Quality of life and related factors of nursing home residents in Singapore
This study investigated the self-reported QOL of Singaporean NH residents in the 5 domains of comfort, dignity, food enjoyment, autonomy, and security. The majority of residents rated their QOL favorably as suggested by a significant proportion of positive responses in the QOL items, which may imply at least a reasonable quality of care in local NHs.
On the other hand, there were still many residents who gave less satisfactory responses, suggesting that their quality of life may have been suboptimal. In our study, more than 30 % residents stated that they could not have their favorite food (31.2 %), could not wake up at the time they desired (36.8 %) or decide what clothes they wished to wear (41.3 %). These indicate that the manpower and resources spent in the NHs may have not been adequate. It may not be possible to increase satisfaction in those domains without spending more resources. However, improvements could be made easily in some other areas. For example, about 15 % residents indicated that staff in the NHs do not respect their modesty during care (e.g. closing the door when bathing them or closing the curtains when they are changing), which can be avoided.
Residents’ QOL can also be enhanced through targeting its modifiable factors. We found potentially modifiable factors in depression, communication with staff, ADL dependence and a non-modifiable factor cognitive function to be significantly related to QOL. Specifically, residents with major depression, inability to communicate with the staff, ADL dependence, and poorer cognitive function had poorer QOL in one or more aspects.
Residents with major depression reported poorer QOL in comfort, food enjoyment, and security, which is in line with findings in extant literature [28, 29]. This is not surprising as depression impacts one’s morale which in turn affects one’s perception of comfort, security and ability to enjoy food. Conversely, a lack of comfort or security and food aversion can likewise worsen depression, resulting in a vicious circle that can have severe detrimental effects on the resident’s well-being.
A resident’s inability to communicate with NH staff was associated with lower QOL in dignity and autonomy. Language barriers between staff and residents have been exacerbated by the increasing number of foreign staff in recent years [30]. The majority of the residents could only speak local dialects such as Hokkien and Cantonese (53.4 %) while most foreign staff are unable to converse fluently in dialects. As a result of communication barriers, residents may not be able to indicate their needs, and opinions to staff. This finding is distinctive to Singapore which has an eclectic mix of ethnicity, language and culture. It is certainly imperative to draw more dialect conversant locals to the NH workforce and this can be done by increasing the benefits of staff working in NHs. Foreign staff could be put through courses in local language and dialects to improve communication between staff and residents, and potentially enhance the well-being of the residents.
Residents with lower independence in ADL had poorer QOL in autonomy. This is not surprising and in accordance with existing studies [13, 16], where NH residents who were more dependent were found to require more assistance from staff, causing loss of autonomy. In pricing safety above autonomy, QOL can often be compromised. If QOL of the residents is a priority, a balance between safety and autonomy would be needed.
Those residents who had cognitive dysfunction (i.e. AMT??=6) had lower domain score of food enjoyment. The association between poorer cognitive function and poorer QOL was supported in the literature [12]. The cognitively impaired residents are typical of dementia, who were unlikely to enjoy the food.
Overall, the study has found QOL in Singaporean NH residents to be satisfactory, and depression and difficulty in communication with staff are the two main modifiable factors that should be addressed. In addition, providing more personalized care to meet the unique needs of each resident and to afford greater resident autonomy will do well to secure better QOL for the residents. Evidently, more manpower in the NH workforce is needed, especially to draw locals to work in the NH sector [4]. This would warrant greater investment to secure better work benefits and career prospects to make the field more attractive.
Some limitations in the study are noteworthy. First, we used a culturally adapted QOL instrument which had not been formally validated in the study population. The instrument measured only five QOL concepts and had suboptimal reliability. However, our pilot study did not support the use of the original instrument which is based on a longer questionnaire using 4-point Likert response scales. This was mainly because many members of our study population were not well educated or cognitively unwell. Nevertheless, our pilot study ensured that validity of the instrument in that only QOL domains most important to our study population were kept in the questionnaire. Second, the results were based on residents in NHs run by VWOs only, which may not be generalizable to residents in private NHs. Third, as residents who were uncommunicative or unable to communicate meaningfully were excluded, the overall QOL could have been an overestimate as these residents are intuitively surmised to have a lower QOL. Fourth, interviewer bias could be an issue. Although training for the interviewers was done to ensure standardization, subtle clues to the answers or tone of voice from different interviewers may influence the residents’ answers. Finally, variations of QOL in dignity and autonomy were found across the NHs (Table 3). This observation indirectly corroborates with findings from previous studies in which QOL domains such as dignity, food enjoyment and global NH satisfaction were positively related to each other [7]. The variations could be due to differing capabilities of the NHs in manpower, infrastructure, and funding. These factors were, however, not investigated in the study due to limited resources. Future studies are necessary to explore and understand the reasons for the variations.