194 JPAIR Multidisciplinary Research Under-Developed Standards: The Reality in an Elderly Facility MARIA FLORDELIZ G. PADAYAO http:///orcid.org/ 0000-0002-9251-7976 mrflrdlz@yahoo.com University of Cebu, Philippines CIELITO L. GUAZON http:///orcid.org/0000-0001-8109-2629 otileiclnozaug@gmail.com University of Cebu, Philippines MERCY MILAGROS BACARRO APUHIN http:///orcid.org/0000-0000-0002-6485-2486 mercy@apuhin.com University of Cebu Philippines MA. ESTELLA P. CABATAÑA http:///ordic.org/0000-0002-9986-3142 mastella17@yahoo.com University of Cebu Philippines ABSTRACT The burgeoning population of the elderly is an alarm that the national health and nursing authorities should start equipping to meet the needs of this fragile group. The Philippines is still under-developed in the standardization of geriatric institutions. Mainly, the objective of this study is to evaluate whether the selected Vol. 28 · March 2017 Print ISSN 2012-3981 • Online ISSN 2244-0445 DOI: https://doi.org/10.7719/jpair.v28i1.509 Journal Impact: H Index = 3 from Publish or Perish JPAIR Multidisciplinary Research is produced by PAIR, an ISO 9001:2008 QMS certified by AJA Registrars, Inc. 195 International Peer Reviewed Journal elderly home in Cebu City, Philippines is practicing a quality facility structuring based on guidelines. A mixed method, specifically, the Sequential Explanatory research, was used to understand the complexities of this phenomenon. Using a multi-level of data sourcing, a meticulous sequencing was followed. First, employing a survey questionnaire; then, an observational checklist and lastly, a cross analysis Focus Group Discussion (FGD). To complete the different sets of sample, an active purposive sampling technique was utilized. Findings showed that lack of national standards and financial incapability were the identified factors why there was a non-parallelism between the elderly needs and conduciveness of quality living. As such, may threaten the holistic health and harmony of well-being among them. The result can be applied as reference in generating a standardized protocol suitable for Filipino aging clientele. Keywords — Gerontology, elderly facilities, mixed method, Cebu, Philippines INTRODUCTION The burgeoning population of the elderly is currently a health-challenging dilemma in the entire world (WHO, 2011; Black & Hawk, 2005). As the aging population surge to double every year, the demand to appropriate caring and health needs are becoming complex. The more they aged, the more they become fragile and susceptible to illness and injury. Lamentably, an increasing number of elderly individuals are now sent by their children and significant others to the institutional facilities because of many complicated personal reasons. In turn, the pressure to care the elderly shifts to elderly homes and its care-personnel. Therefore, the need to upgrade turns to be a must to meet the demands of their clientele. However, the Philippines’ elderly care homes are still underdeveloped in terms of standardization – a real challenge among future gerontologist. Reports regarding accidental injuries happening inside institutionalize facilities are common, yet preventable with the right measures. Falls, for instance, is the second leading cause of accidents in most nursing homes, but these scenarios are still undocumented in the country. In fact, falling alone can cause complicated consequences such as hip fracture, limb injuries or even severe brain and spine damages. Because of the physical and mental conditions, safety is the top priority that administrators should capitalize within the skirt of their home environment (WHO, 2011). 196 JPAIR Multidisciplinary Research These life threatening incidences may occur frequently and repeatedly, if not resolved earlier. Nursing home managers can curb this happening when equipped with the correct and standard facility protocols. Homes, like this, should serve as “healing centers” whereby holistic hierarchies for long term services are practiced, for the betterment of patients (Gladstone & Wexler, 2007). According to the Environmental Theory developed by Florence Nightingale, the type of milieu that the patient has will determine his condition for recovery and comfort. The function of a care provider is to balance the environment suitable to his human-beingness. In the absence of such health, its restoration is unachievable. Limited studies locally have been written that analyzed the physical structure of geriatric institutions. As a response to this new challenge, there is an exigent need to examine the quality of elderly facilities on their real-phenomenological image. This study, therefore, sets the trail for policy makers and gerontologist to generate concrete guidelines that can improve existing homes for the aged in the country. FRAMEWORK Caring becomes risky in the absence of a quality environment to our patients (Florence Nightingale, 1979). In turn, the nurse, as the main care provider, needs to patch up essential components that will harmonize the patient’s mind, body, soul, social, and environment with the degree congruent to his health and healing, especially among frail ones (Watson, 2007). Some 48% of older adults over age 65 are seen in the hospital, 80% were home care patients and 90% were in nursing homes (Mezey, 2001). They enter and exit the healthcare system at many different points throughout old age (Mauk, 2010). Accordingly, the population of senior adults ascended by 4.1% every year and will increase to 11.9% in the future. These patient age groups are the most demanding and fragile patients because of their physical and mental disability (WHO, 2011). Thus, safety and being protected in the home environment should be capitalized among them. As the number of new in-patient surges, issues on internal accidents occur frequently, which nearly doubles since the last decade (WHO, 2011). For instance, falls ranked as the second reason for accident or unintended deaths in the world happening among most geriatric patients at nursing homes. Approximately, an 197 International Peer Reviewed Journal average population of 28 – 35% of falls each year belonged to people aged 65 and 32 – 42% of those above 70 years of age (WHO, 2011). This injury, alone, is causing series of mild to severe complications at 20 – 30% including brain and spine to limb injuries. Also, there was a higher hospitalization stay on falls-related injuries which ranges from 4 to 15 days. At present, it is still a debate whether what standards shall be implemented, since, the country doesn’t have a concrete structured protocol for a geriatric infrastructural design unlike the Singapore and US. Cebu City has its first ever local ordinance which was proposed by Palompon (2011), but it was not tested. The conceptual underpinning of this study was anchored based on their proposal parameters: signage, bathroom, walkways and furniture. As identified, these 4 aspects of an elderly home are usually problematic that causes numerous injuries and accidents among clients. Safety can be improved through modification of simple measures (grab bars, adequate light and non-slippery floor) and introduction of advanced but enhanced technology (Ewles & Simnett, 2003). Or whatever the setting, hospice requires a great deal of patience, expertise, understanding, interdisciplinary communication and compassion on the part of the nurse that needs to be collaboratively shared and discussed among residents and the entire team of the care provider (Mauk, 2010). OBJECTIVES OF THE STUDY The study aimed to evaluate whether a selected elderly home in Cebu City, Philippines is practicing a quality facility structuring based on available references of standards. Also, this specifically sought to answer the following: (1) the difference between local and international standards; (2) level of satisfaction among elderly residents on their geriatric facility, namely, on signage, bathroom, walkways and furniture; lastly, (3) the salient rebuttals of the residents, affiliating schools and nursing home administration regarding the core issues. METHODOLOGY A mixed method, specifically the sequential explanatory research, was used to clearly describe and evaluate the selected elderly home for this study. In consecutive phases, quantitative data were first collected and analyzed. Using a questionnaire checklist anchored from the local ordinance proposed by Palompon 198 JPAIR Multidisciplinary Research (2011), the residents’ perceived level of satisfaction was measured. Prior to the distribution, it was modified accordingly based from pilot-study with Chronbach Alpha level at 0.86, and per advice by hired experts. These were distributed to the residents who have stayed for more than 3 years and volunteered, but not more than 65 years old to ensure that the patients were cognitively capable (Catalan, 2015). Numerical information gathered from the answered survey questionnaires were then transferred to Statistical Software (SPSS – 16) for preliminary analysis using percentage distribution and weighted mean. Later, a group of research assistants (engineering students) were recruited to conduct observational study specifically on area measurement, infrastructural evaluation and in-door facility. A new set of checklist adopted from the local ordinance (Palompon, 2011) and the Nursing Home Standards Workgroup (2014) was employed. Prior to usage, both checklists reliability were examined. Data from this phase were treated using T-test to measure the significant difference between the two references. Afterward, findings were utilized as a counter-explanation to substantiate the preliminary analysis of the first collated data. A qualitative research was finally done to provide breadth and depth in analyzing the quantitative data. Ten (10) open-ended questions were formulated after fusing the analytic data between the beforehand observational and survey output. Each question was initially reviewed by local peer-groups and hired genre specialists. A Focus Group Discussion (FGD) participated by 3 groups with 21 selected volunteers was conducted. Each was composed of different representatives from elderly residents, affiliated school faculties/students, and administration heads and staff. The law of numerical equality in the FGD grouping was considered, which means 7 individuals represents each cohort. This is to ensure equal voicing (Catalan, 2015). Uniquely, a cross analysis between statements was given crucial role in the organized FGD. Statements from each group representatives were used as highlights and rebuttal cues in addition to the structured questionnaire. The Qualitative Context Analysis by Mayring (2005) was applied to sum up the contextual domain of each verbatim. Before concluding, discrepancies identified were re-clarified to the FGD participants. Lastly, a literature triangulation was done to eliminate the idiosyncratic conclusion of this research work. Worth noting, that upon request from the 3 existing elderly homes in the province, only 1 from Talisay, Cebu City, which is a semi-private institution manned by nuns accepted this evaluative research. Ethical considerations were 199 International Peer Reviewed Journal given emphasis before this was executed. Series of letters and consent forms were forwarded. And, a formal one-on-one interaction for clarifications in vernacular was given importance. To control Hawthorne Effect, the respondents were asked ahead for their preferred testing area. Once questionnaires are submitted, they were kept in individualized enveloped, and coded for confidentiality: E for elderly; A was assigned to affiliates; and N was the used to represent the elderly home’s administrators. RESULTS AND DISCUSSION Table 1. Difference between Local Ordinance and International Standards Paired value Computed t – value Critical value Mean Difference Significance Local versus International Standards 1.995 14.624 8.85 .006 When comparing the two guideline checklist between the local ordinance and the Nursing Home standards from Singapore (Nursing Home Standard Group, 2014), the t – test result is significant at the level of .006, which means that there was a significant difference between the sources. The reason for this was the different sourcing used per guidelines. The local ordinance was based on Western standards, while another reference was originally constructed according to a real Singaporean scenario. Also, there were obvious contradictions on specification of measurement and units. Admittedly, some figures were not really applicable for a Filipino elderly resident. Meanwhile, in this study those identified discrepancies were forwarded to among selected local experts and the final judgment was aligned from their comments and the existing Philippine-based studies. Table 2. Level of satisfaction as perceived by the elderly residents Facility Structure Mean Interpretation Signage 1.62 Less Satisfied Bathroom 1.67 Less Satisfied Walkways 1.65 Less Satisfied Furniture 1.62 Less Satisfied 200 JPAIR Multidisciplinary Research “We are thankful for the sisters and caregivers taking good care of us. But, aside from their care, we need as well a facility that we can consider as a home, comfortable for us.” E2 “We are living in a place that we were forced to live. So dark, that we need sunshine. Like a tight chamber that we cannot breath. And, so old like us. How I wish the government can hear us. We were also citizens of the Philippines who paid taxes before. But, today we are like no one that everyone tends to forget.” E5 Based on the evaluation result, most of the elderly participants were unsatisfied on the type of housing facilities they have. Entirely, the weighted mean findings ranged between 1.62 and 1.67, which are all greater than 1.5. This denotes dissatisfaction to the housing facilities specifically on signage, bathroom, walkways and furniture. Likert Scale Range Verbal Interpretation 5 4.50-5.00 Very Satisfied 4 3.50-4.49 Satisfied 3 2.50-3.49 Moderately Satisfied 2 1.50-2.49 Less Satisfied 1 1.00-1.49 Not Satisfied Table 3. Proportion of the residents who are dissatisfied Facility Structure Percentage Signage 66.7% Bathroom 61.9% Walkways 60.1% Furniture 69.0% “Some of the signage’s’ font texts are tiny and blurred, as if they are like decors without purpose after all. It should be checked and rechecked, ensuring that it is friendly to our poor eye sights. ” E2 Signage and directional graphics were unfriendly among geriatric residents. 66.7% (in words) rated it unsatisfactorily. As evaluated per observation, most of the signage posted were blurred, smaller in font sizes, and the color selection is 201 International Peer Reviewed Journal inappropriate, except on the one found at the main entrance. Directional signs and posters are very salient among elderly, for re-orientation and safety purposes (WHO, 2011). However, instead of directing, for some residents, they describe these as decorations with no purpose (E1, E2, E5, E7). To improve, there should be a careful and thorough selection of colors, materials, font size, font styles, graphics and design features (Nursing Home Standards Workgroup, 2014; Palompon, 2011; Reigner, Hamilton & Yatabe, 1995). Filipino transcriptions especially on warnings and danger zones should be available as well. “It is difficult to move inside the bathroom. The size is too small for a nurse and a patient especially in case of emergencies.” A3 “There were times that the floor is slippery, and the handle bar not that easy to reach. It happened one time that I slipped on the floor, how much if among these elderly residents, who have problems in balance.” A1 “With my weak body, I find it difficult sometimes to go to the comfort room. There were instances that I almost about to slip, especially when there is an urge to urinate or such. And it is not well-ventilated, too dark to my poor eye sight and needs to be repainted. E4 Toilets and bathrooms are both important to provide comfort and feeling of refreshment. But, 61.9% of elderly tenants felt discomfort when using both house sections. Per ocular inspection, privacy in the washrooms is not structured. These were mechanically unplanned, as well, since the space of the room and sizes of the doors were technically not recommendable, which was less than 1500mm x 1500mm. Also, there were no sliding doors, no mobility aids and mounted urinals for male not available. Conspicuously, the locations were not easily accessible especially in emergency situations. It is worth noting, from private reports that cases of accidental slips were common not only among residents, but, as well as among student affiliates despite the usage of non-slip tiles (E2, E4, E6, A1, A3). Accidents are really common in this area, it is suggested that ideal sizes of handrail vestibules, anti-slip rubber floor mats and wider or wheelchair friendly spaces must be observed (Nursing Home Standards Workgroup, 2014; Palompon, 2011; Bakalar, 2011). 202 JPAIR Multidisciplinary Research “The ramp way is not spacious, as if we have our own traffic inside the facilities. The size is too small for a nurse and a patient especially in case of emergencies.” A3 “Our walkways is also our program area. If so, expect that we are like sardines, fishes compressed inside a can, in every time we used it.” E5 In terms of walkways, 60.1% of the elderly residents were not satisfied. These were ideally designed with non-slip tiles, but their handrails with curve end, which were made of stainless steel, measured less than the standard diameter. In addition, the hallways were constructed in a minimal height of 2,400 mm, not recommendable as emphasized by the guidelines used. According to claims, the hallway was only enough for a maximum of two person that made transportation difficult sometimes (E1, E2, E5, A2, A4, A7). “The edge is not safe. I remember I got a minor wounds because of that” E1 “Some of the furniture are too impractical that only cause spaces to narrow.” E4 “Those were too heavy and cannot be easily moved. Something that can jeopardize the residents especially during emergencies or high magnitude earthquakes.” A7 Lastly, the furniture used in the elderly home were not standard. Some 69% from the respondents negatively commented on these. There were instances that they got scratches from the edge of tables, cabinets and beds (E1, E5, E7). Likewise, these were non-practical to some settings especially in terms of sizes and mobility (E3, E4, A7). The furniture should be flexible to meet the needs of the residents’ physical capability, and with multi-purpose (A4, Kong, 1999). Furniture must be sharp-free, colors contrasting to the wall and floors and must be stable (Nursing Home Standards Workgroup, 2014; Palompon, 2011; Reigner et al., 1995). Table 4. Thematic analysis from the FGD among nursing home administration Identified Factors Respondents Based on traditional practices N1, N3, N4 Foreign Standards are not applicable N7 Dependent on donations N1, N6 Prioritization of budget N5 203 International Peer Reviewed Journal “The facility was built in early 90’s. During that time there were no standards even hitherto. We don’t know what protocol shall we follow, we don’t have such.” N4 “Everyone has the right to live in a better facility, for health restoration and shelter. This should not be deprived among those weakly and hopeless elderlies. The Government must do something. We know that the administration has a lot of things to consider, however, we like any other NGO’s highly dependent on charities and donations. If only the government can provide us fund assistance, then such standards may be possible” N1 “The Western standards may not be applicable to our set-up. Elderly homes like in US is highly funded by their government, unlike here in the Philippines.” N7 “We know our facility is not standard. But, we are trying our best to provide quality services as we could. We have a lot of things needed here. We need extra personnel, budget, experts and building in order to meet the real holistic needs of our residents. I hope someday, our institution will be called a perfect home for the weakly and deprived ageing clientele.” N3 When the preliminary findings based on the first two phases of the study were presented to the administrative staff, they honestly admitted that claims were true. For them, there is a plethora of issues why these occurred. First, no standards were available before their building was constructed in early 1990’s up to present. Per initiative, they just followed the traditional building styles from those typical elderly homes found within the region and in the country (N1, N3, N4). In addition, some foreign standards were not practical to Filipino elderly (N7). Secondly, the limited budget they have. For a charity institution run by nuns and non-profit volunteers, they were only dependent on donations (N1; N6). Finally, as much as they want to improve, they have no choice but to stick to the budget and prioritize other physiologic needs of their tenants especially on food and medicine (N5). The administrators were already aware of these verbal cues regarding the dissatisfactions that their residents have (N2; N3); as much as possible they were trying their best to improve at the highest level they could (N7). In fact in their plan to build a new building they were planning to follow the structural design based on the guidelines highlighted from the modified checklist guidelines generated by the researcher of this study (N3; N7) 204 JPAIR Multidisciplinary Research CONCLUSION The living conditions of the elderly facility can be described as far below the ideal in both local and international standards. The level of satisfaction among elderly residents in the geriatric facility, namely, on signage, bathroom, walkways, and furniture was found less satisfied. The under-developed standardization and financial incapability among geriatric institutions were the identified factors why there was a non-parallelism between the elderly needs and conduciveness of quality living. RECOMMENDATIONS In the absence of such standards, there is a need to generate a national protocol guideline that will enhance the conditions of elderly homes in the Philippines. Our recommendation relate to the 4 specific areas: infrastructural design for considerations; additional funding and financial sustainability assistance from the government; open more school programs for gerontology and other related disciplines to increase the volume of experts; and lastly, further research replication that validate the findings of this pilot evaluative research, or other possible studies that will standardize the caring practices and services among elderly facilities tailored-fit to their humanistic needs. Through a rigorous follow-up investigation, the core issue of this study can be fully understood that will end up with our very own crafted model-approach flexible to the country’s set-up per se. Hence, the notion of “Health for all” is achieved especially among this under-looked and fragile group. LITERATURE CITED Black, J. M. & Hawk J (2005). Medical – surgical nursing. Clinical Management for Positive Outcomes. (4th ed). Missouri: Lippincott Williams & Wilkins. 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