falls, and diet, which should be followed up every day. The environmental risk assessments include lighting, floors, and supplies (Reference point 1). Long-term care facilities should build an environment to prevent falls, such as installing handrails on both sides of urinals, placing anti-slip mats in bathing areas, and keeping floors clean and tidy. Moreover, they should encourage the elderly to choose and wear shoes with anti-skid soles, and choose walking aids appropriately, per the physical conditions of the elderly, and avoid walking within one hour after taking antihypertensive drugs or antidiabetic drugs. Function-based exercise should be a focus for interventions to protect older, high-risk people from falls and to improve and maintain functional capacity23. Besides, indwelling devices (e.g., urinary catheters and feeding tubes) are often used by the elderly at nursing homes. Inadequate care of the elderly with these devices contributes to high rates of multidrug-resistant, device-related infections24. Therefore, special attention should be paid to indwelling devices and medication safety of the elderly, and there should be close team cooperation to actively assess the physical and mental conditions of the elderly in long-term care facilities, and early warning and prevention should be implemented.
4.3. Challenges and solutions
(1) Problems and obstacles
The quality of nursing staff needs to be further improved (Reference point 1). Lack of human resources for elderly care is the biggest problem at present (Reference point 3). A study has shown that a high workload also results in difficulties attracting permanent staff to long-term care facilities25. With high staff turnover, the possibilities of improving nursing quality and reducing nursing risks are diminished, especially due to the unpredictable and often urgent nature of long-term care facilities care26.
We need to strengthen the training of existing personnel, preferably by training them abroad. The relative cost of recruitment of personnel with seniority and experience is high, hence we should strengthen follow-up training for those who have been recruited (Reference point 4). In addition, it is necessary to formulate a complete and unified training system among long-term care facilities across the entire country (Reference point 1). A study27 has shown that the current employment outlook in long-term care facilities in China is not very optimistic, due to heavy workloads, low professional quality, and low salary levels, causing burnout among the staff. It is suggested that incentive mechanisms of human resources be used to alleviate the current situation. First, reasonably adjusting the working and rest hours of employees is necessary. Second, establishing economic interests as the core of the incentive mechanism, and linking career levels with promotion need to be implemented. Third, job-related tasks need to be enriched and job burnout needs to be relieved with emotional incentive mechanisms.
Care for the elderly is a national strategy, we currently await relevant policies regarding care for the elderly to be issued by the state (Reference point 2). Improving care for frail older adults remains a national priority. Since many adverse health outcomes in older adults result from the interaction of multiple risk factors, multifactorial risk reduction interventions have been proposed to be more appropriate for many of the “geriatric syndromes”28. Multifactorial interventions have been developed for falls, incontinence, pressure ulcer prevention, behavioural disturbances, and insomnia among the elderly. Furthermore, there is a need to identify specific evidence-based practices to reduce the risk of infections in long-term care facilities.
- Nursing risk warning strategy in long-term care facilities
Based on the previous theoretical framework, research, and the correlation analysis of results, a nursing risk warning model of long-term care facilities has been developed. In the model, the risk is first identified through an analysis of factors; second, risk assessment is carried out based on the identified risk factors; third, risk management measures are constructed; finally, a risk early warning strategy is formed. Based on nursing risks, risk early warning intervention measures, and challenges, the solutions (as mediating variables) that are expected to reduce the risk of care in long-term care facilities are identified. Also, factors, as potential and observation variables, that affect nursing risks have many negative effects, such as decreasing the quality of life of the elderly, poor rehabilitation effects, associated economic compensation, decrease in the reputation of the long-term care facilities, increased psychological pressure on the nursing staff, etc. Risk assessment, training and education, and comprehensive preventive measures are the main factors that constitute risk early warning intervention measures and affect each other (Fig. 2).
There are many nursing risks in long-term care facilities, including personal problems of the elderly, management and nursing operation problems, etc. Among them, nursing risks are affected by related factors and result in adverse consequences. The early warning and intervention measures mainly include risk assessment, training, and continuing education, and comprehensive risk prevention measures. Also, there are some challenges as well as solutions, such as the lack of human resources and elderly care policies. These factors, as observational and intermediate variables, jointly affect the risk reduction of nursing in long-term care facilities. Nursing risk assessment plays an important intermediate role in nursing risk prevention and control. Staff training and continued education provide methodological support for risk assessment and risk prevention and control. Many participants expressed a lack of staff in nursing homes, as well as the need for training and continued education. However, nursing home care workers have limited resources to access training, which requires supportive social and national policies29. Therefore, it is necessary to promote supportive national policies for elderly care, provide training and continued education, actively respond to various challenges, strengthen management, and strengthen risk early warning and assessment, to reduce nursing risks and promote physical and mental health, and quality of life of the elderly in long-term care facilities.
- In this study, only long-term care facilities in Chengdu, China were included, so the extrapolation of the results was poor. Cultural and regional differences should be considered when referencing the results of this research.
- This study did not conduct a longitudinal analysis of the results. Mixed studies can be conducted in the future to explore the mechanisms of nursing risk occurrence in long-term care facilities and the mutual effects of related factors, to better safeguard the physical and mental health of the elderly in long-term care facilities.