| Background In the context of global aging,older adults’ demand for care is increasing,and more and more older adults are living in nursing homes.Older people value health-related quality of life more than life expectancy.The health status of older residents in nursing homes is generally worse than that of older ones at home,and the phenomenon of low level of health-related quality of life among them can not be ignored.It’s expected to provide evidence support and directions for action to improve the health-related quality of life of older adults in nursing homes by exploring the influencing factors and the mechanisms of these variables,and implementing revelant intervention measures.ObjectivesThe aims of this study were to describe the level of health-related quality of life,social support,hope,and general self-efficacy among older residents in nursing homes and to construct model of health-related quality of life of this population,which could offer clues for promoting the health-related quality of life of the older nursing home residents;to clarify the meaning of hope and to understand the experience of hope among older residents in nursing homes;based on which,to conduct hope therapy among older nursing home residents so that a higher level of hope and health-related quality of life could be attained.MethodsThis study used the methods of both quantitative and qualitative ones,including questionnaire survey,concept analysis,semi-structured interview and quasi-experiment.For the quantitative part,a cross-sectional survey was conducted to investigate 205 older adults from 16 nursing homes in Wuhan by convenient sampling.Mini-mental State Examination(MMSE),basic information questionnaire,Medical Outcomes Study 36-Item Short-Form Health Survey(SF-36),Social Support Rating Scale(SSRS),Herth Hope Index(HHI),General Self-Efficacy Scale(GSES)were adopted to survey the demographic characteristics,health-related quality of life,social support,hope,and self-efficacy.SPSS20.0 was used to analysis collected data.Description of data was conducted by descriptive statistical analysis.Univariate analysis was used to compare difference between groups in which Mann-Whitney test was for two groups whereas Kruskal-Wallis test was for multiple groups.Spearman test was used to conduct correlation analysis.Multivariate linear regression analysis was conducted to analyze factors influencing health-related quality of life among older adults in nursing homes.In the light of the literature retrieval and the above results,measuremental model and structural model of health-related quality of life were tested using structural equation modeling in Smart PLS 3.0.In the part of concept analysis,Walker and Avant’s model of concept analysis guided the concept analysis of hope among older residents in nursing homes.The concept analysis includes 8 steps:(1)select concept to analysis;(2)clarify the aim of concept analysis;(3)clarify all use of the concept;(4)define the attributes of the concept;(5)define the model case;(6)define additional case;(7)define antecedences and consequences;(8)define empirical reference.In the part of qualitative research,phenomenological method was used to understand the experience of hope among older residents in nursing homes.We used purposive sampling and the principle of saturation of interview material to select 14 older adults from 3 nursing homes from April to May in 2018.We collected information by semi-structured in-depth interviews.With informed consent of study objects,recording pen was used to record information of interview.Colaizzi method was used to analysis transcribed information.Self-controlled hope therapy intervention was used to improve hope and health-related quality of life among older residents in nursing homes.Using the convenient sampling method,24 elderly people from 2 nursing homes in Wuhan City from May to July 2019 were selected for a 5-week intervention,which included instilling hope,establishing goals,strengthening dynamic thinking and pathway thinking,and maintaining hope.The intervention took the form of lecture and discussion.The self-developed general data questionnaire,Herth Hope Scale and SF-36 were used to investigate hope level and healthrelated quality of life of older residents in nursing homes.SPSS was used to compare and analyze data.Wilcoxon rank sum test of paired samples was adopted to analyze hope and dimensions of health-related quality of life after intervention.Paired sample t test was used to analyze the two main domains – physical health and mental health of health-related quality of life.Intentionality analysis and per protocol set were adopted to analyze the results with subjects dropping out.ResultsThe results of the survey were: the total score of physical health of health related quality of life reached 37.07(25.56,46.67)and the total score of mental health was 56.33(50.14,62.15),the score of physical health is lower than that of mental health.The score of physical functioning was 55(25,85),the score of role-physical was 50(25,100),the score of bodily pain was 74(51,100),the score of general health was 55(40,75),the score of vitality was65(50,75),the score of role-emotional was 66.67(33.33,100),the score of mental health was68(52,80)and the score of social functioning was 75(62.50,87.50).The total score of social support of them was 32.60±6.60,in which objective support was 6.84±2.00,subjective support was 17.10±3.82,utilization of support was 8.59±2.15.The total score of hope among older residents in nursing homes was 34(31,36)in which the positive attitude towards reality and future was 11(10,12.50),taking positive activity was 11(10,12),and keeping close relationship with others was 12(10,13).The score of general self-efficacy among older adults from nursing homes was 23(17,29).There was statistically significance in physical functioning,general health,and physical health among older residents in nursing homes in different genders,where male scored higher than female in these dimensions mentioned.People with different marital status just showed statistical difference in physical functioning.Older residents who were not married had better physical functioning than those who were widowed or divorced.There was statistically significance in social functioning and physical health among older residents in nursing homes with different educational backgrounds.In social functioning,older residents who had an educational background of primary school performed better than those who were unlettered.Older adults who were illiterate had lower level of physical health than those who received education of middle school and over.Participants with different jobs showed statistical significance in physical functioning.Among whom,farmers showed better physical functioning than workers.Participants with different residential fees showed statistical significance in physical functioning and general health conditions.Older adults with residential fees less than 1000 yuan had better physical functioning than those with residential fees 1000～1999 yuan and 2000～2999 yuan.Older residents with residential fees less than1000 yuan had better general health outcomes than those whose residential fees were2000～2999 yuan.Hope,general self-efficacy and social support were positively associated with health-related quality of life among older residents in nursing homes.Analysis of factors influencing physical health of health-related quality of life showed that social support(b’=0.15,P<0.05)and general self-efficacy(b’=0.30,P<0.05)were factors influencing physical health of the older residents.Analysis of factors influencing mental health of health-related quality of life showed that hope(b’=0.39,P<0.05)and social support(b’=0.29,P<0.05)were factors influencing their mental health.The results of structural equation model of health-related quality of life among older residents in nursing homes indicated that hope(β’=0.32,P=0.00),general self-efficacy(β’=0.21,P=0.00)and social support(β’=0.25,P=0.00)were positively related to HRQo L respectively among older residents in nursing homes.The direct effect of social support on general selfefficacy(β’=0.38,P=0.00)and the effect of social support on hope(β’=0.47,P=0.00)were separately confirmed.Moreover,the study found that hope mediated between the relationship of social support and HRQo L(t=3.99,P=0.00).General self-efficacy mediated between the relationship of social support and HRQo L(t=2.51,P=0.00).In addition,gender had a direct effect on HRQo L(t=2.07,P=0.04).The concept analysis of hope among older residents in nursing homes showed that hope was(1)the sense of positive feeling for the future by older nursing home adults;(2)may/may not relate to a specific event or outcome;(3)a belief that something good can or will happen;(4)a driving force that provokes the action of older residents.The antecedents of hope among this population are: suffering from a predicament such as loss of body function or being in old age,the ability to understand one’s own expectation.The consequence is proactive actions to achieve the goal.Empirical references to hope include:(1)they actively face difficulties in real life;(2)they take active actions to overcome difficulties such as receiving rehabilitation treatment,taking medicine as prescribed by doctors,etc.(3)they scored higher on the Herth Hope Index.The qualitative study on the hope of older residents in nursing homes fell into 4 themes.Apart from the first theme,each theme has 2～3 subthemes.The themes and subthemes are:(1)understanding hope(hope is to keep you grounded to life,hope is to expect for future);(2)factors promoting hope(sufficient social support,clear life goals);(3)barriers to maintain hope(health damage,economic pressures,needs for respect is not being met);(4)the potential power of hope(self-adjusting,encouraging changing the present situation).The results of the hope therapy were: hope therapy promoted higher hope level among older residents in nursing homes(Z=-3.166,P=0.004).Among which,temporality and future(Z=-2.841,P=0.004)and the dimension of positive readiness and expectancy(Z=-2.229,P=0.036)scored statistically significant,whereas the dimension of interconnectedness(Z=-1.163,P=0.257)with others showed no statistical significance.Results showed that hope therapy improved general health(Z=-10.840,P=0.000),vitality(Z=-3.928,P=0.001),role-emotional(Z=-2.996,P=0.003),mental-health(Z=-4.758,P=0.000),and mental component summary scale(t=-9.438,P=0.000),however,physical functioning(Z=-0.979,P=0.338),role-physcial(Z=-0.535,P=0.593),bodily pain(Z=-0.249,P=0.803),social functioning(Z=-0.991,P=0.322)and physical component summary scale(t=-1.962,P=0.062)showed no statistical significance.The results of intentionality analysis of hope and health-related quality of life and their dimensions in this study were consistent with the results of per protocol analysis.ConclusionsAlthough the level of mental health was higher than physical health regarding to healthrelated quality of life among the older residents in nursing homes,compared with community dwelling older adults,the level of older residents’ mental health was lower than that of community dwelling ones.Our study showed that the score of hope in older residents in nursing homes was generally not high.The score of self-efficacy was medium to low.The level of social support the older residents in nursing homes could get was relatively high.Health care providers should pay attention to and take measures to improve the physical health tatus,hope level and general self-efficacy of this group.Hope,self-efficacy,and social support directly or indirectly influence the health-related quality of life of older residents in nursing homes.Among which,hope has the strongest effect on health-related quality of life.In order to improve the health-related quality of life of older residents in nursing homes,nurses should improve their self-efficacy,social support and especially their hope level.Older female adults in nursing homes should be put more attention to improve their HRQo L.The concept analysis of hope showed that hope is an over used and misused concept.The concept analysis clarified the attributes,antecedents and consequences,empirical referent of hope,which could promote the proper use of this concept in medical and nursing areas.The older people living in nursing homes is a special population.Different older adults showed different experience of hope.Maintaining hope is very important,which needs support from nursing homes,and family members of older residents,such as offering social support frequently,holding sports events to promote physical health and meeting the needs of them for the service in nursing homes.Thus,hope level of older adults can be improved and the confidence for living in nursing homes can be generated.Nurses should build trust with older residents and understand their needs,so that higher hope level of them can be achieved.Hope therapy which was developed based on Snyder’s hope theory,the results of concept analysis of hope and the experiences of hope among older residents in nursing homes could improve the hope level of this population.This intervention could promote better attitudes toward reality and future and promote older residents to take positive actions,but failed to help them maintain close relationship with others.This intervention could improve their general health,vitality,role-emotional,mental health and mental health-related quality of life,however,it failed to promote physcial functioning,role-physical,bodily pain,social functioning and physical health-related quality of life.Future studies should extend the time of intervention to further explore the impact of hope therapy on hope and health-related quality of life among older residents in nursing homes. |
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