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J Korean Gerontol Nurs > Volume 22(2):2020 > Article
Cho, Kim, Chang, Kim, and Kim: Exploring Nurses' Perceptions of Nursing Home Care in South Korea: A Qualitative Study

Abstract

Purpose

The purpose of this study was to describe nurses' perceptions of nursing services provided to nursing home residents, facilitators and challenges of providing care for these residents, and the need to improve the quality of care in the nursing home setting.

Methods

Data were collected through semi-structured, audio-recorded interviews with 19 nurses from six nursing homes in South Korea from February to June 2015. A thematic analysis was used to analyze the data.

Results

Five themes emerged: resident- and family-centered care as quality care, the importance of registered nurses in providing quality care, the importance of collaborating with care workers and resident's families, needs for nursing-home facility-level support for quality care, and needs for national policy for quality care.

Conclusion

To improve the quality of care in nursing homes requires organizational and policy endeavors to increase the number of nurses per shift, provide systematic education for care workers, and develop strategies for collaboration with care workers and families. Nursing-home facility-level support and national policy are also required to meet the complex healthcare needs of nursing home residents with multiple chronic conditions.

INTRODUCTION

In South Korea, older adults account for 13.8% of the population in 2017, and this proportion is expected to increase to 25% by 2030 [1]. Accordingly, the number of older adults who require long-term care (LTC) services is expected to increase exponentially. However, the support for older adults has weakened due in part to changes in family units and social structures [2]. Thus, the need for national or societal support for older adults in LTC facilities has been highlighted.
The national LTC insurance system for older adults was implemented in 2008. Since its launch, the proportion of older adults who were LTC insurance recipients increased from 6.6% in 2014 to 8.4% in 2018. During the same period, the number of nursing homes (NHs) increased rapidly from 5,083 to 5,284 [3]. With this growth, the quality of LTC services in NHs has been described as problematic and partially characterized by recipient dissatisfaction with care/services and poor quality of life [4]. In South Korea, institutional LTC services were provided by NHs and LTC hospitals. Legal regulations differ for NHs and LTC hospitals. LTC hospitals are required to have one full-time medical doctor (MD) per 40 beds and one register nurse (RN) per six beds. Certified nurse assistants (CNAs) can be substituted for two-thirds of the RNs. Nursing Homes are required to have one part-time MD (regardless of the number of patients) who visits NHs twice a month, and one RN or CNA per 25 beds [5]. To receive NH services, older adults must require help in all or most aspects of their activities of daily living [6]. In contrast, LTC hospitals have no admission criteria. The functional and health status of older adults in NHs and LTC hospitals are similar, and older adults and their families are often uncertain about the differences between LTC hospitals and NHs.
In South Korea, RNs, CNAs, and care workers comprise nursing staff in NHs, and there are no licensed practical nurses (LPNs) providing care in the NH setting [7]. RNs must graduate from a four-year university and pass a national RN licensing examination administered by the Korean Ministry of Health and Welfare. CNAs are educated in occupational high schools or private educational nursing institutes rather than colleges or universities and are required to pass a certification examination. Care workers must complete the curriculum at educational institutes and pass the qualification exam. In 2018, the number of CNAs employed in NHs was 10,266, which was 3.4 times higher than the number of RNs (N=2,993) employed in NHs. The number of care workers was 363,568 [3]. RNs and CNAs play important roles in providing care for residents through communication and decision-making among multiple disciplines. However, due to differences in the level of education and training, RNs’ perceptions of the level of care quality in NHs differ from that of CNAs. Thus, the quality of care by RNs and CNAs differs. This is troubling as the number of RNs is positively associated with the quality of care and positive outcomes such as reduced incidence of falls, aggressive behaviors, joint contractures, and the number of residents requiring tube feedings [8]. When the quality of care that is perceived to be good to RNs is implemented in NHs, the residents are likely to receive a better quality of care.
Despite the importance of RNs in NH care, little is known about RNs’ experiences of providing nursing services to NH residents in the context of the current South Korean LTC system. Such understanding is fundamental for developing innovative programs to improve the quality of nursing care and instruments that systematically assesses the quality of care in a way that is most appropriate for the Korean LTC system. The aim of this study was to describe RNs’ perceptions of nursing services important and necessary for NH residents, facilitators and challenges in taking care of these residents, and their needs to improve the quality of care in the NH setting.

METHODS

1. Design

We employed a qualitative descriptive approach with semi-structured interviews and thematic analysis. This approach allows data to remain as close as possible to the participants’ actual accounts without over-interpreting and requires a relatively low level of inference [9].

2. Setting and Participants

Six NHs from Seoul, Gyeonggi-do and Jeollabuk-do Provinces in South Korea participated in the present study. These NHs had 65-296 beds, and four of them were ranked in the top 10% and one was in the top 20% of LTC facilities evaluated by the National Health Insurance Service in 2013. The other NH was not evaluated due to its recent establishment. We called or emailed six NHs to introduce the study, and they expressed interest and agreed to participate.
Purposive sampling was employed to include RNs who had experience with NH care. Inclusion criteria were (a) having an RN license in South Korea, (b) being employed at a participating NH for at least three months (There was no report about nurse training period of NHs, but most of Korean hospitals including LTC hospitals had less than 3 months [10]), and (c) willingness to participate in the study. We recruited RNs who met the criteria in collaboration with NH administrators in the participating NHs. Once NH administrators introduced the study and investigators to the RNs, the investigators explained the study and elicited questions and interest in participating. This recruitment process was repeated until no new themes were yielded. As a result, nineteen RNs participated in the study.

3. Data Collection

We collected data from February 25 to June 20, 2015, using a semi-structured interview guide (Table 1). Two investigators (Kim, JA & Chang, SJ) conducted in-depth interviews in Korean within a private room at each NH. The interviews lasted for 50~90 minutes and were audio-recorded and transcribed verbatim. Transcripts were then compared with the original audio-recordings to determine their accuracy. To protect participant confidentiality, we replaced personal identifiers with random identifiers. All text data were managed via NVivo 10 software (QSR International, Burlington, Massachusetts, USA).
Information regarding the RNs’ characteristics, including gender, age, position, and work experience, was obtained using a structured questionnaire during the interviews. The participants received a small gift upon the completion of the interview.

4. Ethical Considerations

Prior to conducting the study, we obtained approval from the institutional review board at Y-University (No: 2014-0058-1). During the process of obtaining participants’ consent, we explained the study purpose, participants’ responsibility, potential benefits and risks, confidentiality, and voluntariness. RNs who agreed to participate in the study provided written informed consent.

5. Data Analysis

To describe RNs’ experiences of caring for NH residents, we analyzed the interview data using thematic analysis with a semantic approach (i.e., identifying themes/patterns “within the explicit or surface meanings” of what participants said) as has been done by other researchers [11]. Two investigators open-coded transcripts independently, discussed and reconciled codes, and then clustered the related codes together to generate subthemes or themes. Preliminary findings were continually discussed within the research team, and codes, categories/subthemes, and themes were revised accordingly to fit the data and study aim. We also checked if there were differences in perspectives between department directors/unit managers and staff nurses, but did not find evident differences. Exemplars to represent each theme were selected through discussions within the research team. This analysis was conducted in Korean, and the exemplars that were selected were subsequently translated into English. We analyzed the data of RNs’ characteristics using descriptive statistics.

6. Rigor

To enhance the trustworthiness (truth value, applicability, consistency and neutrality) of the findings [12], two coders independently analyzed the data and discussed the findings with the research team. We kept an audit trail regarding study procedures, including the data analysis process. Two additional qualitative research experts conducted a “qualitative audit” of the study’s analysis and findings. Furthermore, two bilingual investigators [initials blinded for peer review] translated the exemplars into English and revised them to accurately reflect the meanings of the original quotes.

RESULTS

Nineteen RNs participated in the study. All were women aged 32~59 years (Mean=48.5). As all nurses working in the nursing homes that cooperated in the study were women, the participants of this study were female nurses. Participants reported employment duration as 9 months to 18 years which included the period of former working experience in NHs. Seven of the RNs were department directors or unit managers, and twelve were staff RNs (Table 2). The analysis of the interviews with these participants yielded five themes in relation to RNs’ experiences of taking care of NH residents: (a) Resident- and family-centered care as quality care; (b) Importance of registered nurses in providing quality care; (c) Importance of collaborating with care workers and residents’ families; (d) Needs for NH facility-level support for quality care; and (e) Needs for national policy for quality care. Table 3 lists the five main themes and subthemes related to each major theme.

1. Resident- and Family-Centered Care as Quality Care

RNs reported various types of care that were considered important and necessary for residents’ physical and psychological wellbeing. Person-centered holistic care was an important theme, and RNs emphasized the importance of meeting residents’ needs for daily living and healthcare:
We try to do everything requested by our residents. We assist them with eating and manage their environment. When they say they are not feeling well, we give them appropriate available medications and follow up with them. We frequently assess their status. With such attention, our residents get better (RN17, department director).
RNs also stated the importance of maintaining residents’ functional status for as long as possible; for this, they provided residents with individualized encouragement to mobilize and engage in activities, and screened for, predicted, and prevented potential illnesses. In one RN’s words, “I keep telling my bedridden residents to attempt movements of their neck, fingers, arms, and legs. … Actually, [with such encouragement,] they improve”(RN2, unit manager).
Maintaining a good relationship with residents by showing respect and treating residents as if they were a family member was mentioned by the participants as one of important components of person- centered holistic care: “In NHs, it is important to develop good relationships with residents because residents usually live here for the rest of their lives. … Without rapport and good relationships, it would be difficult to provide good services” (RN13, staff nurse).
Regarding family-centered care, RNs noted the importance of ongoing communication between RNs and family about residents, counseling for families’ struggles and concerns, and providing emotional support. This was because residents manifested various health issues that required family involvement in care and decision-making, which led to emotional distress. One RN commented:
We know that it is important to make family members feel comfortable. We try not to make them anxious or uncomfortable. Because families usually feel guilty about placing their parents here, we should be cautious and careful when talking to them (RN18, staff nurse).

2. Importance of RNs in Providing Quality Care

All RNs noted their importance in delivering healthcare in NHs. The primary reason for their importance was cited as RNs’ healthcare knowledge and skills that other caring workforce does not have, which are critical to monitoring effects of medications, preventing medication errors, planning individualized care, predicting and evaluating outcomes, and promoting resident safety. Moreover, the participants explained that RNs are important because there are situations RNs need to manage in response to residents’ acute episodes because physicians or advanced practice registered nurses (APRNs) were not present in the facility. Some RNs reported several examples in which resident health status worsened when CNAs performed RN duties. One RN explained:
A resident had diarrhea every day for two months in her previous facility. When I saw her buttocks, they were sore and red. I looked at the meds brought from the other facility. Despite many meds helpful for diarrhea, the resident continued to have diarrhea and lose weight. I heard that, in that facility, CNAs replaced RNs in resident care. When I assessed the resident, I suspected fecal obstruction and performed a finger enema. I removed a lot of very hard stools for about 3 days. Giving so many antidiarrheal meds had caused all of these problems! I think healthcare professionals who have good training and knowledge, like RNs, are necessary in NHs (RN8, staff nurse).
RNs also stated that residents relied more on RNs than other professionals to meet their needs, particularly healthcare needs. Specifically, several RNs noticed that residents prioritized their healthcare needs over attending activities or programs. However, RNs experienced difficulty addressing residents’ healthcare needs primarily due to insufficient RN staffing. This RN shortage resulted in insufficient time to communicate with, and provide holistic care to, residents:
Now, the [required] ratio of nurse to beds is 1:25. This means that nurses can see residents very briefly for treatment. In addition, we have three shifts… so, at each shift, a nurse has to take care of about 100 residents. Although we want to provide high-quality or ideal care to residents, we can’t do this with the very small number of RNs here (RN3, department director).
RNs often had to independently manage residents’ medical emergencies, such as cardiopulmonary resuscitation, which contributed to the emotional burden related to their job. Therefore, RNs expressed a high need for more RNs in NHs, particularly more experienced RNs. Some RNs also articulated the need for continuing education about common health issues and medications related to NH residents and other topics for high-quality practice. Furthermore, a few RNs expressed the need for standards or protocols for nursing practice:
I hope there are certain rules about nursing practice in NHs… what kinds of care… in what circumstances... and so on. If we [RNs] had these rules, it would be much easier for us to work here. Now, we can only say ‘case by case’ … so we are unsure [about our judgment and scope of practice] (RN4, staff nurse).

3. Importance of Collaborating with Care Workers and Residents’ Families

Most RNs believed collaboration with care workers to be important in maintaining or improving resident’s health status and promoting their quality of life. This was primarily because care workers were the first-line personnel who often noticed subtle changes in their residents, which underscores the importance of their attentive care. One RN expressed:
A care worker assigned to a room can notice [subtle] changes in the residents’ status because of their frequent contact. When the care-worker says that a resident is not doing well, it really means that there has been a change in the resident’s status. As we work with care workers, we can monitor residents more closely (RN5, department director).
For better collaboration and improvement in the quality of care provided to NH residents, RNs often had to provide care workers with ongoing instructions or guidance. However, RNs said that many care workers do not follow their instructions or guidance. Some RNs also stated that care workers should receive continuing education about their roles and resident care:
They [care workers] really need [ongoing] education… like why daily enemas are not good for residents. Some care workers prefer enemas because assisting with toileting is burdensome for them. It’s also very hard for us to change the minds of such care workers … [But] I keep trying to educate them [about resident care] (RN6, staff nurse).
Additionally, several RNs reported that there should be more care workers to provide holistic care to residents. One RN said, “Here we lack care workers... Frankly, resident satisfaction can increase when their needs are met. But care workers can’t respond to every resident call” (RN10, department director).
Collaboration with family members also appeared to be critical in providing adequate and timely care to NH residents:
If the resident doesn’t eat well, we try to ask family members to come over and feed her for at least one meal before we consider tube feeding. We can’t spend a lot of time feeding a resident due to lack of staff…[Also,] I think it’s important for residents to be able to see their families as often as possible (RN17, department director).
However, RNs articulated conflicts or struggles that they experienced when interacting with families related to resident care. These conflicts or struggles included lack of family cooperation in resident care, lack of trust in RNs, too many complaints, and threats (e.g., lawsuits). These factors led to delays in care implementation and RNs’ experience of emotional discomfort (e.g., burden, frustration). One RN stated:
Some families don’t want to spend much money taking care of their parents, but they expect their parents to be comfortable and healthy here. I think this is greed. There is no way for residents to stay comfortable without any expenses. But families don’t accept this, so often, we don’t know what to do (RN4, staff nurse).
Another RN stated, “When they [family] are so picky and complaining about everything, I get stressed and feel burdened taking care of the resident…, thinking what the daughter would say this time. It’s too much of a burden! Then, work becomes stressful” (RN12, staff nurse).

4. Needs for NH Facility-Level Support for Quality Care

RNs believed that better resident care requires NH facility-level efforts to implement diverse programs or activities for residents, promote collaboration and communication among facility staff, provide leadership, and value NH healthcare missions. RNs articulated the necessity of more diverse programs and activities for residents, which might contribute to improved quality of life in residents. Particularly, they emphasized the importance of more diverse programs for bed-bound residents:
Actually, we don’t have many programs for these [bed-bound] residents. The programs we have for them are reading books and massage. There is nothing that these residents can participate in, so I feel so sorry for them… So I hope that more diverse programs will be designed for bed-bound residents here (RN2, unit manager).
However, several RNs reported challenges to implementing new, diverse programs, including increased caregiving burden and resident safety issues:
Even though social workers suggest new activity programs, care workers often don’t like the ideas because of the additional work required for them. They would have to transfer a resident to a wheelchair more frequently for programs… There would also be more safety issues.… If residents eat something bad for them [during activities], they can have diarrhe a.… So it is not easy to try new programs to improve the quality of life of NH residents. (RN4, staff nurse)
Some RNs also reported the importance of NH culture in promoting collaboration among staff for quality care of residents. However, such collaboration was often inhibited by poor communication and interactions among facility staff and directors, especially in large facilities, and in cases where there was a lack of leadership or support from facility directors. As one RN commented, “Although this is a small NH, when it comes to decision making, there is not enough leadership to communicate with us and attitude to change for NH residents.… I think we have a closed system in decision-making and communication. Our facility culture is not fluid” (RN14, staff nurse).
RNs perceived that the healthcare aspect of NHs was undervalued in general. The reasons included facility directors’ lack of healthcare background and their preference for reducing wages. For example, one RN commented:
In our NH, the Director has a nursing background, so she understands the quality of care that residents should receive and rules that staff should follow. But, if a social worker or other professional who doesn’t have a medical or nursing background was the director, she/he might not notice types of activities/treatments important for residents because they don’t know… (RN7, staff nurse).
Moreover, RNs reported that the facility’s financial concerns led to hiring CNAs rather than RNs to provide healthcare to residents. In the words of one RN, “In most NHs, leaders hire CNAs rather than RNs due to costs” (RN1, unit manager).

5. Needs for National Policy for Quality Care

RNs reported challenges related to providing quality care to NH residents, such as requirements imposed by national LTC, social welfare, and other healthcare-related policies. Many participants reported that current LTC policies seemed impractical and should be changed to ensure high-quality care. RNs emphasized the need for a policy to keep geriatric APRNs available in NHs for timely, more advanced, and professional care:
I think there should be a policy that allows APRNs to prescribe a certain scope of medications for resident care, especially at emergencies in NHs, and perform L-tube insertion or other procedures. I think this should be done for residents (RN3, department director).
Some RNs expressed concerns about the current social welfare policy/system for NH residents. One RN commented, “They [the government] keep saying ‘welfare for the elderly’, but what they are saying is far from the reality in NHs… The policies made by the government don’t reflect the [NH] reality” (RN2, unit manager). More specifically, the social welfare disbursements to residents were often not used by the residents; instead, the residents’ family members receive and manage the money as if it were personal income. Moreover, NH residents with social welfare [Medicaid] were able to utilize healthcare services without concerns about expenses, whereas residents with the general national insurance and their families worried about the costs of healthcare services.
Other challenges that require national policy involvement included transportation costs and unclear boundaries between NHs and LTC hospitals. RNs reported that transportation costs were greater than healthcare service costs, which impeded residents’ visits to hospitals. With regard to unclear boundaries between settings, RNs articulated that NHs had many residents with similar, multiple, chronic conditions requiring close medical attention as those addressed in LTC hospitals. In one RN’s words, “We often take care of very severe pressure ulcers [the same severity as seen in an LTC hospital]. So, I think the boundary is unclear between NHs and LTC hospitals” (RN11, staff nurse).

DISCUSSION

This qualitative descriptive study explored RNs’ perceptions of nursing services important and necessary for nursing home residents, facilitators and challenges of providing high-quality care for these residents, and the needs to improve the quality of care in the context of the current South Korean LTC system. Through thematic analysis of interviews with 19 RNs, we found that RNs made a lot of efforts to ensure they provide resident- and family-centered care in NHs, and they highlighted the importance of RNs’ availability in NH healthcare and collaboration. Also, participants identified several challenges related to the current NH system/culture and national policies regarding the NH care that have a great impact on NH residents’ health and quality of life.
NH residents in South Korea manifest multiple chronic conditions that require professional health care. RNs in this study reported that professional care could be provided by RNs (not CNAs) based on their healthcare knowledge and skills, but that they also need ongoing education/training about the care of NH residents. In the United States, the Center for Medicare and Medicaid Services selected six clinical conditions that likely lead to avoidable hospitalizations (i.e., pneumonia, dehydration, congestive heart failure, urinary tract infection, skin infection, and chronic obstructive pulmonary disease/asthma) [13]. Updated knowledge and skills in assessing and managing these conditions might help RNs address NH residents’ healthcare needs in a more appropriate and timely manner.
Teamwork is another competency necessary for RNs working in NHs [14]. In our study, RNs perceived collaborating with care workers as imperative in providing high-quality care to NH residents. Andersson et al. [15] reported that the most common causes of serious adverse events in Sweden NHs were teamwork failure, inadequate communication, incomplete or inadequate documentation, and lack of competence. To improve collaboration and further enhance the quality of care, RNs reported that care workers should engage in ongoing education that is related to bedside resident care. Chung and Lee [16] found that RNs experienced difficulty when instructing, explaining, and educating care workers during practice, and suggested educational programs or education- related policies for care workers. Kwak and Kim [17] also found that education for care workers was positively associated with quality of care. Thus, more systematic support for ongoing education/training for RNs and care workers is necessary to increase their knowledge and skills necessary for NH resident care, which, in turn, will improve the quality of NH care.
Family involvement in decision-making about NH care for their family members has been emphasized [18]. A meta-synthesis for synthesizing family caregivers’ experiences of NH care across ten qualitative studies from six countries reported that the adaptation of family members who admitted their relatives to NHs can be facilitated if family members are recognized as partners in caring for their relatives in NHs [18]. In our study, RNs provided examples that impacted their interaction with family members and that prevented them from making decisions about patient care in a timely manner, such as lack of family members’ collaboration in resident care, lack of trust, and frequent complaints. RNs often reported emotional burden, stress, frustration, and anxiety surrounding family interactions. Similarly, in one study that examined facility managers or directors’ perceptions of the quality of NH care [19], families’ differing expectations about NH services were considered one of the main challenges in providing quality care. Additionally, Chung and Lee [16] reported that lack of family availability or visits made it difficult to discuss the resident’s status and potential treatments in a timely manner or provide quality care to the resident. Therefore, RNs need systematic programs to communicate with family members. Furthermore, NH leaders should consider strategies to improve family involvement in resident care.
RNs in this study reported the importance of organizational efforts to implement diverse activity programs (especially for bed-bound residents), promote collaboration and communication among staff, and value the healthcare aspect of the NH setting to influence the quality of care. Several studies support the importance of diverse activity programs in NHs. For example, Cho et al. [20] found that NH residents expressed the desire for more diverse activity programs. To address residents’ needs, NH staff should consider strategies for supporting these residents in safely engaging in diverse activities. Previous studies also reported an association between improved care quality and organizational factors including collaboration, communication, and practice environment in NHs [21-23]. With good communication and collaborative skill, RNs can better understand resident’s condition and needs. Also, it helps to respond sensitively to the residents’ health and functioning status in a timely manner which helps to update the care plans for the residents [24]. Quality of NH care is also significantly associated with supportive practice environments for RNs [23]. Thus, it is necessary for NH leadership to create a more resourceful, collaborative, and communicative environment, which can lead to improved care quality.
RNs also highlighted the necessity of national-level policy support for better NH care. Such support included amending the current LTC insurance and social welfare policies and developing new policies and regulations related to RN staffing standards and APRNs in NHs. In an integrative review of 67 studies about relationships between RN staffing and NH care quality [25], higher RN staffing and higher ratios of RNs in nursing skill mix are associated with better quality of resident care in NHs regarding pressure ulcer, restraints use, hospitalization, and other quality measures. Kim, Lee, and Kang [26] also reported that the number of RNs in the Korean LTC hospital setting was associated with a reduction in the incidence of pressure ulcer in high-risk patients and the prevalence of worsening pressure ulcers. Moreover, the increased number of RNs has been founded to be associated with an improved functional ability among patients with dementia, but this effect was not found with CNAs [26]. In Canada and Germany, at least one RN is required to be on duty 24 hours a day in NHs, and, in the United States, federal NH staffing standards require a minimum of one RN on duty for eight consecutive hours for seven days a week and one RN or LPN for two other shifts [27]. Regulations in most countries do not allow substitution of CNAs for RNs. However, the current regulation of South Korean LTC insurance allows CNAs to be substituted for RNs in NHs [5]. Given that Korean NHs do not have onsite physicians or APRNs, RNs are better suited than CNAs to address significant healthcare needs. Professional knowledge, the capability of providing direct patient care, and leadership of RNs were reported as essential factors for quality improvement in NHs [28]. Therefore, legislation for the requirement of RN staffing is essential to improve the quality of care in Korean NHs.
APRNs, such as geriatric clinical nurse specialists or nurse practitioners, are considered to be a solution to improve the quality of NH care based on the complexity of health problems in NH residents and the limited care provided by physicians in the NH setting [29]. Moreover, as ongoing training for CNAs and care workers is important for high-quality care in NHs, APRNs can provide such training [30]. However, there is no currently available policy or regulations related to APRN practice in NHs in South Korea despite the availability of many geriatric APRNs. Thus, LTC stakeholders must evaluate the practicality of the current LTC insurance policy/system and make efforts to develop strategies (e.g., APRNs) to promote quality care in NHs.

Limitations

The findings of this study may not be generalizable to RNs employed in smaller or lower-quality facilities in South Korea as the interviews were conducted in relatively large and high-quality NHs. The participants were female because all RNs working at the six participating NHs were female. In addition, the participants didn’t provide feedback on the initial findings. Some latent information in the data may be missed due to thematic analysis with a semantic approach.
Despite these limitations, this study is one of the few studies examining NH care in South Korea, thus this study adds valuable knowledge to the existing limited body of evidence regarding the importance of RNs in providing high-quality care. To obtain a more comprehensive picture of NH care quality, more research with diverse participant groups (e.g., CNAs and care workers) and various study approaches is necessary.

CONCLUSION

The findings of this study highlight the role and perceptions of RNs in NHs in South Korea. RNs are essential healthcare providers in NHs, and policy endeavors are needed to ensure more RNs are present per shift. To improve the quality of care, systematic education for RNs and care workers and strategies for collaboration with families are required. Organization and policy efforts are also necessary to value the healthcare aspect of the NH setting and to make APRNs available in NHs in relation to residents’ healthcare needs.

CONFLICT OF INTEREST

The authors declared no conflict of interest.

AUTHORSHIP

Study conception and design acquisition - CE; Data collection - CSJ and KJ; Analysis and interpretation of the data - CE, KHJ, CSJ, KH, and KJ; Drafting and critical revision of the manuscript - CE, KHJ, CSJ, KH and KJ; Final approval - CE, KHJ,CSJ, KH, and KJ.

ACKNOWLEDGEMENTS

This work was supported by a National Research Foundation (NRF) grant funded by the government of the Republic of Korea (grant number: NRF-2014R1A1A3049936, PI: Cho).

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Table 1.
Interview Guide
Questions
Tell me about your role in the nursing home (especially with regard to resident care).
Tell me about your experiences with RNs' care/services affecting NH residents' lives (and especially, quality of life and safety).
If any, what has facilitated or challenged you in providing nursing services to your residents?
What kinds of care do you think is important for your residents, especially for their quality of life?
What kinds of nursing services are necessary for your residents?
What would you like to suggest to improve the quality of care (especially nursing services) in the nursing home setting?

RNs=Registered nurses; NH=Nursing home.

Table 2.
Nursing Home Nurses' General Characteristics (N=19)
Characteristics Categories n (%)
Gender Female 19 (100.0)
Age (year) 30~39 4 (21.1)
40~49 7 (36.8)
50~59 8 (42.1)
Job title Staff nurse 12 (63.2)
Unit manager or director 7 (36.8)
LTC experience (month) ≤12 4 (21.0)
13~60 6 (31.6)
61~120 6 (31.6)
>120 3 (15.8)

LTC=Long-term care.

Table 3.
Themes and Categories/Subthemes in Nurses' Perceptions of Nursing Home Care
Themes Categories/Subthemes
Resident- and family-centered care as quality care Importance of meeting residents' needs for daily living and healthcare
Importance of maintaining residents' functional status
Importance of ongoing communication between RNs and family
Importance of RNs in providing quality care Importance of RNs' healthcare knowledge and skills for NH resident care
Difficulty addressing residents' healthcare needs due to RN shortage
Need for continuing education and standards (protocols) for high-quality practice
Importance of collaborating with care workers and residents' families Providing care workers with ongoing instructions or guidance
Delays in resident care and RNs' emotional discomfort due to conflicts with families
Needs for NH facility-level support for quality care Necessity of more diverse programs and activities for residents
Importance of NH culture in promoting collaboration among staff
Necessity of facility directors' mind for healthcare quality
Needs for national policy for quality care Need for a policy to keep geriatric APRNs available in NHs
Need for change of the current social welfare policy/system for NH residents
Need for policy including transportation costs and unclear boundaries between NHs and LTC hospitals

RNs=Registered nurses; NH=Nursing home; LTC=Long-term care; APRNs=Advanced practice registered nurses.

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